Some strategies seem so simple it’s hard to believe they can make a much of a difference. I have spent a month trying to get insight into what it might be like for my clients with insomnia when I ask them to use CBT to improve their sleep patterns. The plan was to reset my sleep schedule by getting up at the same time everyday, and by not spending time in bed when not sleeping. If you think something that simple shouldn’t work, you’d be right. Because it’s not simple. It’s really, really hard.
It took me three days to be absolutely confident about what was wrong with my sleep pattern. It took me three weeks to feel like I was making progress. It took me two days to undo the previous three weeks.
Let me start at the beginning.
A bad day's when I lie in bed, and think of things that might have been Throughout my life, all significant and lasting changes to my sleep patterns have been dictated by schedules set by others. I can’t think of a single example where I have successfully modified my sleeping patterns to incorporate a cosmetic change in lifestyle. I have certainly planned to. I recall a detailed plan to start my primary school days with piano practice, a plan complete with a written rationale about how it would be more beneficial than leaving it until after school (something tells me I didn’t fall into CBT by mistake). I can’t count how many times a morning exercise plan has suffered Death By Snooze Button, although I do know it’s only marginally more than the number of times I’ve failed to write a novel one early morning hour at a time. Whatever grand plans I make, my waking time has always reverted back to roughly one hour before I need to leave to be somewhere.
I have naturally tended towards the night owl end of the spectrum. I suspect this is less an innate biological rhythm than a product of my love for things being quiet. Not all noise bothers me, just human noise. More specifically, individual human noise. I can handle traffic at 3am, but not someone stopping to chat on their phone outside my window. The clatter of a restaurant is no problem; the guy at the next table eating with his mouth open is a completely different story. When I was ten years old I threw out my twin brother’s donut because he was eating it too close to my ear, and I would do the same again if he dared to repeat that misdemeanour today. This is starting to sound like the rationale for a whole different experiment.
Basically, I sleep late wherever possible so that I can capitalise on the silence of the witching hours. As a child it wasn’t until my siblings were asleep that I could get my best reading done (protected by a blanket dome because, while I loved the silence, I was not particularly cool with the dark, and perhaps more importantly, it was an effective way of hiding my Baby-sitters Club books – I know, so Claudia). At uni I scheduled in the latest possible lectures and studied until 3 or 4am, and nowadays I plan most of my social activities for weekend daytime, so that I don’t waste too many optimum book-reading and movie-watching hours on human interaction.
Until a few years ago, I had never really thought about sleep as anything other than something I do when I do. If I wasn’t sleeping, I would read until I needed to sleep, and then I would go to sleep. I would think of it as having not slept because I stayed up reading, rather than as reading because I couldn’t sleep.
This attitude shifted five years ago, when I found myself desperately tired most days and unable to get to sleep three or four nights out of the week. It was so foreign to me that I immediately went to see a doctor, thinking there must be something seriously wrong with me. I’d always had a dainty little issue with snoring and I decided that whatever was causing the pretty melodious teeny tiny snoring problem was also now stopping me from getting good quality sleep. The doctor agreed. He sent me to a specialist who put a tiny camera in my nose and also agreed. The specialist told me that I would need surgery that my health insurance didn’t cover, and suddenly I decided it was worth reviewing whether there might be another cause.
Here’s what I came up with. Five days a week I was working on my doctoral thesis, using my previously winning formula of working during the quiet evening hours and sleeping in late. Two days a week I was getting up at 5:30am to get the train to my job in a neighbouring city. I would try to go to bed early on the nights when I needed to be up early, but wouldn’t be able to sleep because of having slept late that morning. When I got back from work I was so knackered that I would try to catch up on sleep, often staying in bed for 10 or 11 hours, and then waking up sluggish from having been asleep so long, and therefore feeling like even that wasn’t enough sleep, then staying in bed to rest a little longer. On top of that, during my doctorate I was so overwhelmed by the volume of academic literature that I’d stopped reading for pleasure. Instead of lying in bed reading, I was now lying in bed thinking about how awful my sleep was and glorifying my pre-doctorate years.
I realised that I could test this theory by switching to getting up at 5:30 every day and see if a routine sleep pattern resolved the sleeplessness and fatigue. I decided to put up with the sleeplessness and fatigue instead. Even though I didn’t fix the problem, once I’d made the decision not to, I stopped worrying about it. Everything seemed infinitely more manageable.
The information's unavailable to the mortal man Since then, I’ve not often worried about my sleep, but when I do it rapidly escalates. My non-CBT solution to this is to avoid thinking about it, which means I am not likely to notice when I am not making the wisest of sleep choices. Not thinking about sleep means not having to worry about it, and also not having to admit to making unwise choices in my life. I don’t know about you, but given the unconscious choice, I would rather feel wise than unwise. I wouldn’t mess with that unless I had a really good reason to. A good reason like, say, committing publicly to messing with it.
Filling in the sleep diary for the first night of my “baseline phase”, I saw immediately that I had made an unwise sleep decision that night. The second night it seemed like it might be a pattern. The third night confirmed it. The fourth night was just along for the ride. The problem should have already been obvious, but until I wrote it down I was happily ignoring it. My baseline sleep diary shows the time spent in bed with a thin line and the block represents the time I was asleep. The dotted red line is the time I was supposed to be at work on three out of four of those days. You see my problem.
Let me just start by saying that this is the first and last you will hear about the second step in the experiment, not spending time in bed when not sleeping. This technique is recommended for people who spend more than about 10% of their time in bed doing something other than sleeping (like worrying, working, watching TV). Lower “sleep efficiency” means that your body associates the bed with these other activities, making it physiologically more difficult to fall and stay asleep. My sleep efficiency was over 90% most days because I didn’t get into bed until I was really tired. In the interest of understanding what this task is like for people, I tried once to get up to read in another room when I wasn’t sleeping, and I ended up cold, angry and unable to concentrate. I will never again recommend this to a client unless his or her sleep diary clearly shows that this is very likely to be part of the problem. I’m sorry everyone. I get it now.
Believe we’re gliding down the highway when in fact we’re sleep sliding away The experimental phase involved setting a waking time that I would stick to until it felt like a routine. I usually tell my clients that it could take up to two weeks before it stops feeling like hard work, and up to six weeks for your body to completely reset and settle into the new sleep schedule. Because I don’t consider myself to have a sleep problem, I thought it would take maybe a week to adjust. I don’t know where on earth I got the idea that I was somehow immune to biological reality.
The first morning I woke with my alarm at 7:30 as planned. My sleepy brain did its usual routine of suggesting that I could sleep a little longer and still make it to work on time, that extra sleep was more valuable than extra time to get ready, that I wouldn’t get through the day on the night’s sleep I had. It even threw a new one into the rotation especially for the occasion, telling me that it would be better to wait to start the experiment on the weekend, or maybe Monday. It’s not often my sleepy brain actually plans ahead. I looked to my rational brain to hear its counter argument. As it turned out my rational brain was still asleep. About 30 seconds later, so was I.
Fortunately, I awoke shortly after at 7:45 to the London Alarm Clock, the stirring of the baby elephants living upstairs. As I got out of bed, both brains were in rare agreement: today had not started well. From then on I set three alarms at varying distances from the bed and scattered post-its around my room reminding me of my cause.
Over the following week, I kept waiting for the day where I would wake up ready to leap out of bed delighted to start the day. It simply never arrived. Each morning, the alarm forcefully dragged me from a much happier place. I was getting up as planned, but all the while thinking that you would have to be hoping for some remarkable benefits from it to bother putting yourself through this.
She came a long way, just to explain I was hating my alarm and hating my experiment and hating myself for putting me through this, so much so that I hadn’t noticed that I was getting some remarkable benefits from it. I didn’t notice this until after the second of my sleep deprivation experiments (which I will talk about in more detail in Part III). Following a discernible lack of sleep, I was prompted to check in on how I was feeling, an attempt to find a more tangible reason to feel sorry for myself. I scanned the usual sleep deprivation haunts: eyelids, jaw, shoulders, head. I found… nothing. Nothing to justify how grumpy I was feeling about having hauled myself out of bed, nothing to suggest I was deprived of anything. I was just a little bit tired. That’s it. And weirdly, feeling tired seemed somehow foreign to me.
When I thought back over the weeks of the experiment, the immediate, automatic thoughts were all focused on what it had been like to wake up to an alarm I wasn’t allowed to snooze on. When I took the time to reflect over what else had happened in that time, I realised that I couldn’t remember a single day where I’d felt unbearably tired or irritable. I couldn’t think of any recent examples of triple coffee mornings, of pretending to collect something off the printer just to escape the loudest typing on the planet, of crossing the road because I saw someone approaching who may or may not be going to town on chewing gum. Maybe there hadn’t been any such examples, or maybe I hadn’t remembered them – either way it’s a result.
Something strange happened in the final week. My body started telling me when to go to bed. Not just “oh it’s bedtime, better start getting ready”, but actually telling me I needed to go to sleep, immediately. And then, I had a couple of days where I woke before my alarm. When I needed the alarm, even when I hated the alarm, I was able to get up straight away without having to think about it. Something shifted and my body learnt that it no longer required limb by limb instructions for how to progress from landscape to portrait. Waking up didn’t feel like a habit, but getting up did. I just did it because that’s what I do at 7:30.
Two days after the three-week experiment I ran a marathon after 5 hours’ sleep. About a week after that I returned to the routine.
Then I got a cold. A few days after that I returned to the routine.
And then I slept through my alarm. A couple of days after that I returned to the routine…
You know what? It’s hard to believe that something that can make such a difference can seem so simple.
© Cognitive Behave Yourself, 2013, except for the bits written by Paul Simon. I hope he doesn’t mind. 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.