Body. Mind. Where does one begin and one end?
In my office I see this every day: people who feel in their bodies that something is not well with their psyche. This is extremely common in anxiety and depression, the “common colds” seen daily in psychological practice. Hearts racing, stomachs churning, shortness of breath and sometimes even vomiting and diarrhea are typical of anxiety and panic disorders, whereas appetite issues, sleep disturbances and fatigue are quite common features of mood disorders such as depression. In this blog I will let the spotlight shine on sleep disturbances and some interventions used to treat it.
I am one of those extremely lucky people who can count on one hand the nights I have had trouble sleeping. By the time my head hits the pillow I am already half asleep, and I only wake up with the sound of the alarm clock the next morning. So – even though I cannot really show true empathy and understanding when a client complains of insomnia – I do feel a deep sense of sympathy as it would be utterly awful to me to not have spent my 8+ hours in the Land of Nod! Not sleeping well makes us cranky, tired, a bit slow at times and just not feeling bright-eyed and bushy-tailed enough to tackle our daily challenges.
Insomnia – which I find a beautiful word, by the way – can be pretty ugly. Whether it is initial insomnia (struggling to fall asleep), maintenance insomnia (waking up in the night and then having trouble getting back to sleep) or waking up too early, insomnia can be a hard monster to fight. Especially since fighting it actually feeds it by making you more awake!
There is a song by the South African artists Koos Kombuis and Valiant Swart titled “Insomnia”. For those who don’t mind some foreign linguistics in their music, you can find it here:
Musically and in terms of lyrics the song probably isn’t the best, but oh, does it capture the tone, frustration and relentlessness of staring at the ceiling at night well! Have a listen even if it is purely for entertainment value!
The first 30 seconds of the song is just the ticking of a clock… followed by some dissonant repetitive guitar chords… followed by some really funny bits about waking up in a cold sweat, having had too many pork chops the night before, counting up to two million sheep, being shoved around by massive feelings of depression, anxiety and guilt, and a bizarre willingness to pay a ridiculous price for just 5 minutes of good REM sleep… and the chorus: Insomnia… you are the overture forming the backdrop to my hours ticking by… insomnia… I am awake and there is no rest for me… insomnia…
Sleeplessness can be the result of a plethora of things: medical conditions, older age, pregnancy, side effects of medication, disrupted circadian rhythms due to shift work, anxiety, worry, depression, vivid dreams… The main question for me as a therapist is: Is there anything we can do to make it better?
My usual avenues of intervention might look something like this:
Avenue 1: Figure out if anything can change in the domain of sleep hygiene. (Isn’t this a funny term!? I can’t use it without laughing; it always makes me think my doona cover and pillow case need a tumble in the washing machine!) This is not what it refers to though – “sleep hygiene” focuses on making the whole ritual around bedtime as “clean” as possible. Typical suggestions would be to stick to a certain ritual and time around going to sleep, making sure the room is dark and quiet enough, ensuring screen time is limited in the hour before bedtime and that the phone and laptop are completely switched off during the night, that one limits food and liquid intake in the hours before bedtime, that the temperature in the room is ok, and disturbances minimised. Often getting up at a set time – regardless of how poorly you slept – also helps as this disrupts that terrible cycle of having had a poor night’s sleep, sleeping in till 11am and then not being tired enough to go to bed at a decent time again. Upping exercise and getting more fresh air are usually also encouraged.
Avenue 2: Untangle the feelings and thoughts that run through your head whilst awake at night. In other words: what is the insomnia about? Is it guilt? Shame? Traumatic memories? Anxiety about what the next day might hold? Financial worries? Relationship worries? Anxiety about not being able to sleep? If we can pinpoint what the line of thought is in our hours of insomnia, it might help us get to the heart of the issue that we need to talk about.
In traditional CBT (Cognitive behavioural therapy) we would then try and identify unhelpful and circular thinking patterns (e.g. “I said something to someone today that wasn’t right… she will think I am a terrible person for saying that… I am terrible person for having said that… I can never look her in the eye again…” or “I will not do well in tomorrow’s interview… they will probably ask questions I haven’t prepared for… I am probably not the best person for the job anyway… is there any way I can get out of this interview… I am so anxious that I will definitely mess it up anyway…why can’t I sleep? I need to be rested for the interview!”) Of course, these are not really the type of thoughts that will lull you to sleep. On the contrary – worrying puts our minds in a state of alertness rather than rest.
Therefore the psychotherapeutic intervention would entail trying to find some strategies that will interrupt the flow of these thoughts, either by normalising and reframing some of the fears, or by helping the client to be aware of the self-sabotaging nature of the thoughts and teach some distraction techniques. The main idea is that we cannot think of two things at the exact same time. So: if I am actively thinking of something else or concentrating my attention on something else (e.g. a breathing exercise) then the flow of worrisome thoughts would at least be interrupted even if not ceased. Evaluating our thoughts against the following two questions are often beneficial to curb cyclical insomniatic thinking: (a) Is this thought really true? And (b) Is this thought helpful in getting me where I want to be? Even just having the skill of stepping “outside” of the thought for a minute to reflect on these two questions is often the only thing needed to break the hold of the thought. Taking it one step further is even better: replacing the not-true, not-helpful thoughts with ones that are more true and helpful (e.g. “I feel that I have said something hurtful to another person today, and even if she wasn’t very affected by it or did not notice it, I will still call her tomorrow and apologise to get it off my chest” or “Even though I feel I might not be the best person for the job, I will go into this interview giving it my best shot, even without a good night’s rest, and if I don’t get the job, I can live with that too”).
Avenue 3: In the ACT (Acceptance and Commitment therapy) model the focus will not be so much on changing dysfunctional thinking patterns, but rather to “grow around” or “make room” for depressive and anxious thoughts. Two metaphors that often illustrate this well are the following: (a) the idea of our thoughts coming and going like waves in the ocean (there is no point in fighting the waves’ motion; we are actually better off watching, acknowledging and not getting too attached or tied up in the thoughts), and the idea of a bus stopping at a bus stop for a minute, people getting off and on, and then driving away, maybe to come back again at some point, but not clogging up the traffic, as it is not stuck but comes and goes. Often allowing ourselves the kind of insomniatic thoughts that are the “overture to the nightly ticking hours” makes us drop the struggle… which paradoxically can lead to falling asleep more easily. Additionally, the reframing often means that we step away from the concept of insomnia as the enemy or the monster, but rather acknowledge, accept and “befriend” it. Then, when it is one of those nights, we do not fret so much about the insomnia that it actually prevents us from sleeping.
Avenue 4: If the client identifies disturbing dreams as the main reason for insomnia I would add another angle here. In line with the ACT model we would again try and disarm the vivid dreaming by not seeing it as something to fear, but as a way our body and psyche digest and heal from important emotional threads from our days. These dreams are like helpful messengers from within, often highlighting to us what it is we are struggling with, and often even providing solutions. It is often beneficial to look at what the dream is telling the client, and why the content is so disturbing that it leads to ongoing insomnia. My all-time favourite psychology writer Irvin Yalom describes the “dream weaver” very imaginatively:
“Following Freud, I often imagined the dream weaver as a plump, jovial homunculus, living the good life amidst a forest of dendrites and axons. He sleeps by day, but at night, reclining on a cushion of buzzing synapses, he drinks honeyed nectar and lazily spins out dream sequences for his host…”
(Momma and the Meaning of Life, 1999, p. 87)
In my next blog I hope to get myself and you better acquainted with this dream weaver, as I believe giving dreams a place in therapy often creates significant moments of insight for the client. For now, I will wrap this up, as it is getting late… and the Sandman is knocking on my door.
Felix & Sage Psychology