The Elusive “Good Night’s Sleep” – Peter Walker
Difficulty initiating and maintaining sleep often prompts people to seek the assistance of a psychologist. It is common for clients to attend my practice lamenting the loss of precious hours of sleep. They relate long hours spent staring at the ceiling, tossing and turning, physically and mentally exhausted, yet wide awake. As someone who has, at times, struggled with insomnia, I empathise powerfully with those unfortunate individuals’ who push through until the pre-dawn hours in which our feathered friends’ stir and acknowledge the dawning of a new day. In this instance, birdsong that would otherwise be associated with peace and serenity, provokes murderous rage.
Psychologists have been treating insomnia using behavioural treatments for more than half a century. The most commonly implemented treatment , “Sleep hygiene”, assesses an individual’s sleep related behaviours and adjusts these in order to promote sleep. The client is encouraged to develop effective sleep habits and routines and maintain these over time. For example, clients establish consistent sleep and wake times, they avoid compensatory naps during the day, implement a relaxing routine before bed and ensure the bedroom is used for sleep and sex only, rather than the completion of your tax return or a comfy place to watch your favourite crime series. Most of these behavioural changes are simple and fairly obvious, but the evidence suggests that, in time, these strategies work.
Statistical versus Clinical Effectiveness
It is one thing to say that a treatment is effective, but it is also important to consider how effective a treatment is. In the case of cognitive behavioural therapy for insomnia, there is evidence that treatment works, yet its effectiveness is moderate. An Australian psychologist working in the US, Professor Alison Harvey, has been developing approaches that aim to increase the effectiveness of our treatments for insomnia. These approaches are interesting in that they challenge many long held assumptions about sleep. She proposed a cognitive model of insomnia in 2002 (Harvey, 2002) and argued that we should consider beliefs about sleep and the behaviours that arise from these when treating insomnia.
A Cognitive Model of Insomnia
Harvey draws attention to the following cognitive factors which may maintain sleep problems.
-An intense concern about getting to sleep quickly in order to maximise the amount of time asleep and a fear of facing the day without “sufficient sleep”.
-A tendency in insomniacs to selectively attend to “sleep related threats” such as monitoring sensations in their body for feelings associated with not falling asleep, calculating the time they believe they slept for on rising and signs of fatigue during the day.
-“Distorted perception”, such as overestimating the time it took to fall asleep, is commonly observed in insomniacs.
-Safety behaviours- These were first identified as maintaining factors in anxiety disorders. These are behaviours that individuals’ engage in order to prevent their fears arising but, in fact, act to maintain unhelpful beliefs and behaviours. In insomnia, cognitive strategies (Eg counting sheep) and behavioural strategies (Eg clear challenging tasks from your schedule) may function as safety behaviours. A commonly used safety behaviour in insomnia is “clock watching” whereby an individual regularly looks at a clock in the bedroom to assess the amount of time they have slept. Anxiety about the hours of sleep slipping away inadvertently increases anxiety and arousal, reducing the likelihood of sleep.
-Erroneous beliefs about sleep- The idea that someone needs a specific amount of sleep to remain healthy or that a period of tiredness in the late afternoon means you received insufficient sleep the night before, may lead to a negative preoccupation with sleep.
Effectiveness of Cognitive Treatments
Harvey (2005) reported on treatments that targeted the processes outlined above and the results seem promising. Of particular interest is the success of treatments that alters unhelpful beliefs about sleep. These beliefs are challenged verbally and by conducting behavioural experiments (scheduled activities that test out a potentially unhelpful belief). There are a range of experiments could be implemented and would depend on the nature of the unhelpful belief. A particularly powerful behavioural experiment that has arisen in my own life has occurred since recently becoming a father. Interestingly I have noticed a lack of correlation between my relative quality of sleep and my experience of fatigue or focus during the day. This in turn has led to a reduced concern about sleep and paradoxically seems to have contributed to enhanced sleep quality. Fixed beliefs about the amount of sleep someone “needs” or the belief that performance declines significantly after a night of poor sleep can be undermined in order to promote sleep.
So, for those of you who struggle with sleep it may assist to consider thought processes that are known to maintaining poor sleep. It may be, like many forms of human distress, that it is our unwillingness to suffer a bad night sleep that solidifies the problem.
Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40, 869–893.
Harvey, A.G, Tang, N.K.Y, & Browning, L. (2005).Cognitive Approaches to Insomnia. Clinical Psychology Review, 25, 593-611.