Healthy Sleep Practices
Discuss with the client principles of “sleep hygiene” – provide the link between good hygiene = good health and poorer hygiene = poorer health. Explain that you will be looking to find those helpful practices that they can use before going to bed, supporting restful sleep. Explore with the client their thoughts and attitudes that may be contributing to poor sleep.
It is assumed that you have also considered (and potentially referred) the client to talk with their doctor about possible underlying medical reasons for their sleep disturbance. These may include thyroid irregularities or side effects from medications. Other conditions, such as persistent pain may not be eliminated from a medical perspective, but it is useful to understand what that condition is and how it has been treated or managed. Finally, consider whether other services or treatments might support relaxation, such as massage, yoga or simply walking regularly. Adopting a multidisciplinary approach to an underlying problem is always going to support better outcomes for the client.
Ask them to undertake a sleep diary to monitor their thoughts and behaviours in the hours before they sleep, what their sleep is like and to better understand what is working for them and where they may be having difficulty. Sleep diaries can seem tedious to a client, however, they can highlight patterns in behaviours or thoughts that impact sleep that hadn’t been considered by the client. Performing chain or functional analysis on identified points from their diary can help to link sleep quality with other difficulties in their life.
Ensure you are aware of the theoretical considerations in the association between sleep disturbance and suicide. Of note, the duration of sleep disturbance is also very important. Offering psychoeducation to the client on the why they should improve their sleep (as if they didn’t already want to!) and emphasise that small changes can build to create lasting results – support motivation and engagement.
We recommend the following points to emphasis the value of improved sleep quality;
- Improved mood; reducing the impact of feeling down or anxious
- Enhanced cognitive functioning; concentration, memory, attention and general thought processes
- Improved physiological functioning; including heart functioning and metabolism
- Overall sense of wellbeing; giving the body time to rest and recover from the day’s stresses
Work with the client to revise their sleep routine, based on the sleep diary and their thoughts from the chain analysis. Focus on developing those skills that will enhance relaxation and ultimately sleep.
Other helpful sleep practices to discuss include;
Do’s of good sleep
- Go to bed at the same time each night, when you can
- Get out of bed at the same time each day, when you can
- Set up some standard routines in your day, for example, get up at 7am, go to work by 9am, eat dinner by 6pm, get into bed by 10pm
- Make sure you sleep in a bed! Avoid napping on the couch!
- Make your bedroom restful; make it as dark as you can, if you need some sound, make it soothing and set for only five minutes while you relax into your sleep
- Ensure your bedding is practical and your sleep attire is too! If you are prone to get hot/sweat, ensure you have layers that are easily stripped back. Wear clothes you can’t get tangled in.
- Only use your bed for sleeping (and sex)
- Read boring and otherwise un-engaging material; those articles or stories you know you fall asleep to
- Practice meditation, relaxation and breathing exercises before bed
- Establish a bed time ritual (see the example below)
- Follow your doctor’s advice on medications assisting with sleep; try to minimise dependence
- Exercise regularly (until you are puffing and/or sweating) in the morning
- Drink non-caffeinated beverages before bed
Mindfulness apps are also useful, such as Smiling Mind, where there are meditations designed to support sleep.
If shift work or work rosters contribute to sleep disturbance, encourage the client (advocate for them) to discuss their workplaces fatigue management strategies with the workforce. Review policies and entitlements, request ‘reasonable adjustments’ to their work if they think their wellbeing or sleep is likely to pose a hazard to others.
- Don’t nap during the day. If you have to, limit it to under 20 minutes. Napping disrupts your natural sleep rhythms
- Don’t watch TV in bed, don’t play energetic music or have bright lights in your room and STOP!! playing on your iphone, ipad or other electronic gadget! Make your bedroom a screen free zone!
- Don’t drink alcohol or smoke cigarettes (or illicit substances) before bed (or work towards this). These may seem to help in the short term but in the long term, they disrupt natural sleep rhythms.
- Don’t do heavy exercise at least 6 hours before bed. Exercise is fantastic at boosting sleep processes if it is done in the morning.
- Don’t go to bed hungry or over full
- Avoid stimulants; over the counter (energy drinks), prescribed (as in some cough medicines) and illicit substances (like Speed or amphetamine). They can cause chronic sleep problems by disrupting our brain chemistry
- Don’t regularly let pets (or children if you can help it) sleep in your bed if they also have disrupted sleep cycles or wake you with their fussing.
An example sleep routine
Explain with the client that a sleep routine should start well before they intend on going to sleep. It involves training (or retraining) our brain to prepare for rest. This occurs by regularly and consistently giving your body and brain cues to say; “go to sleep”. Provide examples that the client can relate to, to hone this point. An example you may like to use could be when a baby is born, we teach them how to sleep, offering clear physical and behavioural cues that support them recognise the time to sleep; after dinner comes a bath, a warm drink, a story and bed.
For adults, we introduce cue’s from dinner time and use as many as needed to help build connections and associations that support sleep. If you’ve never done this, just try it for 6 weeks to see the difference! Start the routine earlier or later, depending on your family or life commitments.
6.30pm: Prepare dinner, enjoy positive, lifting music (turn off the News that may report worrying items)
7:00pm: Eat dinner; ideally keep it light, fulfilling and healthy, but refrain from eating until you are uncomfortable or overly full. Make the dinner time clean up, a ritual preparing yourself for a new day. Visualise and become mindful of a preparing positively for the day ahead.
7.45pm If you are a worrier; write a list of things worrying you. Order the list into three columns:
1. To Do Tomorrow 2. To Do this week 3. It’s out of my control
For column 1 and 2, note anything extra you need to assist you in working on it by taking a systematic approach to problem solving. For all those things on column 3, adopt a “it’s out of my control so why focus on it?” attitude. This is hard to do but letting go of those worries you have no control over is a key to restful sleeping.
8:00pm: Take a shower or a bath; visualise washing the day’s stressors from your body and mind. Even if you shower twice a day until you get into a good sleep pattern, this is an excellent de-stressor which is specifically done to boost relaxation
8.20pm: Introduce breathing exercises and mindfulness strategies for at least ten minutes; Find a quiet space; the corner of your bedroom or lounge room, where you will not be interrupted. Watch how you breathe and making sure you are taking regular, gently moderated breaths that can support the development of a calm mind and thoughts. Feel the air going into your lungs, the gentle movement of your stomach in and out and visualise the air flow.
8.30pm:Progressive muscle relaxation or isometric muscle exercises; tensing and releasing your muscles from your toes to your head is a physical way of reminding your body how to relax. Sometimes our muscles forget the “relaxed” position and we remain tense without these reminders
8.45pm: Do your regular lock up rituals; check the doors, close the blinds, put your purse/wallet away – what ever you usually do before you go to bed
9:00pm: Read a very uninteresting article, boring book or mundane magazine. You don’t want to stimulate your mind; you want to calm it, so look to read up on those subjects you know will send you to sleep!
9.30pm: Drink a warm glass of milk, decaffeinated tea or water. Get into bed and practice reflecting on those things that have brought you joy in your life. Think of something that makes you feel loved, safe or secure and focus on the positive feelings. Allow yourself to drift to sleep.
- If your experiences persistent/chronic pain, engage with their doctor and discuss their recommendations on treating the pain before it becomes too distracting; the use of analgesics under the guidance of a pain physician (using them sparingly improves other aspects of life), use hot packs, cold packs or what is effective in alleviating the pain before getting into bed. Consult with an Occupational Therapist (or similar clinician) on modifications to their bed, including wedges that support movement or positions, and use pacing and exercise to foster increased strength to reduce pain. In some cases, clients may never have discussed their pain with their doctor, or the doctors recommendations have been very short sighted or passive. See our other articles on the relationship between persistent pain and suicide to understand the importance of this risk factor in treatment also.
- If the client can’t fall asleep after 20 minutes to half an hour (and they say they are ‘wide awake’), suggest they get up and do a household chore (iron a shirt, sweep the floor or make a cup of tea). Then start the routine again, including having a shower. The process of “training” the mind to sleep is made easier when the cues are repeatedly paired.
- If their sleep is disturbed by nightmares, pain or other problems and it has been like that for a long time, this may be the subject of more intensive therapy or interventions with their doctor or a psychologist/counsellor. Getting good sleep is a foundation for good mental health.