A few years ago, I interviewed on the east coast for a graduate program in psychology. The combination of earlier time zone, unfamiliar bed, and nerves had kept me up all night. At the interview, I struck up a conversation with a current graduate student who studied sleep and insomnia, and told him about my experience.
“I hate not being able to sleep. I kept checking the clock and wondering how much sleep I would be able to squeeze in before the interview.”
“What if it were okay not to sleep?” he asked me. “What if you accepted that sleep might not happen for you?”
Huh? This made zero sense. Getting sleep is infinitely better than not sleeping. When I don’t sleep, I’m easily frustrated, moody, and lethargic. I usually get a headache that worsens during the day, and all I can think about is how much better I would feel if I had slept. How could I accept that something vital to my well-being was something I could do without?
At the time, the rare sleepless night was my only experience with insomnia. But throughout last year, as I struggled to write a dissertation proposal, sleeplessness became a more consistent companion. One sleepless night a month turned into one sleepless night a week, plus fitful sleep the other nights.
I could not quiet my mind: I was sure I was going to fail to write the dissertation and flunk out of my graduate program. As I lay awake in bed, I constantly monitored for signs I was falling asleep, and as a result, often jerked myself back to consciousness once it registered I might be drifting off.
Getting to sleep was maddening. I could feel my blood pressure rise when I walked in the bedroom. The clock taunted me, reminding me of how little darkness was left before the alarm would order me out of bed. I vacilated between anger and despair. There was no condition under which sleep was guaranteed, no trick that would send me off to sleep. Worse, I would get myself so worked up about sleep that I made sleep even more unattainable.
So, in typical psych student fashion, I dove into the research on insomnia. I already knew about sleep hygiene, which has been defined by Stepanski and Wyatt as specific behaviors that can improve quantity and quality of sleep. Sleep hygiene is seen as an important part of insomnia treatment. Stepanski and Wyatt detail basic sleep hygiene recommendations:
- Curtail time in bed.
- Never try to sleep.
- Eliminate the bedroom clock.
- Exercise in the late afternoon or early evening.
- Avoid coffee, alcohol, and nicotine.
- Regularize the bedtime.
- Eat a light bedtime snack.
- Explore napping.
- Monitor use of PRN hypnotics.
Already, I was doing things wrong. I tried hard to sleep. The bedroom clock was my constant companion. Exercise was hit or miss. Bedtime was whenever I was “done for the day,” which, if you’re a grad student (or working professional, or just plain responsible for feeding and clothing yourself or others in modern society) is an arbitrary line in the sand that gets drawn when you’re too tired to squeeze anything else in.
I set my morning alarm when I got home from school, then covered the clock so I couldn’t see its red, glaring face at bedtime. I cut myself off from schoolwork in the evening to give my brain space to “cool down” for the night. I tried exercising during the day to tucker myself out and walking in the sunlight to nudge my circadian rhythm toward sleepiness at night. I established a nighttime routine: drink herbal tea, listen to classical music, then take a shower or bath. I even bought lavender oil to scent my bathwater because I heard it was a relaxing, sleepy-time scent.
But sleep hygiene alone wasn’t enough. Even when I started to make progress on my dissertation, my fears about getting to sleep persisted. The insomnia had taken on a life of its own: just getting to sleep was causing enough anxiety to keep me up at night.
I talked to my doctor, who prescribed me a mild sleep aid. Though it helped, my sleep anxiety was well-rooted, and I had a hard time sleeping even with medicine. I was also not willing to consider stronger medication until I had exhausted every behavioral option I had. So I dug deeper into the sleep literature.
A 2006 review of the psychological and behavioral treatment of insomnia suggested five non-pharmacological interventions met APA criteria as “well-established” treatments: Stimulus control, Cognitive Behavioral Therapy (CBT), relaxation, paradoxical intention, and sleep restriction.
Stimulus control is a behavioral approach that builds on principles of conditioning. Remember Pavlov’s dogs, who had been trained to associate the sound of a bell with dinner time, and as a result, drooled when they heard the bell ring? Because of some of my poor sleep hygiene habits, I had accidentally conditioned myself to feel frustrated in bed. I first felt frustrated when I could not sleep, but gradually began to associate that anger with the place where I felt frustrated: my bed. And anger + bed ≠ sleep.
Stimulus control works by trying to re-condition the bedroom and bedtime to be a calm, non-frustrating experience. The idea is this: only go to bed when sleepy. Not tired, but sleepy, which is what you feel when you have a hard time keeping your eyes open. If after 20 minutes or so, you still are not asleep, get up and go somewhere else to do a relaxing activity, like read. The idea is to get out of bed before you feel frustrated and try to avoid feeling frustrated at all. (New association: sleepy + bed, not anger + bed.) Bed is a place for sleep and sex. That’s it. Nothing else but those two activities should be associated with the bedroom.
The hard part of stimulus control has to do with the maintaining a regular circadian rhythm. Regardless of how much sleep you got (or didn’t) or how deeply you slept, you are supposed to get up at the same time in the morning no matter what. Oh, and no napping.
Humans have a biological drive for sleep, and the less sleep we get, the more we crave sleep. Napping and sleeping in reduces our need for sleep at night, and to get back into a regular rhythm, we want the drive for sleep to be revved at night. Which means no sleeping unless during sanctioned times. And no frustration if sleep doesn’t come.
So: no napping, no sleeping in, and no frustration when sleep doesn’t come. Insert eye roll here. I tried to adhere to the rules, and usually my schedule prevented napping or sleeping in, but on days when I finally got to sleep at 4:00, 5:00, or 6:00 AM, peeling myself out of bed with a smile on my face was a tall order.
And not feeling frustrated? While sleep hygiene and stimulus control helped somewhat, I still had long, miserable nights without sleep. Generally, I felt more relaxed leading up to bedtime, and somewhat less frustrated in bed (because I wasn’t staying in bed when frustrated), but I was absolutely angry and desperate while trying to keep my cool in my living room. In the wee hours of the morning, I constantly wondered whether I could salvage the wreck of my day before it began.
I still had to “get my mind right,” and I had no clue how to do it.
Next week: Making Insomnia a Superpower–Part 2
This blog is not intended to represent medical or psychological advice. What works for me may not work for you. Please consult your doctor and/or licensed mental healthcare provider when making decisions that can affect your physical and mental health.
Psychology Today has a great blog series on Cognitive Behavioral Therapy for Insomnia which explains CBT for insomnia, cognitive restructuring, sleep hygiene, stimulus control, and sleep restriction. I link to parts 1, 2, 3, 4, 5 here for ease of reference, but you can find the same links in related content in Parts 1 and 2.
Part 2 will be posted by June 8, 2015.