If only there was a magic wand. I could make millions out of a ‘quick fix’ to changing habits! Unfortunately my magic wand is red and glittery – and plastic. I call it my ‘self management’ wand because it reminds me that self management is no quick fix, and a good deal of the work we need to do is about helping people recognize unhelpful thoughts and behaviors that might work in the short term, but not so in the long term. Changing patterns for sleeping well despite chronic pain is no different – what might have been going on for years isn’t likely to change overnight.
Some of the thoughts that people have when embarking on cognitive behavioral therapy for insomnia can be quite unhelpful. One woman I worked with became despondent and eventually gave up because she got very irritable and felt too exhausted to carry on with sleep restriction, and told me her husband didn’t want her to stay up until she was sleepy as we had planned ‘because he can’t stand me being grumpy all the time’. She’d been having problems with sleep for four years, and we had worked on a sleep program for three weeks.
Today I’d respond a bit differently: when someone says ‘Oh but I just can’t do this’ I’d spend more time exploring how long the sleep problem had been going, and discuss the short term vs long term gains. If the problem with sleep has been going on for a long time, the difficulty from sleep restriction over a fortnight or so in order to improve sleep over the long term might be worth it. It’s worth using something like a decisional balance chart, or ‘pro’s and con’s’ chart that draws up the good and not so good of each habit that influences sleep. Habits like going to bed early after a few nights of poor sleep might help the immediate fatigue – but the probability of waking during the night is increased, which in turn maintains the poor sleep pattern. Forgoing the sleep program because of irritability or fatigue might keep the peace at home in the short term – but maintains the erratic sleep pattern that can interfere with good relationships in the long term.
If someone is raising the concern that they won’t be able to cope with excessive sleepiness during the initial phases of sleep modification, it’s worth considering introducing change over a Friday to Monday – that way the excessive sleepiness is confined to the weekend. In really challenging cases, the person might be able to take a week off work or a holiday, and time the program to commence during this time.
There is good reason not to change the planned program too much because of the person’s fears of being ‘too sleepy’. This is because one aspect of a sleep program is to evaluate the person’s fears that not being able to sleep will lead to ‘catastrophic’ consequences. By not challenging this belief, a tiny bit of doubt can remain in the person’s mind that the program won’t work in the real world – or when the person isn’t seeing the clinician.
Many people start a program but don’t manage to carry it out. This seems especially common with regard to that horrid part of sleep management: getting out of bed in the middle of the night if you’re not asleep. You’ll probably know these thoughts: ‘oh it’s so nice in bed, it’s too hard to get out of bed’; ‘maybe if I stay in bed I’ll just fall asleep, if I get out of bed I’ll just wake up properly and then I’ll never get any sleep’; ‘I’ll wake my partner if I get out of bed so I’ll just lie here and rest’.
Something worth considering is to explain to the person that at night some of the parts of the brain that help to evaluate and judge and monitor impulse control (frontal lobes) are affected both by fatigue – and by circadian rhythms. In other words, it is actually harder to reason logically at night, leading to more difficulty following through with difficult actions. By letting the person know that ‘it’s not your fault, it’s your brain letting you down’, it can help the person understand why it can be more difficult and as a result, help them apply some additional ‘push’ to overcome that tendency.
Working with catastrophic thoughts
One of the maintaining factors in insomnia is worry, or rumination. Now while there are some subtle differences between these, I’m going to treat them as the same for the purposes of this part of my discussion.
It’s common to think that being a ‘worrier’ causes insomnia – and to a certain extent, especially in the initial stages of the problem, that’s true. It’s very common for people with pain to be worried about a lot of things in the early stages of the pain problem, and what better time to think about these things than when in bed? Well, actually it’s not an especially good time, particularly in the middle of the night because it helps to maintain alertness, and more importantly, because of the problems with logical reasoning (see above). What typically happens is that thoughts just run around and around without coming to any resolution.
Once insomnia is established, self-perpetuating thoughts can maintain it. Things like ‘I’ll never get any sleep tonight’, or ‘tomorrow is going to be a write-off’. By working through these thoughts, perhaps using a whiteboard and listing the thoughts and working through to the ‘worst case scenario’ (in other words, following the catastrophic chain of thinking, we can work through to the underlying fears that have real emotional sting. Then we need to do some reality testing. Reality testing in this case involves making some estimates of how likely it is that each of these thoughts will come true. Using a percentage, each thought that has been jotted down is given a rating in terms of how probable it is that the fear will come true.
The next step is to work out how often each of the catastrophes actually DO come true. For example, if the thought is ‘I’ll never get to sleep tonight’ – how often has that actually come true? How often does the person actually get not a single moment of sleep at night? Probably the answer will be near to nil. The next catastrophe can be discussed the same way – how likely is it that tomorrow is a write-off? It helps to define what ‘write-off’ actually looks like: is it falling asleep at work? Is it forgetting to do a specific task? The question to ask is ‘how many times have you slept so badly that you fell asleep at work?’ Again, the answer is probably next to nil, but might be once or twice.
Then it’s important to point out the mismatch between the feared probability and the actual occurrence of the catastrophe.
You can do some maths here if you like: work out the number of nights in a year where the person has had insomnia, multiple this by the probability they give of ‘never sleeping’, and arrive at a number. Then work out the number of days where the person has actually fallen asleep and multiply this by the number of nights of insomnia. This quite clearly points out the disparity between what the person is worrying about – and the likelihood that it actually happens.
It helps at this point to remind the person again that at night, their logical thinking goes awry and so it makes it harder to think clearly, so some helpful phrases could be brought in to counter that fear. Something like ‘I won’t sleep at all tonight’ could be countered with ‘I probably will sleep at least a bit, and even if I do have a bad night’s sleep, it’s not very likely that I’ll fall asleep at work, so I can deal with it just fine.’
By using information from the person, and working through the maths, it helps to reduce the emotional reasoning that can otherwise influence behavior.
Let me know what you think – worth trying this approach for other catastrophic thoughts?