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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:
- Falling asleep in under 10 minutes on average
- Evening drowsiness
- 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
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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
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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
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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
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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.

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.

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
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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.

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).

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
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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.

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.

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.
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Best wishes,
P
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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
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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

