There are a number of common issues that counsellors hear from clients, and one is that they can’t sleep.
Sometimes the reason for that won’t be anything psychological. There might be too much noise and disturbance. There might be a baby waking up. There might be physical pain in the musculature, the digestive system or the reproductive system. But other times, it’s stress and anxiety keeping us awake.
Some people report being able to fall asleep fairly easily but then they wake up maybe two or three hours later and are lying there wide awake. Others simply can’t get to sleep in the first place, and when they do it’s so late that getting up in the morning is hard and they are tired all day. Others still report nearly drifting off then suddenly jolting back to full awareness.
What’s going on in the mind?
So what’s in our minds that keeps us awake? Physiologically, it likely comes down to our sympathetic nervous system, which is there to alert us to danger or, rather, the perceived threat of danger. This is a very useful tool for the prehistoric cave-dweller charged with keeping watch for sabre toothed tigers. But much less useful when there are no external dangers. Yet our minds seem to create these imaginary threats to our safety as if we need that adrenaline to stay safe.
People often ask: I keep thinking that (something that troubles them) is going to happen but I know rationally that it’s not. In other words, people can’t understand why they can’t simply think themselves out of anxiety. They have to feel safe. Anyone watching a baby slowly letting go of consciousness and falling asleep, secure in the knowledge that there is nothing to worry about, will often wish they could do that too. In a similar manner, some people say they can’t sleep alone or that they need do go through a series of ritual-like activities such as having a hot drink, reading a chapter from a book, and having a bath before sleeping. These are soothing for us, and leave us feeling secure because they follow a predictable sequence of events. We might feel “lost” without them. And, no, scrolling on a phone won’t help. It does kill the boredom, but it keeps the mind alert.
In therapy we have a number of ways of approaching the question of sleeplessness. Someone working behaviourally might suggest something like: If you wake in the night, get out of bed and sit on a hard chair for five minutes before going back to bed. The idea being that it’s so unpleasant we will train our minds not to wake prematurely. The disruption might also break the stress cycle. In CBT the therapist will challenge stressful thoughts and feelings, which they classify as maladaptive. There are a number of categories of maladaptive thinking, such as catastrophisation and future-predicting. By re-wiring the mind in this way, it might help the anxiety go away. In yoga and mindfulness therapy one piece of advice is to concentrate on the breathing. Among others, there is a widely-used 4-7-8 technique, which involves four seconds of inbreath, which is then held for seven seconds, followed by a long eight second outbreath. This feels clunky and some people hate it but it does seem to produce results if one perseveres.
Although I counsel against using anything visually stimulating, such as scrolling on the phone, I think the converse is true of audio. Listening to an audiobook replicates the bedtime story and the only downside is knowing where to re-start in the story the following night. YouTube is a good resource for sleep stories and all kinds of spoken word media. I listen to highly educational but otherwise dull podcasts on the basis that if I don’t fall asleep, at least I’ll learn something.
As a practising psychodynamic therapist, I focus on emotions. The voice that keeps the person awake is trying to protect them, but from what? It will almost certainly be an overwhelming emotion such as fear, hurt, guilt or – what often lurks but is rarely consciously felt – shame. Therapy provides a safe space to experience these emotions, learning that they are tolerable and that the therapist can also tolerate them. Further, the therapist can help process these emotions, helping to give them a meaningful form. This is a largely conceptual experience and probably won’t be as simple as “I feel X because of Y and that’s OK”. It’s what the psychoanalyst Wilfred Bion called “containment” and it replicates the containment ideally, but almost certainly never entirely successfully, provided by a child’s parents and other care givers in their early development.
Lastly, there is medication. Although I would like to think that therapy beats meds, the reality is that, especially in more severe cases, the person needs a solution sooner rather than later. Melatonin is the body’s own sleep hormone and can be bought over the counter in some parts of the world, but not in the UK. Melatonin supplements have to be prescribed by a GP, who might be reluctant to keep their patient prescribed for too long. Some GPs may prescribe Diazepam or another anti-anxiety product to help with sleep. Others may decide on antidepressants. Self-medication is a term I frequently hear, which is basically using alcohol or narcotic drugs to relax. This may well work, but in time the person may be seeking therapy for alcohol or drug addiction rather than insomnia. Finally, there are herbal and mineral supplements. I personally don’t find these helpful although I know many who do. They are harmless and if they work, well, why not?