Sleep, Forgiveness, and Health of Female Abuse Victims

Background: Homeless females are a vulnerable population increasing in number and factors related to their bio-behavioral health disparities need to be better understood. Between 38-42% of homeless persons are female in the region of the United States where this study was conducted, and many have children. Female prison inmates often receive short sentences and cycle in and out between prison and homelessness. Prevalent problems for both incarcerated and homeless females include having been a victim of adverse childhood experiences such as abuse that often occurs throughout the lifespan, which increases risk of continuing the cycle of violence and other crimes perpetrated by victims, (Brewer-Smyth & Burgess, 2008; Brewer-Smyth, Cornelius, & Pickelsimer, 2015; Roy, Crocker, Nicholls, Latimer, & Ayllon, 2014) and has long-term health consequences (Slopen, Koenen, & Kubzansky, 2014). It is therefore critical to intervene with homeless females to prevent or decrease these negative bio-behavioral health outcomes.

Many homeless shelters are faith-based and may promote religious beliefs/ spirituality (R/S) and concepts such as forgiveness. Studies show links between R/S and health (VanderWeele & Koenig, 2017); sleep and health (Itani, Jike, Watanabe, & Kaneita, 2017); and R/S and sleep (Knowlden, Shewmake, Burns, & Harcrow, 2018). Adequate sleep is critical for brain health (Dai et al., 2018) and overall health. Sleep disturbance can result in daytime fatigue, obesity, cardiovascular disorders, hypertension, metabolic derangements, Type II diabetes, cognitive impairment, immune dysfunction, osteoporosis, cancer, and increased all-cause mortality (Itani et al., 2017).

Forgiveness is not releasing perpetrators from responsibility for their actions, but rather it is letting go of a grudge, bitterness, resentment or revenge that can play an important role in sleep and health. Forgiveness has been associated with psychological health in physically abused women (Ysseldyk, Matheson, & Anisman, 2017). Though R/S, forgiveness and sleep quality can play critical roles in health, the relationships between these variables are not well understood, especially in high-risk vulnerable women living in homeless shelters who have often been abused and may or may not have forgiven their abuser. Better understanding is needed for intervention development.

Methods: This cross-sectional, correlational pilot study evaluated adult females living in a faith-based homeless shelter for their R/S measured with the Duke University Religion Index (DUREL), forgiveness measured with the Heartland Forgiveness Scale (HFS), sleep measured with the Neuro-QOL v1.0 Sleep Disturbance Short Form, abuse measured with Muenzenmaier’s scale, and health evaluated with the SF-12v2®. All participants who volunteered to be in the study were interviewed privately, and procedures were followed according to the Institutional Review Board (IRB) approved protocol.

Results: The thirteen women who participated in this study were between the ages of 22 and 59 years (mean = 35). Racial/ethnic backgrounds were: 7 African Americans, 3 Caucasians, 1 Hispanic and 2 reported mixed races. Ten of the participants were being treated for a mental health condition such as bipolar disorder, anxiety, and/ or depression. Of these women, 11 had been victims of abuse during childhood (before age 18) and 12 were victims of abuse as adults. Since abuse is so prevalent in this population, too few participants (8%) were not abused for comparison. As hypothesized, measures of R/S, forgiveness, sleep, and health were all significantly and highly correlated with each other.

Discussion and Conclusion: Direction of causation between variables cannot be determined with this cross-sectional design. For example, sleep quality could affect memory consolidation (Schönauer et al., 2017) about things people have done or situations that might affect one’s ability to forgive. Conversely, forgiveness could promote sleep quality because of decreased feelings such as anger and bitterness that could otherwise prevent sleep (Stoia-Caraballo et al., 2008). Higher sleep quality may contribute to better heath, while poor health could lead to poor sleep quality. Abuse and other forms of trauma that are prevalent in homeless persons, places them at high risk for mental health problems (Kmett & Eack, 2018) that are also prevalent in this population and could be exacerbated by poor sleep and unforgiveness.

Based on the findings here and the existing literature, faith-based shelters that promote R/S and forgiveness may improve sleep quality and general health. Interventions that improve social support focused on socially deprived groups such as this one are likely to help reduce socioeconomic health disparities. A mechanism to improve general overall health could be to promote sleep quality by providing additional support systems beyond housing that also advocate forgiveness and hope. Homeless shelters could help correct bio-behavioral health disparities from previous toxic stress of abuse and promote resilience in adult females through social and other types of support (Akhtar & Barlow, 2018; Brewer-Smyth & Koenig, 2014; Toussaint, Shields, Dorn, & Slavich, 2016). Though further research is needed, findings from this study help to provide a theoretical framework for future studies with stronger designs, prospective measurements, and larger sample sizes, eventually leading to the testing of interventions.