Helping Clients Who Struggle to Sleep
Good sleep and psychological health are intimate bedfellows. Many clients seeking therapy will also complain of disturbed sleep, and when worrying about lack of sleep becomes a trigger for anxiety in itself, a vicious circle sets in. Kathryn Pinkham takes sleep so seriously that she founded The Insomnia Clinic, which uses CBT techniques to help people improve sleep patterns and manage anxiety around sleep. To mark World Sleep Day, she shares some tips for working with sleepless clients.
With a background in mental health, I saw not only how prevalent sleep problems are but also how little access there is to treatment. Sleep has always been seen as a secondary issue for those suffering with mental health issues. However, it is now becoming apparent that many people find that poor sleep is the trigger that starts the cycle of poor mental health.
I have recently developed an online course that offers people the NHS recommended techniques used in the CBT for insomnia programme, but in the form of a step-by-step, self-management programme. With research showing that 70-80 percent of people see improved sleep using these techniques, it is clear that poor sleep is not something patients need to tolerate until their mental health improves.
Here are some common things your client may be doing that are contributing to their trouble sleeping – and some suggestions as to how you can help them break the cycle.
1 Spending too long in bed
The first thing we do when we can’t sleep is start going to bed earlier. Reducing the amount of time we spend in bed, going to bed later and getting up earlier, will encourage our body’s natural sleep drive to kick in. By reducing the time we spend in bed, we will crave more sleep, fall asleep faster and find the quality of our sleep improves.
It is very tempting to look at the clock every time we wake up to monitor how little sleep we are getting. This increases the pressure to fall back to sleep and makes it less likely. Setting an alarm for the morning is one way to avoid looking at the time repeatedly.
3 Lying in bed awake
If we can’t get to sleep or have woken up in the middle of the night, we tend to lie in bed trying to fall back to sleep. The longer this goes on, the more frustrated we get. This, in turn, means we begin to subconsciously relate bed to feeling stressed and being awake rather than asleep. It is better to leave the bedroom and do something relaxing like reading a book, until we are tired enough to go back to bed.
4 Worrying in bed One of the most common complaints people have when they can’t sleep is that they feel they can’t switch off their minds. The more time we spend in bed ruminating, the more we connect our beds to these feelings, rather than to feeling sleepy and relaxed. When we are tired our emotions can get the better of us and affect our thoughts and behaviours. This can lead to us following a train of thought through to an often-disastrous conclusion.
How to quieten a racing mind
I think this is the biggest issue for most people who struggle to sleep. So here are four steps we can follow with clients to help them address unhelpful thoughts:
- Write out thoughts Allocating up to 20 minutes a day to write down our worries provides greater clarity. We can then separate them into ‘real problems’ and ‘hypothetical problems’. For the real problems, make plans and try to fix them. Worrying about what might happen is like paying the same debt twice, if it happens you will deal with it then.
- Identify unhelpful thoughts Noticing physical symptoms surrounding anxiety, such as muscle tension or a churning stomach, can help clients identify when they’re having these unhelpful thoughts.
- Overcome unhelpful thoughts Try to help your client identify the source for their concern. For instance: ‘If I don’t get enough sleep tonight, I won’t enjoy the weekend… I’ll be snappy and irritable with the family… I will get depressed and anxious like I have been in the past and life will be really hard.’ Now encourage your client to look at the situation honestly and realistically, and ask themselves the following questions. Once you have helped your client rationalise their thoughts in this way, they will soon realise how extreme their thoughts have been.
- What is the evidence for their prediction? When they sleep badly, are they always tired and irritable? Is it the tiredness or the feelings about being tired? Often our feelings about being tired make us more stressed, unhappy and irritable than the actual tiredness.
- What is the evidence against their prediction? Have they slept badly before and still managed to enjoy themself? Have they ever slept well and still felt rubbish? Sometimes we put too much emphasis on sleep as the cure to all our problems.
- What is the most likely thing that will happen? Do they usually get some sleep and manage to cope the next day?
- If the worst happened, would they still be able to cope? It wouldn’t be an enjoyable weekend but it takes more than just poor sleep to create depression and anxiety. Last time they were depressed, what other things were going on as well as the poor sleep?
- How else could they view the situation? We’ve looked at the extreme, but what else could happen? Do they sometimes sleep ok? By working with you, they are already taking positive steps to improve their sleep.
- Mindfulness Once you have established with your client that worrying about sleep is only making it worse, mindfulness practices can help them to disengage with their thoughts, treating them as visitors in their mind rather than who they are. As thoughts around sleep arrive in their head, they can be encouraged to notice them, acknowledge them, even write them down if they need to… but then to let them drift away as they re-focus their attention on either their breathing or surroundings, including smells or sounds.
The Insomnia Clinic’s Sleep Well, Live Better online course is now available. Designed by Kathryn Pinkham (Founder of The Insomnia Clinic and NHS Insomnia Consultant) and her team of CBT therapists, the course guides users through tried and tested steps to improve their sleep. It also contains a bonus section around worry and sleep with a video showing techniques used in sessions.