Disrupted sleep can lead to a host of issues, including fatigue, irritability, cognitive impairment, and even weight gain.
Oh no. You’re awake again! Why, though? You were so tired when you went to bed. Did some noise disturb you?
Was it that gin and tonic or late heavy meal? The pneumatic snores of your partner (or even neighbour!)? Or is this just the new normal? A maddening habit you’ve dropped into?
To quote George, a retired colonel and all-round decent man:
“Getting to sleep is not the problem. It’s staying there that’s driving me insane!”
When it comes to delayed sleep onset, there are many ways to help clients overcome insomnia. But nighttime waking can be a whole different ball game.
Nighttime waking can happen once, twice, or multiple times over the course of the night. Some interruptions are a natural part of the sleep cycle: waking up now and then in the night is no big deal, and most of us do it. But frequent or disruptive awakenings can steal daytime wellbeing and energy.
Continual big-time sleep interruptions can drive us mad. Almost literally.
For those, like George, struggling with persistent nighttime awakenings, the issue may be multifaceted. So understanding the nature of this problem and the potential underlying causes is crucial for therapists seeking to help clients address their sleep difficulties.
Here I want to properly define the problem, explore potential causes, and offer you strategies to help clients reclaim their (uninterrupted) sleep.
Defining the problem: The challenge of nighttime waking
Nighttime waking refers to waking up during the night, typically several hours after falling asleep. George would typically awaken at 3 am after dozing off around 11 pm. He’d maybe slip back into sleep at 4, but then awaken at 5 and struggle to get back to ‘proper’ sleep after that.
Intermittent nighttime awakeners (INTAs – and don’t bother googling that, I just made it up!) may wake at the same time each night, wake frequently and be unable to fall back asleep, or keep falling asleep and waking up repeatedly.
Of course, as you know, sleep plays a critical role in maintaining mental1 and physical2 health, and disrupted sleep can lead to a host of issues, including fatigue, irritability, cognitive impairment,3 and even weight gain.4
Daytime struggling
Clients who struggle with nighttime awakenings may report feeling exhausted in the morning, having trouble focusing during the day, or feeling anxious about their inability to sleep through the night. Addressing the problem not only enhances the quality of sleep but also significantly improves overall quality of life.
When George began sleeping through again, he told me he felt reborn – and his wife was happier too; he was no longer “driving her mad!” Solving sleep issues can have a profound and transformative effect on our clients’ lives. But before we get to what we can do to help, we need to know why sleep disruption happens in the first place.
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Possible causes of nighttime waking
Understanding the underlying causes of nighttime waking is essential if we are to find effective solutions. There are several possible factors, ranging from physical conditions to lifestyle habits, that can contribute to this problem.
Often nighttime waking resolves itself, but when it doesn’t, clients can start to feel plagued by it.
So what are the most common causes?
Cause one: Health conditions and illnesses
Various health issues can interfere with sleep, causing us to wake during the night. Conditions such as sleep apnoea (which can be a symptom of overweight), acid reflux, asthma, and chronic pain can lead to frequent awakenings.
Sleep apnoea, for instance, involves intermittent pauses in breathing, which can jolt a person awake as they struggle to catch their breath. Similarly, conditions like heartburn or an itchy rash can disrupt even deep sleep.
In the case of an overactive bladder, the muscles of the bladder start to tighten even when there isn’t much urine in the bladder, leading the sufferer to wake with a feeling of needing to urinate. This tends to happen as we age but might also be due to too much caffeine or alcohol, especially late in the day.
A chronic lack of physical or even mental exercise can also cause us to crave stimulation at night. If, by the time we go to bed, we haven’t ‘used up’ our physical and mental energy, we may feel restless. In addition to the direct impact this can have on sleep, it can also lead us to seek out activities (such as scrolling online, watching TV, or even just lying there worrying) that stimulate us even more.
What to do
Ask your client about their general health. Are they taking meds? Have they been checked out medically? What is their health history?
If your client finds themselves frequently needing to urinate overnight, Robb Wolf’s tip on taking a quarter teaspoon of salt with a tiny amount of water (to help the body hold onto liquid and reduce the need to urinate) may be very useful – though you may want to run this by your doctor, especially if there are any health conditions at play or if your diet is already high in sodium.5
My client George found this tip particularly useful. He also began to lose a little weight and found his nighttime breathing improved (his wife said he’d stopped snoring).
But sometimes it’s what’s on someone’s mind that begins to rip at the fabric of sleep’s sweet vestment.
Cause two: Anxiety and troublesome emotions
Anxiety, depression, and general stress (an inability to properly ‘switch off’) can all spoil sleep quality. This makes sense if we think of worrying as a stimulant like caffeine, which keeps us alert and prepared for physical threat. Why do I say physical?
Anxiety may cause individuals to wake up in the middle of the night, with racing thoughts and troublesome emotions preventing them from returning to sleep.
In fact, not just worry but all emotions, barring perhaps deep contentment, have a way of making us pay attention to them like restless children.
Pay me attention… now!!
We can think of emotions as pests, or perhaps, to be kinder to our feelings, signals, which tug away at your client, sometimes preventing them from sleeping, sometimes trying to jolt them awake once they are asleep. It’s as if they are yelling at us: “Give me attention now!”
If you’ve ever gone to bed angry, you’ll know what a stimulant that feeling is. But any stressful feeling does the same thing: it aims to keep us focused.
Social media in particular is designed to keep us emotionally focused, which is why it’s a great idea to get off our screens an hour or two before bedtime. It’s as if our emotions need to settle down to sleep.
But while our daytime feelings prevent us from sleeping, they also tear away at our sleep. For example, post-traumatic stress disorder may cause flashbacks and can happen even as we sleep in the form of nightmares, which can sometimes be so horrific that they catapult us back into wakefulness.
Depression may cause your client to awaken in the wee small hours too, and for a very particular reason.
Cause three: Depression and rumination
Rumination – negatively reflecting – is a misuse of the imagination. (This mechanism is also utilized constructively during therapeutic hypnosis.) And as I’m sure you know, rumination is the hallmark of depression.
Depression often results in early morning awakenings, where individuals find themselves unable to fall back asleep, even if they initially had no trouble drifting off.
It’s long been known that depressed people dream more, whether they recall those dreams or not.
This is because depressed people build up so many unresolved emotional expectations through time spent negatively ruminating that the brain tries to ‘flush out’ these expectations metaphorically. But overdreaming can exhaust the system, so to speak, leading to exhaustion upon awakening. This can be likened to running down a battery of energy and motivation. Often depressed people feel at their worst just when they have to get out of bed.
A natural way to correct this overdreaming and therefore exhaustion – and thereby, hopefully, lift the depression – may be for the depressed person to awaken during the early hours, when we tend to dream the most.
Unfortunately, when this happens the depressed person may misuse that time to negatively introspect even more, so that the brain needs to overdream the next night… and so on!
What to do
First, find out: What troubles your client?
Do they have a history of emotional distress? What are their biggest concerns and worries? And how can you help them solve those problems, either in practical ways (perhaps by becoming more assertive with other people) or by helping them feel less bothered by them (perhaps through cognitive and emotional reframing).
Second, check for unmet emotional needs.
Unmet needs, either emotional or physical, cause us to go into ‘hunt mode’: We go to bed still ‘seeking’ something from our environment that has not been provided for us. And when needs remain chronically unmet, we feel unsafe.
So to help deal with nighttime wakings, it’s important to deal with any unresolved trauma, effectively treat depression, and/or just help mitigate any niggling worries.
Teach mindfulness and self-hypnosis to your clients so that if they do awaken in the night, they can quickly drift off back to sleep. In this way, their emotional mind will soon learn that there is nothing to be gained from awakening in the night and will start to just sleep through.
Cause four: Consuming passions
Diet and stimulant intake are crucial considerations as well. Consuming caffeine, nicotine, or heavy meals close to bedtime can significantly affect sleep, making it harder to stay asleep throughout the night.
Although alcohol may initially induce sleep, it often leads to fragmented rest as the body processes it.
And certain medications, such as antihistamines or stimulants, can interfere with sleep by causing drowsiness or restlessness. People should be mindful of the side effects of their medications, as they may contribute to nighttime awakenings.
So all of this needs to be checked out. You might have to use behavioural interventions with your client to help moderate or change unhelpful behavioural patterns.
Other possible causes
As people age, various factors can disrupt their sleep patterns, leading to more fragmented and less restorative rest. For example, perimenopause brings hormonal fluctuations that may cause hot flashes or night sweats, causing frequent wakings.
Older adults may experience reduced melatonin production, further impacting their ability to stay asleep.
You might have to consider environmental factors, too. Noise from traffic, neighbours, or household members can make it difficult to remain asleep, while extreme temperatures, poor air quality, or light exposure may also disturb slumber.
Of course, having a new baby (or an older child, for that matter!) can also repeatedly tear away at sleep. Some life periods simply need time to shift!
So, bringing all this together, to help our clients we need to:
- Encourage them to address any underlying physical health issues.
- Help address any emotional problems and help them meet their emotional and physical needs better during the day so they can stop ‘seeking’ at night. This can include teaching specific skills such as mindfulness and self-hypnosis.
- Help them change any unwanted behavioural patterns.
- And, of course, we should also help them improve their sleep hygiene (all the behaviours that promote sleep, both before and at bedtime preparation).
Impaired sleep can be horrendous for our clients. After all, not letting someone sleep is a recognized form of torture! So when you help your clients sleep through soundly, it’s like a new life for them.
That’s what George told me, anyway.
The Most Effective Insomnia Cure?
Whether you’re using it for yourself or your clients, the most effective insomnia cure I know of is hypnosis. Because hypnosis involves deep relaxation and naturally parallels the REM stage of sleep, it can quickly interrupt even long-established patterns of sleeplessness. To learn how to use hypnosis in your practice, take a look at Mark’s online course Uncommon Hypnotherapy.
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About Mark Tyrrell
Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.
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Notes:
- Columbia University Department of Psychology (2022, March 16). How sleep deprivation impacts mental health.
- Colten, H. R., & Altevogt, B. M. (2006). Extent and health consequences of chronic sleep loss and sleep disorders. In: Sleep disorders and sleep deprivation: An unmet public health problem (pp 55–135). Washington, DC: Institute of Medicine of the National Academies.
- John G. McCoy, J. G., & Strecker, R. E. (2011). The cognitive cost of sleep lost. Neurobiology of Learning and Memory, 96(4): 564–582
- Patel, S. R., & Hu, F. B. (2008). Short sleep duration and weight gain: A systematic review. Obesity, 16(3): 643–653.
- Jessica (n.d.) Managing your health during forced time at home… Robb Wolf.
- Check out this fascinating interview with Joe Griffin, who first proposed the expectation theory of dreaming: Kiser, B. (2003). Interview with Joe Griffin – the dreamcatcher. clinical-depression.co.uk.
