SLEEP BASICS Cognitive Behavioral Sleep Interventions

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SLEEP BASICS Cognitive Behavioral Sleep
Interventions

• Caron Treatment Centers
• Stephen M. Lange, Ph.D., ABSNP

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Basic Principles

• We have a 24 hour sleep-wake cycle.
• We have greater control over how we spend our
  daytime hours than our sleep hours.
• We cannot have sleep problems we can have
  problems with our sleep-wake cycle.
• Our sleep quality tonight is shaped by how we
  spend our day.
• Sleep can improve by attention to the B-A-S-I-C
  I-H.

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Basic Principles, Continued

• Sleep is an essential, life sustaining activity.
• Purposes of sleep may include repair of body
  systems, energy conservation, memory
  consolidation, brain development, discharge of
  emotions (NIH, 2003).
• Fatigue and sleep deprivation are relapse
  triggers (Think HALT).
• Sleep is mediated by an internal timing mechanism
  called the Superchiasmatic Nucleus in the
  Hypothalamus.
• Sleep is also mediated by environmental cues,
  especially natural daylight.

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Remember This?

• Here comes the sun, do do do do Here comes the
  sun, and I say It's all right Little darling
  The smiles returning to the faces Little
  darling It seems like years since it's been here
  
• Lyrics by George Harrison, recorded by The
  Beatles

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Basic Principles, III

• Sleep depends on urge to sleep and
  parasympathetic nervous system activity
  (relaxation response).
• Activation of the sympathetic nervous system
  (fight or flight response) inhibits sleep.
• Ways in which patients respond to insomnia, such
  as laying in bed awake, worrying about sleepiness
  and deficits the next day, using their beds for
  mental work can condition a sympathetic response
  to bedtime, perpetuating insomnia.
• We need to teach patients to replace ineffective
  responses to insomnia, such as napping, caffeine
  abuse, worrying, with a relaxation response.

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B-A-S-I-C I-H(An Idea of Dr. Arnie Lazarus)

• B Behaviors
• A Affect (Emotions)
• S Sensations
• I Imagery
• C Cognitions (Thoughts)
• I Interpersonal
• H Health

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Sleep Quality

• Sleep Architecture refers to how we progress
  through the five stages of sleep throughout the
  night. This is not something we have much control
  over.
• Sleep Duration is the number of hours of sleep
  within a nighttime.
• Restorative Sleep is sleep that helps us feel
  rested and alert during the daytime.
• Latency of sleep onset refers to how long it
  takes to fall asleep.

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Sleep Therapy Goals

• Increasing sleep duration is not a well-selected
  goal.
• It is more important to wake rested and to feel
  alert during the daytime than to have a magic
  number of hours of sleep.
• Sleep duration is highly personal and while there
  are averages at different ages, there is no
  magic, universal sleep duration.

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Sleep Therapy Goals, II

• Avoid using decreasing sleep onset latency as a
  sleep goal.
• Can set a difficult standard for individuals who
  are very anxious or who are perfectionists.
• Can lead to frustration when progress is not
  perceived.

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Sleep Therapy Goals, III

• The best sleep goals are
• Increase daytime alertness.
• Increase feeling rested in the morning.
• Improve habits that are sleep promoting.
• Develop realistic expectations about sleep.
• Decrease frustration surrounding sleep.
• Improve understanding of sleep and especially how
  much an individual can affect their sleep
  quality.
• Understand sleep problems as relapse triggers.

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Basic Psycho-education

• Patients need to know that drugs and alcohol
  directly affect sleep architecture, leading to
  sleep that is shallow. Dreaming may be disturbed
  or absent. Patients may think that they have not
  slept at all, and they may wake up feeling tired.
• As a result of the cumulative disturbance of
  sleep architecture, patients enter their first
  weeks of sobriety feeling exhausted with a
  literal sleep debt.
• Additionally, when dreaming has been disrupted
  during active addiction, patients may have a REM
  rebound.

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Basic Psycho-education

• Alcohol, Benzodiazepines, and Opioids can
  exacerbate sleep apnea leading to excessive
  drowsiness, hypertension, death rates.
• Other drug effects that influence patients sense
  of physical and emotional wellbeing include pain
  perception. Patients generally, and those who
  used opiods and alcohol particularly, have
  exaggerated pain perception in the first 4- 6
  weeks following their last use.

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Basic Psycho-education

• It may take 4-6 weeks before these effects wear
  off, and patients with tolerance and withdrawal
  will take the longest. Some patients will take
  much, much longer. Some patients will never
  return to their baseline sleep.
• Help patients realize that current sleep problems
  are likely to improve with time. There is a core
  of acceptance and surrender involved with this
  process.

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Basic Psycho-education

• Unmanageability refers to the chaos between our
  patients and their worlds, and also the chaos
  within physical, emotional and spiritual.
• Without conveying callousness or disregard for
  our patients pain, think about how we can use
  the physical and emotional chaos around
  sleeplessness and fatigue as metaphor.
• First Step includes the acceptance of the world
  as it is, and our powerlessness over much of our
  world, even our interior worlds. Surrender also
  means that we have to accept our bodies
  schedules for healing, and not try to impose our
  wills on our bodies.

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Did You Know?

• Question How many times are the words sleep or
  sleeping mentioned in the Big Book?
• A. 12
• B. 43
• C. 192
• D. 31

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Did You Know?

• Question How many times are the words sleep or
  sleeping mentioned in the Big Book?
• A. 12
• B. 43
• C. 192
• D. 31

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Basic Psycho-education

• Coming to inpatient treatment involves loss on
  many, many levels loss of the (inaccurate!)
  perception of autonomy, loss of social status,
  loss of the familiar, separation from people and
  even pets. We also lose our sleep environments.
  As a child, my favorite sleep environment was my
  grandmothers NYC apartment, with city sounds of
  sirens, delivery trucks, couples walking, the
  elevated train on Northern Boulevard, Queens.
• Just like we have in Wernersville, PA!

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Basic Psycho-education

• At night,we relax our ego defenses, those mental
  tools we use to inhibit affect and impulses.
  While we may be able to work through struggles
  during the day, at night conflicts (internal and
  external), anger, sadness, worry can flood
  through.
• Even though we can have very sleepless nights as
  a result, our nighttime demons are wonderfully
  informative about the emotions we bottle up. It
  hurts less when we use this information!
• If we are sleepless is this part of our moral
  inventory?

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Remember this?

• In the wee small hours of the morning
• While the whole wide world is fast asleep
• You lie awake thinking
• Song lyrics by Bob Hilliard recorded by Frank
  Sinatra and by Carly Simon

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Basic Psycho-education

• Sleep hygiene refers to the way we manage our
  activity level throughout the day and night.
  Humans are diurnal animals. Unlike the nocturnal
  bats, we hunt during the day and sleep at
  night.
• In active addiction, people live the bat
  schedule. It takes work to return to the human
  schedule.
• As all teenagers know (and most ignore),
  deviating from sleep patterns over a weekend can
  result in disrupted sleep for days afterward
  imagine years of abnormal sleep! Said another
  way, if a single jet flight can disrupt your
  circadian rhythms for a week, imagine the
  cumulative effect of years of disrupted
  schedules.

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Basic Psycho-education

• Even though sleep and the surrender aspect of
  First Step are so intimately related, we have
  power over our recovery choices. It is possible
  for patients to feel hopeful about improvements
  in sleep as they practice recovery habits.
• For most individuals with insomnia, it is not
  necessary to take a pill to sleep. In fact,
  behavior change outperforms sleep medications
  whenever research studies compare the two types
  of therapies.

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Used with permission by the cartoonistgroup.com.
The cartoonist is Darrin Bell.
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Using the B-A-S-I-C I-H

• Behaviors can be sleep promoting or sleep
  killers.
• Daytime sleep is the biggest single sleep killer.
  The single most effective sleep intervention is
  daytime sleep restriction. Sleepiness is a drive
  state, like hunger and thirst. Daytime sleep
  reduces the urge to sleep at night just like a
  snack can ruin your supper.
• Sleep promoting (recovery) behaviors during the
  day include waking up at the same time each day,
  moderate physical exercise, daytime sunlight,
  staying intellectually and emotionally engaged.
• Intervention During the day, what do you do to
  keep yourself, awake, alert, active?

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Using the B-A-S-I-C I-H

• Behaviors in the evening and at night that
  promote sleep include Winding down in the
  evening hours, bathing or showering, having a
  nighttime ritual or routine, listening to quiet
  or calming music, and getting up from bed if
  sleep onset latency is greater than 20 minutes.
• Nighttime sleep killers include laying in bed
  awake if sleep onset is delayed, exercise late in
  the evening, using bed for activities other than
  sleep.
• Intervention What do you do to prepare for
  sleep, starting around dinner time?

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Using the B-A-S-I-C I-H

• Affect regulation is an important skill for
  sleep. Going to sleep angry, sad, frustrated,
  anxious is a sleep killer.
• Affect regulation skills can include Progressive
  Muscle Relaxation, meditation, journaling, prayer
  and Bible reading, practicing gratitude.
• Intervention Teach PMR, meditation,
  diaphragmatic breathing.
• Intervention Discuss approaches to self-soothing
  and affect regulation that already fit into the
  patients personality and recovery skills.

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Using the B-A-S-I-C I-H

• Sensation refers to the six senses Vision,
  hearing, touch, smell, taste, and position in
  space.
• Patients should think about what makes them
  comfortable in bed.
• Stimulus Control refers to creating a good sleep
  environment.
• A slightly cool room is preferable for most
  people.
• Progressive Muscle Relaxation, Yoga, or
  stretching can help with body sensations of
  muscle tension.
• Intervention Discuss what aspects of stimulus
  control patients can use in treatment.

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Using the B-A-S-I-C I-H

• Imagery can be useful for some patients
• Patients with significant trauma symptoms or
  psychosis should not use guided imagery.
• Imagery uses the imagination to escape to a
  mental scene which is peaceful and calming.
• Intervention Consult with psychology staff about
  the use of imagery with any individual patient.
  If appropriate, teach use of imagery.

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Using the B-A-S-I-C I-H

• Cognitions refer to thoughts that are sleep
  killers.
• A bad case of the I can't!
• Unreasonable sleep expectations.
• The single most harmful sleep cognition is, I
  will never sleep!
• Worries of the day including those about money,
  family, aftercare, etc. all affect sleep.
  Meditation including especially Breath Awareness
  can help with intrusive, repetitive thoughts or
  worries.
• If my sleep is disturbed, am I wrestling with or
  resisting change? How come the Big Book stories
  all seem to include the line, That night I
  slept after the authors achieve First Step or
  spiritual connection?
• Intervention What do you think about at night
  when you lay in bed?

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Using the B-A-S-I-C I-H

• Interpersonal factors can contribute to sleep.
• Do I need to resolve a dispute?
• Do I need to make amends?
• Do I need to turn over a problem to my Higher
  Power?
• Intervention Do you ever have thoughts, images,
  worries, dreams about conflicts with other people
  at night? Do you replay scenes with other people
  when you try to go to sleep? What does that say
  about moral inventory and amends?

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Using the B-A-S-I-C I-H

• Health behaviors affect sleep
• Three scheduled, healthy meals and two healthy
  snacks help regulate BG.
• Sugar and caffeine at night are sleep killers.
  Think about hidden sugar in cereals and juices.
• Salty foods stimulate thirst which can interfere
  with sleep.
• Nicotine is a psychostimulant. If smoking calms
  you down, then what you are experiencing between
  smokes is withdrawal!
• Craving management and sleep.
• Intervention What do you eat at night?

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Using the B-A-S-I-C I-H

• Maintaining healthy body weight helps with sleep.
  Pushing air in and out of an obese body is more
  strenuous than breathing with a smaller body.
• Obesity can exacerbate sleep apnea.
• The bitter irony is that obesity can adversely
  affect sleep, and poor sleep can raise the risk
  for obesity.
• Intervention Fitness and wellness.

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PMR

• PMR stands for Progressive Muscle Relaxation
• A sense of relaxation is achieved by alternating
  tension and relaxation in muscle groups
• May be combined with guided imagery if
  appropriate

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Breath Awareness

• Using as many senses as possible to experience
  breathing
• A basic meditation skill
• Relaxing
• Promotes a detached awareness that helps regulate
  affect
• Daily mindfulness

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Diaphragmatic Breathing

• Breathing using the diaphragm at the base of the
  chest cavity
• Stretches muscles in the torso
• Deep breathing takes in more oxygen than shallow
  breathing
• Relaxing, calming activity

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Skills Practice

• Diaphragmatic Breathing
• PMR and Breath Awareness
• Gratitude Meditation

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Questions, Comments, Concerns?

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Additional Resources

• Getting a Good Nights Sleep by Nancy
  Foldvary-Schaefer
• How to Get a Great Nights Sleep by H. Valfi and
  Pamela Valfi
• Understanding Sleep by Mark R. Pressman and
  William C. Orr
• Sleep, Sleep Disorders and Biological Rhythms,
  NIH Publication No. 04-4989

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Whats New at Caron Treatment Centers

• Young Adult Female Program
• Follows many of the same treatment modalities as
  Carons highly successful Young Adult Male
  Program
• Focuses on core issues of chemical dependency
  that may face women ages 20-25
• Chronic Pain, Young Adult and Adolescent
  Assessment Programs
• Intensive 5-day programs designed specifically to
  rule in or rule out a diagnosis of chemical
  dependency
• Visit www.AssessMyFamily.org for more information
• Smoke/Tobacco Free Continuum of Care in
  Adolescent/Young Adult Facilities