Section 15: A Handout to Support Coaching and Education about Good Sleep Habits

Up until this point, the focus of this training has been on more serious kinds of sleep disturbances. However, the most likely presentation of sleep problems will consist of clients who will have occasional problems falling or staying asleep due to ongoing life stresses and life changes. Sleep will be a problem in their life, but they will not meet full criteria for a diagnosis of a sleep disorder. They will need guidance and coaching on improving their sleep, not medical or mental health intervention from a sleep specialist.

Much of the information in the following handout will form the central core of coaching and educating around establishing good sleep habits when the clinician has discussions with his/her clients. This psycho-education will be part of an overall approach to managing problems with sleep. However, there is a real benefit to placing this information in the form of a handout.

First, it demonstrates organization, planning and forethought to put information in a handout. This lends an extra level of authority to the information contained in the handout and gives it a greater degree of persuasive power. This helps clients to take the information more seriously.

Second, it allows the client to refer back to the material as many times as they wish. Sometimes clients may be embarrassed or even ashamed to admit that they don’t remember what their clinicians told them, so they don’t ask for reminders. Information in handouts is always available to use and avoids this problem.

You can feel free to use the information in this section to create your own handouts. The information has been carefully researched, with consultation and review by a sleep specialist who is expert in his field.

However, it will also be important to understand some of the reasons why these sleep recommendations have been made. Clients may be skeptical, or may have questions that clinicians, in their role as expert, must be prepared to answer. Because there are often compelling reasons why clients elect to make choices that interfere with sleep, they may also be inclined to seek out evidence that provides support for their choices – ignoring or minimizing information that conflicts with what they are doing from a behavioral perspective.

The more clearly clinicians can discuss – with authority – the facts behind the importance of sleep, the more resistance can be overcome. This means more thorough and more detailed knowledge may be required, and the facts underlying this more detailed knowledge will be the subject matter of the sections that follow.

 

Handout: Tips for Improving Your Sleep

A good night’s sleep is one of the most important tools in managing stress and staying healthy. Most healthy adults should be sleeping between 7-9 hours a night. Your body’s chemistry is designed to have you sleep at night, when it is dark and cool. There is a natural rhythm in your body’s chemistry that works along with the changes in light and temperature to get you ready to fall asleep at a regular time. Because your body has a complicated chemistry of sleep, there are a number of reasons why people can have a hard time getting to sleep and staying asleep. This handout will provide a number of tips to improve your sleep.

 

Preparing for sleep at bedtime:

• Try to get to bed at the same time every night to establish a normal rhythm for sleeping.
• Turn your lights down as you start to get ready for sleep, and make sure your room is as dark as possible during your actual sleep time.
• Make sure you keep your bedroom cool, but comfortable when you sleep.
• Don’t exercise right before bedtime, as this can raise your temperature and make it harder to fall asleep.
• For some people it is advisable not to watch TV right before bedtime, as this can alter brain waves in ways that inhibit moving to a sleepy state.
• As you get closer to bedtime, allow some time to transition from a state of action to a state of relaxation, gradually reducing the level of physical and mental energy being expended as you prepare for bed. If you make this part of a regular routine, you can train your body to get sleepy at the right time to fall asleep sooner and sleep longer.
• Consider relaxed reading, light stretching, yoga or meditation leading up to bedtime as a way to further induce a state of relaxation.

 

Preparing for sleep during the day and night:

• Don’t drink fluids within two hours of bedtime, as this is likely to lead to nighttime trips to the bathroom and interruptions to your sleep.
• Don’t eat high sugar or high carbohydrate foods right before bedtime, as the increased level of energy from those sources can work against reaching a state of relaxation.
• Avoid caffeine and nicotine from cigarettes and other tobacco products in the hours before bedtime, and make sure you have a good plan on how to use prescription or over the counter medications that could disrupt sleep.
• Avoid drinking any alcohol right before bedtime, since alcohol interferes with your deep sleep phases. If you choose to drink in the evening, drink earlier in the evening and drink in moderation.
• Exercise during the day, but early enough that your body can be completely cooled off by bedtime.
• Include good sources of protein as well as fruits in your diet at supper – but several hours before you sleep.
• When you wake up in the morning, expose yourself to bright sunlight or bright lights. This helps to reset your biological clock.

 

Other important tips for people with sleep problems:

• For people with sleep problems, it is usually recommended that you not read or watch TV in bed. You want to train your body that bed is a place to sleep, not stay awake. If your body spends a lot of time being awake in bed, it can make it harder to fall asleep in bed.
• For people who can’t go to sleep or can’t stay asleep because their mind starts racing and worrying, it may be helpful to spend some time working on solutions to stress or worries earlier in the day or earlier in the evening. Even if you don’t completely solve the stress or worries, taking some time to think things through can help reduce the time spent worrying when you are trying to sleep.
• If you can’t fall asleep in bed within about 30 minutes, or if you wake up and can’t get back to sleep, get up from bed, go to another dark, cool place, and don’t go back to bed until you feel tired enough to sleep. Don’t turn the lights up, because that will trigger your body’s chemicals for moving into a wakeful state.
• For people who are sensitive to nighttime noises, or have a hard time sleeping when everything is quiet, the use of a sound machine with white noise or other soothing sounds can make it easier to fall asleep.
• For people who are overweight and experiencing sleep problems, it may be helpful to be checked out for sleep apnea. Sleep apnea is caused by difficulties in breathing that cause a person to partially wake up throughout the night, sometimes dozens or hundreds of times. This causes exhaustion from a lack of deep sleep. Overweight individuals are more prone to one of the two varieties of sleep apnea. However, if a person is chronically tired for no apparent reason, it is always important to consider the possibility that sleep apnea may be present, whether that person is overweight or not.
• There are sleep aids and supplements to help with sleep. There are two natural sleep aids that may be recommended by your physician: melatonin and valerian root. The use of any natural sleep aids and sleeping pills is a serious medical matter that should always be discussed with the physician who monitors your health.
• There are also prescription medications that may be recommended by your physician to assist with sleep problems. These medications should all be used exactly as prescribed by the physician, and you should have regular follow-up visits with your physician to monitor your progress.

These recommendations directly tie into the most common approaches to addressing sleep problems up to and including Insomnia Disorder. These approaches are shown below, with some brief explanatory text. The primary sources for this next section are the Mayo Clinic and National Sleep Foundation.

 

Relaxation Therapies

Relaxation therapies are designed to enhance the body’s system for generating cognitive and muscular relaxation, creating a better physiological state in which to fall asleep. Our body’s relaxation system, known as the Trophotropic System (TS), operates in the interaction between a person’s cognitive equipment and the parasympathetic nervous system, working to slow down the heart rate, reduce blood pressure, and induce a state in which physiological relaxation and rest may occur.

Specific techniques include progressive muscle relaxation, passive relaxation, autogenic training, biofeedback, imagery training, meditation, and hypnosis. Each of these approaches is designed to help the body learn to relax, while also enhancing the person’s capacity to initiate a parasympathetic response – the relaxation response.  Improvements in this area make it easier for the body to move towards a state of relaxation in which sleep can ensue, and therefore for the person to have more control over their sleep. With effort and practice, you can train yourself to be more relaxed at will.

There is an opposite physiological system that can work against relaxation. The body’s system for gearing up to handle threats and challenges, the Ergotropic System (ES), operates through the interaction between a person’s cognitive equipment for recognizing threats/challenges and the person’s sympathetic nervous system, increasing heart rate and blood pressure, inducing increased muscle tension and tonus, and moving a person into a state of high cognitive alertness. This is the system that creates the fight/flight response of readiness. 

Generally speaking, the ES is intrinsically faster to turn on and harder to turn off than the TS. When physically threatened or excited, a person can stay at a state of high alert and high physiological response for an extended period of time, requiring a lengthy cool down period to transition to a more relaxed state. This is why it is helpful not to engage in overly stimulating activities too close to bedtime, but rather to allow a planned transition period for the ES to move to a less activated state. 

These two opposing systems operate interactively in complex ways. Because they are essentially separate systems, mediated by different neurotransmitters operating in different neural networks, they do not by default operate in direct opposition to one another. Turning one system on does not necessarily turn the other one off. They can both be turned on at the same time.

So while it is moderately easy to activate the relaxation response from a neutral state in order to facilitate movement towards a sleeping state, when the ES is operating at a high degree of activation, it may be much more difficult to move towards a sleep-ready state. As threats and challenges are removed, it becomes easier to quiet the ES – reducing the chemistry that makes it harder to relax – and more supportive of the TS’s attempts to move towards a sleepy state. 

This is not to say that the TS is unable to dial down the activation of the ES in order to induce the capacity to move towards sleep – with practice, over time. What is required is a two-part process. First, it is necessary to have a focused period of training to strengthen the functioning of the TS under relatively calm conditions in order to make it more easily activated at will. It is somewhat like needing to build your muscles for walking before you can take on the more complex movements of running.

When the neurological equipment is developed sufficiently, then a focused period of training can be initiated to activate the TS in the presence of increasingly more pronounced states of ES activation. With training, you can gradually increase the capacity of the TS responses to hold back and dial down the ES responses, using traditional conditioning techniques. This is an essential strategy both in systematic desensitization for phobias and in exposure therapy for Post-traumatic Stress Disorder. It is also the essence of the techniques that have been used for thousands of years to maintain a state of focused calm in the application of the martial arts, like karate or kung fu.

If clinicians are intending to utilize relaxation therapies with clients, it is important to be able to provide adequate instructions on how to engage in them, reasonable expectations for the effort required and the time frames needed for improvements to occur, and where there might be challenges and contraindications. For instance, clients with a history of deep trauma may struggle with intrusive flashbacks that generate extreme distress when they attempt to create a state of relaxation through meditation or emptying the mind of thoughts.

As clinicians and clients weigh whether to implement these strategies, it is the clinician’s responsibility to provide sufficient education about these issues that informed consent can be reached.  

 

Sleep Restriction Therapy

Sleep restriction therapy attempts to move a person’s sleep schedule to a more normal and predictable routine by determining how much time, on average, a person would sleep when sleeping normally, then restricting the client’s time in bed to equal that amount – no matter how much sleep is achieved each night the person spends in bed.  (Mayo) To begin with, the client’s average nightly time spent sleeping is determined by reviewing a record of the time actually spent sleeping over several weeks, averaging that time, and using that average as a starting point for setting the amount of time the person will be permitted to stay in bed.

The main idea behind sleep restriction therapy is that time spent in bed tossing and turning can condition a person to associate time in bed with not sleeping. Creating a better alignment between the amount of sleep the client’s body actually needs with the amount of time he/she spends in bed is believed to decrease the likelihood that negative conditioning for sleep will be an ongoing problem.

This approach contains a fundamental understanding about differences in how many hours of sleep different individuals need. While certain individuals may require even more than 7-8 hours of sleep in order to function optimally, other individuals are refreshed and restored by 5 or fewer hours of sleep. This normal variation in sleep need can even be seen in children, although even persons who as adults function extremely well on 5 hours of sleep will on average require more hours of sleep than that when they are children. It is just that at all stages of life they may not need as many hours of sleep as other people their age. 

If an individual requires a much lower number of hours to awaken feeling refreshed, but attempts to set their sleep schedule according to the 7-8 hours that the average person needs, that person can end up spending a good deal of time tossing and turning in bed. Paradoxically, this can condition that person to have problems sleeping. Likewise, children with lower sleep needs who are forced to remain in bed to get a “normal” amount of sleep may end up with sleep problems.

Because there is so much variation in sleep needs, it is frequently necessary to  adjust the time spent in bed up or down by 15 to 30 minute increments in order to determine what any individual’s optimal time for sleep might be. Once this is determined, it creates a baseline that can be adjusted if a client’s sleep needs or circumstances change over time.

 

Stimulus Control Therapy

Stimulus control therapy is based upon the assumption that people can get conditioned to having problems with sleep. They can begin to associate their beds, bedrooms, and their sleep routines with the problems they are having sleeping, turning each aspect of a normal bedtime into cues that activate negative reactions that interfere with falling asleep.

In addition to some normalizing education about how this conditioning process can occur, there are some simple steps to implement this approach to improving sleep. First, the client is advised to avoid going to bed until he/she is feeling sleepy, and to use bed only for sleeping (or sex). This includes clear instructions not to read, watch television, eat, or otherwise use the bed and/or bedroom for activities that could get in the way of sleep.

Second, the client is advised not to lay in bed awake for extended periods of time when trying to fall asleep or when wakened in the middle of a night’s sleep. If the initial period of sleepiness is not adequate to lead to sleep in a reasonable time frame, remaining in the bed awake only serves to reinforce the connection between the bed and the inability to get to sleep. The client is advised to get up out of bed, go someplace that is dark, cool and relaxing, and wait until a renewed sense of sleepiness returns.

Third, the client is advised to establish a regular sleep schedule – designed to occur at the time when he/she is most likely to be ready for sleep – and to support that sleep schedule by refraining from daytime napping and by waking up and getting out of bed at a regular time in the morning at which time he/she is to seek out exposure to bright light, preferably natural sunlight. Later in this course there will be more detail on how a regular sleep schedule supports falling asleep at night.

This approach may require one or more weeks to create sleep improvements, as it is not always an easy thing to return a client to a regular sleep schedule. If clinicians are intending to utilize this approach with clients, it is of vital importance to secure commitment from the client to invest in following the steps conscientiously. In the short run, it likely means that the client will experience additional fatigue. However, as the fatigue accumulates, it increases the likelihood that the client will eventually achieve sleep within the schedule he/she is trying to establish. This will begin to reverse the conditioning process and create a more positive reconditioning for a normal sleep schedule. 

 

Temporal Control Therapy

Temporal control therapy is an approach that simply attempts to regularize the time a person goes to sleep every night and the time that person gets out of bed each morning. This is a component of stimulus control therapy and just good sleep hygiene, but is sometimes used on a stand-alone basis. The idea of this approach is that people tend to sleep better when they are on a regular schedule.

 

Cognitive Behavioral Therapy

In addition to the approaches listed above, CBT has been used successfully to treat Insomnia Disorder.  As in all instances of CBT, there will be cognitive and behavioral components utilized to address the client’s concerns. One of the pieces of changing the client’s behaviors will incorporate the major behavioral strategies already noted above: relaxation therapy, sleep restriction therapy, stimulus control therapy and temporal control therapy.

Additionally, there will be recommendations made to alter other aspects of the client’s bedtime choices, including many of the recommendations in our handout provided above and supported by the information that was provided in section I of this course and will be provided in subsequent sections. The main point of these behavioral changes will be to remove obstacles to the natural process of falling asleep. 

As we noted in our handout, it is important to encourage the client to keep his/her bedroom as dark as possible and as cool as can be comfortably tolerated in preparation for falling asleep. It is important to avoid alcohol, caffeine and other substances that impair sleep. It is helpful for many people to establish a transition time allocated to slowing down and relaxing prior to trying to go to sleep. These are the kinds of behavioral changes that can create a very quick resolution of sleep problems for many people.

The cognitive components of CBT will have several other pieces designed to change the client’s thinking about his/her sleep and reduce any resulting affective material that may be interfering with falling and staying asleep. Some of the changes in thinking may result from simply instituting the behavioral changes noted in the paragraphs above. The client’s confidence about falling asleep may be significantly aided by his/her awareness that useful changes have been made to how he/she approaches sleep, incorporating, to some degree, the placebo effect.

It is often also useful to the client to correct some of the myths and misperceptions that the client may hold concerning sleep, using psychoeducation – a cognitive approach – providing to them more accurate knowledge within a supportive relationship. A client who learns that his/her fears and worries are rooted in a poor understanding of the facts may often relax in ways that support better sleep.  

Other cognitive approaches may be oriented towards correcting negative thinking patterns that get established alongside the client’s sleep problems. This process would be fundamentally the same as utilizing cognitive approaches to correct errors in thinking that accompanies anxiety or depression. The clinician would begin to correct the distortions, e.g., the ‘awfulization’ or ‘catastrophization’, that can take over when a problem becomes entrenched. For most clinicians, this represents an easy transfer of skills from one area of practice to a different problem area.

Another useful cognitive strategy can also be carried over from work that clinicians already do in the application of CBT. This would be relevant when a client has established a pattern of rumination about stresses, fears and worries while the client is attempting to go to sleep or stay asleep.  It can be very useful to the client to spend some time a couple of hours before bedtime examining and writing down the material over which he/she is ruminating, while also using this time to begin to develop potential solutions to the matters that are generating the need for ruminating.

This simple act of writing down the generation of potential solutions activates a very different area of the brain than the area in which rumination takes place. Whereas the rumination occurs in a part of the brain where processing is unlikely to generate reductions in the worries or fears, this other area of the brain is much more successful in both generating solutions and connecting those to solutions to the worries or fears in ways that help bring resolution to things.

 

Sleep Aids

As we have noted in our handout, the decision to take any medications or supplements to help with falling or staying asleep is an important decision that should generally be made in collaboration with a physician who can monitor the use and effects of the sleep aid. While it is considered outside the area of competence for a mental health clinician to consult and monitor in this area, it is important to have awareness and understanding of what options are likely to be employed. This allows the mental health clinician to support the relationship between the client and his/her physician and help close gaps in that relationship. 

There are four general categories of sleep aids that must be considered. First, there are a several health supplements used to aid sleep that are typically found in stores that sell nutritional supplements or in the vitamin aisle of supermarkets and drug stores. These include melatonin, valerian root and 5-hydroxytrypophan (5-HTP).

 

Sleep Aid Supplements

Melatonin is a chemical that is naturally found in our body and is involved in the chemistry of adjusting our day/night sleep cycles. The supplements consist of a synthesized version of the chemical, and they are widely used by people whose day/night cycles have been disturbed by travel across time zones or shift changes. They are also used by people whose bodies do not produce enough melatonin on their own.

It is generally considered a relatively safe supplement, and may even have anti-oxidant effects. (American Cancer Society) However, there are potential side-effects that have been noted, including potential drug interactions with blood thinning medications, and medications for seizures and diabetes (American Cancer Society), and excessive sedation if used in combination with depressants such as alcohol or benzodiazepines. (Mayo)

It is not clear if frequent use of the supplement causes the body to reduce its own production of melatonin as an adaptive response, but other than this concern it has been reported as safe to take for up to two years at a time. (Mayo) Melatonin is typically not recommended for children. It is also not recommended for pregnant women, due to concerns about its effects on hormonal production. (Mayo) 

Because melatonin is marketed and sold as a supplement, it is not regulated or supervised by the FDA.  This means that manufacturers are not held accountable by law to quality standards or the need to demonstrate safety and effectiveness. Quality can vary from brand to brand – and sometimes from pill to pill in the same bottle - in terms of the consistency and dosage of the active ingredient. Additionally, there are not the same strict guidelines for what other ingredients are added to the tablets or pills, meaning there is less oversight to prevent the inclusion of contaminants and potential allergens. For all these reasons, it preferable for the client’s physician to serve as the guide and consultant on when and how to use this supplement.

Valerian, derived from the root of a common herb, is another supplement that is widely marketed for as a sleep aid. It is reported as “possibly effective” in increasing drowsiness and “likely safe” by NIH’s Natural Medicines Comprehensive Database. (Medline) Unlike melatonin, it may be considered safe for use by children. (Medline) Because valerian is a natural sedative, it should not be taken with other sedative medications and should not be taken within two weeks of a scheduled surgery. (Medline)

Because this is a supplement manufactured by numerous companies with no FDA oversight, the same concerns exist about quality control and the inclusion of contaminants and potential allergens in the use of this sleep aid. There are not yet studies that reveal the safety of long-term use, but it is considered safe to take for up to 4 weeks. (Medline)

 

Over the Counter Sleep Aids

The next group of sleep aids will consist of drugs sold as over the counter medications.  As opposed to supplements, these products are manufactured and distributed under FDA supervision, resulting in a much higher level of consistency of dosage and quality of manufacturing. There are two main chemicals used in the making of these sleep aids: diphenhydramine and doxylamine. 

Diphenhydramine is an antihistamine best known as the active ingredient in Benadryl and a host of other medications commonly used to treat allergies and the common cold. It has a sedative effect, so it has been used to treat insomnia. While generally considered safe, it is not recommended for children four or younger, particularly in conjunction with other medications for cold and flu symptoms. (Medline, NIH) It is not likely to be effective as a sleep aid when used for more than a few nights in a row, as the person adapts to it and the sedative effect diminishes.

The most common brand names associated with this medication for sleep concerns are Sominex, Nytol, Compos Sleep Aid, and Unisom. However, diphenhydramine is also an active ingredient in dozens of other products, usually noted by the suffix “PM” to note its sleep promotion effects (e.g, Tylenol PM, Alka-Seltzer PM).

Diphenhydramine should not be taken in conjunction with alcohol, as alcohol will enhance the sedating effects, and clients must be on the lookout for some rare, but serious side-effects, which include vision problems and problems urinating. (Medline, NIH)

Doxylamine is another antihistamine with similar effects and warnings, e.g., not recommended for children 4 and younger, not to be taken with alcohol or other substances with sedative effects. It may also lead to vision problems or problems with urination in rare cases. It is not recommended for use beyond 2 weeks. (Medline, NIH)

Unisom SleepTabs and Aldex AN are the most common brand names associated with a stand-alone version of this chemical, but it is also an active ingredient in many cold products where it is combined with other cold and flu remedies, including Vicks NyQuil products.

Because these are not prescription medications, clients may assume that they do not need to mention their use to a physician. The role of the mental health clinician in such instances is simply to gather information and, where indicated, refer the client back to his/her primary care physician to reinforce the importance of making all medication decisions in concert with a qualified medical specialist.

 

Sedative-hypnotic Prescription Sleep Aids

For clients whose sleep problems may require a more potent sleep aid medication, a group of prescription products has been introduced over the past couple of decades to replace more powerful medications with a concerning level of addictive potential. This new set of medications includes familiar names like Ambien, Lunesta, and Sonata. 

These medications are in the sedative-hypnotic class of drugs, and they all have potential to create some degree of dependence in users. Therefore prescribing physicians must monitor their use carefully, and mental health clinicians should be aware when they are being utilized by clients. There exists the potential for overdose with these medications, leading to loss of consciousness and coma, so there are special precautions that must be observed when these medications are being employed with clients who have suicidal ideation or tendencies. (Medline, NIH) 

There also exists the potential for some serious side-effects with these medications. While these are rare, they can include difficulty swallowing or breathing, and problems with vision, among other symptoms. (Medline, NIH)  None of these medications should be taken with alcohol, as this will enhance the sedative effects.

As these are all prescription medications, the client’s use of these drugs should be monitored carefully by the prescribing physician. In the real world, however, this is not always the case. The role of the mental health clinician in monitoring the use of this category of medications is to assure that a higher level of interaction is occurring between the client and his/her primary care physician. This will help to ensure that dependence on this medication is avoided and that all potential safety risks are prevented. 

 

Benzodiazapine Prescription Sleep Aids

There are two commonly prescribed name brand medications for sleep disturbances that fall into the class of medications called benzodiazepines. These two medications are Halcion and Restoril. A less commonly prescribed generic drug, called Estazolam, may also be used in lieu of the brand name products. Because the addictive potential for this category of medications is so high, they are normally prescribed for very short periods of time, usually less than two weeks. (Medline, NIH)  

As with the sedative-hypnotic medications noted in the previous section, these medications should not be taken with alcohol, but the overdose potential for this category of drugs should be taken even more seriously. If this medication is in a household with children present, great care should be taken to keep it where children cannot get to it. Clinicians should also be on the lookout for the development of more serious side-effects, including difficulty in swallowing or breathing.

If a client is taking this class of medications without the supervision of a physician, it represents a quite serious risk in terms of the development of drug dependence. This is even more of a concern if the client has any prior history of substance abuse or dependence. In such a case, it is important for the clinician to apply his/her persuasive skills to rectifying the absence of adequate medical care. The failure to adopt such an approach might represent a liability risk to the clinician.

 

Other Prescription Medications Sometimes Used to Aid Sleep

There are instances when individual physicians may elect to utilize other classes of medications to serve as an aid to sleep. For instance, some physicians utilize certain antidepressant medications as a method of addressing sleep problems. (Bonnet, Arand) Because this is the case, it is always advisable to verify the purposes behind any prescription that is being taken by a client in order to avoid a misdiagnosis based upon the medications being prescribed.

Additionally, there is a prescription medication called Ramelteon that is sometime prescribed for sleep onset problems. This medication is a melatonin receptor agonist, and it works in a way that is very similar to the effects of melatonin supplements, by facilitating an increase in the uptake of melatonin in the receptor sites in which melatonin operates. (Medline, NIH) There are potential side-effects with this medication that are not noted with melatonin, including rare but serious problems swallowing or breathing, and some problems with fertility and menstruation for women. (Medline, NIH)

The next section will be oriented towards addressing some of the errors in understanding and distortions in thinking related to sleep and sleep problems.

 

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