• 6 Reasons Why You Might Be Sleepy

    6 Reasons Why You Might Be Sleepy

    When we think about sleepiness, it is first important to distinguish between being “sleepy” and being “tired”.

    People often use them interchangeably, but there’s actually an important difference. Whereas sleepiness refers to being able to fall asleep at any given moment (e.g., head rolling, nodding off), being tired is a general lack of energy either physically or mentally (e.g., feeling foggy after a 3 hour exam). You can be tired without being sleepy – just like in cases of insomnia.

    When it comes to being sleepy, there are several reasons why a person might feel a sense of drowsiness throughout their day. In this post, I discuss several reasons for why you might be sleepy.

    1. You are sleep deprived

    The first reason for why you might be sleepy is that you are sleep deprived. Whether it’s from work, taking care of kids, or social activities, you may not be getting the number of hours you need to feel rested.

    It is important to also note that the number of hours each person needs can differ: some people are 8-hour sleepers, others might need more or less than that. Getting the right number of hours for you is important to reduce sleepiness.

    2. Your sleep drive is high

    Similar to the first reason, another reason is that your sleep drive (propensity to fall asleep at any given moment) is very high.

    Sleep drive begins to build after a good night’s sleep. Based on our activities throughout the day, and how long we are awake for, our sleep drive builds up. If your schedule tends to be quite active, then it would make sense that the build-up of sleep drive is high, and sleepiness can be present.

    Evidence of high sleep drive include:

    1. Falling asleep in under 10 minutes on average
    2. Evening drowsiness
    3. Spending more than 90% of the time you spend in bed sleeping.

    In these cases, you likely can produce a little more sleep so it can be helpful to increase the amount of sleep opportunity you have by spending a bit more time in bed.

    3. It could be natural fluctuations throughout the day

    There are certain time points throughout the day where sleepiness is ‘unmasked’ because of circadian factors. These are typically around the late afternoon period (labelled the ‘post-lunch’ dip) and during the evening when sleepiness comes out. In these cases, they are a biological shift and will go away if you can push through.

    4. You are bored

    When there is a lack of stimulation, sleepiness can come out because our mind may begin to focus its attention on evidence of tiredness or sleepiness, such as heavy eyes or an achy body.

    In this case, try to find something interesting to do!

    5. There could be an underlying sleep condition

    There are a few different sleep disorders that can manifest sleepiness:

    Hypersomnia. In hypersomnia, you may feel excessively sleepy and/or sleep longer than usual at night. Stimulants are the first-line treatment for hypersomnia.

    Sleep apnea. Sleep apnea refers to obstructions in the breathing airways that lead to mini-awakenings in the middle of the night. This can lead to sleep deprivation and thus sleepiness during the day. If you notice excessive sleepiness and loud snoring/gasps during the night, a sleep study can be helpful to determine whether sleep apnea is present.

    Narcolepsy. Narcolepsy leads to suddenly falling asleep because of a deficiency in a neuropeptide (i.e., orexin) that regulates wakefulness. Stimulants are the primary treatment for narcolepsy.

    Beyond sleep conditions, other medical conditions can also lead to issues with sleep, like chronic kidney disease, cancer, and anemia. Therefore, checking with your medical provider can be helpful if the sleepiness or fatigue is unexplained.

    6.  Sleepiness can arise as a side effect of medication

    Sleepiness can also result from a side effect of medication (e.g., pain medication, cold medication, anxiety medication, etc.). Should symptoms persist and cause issues, please check with your doctor.

    Best wishes,

    P

  • How Effective Is Cognitive Behavioural Therapy For Insomnia

    How Effective Is Cognitive Behavioural Therapy For Insomnia

    Introduction

    Cognitive behavioural therapy for insomnia (CBT-I) is a research-supported treatment and is considered the first-line intervention for chronic sleep problems by the American Academy of Sleep Sciences.

    In this post, I discuss how CBT-I works, whether it is effective in treating sleep and other problems, and how to get the most out of treatment.

    How CBT-I Works

    CBT-I works by tinkering with our sleep systems to make it work for us, rather than against us.

    When we are struggling with insomnia, we naturally engage in behaviours that counterproductively affects our sleep. For example, we might stay in bed longer, cancel plans, take naps – these behaviours affect our sleep drive (what we need for deep sleep)and circadian rhythm (because we are going to bed and waking up at regular intervals), which is what we need to get the deep sleep that we need.

    We might also stay in bed feeling frustrated, which can increase sleep anxiety and overtime lead to creating an association between the bed and wakefulness – known as conditioned arousal.

    CBT-I therefore uses strategies to 1) increase sleep drive; 2) balance the circadian rhythm; and 3) reduce sleep anxiety.

    What the research says about CBT-I

    Overall, the research for CBT-I is very promising. Studies show that people with different medical and psychological comorbidities (e.g., depression) can benefit from CBT-I (Wu et al., 2015).

    In our own clinical trials at the Sleep and Depression Laboratory at Toronto Metropolitan University, we see remission rates between 70 to 80%. That means, nearly 4 out of 5 people coming into treatment go from being a poor sleeper to a good sleeper within four sessions of CBT-I.

    One particular advantage of CBT-I compared to sleep medication is long-term durability. Oftentimes, people who get off medication will notice that their sleep problem return; on the other hand, people who finish up CBT-I tend to stay a good sleeper years after treatment (Blom et al., 2016). This is because CBT-I targets the causes of insomnia.

    Even more, research from our lab suggests that you don’t have to stay with the recommendations forever after treatment to retain its benefits (Lau et al., 2022). Therefore, you can have your cake and eat it too!

    CBT-I helps more than sleep problems

    Beyond improving sleep problems, such as difficulty falling asleep, staying asleep, waking up too early, CBT-I can also impact other important mental and physical health areas.

    For example, there’s a lot of research that CBT-I improves symptoms of mood and anxiety (Ye et al., 2015). The improvements in sleep and energy can also impact physical issues, such as chronic pain and fatigue (Jungquist et al., 2010).

    How to benefit more from CBT-I

    Below are a few strategies to get the most out of your CBT-I experience.

    1. Work with a therapist

    Although there are self-help books and apps for CBT-I, such as Goodnight Mind by Dr. Colleen Carney, a therapist can be helpful in providing the most effective recommendations by analyzing your sleep diary. The sleep diary is a way of tracking your sleep to understand how to best tinker with your behaviours to support sleep health.

    2. Try out the recommendations

    The recommendations of CBT-I can sometimes be difficult to follow, such as only getting into bed when sleepy and getting out of bed when sleep is not coming. These recommendations sometimes increase our sleep anxiety, which tells us to stay in bed. However, giving the recommendations a real college try can be helpful to support efficacy and not fall into a vicious trap.

    3. Use a sleep diary

    As discussed above, a sleep diary gives us a sense of patterns in our sleep that can inform recommendations. Using a sleep diary (see here for an example: see here) can be helpful in understanding possible problems. For example, if you are generally producing 6 hours of sleep but spending 9 hours in bed, then that can be a reason why sleep feels light and non-restorative. Again, a CBT-I therapist can use this information to support their recommendations for therapy.

    Best wishes,

    P

  • Examples Of SMART Goals For People With Insomnia

    Examples Of SMART Goals For People With Insomnia

    People with insomnia often have a simple goal for their sleep: to sleep better and feel better.

    However, what better sleep looks like from person to person can be very different. Some individuals have greater difficulty falling asleep, whereas others might struggle more with waking up in the middle of the night.

    Moreover, sometimes people may have somewhat perfectionistic goals when it comes to their sleep.

    For example, they might say: “I want to go to bed at 11:00pm, fall asleep immediately, stay asleep throughout the night, and wake up at 7:00am – feeling fully rested the whole day”.

    These goals may not be achievable given what we know about sleep. Moreover, some of these goals may actually not be healthy! For example, falling asleep immediately once going to bed may be a sign of excessively sleepiness (which could mean sleep deprivation, or medical problems like sleep apnea).

    Below, I discuss some SMART goals that are adaptive and specific to sleep.

    SMART Goals for Sleep

    Insomnia is defined by difficulty falling asleep, staying asleep, and/or waking up too early. People with insomnia also have daytime challenges, such as fatigue, irritability, and difficulty concentrating.

    Therefore, goals for insomnia are usually related to these symptoms. Below are a few SMART Goals that are well-calibrated to our knowledge in sleep science to guide your own goal setting.

    Goal 1: To fall asleep on average between 10 to 30 minutes.

    Generally, good sleepers fall asleep between 10 to 30 minutes most days. An average of below 10 minutes means that a person is excessively sleepy. We also use the word ‘average’ because everyone experiences poor nights – these are common for all sleepers and not a cause for concern (unless it’s happening several times a week).

    Goal 2: To generally stay asleep and fall back asleep if awakenings happen

    Most people wake up several times over the course of a night. Most are amnestic (people don’t remember) or they last only a few minutes. Therefore, staying asleep completely is not likely; however, most people I’ve worked with are more than happy if they can just get back to sleep rather than tossing and turning for hours on end.

    Goal 3: To find the right number of hours and sleep schedule for them

    The 8-hour myth is just that – a myth. People vary in their sleep needs and chronotype: that is, how many hours they need to function and when they prefer to go to sleep and wake up.

    Therefore, trying to a force an 8-hour schedule when you need less (or more) is counterproductive and can lead to sleep problems. A more helpful goal is to determine the right schedule that will allow for deep, restorative, and consistent sleep to occur (which your insomnia therapist can help with!).

    Goal 4: To determine whether improved sleep leads to improved energy, and identify other strategies to reduce fatigue

    Many people ascribe their low energy levels to poor sleep. However, the fact is that sleep is only one part of the overall picture.

    Fatigue is multifaceted. Many things can bring about fatigue: lack of light exposure, caffeine rebound, too much activity, too little activity, not being hydrated, poor diet – the list goes on.

    Therefore, it’s important to be aware of other factors that may be contributing to lack of energy. In my own practice, I often work with clients to understand that the treatment may improve sleep, but we should act like curious scientists about changes in the daytime.

    Goals for Sleep Anxiety

    One additional aspect of insomnia is anxiety. People with insomnia tend to experience worry about not being able to sleep and the impact of not getting enough sleep.

    One additional goal then may be to increase confidence in producing high quality sleep. From a paradoxical lens, our desire to want sleep tends to push sleep further away (kind of like the idea of love is just around the corner when we least expect it).

    Therefore, a radical acceptance approach can be very helpful. Radical acceptance means fully accepting the fact that sleep might not come – and that’s okay. Although this thought might seem very scary to some individuals, many of my patients have come to the realization that being awake in the middle of the night is not as dangerous as they thought. In fact, this time becomes seen as a positive experience where they can engage in activities (e.g., watching shows, reading a book) that they typically cannot during the busy-ness of the day.

    If you’d like a book to read to learn about science-based strategies when you are in the darkest dark of insomnia, The Insomnia Paradox can be a helpful resource.

    Best wishes,

    P

  • How To Evaluate A Sleep Diary: For CBT Insomnia Therapists

    How To Evaluate A Sleep Diary: For CBT Insomnia Therapists

    What is a sleep diary?

    A sleep diary is a prospective measure that allows people to track their nightly sleep routine. Carney et al. (2012) developed the Consensus Sleep Diary, which is the gold standard measure for sleep tracking.

    The sleep diary can be found here.

    Each morning, the patient is asked to spend a couple minutes writing down sleep variables from the night before – for example, when they went to bed, when they got out of bed, and how long it took to fall asleep. Typically, patients complete two weeks’ worth of sleep diary to get a reliable and valid index of their sleep pattern.

    Information from sleep diaries give CBT insomnia clinicians a good sense of what recommendations to provide to their patients to best improve their sleep. In this article, I provide a general overview of important terms of a sleep diary, ranges of these sleep indices for good sleepers (and poor sleepers), and strategies to improve a patient’s sleep to a normal range.

    Important terms to know

    Into Bed: Into Bed is the time a patient goes to bed.

    Sleep Attempt: Sleep Attempt is the time that the patient tries to initiate sleep. This can be the same time as Into Bed if the person immediately tries to sleep the moment they go to bed. However, some people like to read in bed or do meditation before trying to sleep. In this case, Sleep Attempt begins at a later time compared to Into Bed.

    Sleep onset latency (SOL): SOL is the time that people take to fall asleep after Sleep Attempt.

    Numbers of awakenings (NWAK): NWAK is the number of awakenings the person has throughout the night.

    Wake after sleep onset (WASO): WASO is the total amount of time a person spends awake in the middle of the night. For example, a person could wake up twice in the night, each awakening being 20 minutes each. In this case, NWAK is 2 and WASO would be 40 minutes total.

    Terminal wake after sleep onset (Term WASO): Term WASO is the amount lingering in bed after the person wakes up for the last time. For example, if the person wakes up at 7:00am and then spends until 8:00am browsing their phone before getting up, Term WASO would be 1 hour.

    Total Sleep Time (TST): TST is the total amount of time a person spends sleeping throughout the night.

    Total Wake Time (TWT): TWT is the total amount of time a person spends awake throughout the night.

    Time in Bed (TIB): TIB is TWT + TST.

    Sleep Efficiency (SE): SE is the proportion of time a person spends sleeping compared to the amount of time they spend in bed (TST / TIB). SE is usually expressed as a percentage; for example, a 50% SE means that a person is asleep only half the time they are in bed.

    Bed/Rise Time Variability: These terms refer to how variable a person gets into bed and gets out of bed throughout the week. Less variability means that a person tends to go to bed/get out of bed at a consistent time every day.

    Normative ranges on the Sleep Diary

    There are general clinical cut-offs insomnia CBT clinicians use to determine whether sleep is closer to the healthy sleeper ranger or the insomnia range.

    Good sleepers typically have:

    • A sleep efficiency of 85-90% (too low is insomnia range; too high is excessively sleepy)
    • A sleep onset latency of 10-30 minutes on average
    • A wake after sleep onset of less than 30 minutes
    • Bed and rise time variability of less than 1 hour on average
    • *The specific number of sleep hours and preference for bedtime/risetime is unique to the person

    Evidence-based strategies to improve sleep

    As we see from the good sleeper ranges, people with insomnia typically have a sleep efficiency that is significantly below 85 percent. They may also experience difficulties with falling asleep, staying asleep, and/or waking up too early.

    There are certain strategies that CBT insomnia clinicians used to break the causes of insomnia.

    To put more pressure on the person’s desire to sleep, a sleep restriction protocol can be used. This is typically done by reducing the amount of time a person spends in bed to become more commensurate with how much sleep they are actually producing. For example, if a person is sleeping 7 hours but spending 10 hours in bed, we would ask the person to spend only 7 and a half hours in bed (TST + 30 minutes). A caveat is that we typically do not go below 6 hours for our time in bed prescription.

    On the other hand, for people who are excessively sleepy (sleep efficiency > 90%), then we would do a sleep extension and add 15 minutes to the amount of time they are spending in bed.

    To regulate our circadian (internal) clock, we typically ask the patient to set an earliest bedtime and latest rise time. For example, setting an alarm for 7:00am every day and getting up at that time.

    Finally, to restore an association between the bed and sleeping, we engage in principles of stimulus control. Generally speaking, this means only going to bed when sleepy and getting out of bed if sleep is not coming to do something pleasant instead (e.g., reading a book). More information on stimulus control can be found here.

    I hope this post was helpful as a general primer into reading sleep diaries!

    Best wishes,

    P

  • A Comprehensive Guide For Applying To Clinical Psychology Programs In Canada

    A Comprehensive Guide For Applying To Clinical Psychology Programs In Canada

    Preamble

    In the Fall of 2018, I (Parky) will have begun my clinical psychology program at Toronto Metropolitan University. From this experience, I thought it would be worthwhile to write up this short guide for those who are, or will be, embarking on this arduous process.

    This manuscript serves as a structured account of applying to clinical psychology programs in Canada. In this text, I attempt to demystify the enigmatic process of applying to Canadian graduate studies in clinical psychology, as well as impart insight into their evaluation criteria. In doing so, I hope to make this journey a little less daunting for prospective students.

    A secondary goal of this guide is to provide concrete examples of activities that potential applicants can engage in during their undergraduate (or post-baccalaureate) studies to strengthen their application and increase their odds of gaining admission into some of the most competitive graduate programs in the world.

    A special thanks and gratitude to Joey Rootman and Jill Robinson for their incredible insights and help in writing this guide.

    Introduction

    Clinical psychology can be viewed as the closest representation of the prototypical idea laymen have of psychologists: A therapist sitting perpendicular to a client lying on a couch and asking, “How does that make you feel?”.

    And in some ways, this is true. As a practitioner, clinical psychologists often conduct assessments and provide therapy to a variety of individuals that exhibit some form of psychopathology.

    Clinical psychologists are also trained as scientists and can be seen working in research or educational settings such as academia and research centers, as well as clinical settings, such as hospitals and private practice clinics. It is not uncommon for clinical psychologists to divide their time among clinical practice, academia, and research. As such, a vocation in clinical psychology can be rather versatile, making the degree and associated training programs highly-sought after.  

    Clinical MA/PhD Programs in Canada

    Clinical psychology MA/PhD programs adhere to the scientist-practitioner (Boulder) model, which underscores the importance of the relationship between empirically validated research and associated applications to clinical populations. As such, students are trained to be researchers as well as clinicians.

    Canadian graduate programs in clinical psychology generally offer a combined Masters (MA) and Doctoral (PhD) program, as opposed to just the PhD. The MA program lasts approximately 2 years, and the PhD program extends this by another 4-5 years (including a year of predoctoral internship).

    Although the MA and PhD are usually distinct programs, it is often strongly recommended that those applying to the MA program continue into the PhD. Many programs will not accept students who plan to terminate their studies after completing the MA. Most provinces, with the exception of Saskatchewan and Alberta, require that students hold a PhD in order to gain registration as a clinical psychologist with the provincial College of Psychologists.

    When preparing your applications, two crucial aspects to consider are the number of institutions you intend on applying to and the quality of these institutions. With respect to the first point, acceptance rates are low; typically, 4-7% of applicants receive an offer of admission. Therefore, it is the norm for prospective students to apply to multiple programs to increase their odds of acceptance.

    A former professor of mine recommended that if a prospective student wanted to maximize their chance of gaining admission, they should apply to at least 12 to 15 programs. That being said, this recommendation is not a hard rule (I applied to 7 myself). Applications are expensive and time-consuming so it is generally advised to avoid applying to programs which you have no or very little intention of attending.

    Second, it is strongly recommended that you apply to institutions whose doctoral and internship training program are (or in the process of being) accredited by the Canadian Psychological Association (CPA). Institutions accredited by the CPA are proven to demonstrate the necessary rigour to develop highly trained clinical psychologists. Oftentimes, graduating from a CPA accredited institution confers professional benefits and are necessary for obtaining internships through the Association of Psychology Postdoctoral and Internship Centers (APPIC) as well as facilitating the search for employment after graduation. It is much less likely that a student exiting a non-accredited program will secure a CPA-accredited internship relative to those who exit CPA accredited programs. Many prospective research and clinical positions require that the applicant attended a CPA-accredited internship.

    Finally, although an in-depth examination of other degrees, such as the PsyD or counselling psychology are beyond the scope of this paper, it is worthwhile to mention these alternatives. These programs may be of interest to those whose passion is oriented towards clinical practice or for those who wish to work with populations that exhibit less extreme mental health concerns. For a further examination of the PsyD, counselling psychology, and other related fields of studies – as well as being an excellent resource in general – I would recommend Mitch’s Uncensored Advice for Applying to Graduate School in Clinical Psychology by Dr. Mitchell Prinstein.

    The Application Process

    Applying to Canadian MA/PhD graduate studies in clinical psychology is often a long, difficult, and confusing process, and can take several months to adequately prepare. Generally, the list of materials you will need to assemble for programs include: 1) Graduate Record Examination (GRE); 2) a list of institutions and associated supervisors you would like to apply to; 3) three (or more) letters of recommendations (LORs); 4) official transcripts; 5) an updated curriculum vitae (CV); and 6) a statement of intent (personal statement). For Tri-Council funding applications, the materials you will need are: 1) Canadian Common CV (CCV); 2) two letters of recommendation; 3) a hypothetical research proposal. Often, programs will ask if you have applied for external funding, such as Tri-Council funding or the Ontario Graduate Scholarship (OGS).

                Preparing for the GRE is probably the most time-consuming and difficult aspect of the application process and applicants should allocate at least 2 months to studying for this exam. The exam should be taken as early as possible. Realistically, the suggested timeline includes studying for the exam over the summer before you begin applications and completing the examination prior to the beginning of fall semester. That way you will have sufficient time to report your scores as well as retake the test if necessary. Note that while the General Test can be taken throughout the year, the Psychology Subject test is only offered a few times annually (April, September, and October). It often takes up to 4 to 5 weeks to receive your scores – so plan accordingly! If the application deadline occurs before you obtain your scores, you may be rejected based on your incomplete application. Remember to check application deadlines when choosing a test date, and if possible, leave time to write the test at least once again if necessary. ***That being said, the GRE has been removed from the program requirements for some institutions in Canada. Therefore, please check to see if sites you are interested in sending an application still requires the GRE.

    By late summer or early fall, you will also want to begin considering which institutions you would like to apply to. There are several factors you might want to consider: the quality of the program and richness of the training, practicum placements, potential funding opportunities, length of time typically spent in the program before internship, geographical location and feasibility of moving, the culture and atmosphere of the university and, perhaps most importantly of all, the “fit” between student and mentor. Each institution typically provides information on their university webpage about faculty and their individual research interests. It is important to determine if the faculty you are interested in working with is accepting new students for the upcoming round of admissions. Faculty may not accept students one year for a variety of reasons (e.g., sabbatical leaves, administration duties) and you would not want to waste your time or money applying to a supervisor who was not accepting students! You may want to contact potential supervisors to confirm that they are taking applications for new graduate students as well as to express your interest in their research. Although not a necessary component in applications, faculty members may appreciate your effort to contact them, especially if you demonstrate keen insight and enthusiasm into their work. If you decide to contact prospective supervisors, it is important to be polite and professional in your correspondence. Proofread your emails before sending them and be sure to demonstrate that you have done research into their current work. Be understanding if you receive a terse response. It is likely because faculty members often lead busy lifestyles and receive a large volume of similar emails during the application period. In addition to the match between research interests, it is important to think about the kind of research supervision and general mentorship you are interested in receiving. For example, some individuals work well with mentors who have a “hands-off” style of supervision, who do not set deadlines, and who expect students to be self-driven in most endeavours. In contrast, some students prefer a more direct style of supervision and mentorship.

    At a similar time, you will want to reach out to your current supervisors and/or professors for letters of recommendations. Most programs will require 2 to 3 academic references. For some schools, but not all, a professional reference may be submitted as substitution for an academic letter. Importantly, make sure that your referees are willing to provide a strong positive testament to your abilities and can speak to your potential success in a primarily research-based graduate program; reference letters that offer faint praise or are outright critical of the applicant can be incredibly damaging to an application (for other so-called ‘Kisses of Death’, see Appleby & Appleby, 2006). Your goal is to facilitate the process for referees. Make writing and submitting the reference letters as simple as possible and ensure that you give plenty of notice (4 to 8 weeks in advance of the application deadline) that you will require a letter in the future. I would recommend drafting a list of all the schools you wish to apply to and providing a step-by-step guide on how to submit the LOR to each school (electronically and/or by physical mail) for your referees’ convenience. This also would be a good time to provide these referees with some direction by identifying examples of times where you have proven yourself worthy for acceptance to clinical programs. Further, you should also send your references an updated CV, set of transcripts, and background information about the program you are applying to. The more information the reference has, the easier it is to write a strong letter.

    Official transcripts, CVs, and the personal statement can be completed and submitted electronically any time before the application deadline (usually December 1st). However, gathering feedback from your peers and supervisors can be incredibly useful so you will want to complete an initial draft a few months before to make necessary revisions. You should spend ample time editing and revising your personal statement, ensure no typos, spelling or grammar mistakes are present. It is strongly recommended that you have at least one other person read your letter to ensure you have not glossed over anything. In the following sections, I will provide additional content and stylistic information regarding the personal statement.

    Finally, an oft-neglected but necessary part of Canadian applications is applying for external funding, which is typically from the three federal granting agencies (Tri-Council): CIHR, NSERC, and SSHRC. Applications are due December 1st for those applying to MA programs and mid-September for those applying to PhD programs. These applications require two academic references as well as a short research proposal (1 page for MA and 2 pages for PhD). Each funding agency requires different information. CIHR is often touted as the heftiest application. Appropriately, you will want to give yourself time for referees to submit their LoRs as well as familiarize yourself with the literature to write a strong research proposal. Note that you do not have to carry out the study proposed; this is simply an exercise of your ability to clearly communicate a potential research idea in a scientific manner. It is important to understand that this information reflects the current funding status in Canada in September 2018. Information and government funding opportunities may change in the future.

    For a more comprehensive and detailed timeline for suggestions as to when these components should be completed, as well as information on interviews after the application period, please refer to Dr. Sophia Choukas-Bradley Tips for Applying to Graduate School in (Clinical) Psychology: A Step-by-Step Guide.

    Evaluation Criteria

    Although the admission criteria are fairly standardized among institutions (e.g., at least an A- average, research experience), there is a fair bit of ambiguity as to what makes a successful applicant aside from the quantitative scores observed in GPA and GRE scores. In the following text, I break down the general evaluation criteria into three subsections: 1) Academic Background 2) Skills and Professional Development and 3) Supplementary Materials and Evaluations.

    Academic Background

    Academic background includes the quality of the institution and the program you attended previously, GPA, and GRE scores for the General and Subject tests. The quality of your institution and respective program is likely set in stone; however, for more keen students beginning their undergraduate education, it is advisable to pursue a 4-year honours degree in psychology at a respected university. Although an honours degree is not necessary (programs will also take students with an equivalence in terms of coursework and research experience), honours programs tend to confer many academic and professional benefits for students, such as testing a unique research hypothesis by designing a research study, presenting at conferences, writing a thesis, and being surrounded by like-minded individuals that can support and inspire one another to succeed. While it is not the norm to enter a clinical psychology program without an honours degree, it is possible though not recommended. The vast majority of students will hold an honours degree before entering graduate school. If you are too late in your program to enroll in the honours program before graduation, you may want to explore the possibility of pursuing a postgraduate honours, in which you attend for one year after graduating to obtain an honours degree. Not all institutions will provide students with this opportunity so it is imperative that you speak with your academic advisor early in your program.

    With respect to GPA, undergraduate institutions generally require an A- cumulative GPA or GPA over the last two years. Successful applicants, however, typically have a substantially higher GPA. Although having a lower GPA does not necessarily preclude you from admission, especially if you have strong credentials in other areas (the same applies with GRE scores), it is important to note that certain institutions may use this as a benchmark to cull applicants if there is a large volume of applications. Do not be discouraged by the 60% you received in your first-year economics class but be aware that several failing or low grades, especially in psychology-related courses, will not bode well for your application.

    GRE scores on the general test are broken into three sections: Verbal Reasoning, Quantitative Reasoning, and Analytical Writing. Although a scaled score is calculated, what is most important is your standing relative to other individuals (i.e., your percentile). Applicants should attempt to aim for at least the 80th percentile in each section to be competitive (although looking up the statistics of admitted students in programs is also helpful and may be more useful than a specific percentile demarcation). If you have lower scores, remember that the GRE is only one part of your application and is unlikely to be the deciding factor in admissions. The Psychology Subject GRE is less important and is unlikely to be the deciding factor in gaining admission, and in most schools, is an optional (but recommended) part of your application. If you do well, it may offset a less than desirable academic record by demonstrating your proficiency in the foundations in psychology and its associated sub-disciplines.

    Overcoming this beast of a test will be different for every student. There are plenty of test preparation courses available (Kaplan, Magoosh, Princeton review) to help you make your way through the exam. That being said, it is worth noting that the material covered in the general GRE is not inherently difficult to grasp; rather, the variation in test scores comes from speed and accuracy which can only be attained through practice. With this in mind, I recommend you think deeply about whether an expensive test preparation course is right for you. An alternative option is using the available free online courses (e.g., Greenlighttestprep) or purchasing used preparation materials from students who have taken the test in the recent past. If you reach a topic that you have trouble understanding, try contacting a local GRE tutor. Practice tests (e.g. Princeton, Manhattan, Magoosh, ETS), on the other hand, are relatively good value and crucial to assess your progress and get as much practice as possible. Additionally, saving some time and money to retake the GRE if need be is a good way to overcome test anxiety, get a feel for the environment, and improve your scores. Finally, if you have received your scores and are unsure if they are sufficient for acceptance into your desired institution (because they are lower than the scores listed in their program statistic pages) contact your potential supervisor and ask if they would recommend retaking the test before putting down your deposit for another date. Recommended study resources for both the subject and general GRE are listed in the appendix.

    Skills and Professional Development

    In this section, I discuss the necessary skills and qualifications desired by MA/PhD graduate programs in clinical psychology. Although clinical psychology programs adhere to the scientist-practitioner model, first and foremost students are trained as researchers. Consequently, your capacity as an independent scientist is the most important quality to cultivate during your undergraduate and postgraduate studies. Research experience can be obtained in many ways: volunteering in psychology or related research laboratories, completing directed studies (i.e., working in labs or undertaking small research projects for course credit), or completing an honours thesis. Importantly, I would embolden you to join labs that you have a budding interest in and take copious initiative to demonstrate to your professor and the graduate students your capacity as a researcher. Research assistants often feel grateful for their position and typically perform a variety of tasks such as data cleaning and entry, transcription, and running studies. However, you should feel comfortable asking for more responsibilities and opportunities for professional development should you want to broaden your experiences. By involving yourself in a research lab, you put yourself in a position to take on more responsibility, which could cascade into paid/leadership positions and tangible evidence of your contributions (e.g., co-authorships on presentations and scholarly publications). Arguably, the best way to gain admittance into graduate school is to demonstrate that you are capable of doing graduate level work. The gold standard here would be a publication or first author presentation (poster or symposium), but any evidence that you can think like a scientist (study development, hypothesis generation, etc.) would also lend well to an application.

    Given the emphasis on research potential, applicants should demonstrate their proficiency to conduct research, namely understanding and applying research methodology and statistical analysis. One form of evidence comes from a strong educational background. You should strive to do well in courses involving research methods and statistics and do not be afraid to take additional advanced courses to place yourself a cut above the rest. In conjunction, you can also take the initiative to help your supervisor or graduate students design research materials and ask to assist in analysis. A letter of recommendation that speaks about how a student helped design a study or present research at a conference will go a long way in furthering your application.

    One possible inquiry you may have is whether you should focus delving into a single stream of research in one lab or volunteer at multiple labs to gain experience – the age old question of breadth or depth. The answer, albeit arduous, is that a mix of both would be ideal. The two concepts are not mutually exclusive and both can lend well to an application. The benefits of gaining depth into a field of research will inform an appreciation for the work being conducted and allow you to think like a scientist, helping you to consider hypotheses and limitations within one research area. This experience will increase your confidence towards individual pursuits in developing your own research questions and designs and later present your research at conferences. Notably, your professor will be able to write a much stronger letter of recommendation (or if you are applying to them, they will know that you are capable of graduate level work). Your extensive training and research may also look very inviting to potential supervisors who study a similar field during application periods.

    Although depth in your training is invaluable, you should not neglect obtaining a breadth of research experience as well.  Research labs often operationalize and examine variables and hypotheses in different ways, and subsequently, train their research assistants to do a variety of unique tasks. Consequently, you will be able to develop a large range of marketable skills that may make you stand out as an applicant. Working in multiple labs can confer a more nuanced understanding of research. For example, if you worked in a research lab studying sexual health and a second lab studying depression, you might start to consider the relationship between depression and romantic dyads, and what factors in a romantic relationship protect against or exacerbate depressive symptomatology. A final benefit of volunteering in a variety of labs is that it simply allows you to discover what you like. If you do decide to pursue graduate studies, you will likely study a similar topic for a number of years. As such, you will want to make sure that the topic you are studying is something you are passionate about.

    In summary, it is recommended that you attempt to work in at least a couple different labs. Assuming that the work is interesting and your supervisor seems to be invested in your education and success, you should volunteer for at least two years to gain a deeper understanding of the research, how it is conducted, and what areas have yet to be fully explored.

    Supplementary Materials and Evaluations

    The personal statement is perhaps the most time intensive portion of your application outside of the GREs. With that in mind, I recommend starting drafts in September. While each school requires a unique personal statement tailored to that program, they all tend to ask variations of the same question (be sure to double-check this) which means that some aspects of your statement can be recycled. Typically, a program will ask something along the lines of “What makes you a good fit for program XXX?” Responses to this question will, of course, vary from person to person but there are a number of areas that I highly recommend you cover. Specifically, your primary goal is to prove that you can think and act like a clinical scientist as evidenced by your wealth of research experience, coursework, GPA, GRE, and any other experiences and skills you have obtained. You will also want to outline your goals for the future and how this specific program will help you attain those goals. Show that you have researched the school and are dedicated to your application with them.

    Structurally you have many options. First, many people start with a personal anecdote about why they want to pursue clinical psychology. Beware however, this is the least important and most unnecessary part of the statement so do not get carried away. Launching into a personal montage may be regrettable. Use these introductory statements to quickly lead your reader to the reasons why clinical psychology is appealing to you. There are many things that could be discussed at this point, but some are better than others. Importantly, be conscious of how much information you disclose: do not say that you are interested in Clinical Psychology because of your own (or a loved one’s) past experience with depression or any other disorder (refer to the “Kisses of Death” mentioned previously in the article). Rather, express your passion for a specific area of research or focus on the innate desire you have to reach into the unknown and return with knowledge that will benefit specific populations. While your end goal may be to focus on clinical practice, these MA/PhD programs are interested in applicants that are passionate about research as well. It is important that you present a balanced picture of yourself. If you have no affinity or interest in research, it might be advisable to pursue other career options.

    Following this, the bulk of your statement should highlight how your past experiences have prepared you to enter a rigorous clinical psychology graduate program. Here, you should point to your overall GPA (if it is less than excellent, highlight your psychology GPA) and any awards or scholarships you hold. More important than your GPA, which speaks for itself, is your past research experience. Avoid simply restating your CV. Instead, expand on what you learned from these research experiences and link them to your fit in the MA/PhD program. Avoid recycling old ideas. If one research experience taught you how to run proper analyses, make sure that the next experience you speak to expands on and provides you with new knowledge or opportunity. Here are some ideas of what ground you should aim to cover: time management, self-motivation, experience working with clinical populations, writing and communication skills, professionalism, and statistics training and experience with study designs. Use concrete examples to prove that you have the background to manage the rigor of a clinical research-oriented program.

    Finally, you will have to close your statement with a section which refers to the reasons why this program is the best fit for you. Here, you will primarily be discussing the fit with your ideal supervisor(s) and their research program. It is also good to briefly point out other unique portions of the program (refer to their clinical handbook) that are of interest to you and your career. Hopefully, at this point you have been in contact with proposed supervisors and this is a fantastic time to remind them who you are with a statement, such as “I have been in touch with Dr. Bill B. Likert and I discussed how XXX might mediate…”. Before signing off, it can be helpful to prove, on the spot, that you can develop research questions by placing yourself, and your past experience, in the context of your potential supervisor’s lab in the form of a research question. For example, something along the lines of “My experience researching X has made me curious if perhaps X may be a mediating variable in the relationship between Z and Y that Dr. Likert emphasized in his recent paper. Specifically, because the literature shows that…” would be an excellent way to demonstrate your ability to form novel hypothesis and think like a scientist-practitioner.

    Most programs request a statement of approximately 2 pages single spaced in length. Use all the space you are given. At first this may seem like too much room for your previous experience to fill but you will soon find that, after the umpteenth-thousandth edit, your mind may change. Send this statement out to as many people as possible, and incorporate useful feedback. When you are done, upload or mail it in!

    Tri-Council C-GSM or Doctoral Funding Application

    The Tri-Council funding application is relatively straightforward. First, you need to decide which funding agency will best fit your research proposal (i.e., NSERC, SSHRC, or CIHR). For clinical students, this will be CIHR (clinical research) but SSHRC (social research) is also common as proposals given that SSHRC tend distribute more funding awards if you are looking to increase your odds of receiving one of these prestigious awards. Look into the types of projects these agencies fund and their respective mandates and pick what best suits your interests. You may send a summary of your proposal to each research agency to determine exactly who you should submit your application to. Remember, if you submit it to the wrong agency, you lose the opportunity at tens of thousands of dollars. Be sure before you submit. The application requires two academic recommendations, a Canadian Common CV (CCV) and a hypothetical research proposal. The doctoral award also requires relative research contributions, an online application, and recommendation from your department head. Creating a CCV requires you to input your current CV into the format required on the government website.

    Your hypothetical research proposal will be a maximum of 1 or 2 pages in length (not including references) and should include the following sections: background, objective and hypothesis, methods, and significance. When considering a potential project, the most important factor is feasibility. Pick a research project that is manageable and can be completed throughout your masters. Moreover, keep in mind that no one will hold you to this project; rather, this proposal is a means of assessing your ability to formally write and think like a scientist. I would be shocked if you did not feel suffocated by the word limit, so get your concision pants on because it will be tight in there. Add your references to the following page and ensure that they are in proper APA format. Few resources are available to guide you through writing this proposal, but seek out professors in your program for guidance. Your scholarly writing centre, college of graduate studies, or library may also host Tri-Council writing workshops as these grants often span several disciplines. Contact your local librarian or graduate student advisor in psychology to explore these options.

    Final Thoughts

    I would like to leave a few miscellaneous pieces of advice for making your way through this process. First, do not be discouraged if you do not get in on the first round. Take the time in between application years to bolster your experiences. Some people may take a year or two off to work as a research assistant. If you need, write the GRE again or volunteer with different populations. I all know some incredible, qualified applicants that have been rejected multiple times. To some extent it is luck of the draw: perhaps the professor you apply to is not taking students or you are competing with their lab manager of five years. On a similar note, some people feel that they are too old to pursue graduate level education and want to get on with having a job before their knees give in. While that is your decision to make, these programs should be viewed more as a training sequence than a basic education. You are paid (pittance) along the way through a combination of external (tri-council/OGS) and internal (research/teaching assistantships) funding but you gain hands on (often world class) training, and formal classes are minimized as your degree progresses. It is never too late to gain further education. The time will pass anyway!

    One of the last important pieces of advice I hope to impart is to reach out for help. Graduate students and your supervisors have been through the process and are often willing to help in more ways than you might expect. Don’t be afraid to reach out and ask for help – people love to feel useful!

    Finally, you may wonder if you should take a year off or apply to these programs. While, in theory, applying in your final year of undergrad “can’t hurt”, I are sure you now recognize that this application process is no small or inexpensive feat. With that in mind, I would like to point out that juggling this application process with your coursework might negatively impact your ability to excel in your commitments, or even lead you towards a minor mental breakdown. If you are struggling to balance 5 courses, study for the GRE, complete an honours thesis, and volunteer in a research lab(s), your applications may suffer. You do not want to waste time or money putting out sub-par applications because you will most likely receive sub-par (or worse) results. Many people take a year or more off after completing their undergraduate degree. This gives you the opportunity to work in a psychology-related field, beef up your CV, and have a few days on the beach in between.

    I hope this guide has helped you get a better picture regarding the application process to Canadian clinical psychology programs. While clinical psychology programs can certainly be competitive, people just like yourself have managed to succeed in these endeavours. After all, somebody has to get in – it might as well be you.

    Best wishes,

    P

  • How To Improve Sleep Hygiene For Optimal Sleep Health

    How To Improve Sleep Hygiene For Optimal Sleep Health

    What is sleep hygiene?

    Sleep hygiene refers to best practices for behaviours and environmental factors that are most conducive to sleep (Stepansky & Wyatt, 2003). Specifically, they are a list of things we can do in our lives to reduce possible disruptions in our sleep and make sure that the environment is a good place to sleep.

    Although sleep hygiene may not be the answer to more challenging sleep problems, such as chronic insomnia, proper sleep hygiene can lead to better sleep outcomes (Caia et al., 2018).

    Below are some tips to improve sleep hygiene for optimal sleep health.

    Improving the sleep environment

    Temperature. Temperatures that are too high can make it harder to fall asleep, lead to more awakenings in the middle of the night, and even reduce the amount of time we spend in deep sleep (Okamoto-Mizuno & Mizuno, 2012). On the other hand, cold temperatures can impact our heart rate response which could be related to adverse cardiac events (e.g., heart disease). Therefore, choosing a comfortable temperature can be helpful to keep sleep quality and quantity high.

    Noise. Unsurprisingly, loud noises can also be a barrier to falling asleep/staying asleep. Noise cancelling headphones or other strategies to minimize sound during sleep can therefore be helpful. Some people find it useful to listen to white noise or pleasant sounds; in this case, I would encourage you to continue with the things that work well for you and that you enjoy!

    Light. Reducing light exposure can help our body set the stage for sleep. If ambient light is a problem, blackout curtains can be a useful investment to optimize the sleep environment.

    Mattresses/blankets. A well-chosen mattress, blanket, and pillow can also help with making sleep more conducive. For some, weighted blankets may help to reduce anxiety and stress (Eron et al., 2020). With respect to mattresses, people may have differing preferences for the firmness of the mattresses. Even other components of the sleep environment, such as pillows and pajamas, may be important to consider if the ones you are currently using are causing you grief.

    Curtains drawn for light

    The nighttime routine

    Additional Do’s and Don’ts

    1. Avoid caffeine in the evening

    The half-life of caffeine is about 5 hours. Half-life is how long it takes for 50% of caffeine to be eliminated from your body. Therefore, it is best to avoid consuming additional caffeine after the late-lunch period. Otherwise, the remaining effects of caffeine could be stimulating and affect your ability to fall asleep.

    2. Avoid substance use like alcohol and marijuana

    Although the antidepressant effects of alcohol and marijuana can make it easier to fall asleep, the chemical breakdown of these drugs can lead to more awakenings in the middle of the night. The result is falling asleep quicker, but less refreshing, troubled sleep overall. Avoid non-prescription drugs especially during the evening for proper sleep health.

    3. Limit vigorous physical activities in the evening

    Although increasing physical activity during the day can be helpful to increase pressure to sleep (which helps with consolidating sleep and increasing sleep quality), intense physical activity in the evening could increase physiological arousal and make it harder to fall asleep. If you enjoy moving around in the evening, it is recommended to keep to light activities, such as walks and yoga.

    Boy playing on his iPad tablet

    4. Avoid eating heavy dinners

    Eating a heavy dinner can lead to acid reflux in the middle of the night because you are laying down, which could affect how gravity keeps the food in your stomach. Heavy foods can also cause your metabolism to run faster and send more blood to your brain causing vivid dreams or nightmares.

    5. Daily relaxation strategies are helpful

    Finally, keeping to regular relaxation practice in the morning or afternoon can be a great way to reduce stress, which can help with sleep. It is recommended to engage in relaxation exercises outside of the bedtime routine because we do not want to create an association between ‘needing to relax’ and falling asleep. Efforts to sleep can sometimes move into more insidious territories of being a crutch for good sleep. Over time, this can lead to insomnia.

    Final comments

    I hope this post was helpful to learn more about ways to optimize your behaviours and the environment for good sleep hygiene! For those interested, here’s a couple interesting posts on feeling more energized in the morning and goals to set to optimize your sleep!

    If you found this post helpful, please consider subscribing to the mailing list!

    Best wishes,

    P

  • What Makes Teens Constantly Tired? A Sleep Science Perspective

    What Makes Teens Constantly Tired? A Sleep Science Perspective

    Many parents and teachers may hold the belief that teens can be somewhat lazy. Teens seem to sleep in all the time on weekends, may act tired all the time, and it’s often a hassle to get them out of bed for school on time. The common culprit that people run to for an explanation that teens are mismanaging their time and not sleeping at the right time.

    But this explanation may not necessarily be true.

    There are many biological, social, and behavioral changes that happen during adolescence that may better the reason why sleep seems so much more problematic in this part of human development. These changes make adolescents susceptible to a variety of different sleep problems, such as sleep deprivation, circadian problems, and chronic insomnia.

    Consequently, the reason why your teen seems sleepy all the time and it is a monumental task to get them to sleep and wake up at a reasonable hour may not be because of low motivation and poor sleep habits. Below, I discuss each of these factors in turn.

    Biological changes push towards a later bedtime

    Our circadian rhythm is the internal clock that tells us when we prefer to sleep and wake (along with a host of other processes). People can be ‘early birds’ or ‘night owls’ – and anywhere in between. Our circadian rhythm matures over our life beginning with adolescence.

    During adolescence, the circadian rhythm sees a natural push towards a more evening preference (Giannotti et al., 2002). That is, their body biological prefers to sleep a little later compared to when they were children – a 10:00pm to 7:00am sleeper may become a 12:00pm to 9:00am sleeper. During our adult and older adulthood years, we begin to shift towards a more morning preference.

    Moreover, there is also research to suggest that the build-up of sleep drive is slower as we move into adolescents but sleep needs stay the same (Carskadon, 2011; Jenni et al., 2005). This process also makes teen stay up longer before they get sleepy because of the reduction in sleep drive, but they still require the same 8 to 10 hours as recommended by the American Academy of Sleep Medicine (Paruthi et al., 2016).

    As we can see, the circadian rhythm system and sleep drive system both push adolescents towards a naturally later bed and rise time.

    Model of how sleep problems can occur because of changes in teen sleep

    Behavioural changes that push towards a later bedtime

    Besides biological changes in sleep, there are also changes in sleep habits and behaviours during adolescence that may lead to delayed/poorer sleep.

    There may be a social pressure to stay up later; for example, other teens may stay up later to spend more time with each other in the evenings.

    Screen time use is also increased during this period (Leatherdale & Ahmed, 2011). There is some research that screen time (e.g., use of phones, computers) can lead to greater levels of alertness and affect production of melatonin (Fossum et al., 2014). However, not all studies have found this relationship (e.g., Wood et al., 2013).

    In addition to screen use, adolescents may also be less informed about how sleep habits can affect their nighttime sleep. Adolescents may consume more caffeine in the evening (Martyn et al., 2018), which can affect how long it takes to fall asleep.

    School start times conflict with adolescent sleep times

    The psychosocial changes in adolescent sleep development conspires with early school start times to cause sleep problems. School start times are typically around 8:00am but teens usually don’t prefer to wake up until a little later because of the evening tendency.

    The result is a type of chronic sleep deprivation because of this mismatch between school start times and adolescent sleep preference. It may also be the reason why so many teens ‘catch-up’ on sleep during the weekend by sleeping in.

    Unsurprisingly, studies have shown that delaying school start times can have a beneficial impact on sleep health and academic performance in teens (Thacher & Onyper, 2016).

    Back to school clock

    Conclusions

    In conclusion, your teen may not be as lazy as you think. There are biological, social, and behavioural factors that all conspire together to create a ‘perfect storm’ of poor sleep.

    Keeping to a consistent bed and wake up routine and reducing nighttime habits that may disrupt sleep can be good ways to support sleep health during the adolescent period. Keeping active during the day can also help to increase sleep drive, leading to deeper sleep. That being said, societal changes, such as changing school start times, could have an important impact on improving sleep health from a systemic perspective.

    If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!

    Best wishes,

    P

  • 11 Important Qualities To Look For In A Therapist

    11 Important Qualities To Look For In A Therapist

    Introduction

    Patients go into therapy in a very vulnerable state. It is easy to assume that you are the problem when therapy is not going right. Consequently, understanding what makes a good therapist allows patients to determine where the issues lie.

    Moreover, the therapist and patient relationship is an important part of therapy. Finding someone who is likely to work well with you is essential for a positive experience and improve the likelihood of treatment success.

    Below, I discuss 11 (odd number, I know) important qualities to look for in a good therapist. These qualities are what I consider to be a strong therapist as a current practicing clinician.

    1. The therapist is a good listener

    Perhaps above all, your therapist needs to be a good listener. If they are not hearing what you are saying, then they cannot understand the emotions and underlying thoughts you are experiencing. For example, they may not notice that you are shying away from certain topics because of guilt and shame. Because of that, they miss an important point of therapeutic contact. Moreover, they won’t be able to incisively determine what might be causing your current problems. A therapist that does not listen is not an effective therapist.  

    Person holding their ear out

    2. A good therapist is empathetic

    A good therapist must be in tune with your emotions. To be empathetic is to show that they truly understand and care about your situation. If you sit in front of a therapist and feel as though they are simply there for a paycheck, you’re probably not going to want to share very much or work deeply on your troubles.

    3. A good therapist validates your concerns

    We are often our own worst enemies. We may shame ourselves for having difficult emotions, or feel guilty for not being to solve a problem by ourselves. A good therapist will validate your experience: that it is tough to be the circumstance you are in and that you want to become more autonomous in resolving your problems. A good therapist will never minimize your emotions or experience; and if they do, it’s only after significant trust is built to remind you that you are much stronger and resilient than you give yourself credit for.

    4. A good therapist shows unconditional positive regard

    Unconditional positive regard was introduced in humanistic psychology by Dr. Carl Rogers. It is the idea that people are innately good, have the answers to their problems, and just need a little support to get to where they want to be. Although you may not love who you are in that moment, your therapist should show genuine appreciation for who you are as a person. They will find positive qualities when you think you have none. Moreover, they’ll show genuine belief that you can get to where you want to be in your mental health journey.

    5. A good therapist is honest and transparent

    A good therapist will never try to trick or deceive you. They will be very clear about how the treatment works and walk you through how different strategies work. They will also voice concerns if something about the therapy is troubling them.

    For example, they may say “I hear on the one hand that you want to improve your mood, but that does mean we can’t always follow our feelings when it comes to getting out of bed. If we do, then the depression will stay”. Having these frank conversations is important to understanding your feelings but also providing you with some harder grains of truth to support you in your journey.

    6. A good therapist explains concepts clearly

    A good therapist discusses topics and provides information about the treatment, your psychological symptoms, and the potential causes of your symptoms in a very translational and easy to understand manner. They should not be using technical jargon and clinical concepts that make you more confused and blindly trust them. Within a few treatments, you should be able to answer questions and even teach concepts to other people if you were inclined to do so.

    7. A good therapist focuses on your goals and values

    A good therapist never pushes you to a certain goal unless it is pertaining to something life-threatening. Otherwise, they should always focus on where you are and where you want to go in your therapeutic journey.

    For example, a patient may struggle with anxiety about driving cars and flying planes. Although the therapist, wanting to help, may desire to help get rid of both anxieties about planes and driving, the patient may be only interested in working through their fears of driving cars at this time. They don’t feel ready to talk about their issues with planes. In this case, a good therapist will focus on reducing anxiety about cars, and simply let the patient know that they always check in if they want to tackle their other problems when ready.  

    Blocks for collaboration

    8. A good therapist checks in with what you are feeling or thinking

    Therapy is not the therapist driving the bus with you blindfolded. A good therapist will check in throughout the session to see how you are feeling with how treatment is progressing. They will incorporate your feedback and re-focus if you are feeling confused about uncertain aspects. In some ways, your opinion will matter more than the therapist when it comes to deciding which components of therapy are most important and what home practices are most helpful.

    9. A good therapist collaborates but does not collude

    Collaboration and collusion are different concepts. A good example of collaboration is working together to decide which goals are most important. A good example of collusion is when a therapist decides to completely change the treatment because you are anxious about whether you can do a certain home practice. They are feeding your belief that you cannot do something and that something doesn’t work for you despite not even trying it out. Collaboration leads to positive relationships and better outcomes; collusion leads to worst outcomes and maintains fears and lack of self-efficacy.

    10. A good therapist engages in evidence-based practices

    A good therapist is also a good researcher. Because of this, they will refer to the research for best practices with patients to ensure that everything they are doing are well-supported by evidence. In the beginning of the first session, the therapist will likely discuss the therapeutic modality they will be using and its evidence base.

    11. A good therapist is flexible

    Finally, a good therapist recognizes when something is working and when it is not. Just because the evidence says it works does not mean that it works for everybody. A therapist will be flexible in deciding alternative options or changing strategies if something doesn’t work or resonate well with the patient.

    If you found this post helpful, please consider subscribing to the mailing list! Find more helpful posts below:

    Best wishes,

    P

  • Why Can I Sleep Anywhere Except On My Bed?

    Why Can I Sleep Anywhere Except On My Bed?

    Introduction

    People with chronic insomnia often go to bed sleepy. However, the moment their head hits the pillow, the brain begins to go into hyperdrive mode, and they end up wide awake.

    There’s a saying that people with insomnia actually can sleep. It’s just that they can sleep anywhere except their own bed.

    I often hear from my own patients that they would find it very difficult to fall asleep. After rolling around in bed for hours, they may move to the couch or the guest bedroom and find themselves falling asleep quite quickly, thereafter.

    But why does this happen?

    Bedtime associations and learning principles

    The reason that people with insomnia find their bed to be a particularly activating spot is because their brain has been conditioned to associate the bed with wakefulness. This is one of the causes of insomnia.

    This learning principle can occur in many contexts. A famous example is of Ivan Pavlov and his dogs. The idea is that Pavlov ran the bell whenever he fed the dogs. And over time, the dogs began to learn that the bell meant that food was near – i.e., an association between ringing of the bell and food. Consequently, the dogs began to salivate just by hearing the ringing of the bell.

    These types of learning principles can happen for humans too. If a person spends a lot of time in bed awake, worrying and ruminating, then they will begin to associate their bed with wakefulness. This is called conditioned arousal.

    This also explains why sometimes people sleep much better when they travel. By removing themselves from the bedroom environment and context of their conditioned arousal, the association weakens and they are able to fall asleep easier.

    How do I start sleeping in my own bed again?

    There is an evidence-based strategy to treat conditioned arousal, which is known as stimulus control (Bootzin et al., 2016). This is a strategy that works by making sure that the bed is only for sleep and restoring the association between the bed and sleep. The rules are as follow.

    1. Go to bed only when sleepy. Set a normal bedtime, but if you find that you are not sleepy at that time, then don’t go to bed until you are sleepy. For some, they may get worried because they may not get sleepy until late into the night, but facing this anxiety is important to freeing yourself from insomnia.

    2. Get out of bed to do something pleasant (e.g., reading a book) if sleep is not coming. If you find that your brain is going into overdrive the moment your head hits the pillow, or if sleep hasn’t come after 20 minutes, get out of bed.

    3. Only go back to bed if feeling sleepy. If you find that you go back to bed and sleep is not coming again, repeat the cycle by getting out of bed.

    4. Wake up at a consistent time every morning. No matter how little sleep you get, try to stick to a consistent rise time. This will be important to break the cycle and build sufficient sleep pressure to return to a schedule the next night.

    5. Use the bed only for sleep. Using the bed only for sleep is helpful to further reinforce to our brain that the bed is only for sleeping.

    Although these are tough recommendations to follow, they can be very effective in breaking down the association between bed and wakefulness.

    If you’re interested in learning more about CBT for Insomnia – the gold standard for treatment of chronic insomnia – check out my book: The Insomnia Paradox

    If you’d like to work with me and live in Ontario, Canada you can contact me here 🙂

    Best wishes,

    P

  • When You Should End Therapy From A Therapists Perspective

    When You Should End Therapy From A Therapists Perspective

    Deciding to terminate therapy

    Ending therapy can be anxiety-provoking and feel like a scary conversation to have with their therapist for many patients. People may have many worries about terminating therapy, such as whether they’ve developed enough skills to go out on their own, whether the therapist will be offended, or what they will do if their symptoms come back in the future.

    Because of these worries, patients become uncertain whether they should end therapy; and if they are – how to go about it.

    Although terminating therapy can be a daunting decision, the process can actually be very helpful and productive. For example:

    1. Ending therapy gives you the chance to take the skills you have learned in therapy to become your own therapist and not rely on your current therapist as a crutch.

    2. It allows you to work with your therapist to decide on other potential treatment avenues if this particular therapy isn’t working (your therapist will not be offended!).

    3. Formal termination allows you and your therapist to come up with a plan to make sure that you keep your gains and continue progressing in the areas you wish to work on.

    Below, I provide a few instances that may come up during therapy where it may be helpful to consider whether it is beneficial to discontinue treatment. I also provide a few tips on getting the most out of treatment completion.

    You have developed important clinical skills and reached your goals

    The most obvious reason for ending therapy is simply because you do not need it anymore. You’ve developed the tools needed to manage your symptoms and you have reached your therapy goals.

    For certain therapies, such as cognitive behavioural therapy, the main goal of therapy is to make you your own therapist. Therefore, the therapist will also likely bring up that terminating treatment at this time is ideal to allow you to grow into your own ideal clinician.

    Deciding to formally terminate therapy will also allow the therapist a chance to discuss with you a plan of action to make sure that you continue moving towards your goals. This can be helpful to summarize important learning points and decide whether further resources are needed to properly support you on your journey.

    You do not feel therapy is helping

    In this case, I would personally recommend bringing this up with therapy and letting your therapist know that the sessions have not been doing well. Again, it’s important to realize that your therapist will not be offended and will be able to work with you to determine the best path moving forward.

    In certain instances, you may decide to continue therapy with this particular therapist because the discussion went well and feels right to simply make some amendments in therapy. In other cases, the therapist may provide recommendations to try out different treatments or work with another clinician.

    Either way, openness and transparency with your therapist will always be beneficial.

    It feels like you are using the therapy as a crutch

    There’s a saying that we therapists like to use: “collaborate, but don’t collude”.

    If you find that the sessions are now a way to avoid taking on the world alone (and relying on your therapist a bit too much), then it may be time have a conversation with your therapist about this issue.

    It’s also important remember that terminating therapy doesn’t mean that you will never talk to your therapist again. It is possible to set up booster sessions (an occasional periodic session to check-in and make sure everything is going well) so you do not feel completely on your own.

    There’s less to talk about these days

    When you and your therapist do not seem to have as much to talk about, this could be a sign that therapy has run its course. Most challenges in your daily life have been resolved or they are within your capacity to handle without therapeutic intervention.

    Tips for ending therapy

    1. Be honest and transparent. Some patients prefer to cut and run when it comes to therapy and simply stop attending appointments. However, I believe that being open with your therapist about your desires to discontinue therapy can be helpful in many ways. The therapist will not try to rope you back into treatment if it is not something you want. Moreover, you and the therapist will be able to 1) plan for the future 2) get additional resources as necessary, and 3) open up conversations to come to therapy in the future if this is ever needed.

    2. Keep a professional relationship with the therapist. There are times when the patient (and therapist) enjoys the other person’s personality on a more friendly level. The patient may want to keep in close contact with the therapist as a potential acquaintance/friend. This is an ethical grey area and it is not recommended because the patient may one day want to resume treatment with the therapist. However, if a friendship is developed, then an issue of multiple role relationships will occur (and the therapist may not be able to see the patient again).

    3. Gift-giving token appreciations. Therapists are not allowed to accept gifts of more than token value. If you would like to provide the therapist a gift of appreciation, I would consider something small like a card or a pen. It’s the thought that counts!

    Summary

    I hope this post was helpful in clarifying some anxiety about ending therapy! If you found this useful, please consider subscribing to the mailing list for more evidence-based information on mental health!

    If interested, see below a couple posts that may be helpful for people who are interested in pursuing therapy.

    Best wishes,

    P