In this blog, we have discussed the mental health underpinnings of chronic insomnia, including two very important psychological issues that may need to be addressed. One post discussed the pervasive problem of time monitoring behavior and another two posts discussed the less common but severe problem of losing sleep over losing sleep. In the two-part post, we also described the seriousness of this condition (Part 1, Part 2).
Treatment-wise, we delved into the use of strategies such as sleep hygiene and cognitive-behavioral therapy (CBT-I) and how these two approaches must be properly sequenced to decrease insomnia instead of aggravating the condition. We also looked at deeper emotional and spiritual connections to insomnia by examining the potential value of prayer, gratitude and forgiveness in the treatment of unwanted episodes of sleepiness. Finally, we have delved into the difficulties in tapering off sleeping pills.
In my book Sound Sleep, Sound Mind, I often talk about an overarching theme in which it appears some insomnia patients actually do not want to go to sleep despite their sincere protests to the contrary. Just recently, we saw a patient who fit this mold perfectly, and I thought it would be instructive to describe the conversation that ensued.
The patient had been attempting PAP therapy for a few months with limited success, often using it no more than 1 to 2 hours per night and sometimes not at all. This individual had used CPAP in the past, but when this individual qualified for ASV at our center, the response was described as noticeably more comfortable. Nonetheless, PAP usage never attained a high level, and the patient presented in clinic with a great deal of frustration and disappointment. In fact, there was no longer any optimism PAP therapy was going to work.
Once we informed the patient a break was needed from the PAP due to the obvious development of negative conditioning directed at the machine, we turned our attention to the insomnia. Remarkably, the patient reported going to bed most nights at midnight and lying awake anywhere from 4 to 5 hours “trying” to go to sleep. We ascertained what trying to go to sleep meant. The response was “lots of tossing and turning” and “just trying” to go to sleep.
Notice at this point, we could have easily explained that trying to go to sleep rarely proves effective, and we could have further discussed how she was developing a negative conditioning towards her bed and bedroom not dissimilar to the negative conditioning to the PAP device. Instead, however, we asked the question, “what prevents you from going to sleep?” to which the reply was, “my mind is racing and I can’t turn it off.” The next question is the one that has the potential to be the most revealing, and in this case provided the segue to move into a deeper realm of psychology, one in which in our experience better explains insomnia in ways sometimes more valuable than the more standard but narrowed conditioning formula.
We asked, “what are you thinking about?” The patient immediately replied, “I think about what I was doing at work today and how it could or should have been better.” I asked for a brief expansion of this information, and the reply went into some detail on the mundane aspects of administrative and clinical work being done at a medical clinic job site and how it could be improved upon. Now, with this new information and a few more questions, it was obvious the patient was describing a degree of frustration and disappointment with work. I then asked the patient to consider an odd theory about these experiences that might better explain the insomnia in ways probably not previously discussed in prior encounters with other doctors or nurses.
I said, “Let’s ask the question of whether or not the real reason you do not go to sleep at night is that you actually do not want to go to sleep.” The patient replied, “but I do want to go to sleep; that’s why I am trying so hard to do so.” I then replied, “let’s stick with this idea as a theory for now. I don’t want you to buy into it because I say so. Let’s walk through your experiences to see if there might be a grain of truth in the idea that you actually do not want to go to sleep.”
The patient remained receptive, so I asked, “why would you be spending this time at night thinking about making your workday experiences better?” The individual paused briefly, “you mean, why do I want them to be better?” I said, “no, I am asking what feelings or emotions are prompting you to think about improving your work performance.” The patient replied, “oh, well, I’m frustrated and disappointed that I am not doing a better job.”
We were getting close to the “ah-ha!” moment, so I launched into what I call the philosophical aspects of psychology and its relationship to insomnia. “Let me describe for you something about how the human spirit likes to engage itself on a daily basis. People seek to create or produce things. This drive to do something and accomplish something is innate, and it is one of the most critical components of how people find meaning and purpose in their lives. In fact, these ideas are so valid that if you conducted an experiment that removed someone’s sense of accomplishment or limited their capacity to create or produce things during the day (say, by making them do nothing during the day), chances would be astronomical insomnia would soon develop.”
“If we cannot achieve some sense of satisfaction or contentment with what we have accomplished, created, or produced during waking hours, then it is not unusual to want to fix this problem, because no matter what level of awareness a person may experience about this lack of fulfillment at the day’s end, this dissatisfaction drives the individual to fix the problem. And, at bedtime, there is no seemingly saner or simpler way of doing so than to try to fix it in your mind. Thinking about the day in your mind appears to be an easy and ready-made fix, despite the fact it rarely works. Still, humans are more than capable of repeating behaviors incessantly that do not provide the results they were hoping for.”
“In your mind, you are attempting to build this satisfaction by making an effort to repair the deficiency experienced in your daytime efforts. Unfortunately, your accounting of the daytime actions and efforts may or may not be accurate. You may have done a great deal, but for some reason you did not perceive it as such. Or, maybe your perceptions were accurate. No matter, either way you FELT like something was inadequate, unsatisfying or unresolved from the daytime, so the need arose to recover the day just as soon as you climbed into bed.
“Thus, racing thoughts in the bed at night are the signal you are suffering from unfinished business or unresolved emotions (usually both) about that day’s events. In effect, your day is not done! In such circumstances, it is nearly impossible to let yourself fall asleep, and many people in this situation resort to sleep aids.”
At this point, the patient fully understood the nature of the problem and realized there would be no further point to lying in bed, tossing and turning, and prolonging the racing thoughts. The discussion swiftly turned to getting up out of bed and finding some activity that might provide a small degree of satisfaction, which would then allow for sleepiness to return, after which the patient could hop back into bed.
In discussing what to do during the interval awake, we delved into a variety of tasks that can create satisfaction without necessarily over-stimulating oneself to the point of staying up all night. Some of the most common ones including writing in a journal, household chores, laundry, and working on hobby, like making jewelry. Things that involve the use of hands (a more active approach) are better than things like watching television (a more passive approach). Even a video game has the benefit of using your hands. The goal of course is to only perform the task for a duration of about 30 to 90 minutes with the intended effect of the return of sleepiness.
In contrast, if you videotaped six episodes of your favorite cliffhanger television soap opera or suspense thriller, you can imagine how you might get hooked into watching too many episodes and staying awake too long. Notice, however, this approach may still provide some degree of emotional release and therefore satisfaction, as might any great movie, but the timing is not right to go down this path. The more active approach of using your hands, even sitting down with pen and paper to write up lists of things you need to accomplish in the coming weeks or months, that is, planning behavior, will produce the sense of accomplishment.
In closing, notice how all the above discussion naturally led to the individual recognizing the major cognitive-behavioral instructions to not lie awake in bed, to restrict time in bed to increase sleep pressure, and to realize it makes no sense to try to sleep when one is not sleepy even though these points were not the initial therapy focus. CBT-I is a very potent form of insomnia treatment, but many patients may find it difficult to fully understand or apply the steps upon first hearing about this technique. On the other hand, with the emotion-focused approach we will explain to the patient that insomnia begins first thing in the morning, shortly after awakening, because if you conduct your daily business and activities without gaining a sense of satisfaction, it will no longer surprise you to suffer from insomnia at night.
When insomnia patients put all this information together, it sometimes proves more appealing and realistic to hear about the emotional connections first instead of following strict CBT-I instructions that may or may not seem like a comprehensive approach. In fact, CBT-I is comprehensive for an individual who can follow the rules carefully. But, there are many patients who complain they tried CBT-I, but it did not work. Often, these are the patients who needed to hear what underlies the problem of racing thoughts, namely, the issues we described of how daily living might be unsatisfying, which often lead to insomnia. By knowing this key point, which we call, “the day is not done!” then, many insomniacs more naturally align with the CBT-I instructions even if they do not call it CBT-I or recognize it as CBT-I instructions.