Thinking about sleep – or not…

It’s 3.00 in the morning.  You haven’t slept since you got into bed at 11.00, and the last time you had a full night’s sleep was some months ago.  Every morning you wake up feeling as though you haven’t really slept yet – and every day is just the same.

I can understand why people who have sleeping problems (and yes, I’m one of them!) often have quite strong reactions when they’re introduced to some of the concepts that are most successful for restoring a normal sleep pattern.  While the basic principles of sleep hygiene are well-known and reasonably simple, putting them – and other more challenging strategies in place – can be quite a difficult process.

It’s what goes through a person’s mind that makes it difficult – so today I’ve focused on some of the common thoughts that people can have, and how we as clinicians can respond to them.  These responses are primarily from a cognitive behavioural approach, with some ACT thrown in for good measure.

Introducing baseline
The most common reaction to ‘Now I’m going to ask you to record your sleep habits over the next week or so, please don’t change anything you’re currently doing’ is ‘Can’t you tell me just one thing I can do to help my sleep now?’ Your response needs to be along the lines of helping the person understand why you’re spending this first week or so recording current sleep habits.
The reason? So that you and the person have a really good understanding of the various factors impacting upon his or her sleep – so that you can work with the person to change unhelpful patterns. You can draw parallels with other health problems in which an accurate diagnosis is needed before prescribing an intervention – baseline assessment is part of that diagnosis process. Another point to make is that by prematurely changing one thing, if it doesn’t work (maybe because it’s not the most important factor, or maybe because there has been insufficient time to learn it) this can reduce the person’s confidence in the overall process, making it more difficult for the person to be 100% committed to the subsequent steps.

Reducing time in bed not sleeping
It doesn’t seem to make sense that to help promote better sleep, initially at least, it can be important to reduce the amount of time actually spent in bed! ‘But if I’m not in bed I’m not going to sleep at all!’ can be one cry, while another is ‘but I’m far too tired to stay up, I need to go to bed as soon as I start feeling tired so I’ll fall asleep then.’ Oh darn.
The rationale behind reducing the time spent in bed while awake is based on a behavioural model of insomnia. When a person remains awake while in bed, he or she may be resting and enjoying that time, but most likely the person is feeling stressed, worrying that he or she isn’t sleeping, and getting more frustrated all the while! What then happens is the association between being in bed and being awake is strengthened – along with the unpleasant emotions and thoughts that go along with being awake when wanting to be asleep.
What can you say as a clinician? It’s important to use the information gleaned from the sleep diary collected during the week before starting intervention, and to use this so the person discovers his or her own reasons for extending the time in bed – and its failure to address the problem. Sometimes reviewing the ‘workability’ of the habit (ie ‘Is this working for you? Are you getting more sleep?’) can challenge the helpfulness, while at other times it offers an opportunity to illustrate the learned association between walking into the bedroom to go to sleep and putting the head on the pillow but remaining wide awake. By using the person’s own information and own discovery process, it becomes far easier for you as clinician to introduce a different approach – suggesting that while the person isn’t actually getting to sleep for a couple of hours, it might be useful to only get into bed when the chance of falling asleep is high. In other words, setting bedtime a lot later! (shame our patients aren’t our kids, huh?!)

It’s worthwhile reviewing the behavioural model of insomnia again when introducing the idea of delaying bedtime – especially flagging to the person that it’s highly likely that they’ll initially have a hard time getting off to sleep even with a delayed bed time.  Why?  Because of that conditioned response – bed = awake!  By ‘innoculating’ the person to the chance that they’ll have some delayed sleep onset initially, it can help them to persist with what might not look like a very helpful strategy at first!

At the same time as introducing the idea of a later bedtime, now is a good opportunity to discuss getting out of bed if awake during the night.  Again this is not likely to be greeted with particular enthusiasm, especially during winter!  The temptation is to stay in bed – but if the person isn’t sleeping, this only serves to perpetuate the association between being awake and being in bed.  By guiding the person through the logical consequences of being awake and remaining in bed even in the middle of the night, he or she is much more likely to understand and be more comfortable with the process of behaviour change.  This does mean getting out of bed in the middle of the night, and going to a quiet place with low stimulus for a while until ‘sleepy-tired’, then returning to bed when actually ready to fall asleep.

This new habit is most likely to provoke a thought like ‘If I lie on the couch, I might fall asleep there – at least I’m getting some of that sleep that I need’. It’s really important to catch that thought and check in on whether it’s going to be helpful long-term – and you know I’m going to suggest that it’s not!  The reason it’s not is the same reason I’ve discussed above: the association between being awake and being in bed needs to be weakened, while the association between being asleep and being in bed needs to be strengthened.  Sleeping anywhere other than the bed (and at the correct time of night) reduces the strength of the relationship between bed and sleep and works against behaviour change.

I’m going to stop here for today – there are quite a few more aspects that I’ll discuss tomorrow, if you’re up to it.

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