Is Watching TV Before Bed Harmful For Sleep?

The third variable that I will be manipulating across a two week period to examine its impact on sleep is TV – specifically watching it in the last two hours before bedtime.

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how useful avoiding TV before bedtime is at helping people to improve their sleep.

jens-kreuter-85328

TV or bright screen usage is not something that I have been keeping track of this year, but the reason I want to study it is that I know that:

  1. A lot of people watch TV in the last two hours before bedtime.
  2. A lot of my clients say that it helps them to wind down before bedtime.
  3. I do not recommend using bright screens in the last two hours before bed.

I generally don’t include the TV in with other bright screen use, as computers, tablets and phones are usually closer to people’s eyes and therefore their light receptors than a TV is. It might still be having an impact, especially with how big some TVs are these days.

I also know that people who like to watch TV before bed probably aren’t going to stop this, especially if it has become a long engrained pattern. Surely we should see if it has a significant adverse impact on sleep before recommending that it needs to be cut out alongside the computer, tablet or phone usage.

The Experiment

markus-spiske-37931.jpg

To explore the impact of TV on sleep, I decided to once again be a little bit more extreme than I usually am.

For the first week I watched:

  • One hour of TV before bed on Sunday and Wednesday
  • One and a half hours of TV before bed on Tuesday and Friday
  • Two hours of TV before bed on Monday, Thursday and Saturday

For the second week, if I watched any TV, it had to wrap up at least 2 hours before bed. What this meant is that I had to be creative with what else I could do before bed that didn’t involve bright screens. This meant talking to my partner more, journalling, reading or meditating.

If you decide to try this at home and switch off your TV in the two hours before bed, just focus on doing something that isn’t too physically demanding or emotionally intense, as the key is to try to relax and lower your arousal levels, and then go to bed once you feel sleepy.

Other ideas that don’t involve bright screen time include playing board games or card games, playing a musical instrument or listening to music, colouring, drawing, painting, knitting, cross-stitching or any other hobby really.

The Outcome

episode-3-tv-sleep-diary

Comparison 1: No TV vs baseline data

With no TV in the last two hours before bed, my sleep efficiency was at 96.84%, 0.64% higher than the baseline data, but not as high as the no alcohol data and just below the no caffeine data. If you take out the Friday where I caught up with old friends and Saturday night where I went to a wedding, this increases to 97.7%, higher than no caffeine, but still not better than the week where I had no alcohol.

My time to get to sleep was nearly 2 minutes longer than baseline, but my time awake during the night was half of what it was during the baseline period, with awakenings only being recalled on the two nights that I’d consumed alcohol. My bedtime was still 17 minutes later than at baseline, but was earlier than all of the caffeine and alcohol data, and is positively trending in the right direction again. My time in bed was 2 minutes less than baseline, and I was getting out of bed 15 minutes later in the mornings.

My sleep quality was rated as a 4.29, equal to caffeine, better than alcohol and no caffeine, but not as good as the no alcohol data. Take out the last two nights where I did drink alcohol, and my sleep quality with no TV rises to a 4.8 – the best rating so far!

no-tv-bestno-tv-goodno-tv-2

Objectively, There were 3 nights where my sleep had a restful: light sleep ratio of more than 2:1, which is excellent. The Feb 21 Misfit data (20/2/17 on the sleep diary) was the best, with a substantial block of deep sleep and a ratio of 2.15:1.

no-tv-bad

The worst sleep was the Friday night, with a ratio of 0.75:1. More evidence that alcohol has a tremendous impact on objective sleep quality!

Comparison 2: TV vs No TV

Looking at the sleep diary data, I woke up 0.28 fewer times per night when I didn’t watch TV than when I did, went to bed 12 minutes earlier, fell asleep 3.57 min quicker, awoke for 1.43 minutes less, and had better sleep efficiency and subjective sleep quality.

I did sleep 7 minutes more per night on the week that I watched TV, but I was within the recommended 7-8 hours of sleep on both weeks.

I also spent 12 minutes less in bed and was able to get out of bed 24 minutes earlier in the week when I didn’t watch TV before bed.

By remaining away from the TV and other bright screens in that last two hours before sleep, my body clock (or circadian rhythm) really did seem to start to shift forward to an earlier sleep and rise time, which is really important for someone like me with a tendency towards having a delayed circadian phase.

tv-badtv-good

Objectively, even with watching 2 hours of TV before sleep my sleep wasn’t too bad. Like the no TV week, my worst night of sleep objectively was on Feb 18 (17/2/17 on the sleep diary), where I caught up with some volleyball friends for dinner and had some alcoholic drinks. My restful: light sleep ratio was 0.97:1 on this night – better than when I avoided TV the week after.

My best sleep objectively was Feb 13 (12/2/17 on the sleep diary), where I watched 1 hour of TV before bed. The restful: light sleep ratio on this night of 2.14:1 was nearly as good as my best night of the week with no TV. The 6 hours and 13 minutes of restful sleep that I obtained on this night were the most that I have had on any night this year!

IS AVOIDING TV BEFORE BED A GOOD SLEEP STRATEGY?

frank-okay-109313.jpg

EFFECTIVENESS

For me, yes. Not as useful as avoiding alcohol, but better than avoiding caffeine. It beat watching TV before bed on 7 out of the 9 categories that I measured on the sleep diary, so I give the effectiveness of this strategy a 19/25.

APPLICABILITY

For me, not watching TV was fun, as the other things that I did instead are more in line with my values and who I’d like to be, especially socializing, meditating and reading regularly. Journaling is good too, but I generally don’t recommend doing this in the last two hours before bed either for the challenging emotions that it may bring up at times.

For others, especially if their housemate or partner really enjoys watching TV together with them, I imagine that it would be a lot harder. I give the applicability of this strategy a 17/25, as I’m not saying that you have to stop watching TV altogether. Just not in the last two hours before you go to sleep.

SCIENCE

Data from Project Viva has found that for every 1 hour of increased TV viewing per day, a child’s sleep decreased by 7 minutes each night. Having a TV in their bedroom was even worse, and was associated with 8-31 minutes of less sleep per night (Cespedes et al., 2014).

Data from the GECKO Drench cohort has supported these findings and found that more televisions at home or in the bedroom led to more television watching for children, which was significantly associated with reduced sleep duration and higher BMI (Sijtsma, Koller, Sauer & Corpeleijn, 2015).

A systematic review by Hale and Guan (2015) found 67 studies that looked at the relationship between screen time and sleep in children and adolescents and found adverse sleep consequences in 90% of the studies. They did say that a causal link is not yet confirmed but recommended that we:

limit or reduce screen time exposure, especially before or during bedtime hours to minimise any harmful effects of screen time on sleep and well-being

— Hale and Guan (2015).

I’m still not sure if TV is less problematic than other bright screen use where the screens are closer to the eyes, but McIntyre and colleagues (1989) did find that more intense light exposure led to a higher suppression of melatonin. 1 hour of light exposure at midnight suppressed melatonin by 71% with 3,000 lux, 67% with 1,000 lux, 44% with 500 lux, 38% with 350 lux, and 16% with 200 lux (McIntyre, Norman, Burrows & Armstrong, 1989).

If you can download a lux meter app and then look at what it says where you usually sit to watch TV, it might give you an estimate of how problematic the behaviour is. Using the LightMeter App, sitting in my office with the lights on is 98 lux, and looking at the computer is 1287 lux. The TV reading would probably be somewhere in between.

I therefore give the science of this strategy a 33/50.

Overall, avoiding watching TV in the two hours before bed as a way to sleep better gets a score of 19/25 + 17/25 + 33/50 =

69/100: Credit

Watching TV for the 1-2 hours before going to sleep did mean that I went to bed later, took longer to fall asleep, woke up more during the night, spent more time awake during the night, and got out of bed later in the morning.

By avoiding TV and other bright screens in the last 2 hours, I was able to engage in other more beneficial activities that helped to reduce my arousal levels more. I also obtained 3 nights of sleep that objectively had a restful: light sleep ratio of more than 2:1 for the first time this year. It also seemed to help bring my body clock forward a bit, so that I was feeling sleepy earlier, getting to bed earlier and getting up at a more desirable time in the morning, which helped me to do more exercise before work and be more active during the day.

WHAT I RECOMMEND

I know that TV is enjoyable to watch for many people, but some data suggests that the more we watch, the less sleep we get. If you really want to watch your favourite show and it is within 2 hours of going to bed, go for it, just try not to make it a nightly habit. It would be even better if you could record your favourite late night programs and then watch them earlier the next day – that way you’d know that it won’t impact your sleep.

The 2016 Sleep Healthy Survey of Australian Adults showed that our sleep problems are 5-10% worse than they were in 2010, with 33 to 45% not sleeping enough or sleeping poorly. Of the 44% who surf the internet just before bed every night, the percentage of people having sleep difficulties climbs to nearly 60%.

Reading, meditation and even listening to music all have studies supporting their efficacy in reducing stress levels more than what watching TV does, and they all have the added benefit of not including bright light. Removing TV from bedrooms and pre-sleep routines are unlikely to be harmful and could be beneficial.

CONCLUSION

If you have sleep problems and watch TV before bed, it’s definitely a variable that is worth experimenting with. Try watching your average amount of TV one week, then switch it off in the last two hours the next week, and see what it does for you.

If nothing, at least you know that you don’t have to feel bad about watching TV pre-bed. If it is having an impact, surely it’s worth switching it off a bit earlier if it means better sleep for you and all of the other benefits that come with this.

Thanks for reading! If you would like a personalised sleep report and the five things that you could do to best improve your sleep, please check out our services.

Does Alcohol Reduce Sleep Quality?

The second variable that I will be manipulating across a two week period to examine its impact on sleep is alcohol.

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how effective avoiding alcohol is at helping people to improve their sleep.

quentin-dr-125010

If you look at my sleep diaries from the first four weeks of 2017 in the benefits of tracking your sleep and caffeine and sleep articles, I consumed alcohol on 5 out of the 28 nights, or 1.25 nights per week. If I were to continue at this frequency, it is unlikely that it would significantly disrupt my sleep, but there were two nights where I had more than two standard drinks, which isn’t recommended on a long-term basis.

Self-Assessment

If you are unsure if you are drinking at hazardous levels or not, please take a few seconds to fill out the following questionnaire. Known as the AUDIT (alcohol use disorders identification test), there are ten questions which contribute to your overall score:

  1. How often do you have a drink containing alcohol?
    • Never (0 points) – skip to question 9
    • Monthly or less (1 point)
    • Two to four times a month (2 points)
    • Two to three times a week (3 points)
    •  Four or more times a week (4 points)
  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
    • one or two (0 points)
    • three or four (1 point)
    • five or six (2 points)
    • seven to nine (3 points)
    • ten or more (4 points)
  3. How often do you have six or more drinks on one occasion?
    • never (o points)
    • Less than monthly (1 point)
    • Monthly (2 points)
    • Weekly (3 points)
    • Daily or almost daily (4 points)
    • (if total score for questions 2 and 3 is 0, skip to question 9)
  4. How often during the last year have you found that you were not able to stop drinking once you had started?
    • never (o points)
    • Less than monthly (1 point)
    • Monthly (2 points)
    • Weekly (3 points)
    • Daily or almost daily (4 points)
  5. How often during the last year have you failed to do what is normally expected from you because of drinking?
    • never (o points)
    • Less than monthly (1 point)
    • Monthly (2 points)
    • Weekly (3 points)
    • Daily or almost daily (4 points)
  6.  How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
    • never (o points)
    • Less than monthly (1 point)
    • Monthly (2 points)
    • Weekly (3 points)
    • Daily or almost daily (4 points)
  7. How often during the last year have you had a feeling of guilt or remorse after drinking?
    • never (o points)
    • Less than monthly (1 point)
    • Monthly (2 points)
    • Weekly (3 points)
    • Daily or almost daily (4 points)
  8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
    • never (o points)
    • Less than monthly (1 point)
    • Monthly (2 points)
    • Weekly (3 points)
    • Daily or almost daily (4 points)
  9. Have you or someone else been injured as a result of your drinking?
    • no (0 points)
    • yes, but not in the last year (2 points)
    • yes, during the last year (4 points)
  10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?
    • no (0 points)
    • yes, but not in the last year (2 points)
    • yes, during the last year (4 points)

If your score is 8 or over, this is an indication that you are using alcohol at a hazardous and harmful level. Please seek out further information on how to cut down your drinking to safe levels, and if possible set some goals for your self in relation to your drinking so that it is less dangerous and you are able to keep track of it.

If your score is over 15, it may be difficult to cut down by yourself, and a referral to a drug or alcohol service for further assessment, counselling and monitoring may be preferable to ensure that you can make the right changes for your long-term health.

My score was 5, as I did injure myself a few times when younger and occasionally have more drinks in a single night out than I should. As long as I don’t go on too many more poker cruises that include 4 hours of free drinking, I should be okay, but it is probably something that I need to keep an eye on if it ever does become more frequent in the future.

eaters-collective-109606

The Experiment

To explore precisely why I shouldn’t increase my alcohol consumption, I decided to once again be a little bit more extreme than I normally am.

For one week only, I had:

  • One standard drink on Monday
  • Two standard drinks on Tuesday
  • Three standard drinks on Wednesday
  • Four standard drinks on Thursday
  • Five standard drinks on Friday
  • Six standard drinks on Saturday
  • Three standard drinks on Sunday

On the other week, I had absolutely no alcohol that I was aware of (apart from Listerine mouthwash).

WARNING: If you are trying to improve your sleep at home, I DO NOT RECOMMEND experimenting with any more alcohol than you normally have, and no more than two standard drinks on any given night if possible. If you are pregnant, not drinking any alcohol is the safest recommendation. If you are under 18, delaying when you first begin drinking for as long as possible is the best thing you can do. The prefrontal cortex is still developing and growing until at least the age of 25, and alcohol can disrupt this growth process. Being smarter and healthier, in the long run, seems like a pretty good payoff for not beginning to drink until after your brain has properly developed.

The Outcome

sleep-and-alcohol

no-alcohol-badno-alcohol-good

Objectively, Jan 30 (29/1/17 on the sleep diary) was the worst night of sleep for no alcohol, but I think that may have been that I was doing work on my computer until too late. Even then, there was more restful than light sleep. Feb 07 (6/2/17 on the sleep diary) was the best night of objective sleep so far, with a restful: light sleep ratio of 2.98:1.

Comparison 2: No alcohol vs alcohol

With the alcohol week, I woke up 1.57 times on average, 1.43 more times than without alcohol. I did manage to spend 28 more minutes in bed and get to bed 35 minutes earlier each night, but only obtained an extra 15 minutes per night of sleep. Despite getting the recommended 7-8 hours of sleep per night (7 hours and 14 minutes) my sleep quality was the worst it had been all year (3.57/5) and I felt much more tired, unmotivated and unproductive during the day. It took me longer to fall asleep, I spent more time in bed awake each night, and my sleep efficiency was 95.8%, also the lowest it had been all year.

Objectively, my worst night was Feb 01 (31/1/17 on the sleep diary), which took place after only two standard drinks. The night after six standard drinks wasn’t as bad as I thought it would be objectively, with a restful: light sleep ratio of 1.15:1. It seems that with alcohol, the longer I spend in bed, the less restful my sleep becomes.guillermo-nolasco-134842

Is Avoiding Alcohol a Good Sleep Strategy?

EFFECTIVENESS

For me, yes. It gave me the best sleep quality and sleep efficiency for the year so far. My total sleep time and the time that I went to bed wasn’t ideal for this week, but otherwise, it seemed all positive. I give the effectiveness of this strategy a 21/25.

APPLICABILITY

For me, it wasn’t too difficult to not drink for a week. It is one of the main complaints that I do hear from many clients’ that abstain from alcohol though, and that is that their social lives do take a hit once they stop drinking. Many functions and social events are at bars or involve the consumption of alcohol, and if they have been previously heavy drinkers then sometimes it can be hard to not just go with the flow and join in with others. Previous drinking buddies also may not understand or be as supportive as hoped, especially if that is what they used to enjoy doing with you. Given the potential social implications, I’ll give this strategy an applicability score of 14/25, with minimising alcohol being easier to apply than abstaining from alcohol altogether.

SCIENCE

This excellent handout from Elsevier gives all of the science you need to know about alcohol and sleep:

alcohol-and-sleep-disruption

I, therefore, give the science of this strategy a 40/50.

Overall, avoiding alcohol as a way to sleep better gets a score of 21/25 + 14/25 + 40/50 =

75/100: Distinction

The alcohol-impaired my sleep quality and sleep efficiency, which are two things that I find more important than sleep quantity or duration. I also felt generally more tired, apathetic, anxious and irritable during the week that I was drinking every day.

As I tend to struggle from fatigue at times, cutting out alcohol as much as possible seems to be a good way to go for me, as it led to the best sleep quality and sleep efficiency that I had experienced all year. Now I just need to bring my delayed circadian rhythm forward a bit so that I can feel sleepy earlier, get to sleep earlier and potentially increase my total sleep time.

What I Recommend

I know that alcohol consumption is almost normalised in Australia because of how many people drink and how it is a part of so many social events, but it does cause serious harm and costs to individuals, relationships, families and society if it is consistently used at high-risk levels.

According to the World Health Organisation, high risk drinking increases the risk of:

  • medical and psychological problems
    • alcohol dependence
    • memory loss
    • depression
    • anxiety
    • premature aging
    • drinker’s nose
    • vitamin deficiency
    • bleeding
    • inflammation of the stomach and pancreas
    • liver damage
    • ulcers
    • vomiting
    • diarrhea
    • malnutrition
    • impaired sexual performance
    • deformities during pregnancy or low birth weight babies
    • numbness
    • painful nerves
    • tingling toes and fingers
    • trembling hands
    • impaired sensation
    • falls
    • weakness of heart muscle
    • heart failure
    • anemia
    • impaired blood clotting
    • cancer of throat, mouth and breast
    • frequent colds
    • pneumonia
    • reduced resistance to infection
  • social, domestic, legal and occupational problems
    • aggressive behaviour
    • irrational behaviour
    • impaired judgment and decision making capacity
    • frequent arguments
    • frequent violence
    • accidents and death from drunk driving
    • losing jobs due to inconsistent performance and attendance

Therefore minimise your alcohol consumption where you can, keep it under 2 standard drinks per day, and give yourself some alcohol-free days throughout the week (and alcohol-free weeks throughout the month or alcohol-free months throughout the year).

I kn0w that some studies say that a glass of red wine a night is good for cardiovascular health and stress, but there are other, potentially healthier ways to consume antioxidants, socialise with others and reduce your stress levels.

Conclusion

If you can maximise the benefits of not drinking (including better sleep, greater productivity, better health etc.), minimise your positive expectations of what a drink can do for you, and build up your drink-refusal self-efficacy (capacity to say no to others who offer you a drink), you are at a much lower risk of hazardous alcohol consumption going forward. The less alcohol that you drink, the healthier that your brain and body should feel, especially in the long run.

If you are wanting to reduce your consumption of alcohol but need extra support, please check out the following link and contact the appropriate services or make an appointment to see a medical professional now. It’s unlikely to resolve itself without any action being taken.

Thanks for reading! If you would like a personalised sleep report and the five things that you could do to best improve your sleep, please check out our services.

Does Caffeine Negatively Impact Sleep?

Now that I have recorded my regular sleep for two weeks as a baseline, the fun of experimenting begins.

For each episode, I will be manipulating one variable and looking at the impact that it has on my sleep over a two week period.

I will then discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. My sleep data will be given a score out of 25, the applicability will be given a rating out of 25, and the science will be given a score out of 50. These three factors will then be combined for an overall score and grade for how effective the strategy is at helping people to improve their sleep

The first episode is on caffeine.

clear glass cup filled with coffee

 

I usually don’t consider myself to be a big caffeine consumer, but as you can see in my baseline sleep diary data from the benefits of tracking your sleep article, I did have at least one caffeinated beverage on 10 out of the 14 days for the 2-week baseline period.

During this time, I slept pretty well, so it didn’t seem like small amounts of caffeine earlier in the day made too much of a difference in my sleep.

The Experiment

To really explore the effects of caffeine on sleep, I decided to be a little bit more extreme than what I usually am.

For the first week, I had absolutely no caffeine that I was aware of, including chocolate, soft drinks, tea, coffee or energy drinks.

For the second week, I had:

  • 50mg on day 1 (black tea)
  • 100mg on day 2 (instant coffee and dark chocolate)
  • 200mg on day 3 (Gloria Jean’s coffee and can of Red Bull zero)
  • 400mg (250ml of Red Bull and 1000ml of Monster energy drinks) on day 4
  • 200mg on day 5 (Gloria Jean’s coffee and can of Red Bull zero)
  • 100mg on day 6 (percolated coffee) and
  • 50mg on day 7 (can of coke zero).

400mg is much more than I would recommend for my clients to have on any given day. To make it even more interesting, I also had caffeine right before bedtime on days 3, 4 and 5. This is NOT RECOMMENDED to those who are trying this at home, especially if you have insomnia, are pregnant or are sensitive to caffeine.

The Outcome

caffeine-sleep-diary

Comparison 1: No caffeine vs baseline data

Without any caffeine, my sleep efficiency was precisely the same (96.4%) as the two week baseline period. When you consider that I was also on holidays and travelling down the great ocean road and spending time out in the sun and at the beach, this was a bit surprising to me. I thought cutting out caffeine would help more than it did. With no caffeine, I went to bed 20 minutes later, got out of bed in the morning 17 minutes later, spent 3 minutes less in bed each night, and slept 3 minutes less per night too, but was still getting the recommended 7-8 hours sleep on average. My sleep quality on a scale from 1 = terrible to 5 = excellent was 4.14, which was pretty good.

Objectively, I had a deep sleep on Jan 19 (18/1/17 on the sleep diary) and a terrible sleep on Jan 20 (19/1/17 on the sleep diary), even though I had no caffeine on either day. That means that something else seems to have a more significant impact on the quality of my sleep than caffeine.

Comparison 2: No caffeine (week 1) vs caffeine (week 2)

Looking at the caffeine data, there does seem to be a bit of a time and dose-response effect. My three worst nights on the sleep diary data for the caffeine week happened when I had more caffeine and when I had it right before bed.

Looking at the week as a whole, I spent 22 minutes less in bed per night with caffeine, went to bed 37 minutes later, woke up 15 minutes later, obtained 19 minutes less sleep per night, and was now getting less than the recommended 7-8 hours of sleep per night (6hours 47minutes). My time to get to sleep was pretty similar, however, and my sleep efficiency and time awake during the night were actually better on average with caffeine than without, as was my subjective sleep quality (4.29/5).

Objectively Jan 23 (22/1/17 on the sleep diary) was my deepest sleep yet, with over a 2:1 restful: light sleep ratio. This was with 50mg of caffeine that day. Even when I had 400mg of caffeine (including when I normally go to bed) on Jan 26 (25/1/17 on the sleep diary) my sleep was still more restful than light based on my Misfit Ray data.

Is Avoiding Caffeine a Good Sleep Strategy?

EFFECTIVENESS

From my personal experience with this experiment, avoiding caffeine completely had no added benefit to my sleep in comparison to the amount that I normally consume. As it was neither harmful nor helpful I give the effectiveness of this strategy a 13/25.

APPLICABILITY

It wasn’t too difficult for me to cut out caffeine from my diet, but I get how it may be for someone who is a regular coffee or tea drinker and really enjoys this as part of their daily routine. I know some people also find that it helps them to stay focused and productive at work and that it is a nice social pastime to share with friends and family. That’s not even getting into the people I know that adore eating chocolate on a regular basis and would find it extremely challenging to stop this daily treat. For their benefit, I’ll give the applicability of this strategy a 15/25.

SCIENCE

The science suggests that too much caffeine can lead to increased cortisol and adrenaline levels, and therefore higher anxiety and stress during the day, plus higher arousal levels at night. Snel and Lorist (2011) found that it can increase wakefulness and counteract degraded performance related to sleepiness, but it can also cause irritability, headaches and dizziness. A lot of why people do perform better after caffeine is because they expect to perform better too. If the dose is too high, it can disrupt subsequent sleep quantity and quality (Snel & Lorist, 2011). There is also no nutritional requirement for caffeine in our diets. As a result, I’ll say that avoiding (or minimising) caffeine consumption is likely to assist more than harm sleep quality. I, therefore, give the science of the strategy a 30/50.

Overall avoiding caffeine as a way to sleep better gets a score of 13/25 + 15/25 + 30/50 =

58/100: Pass

The caffeine did seem to contribute to me staying up later and getting less sleep but didn’t seem to impair my sleep quality too much as long as I waited until I felt sleepy and then went to bed then.

It could have been quite a different story if I still tried to go to bed at my baseline time of 11:52pm rather than 12:49am, especially if I then became annoyed that I wasn’t sleepy or couldn’t get to sleep.

Arousal levels at night play a huge role in how likely we are to get to sleep, stay asleep and sleep soundly during the night. Caffeine does raise our arousal levels after we consume it, therefore it can impact sleep.

What I Recommend

Caffeine is not something that I spend a lot of time on in session with my clients. It is a part of good sleep hygiene instructions, which I include in my session one handout:

“Cut down on all caffeine products. Caffeinated beverages and food (coffee, tea, cola, chocolate) can cause difficulty falling asleep, awakenings during the night, and shallow sleep. Even caffeine early in the day can disrupt nighttime sleep.” – Perlis and Youngstead (2000)

I also include some information on how much caffeine is in certain products. If you aren’t sure how much caffeine you have each day, or how much caffeine is in a product that you consume on a regular basis, go to the website caffeine informer.

At caffeine informer, it tells me that my safe daily maximum is 650mg, and a lethal dosage of caffeine for me would be 16550mg. That means that even 400mg of caffeine is safe for me to consume in a day due to my height and weight, but it wouldn’t be for someone who is 65kg.

If you are interested, put in your weight, and figure out what the safe amount is for your health. Then tally up all of the caffeine products that you have in a typical day, and see if this is within the safe limits.

If you are wanting to have a consistently good night of sleep, divide this safe number by at least two, and minimise the consumption of caffeine as much as possible in the last 9 hours before sleep.

Why 9 hours?

Caffeine has a half-life of approximately 4.5 hours, which means that in 9 hours, 1/4 of the caffeine that you consume is still in your system. If you have a large coffee at 2pm that has 200mg in it, by 11pm you will still have approximately 50mg in your system, even if you can’t feel it. This may have minimal impact on sleep quality or quantity, as seemed to be the case with me, or it could have a more negative impact on someone who is particularly sensitive or reactive to it.

Based on my findings and what the science suggests, minimising caffeine consumption and having it earlier in the day is a good idea, but we probably don’t need to stop consuming it altogether.

Conclusion

If you struggle with sleep problems and have a bit of caffeine, that is okay. As long as you focus on winding down and relaxing before sleep and waiting until you feel sleepy before going to bed, you can get to sleep quickly and sleep well during the night. It is elevated arousal levels that keep you up, not the caffeine per se. People that stress out about the caffeine that they have had will sleep worse than those who consume a moderate amount of caffeine and don’t worry about it.

Thanks for reading! If you would like a personalised sleep report and the five things that you could do to best improve your sleep, please check out our services.

The Benefits of Tracking Your Sleep

To improve your sleep, the first thing you need to do is to get a baseline of where it is at.

To do this, the many sleep recording options can generally be split into two categories: Objective Measures and Subjective Measures.

Objective Measures

The gold standard for objective measures is called polysomnography (PSG). This typically involves spending a night in a sleep laboratory or hospital, with many wires hooked up to record brain waves (EEGs), eye movement (EOGs), heart rate (ECGs) and limb movements (EMGs) as well as oxygen saturation and blood flow. The end result looks something like this guy below.

d61d44254608dd06ccdd2ff02982d14d_xl

The measuring equipment used in a PSG is the most accurate way of recording sleep. It is the most reliable way to pick up and diagnose sleep disorders such as Obstructive Sleep Apnea, Restless Legs Syndrome, Periodic Limb Movement Disorder, and many parasomnias. Similar equipment would also be used the following day during a Multiple Sleep Latency Test, which makes it easier to diagnose Narcolepsy and Hypersomnia.

The problem with a hospital-based PSG is just how “normal” is the sleep that is being recorded, especially with sensitive sleepers or those that suffer from insomnia? Sleeping in a foreign environment and a different bed with restricted movement, limited choice in sleeping positions and sleep technicians coming into the room during the night to replace any wires that fall off can be a challenge. I usually don’t have difficulty in falling asleep anymore, but I did the night I spent at the Austin Hospital back in 2014 when I did my own PSG.

Fortunately, there are other options.

There are now home PSG kits that can typically be hired at a cost from a sleep physician for a night. The benefit is that you get to sleep in your own bed, which may feel more usual, and there aren’t any interruptions during the night if any wires fall off. The negative is that you still have to wear all of the wires, which does limit position and comfort, and if something does go wrong or cables fall off then you won’t get as much or all of the required data.

A Sleep Profiler is potentially even better at getting a picture of what your “normal” sleep is like, even if it is slightly less accurate, as it records your sleep at home over multiple nights, and doesn’t have wires all over the place:

sleep-profiler

Once again, this can generally be borrowed for a fee from a sleep physician or specialist sleep clinic, who will then be able to score up the data for you and give you accurate, easy to understand feedback on what is happening with your sleep and what can be done to improve it.

During the clinical trial that I ran as part of my Doctoral research, we used a wrist activity monitor called an ActiWatch 2 by BMedical.

product_4The ActiWatches were an excellent choice to record participants sleep as they were quite unobtrusive by comparison. They were merely worn on the participant’s non-dominant wrist like a watch for the duration of the study and recorded the participants’ sleep, activity levels and light exposure over 14 consecutive days and nights at a time. This was convenient as I saw participants for a treatment session every two weeks, and could easily compare this objective data with their subjective data from the sleep diaries that they were completing to track their perceived quality and duration of sleep.

Wrist activity monitors are surprisingly accurate, especially the Actiwatches by BMedical, but they can come with a hefty price tag, with the ActiWatch 2 retailing for $1485 at the time of this writing. They can also be borrowed or rented out for less from some places if you want to just get a 2 week baseline period of how your sleep is.

The last objective measures that we can use to monitor our sleep are all of the new trackers and mobile apps that are being developed by companies recently for mass consumption by the general public. Some of these work by placing a phone or apparatus under your sheet or pillow, which is fine if you sleep alone, but not so good if you share the bed with a partner, as it is likely to pick up their movement too.

The three activity trackers that I have tried over the last few years are the Misfit Ray, the Fitbit Charge and the Jawbone UP3:

I found the Fitbit the most appealing initially, as it had a visual display which showed me the time and my progress throughout the day. The Jawbone and Misfit had no screen and needed to be synced up to my phone so that I could view their data through their respective mobile apps.

The UP3 was definitely the most accurate for recording my sleep, and with the added benefit of the heart rate monitor gave me a reading of light sleep, deep sleep and REM sleep, while the other two only gave me light vs deep sleep. The Jawbone was the most expensive, however, and the last time I checked the stores in Melbourne, I couldn’t find Jawbone products anywhere.

The big benefit of the Misfit Ray and the reason why this is the activity tracker that I continue to use is that it uses batteries that only need to be replaced every 4 months versus the 5-day charge of the Fitbit and 7-day charge of the Jawbone. The Misfit Ray can also be worn in the shower and in the pool when I go swimming, so I don’t have to keep taking it off every time I am around water. It even has a bike and a swimming feature, which helps to track a wider variety of activities more accurately across my week.

There are plenty of other companies that are getting into this market, and many clients will ask me if it is helpful to buy these products. I do believe that they are useful, providing that they are internally consistent. What I mean by this is that if you have a good night’s sleep and the data from the tracker shows a better quality of sleep, and then you have a terrible night’s sleep, and the data shows an inferior quality of sleep, it is useful to keep monitoring your sleep using this device. If the information that is being produced shows absolutely no relationship to how your sleep feels, it’s probably not going to be very helpful to keep monitoring your sleep in this way.

If you have tried the over-the-counter sleep tracking devices and still have no idea of what your sleep is actually like, a referral to a sleep physician from your general practitioner would be advisable, especially if you are concerned about your sleep quality, sleep duration, or the impact that your sleeping difficulties are having on your level of daytime functioning.

Subjective Measures

Subjective measures include questionnaires and sleep diaries. If you want to get a quick idea of your sleep difficulties, a validated questionnaire can help. The ones that I used during my research were the Insomnia Severity Index (ISI), The Pittsburgh Sleep Quality Index, The Epworth Sleepiness Scale, the Fatigue Severity Scale, the Sleep Hygiene Index, and the Dysfunctional Beliefs About Sleep Scale (DBAS-16). I continue to regularly use the ISI and the DBAS-16 to assess and monitor the severity of people’s insomnia in my clinical work that I do at the Melbourne Sleep Disorders Centre.

A more thorough way to get an understanding of someone’s perceived sleep is by using a sleep diary. Many different sleep diary templates can be downloaded from the internet and used for free. The one that I like the best is the American Academy of Sleep Medicine’s two-week sleep diary. By getting client’s to graph their sleep visually after getting out of bed each morning, it makes it easy to see patterns and potential problems in their two weeks of data.

For my research, I modified this diary slightly by adding boxes for the participant’s bedtime, how long it took them to fall asleep at the beginning of the night, how long they were awake for during the night and the time that they got out of bed in the morning. Using just these four variables alongside the visual diary, I was then able to calculate an individual’s average time to bed (TTB), their sleep onset latency (SOL), their number of awakenings (NOA), their wake after sleep onset (WASO), their rise time (RT), their time in bed (TIB), their total sleep time (TST) and their sleep efficiency (SE), which is their TST/TIB. If filled out thoroughly by a client or participant, it is also possible to look at the impact of medication, caffeine, alcohol, exercise and work on sleep, as well as the timing of each of these variables. 

Here’s my two-week sleep diary from the start of 2017:

sleep-diary-baseline-period

Now hopefully you can read the instructions as well as the data, but if not I will break down the critical information to be gleaned from this chart:

  • Even though I was not trying to do anything special concerning my sleep, I was pretty good at sticking to my eight easy steps for good sleep.
  • I went to bed and woke up at similar times, with the only exception being the Sunday night where I crashed early after playing a beach volleyball tournament all day. For my wake times, 6:50am was the earliest and 8:00am was the latest, which is well within the maximum 2-hour window that I recommend to clients.
  • I only had caffeine once after 1pm, and not at all after 6pm.
  • I waited until I felt sleepy before going to bed, and as a result, I always managed to fall asleep within 10 minutes.
  • I woke up on average once per night but generally had no difficulty in returning to sleep. The most times that I recalled waking up was three times, but that was a hot night.
  • I still have a minor delay in my circadian rhythm, which means that I am a little tired upon awakening, but this typically wears off once I shower and have breakfast.
  • I do some form of exercise every day but sometimes do it too late, such as when I have a 10:10pm basketball game. I need to stay up a bit later to wind down and wait until I feel sleepy on these nights (see 12/1). For this reason, I sometimes don’t get as much sleep as I would like to on weeknights.
  • In general, I am getting enough sleep with 7hours and 9minutes per night on average.
  • I am definitely not spending too much time in bed, with an average of 7hours and 25minutes per night.
  • Based on my excellent sleep efficiency of 96.4%, I would suggest that I could actually benefit by spending 15-30minutes more in bed each night.

If a client or participant came to me with a sleep diary that was identical to this, I would recommend for them to aim for a consistent sleep schedule between 11:45pm and 7:30am over the next two weeks. I would encourage them to wait until they feel sleepy before going to bed and to also focus on minimising late-night exercise. I would recommend them getting 20-30 minutes of sunlight exposure when possible after rising in the morning, staying away from bright screens in the last two hours before bed and actively winding down and relaxing before bed to lower their arousal level.

Objective vs Subjective

Here is the objective data from my Misfit Ray for the last 6 nights of the above sleeping period. To compare the Misfit to the sleep diary data, look at Jan 10 on the Misfit and 9/1/17 on the sleep diary, as the Misfit shows the date of the next morning and the sleep diary the date that the night begins on:

fullsizeoutput_1cfullsizeoutput_dfullsizeoutput_1dfullsizeoutput_1efullsizeoutput_22fullsizeoutput_23

The main discrepancy is the 37 minutes awake shown on the Jan 13 Misfit data, which is the night that I had a 10:10pm basketball game (12/1/17). I don’t recall being awake for that long (or at all) once I fell asleep that night, but I could have potentially been more restless at the start of that night due to the late exercise. My poor quality of sleep on that night relative to the other nights of data does back up this theory.

The Jan 15 data also shows an exceptional night of sleep, with almost double the amount of restful to light sleep. Considering that this was a Saturday with no work, no caffeine after 10am, plenty of relaxing and a nice swim between 4 and 5pm, it does make sense that it was objectively an excellent sleep, even if the awakening wasn’t picked up by the Misfit.

Apart from a few minor differences, the consistency between the subjective and objective data is actually quite impressive, and something that I hope will continue as I begin my journey of manipulating one variable every 2 weeks this year to look at the impact that it has on my sleep. The first episode that will be released using both video footage and a blog post on caffeine.

Thanks for reading! If you would like a personalised sleep report and the five things that you could do to best improve your sleep, please check out our services.

 

 

 

The Four Key Components of Cognitive Behavioural Therapy for Insomnia

Cognitive behavioural therapy for insomnia (CBT-I) is an efficacious treatment for primary insomnia, resulting in enduring and long-term sleep benefits. It is considered to be an effective treatment for insomnia that is co-morbid with substance abuse, medical and/or psychiatric conditions. Because of the overlap between insomnia, physical health, and psychological health, improving the sleeping quality through CBT-I in these individuals also often results in subsequent improvements in the co-morbid conditions.

CBT-I for individuals with insomnia and depression

Depression is a psychiatric condition that improves through CBT-I. However, the effect sizes of CBT-I are often smaller than those reported through CBT for other mental health disorders (Harvey & Tang, 2003). Furthermore, only 50% of the participants in one of the more successful CBT-I studies for co-morbid insomnia and depression remitted from insomnia (Manber et al., 2008). If insomnia does not remit, then depression is likely to relapse (Perlis et al., 1997), persist or worsen in severity over time (Staner, 2010). It is therefore essential to optimise the four CBT-I components for this population.

pexels-photo-271897.jpeg

Component One of CBT-I: Psychoeducation

The psychoeducation component of CBT-I consists of general sleep education and sleep hygiene recommendations. This should be introduced in CBT-I before the administration of any behavioural prescriptions or the undertaking of any cognitive restructuring and is typically presented to the client and discussed during the first session. Essential components of general sleep education include information around why people sleep, the stages of sleep, and differences in sleep requirements (Kripke et al., 2002). It also contains what ‘normal’ sleep looks like, what happens to sleep with age and sleep inertia (Jewett et al., 1999). The two process theory of sleep regulation that incorporates circadian rhythms and homeostatic pressure (Borbély, 2000), and a model of insomnia and how it progresses over time (Ebben & Spielman, 2009) are helpful models to include. Sleep hygiene recommendations are also introduced to highlight the factors that may be exacerbating an individual’s insomnia severity and contributing to their poor subjective sleep (Perlis & Youngstedt, 2000).

Although the psychoeducation component of CBT-I is not an empirically supported individual intervention for insomnia (Morin, Culbert, et al., 1994), it is still a crucial component of the multimodal treatment and serves several purposes. Psychoeducation not only provides essential information that can help individuals sleep better, but also gently challenges some of the unhelpful thoughts, beliefs and attitudes that participants may have about sleep with real evidence from scientific research. Elevated dysfunctional beliefs and attitudes about sleep, as measured by the DBAS-16 scale, are significantly correlated with high insomnia, depression, and anxiety severity, but not with sleeping measures (Morin, Vallieres, & Ivers, 2007). Thus, psychoeducation can reduce insomnia and depression severity through lowering the intensity of participant’s firmly held beliefs about sleep, even if it does not directly improve sleep.

Psychoeducation can also be important for developing therapeutic alliance (Krupnick et al., 1996), as discussing essential factors of sleep allows CBT-I treatment to begin in a non-threatening manner. Many of the individual interventions are directive, with little room for discussion, but psychoeducation provides for the development of rapport with the participant through discussion of their sleep difficulties and beliefs as the information is being presented. A strong therapeutic alliance can then increase adherence to later behavioural instructions, result in more openness to cognitive restructuring, and improve overall outcomes for the participant (Trockel, Karlin, Taylor & Manber, 2013). Thus, beginning broadly with psychoeducation is likely to result in a better understanding of how to improve sleep, a reduction in unhelpful beliefs about sleep, and a better therapeutic alliance that can increase the clinical outcome for the other interventions in CBT-I.

1A. Sleep hygiene recommendations

Sleep hygiene recommendations were developed to educate individuals with insomnia about the possible factors that promote and inhibit optimal sleep (Hauri, 1977). By following these recommendations, it was proposed that one’s sleeping practices would no longer be perpetuating their insomnia (Mastin, Bryson, & Corwyn, 2006). However, there is no standard prescription for what optimal sleep hygiene consists of, and no weighting of what factors are most important. Even the developer of sleep hygiene has changed his recommendations over time (Hauri, 1993).

Stepanski and Wyatt (2003) reviewed seven studies that attempted to define sleep hygiene and found 19 different rules. Worse still, there was only one rule that was agreed upon unanimously, and that was to not consume caffeine before going to bed. Six of the studies recommended daily exercise, but not too close to bedtime. Six studies also recommended avoiding alcohol in the evening. Beyond these three items, most of the sleep hygiene rules were only supported by two or three studies (Stepanski & Wyatt, 2003). The lack of a standard definition of sleep hygiene means that it is tough to determine its efficacy, and may explain why it is not a supported intervention for treating insomnia (Morin et al., 2006).

Improving sleep hygiene knowledge has little impact on improving sleep quality, however improving sleep practices in line with sleep hygiene recommendations does (Brown, Buboltz, & Soper, 2002). This means that informing clients about sleep hygiene may not result in behavioural change, but when this does take place, it can have a substantial effect on their sleep and health (Brown et al., 2002).

The aim for sleep hygiene in CBT-I is, therefore, to determine which aspects are most likely perpetuating insomnia and depression in each client, and customise the treatment to the individual. By doing this, clients only have to focus on the issues that are of most concern to them and not waste their time worrying about recommendations that are already followed reasonably well (Hauri, 1993). Administering a questionnaire such as the Sleep Hygiene Index (Mastin et al., 2006) at baseline would also help the therapist target appropriate sleep hygiene factors for each participant during the psychoeducation phase of treatment.

pexels-photo-267684.jpeg

Component Two of CBT-I: Sleep Scheduling

Both stimulus control and sleep restriction therapies can be combined under the term sleep scheduling. Taken together, sleep scheduling aims to eliminate the behaviours in insomnia that commonly disrupt sleep. By breaking conditioned responses, increasing homeostatic pressure for sleep and re-entraining the natural circadian rhythms, sleep scheduling results in both higher sleep quality and sleep efficiency (SE) over time, which increases the perception of a restorative night’s sleep (Ebben & Spielman, 2009; Vitiello, 2007). Sleep scheduling is usually administered after the psychoeducation component and before any formal cognitive therapy in CBT-I treatment.

2A. Stimulus control

Stimulus control therapy was initially conceived in the early 1970s as a direct application of instrumental conditioning principles to break the conditioned response of the bed, bedroom and bedtime in patients with insomnia (Bootzin, 1972). Any stimulus is thought to be able to produce several reactions in people, depending on their conditioning history with the stimulus. Individuals with insomnia are so used to being awake and frustrated in bed that over time the bed becomes conditioned with being aroused, annoyed and alert rather than with feeling tired and sleeping (Ebben & Spielman, 2009).

The stimulus control instructions aim to limit the time in bed awake so that the bed becomes reconditioned with the feeling of sleepiness and the behaviour of well-consolidated sleep. These include only going to bed when tired, waking up at the same time every day, just using the bed/bedroom for sleep and sex, avoiding naps during the day, and getting up if unable to fall asleep within 20 minutes of retiring to bed, (Lieberman & Neubauer, 2007).

Stimulus control is thought to help individuals with insomnia and depression in some ways. Firstly, by removing all other conditioned responses except for sleep, the bed soon becomes reassociated with falling asleep quickly. This reduces the time spent in bed ruminating, and over time positive associations can develop, where the individual becomes tired and sleepy whenever they retire to bed (Ebben & Spielman, 2009). Secondly, waking up at the same time each day allows for entrainment of the circadian rhythms, which then promotes sleepiness for the participant at a similar time each night. By not changing the waking time, regardless of when the individual goes to sleep or how many times they get out of bed during the night, this also mildly deprives them of sleep, and combining this with no naps during the day strengthens the homeostatic drive for sleep. This then allows the participant to fall asleep quicker when they finally do go to bed at night (Ebben & Spielman, 2009). All of these factors combine to improve sleep self-efficacy, sleep efficiency and sleep quality, which helps participants’ feel less concerned, more refreshed and more in control of their sleep.

Stimulus control as a stand-alone therapy is a supported behavioural treatment for chronic insomnia, according to the AASM (Morin et al., 2006). It has reliable and robust effect sizes in the available research in the field (Lacks, Bertelson, Gans, & Kunkel, 1983; Riedel et al., 1998; Turner & Ascher, 1979). The main difficulty with stimulus control is adherence to the instructions (Riedel & Lichstein, 2001). The guidelines appear somewhat counter-intuitive, and individuals with insomnia and depression have many preconceived notions as to what the cause of their insomnia is that does not involve instrumental conditioning (Bootzin, 1972). It is therefore essential to explain the rationale in substantial detail for participants to actually get out of bed after 20 minutes and to wake up at the same time each day. If the guidelines are not followed, their bed will not become reconditioned with sleep, their circadian rhythms will not be re-entrained, and their sleep will be unlikely to improve (Harvey, 2002). It is therefore vital to introduce cognitive techniques after stimulus control in CBT-I, so that any dysfunctional beliefs or safety behaviours that may limit willingness to adhere to stimulus control instructions are explored, understood and overcome.

2B. Sleep restriction

Sleep restriction, or bed restriction as it is sometimes known, was initially conceived in the mid-1980’s to take advantage of the positive benefits of sleep deprivation on various sleep measures (Spielman et al., 1987). It is a useful technique for the treatment of insomnia (Morin et al., 2006) that involves limiting the time in bed to an individual’s average subjective daily amount of sleep (Spielman et al., 1987). By only spending enough time in bed for sleep, sleep restriction temporarily induces sleep deprivation, which increases the homeostatic drive for sleep, decreases sleep fragmentation and consequently improves SE (Vitiello, 2007). However, it is important to prescribe the sleep at a constant time that is in line with an individual’s circadian rhythms and lifestyle (Ebben & Spielman, 2009).

Sleep restriction is similar to relaxation in reducing sleep onset latency (SOL) and wake after sleep onset (WASO) across CBT-I treatment, and more effective in maintaining these improvements by follow-up 3-months later (Friedman et al., 1991). After 12 months follow-up in another study, WASO had gotten worse since post-treatment with relaxation but continued to improve with sleep restriction (Lichstein et al., 2001). Therefore, one benefit for sleep restriction appears to be its enduring long-term insomnia improvements, which is essential in reducing the risk of depressive relapse (Perlis et al., 1997).

The downside of sleep restriction is that it temporarily increases daytime somnolence and reduces vigilance in the initial phases of treatment (Kyle et al., 2014) so adherence to this treatment may be difficult to obtain from individuals who are already concerned about daytime consequences of insomnia (Riedel & Lichstein, 2001). If there is excessive daytime sleepiness, caution should also be given regarding driving or operating machinery, and some time off work may be required. However, this increase in sleepiness prevents individuals with insomnia and depression from lying in bed ruminating or worrying, and it has been shown to significantly improve sleep initiation and increase overall sleep quality (Lieberman & Neubauer, 2007).

At 12 months follow-up, both stimulus control and sleep restriction adherence were the most significant predictors of ongoing improvements in SOL and WASO (Harvey, 2002). Consequently, as long as the long-term benefits of sleep scheduling are made salient and adherence issues are addressed in therapy, both stimulus control and sleep restriction can produce dramatic and robust improvements in insomnia symptoms.

pexels-photo-416160.jpeg

Component Three of CBT-I: Relaxation

Relaxation reduces excessive physical tension and calms pre-sleep cognitive activity, fostering a more positive outlook and reducing overall concerns about sleep disturbances (Harsora & Kessmann, 2009). Relaxation techniques are therefore carried out across the entire CBT- I intervention with the objective of reducing physiological and cognitive arousal so that an individual can transition to sleep quicker and have a deeper, more restorative sleep (Edinger & Means, 2005).

Relaxation techniques sometimes included in CBT-I include:

  • imagery training (Morin & Azrin, 1987),
  • meditation (Woolfolk et al., 1976),
  • thought-stopping (Levey et al., 1991)
  • biofeedback training (Freedman & Papsdorf, 1976),
  • diaphragmatic breathing (Smith & Neubauer, 2003),
  • autogenic training (Simeit et al., 2004) and
  • progressive muscle relaxation (Bernstein et al., 2000).

3A. Progressive Muscle Relaxation

Progressive Muscle Relaxation (PMR) is the most commonly used relaxation technique in CBT-I and is efficacious as a stand-alone treatment for insomnia (Morin et al., 2006). PMR involves tensing and releasing different groups of muscles throughout the body to reduce physiological arousal. It may have some additional cognitive benefits through focusing on and paying attention to particular areas of the body, but it is not as cognitively based as autogenic training, imagery training, thought stopping, or meditation.

In comparison to autogenic training and biofeedback training, PMR was not significantly different (Freedman & Papsdorf, 1976; Simeit et al., 2004). However, cognitive relaxation techniques were found to be more effective for reducing SOL (Morin, Culbert, et al., 1994). Consequently, cognitive relaxation techniques should be incorporated into CBT-I protocols more frequently.

Rather than administering only one relaxation technique in CBT-I for insomnia and depression, it may be more beneficial to briefly introduce several methods (both cognitive and somatic focused) and let the individual determine which techniques are the most effective in reducing their arousal levels and allowing them to feel relaxed both during the day and at night. Mindfulness meditation has been increasing in popularity immensely lately and has also been proving to be helpful in reducing arousal in more recent studies by Ong, Shapiro and Manber (2008).

In one study that treated individuals with insomnia with relaxation techniques, SE was found to increase from 67.0% to 78.8% over 6 weeks of treatment (Lichstein et al., 1999). Both anxiety and depression scores were also reduced after the 6 weeks of relaxation (Lichstein et al., 1999). Relaxation has been found to be the most effective when initially practised during the daytime so that the participant can practice reducing their arousal levels rather than using the techniques to help them fall asleep (Harsora & Kessmann, 2009). Once arousal levels are efficiently being reduced, relaxation treatments can reduce  SOL more than sleep hygiene education or the combination of stimulus control plus sleep restriction (Waters et al., 2003). Although CBT-I is typically superior to relaxation alone (Edinger et al., 2001a), the additional benefits of relaxation on depression (Jorm et al., 2008), stress (Kaspereen, 2012) and anxiety (Manzoni, Pagnini, Castelnuovo, & Molinari, 2008) warrant it being added to a CBT-I intervention for co-morbid insomnia and depression.

pexels-photo-208166.jpeg

Component Four of CBT-I: Cognitive Therapy

The term cognition refers to all mental activities, which are experienced in the form of verbal thoughts or images. Many cognitive processes have been found to be critical in differentiating individuals with insomnia from ‘normal sleepers’, including attention, perception, memory, beliefs, attributions and expectations (Harvey et al., 2005). These differences contributed to higher anxiety levels and increased cognitive arousal in individuals with chronic insomnia (Harvey & Tang, 2003).

To help break the cycle of insomnia, emotional distress and further sleep disturbances, specific cognitive techniques need to be implemented alongside the behavioural interventions in CBT-I. Cognitive techniques are formally introduced in CBT-I after both the psychoeducation and sleep scheduling components have been administered. Cognitive techniques for insomnia include cognitive restructuring (Edinger & Carney, 2008; Morin, 1993), cognitive control (Morin & Espie, 2003), constructive worry (Edinger & Carney, 2008), distraction (Ree, Harvey, Blake, Tang, & Shawe-Taylor, 2005), paradoxical intention (Broomfield & Espie, 2003), and mindfulness and acceptance of thoughts (Ong, Shapiro, & Manber, 2008).

4A. A cognitive model of Insomnia

Through research on the cognitive processes involved in insomnia, Harvey and colleagues developed a cognitive model that identified the five main aspects that were likely to be perpetuating insomnia (Harvey, Sharpley, Ree, Stinson, & Clark, 2007). The model proposed that individuals with insomnia typically:

  • Spend excessive time ruminating about why they have not slept well in the past, and worrying about not sleeping well in the future.
  • Misperceive their sleep to be worse than it is, overestimating initiation and maintenance of sleep problems and underestimating total sleep achieved, which exacerbates their anxiety and arousal over time.
  • Pay more attention to both external and internal threats to sleep in bed at night and to functional impairments and tiredness during the day.
  • Have many unhelpful and unrealistic beliefs about sleep, including hours of sleep needed, consequences of poor sleep, causes of their insomnia, and what they should do about it, and
  • Maintain these attentional biases and unhelpful beliefs about sleep through safety behaviours, such as not going to work after a miserable night’s sleep, napping during the day, and spending extra time in bed in an attempt to catch up on ‘lost sleep’.

Harvey and colleagues (2007) then developed a cognitive therapy for insomnia, which consisted of Socratic questioning and carefully planned behavioural experiments, to address all aspects of their cognitive model. They found significant improvements in SOL (over 50%), WASO (37%) and total sleep time (TST – 11%) by post-treatment, with findings maintained by follow-up 1 year later and all 19 participants no longer meeting diagnostic criteria for chronic insomnia (Harvey et al., 2007). Significant improvements were also found in work and social adjustment, unhelpful beliefs, worry, depression severity and anxiety severity (Harvey et al., 2007).

Although these findings were promising, there was no control group in the study of cognitive therapy, and the duration of treatment varied between 6 and 22 weeks. As the optimal dose of CBT-I is 4 sessions across 8 weeks (Edinger et al., 2007), it may be possible to target all five factors from the cognitive model (Harvey et al., 2007) and achieve similar gains, but in a shorter period of time than what is found through purely cognitive interventions for insomnia. This is supported by a recent study by Roane and colleagues (2012), who found that the behavioural and cognitive interventions of CBT-I both produced significant reductions in unhelpful beliefs and attitudes about sleep, but created these cognitive changes in different areas.

4B. Constructive worry

To target worry and rumination in co-morbid insomnia and depression, both the constructive worry (Edinger & Carney, 2008) and the cognitive control (Morin & Espie, 2003) techniques could be efficiently used in CBT-I. The constructive worry technique instructs individuals with insomnia to spend time earlier in the evening problem solving any issues that they believe may keep them awake or cognitively aroused in bed at night (Edinger & Carney, 2008). Cognitive control also instructs individuals to spend 20 minutes reflecting on the day that has been a few hours before going to bed and to write a to-do list about what needs to be done the next day (Morin & Espie, 2003). By targeting these concerns earlier in the evening, less information needs to be processed in bed, and this can subsequently result in less cognitive arousal and frustration. If anything new comes up that they have not thought about, they can also quickly write this down on a notepad next to their bed and then continue to relax and allow sleep to come (Morin & Espie, 2003). These cognitive techniques are likely to be effective alongside sleep scheduling instructions in CBT- I by reconditioning the bed with sleepiness and sleep instead of worry, rumination and a racing mind.

Out of all the cognitive processes, individuals with insomnia have a propensity to use thought control strategies more frequently than normal sleepers (Ree et al., 2005). The strategies of aggressive suppression and worry appear to be particularly unhelpful, with their use predicting increased sleep impairment, anxiety and depression (Ree et al., 2005). Conversely, cognitive distraction is used more frequently by normal sleepers and predicts better sleep quality (Harvey & Payne, 2002). Thus, cognitive distraction techniques are likely to be helpful in allowing individuals to reduce their cognitive arousal levels and should be encouraged in CBT-I interventions for comorbid insomnia and depression.

4C. Imagery training

One particularly beneficial distraction technique is imagery training. Although it is often considered to be a relaxation exercise, imagery aims to distract the individual from obtrusive and pre-occupying sleep-related thoughts by using visualisation techniques. Thinking in the form of images has been found to resolve worry more efficiently than thinking in the form of words (Nelson & Harvey, 2002). Imagery can therefore also be considered as a cognitive technique in CBT-I.

Imagery involves visualising an interesting and engaging situation that is also pleasant and relaxing immediately before sleep (Harvey & Payne, 2002). Rosen and colleagues (2000) compared imagery to PMR and sleep hygiene education across 4 weeks of treatment, and found significant improvement in SE and WASO in both the imagery and PMR groups by post-treatment. Furthermore, the imagery group exhibited 16 minutes less WASO than the PMR group and had increased self-efficacy and depression severity by the 6-month follow up (Rosen, Lewin, Goldberg, & Woolfolk, 2000). Imagery should, therefore, be incorporated into a CBT-I intervention for comorbid insomnia and depression as both relaxation and a cognitive distraction technique.

4D. Highlighting sleep-state misperception

Another critical area that may need to be challenged cognitively is sleep-state misperception. To challenge sleep state-misperception, an individual’s objective sleep data, which is usually provided by a wrist activity monitor (Hauri & Wisbey, 1992), needs to be compared with their subjective sleep data from their sleep diaries. If a significant discrepancy is found between objective and subjective sleep, it often indicates that individuals perceive themselves to be awake during the light stages of sleep (stages 1 and 2) (Harvey et al., 2007).

Providing information that highlights the inconsistencies between objective and subjective sleep and giving information that sleep becomes lighter as the night goes on will often reduce anxiety about an individual’s quality of sleep, and result in better subjective sleep and increased the perception of a more restorative night’s sleep. Stimulus control is also a useful behavioural intervention for sleep state misperception, as it is not possible for the participant undergoing CBT-I to get up out of bed after 20 minutes of being awake if they are actually sleeping (Lieberman & Neubauer, 2007). Cognitive restructuring (Morin, 1993) can then be administered to look at the validity and utility of thoughts around being awake when they might actually be asleep.

4E. Cognitive restructuring

Cognitive restructuring is introduced after sleep scheduling in CBT-I to address and challenge any unhelpful beliefs and attitudes about sleep that may be perpetuating insomnia. To determine how strongly held participant’s beliefs are in CBT-I interventions, the DBAS-16 is often administered (Morin et al., 2007). The DBAS-16 highlights four main areas of unhelpful beliefs about sleep, including excessive worry about not sleeping, catastrophising the consequences of insomnia, having unrealistic expectations for sleep, and overestimating the effects of sleep medications (Morin et al., 2007).

Cognitive restructuring aims to elicit, identify, discuss, appraise, and correct any unhelpful thought processes that may be maintaining catastrophic beliefs about sleep and insomnia through Socratic questioning (Harvey et al., 2007). These questions focus on the accuracy of beliefs about sleep that an individual has, the evidence to support these beliefs, whether there are any alternative explanations for these beliefs, whether they underestimate their ability to cope with any problems they have, what they fear will happen if these beliefs are correct, and what they can do to address the issue (Morin, 1993). A reduction in these scores predicts better outcomes for individuals after CBT-I treatment (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001b).

4F. Mindfulness or acceptance-based techniques

Individuals with insomnia also exhibit an attentional bias for sleep-related threat during both the day and night. One way to target this is through the introduction of mindfulness or acceptance-based techniques (Dalrymple, Fiorentino, Politi, & Posner, 2010; Lundh, 2005; Ong & Sholtes, 2010). These techniques involve a non-judgmental, present-focused awareness, which means being aware of any thoughts, feelings or sensations that arise without changing them in any way. It also involves bringing back attention to whatever is occurring in the present moment and getting in touch with the breath or any of the five senses rather than getting caught up in the past or future (Dalrymple et al., 2010; Lundh, 2005; Ong & Sholtes, 2010).

Mindfulness and acceptance-based therapies theorise that it is not the content of thoughts that are troublesome to individuals, but rather the judgments or evaluations that are made about these thoughts. By remaining in the present and practising ‘defusion’ and acceptance techniques (Harris, 2007), the impact that these perceived sleep threats have should diminish over time. This could result in lowered arousal, more restorative sleep, and fewer impairments in daytime functioning (Dalrymple et al., 2010; Lundh, 2005; Ong & Sholtes, 2010).

Several studies have found modest improvements in sleep through mindfulness, as an individual intervention for sleep (Britton, Shapiro, Penn, & Bootzin, 2003; Heidenreich, Tuin, Pflug, Michal, & Michalak, 2006). However, recent findings have been more promising (Gross et al., 2011), especially when mindfulness is combined with other sleep interventions (Ong et al., 2008; Ong, Shapiro, & Manber, 2009). Although increases in mindfulness skill were not significant across all participants by post-treatment (Ong et al., 2008), participants with reduced pre-sleep arousal and sleep effort were found to be less likely to have had an insomnia relapse by follow-up one-year later (Ong et al., 2009).

Another study also found that mindfulness improved self-regulation of sleep by allowing it to occur naturally rather than forcing it, which subsequently predicted greater well-being (Howell, Digdon, & Buro, 2010). Adding mindfulness to CBT-I can therefore not only reduce insomnia severity but also improve daytime functioning. Mindfulness-based cognitive therapy is thought to be an effective treatment for relapse prevention in MDD (Ma & Teasdale, 2004). Because of the long-term improvements found for both conditions, mindfulness should be incorporated in some capacity in CBT-I interventions for co-morbid insomnia and MDD.

4G. Safety behaviours

The last cognitive aspect of insomnia that needs to be addressed in CBT-I is safety behaviours, which are habitual sleep-related behaviours or routines that people develop because they think that it helps with their insomnia (Harvey et al., 2007). Safety behaviours may lead to reduced adherence to behavioural interventions in CBT-I and need to be addressed through behavioural experiments for homework, to ensure optimal outcomes for co-morbid insomnia and depression.

Paradoxical intention is one such intervention that can be implemented as a behavioural experiment to reduce pre-sleep arousal and sleep effort, which can subsequently reduce the likelihood of insomnia relapse following the conclusion of CBT-I treatment (Ong et al., 2009). By instructing an individual that has continued to put considerable effort into sleeping that they should try to remain awake in bed for as long as possible, they are likely to obtain a more restorative night’s sleep (Broomfield & Espie, 2003). It is then possible to explain that it is their effort and performance anxiety that often leads to increased pre-sleep arousal and poorer quality of sleep throughout the night (Broomfield & Espie, 2003). Once the individual understands this, durable cognitive change is likely to occur, and more significant benefits can be obtained from the CBT-I intervention.

Due to the varied cognitive perpetuating factors for each individual with insomnia and depression, it is unlikely that a standard cognitive technique will be sufficient to help all individuals undergoing CBT-I. Conversely, if all cognitive strategies are provided, many of these will be unnecessary, and result in an excessively lengthy cognitive component of CBT-I (Harvey et al., 2007). As a result, the cognitive factors that appear to be perpetuating insomnia severity for each individual should be thoroughly assessed initially and then monitored throughout the CBT-I, with a particular focus on any adherence issues. By tailoring the cognitive treatment to the individual characteristics of each case of insomnia, it is then possible for optimal outcomes to be achieved.

pexels-photo-269141.jpeg

How Can CBT-I Be Optimised Further?

For optimal outcomes to be achieved through CBT-I treatment, it must be flexible enough to be tailored to the patient and their primary presenting concerns. The most prominent risk of administering manualised CBT-I is if it is being implemented in a directive rather than a collaborative manner between the therapist and the patient (Cahill et al., 2008).

Treatment goals need to be negotiated with the patient rather than assumed, and any structure that is implemented should be provided in an autonomy-supported rather than a controlling way (Ryan & Deci, 2008; Zuroff et al., 2007). To achieve this, the patient needs to feel validated and understood with their concerns (Ryan & Deci, 2008), be provided with meaningful rationales for any suggested interventions or homework exercises (Deci, Eghrari, Patrick, & Leone, 1994), and have minimal pressure by the therapist to change in a particular direction (Miller & Rollnick, 2002).

It is also essential to view the patient with unconditional positive regard (Assor, Roth, & Deci, 2004) and provide them consistent support irrespective of their treatment decisions (Moller, Deci, & Ryan, 2006). Self-determination theory suggests that these factors help to ensure that an individuals’ psychological needs for competence, relatedness and autonomy are met (Ryan & Deci, 2008). If CBT-I therapists can meet these needs while educating patients about the effective interventions that are likely to help their insomnia and other presenting concerns, optimal improvements can be achieved.

If a patient undergoing CBT-I has an external locus of control, they are likely to attribute their difficulties to factors outside of their influence, and may, therefore, struggle to find an autonomous motivation to improve their situation. In these cases, motivational interviewing strategies (Miller & Rollnick, 2002) could be implemented either before or during the CBT-I intervention to enhance support, motivation and therapeutic alliance. This can subsequently improve adherence to treatment recommendations and result in higher overall treatment outcomes (Trockel et al., 2013; Zuroff et al., 2007).

A motivational interviewing intervention before CBT for anxiety has been shown to reduce resistance to CBT interventions (Westra, 2011), improve compliance with homework, and produce more significant overall reductions in worry in comparison to a CBT only intervention (Westra, Arkowitz, & Dozois, 2009). Encouraging family members or partners to help motivate and support the individual undergoing CBT-I can also improve adherence rates to the CBT-I interventions (Ellis, Deary, & Troxel, 2014), and could be utilised more if motivational ambivalence is present. The most optimal CBT-I treatment may, therefore, be one that supports the patients’ needs for autonomy while also motivating them to adhere to empirically supported interventions.

Although CBT-I consistently reduces psychological symptoms and distress, other daytime improvements through CBT-I have been less consistent (Morin et al., 2006). Acceptance and commitment therapy (ACT), and especially the values clarification and committed action components of ACT, can help patients endure more emotional discomfort and overcome barriers to change in the pursuit of their value-driven goals (Harris, 2009). A case-study of ACT principles following CBT-I (Dalrymple et al., 2010) indicates the potential for an amalgamation of ACT with CBT-I whenever presenting concerns consist of a lack of purpose or meaning. Mindfulness has already been shown as a helpful addition to CBT-I for certain individuals (Ong et al., 2008), and ACT teaches four mindfulness skills and concepts as core components of its treatment (Harris, 2009). Positive Psychology principles (Seligman, Rashid, & Parks, 2006) have been included alongside CBT to improve positive emotion, engagement and overall well-being in individuals with depression (Karwoski, Garratt, & Ilardi, 2006), but has yet to be attempted alongside CBT-I.

By incorporating more evidence-based interventions with CBT-I when necessary, and personalising the treatment approach to the characteristics of the client, optimal outcomes can be achieved in a higher proportion of individuals with depression seeking treatment for insomnia.

Thanks for reading! If you would like a personalised sleep report and the five things that you could do to best improve your sleep, please check out our services.

Dr Damon Ashworth

Clinical Psychologist

Insomnia and Depression: We Need to Start Targeting the Sleep Problems

What is Insomnia?

Insomnia can be defined as the subjective difficulty in the initiation or maintenance of sleep, or non-restorative sleep, resulting in significant impairment in daytime functioning (American Psychiatric Association, 2013).  Common daytime symptoms of Insomnia include low energy, fatigue, impaired concentration and memory difficulties (Edinger et al., 2004).

How common is Insomnia?

Acute or short-term Insomnia is prevalent, with up to 20% of the general population experiencing sleep difficulties on any one night (Staner, 2010). However, once these symptoms have persisted for at least one month, Insomnia becomes classified as chronic, and the prevalence rates drop to about 6% (Staner, 2010).

What impact does it have?
  • Chronic Insomnia is a debilitating and costly condition, with direct health care costs of Insomnia estimated to be $118.7 million in 2010 in Australia (Economics, 2011).
  • Indirect factors are an even more massive burden for society, with reduced employment levels, lower productivity, higher absenteeism, and a higher risk of a motor vehicle or workplace accident as a result of Insomnia accounting for $1.5 billion of costs to Australia in 2010 (Economics, 2011). This higher cost of indirect factors means that Insomnia is under-treated in Australia.
  • Insomnia has been shown to be significantly related to a higher risk of both workplace and non-workplace accidents (Kessler et al., 2012). The average annual costs to government (direct and indirect) found to be 11.9 times higher for individuals with Insomnia than for good sleepers (Daley, Morin, LeBlanc, Gregoire, & Savard, 2009)
  • If Chronic Insomnia is not treated adequately, it results in a higher risk of mental health problems, with up to 61% meeting criteria for another psychiatric disorder (Stepanski & Rybarczyk, 2006).

What’s the relationship between Insomnia and Depression?

Insomnia and Depression are highly correlated with each other, with up to 90% of individuals with Major Depressive Disorder (MDD) having sleep quality complaints, and 67% having severe enough sleep disturbances and daytime impairments to meet an additional diagnosis of Insomnia (Franzen & Buysse, 2008). This equates to a 61% higher prevalence rate of Insomnia in MDD than in the general population.

Insomnia is also thought to share other common features with Depression, including low energy, fatigue, decreased motivation, indecisiveness and impaired concentration (Spielman & Anderson, 1999). Consequently, there appears to be a healthy relationship between low satisfaction with sleep and poor overall mood (Staner, 2010). However, these sleep disturbances are rarely a focus of intervention in the treatment of Depression.

The definition of an MDD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has Insomnia listed as a symptom of Depression (American Psychiatric Association, 2013). Because of this definition, mental health clinicians have tended to overlook the course of Insomnia, view it as a secondary condition to Depression, and therefore not worthy of clinical attention (Stepanski & Rybarczyk, 2006). However, for the Insomnia to be genuinely secondary to Depression, it must have begun with the onset of the depressive episode, and remit once the MDD does. As soon as the course of Insomnia differs to that of an individual’s Depression, a co-morbidity of MDD and Insomnia is present, and an additional diagnosis of Insomnia should be given (American Psychiatric Association, 2013).

young man in bed with eyes opened suffering insomnia and sleep disorder thinking about his problem

What comes first: the poor sleep, or the low mood?

  • Insomnia has an earlier average age of onset in comparison to Depression.
  • Between 40-69% of individuals with Depression reported that their Insomnia appeared before any other depressive symptoms (Franzen & Buysse, 2008; Johnson, Roth, & Breslau, 2006).
  • Eight epidemiological studies have identified that Insomnia at baseline significantly increased the risk of developing MDD by follow-up 1-3 years later (Riemann & Voderholzer, 2003).
  • If an Insomnia episode remained for longer than 2 weeks, there was nearly a 50% chance of developing MDD at a later date (Buysse et al., 2008).
  • While prior Insomnia was found to be significantly associated with the onset of MDD, Depression was not significantly associated with the later start of Insomnia (Johnson et al., 2006).

Even if Insomnia was initially secondary to Depression, once it remains for one month it is likely to have developed into a separate and chronic problem. This is due to the poor sleeping practices, daytime habits, and unhelpful beliefs about sleep that people evolve over time in an attempt to overcome their Insomnia. These perpetuating factors may include excessive time in bed awake, high caffeine during the day or alcohol usage at night, napping during the day, extreme focus on and worry about sleep, and conditioned hyper-arousal at night (Yang et al., 2006). Unless these perpetuating factors are targeted explicitly through treatment for Insomnia, it is unlikely that sleep complaints will improve (Carney, Harris, Freedman & Segal, 2011).

Untreated Insomnia increases both the severity and duration of Depression (Staner, 2010). Furthermore, if Insomnia remains after Depression has remitted, the chance of an MDD relapse is much higher. Research indicates that 40% of individuals with Depression will relapse within a ten month period (Paykel, 2008). Of all the 21-items on the Beck Depression Inventory, sleep difficulties were the only symptom that significantly predicted a depressive relapse over the 4-week period following remission (Perlis, Giles, Buysse, Tu, & Kupfer, 1997). Chronic insomnia must, therefore, be targeted alongside MDD when the conditions co-exist for optimal treatment outcomes.

How do we treat Insomnia and Depression together?

When Depression and Chronic Insomnia occur together and vary in their course, it is important to target them both in an active treatment intervention. Medical practitioners appear to administer antidepressants and hypnotics over psychological treatments because they are more easily accessible, quick to administer and offer lower initial and short-term costs (Economics, 2011). They are also more likely to favour pharmacological over non-pharmacological interventions due to the traditional biomedical model of training in these facilities, which minimises the psychological and social factors involved in mental health disorders (Frostholm et al., 2005). Consequently, antidepressants are the most common treatment for Depression (McManus, Mant, Mitchell, Britt, & Dudley, 2003), and hypnotics are the most common treatment for Insomnia (Charles et al., 2009).

Hypnotics have been found to improve sleep in individuals with Depression alongside antidepressant treatment (Asnis et al., 1999). Another extensive study recruited 545 patients with a diagnosis of both Insomnia and Depression and found significant improvements in sleep efficiency, sleep quality, and total sleep time after both four and eight weeks in a combined antidepressant and hypnotic treatment when compared to an antidepressant plus placebo treatment (Fava et al., 2006). Importantly, Depression improvements were also significantly higher at both week 4 and week 8 (p < .01). Therefore, when co-morbidities exist, explicitly treating both Insomnia and Depression can result in higher amelioration of both conditions.

Sleeping pills vs Cognitive Behavioural Therapy for Insomnia (CBT-I)

Several clinical trials have compared the efficacy of hypnotics to non-pharmacological treatments for Insomnia, and have found similar short-term benefits (Riemann & Perlis, 2009). A meta-analysis comparing the two types of procedures across 21 studies found that that cognitive and behavioural therapies for Insomnia had similar efficacy over 4 weeks to hypnotics, with an average effect size of 0.79 vs. 0.80 (Smith et al., 2002). However, the non-pharmacological treatments produced significantly higher reductions in the time taken to fall asleep at the beginning of the night, known as sleep onset latency (SOL) (Smith et al., 2002).

CBT-I may be preferable over hypnotics for the treatment of Chronic Insomnia due to its low risk of adverse effects (Smith et al., 2002). It also has more considerable empirical evidence of long-term sleep benefits, with research showing therapeutic gains maintained or further improved at 1-month, 3- month, 6-month, 1-year, and 2-year follow-up assessments (Morin et al., 2006; Riemann & Perlis, 2009). In contrast, sleep improvements made through hypnotics are rarely retained through long-term treatment (Riemann & Perlis, 2009) and often return to baseline levels of sleep disturbance following the cessation of hypnotic use (Jacobs et al., 2004). Although CBT-I may be seen as an initially expensive treatment, it becomes more cost-effective than GP visits and hypnotic treatment over time due to its more significant long-term benefits for Chronic Insomnia (Harsora & Kessmann, 2009). As a result, CBT-I should be more widely used than sleeping pills in the treatment of Chronic Insomnia.

An individual’s belief that they are able to do a task well is known as self-efficacy (Maciejewski, Prigerson, & Mazure, 2000). Increased self-efficacy towards sleep is more likely to occur when an individual with Chronic Insomnia attributes their sleeping improvements to their own behaviour rather than sleeping medication (Harvey, Tang, & Browning, 2005). Because self-efficacy is thought to play a mediating role between stressful life events and Depression severity (Maciejewski et al., 2000), treating Insomnia with CBT-I is likely to have additional positive effects on mood in comparison to hypnotic treatment. This lends further support to the view that CBT-I needs be implemented in the treatment of co-morbid Insomnia and Depression.

What is CBT-I?

Cognitive behavioural therapy for insomnia (CBT- I) is a multi-modal treatment that combines several individual strategies that have been previously developed and utilised in the non-pharmacological treatment of Insomnia (Edinger & Means, 2005). Many of these unique techniques have been shown to be efficacious as stand-alone treatments. This includes stimulus control (Morin & Azrin, 1987), sleep restriction (Friedman, Bliwise, Yesavage, & Salom, 1991), paradoxical intention (Turner & Ascher, 1979), and progressive muscle relaxation (PMR) (Pendleton & Tasto, 1976).

The four main components of CBT-I include:

  1. Psychoeducation about sleep and sleep hygiene recommendations, which helps people to develop more realistic expectations of their sleep and become more aware of factors that can have a negative impact on their sleep.
  2. Sleep Scheduling, which involves stimulus control (helps people to recondition the bed with calmness, sleepiness and sleep instead of spending excessive time awake in bed alert, worried or frustrated) and sleep restriction (helps people to only spend the amount of time in bed that they need for sleep) interventions.
  3. Cognitive therapy, which challenges some of the unhelpful thinking patterns and beliefs about sleep that typically develops in insomnia, such as “I need 8 hours of sleep to function well during the day!”, “I must catch up on lost sleep”, or “If I don’t sleep well tonight, I’ll be ruined for the rest of the week!” These beliefs only increase the anxiety and pressure around sleeping, which makes the Insomnia severity worse over time.
  4. Relaxation techniques, which helps people to lower their stress and arousal levels during the day and before sleep so will find it easier to get to sleep and stay asleep.

Does CBT-I work?

The research findings on the efficacy of CBT-I in Primary Insomnia participants suggests superior efficacy for CBT-I over wait-list and placebo controls, as well as PMR, sleep hygiene education and pharmacological interventions. The meta-analysis found that multi-modal CBT-I produced large effect sizes in both SOL (1.05) and WASO (0.92), and moderate effect size (0.75) for TST (Morin, Culbert, et al., 1994).

The cumulative findings of the research on CBT-I suggest that it enhances sleep-related self-efficacy, corrects dysfunctional beliefs about sleep, reduces the use of sleep medications, improves mood and reduces anxiety symptoms, and leads to long-term functional improvements in both daytime and night-time functioning (Morin et al., 2006). Given such findings, CBT-I can be considered both highly efficacious and effective treatment for sleep difficulties and related complaints in individuals with Chronic Insomnia. CBT-I is classified as a well-established empirically supported treatment according to the criteria set forth by the American Academy of Sleep Medicine (Morin et al., 2006).

Once CBT-I’s efficacy was established, varied lengths of treatment, as well as forms of administration, were assessed. CBT-I remains efficacious even when protocols vary in length from 4-weeks (Edinger et al., 1992) to 8-weeks (Morin et al., 1993). When it is administered individually (Edinger et al., 2001) or in a group setting (Morin et al., 1999). And potentially even when it is self-administered (Rybarczyk, Mack, Harris & Stepanski, 2011), administered with telephone consultation (Mimeault & Morin, 1999), or delivered via the Internet (Strom, Pettersson, & Andersson, 2004).

The Effectiveness of CBT-I for co-morbid Insomnia and Depression

At the time of my Doctoral research, eight studies had investigated the non-pharmacological treatment of Insomnia symptoms in individuals with co-morbid Depression:

The first study administered a six-week self-help sleep program to 57 individuals with Insomnia and Depression (Morawetz, 2003). At post-treatment, the majority of individuals who substantially improved their sleep had also significantly reduced their Depression severity, with 57% reaching depressive remission based on the Beck Depression Inventory scores, and a further 13% achieving at least a 40% reduction in their ratings. Interestingly, all individuals who failed to make substantial improvements in their sleep also failed to substantially reduce their depression severity (Morawetz, 2003).

The second study assessed six weekly sessions of CBT-I treatment in eight participants with Chronic Insomnia and mild Depression (Taylor, Lichstein, Weinstock, Sanford, & Temple, 2007). They found significant improvements across several sleep measures, which remained significant by the follow-up assessment three months later. Importantly, Depression severity also significantly reduced from pre-treatment to follow-up in all but one participant (Taylor et al., 2007).

A randomised controlled trial (RCT) was then conducted for 30 participants with co-morbid Insomnia and Depression, who were assigned to an SSRI and CBT-I treatment condition or an SSRI and quasi-desensitisation therapy (control) condition for 12 weeks (Manber et al., 2008). The combined treatment group had a 42.3% greater remission rate from Insomnia. A higher remission rate was also found for Depression with CBT-I (61.5%) in comparison to the control therapy (33.3%), but this finding did not reach statistical significance, possibly due to the concurrent commencement of antidepressant treatment in both treatment groups (Manber et al., 2008).

The next RCT recruited 37 individuals with ongoing Insomnia and Depression symptoms following adequate antidepressant treatment and compared treatment-as-usual plus four weekly sessions of CBT-I to a treatment-as-usual control group (Watanabe et al., 2011). At the eight-week assessment, sleep efficiency, Insomnia severity and Depression severity were all significantly better in the CBT-I group. 50% reached remission from their Insomnia compared to 0% of the control group, and 50% achieved remission from their Depression compared to 6% of the control group (Watanabe et al., 2011).

The remaining studies produced promising findings, with CBT-I significantly reducing Insomnia and Depression severity across treatment (Wagley et al., 2012). It also improved sleep and reduced anxiety (Lancee, van den Bout, van Straten, & Spoormaker, 2013; Maroti, Folkeson, Jansson-Frojmark, & Linton, 2011), lessened suicidal ideation, improved energy, self-esteem, productivity, and well-being (Manber et al., 2011).

Why CBT-I for Co-Morbid Insomnia and Depression?

The rationale for CBT-I treatment in individuals with co-morbid Insomnia and Depression is that the Insomnia is thought to be maintaining a level of Depression through poor satisfaction with sleep and impaired daytime functioning (Franzen & Buysse, 2008; Staner, 2010). Initial antidepressant treatment may improve mood substantially, but its inability to directly address the perpetuating factors of Chronic Insomnia means that gains will often stagnate above the remission threshold in co-morbid cases. By directly targeting the Insomnia with CBT-I at this point, Insomnia is likely to improve, which should subsequently result in additional reductions in Depression severity. As long as a control group is used for comparison, it would then be possible to determine how much of the improvements in Depression could be attributed to the CBT-I intervention.

sebastian-sammer-221490

My Research (Ashworth et al., 2015)

  • The RCT that I conducted as part of my Doctoral Thesis examined this very rationale and found that both Depression and Insomnia severity were significantly reduced over four sessions of CBT-I treatment in comparison to a sleep education intervention.
  • These significant differences were maintained at the 3-month follow-up and resulted in a ten-times higher long-term remission rate from both conditions through CBT-I.
  • Reductions in stress and improved sleep hygiene behaviours seemed to be required for CBT-I to produce short-term improvements in Depression severity, whereas cognitive changes seemed to be needed for short and long-term Insomnia improvements, as well as longer-term enhancements in Depression.
  • Relaxation and behavioural interventions need to be prioritised initially in CBT-I treatment for co-morbid Insomnia and Depression, followed by cognitive interventions for optimal longer-term outcomes.

The cumulative research findings indicate that CBT-I, both on its own, and in addition to antidepressants, is a promising treatment for co-morbid Insomnia and Depression. By optimising the CBT-I intervention for this population and administering it at the right time, significant improvements in sleep and mood are likely to occur, resulting a higher remission rate from both Chronic Insomnia and MDD, and lower risk of relapse into the future, reducing the overall burden of these conditions on society.

Thanks for reading! If you would like a personalised sleep report and the five things that you could do to best improve your sleep, please check out our services.

Dr Damon Ashworth

Clinical Psychologist

Do You Want To Be Deliberately Better?

“Good company in a journey makes the way seem shorter.” — Izaak Walton

ashley-batz-1298.jpg

It was 2016 when I first decided to take on the challenge of being accountable to myself. I later wrote this blog so that I could take responsibility for my actions in an open, transparent way, do what I said I was going to do, and “practice what I preach.”

For me, as a Psychologist, becoming deliberately better is all about evidence-based living. It is about engaging as much as possible in thinking patterns and behaviours that through research have been shown to lead to a happier, more satisfying, higher quality of life.

The following were five key areas that I planned to focus on for the year of 2016, with the idea of it having positive flow-on effects for my long-term psychological well-being in 2017 and beyond.

The best part is that just by stating these objectives where they can be publicly seen, my desire to be consistent and faithful to my word did seem to actually help me to stay more committed to achieving these goals:

1. Tuning in rather than tuning out

jeremy-bishop-211453.jpg

Too often in Western Culture, we spend all of our day “doing”, rushing around and completing tasks, and not enough time “being”, simply living in the moment and being connected with our thoughts and feelings and sensations as we are experiencing them in the present.

Other ways that people tune out of their experiences are through distracting themselves with watching too much TV or spending too much time on social media or surfing the internet, smoking cigarettes or using drugs, drinking too much caffeine or alcohol, eating junk food and keeping busy with too much work. Some of these strategies are successful in blocking out what we feel in the short-term, but if we never listen to the signals that our body sends us, they will only amplify in intensity over time, until eventually, we will have no choice but to take notice of the message that is being given.

Formal mindfulness practice is considered to be the best way to first adjust to and get the most benefits out of tuning in and just being. Mindfulness practice consists of maintaining our attention on whatever is occurring at the moment in an open, curious, accepting, patient, non-judging, and non-striving way. I recommend learning guided meditations first, and then practising on your own if you’d prefer once you have figured out the various forms of meditation and how they help you. A few free apps that I would recommend if you are interested in learning these skills are Smiling Mind, Calm, and Headspace.

Once you have learnt the basics of mindfulness, it then becomes a lot easier to also engage in informal mindfulness practice, where you apply these same mindfulness principles in whatever task that you do throughout the day. By tuning in through Mindfulness, the benefits have been shown to include reduced stress, pain and anxiety, improved sleep and mood, a higher capacity to soothe yourself when you are distressed, and a reduced risk of a future depressive episode.

2. Turning towards my values rather than away from fear

ali-inay-2278.jpg

I regularly bring up values with my clients. It is for a good reason. The way I see it, there are two primary motivators in life. We can either be motivated to move towards what is important to us (our values), or we can be driven to move away from the things that we fear.

What is interesting, as first pointed out to me in Daniel Kahneman’s book ‘Thinking, Fast and Slow’, is that most people are predisposed towards being risk adverse, and being more motivated by what they may lose rather than what they could gain. This means that most people play it safe, stay in their comfort zone, try not to change things too much, and don’t take any chances, even if the potential gains outweigh the potential losses.

Most people need at least a 2:1 ratio of things being likely to turn out well before they will take a risk, and some people will never take a chance unless a positive outcome can be 100% guaranteed (which isn’t really a risk at all). The risk of dying in a plane crash or being eaten by a shark are both extremely low, but I’ve met several people who choose not to fly or swim in the ocean because of these fears. My question to these individuals is “What do you lose by not taking this risk?” The chance for fun? Excitement? Adventure? Considering that these values are all important to me, I’d allow myself to feel the fear, sit with it, and take the risk so that I can live a more vibrant, enjoyable and meaningful life.

All of the most successful treatments for anxiety involve exposure to the feared stimuli as an essential part of the treatment. By facing up to our fears, anxiety can be reduced and no longer cause significant distress or functional impairment. It is uncomfortable, but worth it in the pursuit of a goal that is consistent with your values. By living in line with your values and not those of your family, friends or society, you are much more likely to feel energised, motivated and satisfied with where you are at and where you are headed.

3. Maintaining an ideal work/life balance

manuel-moreno-39516.jpg

One of the biggest traps that I see with my clients is putting off enjoyment today until some designated time in the future (e.g. once I finish uni, once I get a job, once I pay off the house, once I’ve saved a certain amount). What tends to happen in the meantime is that they dedicate most of their life to study and work and saving, and postpone looking after themselves or having fun, exercising, engaging in hobbies, being creative, learning a new skill, travelling, and socialising with others.

The Grant Study, which began in 1938 with 268 Harvard undergraduate men, is still running and collecting data over 77 years later. Across all of this data, they found that one thing was the most significant predictor of health and happiness later in life, and this was relationship warmth. Individuals who were in loving relationships, had close families, and good friends outside of their partner and family were considered to be the most satisfied with life. It wasn’t just about the number of friends or family either, it was about having those quality relationships where you knew that you could depend on the other person when you needed them the most.

Making more money did have some correlation with overall happiness and health outcomes, but individuals with greater relationship warmth also tended to make more money. It is, therefore, crucial to spend time with others and to put energy into cultivating positive relationships. Given this data, socialising with those that we care about should never be seen as a waste of time.

4. Writing things down rather than keeping things in

aaron-burden-64849.jpg

Planning and reviewing are essential for minimising stress and ensuring that we are staying on track with our goals. In the excellent book ‘Getting Things Done’ by David Allen, he recommends both a daily review and a weekly review, where you are able to go through everything that has occurred and process it into an all-encompassing management system. By having everything where it is supposed to be, and either filed away or waiting to be done at a particular time and place, it is meant to ensure that our head is as clear as possible. This then enables us to focus on whatever is most important to us at the moment (e.g. the task that we are doing).

I recommend to my clients to quickly jot down whatever is incomplete or still to be done at the end of the workday, followed by a quick plan on when you are able to address this task and the first step that you would do. It shouldn’t take any longer than 5 minutes a day, and can really help in making sure that you can switch off from work once you are at home. For individuals that don’t sleep well due to a racing mind, doing this same process with anything that is on their mind two hours before they go to bed will also reduce their likelihood of being up all night thinking.

The crucial step is ensuring that we are writing down when we will do it (and what the first action is), rather than just making a to-do-list. The Zeigarnik effect shows that our brains will continue to remind us of something that is incomplete until we have done it or have a plan to do it. Surprisingly, once we have a plan (and it has been written down in a place that we won’t forget), our brains treat the task as already being done, and the result is a less busy mind, less stress and more energy. So even if you want to finish painting the house, but won’t have time until your annual leave in 3 months time, write it down. Or create a someday/maybe file, and put it in there.

5. Developing a growth rather than a fixed mindset

markus-spiske-104913.jpg

In her book ‘Mindset: The New Psychology of Success’ Carol Dweck has identified a concept that is more crucial towards academic and occupational success than intelligence.

Individuals with a fixed mindset believe most of our traits, including our intelligence and personality, are fixed or unchangeable. Because of this, they tend to view successes as evidence that they are great, and mistakes as evidence that they are horrible or not good enough. Unfortunately, what this means is that whether they win or lose carries massive consequences, because in many ways their identity is on the line with everything they do. If they experience a setback, they won’t try to learn from it or improve, because what’s the point, they apparently aren’t good enough, so why bother trying. They’ll also give up more easily when things become challenging and tough.

Conversely, the individuals with a growth mindset will view their performance on a task as just that – their performance on the task, and not an indication of how smart or capable they are. They see setbacks as chances to learn and grow and improve their skills going forward. Because of this, they are more happy to challenge themselves and persevere through difficulties. They are also much more compassionate and understanding of themselves when they make a mistake, rather than self-critical like the individuals with a fixed mindset.

Fortunately, a growth mindset can be taught. By praising behaviour and effort (“You tried so hard”) rather than characteristics (“You are so smart”), and viewing mistakes as an essential part of the learning process, growth mindset training increases motivation, resiliency and achievement. So even if you don’t naturally look at things in this way, it’s never too late to learn and grow.

 

Dr Damon Ashworth

Clinical Psychologist

How Should We Define Success As A Nation?

The Olympic Slide

Following the completion of the Rio Olympic Games, a theme of concern became evident across the various media platforms in Australia. Our overall medal tally at the Olympic Games has been in decline since it’s peak of 58 in Sydney in 2000, with 49 in Athens in 2004, 46 in Beijing in 2008, 35 in London in 2012, and now 29 in Rio.

The final medal tally in Rio puts Australia in 10th place with 8 gold medals, 11 silver and 10 bronze, well behind the Australian Olympic Committee’s predictions of 13 gold and 37 medals. Australia’s performance still wasn’t too bad considering our population size, but we were miles behind the two countries with the most gold medals. First place was the usual victors, the U.S.A, with 46 gold and 121 medals overall. Second place was the U.K., with 27 gold and 67 medals overall.

Australia is a proud sporting nation, and part of our national identity has taken a hit seeing the sharp decline in Olympic glory this century in comparison to the ongoing ascension of the U.S. and the U.K.

The U.S. has increased their tally from 37 gold and 93 medals in 2000, while the U.K. has dramatically improved theirs from 11 gold and 28 medals overall back in Sydney. We used to be better than the U.K., not even that long ago, and now we are not even close. Let’s not even get started on ‘The Ashes’, where we have now lost five of the last seven test cricket series to England dating back to July 2005.

If we were to look at these statistics alone as a measure of a country’s overall success, then it is a worrying trend for Australia and a very positive sign for the U.S. and the U.K.

If we wanted to reverse this trend, it would be essential to figure out exactly what the U.S. and the U.K. are doing right and try to emulate what they are doing so that we can get closer to their levels of success in the future. It would really come down to spending more taxpayer’s money on:

  1. improved programs to get people to participate more in a sport at a young age,
  2. enhanced facilities to increase opportunities to excel,
  3. improved coaching to help bring out the best in athletes, and
  4. more focused investment towards the sports and top athletes that have the highest potential of producing multiple gold medals at the Olympic Games.

The problem is that we have already tried to do this, with the Australian Sporting Commission following the lead of the U.K.’s recent success with their own ‘Winning Edge’ program. In the four years leading up to Rio, this program unevenly distributed $340m towards summer Olympic sports, particularly the events that Australia was thought to have a better chance to win in, such as Hockey, which cost us $28million for zero medals.

At over $11million of taxpayers money per medal won in Rio, it becomes crucial to wonder if the extra cost is really worth it, or if there are better ways that Australia can try to measure ourselves or improve on the world stage?

What if there was a medal tally for non-Sporting indicators of success?

1. Gross Direct Product

Traditionally, apart from Olympic Glory, Nations have utilised their Gross Direct Product (GDP) to compare themselves to other countries and show the world just how successful and prosperous they are. If we were to look at the nominal GDP of all nations in 2016, the U.S. once again smashes the field and collects the gold medal with $18,558,130 million, China collects the silver with $11,383,030 million, and Japan picks up the bronze with $4,412,600 million. The U.K. comes in fifth place with $2,760,960 million, and Australia is lagging behind again in 13th place with $1,200,780 million.

Per capita, the country with the highest GDP is Luxembourg with $101,994, Switzerland is second with $80,675, and Qatar is third with $76,576, based on the 2015 International Monetary Fund 2015 estimates.

If we look at GDP calculations that take into account purchasing power parity (PPP) relative to inflation rates and local costs of goods and services, China picks up the gold, the U.S. is relegated to silver, and India comes from nowhere into the bronze medal position. The U.K. drop to 9th and Australia drop all the way down to 19th.

Per capita adjusted for PPP, Qatar wins the gold, Luxembourg pick up the silver, and Singapore takes home the bronze, based on the 2015 estimates provided by the International Monetary fund.

2. The Human Development Index

The United Nations no longer believe that GDP should be the sole factor when determining which countries are best at helping their citizens to successfully develop. Taking into account GDP at purchasing power parity (as a measure of standard of living) alongside life expectancy, education and adult literacy levels, it is known as the Human Development Index. Based on the 2015 Human Development Report results, Norway picks up the gold, with Australia claiming the silver, and Switzerland taking home the bronze.

Importantly, Australia’s score has slightly improved both from 2013 to 2014, and 2014 to 2015, a good indication that we are not in an overall decline as a nation. Our ranking has also improved from 4th in 2008 to 2nd from 2009 onward. Meanwhile, the U.S. rank 8th in the world, a significant drop from their third place rank in 2013, and the U.K. are 14th, a massive jump from 27th in 2013.

Once inequality is taken into account, the average level of human development in Australia is still the second best in the world, with Norway continuing to claim the gold medal, and the Netherlands stepping up to claim bronze. The U.K. drop down to 16th in the world, and the U.S. slide all the way down to 28th.

But what if GDP isn’t the best way to measure a country’s standard of living? What other factors could we also compare nations on to see how Australia stacks up?

3. The World Happiness Report

The first World Happiness Report was released in April 2012 after a resolution in July 2011 invited member countries to measure their citizens’ happiness levels and use these findings to guide their public policies. Reports are now issued each year, with the 2016 release considering 6 main elements to be crucial to how successful we can perceive a Nation to be. These elements are:

  1. GDP per capita
  2. Level of social support
  3. Healthy life expectancy
  4. Freedom to make life choices
  5. Level of generosity
  6. Trust, or perceived absence of corruption in government and business

Based on the results of this report, Denmark wins the gold medal, with Switzerland getting the silver, and Iceland taking home the bronze. Australia is currently in 9th place, with the U.S. 13th, and the U.K. 23rd.

Once again, Australia has improved slightly since the last report, a good indicator that we are not rapidly declining as a country, whereas the U.S. and the U.K. are both on the decline. No country has taken a more prominent hit recently than Greece, with their significant financial difficulties also beginning to influence the social fabric of the once proud nation.

Surely overall Happiness, as measured by these factors, is more important than sporting or Olympic success. Assuming this is true, shouldn’t we be emulating Denmark or the other 7 countries that are ahead of us on this instead of always trying to look up to and compete against the U.S. or the U.K.?

4. The Happy Planet Index

The Happy Planet Index has a slightly different take on what matters most, and to them, this is sustainable well-being for all. They combine life expectancy with individual levels of well-being adjusted for inequality of outcomes within a country and divide this by their ecological footprint to obtain the overall result on the Happy Planet Index. Most Western Countries fare poorly on this scale, with Costa Rica winning the gold, Mexico the silver, and Colombia the bronze. The U.K. is 34th, with both Australia and the U.S. far behind in 105th and 108th place respectively.

Australia does okay in three out of the four items that make up this scale, coming in 7th place at 82.1 years for life expectancy, 11th place at 8% for inequality, and 12th place at 7.2/10 for subjective well-being. What really lets us down is our ecological footprint, which is 139th out of the 140 countries included in the data. Only Luxembourg is worse. The U.S. isn’t much better with their ecological footprint, coming in 137th place, while the U.K. is slightly better, currently in 107th place. Obviously more needs to be done by these Western countries to reduce the ecological footprint that they are having on our planet. Haiti wins gold for the least ecological footprint, with Bangladesh the silver, and Pakistan the bronze.

For subjective well-being, Switzerland wins the gold with a score of 7.8/10, Norway gets the silver with 7.7/10, and Iceland claims the bronze with 7.6/10, well ahead of the U.S. in 18th place (7.0/10) and the U.K. (6.9/10).

For inequality, the Netherlands claim the gold with 4%, Iceland the silver with 5%, and Sweden the bronze with 6%. The U.K. is 19th with 9% inequality, and the U.S. is 34th with 13%.

Lastly, for life expectancy, Hong Kong claim the gold with 83.6 years, Japan the silver with 83.2 years, and Italy the bronze with 82.7 years. The U.K. is 24th with an average life expectancy of 80.4 years, slightly ahead of the 31st ranking for the U.S. with 78.8 years.

5. Health System

If we were to think of ways to further improve our quality of life, having a good health system should be a top priority, yet none of the U.K. (18th), Australia (32nd), or the U.S. (37th) can claim a medal based on the World Health Organisation’s 2000 ratings. France gets the gold, Italy the silver, and San Marino the bronze.

6. Academic Performance

Equally critical to the future of a country should be a good quality of education at the primary, secondary and tertiary levels. When it comes to the 2014 OECD global education rankings, the U.K. is 20th for maths and science, and 23rd for reading, while the U.S. is 28th for maths and science, and 24th for reading. Australia doesn’t fare much better, coming in at 14th in maths and science, and 13th in reading.

More worryingly, Australia has dropped from 6th in maths, 8th in science and 4th in reading in the year 2000. When it comes to schooling, we really do seem to be declining as a nation and are now 17th for percentage of students acquiring at least the necessary skills in these areas, and 19th in secondary school enrollment rates, behind both the U.S. and the U.K.

For reading, China claims the gold medal, with Singapore collecting the silver, and Japan the bronze. For maths and science, Singapore claims the gold, Hong Kong the silver, and South Korea the bronze. South Korea was very similar in their academic performance to Australia back in 2000. Although their increase and our decrease may not seem like such a big deal, a 25 point improvement on what is known as the PISA tests would lead to an approximate expansion of $4.8 trillion to Australia’s GDP by the year 2095. Clearly, education matters.

7. Global Gender Gap Index

Based on the 2015 data, Iceland wins the gold with the least gender gap between males and females of 88.1%. Norway the silver with 85%, and Finland the bronze, with 85% also. The U.K. rank 18th with 75.8%, the U.S. 28th with 74%, and Australia 36th with 73.33%.

In regards to the gender gap, Australia has improved in their score from 72.41% in 2008, but have dropped 15 places from 21st in the rankings over that seven-year time span, meaning that we are closing the gap at a much slower rate than a lot of other countries. We’re now 32nd in economic participation and opportunity, 1st in educational attainment, 74th in health and survival, and 61st regarding political empowerment.

8. LGBTIQ Rights

Based on the first countries to legally recognise same sex-unions, Denmark gets the gold, Norway the silver, and Sweden the bronze.

To qualify for a medal, these countries also had to have legalised same-sex marriage and allow same-sex couples to adopt a child. They must have LGB individuals who are able to openly serve in their military and ban all anti-gay discrimination. They must also have legal documents be amended based on an individual’s recognised gender without the need for surgery or hormone therapy.

The U.K. nearly ticks all of these items, except same-sex marriage is still illegal in Northern Ireland. Same-sex marriage is now legalised in Australia, finally. Apart from some tribal jurisdictions, the U.S. now has legalised marriage, but still has some laws that discriminate based on gender identity and expression, as does Australia.

9. Refugee Resettlement Actions

By the end of 2014, one out of every 122 people were internally displaced, a refugee, or seeking asylum, with half of these refugees being children. Wars, persecution and ongoing conflict now mean that we have more people than ever before trying to reach safety and begin their new lives in a foreign land, with 59.5 million being forcibly displaced in 2014 alone. Due to their close proximity to Syria, both Lebanon and Turkey are taking in vast amounts of refugees annually, with 1.59 million Syrian refugees in Turkey at the end of 2014, and more than 25% of Lebanon’s overall population is Syrian as of the 24th of September 2015.

Based on this article, Germany should win gold, Sweden silver and the U.S. bronze. Meanwhile, the recent Brexit scandal was related to the U.K. not wanting to take on as many refugees and immigrants. Australia’s treatment of refugees and asylum seekers, especially the children, is so notoriously bad that China (not always the best for human rights issues) and the United Nations are publicly speaking out against it. To help end the business of abuse related to refugees and asylum seekers in Australia, please sign this pledge.

10. Freedom of Press

Based on the 2008 results, Finland and Iceland both get the gold medal, with Denmark and Norway taking home the bronze. The U.S. has been the 9th best, followed by the U.K. in 10th, and Australia in 13th.

11. Lowest Infant Mortality Rates

According to the 2015 estimates provided by the CIA World Factbook, Monaco wins the gold with 1.81 deaths per 1000 live births, Iceland wins the silver with 2.06, and Norway and Singapore both claim the bronze with 2.48 per 1000 live births. Australia is 31st, with 4.43, the U.K. is 32nd with 4.44, and the U.S. is 50th with 6.17 deaths per 1000 live births.

12. Soundness of Banks

Based on the 2009 World Economic Forum rankings on a scale from 1 (banks need more money) to 7 (banks are generally sound), Canada picks up the gold with a score of 6.7/7, New Zealand the silver with 6.6/7, and Australia the bronze with 6.6/7. The U.S. comes in at 108th with a rating of 4.7/7, and the U.K. is 126th with a score of 3.8/7. Resilient financial systems are crucial for economic stability, and unstable or unregulated systems were the main culprits in the 2008 financial crisis.

13. Unemployment Levels

Based on 2015 figures, Qatar gets the gold with 0.4%, Cambodia the silver with 0.5%, and Belarus, according to their 2014 data, get the bronze with 0.7%. By March 2016, Australia’s unemployment rate is 5.8%, slightly worse from its 31st ranking in 2013 with 5.7%. In 2013, the U.K. and U.S. were 44th and 45th with 7.3% each, but as of July 2016, the U.K. has improved their rate to 4.9%, and the U.S. have improved theirs to 5.0% by April 2016. Relative to the rest of the world, Australia is declining regarding unemployment too.

And the overall winner is… Norway!

Final medal tally:

Country Gold (3 pts) Silver (2 pts) Bronze (1 pt) Total points
Norway II III II 14
Iceland II II II 12
Switzerland I II I 8
China (excl. Hong Kong) II I 8
Denmark II I 7
Qatar II I 7
Singapore I I II 7
U.S.A I I I 6
Australia II I 5
Hong Kong I I 5
Luxembourg I I 5
Netherlands I I 4
Finland I I 4
Japan I II 4
Sweden I II 4
Italy I I 3
U.K. 0

Conclusion:

Australia is doing alright. We aren’t the best country in the world in any of the critical issues that I’ve analysed, and depending on what it is, we could learn a lot from whoever is ahead of us in the rankings, especially Norway and Iceland. This would be much better than always just trying to emulate the U.S. or the U.K., or overreacting to the media every time they catastrophise and tell us that the apocalypse is near.

Worldwide murder rates (per capita) have continued to decline since the fourteenth century, especially since the 1970s. Higher levels of equality and rights have been achieved across the globe for different races, ethnic groups, females, spouses, children, people with disabilities, and animals, with some countries being more progressive than others.

Australia still has a long way to go as a Nation, especially when it comes to obesity levels, mental health, climate change policy, indigenous health and well-being, LGBTIQ rights, gender equality, our refugee and immigration policy, and any other area where people are treated unequally or discriminated against.

At least with the National Broadband System, a higher percentage of the population will have access to a reliable internet connection, which can help more people to become informed, talk about the critical issues through social media, put more pressure on the politicians, and bring about more rapid social change.

I invite you all to speak up, take action, and follow in Mahatma Gandhi’s footsteps in being the change that you wish to see in the world.

Dr Damon Ashworth

Clinical Psychologist

Angry Boys Become Angry Men: The Constraints and Consequences of Idealising Hyper-Masculinity

The messages that we deliver to boys about what it means to be a man can have a powerful impact on who they become

I recently watched a fascinating documentary on Netflix titled ‘The Mask You Live In’ about the American masculine ideal and the consequences of teaching boys not to value emotions, sensitivity, connection, caring, and empathy.

Although the data that is presented throughout the documentary is related to American males, the messages that they refer to at the beginning of the film are all things that I remember hearing growing up in Australia:

  • “Man up!”
  • “Be a man!”
  • “Don’t be a mamma’s boy!”
  • “Stop being weak.”
  • “You’ve got to be tough!”
  • “You’ve got to be strong!”
  • “Stop crying!”
  • “Boys don’t cry!”
  • “Don’t be a pussy!”
  • “Grow some balls!”
  • “Don’t let anybody disrespect you!”

The constraints of idealising hyper masculinity

ben-white-124388.jpg

“Our boys are born with empathy just as our girls are, and yet we socialize that sensitivity, emotion, and empathy out of them.” – Jennifer Siebel Newsom

In ‘The Mask You Live In’, they explain that there are typically more similarities between boys and girls than there are differences. Yes, more males fall on the masculine end of the masculine-feminine spectrum, and more females fall on the feminine end. However, there is approximately a 90% overlap between the two populations if you assess 50,000 boys and 50,000 girls, with results being normally distributed for both males and females. Given this, there is actually a large percentage of children who identify as girls that are more masculine than some boys, and a similarly large percentage of children who identify as boys that are more feminine than some girls. Yet if you looked in toy stores, or on the TV, or even in playgrounds or school yards you’d never realise this.

Males and females do begin with small biological differences at birth, due to having an XX or an XY chromosome, and these biological differences do widen further once children reach puberty. Even so, the gender roles that we now perceive to be normal are still much more socially created rather than biologically predetermined. Thanks to the media, the entertainment industry and marketing, we are now seeing hyper-masculinity and hyper-femininity as the ideal.

If you don’t believe me, pay attention to the first answer that pops into your head when you read these questions:

  1. What are girls favourite colours?
  2. What are boys favourite colours?
  3. What toys do girls play with?
  4. What toys do boys play with?

If you instinctively thought 1. pink and purple, 2. blue and red, 3. dolls, make-up and ponies, and 4. cars, balls, and action figures then you have proved my point. Most children do not fit into these categories naturally but are instead socialised into these roles as they grow and are encouraged to do so based on what their parents and the TV says, or what their peers do.

If boys are generally 90% similar to girls, and yet socialised to disavow anything that even resembles femininity, how whole or authentic can they indeed grow up to be? Of course, we all want our children to succeed in life, but can this even be done without feeling pain, vulnerability, sadness, and fear, or knowing how to efficiently deal with these emotions when they arise? Surely it has to be damaging to continue to encourage boys to switch off from themselves at such a young age and to externalise their emotional pain by lashing out at others if they feel vulnerable, insecure,  disrespected, or under threat…

The consequences of idealising hyper-masculinity

Based on the research presented in ‘The Mask You Live In’, the consequences are:

1. Bullying:
  • 1-in-4 boys report being bullied at school.
  • Only 30% of boys that are bullied notify adults, because it is also considered “weak” to get help or tell on someone else.
2. Drinking and Drugs:
  • By age 12, 34% of boys have started drinking
  • 1-in-4 boys binge drink (have five or more drinks in one sitting)
  • The average boy tries drugs at age 13
  • Both drinking and drugs are often used to treat loneliness
  • Also the only time where they can often be emotional, connect with their friends, and tell their friends how much they love them.

9.3% of Australian males between the ages of 16 and 54 are likely to meet criteria for substance use disorder in the past 12 months, with 1-in-3 (35.4%) expected to experience a substance use disorder in their lifetime. The highest rate of substance abuse is found in males under 24 years of age (Australian Bureau of Statistics, 2007).

3. Suicide
  • Every day, 3 or more boys in the U.S. commit suicide
  • For boys, suicide is the third leading cause of death
  • For 10-14 year olds, the suicide rate for males is 3 times that of females
  • By 15-19 years of age, the suicide rate for males increases to 5 times that of females

Five out of the nearly 7 people that die of suicide in Australia each day are males, which equated to 1,885 male deaths by suicide in 2013. For the 15-19 age group, 34.8% of all male deaths are a result of suicide, with each suicide likely to profoundly impact at least another six people for the rest of their lives (Australian Bureau of Statistics, 2013; 2015).

4. Mental Health
  • Fewer than 50% of boys and men with mental health difficulties seek help
  • Boys are 3 times more likely to be diagnosed with ADHD

5.3% of Australian males over 15 are likely to have experienced depression to a clinically significant severity in the past 12 months, with 1-in-8 expected to experience a mood disorder in their lifetime. For anxiety, 10.8% of Australian males are likely to have experienced it to a clinically significant amount in the past 12 months, with 1-in-5 expected to experience an anxiety condition in their lifetime (Australian Bureau of Statistics, 2007).

5. Academic Performance
  • Compared to girls, boys are more likely to flunk or drop out of school
  • Boys are less likely to go to College
  • Boys are 2 times more likely to be in special education
  • Boys are 2 times more likely to be suspended and 4 times more likely to be expelled
6. Violence
  • Every 9 seconds, a woman is beaten or assaulted in the U.S.
  • 1-in-6 boys is sexually abused.
  • Every hour, more than 3 people are killed by a gun.
  • That’s over 30,000 lives annually.
  • 90% of homocide perpetrators are male.
  • Almost 50% are under 25 years of age.
  • Mass homicides (where 4 or more people are killed) occur on average every 2 weeks.
  • 94% of mass homicides are committed by males.
  • The youngest mass shooter was 11.
  • The rate of mass shootings has tripled since 2011.
  • There has been almost one school shooting per week since the Sandy Hook Massacre.

Girl’s in the US have just as much access to guns, so why are nearly all mass shootings being committed by males?

The documentary suggests that it is because men are taught to externalise their emotional pain. If a girl feels sad or scared, they are usually trained to look within to identify what it is, put a label to it, and express how they feel to someone else (without acting on it). They then decide what (if anything) needs to be done to feel better in time. But if a boy feels sad or scared, it is either dismissed or criticised, and the boy is left on their own to deal with these overwhelming sensations that they cannot even put a name to. Most boys are not taught to be introspective, to tune into to what they feel, or to be self-aware. They are trained to bottle it up or deny what they feel or distract themselves by keeping busy. The one emotion that often isn’t discouraged in boys, especially when you look at the media, is anger and violence. So in time boys begin to learn that if they feel bad, it must be the fault or someone else who was disrespecting them. In a world void of communicating how they feel, the easy way for boys to get this respect and to be heard is through violence.

The Solution

Research by John Gottman in his 2002 book ‘The Relationship Cure’ supports an emotion-coaching (“I understand. Let me help you!“) environment as being the best for helping boys to develop more prosperous and more connected relationships when they are older. An emotion-coaching environment can also encourage boys to turn towards adults more frequently because they learn how helpful guidance from empathically attuned adults can be when they are trying to cope with overwhelming feelings.

We need to create an environment where:

  • it is okay for boys to feel scared or sad or embarrassed or vulnerable or ashamed
  • it is okay for boys to share or express how they feel without having to act it out
  • boys are encouraged to learn and identify what is going on for them internally and to develop self-awareness and emotional intelligence
  • boys are encouraged to seek help and support if they are struggling, whether this is from their peers, family, teachers, coaches, mentors or a psychologist or counsellor
  • we try to understand what boys are going through emotionally instead of dismissing their feelings (“You’ll get over it!“) or disapproving them (“Don’t feel that way!“), and
  • it is not seen as a sign of weakness to be emotional or seek help when things are challenging, as this can actually help boys to develop greater long-term resiliency.

ben-white-128604

As they say at the end of ‘The Mask You Live In’:

Everyone deserves to feel whole, and each of us can do our part in expanding what it means to be a man for ourselves and the boys in our lives.

Take the challenge. Exert your influence. We all have a role to play in creating a healthier culture.

If you are a male and are wanting to understand your emotions better, change your behaviours, or just feel whole, an appointment with a psychologist could help.

For more information, please check out Man Therapy or The Representation Project.

Dr Damon Ashworth

Clinical Psychologist

What Do Clients Find Most Helpful About Therapy?

When clients first begin their therapy journey, they often ask to be taught specific skills that are going to help them achieve their particular goals.

Clients believe that if they can be taught these skills, they will be able to overcome their difficulties or the problems that led to them entering therapy, and they will have no subsequent complications or need for additional treatment going forward.

Cognitive Behavioural Therapy (CBT) is a short-term treatment that clients can easily understand. It is based on the premise that all difficulties arise from unhelpful cognitions (beliefs, expectations, assumptions, rules and thoughts) and unhelpful behaviours. CBT aims to help clients see that their cognitions and behaviours are unhelpful, and tries to teach them skills that can help them to replace these unhelpful cognitions and behaviours with more helpful ones. If this is achieved, the assumption is that clients will change and therefore improve.

I do believe that if a client is able to have more helpful cognitions and behaviours, then they will have significantly improved psychological health and overall well-being. I’m just not sure if I agree that the process that is required to get to this outcome is the same as what many CBT clinicians would believe. In fact, focus on distorted cognitions has actually been shown to have a negative correlation with overall outcomes in cognitive therapy for depression studies (Castonguay, Goldfield, Wiser, Raue, & Hayes, 1996).

What actually leads to improvements in treatment?

My previous article “What Leads to Optimal Outcomes in Therapy?” answers this question in detail and shows that the outcome is dependent upon (Hubble & Miller, 2004):

  • The life circumstances of the client, their personal resources and readiness to change (40% of overall outcome variance)
  • The therapeutic relationship (30% of total outcome variance)
  • The expectations about the treatment and therapy (15% of global outcome variance)
  • The specific model of treatment (15% of overall outcome variance)

For cognitive therapy for depression, both therapeutic alliance and the emotional involvement of the patient predicted the reductions in symptom severity across the treatment (Castonguay et al., 1996). Many therapists are now aware of these findings, but clients are generally not.

What do clients view to be the most valuable elements of therapy once they have improved?

By the end of treatment, especially if it is a successful outcome, clients tend to have a much different outlook on what they think are the most valuable aspects of therapy when compared to what they were looking for at the beginning of their treatment.

In Irvin Yalom’s excellent and informative book ‘The Theory and Practice of Group Psychotherapy’, he goes into detail about a study that he conducted with his colleagues that examined the most important therapeutic factors, as identified by 20 successful long-term group therapy clients. They gave each client 60 cards, which consisted of five items across each of the 12 categories of therapeutic factors, and asked them to sort them regarding how helpful these items were across their treatment.

The 12 categories, from least helpful to most helpful were:

12. Identification: trying to be like others

11. Guidance: being given advice or suggestions about what to do

10. Family reenactment: developing a greater understanding of earlier family experiences

9. Altruism: seeing the benefits of helping others

8. Installation of hope: knowing that others with similar problems have improved

7. Universality: realising that others have similar experiences and problems

6. Existential factors: recognising that pain, isolation, injustice and death are part of life

5. Interpersonal output: learning about how to relate to and get along with others

4. Self-understanding: learning more about thoughts, feelings, the self, and their origins

3. Cohesiveness: being understood, accepted and connected with a sense of belonging

2. Catharsis: expressing feelings and getting things out in the open

1. Interpersonal input: learning more about our impression and impact on others

The clients were unaware of the different categories, and only rated each of the 60 individual items concerning how helpful it had been to them.

What becomes apparent when looking at these categories is that giving advice or suggestions about what to do is often not found to be a beneficial element of the therapy process, even though this is precisely what most of the clients are initially looking for. What is far more important is the client developing a more in-depth knowledge of themselves, their internal world, and how they relate to and are perceived by others in interpersonal situations.

 

The top 10 items that the clients rated as most helpful were (Yalom & Leszcz, 2005):

10. Feeling more trustful of groups and of other people.

 

9. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same.

 

8. Learning how I come across to others.

 

7. Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others.

 

6. Expressing negative and/or positive feelings toward another member.

 

5. The group’s teaching me about the type of impression I make on others.

 

4. Learning how to express my feelings.

 

3. Other members honestly telling me what they think of me.

 

2. Being able to say what is bothering me instead of holding it in.

 

1. Discovering and accepting previously unknown or unacceptable parts of myself.

Each of the 20 clients that made up these survey results had been in therapy for an average of 16 months and were either about to finish their treatment or had recently done so. Obviously, these items were about group therapy so the most important factors for change in individual treatment may be different. However, even with individual therapy, Yalom believes that in the end, it is the relationship that heals.

For more information, feel free to check out Chapter 4 in ‘The Theory and Practice of Group Psychotherapy’ by Irvin Yalom and Molyn Leszcz (2005), or any of the other studies out there that look into the outcomes or therapeutic factors involved in change across psychological treatment.

If you have ever wanted to discover and learn more about yourself, accept yourself more, express yourself better, take greater responsibility for your life, challenge yourself and develop more trust in others, longer-term psychological therapy may be just what you need!

 

Dr Damon Ashworth

Clinical Psychologist