The Little Things That We Do Matter Over Time

“Watch your thoughts; they become words. Watch your words; they become actions. Watch your actions; they become habits. Watch your habits; they become character. Watch your character; it becomes your destiny.”

– Lao Tzu

I love the above quote by Lao Tzu. It highlights that all of the little choices in life are important, especially in the long run. Not a single option or action unless it is unusually severe or unforgivable. I’m talking about the little things we do regularly, which accumulate over time and define who we are and how others see us.

            It may be something like choosing to make your bed every morning or getting up to go to the gym before work. Or having a veggie smoothie rather than a jam-filled doughnut and caramel macchiato for your 3 pm work snack. Taking the easy or not-so-healthy option may not seem like such a big deal if it’s just the once, but what if this becomes a habit over time?

            Without realising it, you may wake up one day and recognise that you have severe sugar, nicotine, alcohol or smartphone dependency. But, unfortunately, it’s no longer as easy to stop this behaviour as you may have believed. Especially once it becomes an ingrained habit. 

Neuropsychologist Donald Hebb famously said in 1949:

Neurons that fire together, wire together.

– Donald Hebb

It means that the more we do a particular action, the more these pathways become ingrained or more substantial in our brain. So the first time we do something, it might be a little path. But if we do it enough, it can become a superhighway, where our brain finds it much easier to repeat that behaviour than do anything else. 

            Most obese, unfit or unhealthy individuals probably didn’t expect they would be where they are. But it didn’t just happen overnight either. They started with an initial thought, felt something, experienced an urge or craving, and chose to act in a certain way. The more they repeated this action in similar situations, the more the brain learnt that this is just what they needed and that this is the correct behaviour whenever they think or feel this way.   Eventually, the action no longer feels like a choice but a compulsion. People may not even realise what they are doing until it is too late. Let alone be able to change it going forward.

William James said something similar but offered a solution to this trap: 

“Thoughts become perception; perception becomes reality. Alter your thoughts; alter your reality.”

– William James

I’m not sure if I agree with William James completely. In my experience, it is often easier to act ourselves into new ways of thinking rather than think ourselves into new ways of acting. While how we think and feel about things is vital, it is tough to make any positive long-term change if we don’t challenge and change our behaviour.

            Suppose we instead change our behaviours first regardless of our thinking. In that case, we will have more and more evidence contrary to the unhelpful thoughts or beliefs that we hold. In time, shifting these negative thoughts and perceptions becomes more comfortable. By doing this, you can shape your reality.

Why Bother Trying to Change?

Someone once asked me: “will you ever just be satisfied with how you are and stop using questionnaires and other measures to keep tracking and changing your life?” It seemed like a weird question, but it is consistent with how my father views life. He knows what makes him happy and does it. He’s not too worried about changing or growing. Instead, he focuses on enjoying each day, even if it’s the same as yesterday.

            That’s great for my father, and on some level, it would be nice, but I can’t do things that way. Maybe it was because I was an often stressed out, anxious and unhappy child. Or perhaps I have seen how much I’ve been able to improve my life and my relationships with others through learning, monitoring, and challenging myself over time.

A quote by Charles Bukowski probably sums it up better than I ever could:

“People are strange. They are constantly angered by trivial things, but on a major matter like totally wasting their lives, they hardly seem to notice.”

– Charles Bukowski

Some Worrying Statistics

According to the Centre for Disease Control and Prevention, people should do at least 4 hours of moderately vigorous physical activity each week. Yet, researchers have found that the average American adult only does 17 minutes each day.

            According to the 2017 OECD findings, more than 50% of adults and nearly one in six children are overweight or obese. This figure is likely to increase further by 2030.

            In addition, the World Health Organisation says that 3 million people died worldwide in 2016 due to harmful alcohol use. Fortunately, alcohol drinking has continued to decrease in Australia since its peak in 1974–1975. However, regular teen alcohol consumption is still the most significant risk factor for problematic alcohol drinking in adulthood.

            In 2014 in the US, 6.2 million people suffered from an illicit substance use disorder. Furthermore, over 115 people die every day from opioid abuse or misuse. Moreover, social isolation and loneliness are becoming more severe problems these days. One-quarter of Americans reported that they have no one to discuss important matters with or call in case of an emergency. Too much social isolation and loneliness can increase the risk of people dying. Perhaps even more than cigarette smoking.

            The average American household watched 8 hours and 55 minutes of TV daily in 2009–2010 (the peak). In 2018, it dropped to 7 hours and 50 minutes per household, which is still extremely high. From 1950 to 2010, viewing time per household increased every decade. It became what Americans did for leisure, as documented in Robert Putnam’s sociological book ‘Bowling Alone’.

            59% of all Americans and (48% of Europeans) now play video games, including 97% of teenagers in the USA. However, a 2016 study found that 6% of gamers worldwide could be considered addicted. Another study found that 7% were problematic gamers who played at least 30 hours weekly.

            Lastly, smartphone usage continues to increase worldwide. Excessive social media and smartphone usage can result in adverse mental health outcomes. Australia is now fourth in the world regarding smartphone usage. The average for all Australian mobile phone users is 2.5 hours a day, which adds up to 38 days per year. We check something on our phones 30 times daily, and 45% of Australians now say they couldn’t live without their phones.

It is Possible to Choose to Change 

It’s pretty easy to see the long-term consequences of our brains wanting to conserve energy, take the easy option, or avoid pain. However, these seemingly insignificant moments can happen hundreds of times per day. In each moment, as long as we pay attention, we have a choice. We can stay on autopilot and do what is easy. Or, we can tune into our core values, ask ourselves what type of person we would like to become in the long run, and then act consistently with this vision.

            It may feel strange, different, or even uncomfortable when you start making more challenging choices and living by your values. However, that doesn’t make it wrong. For example, going to the gym will always hurt the first time you go, but the 20-minute walk you choose to do today is better than the 10km run you put off until next week. 

            Likewise, it may be tempting to say that you’ll start a new diet on Monday, but why put off making a healthy decision in the here-and-now if you don’t have to? These moments will eventually define who you become. You can begin to make a positive long-term change today.

But What Do We Do if We Want to Change?

Let me ask you the following three questions:

1. Is there anything you wish you could do more in your life?

2. Is there anything in your life you want to do less?

3. Finally, what is stopping you from making these changes?

If you answered YES to question 1 or 2 and don’t know the answer to number 3, it is worth exploring deeper.

Isolation and Loneliness: Which One Is More Damaging to Our Long-term Health?

Just the other day, I was having a debate with a client about isolation versus loneliness.

He believed that social contact with others was a more significant predictor of well-being, whereas I thought how close we felt was more important for long-term health and happiness.

In other words, he thought that the number of interactions with others was more important than the quality of the relationships. I was solidly on team quality over quantity when it came to the type of relations that we wanted in our lives.

Because I wasn’t sure whose position was more supported by research, I further explored the issue.

My aim in writing this post is to define the difference between isolation and loneliness clearly. I will then highlight what the scientific evidence suggests.

Isolation

The Merriam-Webster dictionary for English language learners defines isolation as:

“The state of being in a place or situation that is separate from others: the condition of being isolated”

Notice with this definition that there is no emotion connected to it. It merely indicates being isolated or separate from others.

Someone could choose to live a solitary life in isolation, and they may be happy with their choice. Alexandra de Steiguer, a shy individual who spent a lot of time alone when she was a child, chooses to isolate herself each winter as the sole ‘caretaker’ of the Oceanic Hotel on an island in New Hampshire. For the past 19 winters, she has spent months on the island without any guests.

de Steiguer states:

“it’s the thing I look forward to every year… When I come out here it’s like a homecoming. All those details of mainland life just fall away.”

She later says:

“Being alone (has) it’s advantages. It’s peaceful, and I can use my imagination…It makes me feel connected to life (and the natural world) in a way that I don’t normally feel.”

I don’t think I could do what she does, especially after watching ‘The Shining’, but each to their own.

Henry David Thoreau also glorified isolation and solitude in his famous book ‘Walden; or Life in the Woods’, stating:

“I find it wholesome to be alone the greater part of the time. To be in company, even with the best, is soon wearisome and dissipating. I love to be alone. I never found the companion that was so companionable as solitude.”

To write the book, Thoreau built a cabin near a pond in 1845 and lived there for the next two years.

He also highly valued simplifying life and reconnecting with nature:

“I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived.”

Before you think about selling up everything in Emile Hirsch’s ‘Into the Wild’ style and moving to the wilderness by yourself, it is important to highlight two things first:

  1. Thoreau walked into the nearby town of Concord, Massachusetts, almost daily and received visitors regularly.
  2. In ‘Into the Wild’, Hirsch’s character Christopher McCandless (**spoiler alert**) dies after eating a poisonous plant and concludes, “Happiness only real when shared.”

When solitude doesn’t involve nature and someone forces it upon you, it is often considered a devastating form of punishment. For this reason, various prisons use solitary confinement all over the world. However, prisons often violate human rights with solitary confinement. For example, the UN’s Mandela Rules state that humans must not be “without meaningful human contact for more than 15 consecutive days” (Martin, 2016).

People would rather be out in the prison yard where they could be stabbed or beaten up instead of in isolation, making me realise that humans are social creatures. Too much time in isolation can lead to active psychosis or acute suicidality in approximately one-third of the prisoners exposed to solitary confinement (Rodriguez, 2016). It can also lead to crippling social anxiety for prisoners once released into society (Breslow, 2014).

Consequently, I can’t help but feel that except for a few individual cases or people who are very introverted, too much isolation does more harm than good.

Loneliness

The Merriam-Webster dictionary defines loneliness as:

“Sad feelings that come from being apart from other people”

Notice the focus of the definition is on the feelings of sadness. Unlike isolation, loneliness suggests a deficit and a longing for companionship and a genuine connection that is not there.

As JD in ‘Scrubs’ suggests, it is also possible to feel lonely in a crowded space, even though you could not be considered isolated:

So what is more damaging — being separate from others, or feeling apart from others?

The Village Effect

Our brains light up during human interactions, primarily in-person face-to-face contact. Online communication and passively watching videos don’t have the same effect.

In her 2017 TED talk, Susan Pinker looks at different reasons why people live longer, including the role that relationships play:

As you can see in the graph above, minimising isolation and loneliness was more critical for staying alive than someone’s BMI, activity level, smoking and drinking behaviours, or even their heart health and blood pressure. While these factors are still relevant, having constant and close relationships is almost essential for our long-term health and longevity. Quantity, or level of integration, is seen as slightly more important than the closeness of relationships or quality — one point for my client.

Either way, in her book ‘The Village Effect’, Pinker suggests that we would all benefit from the type of interconnectedness that a small village lifestyle provides.

Pinker also believes that we would benefit more by increasing our in-person face-to-face contact and cutting back our use of technology to better connect with others.

Alone Together

Another fascinating book that I read in 2017 was ‘Alone Together’ by Sherry Turkle.

Turkle’s 2011 book also highlights the difference between how often we interact with other people and how sad, disconnected or alone we feel.

Her 2012 TED talk nicely summarises the negative aspects of technology and how it is leading to a greater sense of loneliness, even though it is easier than ever to remain in contact in some way or another:

As Turkle says:

“we use conversation with each other to learn how to have conversation with ourselves. A flight from conversation can really matter, because it can compromise our capacity for self reflection. For kids growing up, that skill is a bedrock for development.”

Turkle concludes:

“we’re lonely, but we’re afraid of intimacy. (We want) the illusion of companionship, without the demands of friendship.” (As a result, we) expect more from technology, and less from each other. (We imagine, that with technology), we’ll never have to be alone.”

It’s pretty scary stuff when you think about it. However, Turkle’s findings indicate that loneliness is more damaging than isolation, so one point for me.

Other Research

Social isolation is associated with:

  • an increased risk of depression (Hari, 2018),
  • more heart disease (Barth, Schneider, & von Känel, 2010),
  • a more significant risk of infectious illness (Cohen et al., 1997),
  • quicker cognitive decline (Bassuk, Glass & Berman, 1999),
  • elevated blood pressure (Shankar, McMunn, Banks & Steptoe, 2011),
  • more significant inflammation and metabolic responses to stress (Uchino, 2006), and
  • increased mortality (Eng, Rimm, Fitzmaurice & Kawachi, 2002)

Loneliness is associated with:

  • a higher risk of major depressive disorder (Hari, 2018),
  • increased blood pressure (Hawkley et al., 2010)
  • heightened cortisol (Cacioppo et al., 2000)
  • elevated inflammation (Steptoe et al., 2004), and
  • increased risk of heart disease, functional decline and early death (Patterson & Veenstra, 2010; Perissinotto, Stijacic Cenzer & Covinsky, 2012).

A 2013 study titled “Social Isolation, Loneliness and All-Cause Mortality in Older Men and Women” looked at 6,500 men and women over 51 from the English Longitudinal Study of Ageing between 2004 and March 2012. After taking demographics and health at baseline into account, social isolation significantly predicted later mortality, but loneliness did not (Steptoe, Shankar, Demakakos & Wardle, 2013).

Both loneliness and social isolation were associated with an increased risk of mortality. Still, reducing isolation was considered more critical in reducing the risk of premature death than loneliness. Furthermore, loneliness did not add to the risk of early death for already socially isolated people (Steptoe et al., 2013).

Final Outcome and Recommendations

THE VERDICT: SOCIAL ISOLATION IS MORE DANGEROUS THAN LONELINESS!

I am surprised to be wrong, but I am glad to have a bias pointed out whenever it occurs. I have never felt socially isolated, but I have felt lonely, so my own experience must have influenced my opinion to some degree.

Social isolation is more hazardous to our long-term health than the subjective feeling of loneliness. However, both of these states are potentially damaging, and you should take steps if you are experiencing them regularly.

Lifeline recommends the following strategies for overcoming social isolation and loneliness:

  • “Connect or reconnect with friends and family — staying in contact with loved ones can prevent loneliness and isolation. If your family don’t live nearby, technology can help you keep in touch.
  • Get out and about — regular outings for social functions, exercise, visiting friends, doing shopping, or simply going to public places can help.
  • Get involved in your community — Try a new (or old) hobby, join a club, enrol in a study, or learn a new skill. Try looking online at your local TAFE/Community College, library or community centre for things in your area that might be interesting to you.
  • Volunteer — helping others is a great way to help yourself feel more connected.
  • Consider getting a pet –pets are wonderful companions and can provide comfort and support during times of stress, ill-health or isolation.
  • Get support — If loneliness and social isolation are causing you distress, you should discuss your concerns with a GP, counsellor or a trusted person.”

Engaging in treatment with a clinical psychologist could help if social anxiety or other mental health difficulties contribute to your isolation or loneliness. If not, the meetup website is an excellent resource for getting out there, trying some new things, and meeting some new people.

As George Valliant says:

“Joy is connection… the more areas in your life you can make connection, the better.”

Is Your Screen Time Eating Up Your Free Time?

How Did We Get Here?

In the classic Sociology book ‘Bowling Alone’, Robert Putnam argues that social capital (reciprocal connections among people) has been in a steady decline ever since its peak in 1964.

By 2000, the average American was 58% less likely to attend a club meeting than an individual only 25 years earlier. It may not seem like a big deal until you realise that regularly participating in a social group halves your risk of dying in the next 12 months.

It’s not just the joining of groups that have changed either. For example, we are 45% less likely to invite friends to our place and 33% less likely to have dinner around the table with the whole family. We are also 40% less likely to join a bowling league, surprisingly the number one participation sport in the U.S. (Putnam, 2000).

This overall decline in social capital has also resulted in a loss of mutual trust. For example, from 1966 to 1998, the proportion of Americans who endorsed trusting the federal government “only some of the time” or “almost never” rose from 30% to 75%. Without this trust in others, we no longer know who to turn to for help and support when needed.

Why Has Social Capital Declined?

Putnam believed that some of the main culprits for the loss of social capital were:

  1. The changes in family structure. More people live alone, in a single-parent home, or decide not to have children.
  2. Suburban sprawl and longer commutes. With less time, energy and interest for leisure and social activities outside of work and commuting.
  3. A generational effect. Older generations (pre-boomers) have been consistently more civic and socially engaged than the Baby Boomers, who have been more civic and socially engaged than generation X’ers, who have been more civic and socially engaged than Millennials. The only thing that Millenials do more than older generations is hours spent volunteering individually.
  4. Technology has led to the privatisation of leisure time. The more people watch TV or spend time on social media or their smartphones, the less time they spend involved in social capital-type activities. Putnam believed that TV might have contributed up to 40% of the overall decline in social capital since 1965. The internet and smartphones have increased this privatisation of leisure since 2000.

How Much Time do People Spend on Technology?

The 2013 documentary ‘The Mask You Live In’ has some pretty scary statistics about how much technology is consumed by male children and teenagers. For example, in the U.S., the average boy:

* spends 40 hours a week watching television, including sports and movies.

* spends 15 hours per week playing video games.

* spends 2 hours per week watching porn, with 21% of young men using porn daily.

The Potential Consequences of Excessive Technology Use

Although some people write off the TV, video games, and the internet as harmless forms of entertainment that help keep kids safe, out of trouble and off the streets, they come with their risks and potential consequences. For example, the following data in ‘The Mask You Live In’ documentary:

* 31% of young males report feeling addicted to the video games they play.

* 50% of parents don’t monitor the content or ratings of video games, even though 90% of games rated appropriate for children over 10 contain violence.

By 18, the average male has seen 200,000 acts of violence on screen, including 40,000 murders.

Exposure to violent media may:

* lead to children becoming less sensitive to the pain and suffering of others,

* lead to children becoming more fearful of the world around them, and

* lead to children behaving in more aggressive and harmful ways towards others.

Exposure to pornography:

* increases sexual aggression by 22%.

* increases the acceptance of rape myths (that women desire sexual violence) by 31%

— The Mask You Live In

The typical response by the content producers to statistics like these is that the content we watch doesn’t impact our behaviour.

BUT if this was the case, WHY do we have a multi-billion dollar advertising industry?

IF media images don’t affect people’s subsequent behaviour, WHY would commercials, or product placements exist?

WHY would companies be happy to pay millions for 30-second Super Bowl commercials?

BECAUSE the COMPANIES paying for the commercials and the marketers producing the commercials THINK that WHAT WE SEE IMPACTS OUR BELIEFS AND BEHAVIOURS.

If a 30-second commercial can change our attitude or behaviours towards something, why won’t seeing 200,000 acts of violence before 18?

Who is fooling who? The general public, or the multi-billion dollar corporations and industries?

The Problem of Smart Phones and Digital Streaming

Since 2013, the problem of technology has only gotten worse, and it is now eating into even more of our leisure time, as shown in this clear depiction by Adam Alter in his 2017 TED talk:

The New York University psychologist presented data from the Bureau of Labor Statistics to show that sleep, working, commuting and activities of daily living (cleaning, showering, eating etc.) have all taken up a similar amount of time over the past ten years.

As shown in the red (data from the mobile app ‘Moment’), what has changed is how much time we spend looking at screens. It used to be only minutes in 2007. Now our phones, laptops and tablet usage is taking up most of our free time and dramatically cutting into our social and leisure time, much like TV had previously done in the second half of the 20th century.

Unlike TV, this has not been by accident, with today’s most brilliant minds often focusing on how to attract and sustain our attention on their games, sites, and apps. Alter explored this brilliantly in his recent book ‘Irresistible’, which I put in my top 40 favourite psychology books countdown.

A 2017 review by Brendan Meagher on the Australian Psychological Society Website introduced me to the term ‘problematic mobile phone use’. It is “an inability to regulate one’s mobile phone use, which has negative consequences in daily life” (Billieux, 2012).

Australia is now fourth in the world in terms of smartphone usage. 84% of us have a mobile phone, with 85% of teenagers and young adults exceeding 2 hours of screen use on their phones every day. The average for all Australian mobile phone users is 2.5 hours a day, which adds up to 38 days per year. We check something on our phones 30 separate times each day, and 45% of Australians now say that they couldn’t live without their phones (Meagher, 2017). The scariest statistic is that 42% of Australians over 18 still use their phones while driving, despite this creating a much higher risk of car accidents (Rumschlag, 2015).

Consequences of Excessive Mobile Phone Use

Mobile phone overuse has similarities to addictions or substance use problems, including tolerance, withdrawal, and daily-life disturbance (Kwon et al., 2013).

Adverse consequences include increased risk of aggression, sleep disturbance (Yang et al., 2010) and physical health problems (Lee & Seo, 2014).

It can also negatively impact relationships, lead to fewer social interactions across a week, and impair academic performance (Kuss & Griffiths, 2011).

Is Your Mobile Phone Use Problematic?

If you are unsure, Meagre recommends considering the following questions:

* Do you think you spend too much time using your mobile phone?

* Has your mobile phone use caused problems in a relationship?

* Do people say that you spend too much time on your mobile phone?

* Does the time you spend on your mobile phone stop you from doing other tasks?

* Have you tried to cut down your mobile phone use?

* Have you used your mobile phone while driving or crossing a road?

Could You Cut Down Your Screen Time?

If you answered yes to any of the above questions like I did, you might benefit from tracking your usage and seeing how much time you spend on your phone actively doing something.

I bought the full version of the app ‘Moment’, as recommended by Adam Alter. I didn’t try to change how much I used my phone to get an accurate baseline for the first week. My average was 1 hour, 48 minutes of screen time a day. Less than the national average, but still not how I wanted to spend my spare time.

I then took on the ‘Bored and Brilliant Challenge’ on the ‘Moment’ app for the following week and set the goal of less than 1 hour of screen time each day.

The ‘Bored and Brilliant Challenge’ was first developed by Manoush Zomorodi after she realised just how long it had been since she had last felt bored, thanks to always being able to look at her phone whenever she had a spare second. She also realised that she had very little time to let her mind wander without this time of boredom, which was when she had her best creative ideas. She then decided to set a challenge on her podcast for her listeners, which became the focus of her subsequent book of the same title.

  • On day 1, the aim was to observe my phone usage.
  • On day 2, I aimed to keep my phone out of reach and in my bag instead of my pocket.
  • On day 3, the aim was not to take any photos.
  • On day 4, the aim was to delete an app that I used more than I wanted to. So I deleted Facebook, Twitter and LinkedIn from my phone.
  • On day 5, I took a fake cation and put my phone in aeroplane mode to have fewer distractions during the day.
  • On day 6, I aimed to observe things that I would have missed if glued to my phone, especially while on public transport.
  • On day 7, I tried to make something creative. It consisted of me cooking a nice meal for dinner, and it didn’t taste too bad either.

As the above data shows, I managed to pick up my phone three times less per day. My baseline was nine less than the average Australian already, but I’m glad to reduce it to 18 times per day.

The second picture is interesting to me. My phone use took up 7% of my waking life across the challenge. It still seems too much, but it was a decent drop from 12% of my waking life the week before.

As shown in the data above, the average person who takes on the ‘Bored and Brilliant Challenge’ creates 58 minutes more free time each day by cutting down their phone usage. That’s nearly an extra hour each day to do whatever you want. If people feel time-poor already, that might be a lovely feeling.

Other Suggestions for Cutting Down Screen Time

  • Book social outings or join a club or sports team. Exercise is also great for mental and physical health, so combining socialising with exercise is recommended.
  • Develop a list of other non-screen activities that you may enjoy and can do regularly.
  • Stop channel surfing on your TV — figure out which shows you want to watch ahead of time and record them. It increases the enjoyability of the programs you watch and cuts down how much time you spend watching TV as you can fast forward through commercials.
  • If you use a TV streaming site such as Stan or Netflix, decide if there is a program you really want to watch and how long you want to watch it before you switch it on. Then, you can set the alarm or reminder to help manage binge-watching.
  • Stop leaving your TV on in the background or switching it on as soon as you get home. Listening to most music is likely to be more relaxing than watching TV.
  • Install the app or plugin ‘Freedom’ on your computer. Freedom helps you block specific sites you can waste time on and makes it easier to set limits for yourself.

Conclusion

Hopefully, with everything discussed here, you can now see the potential pitfalls of excessive technological devices, especially those involving bright screens.

If you feel rushed, always complain about being busy, spend too much time on your phone, or want to find more time for social and leisure activities, I encourage you to consider the role that technology plays in your life. Suppose there is an area where it is becoming problematic or causing you distress. In that case, I recommend implementing any of the above suggestions or challenges to see what difference it can make in your life.

Dr Damon Ashworth

Clinical Psychologist

Which Strategies Does Cognitive Behavioural Therapy for Insomnia Have?

Chronic sleep problems such as insomnia do not go away without appropriate treatment1. Once people start to sleep poorly, they tend to develop ways of thinking and behaviours around sleep that worsen their problems over the long run2. Fortunately, cognitive behavioural therapy for insomnia (CBT-I) can improve your sleep, as it directly targets these unhelpful thoughts and behaviours around sleep3. This chapter will go into the different components of CBT-I and introduce the instructions for many of the recommended sleep strategies included in CBT-I.

Cognitive Behavioural Therapy for Insomnia (CBT-I)

CBT-I is an effective treatment for insomnia, with many studies showing it to be similar to sleeping pills in improving sleep in the short term4. However, it is much more helpful than sleeping pills at improving sleep in the long run4.

Research shows that CBT-I consistently reduces the time taken to get to sleep3. In addition, it decreases the amount of time spent awake during the night3. CBT-I also improves sleep quality and efficiency5. Most of these improvements persist after treatment finishes5. Conversely, sleeping pills typically lead to sleep difficulties once people with insomnia stop taking them4.

Medical Practitioners do not recommend sleeping pill use beyond 2-4 weeks at a time. It is because sleeping pills can stop working as well after a while7.  You may need to start taking larger doses to get the same effects when this happens. Sometimes doctors prescribe sleeping pills because they think they will work faster for patients than psychological therapy. However, even two sessions of CBT-I can make a significant difference to one’s sleep at night8.

Let’s look at the four main components of CBT-I. What are the sub-skills or individual strategies in each component, and what scientific research supports these strategies?

Component One of CBT-I: Psychoeducation

Psychoeducation provides people with helpful information about sleep, including sleep hygiene recommendations, homeostatic pressure, circadian rhythms, and hyper-arousal. Sleep hygiene means having a comfortable bedroom environment, minimising light exposure before bed, exercising during the day, minimising caffeine and alcohol and doing things to wind down or manage worries before bed.

 Sleep hygiene recommendations were first developed in 1977 to educate individuals about the possible factors that promote and inhibit optimal sleep9. Your improved sleeping practices should improve how well you sleep by following these recommendations. However, there is no standard prescription for optimal sleep hygiene and no weighting of the most critical factors. 

In 2003, researchers reviewed seven studies that attempted to define sleep hygiene recommendations and found 19 different rules10. Nineteen rules are way too many to have to think about or follow at one time. It could cause a lot of stress for you, and we know from the last chapter that we are trying to avoid hyperarousal. It is one of the reasons why I do not talk too much to my patients about them in general. I prefer only to mention the particular ones that could help that individual.

See if any of the below sleep hygiene recommendations may be worth you trying:

  • Try to get up at the same time, seven days a week
  • Only be in bed for the amount of time you need to sleep
  • Only use the bed for sleep and sexual activity
  • Minimise alcohol, especially in the evenings
  • Minimise caffeine intake after 2pm
  • Exercise regularly during the day
  • If you have any, write down your problems a few hours before bed and how you will address them.
  • Do not try to force yourself to fall asleep when you are in bed10.

The lack of a standard sleep hygiene definition means it is tough to determine its efficacy. It may explain why a 2006 review found that sleep hygiene is not a scientifically supported intervention for treating insomnia3. The psychoeducation component of CBT-I is also not an empirically supported individual intervention for insomnia.

In 2002, researchers found that improving sleep hygiene knowledge has little impact on improving sleep quality12. However, they did find that changing sleep practices in line with sleep hygiene recommendations does12. In addition, changing your behaviours to be more conducive to sleep can improve your sleep and overall health. Just don’t focus too much on every single sleep hygiene rule. 

Any helpful psychoeducation intervention needs to teach you the main factors contributing to your particular sleep difficulties. Every case of insomnia is related to issues with homeostatic pressure, circadian rhythms or hyperarousal. Then, we need to recommend specific behavioural and cognitive strategies for you to address these factors. Administering a questionnaire such as the Sleep Hygiene Index13 at your baseline assessment could also help you target appropriate sleep hygiene factors in your individualised sleep plan. 

Component Two of CBT-I: Sleep Scheduling

Sleep scheduling provides you with helpful information on when to be in bed at night. It can inform you when to go to bed at night and get out of bed in the morning. It can also tell you about your ideal amount of time in bed at night. 

I recommend introducing both stimulus control and sleep restriction therapies after the psychoeducation component of a CBT-I treatment. Stimulus control and sleep restriction eliminate the behaviours that commonly disrupt sleep. They are great at breaking conditioned responses at night-time, increasing homeostatic sleep pressure, and strengthening circadian rhythms. In addition, research indicates that sleep scheduling improves sleep quality and efficiency over time, improving the perception of a refreshing night’s sleep14.

Stimulus Control

Stimulus control therapy was developed in 197215 to break the conditioned response of the bed, bedroom and bedtime in patients with insomnia. Any stimulus can produce several reactions in people, depending on their conditioning history with the trigger. For example, individuals with insomnia are so used to being awake and frustrated in bed that the bed and bedroom become conditioned with being tense, worried, annoyed and alert over time rather than feeling calm, relaxed, sleepy and asleep14,16. Has this happened to you at all?

The stimulus control instructions aim to limit the time in bed awake so that you can recondition the bed with the feeling of sleepiness and the behaviour of well-consolidated sleep. 

The stimulus control instructions are as follows17:

  • Only go to bed when sleepy, 
  • Wake up at the same time every day, 
  • Only use the bed/bedroom for sleep and sex, 
  • Avoid naps during the day, and 
  • Sit up or get out of bed if you cannot fall asleep within about 20 minutes of retiring to bed.
  • If you have to get up during the night, do something calming or relaxing until you feel sleepy again, and then lie back down in bed for sleep. Ideally, this activity during the night should not involve bright light, rigorous exercise or be too cognitively demanding.

Stimulus control therapy is a supported behavioural treatment for chronic insomnia, according to the American Academy of Sleep Medicine (AASM)3. Furthermore, it has reliable and robust effect sizes in the available research in the field18,19,20

The main difficulty with stimulus control is adherence to the instructions21. A good friend wanted me to emphasise how difficult he found it was to follow the instructions. Many stimulus control guidelines seem counter-intuitive, especially the waiting until you feel sleepy before going to bed and getting up if you can’t sleep. Individuals with sleep problems also have many preconceived notions about the cause of their insomnia that do not involve instrumental conditioning.

            It is essential to highlight how important getting out of bed after 20 minutes if sleep doesn’t feel close. If you do not get out of bed when you are awake or frustrated for extended periods, your bed cannot be reconditioned with feeling calm, sleepy and sleeping well. It is also essential to explain why you need to wait until you feel sleepy before bed. The aim is for the bed to equal being asleep, and it is much easier to fall asleep in bed if you are already feeling sleepy before going to bed. Finally, it is important to say why you need to get out of bed at the same time each morning, no matter how badly you have slept. Your sleep pressure will be even higher for the following night, and it will become even easier to fall asleep quickly once you get in bed over time.

If people do not follow the stimulus control guidelines, their bed does not become reconditioned with sleep. Their circadian rhythms also fail to strengthen, and their sleep is unlikely to improve22

Introducing cognitive and relaxation techniques alongside stimulus control instructions can help overcome unhelpful beliefs about the strategy’s risks. Relaxation strategies can also reduce the likelihood of engaging in safety behaviours that limit your willingness to adhere to stimulus control instructions.

Sleep restriction

Sleep restriction therapy was developed in the mid-1980s to take advantage of the positive benefits of short-term sleep deprivation31. By spending less time in bed, sleep restriction temporarily induces sleep deprivation, which increases homeostatic pressure. This increased homeostatic pressure then decreases sleep fragmentation and consequently improves sleep efficiency16

Sleep restriction instructions are as follows31:

  • Determine your average total sleep time over the past 1-2 weeks. If it is less than five hours per night, say that it is five hours. 
  • Add 30 minutes to this amount. The total is your new time in bed prescription. For the next two weeks, only spend this amount of time in bed every night.
  • Figure out which time you would like to wake up, seven days a week. It is your rise time or time to get up each morning. Set the alarm to help you wake up at this time. When the alarm goes off, get out of bed and try not to sleep again until the next night. 
  • Minus your time in bed allocation from your rise time to figure out your bedtime. For example, if you wake up at 6 am and are meant to be in bed for 6 hours and 30 minutes every night, aim to go to bed around 11:30 pm.
  • The bedtime should be approximate rather than absolute for the restriction to be maximally effective. For example, if it is 11:15 pm and you notice many sleepiness signs, go to bed rather than wait until 11:30 pm. On the other hand, if it is 11:30 pm and you are wide awake, wait until you feel a bit sleepier. Then go to bed.  
  • Once you have your bedtime, rise time and time in bed prescription, track your sleep for the next two weeks using a sleep diary or activity tracker. Then figure out your sleep efficiency, which is the percentage of your time in bed spent sleeping.
    • If your sleep efficiency for the next two weeks is under 85%, cut down your time in bed by a further 15 minutes each night.
    • If it is between 85-90%, keep your time in bed prescription as it is.
    • If it is above 90%, extend your time in bed by 15 minutes each night.

Keep tracking for another two weeks and repeat until your sleep efficiency is between 85-90% regularly. 

The AASM also recognises sleep restriction as a supported intervention for chronic insomnia3. Sleep restriction is similar to relaxation in reducing how long it takes to fall asleep and how much time you are awake during the night. However, it is more effective in maintaining these improvements in the long-run23. For example, in one study, time awake during the night had increased 12 months post-treatment with relaxation but continued to decrease with sleep restriction24. In addition, sleep restriction produces enduring insomnia improvements, even a year after treatment finishes. Other research has shown that these sustainable improvements would reduce the risk of you developing depression26.

The downside of sleep restriction is that it temporarily increases daytime somnolence and reduces vigilance in the initial phases of treatment27. It makes adherence to sleep restriction therapy difficult if you are already concerned about the daytime consequences of your sleep problems21

It is also essential to prescribe time to bed and rise times consistent with your circadian rhythms and usual lifestyle14. Trying sleep restriction like this is likely to increase your adherence rates.

            If you have excessive daytime sleepiness, please be cautious regarding driving or operating machinery during sleep restriction therapy. If daytime sleepiness is a big concern, you may require some time off work in the first 1-2 weeks of trying this strategy. However, as long as you are not endangering yourself or others, the increased sleepiness will prevent you from lying in bed at night, ruminating or worrying. It can also significantly improve your sleep initiation and increase your overall sleep quality17.

Sleep scheduling is the empirically most robust component of a CBT-I intervention. At 12 months follow-up, both stimulus control and sleep restriction adherence were the most significant predictors of ongoing improvements in the time taken to fall asleep and time awake during the night22. Thus, as long as you know the long-term benefits and address adherence issues, sleep scheduling is the best strategy to try if you want to improve your sleep. 

Component Three of CBT-I: Relaxation techniques

Because hyperarousal plays a massive role in most sleep problems, it is vital to develop strategies to quieten the mind and calm the body. Relaxation strategies reduce excessive physical tension and calm pre-sleep cognitive activity, fostering a more positive outlook and reducing overall concerns about sleep disturbances28. They can also help you transition to sleep quicker and have a deeper, better quality sleep29.

Relaxation techniques sometimes included in CBT-I include:

  • Progressive muscle relaxation30,
  • Imagery training32,
  • Meditation33,
  • Thought-stopping or autonomic suppression34,
  • Biofeedback training35,
  • Diaphragmatic breathing36, and
  • Autogenic training37

These relaxation strategies all have at least one study showing that they can effectively improve sleep. For example, in one study that treated individuals with insomnia with relaxation techniques, sleep efficiency or the percentage of time in bed spent sleeping increased from 67.0% to 78.8% over six weeks of treatment25. In addition, anxiety and depression levels also reduced after practising the relaxation techniques for six weeks25

Relaxation techniques are most effective for sleep when you practise them initially during the daytime. It helps to focus on lowering arousal rather than trying to fall asleep28. Once you have practised relaxation techniques sufficiently, you can reduce the time taken to fall asleep at the start of the night more than if you try to follow sleep hygiene education38. CBT-I is typically superior to relaxation alone39, but relaxation strategies have additional benefits on depression40, stress41 and anxiety42. Therefore, it is worthwhile to learn relaxation alongside other effective sleep strategies if you have chronic sleep problems or daytime stress, anxiety or depression.

Progressive Muscle Relaxation

Progressive Muscle Relaxation (PMR) is CBT-I’s most commonly used relaxation technique. The AASM considers it an effective stand-alone treatment for insomnia3. PMR involves tensing and releasing different groups of muscles throughout the body to reduce physiological arousal. 

PMR instructions are as follows30:

  1. Tense the muscles in your arms, bringing your hands towards your shoulders to feel your biceps tighten. Then take in a deep breath through your nose down into your stomach. Then relax your arms as you breathe out all the air through your mouth. Next, let your hands hang down by your side and give them a shake. Then repeat one more time by tensing, breathing and relaxing your arms.  
  2. Then tense the muscles in your face, including the ones in your forehead, nose, jaw and around your eyes. Notice the tension. Then take in a deep breath through your nose and into your belly. Relax all the muscles in your face as you breathe all the air out through your mouth. Let your face muscles droop as your jaw hangs loose. Then repeat one more time.   
  3. Tense the muscles in your neck by bringing your shoulders up to your head. Hold this pose tight for a few seconds. Then take in a deep breath through your nose into your stomach. Pause for a second or two. Then breathe all the air out through your mouth as you relax your neck and let your shoulders drop. Next, move your head around slowly in a circular motion if this helps you to relax your neck. Then repeat once more. 
  4. Tense the muscles in your stomach and back, bringing your abdomen closer to your spine. Hold this for a second, then take a deep breath into your belly while still keeping your stomach and back tense. It may make it a little harder to breathe in as deeply as with the other muscle groups. Then breathe all the air out of your mouth as you slump down and push your belly out. Repeat one more time.  
  5. Tense the muscles in your buttocks and thighs, squeezing them tightly. Take a deep breath in, pause, and relax these muscles as you breathe all the air out. Shift back and forth from left to right a little in your seat, then repeat.  
  6. Lastly, stretch out your legs and tense your calves and feet, bringing your toes back towards your body. Breath in, pause, breathe out and relax your calves and feet. Shake out your legs, and then repeat one last time. 

PMR may have some additional cognitive benefits by helping you focus on and pay attention to particular body areas. However, PMR focuses more on reducing bodily tension than imagery training, thought stopping, or meditation. I, therefore, recommend it if you feel physically tense at the end of a long day and want to learn how to reduce it. 

Studies comparing relaxation techniques have found that PMR does not produce significantly better results than autogenic training or biofeedback training35,37. However, cognitive relaxation techniques such as imagery training are more helpful in reducing how long it takes to fall asleep at the start of the night43

Imagery training

One particularly beneficial mental relaxation technique is imagery training, which aims to distract you from intrusive and pre-occupying sleep-related thoughts by using visualisation. Imagery involves visualising an engaging situation that is pleasant and relaxing immediately before sleep44

I try to imagine a beach I often visited when I was younger or hiking in the Austrian Alps. Still, you can try to imagine whatever you find calming and peaceful. Imagery can distract you from your worries and bring on the feelings of relaxation you initially felt when you visited these places. 

The more you can engage all your senses in the visualisation exercise and explore the space, the more effective it is. For example, if it is a beach visualisation, try to hear the seagulls flying around and the waves crashing in. See if you can feel the breeze and warm sun on your skin and the touch of your toes in the warm and soft sand. Thinking in the form of images resolves worry more efficiently than thinking in the form of words, and this may be one of the reasons it can help us fall asleep in bed45

Researchers have compared imagery to PMR and sleep hygiene education across four weeks of treatment and found significant improvements in sleep efficiency and time awake during the night in the imagery and PMR groups by post-treatment46. Furthermore, the imagery group exhibited 16 minutes less time awake during the night than the PMR group. They also had increased self-efficacy, and reduced depression severity by the 6-month follow up46. I, therefore, recommend imagery as both a relaxation strategy before bed and a cognitive distraction technique in bed.

Meditation

The most popular form of meditation these days is mindfulness. If you are interested in learning mindfulness meditation, I recommend starting with 10 minutes a day, either in the morning or night. Several meditation apps are mentioned in the previous chapter. After a few weeks of daily practice, you will hopefully begin to see some of the benefits. You will then know if it is something that you would like to continue to do or not. 

Several studies have found modest improvements in sleep through mindfulness meditation as an individual intervention for sleep47,48. However, recent findings have been more promising49, especially when combined with other sleep interventions50,51. 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-being52. Adding mindfulness to other recommended sleep strategies can reduce insomnia severity and improve daytime functioning. 

Component Four of CBT-I: Cognitive Therapy

Cognitive therapy can provide you with the skills to challenge your unhelpful or unrealistic beliefs about sleep. For example, many individuals with insomnia attribute all of their tiredness, mood difficulties or poor performance at work to their sleep difficulties. It puts way too much pressure on them to get a good night’s sleep. It is vital to see the other factors that may contribute to how you feel during the day. You can also look at data that challenges your fears and helps you to develop realistic expectations about your sleep.

Cognition refers to all mental activities you experience in verbal thoughts or visual images. Many cognitive processes are critical in differentiating individuals with sleep problems from ‘normal sleepers’, including attention, perception, memory, beliefs, attributions and expectations53. These differences contribute to higher anxiety levels and increased cognitive arousal in individuals with chronic insomnia54.

You can implement specific cognitive techniques alongside or after the behavioural interventions in CBT-I. 

Cognitive techniques for insomnia include: 

· Cognitive restructuring55,56

· Cognitive control57

· Constructive worry55

· Distraction58

· Paradoxical intention59, and 

· Mindfulness and acceptance of thoughts50.

Out of all the cognitive strategies, the paradoxical intention intervention is the only cognitive intervention that the AASM considers an effective stand-alone treatment for insomnia3

The instructions for paradoxical intention are as follows59:

  1. Go to bed at your usual bedtime
  2. Lie down in bed with the lights off. 
  3. Don’t read or look at your phone or anything else.
  4. Try to see if you can stay awake for “just a little bit longer” without doing anything to force yourself to stay awake. 
  5. If you are still awake, congratulate yourself for successfully achieving your goal. Then, don’t look at the time on the clock and keep focusing on staying awake for “just a little bit longer”. 
  6. Keep this up all night if you have to. But, whatever you do, do not try and force yourself to sleep and keep trying to stay awake “just a little bit longer”.

It can take a little time to fall asleep using paradoxical intention initially. Still, once you do, you are much more likely to stay asleep and sleep well during the night. 

A cognitive model of insomnia

Through research on the cognitive processes involved in insomnia, Allison Harvey and colleagues developed a cognitive model that identified the five main aspects that are likely to be perpetuating insomnia60

The model proposed that individuals with insomnia typically:

  • Spend excessive time ruminating about why they have not slept well in the past. They also spend a lot of time worrying about not sleeping well in the future.
  • Misperceive their sleep to be worse than it is. They tend to overestimate how long it takes them to fall asleep at the night’s start. They also overestimate how much time they spend awake during the night. Because of this, they underestimate their total sleep achieved, which makes their anxiety and arousal worse.
  • Pay more attention to external and internal threats to sleep in bed at night. They also focus more on their functional impairments and tiredness during the day than good sleepers. 
  • 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. These may include not going to work after a poor night, napping during the day, and spending extra time in bed to catch up on ‘lost sleep’.

The researchers then developed a cognitive therapy for insomnia, which consisted of Socratic questioning and carefully planned behavioural experiments to address all aspects of their cognitive model60. They found significant reductions in time taken to fall asleep (over 50%) and time awake during the night (37%). They also improved total sleep time by 11% post-treatment, with findings maintained by follow-up one year later. In addition, significant improvements occurred in work and social adjustment, unhelpful beliefs about sleep, worry, depression severity and anxiety severity60.

Although these findings were promising, it did take a lot more sessions than a typical CBT-I intervention61. A 2012 study by Roane and colleagues found that behavioural and cognitive sleep interventions change cognitions around sleep but do so in different ways62. Both strategies can help create long-term changes to sleep-related beliefs and behaviours. Combining behavioural and cognitive sleep strategies is likely more beneficial than just one. 

Constructive worry

To target worry and rumination that is often present in sleep problems, you can use both the constructive worry55 and the cognitive control57 techniques. 

The constructive worry technique instructs you to spend time a few hours before bed to write down whatever your worries or concerns are at the moment. You are then encouraged to solve any issues you believe may keep you awake or cognitively aroused in bed that night55. By having a plan to address these worries, you will likely feel more in control and less concerned, even if the goal is to focus on something else. 

Cognitive control also instructs you to spend 20 minutes reflecting on the day that has been a few hours before going to bed. Then write a to-do list about what you need to address the next day57. By targeting these worries or concerns earlier in the evening, you have less information that you need to process in bed, resulting in less cognitive arousal and frustration. If something new pops up that you have not thought about before, you can also quickly write this down on a notepad next to your bed and then continue to relax and allow sleep to come57

Either the constructive worry or cognitive control intervention can be helpful alongside stimulus control. Both strategies would help you recondition the bed with sleepiness instead of fear about not sleeping.

Distraction

Out of all the cognitive processes, individuals with insomnia tend to use thought control strategies more frequently than normal sleepers58. The aggressive suppression and worry approaches appear to be particularly unhelpful, with their use predicting increased sleep impairment, anxiety, and depression58. Conversely, ‘normal’ sleepers use cognitive distraction more frequently, and this strategy predicts better sleep quality44. Thus, mental distraction techniques are likely to help you reduce your cognitive arousal levels in bed at night. As long as what you distract yourself with isn’t too energising, it can help you not worry about things until you drift off to sleep. Try not to look at the phone too much or watch TV in bed, though, and put a timer on the device if you need one so that it switches itself off once you are asleep. I’ve spoken to different people who have found white noise, relaxing melodies, nature sounds, audiobooks, or even stand-up comedy helpful as a distraction in bed. You could also think about good things that happened during the day or what you are grateful for in your life.

Highlighting sleep-state misperception

Another critical area to challenge is a harmful sleep-state misperception. To challenge this, you can compare your objective sleep data (provided by a fitness tracker or sleep study) to your subjective sleep data (collected by a sleep diary). If you find a significant discrepancy between objective and subjective sleep, you may perceive yourself to be awake during the light stages of sleep when you are asleep60. It means that you are probably sleeping more than you realise and spending less time awake during the night. 

Seeing evidence that highlights the inconsistencies between objective and subjective sleep can reduce your anxiety about sleeping if you sleep longer each night than it feels like you are. It can also result in better subjective sleep and feelings of a more refreshing night’s sleep. 

Stimulus control can be a helpful behavioural intervention for sleep state misperception. The instruction about getting up after 20 minutes if you can’t sleep is beneficial. It will show you that you are sleeping more than you realise because it is impossible to get up from bed if you are asleep17. If you do get up and check the clock, more time is likely to have passed than you realised, which indicates that you must have been asleep for at least a little bit. Cognitive restructuring56 techniques can then help you challenge the validity and utility of your thoughts around being awake when you might be sleeping.

Cognitive restructuring

Cognitive restructuring aims to elicit, identify, discuss, appraise, and correct any unhelpful thought processes that may be maintaining any catastrophic beliefs you have about sleep. 

Cognitive restructuring questions ask the following56:

  1. What are you thinking?
  2. Are these thoughts accurate? 
  3. Is there any evidence to support these beliefs?
  4. Are these thoughts helpful to have? 
  5. Are there any alternative explanations for these thoughts?
  6. What do you fear will happen if these beliefs are correct?
  7. Do you underestimate your ability to cope with these problems? and
  8. What can you do to address the issue?

In CBT-I, cognitive restructuring is introduced after sleep scheduling to address and challenge any unhelpful beliefs and attitudes about sleep that may worsen your insomnia. For example, the Dysfunctional Beliefs about Sleep Scale (DBAS-1663) can determine how negative your thoughts about sleep are. A reduction in DBAS-16 scores predicts better outcomes for individuals after CBT-I treatment64.

Mindfulness or acceptance-based techniques

Individuals with insomnia also exhibit an attentional bias for sleep-related threats during the day and night. One way to target this is by introducing mindfulness or acceptance-based techniques65,66,67. These techniques involve a non-judgmental, present-focused awareness, which means being aware of any thoughts, feelings or sensations that arise without changing them. It also consists of bringing attention to the present moment and getting in touch with whatever is occurring. Being mindful and in the present is considered more helpful than being caught up in the past or future65,66,67.

Mindfulness and acceptance-based therapies theorise that the content of thoughts is not problematic but rather the judgments or evaluations you make about these thoughts. By remaining in the present and practising ‘defusion’ and acceptance techniques68, the perceived impact of sleep threats should diminish over time. It could result in lowered arousal, more restorative sleep, and fewer impairments in your daytime functioning65,66,67.

Safety behaviours

The last aspect of insomnia to challenge on a cognitive level is safety behaviours. Safety behaviours are habitual sleep-related behaviours or routines that you may have developed because you think it helps with your insomnia, even if it does not60

Safety behaviours often lead to reduced adherence to the behavioural interventions of CBT-I, such as stimulus control or sleep restriction. Therefore, you need to address safety behaviours through behavioural experiments, followed by reflection and cognitive reappraisal of the effectiveness of the safety behaviour. 

Earplugs and eye masks are two examples of safety behaviours. Once you realise that you can sleep well without an eye mask and earplugs, your need for them may diminish over time. However, unless you challenge yourself to sleep without them, your beliefs about their necessity remain intact. If you can sleep without them and sleep well, you can use this positive example to help try other strategies that could be more effective.

Paradoxical intention can be implemented as a behavioural experiment to reduce pre-sleep arousal and sleep effort. People with lower pre-sleep arousal and sleep effort reduce their likelihood of insomnia relapse following CBT-I treatment51. When I have first instructed individuals to try paradoxical intention, they often tell me that I am crazy. However, if you try it for a few nights, research indicates you will generally obtain a more restorative night’s sleep59. It is then possible to reflect on the relationship between sleep effort, performance anxiety, pre-sleep arousal and poor sleep quality. Once you understand from experience that trying less to sleep in bed leads to better sleep, permanent cognitive change is possible. You will also be able to benefit more from any subsequent sleep strategy that you try to implement.

When thinking about changing your sleep, remember back to the lesson of sleep hygiene recommendations. We should not just try to change everything all at once. We first need to figure out what we want and need to improve. We then need to have a proper baseline assessment to determine how things are. Finally, we need to develop an individualised plan to improve these areas and track progress over time. By tailoring your strategies to your specific sleep problem and unique lifestyle, it becomes possible to achieve optimal outcomes for yourself.

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The World Became Much Less Abundant in 2021

From 2020 to 2021, the global resource abundance plummeted. The drop of 22.6% was double the previous most significant one year drop of 11.3% in 2010. While this highlights the negative impacts of the COVID-19 pandemic globally, look at how our current value is still 448.5% higher than it was in 1980:

Yes, it is now much lower than the peak of 708.4 that we had in 2020. As a result, 88% of the commodities measured (44 out of 50) became more expensive in 2021. In particular, energy prices increased by a whopping 131.4%.

Only six commodities decreased their relative cost from 2020 to 2021, including bananas, tea, plywood, tobacco, rice, and groundnuts.

 However, according to the Simon Abundance Index (SAI), global resource abundance has still doubled every 16.7 years since 1980. It means that we are much more likely to be able to afford 50 of the most common commodities with much fewer working hours than we did in 1980. We can buy more food after less time at work than our parents and grandparents used to be able to. Same with energy, materials, metals and minerals.

Having more people worldwide doesn’t make everything more expensive and scarce either. For every 1% increase in the world’s population, the average time price of these commodities decreases by 0.88%. Our personal resource abundance (2.69%) and population resource abundance (5.8%) increase for every 1% increase in the global population.

As Julian Simon noted in his 1996 book The Ultimate Resource 2:

“The ultimate resource is people — skilled, spirited and hopeful people who will exert their wills and imaginations for their benefit, and so, inevitably, for the benefit of us all…(in the future) there will be more people to solve problems and the bonus of lower costs and less scarcity.”

Resource abundance is still growing at a faster rate than the global population. The threat to our economic well-being is not an increasing population. The fiscal decisions by countries prioritised people’s lives during the pandemic, reduced work output, and increased inflation rates through the printing of money. Now that more people are returning to work, countries should print less additional money for people not working, entrepreneurship will increase, and our global abundance is likely to rise again. If you don’t believe me, look at how the world responded to the 2008 global financial crisis from the years 2011 to 2020.

Many thanks to Marian L. Tupy and Gale Pooley for the excellent data in their Human Progress article on The Simon Abundance Index 2022.

Dr Damon Ashworth

Clinical Psychologist

Why Do We Not Celebrate the Positives?

Recently, an article released in The Age newspaper was titled “Dip in thefts, drugs and family violence but police say drop in crime may not last”.

In 2021, the number of recorded offences in Victoria, Australia, dropped by 12.6% over the previous year. As a result, the police recorded 70,000 fewer offences. It was the lowest rate of offending (per person) that has been seen in the state since 2012.

The crime rates in Victoria may be lower than ever, but I am not too sure because the data at crimestatistics.vic.gov.au only goes back to 2012 when I look. Less property and deception offences. Fewer drug offences and family violence incidents.

Indeed, this is a cause for celebration?

Not so fast, the experts in the article say, given that “Victoria was in periods of restriction for significant periods of last year”.

Victoria Police’s Deputy Commissioner also seems to think that “it is likely that overall crime will increase as the community returns to normal”, but it’s not like the 154 days of lockdown in 2020 resulted in less crime than the 113 days locked down in 2021.

2020 nearly beat out 2016 for the most criminal offences recorded in a year, even though the lockdowns lasted 41 more days than in 2021.

If the lockdowns were responsible for the reduced crime in 2021, wouldn’t more crime be committed in 2017, 2018 or 2019 than in 2020?

I guess only time will tell. But maybe it is a good sign that a person in Victoria in 2021 was less likely to be the victim of a criminal offence than in any other year since 2012?

Why don’t we celebrate the positives when they occur?

I see it in my friends on social media and the patients I see in my consulting rooms. So many people think that everything is getting worse, and some even believe that the world might be ending.

Yes, the situation in Ukraine is scary. There also remains inequalities against people based on class, gender, nationality, sexual identity, ethnicity, age and disability. However, progress has occurred in many of these areas.

Despite this, in 2016, 65% of the US thought the world was getting worse, and only 6% believed it was getting better. In 17 other surveyed countries, 58% thought the world was either getting worse or staying the same.

People used to worry that overpopulation would lead to poverty and famine everywhere. However, even though our worldwide population is 8 billion now, the poverty rates have declined from 42% in 1981 to 8.6%. In addition, since 1900, our life expectancy has more than doubled, and obesity now impacts more people worldwide than hunger.

Yes, COVID-19 has been a challenge for many people and continues to be a challenge for many more. However, despite the pandemic, the economies in certain countries, including Bangladesh, Ghana, and China, became more prosperous in 2021 than in 2019.

Just because progress occurs, it “does not mean that everything gets better for everyone, everywhere, all the time”, Steven Pinker says. “That would be a miracle.” But unfortunately, while we are progressing in general and heading in the right direction, it is not a miracle. Things continue to be imperfect and always will be.

For more amazing facts about how things have improved and continue to improve, please check out books like ‘The Rational Optimist’ by Matt Ridley, ‘Factfulness’ by Hans Rosling, ‘Enlightenment Now’ by Steven Pinker, or any others like them.

For a more positive outlook on humans, please check out the excellent book ‘Humankind: A Hopeful History’ by Rutger Bregman. I also really like websites such as humanprogress.org. They highlight the positive stories worldwide that don’t get as much celebration in the news as they deserve.

Would You Prefer to Enjoy Your Life Now, or Wait Until You Are Retired?

Recently, my girlfriend has been sharing some videos of people who follow the FIRE principle with me.

FIRE is an acronym that stands for Financial Independence, Retire Early.

Some people describe FIRE as a financial movement involving frugality and extreme savings and investments. To do this, you work hard, save up to 70% of your annual income, and reinvest your savings into investments that will help you make even more. Eventually, you can retire early and use small amounts of money from your ongoing investments to live off.

It’s not a bad idea in theory. Who wouldn’t like to not have to work and do the things they would like to do instead of what they have to do?

I wonder how happy a life it would lead to in reality? The few videos I have seen show extremely driven couples working excessively for over ten years, spending very little money while they are doing this, and then retiring in their 40s.

While they are sacrificing so much in the present, what are they missing? Fun activities, school events or holidays with their children while they are young? Socialising with their friends and extended family? Even having enough time or being willing to pay for things that help them look after their health? Including healthy eating, gym memberships, massage or spa treatments, or a fun day out to a concert or movie? If reaching FIRE as early as possible is the primary goal, then most of this stuff will be seen as unnecessary or against the plan you are trying to achieve.

But who gets to the end of their life and looks back and thinks, “I should have worked longer and harder, especially when my children were young?”

And then once you reach FIRE, is the life that you are going to live suitable to who you are and your essential values?

In 2021, I had to take the first seven months off work while recovering from a severe health condition. Having no paid work to do each week or day was not as enjoyable or glamorous as other people may imagine.

Especially if you are in your 30s or 40s, most of your friends will be busy with work and family. So it’s not like you will have heaps of buddies that you can hit the golf course with throughout the workweek unless most of your friends are in their late 60s or early 70s. 70 something was the typical age of people I went on long bike rides while I kept rehabilitating my health last year.

Suppose a driven person is willing to sacrifice everything in the short-term for at least ten years to reach their FIRE goal. Will they be happy sitting around on a beach, doing nothing except relaxing and sipping Pina Colada’s every day?

I doubt it. Maybe for the first week. But then what?

So why do people do it?

I think it’s because we get the dream sold to us. We get told that work is a nightmare that we couldn’t possibly enjoy. But we are also told that we should study hard at school to get into a good University or College. Then we can get a good degree. Then we can get a good job. Then we can work hard in this job until we have enough money to retire. And then we can FINALLY enjoy life.

It reminds me of the story of the fisherman who is told by a Westerner on holiday in his coastal town that the fisherman needs to work harder to make more money. “But why?” asks the fisherman. “So that you can buy bigger boats and more of them!” says the Westerner. “But why?” says the fisherman. So that you can make more money and then retire after 20 or 30 years!” says the Westerner. “And then what?” asks the fisherman. “Well, then you can buy a boat and live by the beach and enjoy your life!” says the Westerner. “But that is what I already do,” replies the fisherman, as he shakes his head at the Westerner for having such silly thoughts.

Maybe we can stop trying to wait for the pot of gold at the end of the rainbow and see if we can try to enjoy our lives now? We may not need to have an excessive amount of money to do this. And we don’t need to retire early and do nothing every day.

Not all work is glamorous. And going to university and obtaining a good degree does lead to more considerable earning potential later in your career. Regardless of how much someone makes though, work does help provide a sense of purpose and structure for a lot of people.

My Personal Experience

Completing a Doctorate for me did enable me to work as a Clinical Psychologist. It is a job that I love but also one that I can find emotionally exhausting. Seeing seven or eight people a day, five days a week for individual therapy is not ideal even though it would be lucrative.

After working as a Psychologist since September 2013, I’ve learned to do whatever is sustainable and enjoyable for me.

Yes, I am volunteering in Port Vila, Vanuatu, as a Clinical Psychologist on the Australian Volunteer Program, funded by the Australian Government. I receive a stipend for this, or just enough money to get by here and pay for my accommodation and food and living expenses.

I am receiving way less money than I could get working back in private practice in Melbourne, Australia. However, I am also working in a way that feels sustainable to me. I am six months into volunteering here on a full-time basis again, and I haven’t felt the need to take any holidays yet. Weekend trips to beautiful beaches now and then is sufficient for me.

Even though I am working full-time hours each week, I am not wrecked when it gets to Friday at 5 pm. I am happy that it is the weekend and that I can do some fun things with my girlfriend, daughter, and friends. But I do not feel like I need to spend half the weekend by myself just recovering.

I am also happy. Happy to be working. Delighted to be experiencing all of these things. Glad to be meeting all of the people that I do. And happy that I am doing something meaningful and hopefully making a difference in the lives of the people I see.

No matter how hard I work, I do not get paid any extra, and I kind of like it that way. By choosing to volunteer, I highly doubt that I will be reaching FIRE anytime soon, or at all. 

One of my favourite writers is the Psychiatrist Irving Yalom, and he was still seeing patients and writing a few hours on weekdays well into his 80s. Now that seems much more enjoyable and meaningful than retiring in my 40s.

What does everyone else think?

How Do We Not Build Up More Regrets?

Over the past five years, I have been trying to live my life in a way that will not accumulate more regrets.

Most people tend to find change both problematic and scary. Sometimes, we remain stuck in a bad or unideal situation for too long because we fear what we could lose if we leave or change where we are.

However, we also tend to regret things we don’t do much more than the changes we make. So even if something doesn’t work out exactly how you have planned, more times than not, you will be glad that you have taken a risk and given something new a chance.

So, if you are in a difficult situation, including a bad relationship or a bad job, and are thinking about leaving but are also scared to do so, make sure that you make the comparison fair for yourself. First, compare what you might gain if you leave to what you might achieve if you stay. Then think about what you might lose if you go, but compare it to what you might lose if you stay.

If you think about what you might lose versus what you might gain if you leave, prospect theory indicates that the potential losses will likely loom larger for you. The potential gains of you going won’t help you overcome your fears of leaving enough. You will be more likely to stay, even if the current situation is not ideal for you.

Every decision we make has positives and negatives, so don’t forget about the negatives of maintaining the status quo or doing nothing if you are in a harmful or toxic situation.

If you really want to leave but feel afraid, think about the positives of leaving plus the negatives of not making the change. In this way, both your approach system and your fear system will work together and push you in the same direction of making a change and running away from the current situation you are in.

If you are still feeling indecisive, toss a coin. Then let the coin be responsible for the action you take. It might just help you to make the change that deep down you know you want to take.

The Positives of Making a Change

Steven Levitt from Freakonomics fame asked people over a year to flip a virtual coin if they were on the fence about something. If the coin landed on heads, the website told them to go ahead and make a change. However, if the coin landed on tails, they were instructed to keep the status quo.

From more than 20,000 coin tosses, the most common life dilemma that people flipped a coin about was whether or not to quit their jobs. A large percentage of people were also indecisive about whether or not to break up their intimate partners. The website asked a series of questions first to help people arrive at a decision. If these questions didn’t help, the website instructed visitors to flip a coin.

Levitt contacted each person who flipped a coin via email two months and six months after the coin toss. Those who did make a significant change in their lives reported being happier two months later than those who maintained the status quo. Their happiness was even higher six months after their decision. The results were similar regardless of whether or not they followed the coin toss instructions if it landed on heads and made the change or went against it if it landed on tails and made the change anyway.

Levitt concluded that “people are too cautious when it comes to making a change” and probably should take action if they are uncertain about whether or not to.

How Do I Not Regret Things?

For me, preventing the accumulation of regrets is about trying to live my life in a way that is consistent with the life that I want—or trying to be the person I would like to be in every situation.

Getting to this point requires a decent amount of self-awareness and self-knowledge of who I am, what I care about, and what I want.

I’ve completed many personality tests, identified my main defence mechanisms and lifetraps, seen how my character strengths and values have changed over time and become aware of my virtues and faults.

Now that I am aware of these things, it is easier to determine what I would like. In addition, completing the future authoring program has also helped help me to clarify what I really would like in the future.

Some of the questions that they asked me were as follows:

What is One Thing You Could Do Better?

Tune in instead of tuning out. Listen to my body and mind and become more aware of what I feel and what I need.

What Things Do You Want to Learn About?

I want to learn more about running a successful business and private psychology practice.

Which Habits Would You Like to Improve?

I want to stay on top of all my responsibilities at work. I want to connect more with friends and family and ask them for help rather than doing everything myself. I want to remain a non-drinker of alcohol and continue learning new things, going on adventures, exercising, trying to eat healthily, taking my medication, and looking after my health.

What Type of Social Life do You Want in the Future?

I want to maintain connections with the essential people in my life, including my parents, siblings, host family, partner, daughter, family, and friends.

What Leisure Activity Do You Want to Do in the Future?

I want my leisure to be about being active, lifting weights, cooking well, learning new skills, being creative and socialising with those I love.

How Do You Want Your Family Life in the Future?

I want to be connected with them all, even if we are in different countries, share the good things and get support if needed. I also want to try to be there for as many big moments as possible and visit them when I can. Prioritise my partner and family here in Vanuatu and be consistent, reliable, supportive, loving, and caring.

What Type of Career Do do You Want in the Future?

I want to have a thriving private practice as a clinical psychologist. Run both groups and individual sessions and positively impact the community. I would also like to live a sustainable lifestyle where I enjoy my work and remain healthy, with enough time for leisure, relationships and personal growth.

What Qualities Do You Admire?

I want to deliberately and continually learn and improve. I want to be grateful, efficient, effective and courageous. I want to reflect on my mistakes, learn from my experiences, and gain wisdom over time. I want to be fully present, kind and compassionate to myself and others.

What Does an Ideal Future Look Like to You?

I want to be the best me that I can be. I want to help as many people as I can. I want to end up in a place where I feel satisfied and valuable and where I belong. I want to feel like my life is worthwhile and a net positive on the world. 

I hope to save up enough money, live in Vanuatu, build a comfortable home and have a good life with my partner and her daughter. I want to make a real difference to the country’s mental health and share with people worldwide all of the knowledge and skills they need to improve their sleep and mental health.

What is a Future that You Want to Avoid?

I don’t want to be a drunk, obese, unemployed loner. I don’t want to fail to meet my obligations or stop striving to achieve my goals. I don’t want to be a bad influence on my partner or children or any clients that I see. I don’t want to end up in jail, commit any crimes or deliberately hurt others. I don’t like to be prideful and not apologise or make amends when I err. I also don’t want to disappoint my friends and family or be considered selfish, unkind, or shit.

Ending the post by talking about the life that I do not want may seem negative, but remember that losses loom larger than gains. By writing down the life I want to avoid, I become motivated to run away from this, make the changes I need to achieve the life I want and not keep building up regrets as I go. 

Dr Damon Ashworth

Clinical Psychologist

Can You Improve Your Gratitude?

Out of the 24 possible character strengths in the VIA Character Strengths Survey, only five are strongly associated with satisfaction with life. People with hope, zest, gratitude, curiosity and the ability to love and be loved as their top strengths seem to have higher life satisfaction.

Gratitude has never been a strength of mine. Every time I have taken the survey since 2012, hope, zest, and gratitude have never even been in my top 10 strengths. In fact, only curiosity has been a top-five strength, coming in at #3 in 2017 and #2 in 2018.

But then something happened.

I’ve already written about the details, but I suffered a stroke on January 2nd, 2021, was misdiagnosed three times, nearly died, had emergency brain surgery, and spent over a week in a coma. I was then in a hospital for over a month and spent the next six months doing regular outpatient rehab.

It is now over a year later. Apart from some minor balance and coordination difficulties, everything else is how it was. I’m back to working as a Clinical Psychologist and, in general, enjoying my life.

Last week, I went through different personality assessments with a colleague and re-took four tests to show them what the results would look like.

On the VIA Character Strengths Survey, my #1 strength was gratitude. I was shocked initially, but upon further reflection, I really do feel lucky to be alive and be able to think clearly and interact with those that I care about.

The flap in my artery that contributed to my stroke is still there. So I could have another blood clot and stroke again in the future. Looking after myself and taking regular medication lowers my risk of recurrence, but nothing is guaranteed, and I don’t want to take anything for granted. So I want to appreciate everything I can. My friends and family. Where I live. The work I get to do. As many moments that I am alive as I can.

Life may not always be easy, but at this stage, I’d much rather experience the ups and downs and joys and sorrows than no longer be here.

I haven’t always felt this way. For a long time growing up, I would have been glad if a stroke took away my life prematurely. But it is interesting how nearly losing your life can make you appreciate what you have more.

The Psychiatrist and Author Irving Yalom found something similar when he worked with a group of patients with terminal breast cancer. Many even said that it was a pity that it took until they were nearly dead to start living fully. Yalom concluded that even though death is the end of us, reminding ourselves that we will one day die can enervate and energise us.

Apart from having a near-death experience or reflecting on our inevitable death one day (practising memento mori), there are several things that you can do to improve your level of gratitude.

The two that I have most commonly heard of and tried myself are the What Went Well exercise and the Gratitude Visit.

What Went Well?

For the What Went Well exercise, the aim is to get into a daily habit of noticing the positive things that happen in your life. You could start a specific gratitude journal or include What Went Well in your usual journal. I have been using the Stoic app on my phone and having this question as one of the prompts in my daily writing exercise.

Whatever you choose to write in, take a few minutes each day to think about three things that went well during the day. It might be something that you appreciated, felt good about, or were grateful for. Ideally, this could be different things on different days, but it is okay to also say similar things to another day if you want to. For example, I kept writing down gratitude for my health, being alive, my partner, and her daughter. I’m also thankful for my family, friends, cognitive faculties, reading, walking, and enjoying nature or a nice meal. It can be whatever you want it to be.

The Gratitude Visit

The Gratitude Visit takes more time than the What Went Well exercise and cannot be done as often. However, even one of these visits can have a lasting impact on how you feel. Firstly, try to think of someone who has had a positive impact on your life, but you maybe have never told them just how grateful you are for the things they have done or the influence they have had in your life.

Then, write them a letter, fully explaining the positive influence on you, and how much you appreciate them and are grateful for the things they have done.

If the international borders were open, I would want to fly back to Australia and thank my family for their assistance following my stroke. Unfortunately, this isn’t possible because of the COVID-19 pandemic, but I want to do it the next time I get back to Melbourne.

If you can meet up with the person you have written the letter to, please contact them and catch up together on a particular date and time. Then, when you are in person, find an appropriate place where you can read the letter to them aloud, take your time reading it to them, and allow them to respond back to you afterwards. Give each other a hug if this feels appropriate. Then be thankful that you have taken this step, try to be as fully present as possible, and enjoy the rest of your time together.

Other Gratitude Exercises

By browsing the Internet, there are several different gratitude exercises that you can find that I haven’t tried yet.

You could try the Give It Up practise and deprive yourself of something you usually enjoy for one week every month. It might be chocolate one month, red wine the next month, Facebook the third month, and Playstation the month after that. By seeing how you feel with and without these activities, you might realise more about what does and doesn’t make you feel good and not take the little things in your life for granted as much.

You could take a Savouring Walk for 20 minutes a day outside by yourself and see if you can notice different positive things that you usually do not. It might just be the intricate architecture of the building at the corner, or the smell of flowers or fresh cut grass, or the feeling of warm sun on your skin. Then see how this compares to the walks you do when you are rushing from place to place or caught up in your negative thoughts or worries.

You could Create Savouring Rituals, where you identify activities that bring you pleasure. Then, try to savour two of these activities every day, and allow yourself to enjoy it, not multitask, and feel whatever you do during these times.

You can also create an Awe Diary, Foster Admiration with your partner or another willing person, or try the Mental Subtraction of Positive Events or Mental Subtraction of Relationships. The Positive Psychology website is an excellent resource for more details about these exercises or the myriad benefits of gratitude.

If you find any of them helpful in increasing how much gratitude you experience, please let me know.

Dr Damon Ashworth

Clinical Psychologist

Is Vanuatu the Happiest Country in the World?

The latest Happy Planet Index puts Vanuatu second in the world in terms of sustainable well-being. To determine a country’s score on the Happy Planet Index, they look at a country’s well-being, multiplied by their life expectancy and then divided by their ecological footprint.

The only country with a better Happy Planet Index score is Costa Rica, with 62.1. Vanuatu is second with a score of 60.4, followed by Colombia (60.2), Switzerland (60.1) and Ecuador (58.8).

Although the Happy Planet Index helps to highlight the importance of living sustainably and trying to slow down climate change, is the sustainable happiness score the same as people’s overall satisfaction with their lives?

Not really. The well-being indicator is probably more indicative. To assess well-being, people in each country are asked to rate the quality of their lives overall on a scale from 0 (horrible) to 10 (the best life you could ever imagine).

The majority of the well-being data is taken from the Gallup World Poll, but Vanuatu is not usually included in this Poll. Therefore, the Happy Planet Index gives us an excellent chance to compare Vanuatu to the rest of the world regarding how satisfied their residents are with their lives compared to residents of other countries.

Here are the top 20 countries:

  1. Finland = 7.84 (out of 10)
  2. Denmark = 7.62
  3. Switzerland = 7.57
  4. Iceland = 7.55
  5. Netherlands = 7.46
  6. Norway = 7.39
  7. Sweden = 7.36
  8. Luxembourg = 7.32
  9. New Zealand = 7.28
  10. Austria = 7.27
  11. Australia = 7.18
  12. Israel = 7.16
  13. Germany = 7.16
  14. Canada = 7.10
  15. Ireland = 7.09
  16. Costa Rica = 7.07
  17. United Kingdom = 7.06
  18. Czech Republic = 6.97
  19. Vanuatu = 6.96
  20. United States = 6.95

Vanuatu isn’t the happiest country on the planet, but the residents of Vanuatu are, on average, quite satisfied with their lives. However, the loss of tourism with the COVID-19 pandemic and the international border closures have made it financially challenging for many people. The capital city of Port Vila can also be quite expensive to live in.

Many young people are also travelling to Australia and New Zealand to work on farms and make as much money as possible. This leads to better financial opportunities for them, their families and communities. However, it also puts pressure on their partners, families and communities left behind while the young people work overseas for months and sometimes years.

The big positives in Vanuatu seem to be the connection that people have to their country, island, land and community. There are close-knit kinship and family ties and minimal large-scale conflict and political unrest.

Vanuatu is also a beautiful country with an exceptional natural environment and many people that want to preserve these resources as much as possible. For example, Vanuatu was one of the first countries to ban plastic drinking straws and plastic bags.

Work is also not an overly important aspect of many people’s lives. Following a death, people grieve with their family and friends and don’t rush back into their daily activities. Vanuatu also allows for up to 21 sick days per year, more public holidays than pretty much any country in the world, and 21 annual leave days a year too.

Based on the 2021 World Happiness Report, Finland once again wins the happiest country on the planet. Vanuatu is not the happiest country globally, but it is in the top 20 in the world. It is also a more joyful place than the USA, France, and many other countries around the globe.

By looking at surveys such as the Happy Planet Index or the World Values Survey, it is possible to see which places may be the best fit for you. If you really care about the environment and climate change, Costa Rica and Vanuatu will be right up there for you.

An excellent work-life balance, close connections with the important people in my life, not too much stress, lots of relaxation, beautiful natural resources and a population that feels like they are living a pretty good life are essential to me.

Dr Damon Ashworth

Clinical Psychologist