For centuries, poets and playwrights have ascribed a kind of magic to sleep: “We are such stuff as dreams are made on, and our little life is rounded with a sleep,” says Prospero in Shakespeare’s The Tempest. Poet e.e. cummings wrote, “over my sleeping self float flaming symbols of hope, and i wake to a perfect patience of mountains.” Sleep used to be regarded as transcendent and restorative — a place where dreams connected to a better self. But in today’s 24/7 digital age, sleep is often perceived as a thief of time, an elusive lover or even a sign of weakness.
It’s also a biological wonder. A growing body of research is connecting sleep — both its quantity and quality — to a variety of physical and mental health issues. These findings suggest that sleep is no longer a bit player in health prevention and maintenance but a candidate for center stage. Clearly, the digital age needs to tune out, turn off and go to bed. Some counselors are making sleep therapy a significant part of their practices and helping clients learn to get more and better sleep.
Although sleep disturbances have long been associated with mental illnesses, new findings indicate that the link may be more complicated and intertwined than previously thought. For example, insomnia is known as a side effect of depression, but a growing body of research suggests it can precede and perhaps even cause depression. And now there is evidence that specifically targeting co-occurring insomnia can reduce depression symptoms. A recent study at Ryerson University in Toronto found that patients with both depression and insomnia who were successfully treated with cognitive behavior therapy for insomnia (CBT-I) were almost twice as likely to experience significant relief from depressive symptoms. A 2007 study in SLEEP, the peer-reviewed scientific and medical journal of the Associated Professional Sleep Societies, determined that chronic insomnia is not only related to stress but may also cause anxiety disorders. Another SLEEP study, published in a 2013 online supplement, found that insomnia alters the brain’s emotional circuitry. Specifically, it raises the activity level in the amygdala, which plays a significant role in emotional processing and regulation.
In addition to wreaking havoc with people’s mental health, lack of sleep puts stress on the cardiovascular system, suppresses the immune system and can cause endocrine dysfunction. These outcomes cause or are associated with obesity, heart disease, diabetes and dementia.
A recipe for insomnia
Lori Puterbaugh, an American Counseling Association member from Tampa, Florida, believes sleep deprivation is an epidemic in the United States. She says counselors, because of their behavioral training and other skills, can help remedy the problem.
Puterbaugh, a licensed mental health counselor and licensed marriage and family therapist in private practice, asks all of her clients about their sleep habits. At intake, she gives them a short questionnaire that asks about sleep duration and quality, including hours per night spent sleeping, time spent falling asleep, instances of waking up during the night and how rested they feel the next day.
Puterbaugh, who is also a member of the American Mental Health Counselors Association, a division of ACA, finds that many of her clients aren’t sleeping well and often are doing all the wrong things to actually get a good night’s sleep. “Most people’s routine is a recipe for insomnia, and they don’t even realize it,” she says.
In fact, many of the activities people engage in to relax before going to bed, including watching TV, surfing the Internet or interacting with other electronic devices such as smartphones and tablets, are stimulating the brain, Puterbaugh asserts. Even worse, she says, some people are convinced that these habits — their “sleep safety” activities — are actually essential for them to be able to sleep.
Some clients have the right mind-set about attempting activities and routines that promote sleep, but they don’t possess the know-how to follow through properly, says Robert Turner, a licensed professional counselor (LPC) and ACA member from Littleton, Colorado, who devotes part of his practice solely to treating insomnia. “There is a lot of access on the Internet to positive things people can try, but they don’t do it correctly,” he says. “For example, they may try deep breathing, but they actually hyperventilate, or they exercise, but they do it too soon before bed.”
Other people find that the more they chase sleep, the faster it seems to run. “They perpetuate sleep problems by going to bed early, staying in bed longer and napping during the day,” says Kim Restivo, an LPC in Wilmington, North Carolina, who also dedicates part of her practice to the treatment of insomnia.
“People will sometimes say, ‘It takes me awhile to get to sleep, so I will go to bed earlier,’ and that backfires,” says Turner, who has been working with sleep issues for more than 30 years. They instead end up tossing and turning, which adds to their anxiety and makes it even less likely that they will be able to fall asleep.
Puterbaugh says she often has to dispel myths about what qualifies as good sleep. “Many people are under the impression that the normal way to fall asleep at night is that your head hits the pillow and then you’re sleeping peacefully,” she says. They don’t realize that the time it takes to fall asleep varies according to the individual and changes throughout life, she explains.
“Clients sometimes have this idea of sleep as an on/off switch,” adds Turner.
Restivo tries to normalize occasional lack of sleep with her clients. “Everyone has bad nights,” she says. “It doesn’t mean that you are always going to have them.”
Some people also mistakenly think that waking up in the middle of the night should be an aberration, so when it happens to them, they lie there worrying about why they woke up, what is wrong with them and how they’re going to get back to sleep, Puterbaugh says. “I tell them that it’s not that uncommon to wake up to move over, to go to the bathroom or because you’re in the middle of a light sleep cycle and there was a noise,” she says.
“If people aren’t aware of the variations, they sometimes think that it’s just them — that there’s something really wrong with them,” she explains. “Sometimes you can reduce anxiety about bedtime just by giving them that kind of information.”
People often develop a kind of performance anxiety when it comes to sleep, Turner says. Restivo adds that it is important to reduce that anxiety because it often causes catastrophic thinking.
“They’re thinking, ‘Oh my gosh, I’m awake,’” Puterbaugh says. “‘What if I lie here all night and can’t get back to sleep? I’m going to have a horrible day at work tomorrow because I’ll be too tired.’ It’s just this cavalcade of things that are going to go wrong, and [counselors] can help them interrupt that.”
“You want to remove the sense that the bedroom is where you go to fight this dragon,” asserts Turner.
Rest for the weary
To slay that dragon, counselors and clients need to work together to change thinking and behavior.
“It becomes an education process,” Puterbaugh says. “And initially their anxiety levels go up because you are asking them to give up their security blanket [sleep safety activities].”
Puterbaugh and her clients discuss how spending a significant portion of the evening surfing the Internet or watching TV in bed, or other habits such as drinking alcohol or eating right before bedtime, can disrupt sleep. They then explore changes the client could make to promote more and better sleep.
“There’s a difference between having a cup of chocolate ice cream in the evening and having a whole gallon,” Puterbaugh says. “There’s a difference between watching TV in the evening for a little while and watching or falling asleep to it in bed.”
Puterbaugh tells her clients that the changes they make don’t have to be drastic to produce a significant difference. “Can you stop watching TV [or engaging with other electronic devices] an hour before you’re ready to go to bed and use that time to do something quiet under softer lighting?” she asks.
In addition, Puterbaugh advises clients to use relaxation exercises or positive visualization rather than lying in bed feeling anxious as they try to fall asleep or when they wake up during the night.
When working with clients struggling with insomnia, Turner starts with cognitive restructuring. “We shift the focus to ‘how can I manage’ rather than ‘I can’t manage because I didn’t sleep,’” he says.
Turner learned the principles of CBT-I during his time as a guest at the School of Sleep Medicine at Stanford University. CBT-I uses the tools of cognitive behavior therapy to change sleep behavior. Among the techniques are having clients keep a sleep diary to look for patterns, identifying triggers that make some nights worse than others and establishing good sleep hygiene. In part, that involves ensuring the bedroom is a dark and quiet place that is used exclusively for sleep (and sex).
Turner may also use another CBT-I technique, sleep restriction/sleep scheduling, but he acknowledges this is difficult because it requires the client to stick to a rigid sleep schedule temporarily. The client uses the sleep diary to track his or her sleep for a week to determine the average number of hours of actual sleep time.
“If by the end [of the week] you have averaged five hours, then you get only five hours to sleep, and you get out of bed until you’re having more success,” Turner says. This means staying up until five hours before a client’s normal wake time, whether that is midnight or 3 o’clock in the morning. The idea is to greatly increase the body’s desire for sleep so that when the client goes to bed, he or she actually falls asleep and stays asleep. Once the client is consistently falling asleep on this schedule, the interval is slowly increased until he or she is able to consistently get a full night’s sleep.
By reducing the number of hours spent tossing and turning, sleep restriction helps client to consistently see the bed as somewhere to sleep, not just “try” to sleep, explains Restivo, who also uses CBT-I with clients.
Restivo was trained in CBT-I at a seminar led by Michael Perlis, director of the behavioral sleep medicine program at the University of Pennsylvania. There is no specific certification in CBT-I, but doctoral-level practitioners can become certified in behavioral sleep medicine (go to the American Board of Sleep Medicine’s website at absm.org for more information). Non-doctoral-level clinicians who are actively involved in behavioral sleep medicine clinical care, education or research are eligible to join the SBSM as associate members. Members of SBSM can be listed on the site as behavioral sleep medicine providers.
Not all counselors who work with their clients on sleep issues choose to use CBT-I. Some simply combine their usual counseling methods with the principles of good sleep hygiene, which were originally developed by psychologist and sleep researcher Peter Hauri. According to the National Sleep Foundation, these principles include:
- Avoid napping during the day because it can disturb the normal pattern of sleep and wakefulness.
- Avoid stimulants such as caffeine, nicotine and alcohol too close to bedtime. Although alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half of the sleep cycle as the body begins to metabolize the alcohol, causing arousal.
- Exercise to promote good sleep. Vigorous exercise should be done in the morning or late afternoon. A relaxing exercise, such as yoga, can be done before bed to help initiate a restful night’s sleep.
- Stay away from large meals close to bedtime. Dietary changes can also cause sleep problems, so if someone is struggling with a sleep problem, it is not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine.
- Ensure adequate exposure to natural light. This is particularly important for older people who may not venture outside as frequently. Light exposure helps maintain a healthy sleep-wake cycle.
- Establish a regular relaxing bedtime routine. Also avoid emotionally upsetting conversations and activities before trying to go to sleep. Don’t dwell on problems or bring them to bed.
- Associate your bed with sleep. It is not a good idea to use your bed to watch TV, listen to the radio or read.
Sometimes sleep therapy uncovers other sleep disorders such as sleep apnea, a condition that causes the individual to briefly stop breathing frequently throughout the night. Sleep apnea puts incredible pressure on the cardiovascular system and can be deadly. Restivo, Turner and Puterbaugh emphasize that counselors who are treating clients with sleep problems should advise those clients to see their physicians for a thorough physical checkup.
These counselors say that tracking the quantity and quality of their clients’ sleep and working with them to improve their sleep is an important process because sleep is such an essential part of overall wellness.
Puterbaugh believes that the high incidence of depression, anxiety and attention-deficit/hyperactivity disorder occurring within a sleep-deprived society is no coincidence. “Sleep therapy isn’t going to make everything better,” she says, “but it is a factor — a factor that’s free to treat.”
To contact individuals interviewed for this article, email:
Lori Puterbaugh at email@example.com
Robert Turner at firstname.lastname@example.org
Kim Restivo at email@example.com
To read more about cognitive behavior therapy for insomnia (CBT-I), see stanfordhospital.org/clinicsmedServices/clinics/sleep/treatment_options/cbt.html, an online resource developed by the Stanford Center for Sleep Sciences and Medicine.
To learn more about insomnia and other sleep disorders, as well as sleep research, see the National Sleep Foundation’s website at sleepfoundation.org.
In addition, the following publications were mentioned in this article:
- “Chronic insomnia as a risk factor for developing anxiety and depression,” SLEEP, November 2007
- “Elevated amygdala activation during voluntary emotion regulation in primary insomnia,” SLEEP, online supplement, 2013
Laurie Meyers is the senior writer for Counseling Today. Contact her at firstname.lastname@example.org.
Letters to the editor: email@example.com