When treating insomnia I always start with the basics. So on this occasion I was rather embarrassed when I realized that I hadn’t yet asked my client a very important question.
“What do you do when you can’t sleep?” I asked Karen.
She looked back at me wearily: “I get up and make myself a nice hot cup of tea. Then if I still can’t sleep I’ll get up and have another one.”
Being a therapist is a little like being a detective sometimes. Just then, I have to admit, I was more Inspector Clouseau than Sherlock Holmes. When people can’t sleep there are always reasons. Before we can hope to treat insomnia, we need to check out why sleep may have gone bad for the exhausted soul in front of us.
Sleep is essential for emotional health
We all need sleep… let’s rephrase that! – we all need quality sleep. According to the National Sleep Foundation, people who have sleep problems are more likely to go on to develop psychiatric problems than people who sleep well. No surprises there. Furthermore, chronic insomnia can impact health by compromising the immune system.
The right make up of sleep (around 25% REM sleep to 75% slow wave sleep) stabilizes the workings of neurotransmitters in the brain which determine mood and motivation and emotional stability during the day. Sleep is a central pillar on which your mental and physical health rests.
Whatever a client comes to see me for, even if it isn’t specifically for insomnia treatment, I’ll ask about their sleep patterns, because good sleep is so central to human health and happiness.
But what questions should we ask? Obviously, whether they are getting up to drink tea… but what else?
How to treat insomnia: 3 questions it’s vital to ask
1) Check their wind down routine
During the millions of years of human development before we got electric light, our daily light cycle didn’t just go from bright light to pitch dark in a flash. Light levels eased slowly into shadow, dusk and darkness, stimulating production of melatonin, the brain’s ‘sleep hormone’. The dim flickering of a cave fire wouldn’t have provided much light.
People who are watching bright scenes on TV or sitting with their noses up against a bright computer monitor just before bedtime may find that these activities set their natural wind down pattern back by hours.
Find out what, exactly, your client is doing in the hours before bedtime?
TV is a stimulant. Alcohol can get people off to sleep but spoil its quality and wakes them up in the night. Too much noise before bedtime puts the brain on high alert.
Check for and ask about all these things. Karen usually watched TV before trying to sleep, and we decided to change her routine so that she read a physical book (not a digital one) in a hot bath for half an hour before she went to bed.
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2) Ask about their cave
Okay, it’s not a ‘cave’, it’s their bedroom, but still!
Is it quiet, cosy, overly warm, too cold?
Can they hear those sexually enthusiastic neighbours all night, or those wide awake Heavy Metal aficionados down the street?
Is their bedroom dark enough (recent research suggests even the smallest amount of light interferes with melatonin production and therefore sleep quality)?
Karen said her room was cosy and dark, and she couldn’t hear anything that was keeping her awake.
“It’s a nice room – it’s both my office and my bedroom,” she told me when I asked her to describe it.
That was another important clue – Karen and I discussed whether having her work desk with all its papers and memos was keeping her mind on her business worries, priming her to feel alert and not relaxed.
Here’s another factor: Do they tend to get cold feet? It’s not just a metaphor – cold extremities will prevent sleep onset because, for the shift into sleep to occur, core body temperature needs to cool relative to the extremities. One way to do this is to artificially warm up the feet, which tends to make us feel sleepy.
So it can help to invest in some air conditioning or woolly socks to warm the feet to get them sleepy (and feeling like an altogether different species to those wild fast-living energetic neighbours).
3) Ask about their concerns
Worry is just as much a stimulant as caffeine – worse, in fact. We evolved to stress when in danger so that we wouldn’t lose alertness while the danger lasted. If your brain registers a threat in the environment, even if that threat is generated by your own mind, then you won’t sleep until your brain registers the environment as less threatening.
So, asking about worries and when they do their worrying and helping your client solve those worries will have a massive benefit on how soon they fall asleep and the quality of their sleep once they do drift off. (1)
Of course there are other things to check for, such as medication side effects and whether physical pain keeps them up at night.
Also, poor sleep may have just become a habit – in which case rearranging the furniture or even sleeping in another room may change the pattern enough for sleep to re-establish itself.
Karen wound up moving her bed into a different room and using that exclusively for relaxation and sleep. We addressed the things she was worried about, but as her sleep improved, she noticed a change in her thinking.
“It’s funny,” she said to me after a week of sleeping well, “how I still have the same work deadlines and family pressures, but now everything seems so much more manageable. Those worries seem so much smaller.”
In our fast-paced culture, we may not always acknowledge it but it’s certainly true – we all need to sleep, and sleep well.
Insomnia is often a feature of depression. Learn about our structured approach to treating depression here.
- It’s been known since the 1950s, for example, that depressed people, who worry continually, dream up to three times as much as normal (thus throwing the proper make-up of sleep completely out of kilter) and awaken exhausted even after many hours sleep.
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