SLEEP BASICS
Cognitive Behavioral Sleep Interventions
Caron Treatment Centers
Stephen M. Lange, Ph.D., ABSNP
Basic Principles
• We have a 24+ hour sleep-wake cycle.
• We have greater control over how we spend our
daytime hours than our sleep hours.
• We cannot have sleep problems; we can have problems
with our sleep-wake cycle.
• Our sleep quality tonight is shaped by how we spend
our day.
• Sleep can improve by attention to the B-A-S-I-C I-H.
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Basic Principles, Continued
• Sleep is an essential, life sustaining activity.
• Purposes of sleep may include repair of body systems,
energy conservation, memory consolidation, brain
development, discharge of emotions (NIH, 2003).
• Fatigue and sleep deprivation are relapse triggers
(Think HALT).
• Sleep is mediated by an internal timing mechanism
called the Superchiasmatic Nucleus in the
Hypothalamus.
• Sleep is also mediated by environmental cues,
especially natural daylight.
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Remember This?
Here comes the sun, do do do do
Here comes the sun, and I say
It's all right
Little darling
The smiles returning to the faces
Little darling
It seems like years since it's been here
Lyrics by George Harrison, recorded by The Beatles
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Basic Principles, III
• Sleep depends on urge to sleep and parasympathetic
nervous system activity (relaxation response).
• Activation of the sympathetic nervous system (fight or
flight response) inhibits sleep.
• Ways in which patients respond to insomnia, such as
laying in bed awake, worrying about sleepiness and
deficits the next day, using their beds for mental work can
condition a sympathetic response to bedtime, perpetuating
insomnia.
• We need to teach patients to replace ineffective responses
to insomnia, such as napping, caffeine abuse, worrying,
with a relaxation response.
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B-A-S-I-C I-H
(An Idea of Dr. Arnie Lazarus)
• B = Behaviors
• A = Affect (Emotions)
• S = Sensations
• I = Imagery
• C = Cognitions (Thoughts)
• I = Interpersonal
• H = Health
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Sleep Quality
• Sleep Architecture refers to how we progress
through the five stages of sleep throughout the
night. This is not something we have much control
over.
• Sleep Duration is the number of hours of sleep
within a nighttime.
• Restorative Sleep is sleep that helps us feel rested
and alert during the daytime.
• Latency of sleep onset refers to how long it takes
to fall asleep.
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Sleep Therapy Goals
• Increasing sleep duration is not a well-
selected goal.
o It is more important to wake rested and to feel
alert during the daytime than to have a magic
number of hours of sleep.
o Sleep duration is highly personal and while
there are averages at different ages, there is no
magic, universal sleep duration.
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Sleep Therapy Goals, II
• Avoid using decreasing sleep onset latency
as a sleep goal.
– Can set a difficult standard for individuals who
are very anxious or who are perfectionists.
– Can lead to frustration when progress is not
perceived.
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Sleep Therapy Goals, III
• The best sleep goals are:
o Increase daytime alertness.
o Increase feeling rested in the morning.
o Improve habits that are sleep promoting.
o Develop realistic expectations about sleep.
o Decrease frustration surrounding sleep.
o Improve understanding of sleep and especially how
much an individual can affect their sleep quality.
o Understand sleep problems as relapse triggers.
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Basic Psycho-education
• Patients need to know that drugs and alcohol directly affect
sleep architecture, leading to sleep that is shallow.
Dreaming may be disturbed or absent. Patients may think
that they have not slept at all, and they may wake up
feeling tired.
• As a result of the cumulative disturbance of sleep
architecture, patients enter their first weeks of sobriety
feeling exhausted with a literal “sleep debt.”
• Additionally, when dreaming has been disrupted during
active addiction, patients may have a REM “rebound.”
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Basic Psycho-education
• Alcohol, Benzodiazepines, and Opioids can
exacerbate sleep apnea leading to excessive
drowsiness, hypertension, death rates.
• Other drug effects that influence patients’ sense of
physical and emotional wellbeing include pain
perception. Patients generally, and those who used
opiods and alcohol particularly, have exaggerated
pain perception in the first 4- 6 weeks following
their last use.
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Basic Psycho-education
• It may take 4-6 weeks before these effects wear
off, and patients with tolerance and withdrawal
will take the longest. Some patients will take
much, much longer. Some patients will never
return to their baseline sleep.
• Help patients realize that current sleep problems
are likely to improve with time. There is a core of
acceptance and surrender involved with this
process.
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Basic Psycho-education
• Unmanageability refers to the chaos between our patients
and their worlds, and also the chaos within – physical,
emotional and spiritual.
• Without conveying callousness or disregard for our
patient’s pain, think about how we can use the physical
and emotional chaos around sleeplessness and fatigue as
metaphor.
• First Step includes the acceptance of the world as it is, and
our powerlessness over much of our world, even our
interior worlds. Surrender also means that we have to
accept our bodies’ schedules for healing, and not try to
impose our wills on our bodies.
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Did You Know?
• Question: How many times are the words
“sleep” or “sleeping” mentioned in the Big
Book?
A. 12
B. 43
C. 192
D. 31
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Did You Know?
• Question: How many times are the words
“sleep” or “sleeping” mentioned in the Big
Book?
A. 12
B. 43
C. 192
D. 31
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Basic Psycho-education
• Coming to inpatient treatment involves loss on
many, many levels – loss of the (inaccurate!)
perception of autonomy, loss of social status, loss
of the familiar, separation from people and even
pets. We also lose our sleep environments. As a
child, my favorite sleep environment was my
grandmother’s NYC apartment, with city sounds
of sirens, delivery trucks, couples walking, the
elevated train on Northern Boulevard, Queens.
• Just like we have in Wernersville, PA!
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Basic Psycho-education
• At night,we relax our ego defenses, those mental tools we
use to inhibit affect and impulses. While we may be able to
work through struggles during the day, at night conflicts
(internal and external), anger, sadness, worry can flood
through.
• Even though we can have very sleepless nights as a result,
our nighttime demons are wonderfully informative about
the emotions we bottle up. It hurts less when we use this
information!
• If we are sleepless is this part of our moral inventory?
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Remember this?
In the wee small hours of the morning
While the whole wide world is fast asleep
You lie awake thinking…
Song lyrics by Bob Hilliard recorded by Frank Sinatra and by Carly Simon
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Basic Psycho-education
• Sleep hygiene refers to the way we manage our activity
level throughout the day and night. Humans are diurnal
animals. Unlike the nocturnal bats, we “hunt” during the
day and sleep at night.
• In active addiction, people live the bat schedule. It takes
work to return to the human schedule.
• As all teenagers know (and most ignore), deviating from
sleep patterns over a weekend can result in disrupted sleep
for days afterward – imagine years of abnormal sleep! Said
another way, if a single jet flight can disrupt your circadian
rhythms for a week, imagine the cumulative effect of years
of disrupted schedules.
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Basic Psycho-education
• Even though sleep and the surrender aspect of
First Step are so intimately related, we have power
over our recovery choices. It is possible for
patients to feel hopeful about improvements in
sleep as they practice recovery habits.
• For most individuals with insomnia, it is not
necessary to take a pill to sleep. In fact, behavior
change outperforms sleep medications whenever
research studies compare the two types of
therapies.
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*Used with permission by the cartoonistgroup.com. The cartoonist is Darrin Bell.
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Using the B-A-S-I-C I-H
• Behaviors can be sleep promoting or sleep killers.
o Daytime sleep is the biggest single sleep killer. The
single most effective sleep intervention is daytime sleep
restriction. Sleepiness is a drive state, like hunger and
thirst. Daytime sleep reduces the urge to sleep at night
just like a snack can “ruin your supper.”
o Sleep promoting (recovery) behaviors during the day
include waking up at the same time each day, moderate
physical exercise, daytime sunlight, staying
intellectually and emotionally engaged.
o Intervention: During the day, what do you do to keep
yourself, awake, alert, active?
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Using the B-A-S-I-C I-H
• Behaviors in the evening and at night that promote sleep
include: Winding down in the evening hours, bathing or
showering, having a nighttime ritual or routine, listening to
quiet or calming music, and getting up from bed if sleep
onset latency is greater than 20 minutes.
• Nighttime sleep killers include laying in bed awake if sleep
onset is delayed, exercise late in the evening, using bed for
activities other than sleep.
• Intervention: What do you do to prepare for sleep, starting
around dinner time?
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Using the B-A-S-I-C I-H
• Affect regulation is an important skill for sleep. Going to
sleep angry, sad, frustrated, anxious is a sleep killer.
• Affect regulation skills can include Progressive Muscle
Relaxation, meditation, journaling, prayer and Bible
reading, practicing gratitude.
• Intervention: Teach PMR, meditation, diaphragmatic
breathing.
• Intervention: Discuss approaches to self-soothing and
affect regulation that already fit into the patient’s
personality and recovery skills.
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Using the B-A-S-I-C I-H
• Sensation refers to the six senses: Vision, hearing,
touch, smell, taste, and position in space.
o Patients should think about what makes them
comfortable in bed.
o Stimulus Control refers to creating a good sleep
environment.
o A slightly cool room is preferable for most people.
o Progressive Muscle Relaxation, Yoga, or stretching can
help with body sensations of muscle tension.
o Intervention: Discuss what aspects of stimulus control
patients can use in treatment.
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Using the B-A-S-I-C I-H
• Imagery can be useful for some patients
o Patients with significant trauma symptoms or psychosis
should not use guided imagery.
o Imagery uses the imagination to “escape” to a mental
scene which is peaceful and calming.
o Intervention: Consult with psychology staff about the
use of imagery with any individual patient. If
appropriate, teach use of imagery.
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Using the B-A-S-I-C I-H
• Cognitions refer to thoughts that are sleep killers.
o A bad case of the “I can't!”
o Unreasonable sleep expectations.
o The single most harmful sleep cognition is, “I will never sleep!”
o Worries of the day including those about money, family, aftercare,
etc. all affect sleep. Meditation including especially Breath
Awareness can help with intrusive, repetitive thoughts or worries.
o If my sleep is disturbed, am I wrestling with or resisting change?
How come the Big Book stories all seem to include the line, “That
night I slept” after the authors achieve First Step or spiritual
connection?
o Intervention: What do you think about at night when you lay in
bed?
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Using the B-A-S-I-C I-H
• Interpersonal factors can contribute to sleep.
• Do I need to resolve a dispute?
• Do I need to make amends?
• Do I need to turn over a problem to my Higher Power?
• Intervention: Do you ever have thoughts, images, worries,
dreams about conflicts with other people at night? Do you
replay scenes with other people when you try to go to
sleep? What does that say about moral inventory and
amends?
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Using the B-A-S-I-C I-H
• Health behaviors affect sleep
o Three scheduled, healthy meals and two healthy snacks help
regulate BG.
o Sugar and caffeine at night are sleep killers. Think about hidden
sugar in cereals and juices.
o Salty foods stimulate thirst which can interfere with sleep.
o Nicotine is a psychostimulant. If smoking calms you down, then
what you are experiencing between smokes is withdrawal!
o Craving management and sleep.
o Intervention: What do you eat at night?
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Using the B-A-S-I-C I-H
• Maintaining healthy body weight helps with sleep. Pushing
air in and out of an obese body is more strenuous than
breathing with a smaller body.
• Obesity can exacerbate sleep apnea.
• The bitter irony is that obesity can adversely affect sleep,
and poor sleep can raise the risk for obesity.
• Intervention: Fitness and wellness.
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PMR
• PMR stands for Progressive Muscle
Relaxation
• A sense of relaxation is achieved by
alternating tension and relaxation in muscle
groups
• May be combined with guided imagery if
appropriate
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Breath Awareness
• Using as many senses as possible to
experience breathing
• A basic meditation skill
• Relaxing
• Promotes a detached awareness that helps
regulate affect
• Daily mindfulness
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Diaphragmatic Breathing
• Breathing using the diaphragm at the base
of the chest cavity
• Stretches muscles in the torso
• Deep breathing takes in more oxygen than
shallow breathing
• Relaxing, calming activity
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Skills Practice
• Diaphragmatic Breathing
• PMR and Breath Awareness
• Gratitude Meditation
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Questions, Comments, Concerns?
•
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Additional Resources
• Getting a Good Night’s Sleep by Nancy Foldvary-
Schaefer
• How to Get a Great Night’s Sleep by H. Valfi and
Pamela Valfi
• Understanding Sleep by Mark R. Pressman and
William C. Orr
• Sleep, Sleep Disorders and Biological Rhythms,
NIH Publication No. 04-4989
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What’s New at Caron Treatment Centers
• Young Adult Female Program
– Follows many of the same treatment modalities as Caron’s highly
successful Young Adult Male Program
– Focuses on core issues of chemical dependency that may face women ages
20-25
• Chronic Pain, Young Adult and Adolescent Assessment Programs
– Intensive 5-day programs designed specifically to rule in or rule out a
diagnosis of chemical dependency
– Visit www.AssessMyFamily.org for more information
• Smoke/Tobacco Free Continuum of Care in Adolescent/Young
Adult Facilities
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