“Medical stuff” therapists help treat - Insomnia
Did you know that counselors treat insomnia, chronic pain, and gastrointestinal issues? Obviously there are limits here. You're going to have to go to a gastroenterologist for your colonoscopy. Sorry... I'm not that full service. But once doctors have ruled out medical causes for your sleep, pain, or GI problems, mental health folks can often help.
Tired... when you're angry and feel awful but you can't fall asleep.
I'll tackle pain and GI issues in another blog post but today I want to talk about insomnia. Mental health professionals have a lot to offer in treating your insomnia. Here's how I do it (and hopefully other mental health folks with other approaches can chime in, below).
Sleepy... where you are apt to lose consciousness if you lay down...
First, l advise clients to make sure their doctor has ruled out serious medical causes for insomnia and fatigue. I strongly prefer to consult with physicians directly when treating insomnia but a client report of recent checkups will do in some cases. Sometimes serious issues like sleep apnea can cause insomnia and behavioral interventions may either not help OR make these WORSE if they're not addressed first.
I then assess client sleep behaviors so I can develop a theory of what the problem is and how we might approach it. Sometimes I can do a fairly accurate assessment through an unstructured interview (just talking) and other times, I need clients to maintain sleep journals for a week or two, to figure out what's going on. This is where things go all "choose your own adventure," depending on what I learn in the assessment.
Based on assessment results, I then work with my client to address practical issues that might be impacting their sleep. For anyone not sleeping well, I ask them to make changes on a sleep hygiene checklist.
While my client is implementing the checklist in their life (this can take a few weeks as it's not easy to change up all items in a short time period), we work on acceptance, mindfulness, relaxation training, and psychoeducation on sleep. I share with my clients, various perspectives on sleep and what we know as professionals, about sleep and wakefulness. Chronobiology is an interesting concept that suggests being mindful of and adapting to your natural biological rhythms around sleep. We may add light therapy to help the client reset their biological clocks for sleep.
CBT for Insomnia is the final step if the client's sleep doesn't respond to the steps above. This is a highly effective, very evidence based, and frankly painful way to address recalcitrant sleep issues. It involves meticulously monitoring sleep and restricting it in strategic ways to increase quality and then quantity of sleep. Most clients don't actually have to do a full CBT-I protocol in my experience but when nothing else works, this is the "big guns" of insomnia treatment. It's highly manualized, monitored, and documented so that if it doesn't work (which hasn't yet happened in my experience), we have a full attempt documented when we consult with other professionals on next steps.
The first step of CBT-I is called stimulus control. The goal of this phase is to break the association between the idea of "being in bed" and "being awake." Some of this is addressed in sleep hygiene, above. But in a full CBT-I protocol, we put sleep hygiene on hyperdrive and we try to create an association in the brain of bed = sleep. Sleepy = bed. Tired is not sleepy (see pictures for reference).
The second step is sleep restriction. If the client can't get a full night of sleep from 10pm-6am, we might try 12am - 6am or 2am - 6am until the client is so sleepy they have to sleep well for a small time. This is the painful part. Most folks don't get to this phase but rest assured for those who do, we eventually expand those high quality four hours to something sustainable long-term.
Finally, we talk about prevention and maintenance. Unfortunately some people prone to insomnia may have to repeat steps three, four, and five above, whenever their sleep is thrown off kilter. Some can NEVER abandon strict adherence to sleep hygiene practices. But the idea is to minimize episodes of insomnia in the future by coming up with a maintenance and relapse action plan.
So if you and your doctor are out of medical ideas for addressing insomnia or if you and your doctor are concerned about long-term use of sleep medicines, call your local mental health professional and see what they can offer!