“Let me just check that I’ve understood you correctly. You’re telling me that you’re not getting enough sleep, you’re hitting snooze a lot because you’ve not slept enough, having to drag yourself out of bed because you didn’t get enough sleep, you’re generally late to work, and then once you get there you’re tired most of the time on account of all that sleep you’re not getting? You know what I think you need? Let’s cut back a little on your sleep.”
1. Get out of bed at the same time every day, regardless of how well you slept.
2. Do not stay in bed if you are not sleeping.
That’s right, I ask people with sleeping problems to stop trying to catch up on desperately needed sleep and to spend less time in bed. A lot of people. And for some mysterious reason, most of them are not particularly keen on the idea.
How hard can it be?
I know I’m not the only one who’s had something outside my control has disrupt my sleep. A loud noise or a dream waking me up, jetlag, a problem to be solved before bed, or maybe a stressful few weeks where my body just won’t quite properly switch off – any number of circumstances can result in the torment of having to start the day feeling like I’m ready for bed.
When I wake up tired, it’s hard to remember what alert feels like. Chirpy people appear to be the smug beholders of some protected secret, or dirty liars trying to trick me into believing the whole world doesn’t feel the same way. All my instincts are geared toward preservation – get more sleep however I can. Of course, instincts don’t always go hand in hand with life. Life doesn’t know I’m sleep deprived.
On days like this I don’t feel I have much of a choice, or at least the choice is not complicated: I can get all the sleep I need, when I feel I need it, or I can keep my job and earn my money and pay my rent and eat my food. So I get up. Or rather, I calculate the last possible minute I can stay in bed until while still getting to work at a time that won’t raise anyone’s attention, and then I get up. I go to work. I do my job. I drink coffee. Sometimes the whole day will feel like it takes quadruple energy, other days pass with only the occasional fleeting reminder of how I felt that morning. What’s the one time I am guaranteed to remember what happened last night? Just as I’m about to go sleep again.
Sleepy brain: “HEY, remember last night and how crap your sleep was? REMEMBER THAT? Imagine how awful it would be if that happened again tonight. IMAGINE IT. You’d be SO TIRED tomorrow if that happened again. Today was tough for you, wasn’t it? Poor thing. Oh man, I bet you’re worried about it happening AGAIN. Because that would be SO hard to cope with. Yep. You really don’t want that. Sleep tight. Don’t let the bed bugs bite. Imagine if you had bed bugs. Are you itchy? Bed bugs would suck big time. Sweet dreams.”
And thus begins the cycle of insomnia.
It’s not one bad night that brings people to CBT, it’s the relentless pattern that they have been struggling to break. There are any number of things that can kick-start a sleeping problem, and a few key ones that tend to keep it going: a sleep schedule that’s completely out of whack, spending lots of time in bed when not sleeping, and worrying about sleep. For some lucky folks it might not take long before things escalate to the full clusterfuss of all three:
The good news is that the cycle can be broken. The bad news is that breaking the cycle will make me feel worse. The good news is that eventually I will start feeling better. The bad news is that to a sleepy brain, “eventually” is not much of an incentive.
If I were thinking rationally first thing in the morning (which I’m not), I would reason that getting up at my normal time will keep my sleep schedule on track so that my body will know roughly when it’s supposed to be asleep and when it’s supposed to be awake. I would reason that sleeping in is like getting all the horrors of jetlag without any of the perks. I would reason that I can actually function after the occasional bad night, or at least that those occasional nights are less disruptive than the consequences of an irregular sleep routine. I might also tell myself that if my body really needs to catch up on sleep, then the following night it will either remind me to go to bed a little earlier, or send me into deeper sleep to make up for it.
My rational, CBT-trained brain knows that the number of hours of sleep I have might not always be as important as maintaining the quality of my sleep. We get the best quality sleep when there is the most pressure to go to sleep. Pressure to sleep comes two main factors: our daily sleep/wake cycle and the amount of time since we last slept.
For most people, the sleep/wake cycle increases pressure to sleep as it gets later at night, decreases towards the morning, and then increases and decreases again sometime in the mid-afternoon. The decrease in the morning is the “second wave” one gets on an all-nighter, back when such things were remotely possible. The increase in the afternoon is when the fundraising chocolates at the reception desk take in their biggest earnings. The sleep/wake cycle works best when we have a regular sleep routine and when we get a little bit of exposure to sunlight every day. It just does.
The other source of pressure to sleep is pretty much a straight line increasing with the amount of time since waking up. After a good night’s sleep, waking up might reset that to zero, but after a rough night it might start a few notches higher. Mitigating factors aside (e.g. light, noise, stress), it’s easier to fall asleep – and we get better quality sleep – if we go to bed when both lines are higher.
That means, rationally speaking, sleeping in can reduce my pressure to sleep the following night, making it harder to fall asleep and possibly reducing the quality of my sleep. If I’m struggling to get to sleep the next night, I’ll probably worry more, which will make it even harder. So, rationally speaking, I should just get up at my normal time.
Unfortunately, my sleepy brain is an idiot. My sleepy brain is trying to conserve energy. You know what takes energy? Being rational.
This means that when I treat sleep problems with CBT, I am asking people to do something that requires a lot of energy when they feel they have little energy to spare. I am asking them to go against their primal instincts, to fight their inbuilt urge to sleep when tired. Then I am asking them to stick with it, even though it is making them feel worse.
I just don’t understand why people would be so reluctant to try this technique.
- What is it like to force yourself out of bed, before you’re ready to get up, when you don’t have anything in particular you have to be up for?
- What’s it like to do this every day?
- Does it eventually get easier?
- Can I really cope on just a few hours’ sleep?
I want to find out the answers to these questions so that I can better understand how much I am asking of my clients with insomnia. Before I change anything, I am going to keep a sleep diary to get a baseline recording of my waking time and the number of hours I sleep each night. Using that, I will set myself a new time to wake up and then force myself to get up straight away. No snooze button allowed.
I want to know what it’s like to deliberately reduce the amount of sleep I’m getting. If I don’t get that experience from the initial phase of the experiment, then I will restrict the amount of time I spend in bed so as to temporarily deprive myself of sleep. (A genuine technique I use in therapy. Now that I think about it, why does anyone come back, ever?)
© Cognitive Behave Yourself, 2013. Excerpts and links may be used, provided that full credit is given to Jane Gregory with a link to the original material. For CBT in North-West London please visit hampsteadcbt.com.