-
What Topics Are Off Limit In Therapy: Limits To Confidentiality
People going to therapy are often worried about what to say to their therapist (or whether they should say anything at all about certain topics).
They may have worries, such as: “what if my therapist judges me?”, “what if they think I am crazy and tries to institutionalize me?”, or “what if they tell my spouse or family about my issues?”.
Closing yourself off from the therapist can weaken the therapeutic relationship (Keijsers et al., 2000). Moreover, the therapist may not be able to properly work with you because they do not have the full story, which can negatively affect outcomes in therapy (Corso et al., 2012).
Addressing concerns of confidentiality
In this post, I provide information and address specific concerns about confidentiality and what topics are off limits in therapy.
The short answer is that there is none. Certainly, there are limits to confidentiality (which we will talk about), but you should generally feel comfortable discussing with your therapist about anything you wish to share.
Your therapist is trained to be empathetic and understanding in their response and will certainly appreciate your vulnerability and openness.
What if my therapist thinks I’m crazy?
It is understandable to feel vulnerable and anxious about sharing things about yourself that you may have never talked to others about before.
However, I can assure you that your therapist has likely heard it all before. And I can be even more certain that your therapist will respond in a non-judgmental and empathetic manner.
In the same vein, it is unlikely for you to be ‘institutionalized’ for discussing certain thoughts. The only limit to confidentiality that would be a concern is if you were in ‘immediate risk of harm to yourself or others’. This means that you are in significant danger of hurting yourself or somebody else.
Even in this case, the therapist will never go behind your back; they will have an open and honest conversation about your thoughts and work with you to get you to where you want to be.
What if my therapist shares things I don’t want them to?
Some patients may have concerns that the therapist will share information with other people, such as family members or loved ones.
Rest assured; the therapist will never share any information to other people in your life unless you provide explicit consent. In fact, if someone who is not authorized calls and asks about your appointment, the therapist cannot even disclose if you are even a patient at the clinic.
For minors, this can sometimes be a different case. For example, the therapist may have to disclose information to parents regarding assessment and treatment. However, it is also possible to set confidentiality rules with the parents before treatment starts so that the minor has full autonomy about what information can be shared with parents.
Limits to confidentiality
Generally speaking, there are 5 instances where a therapist may have to break confidentiality to let the right people know.
1. Presenting immediate danger to oneself or others. Note: this means an urgent situation where a person’s life is in imminent danger. Therefore, self-injury would not be included in this limit to confidentiality.
2. Inappropriate behaviours from healthcare professionals. In this case, if the therapist hears that a healthcare professional has ever engaged in behaviours that are not ethically appropriate. In this case, the therapist must let the right regulatory know.
3. Knowledge of ongoing abuse of a minor.
4. Knowledge of ongoing abuse of someone in a long-care facility.
5. A court of law subpoenas records. This is a more unlikely event, but if the court rules that a psychologist must provide records, then this may be one instance where confidentiality may be broken. The psychologist, however, can work with a lawyer to alter what can be disclosed.
Confidentiality and the circle-of-care
Patient information is shared with what is called the primary ‘circle-of-care’ in health settings. These are individuals that directly work with you in healthcare settings (e.g., physicians, nurses, psychiatrists) to ensure that everyone is working together and has all the appropriate information.
In this way, your doctor may know what you have discussed with the therapist, so they have all the up-to-date information to provide you with the best possible care.
If there is information you don’t want shared with others in the healthcare team, then you can ask the therapist for a ‘lock-box’, in which this information will be ‘locked’. This information will not be shared with anybody in the circle-of-care.
Conclusions
Overall, you should feel comfortable knowing that you can share anything with your therapist. Limits to confidentiality do not mean that you cannot share this information with your therapist; in fact, it’s encouraged to make sure that we can protect the patient and others from further harm. Information shared as part of the ‘circle-of-care’ is to ensure that we are providing support in the best and most up-to-date manner.
For first time patients in therapy, here’s a couple additional posts that might be helpful!
1. What should I expect in therapy as a first-time patient?
2. How do I get the most out of therapy?
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,P
-
Is Hitting The Snooze Button A Bad Idea: A Sleep Science Perspective
It’s nighttime and you have work tomorrow at 9:00am. You set the alarm for 7:00am thinking maybe you can get your day started a little earlier and have some time to make breakfast and get a short work out in.
7:00am rolls around and you are jolted awake by the familiar obnoxious buzzing of the alarm. The alarm tries to pull you out of your comfortable sheets into the cold reality of having to start your day.
Almost unconsciously, you press on the snooze button to get 10 more minutes of blissful coziness. And another. And another. And maybe once more for good measure. Couldn’t hurt, right?
Is it true that you snooze, you indeed lose?
People commonly ask the question if snoozing is indeed a bad thing. As a sleep therapist, my answer is that we are not sleep police. There are behaviours that are optimal for sleep, but these behaviours may not be optimal for your preferences and values.
That being said, it is helpful to provide information on how hitting the snooze button can impact our sleep health to be able to make an informed decision. Below, I discuss how snoozing can impact our overall sleep and how we feel during the day.
Snoozing leads to disrupted sleep
Although snoozing can feel quite comfortable in the moment, the behaviour itself can be seen as a voluntary disruption your own sleep! This is because snoozing is essentially the equivalent of intentionally creating awakenings in what would otherwise be consolidated sleep.
The increase of awakenings can lead to poorer sleep quality and paradoxically sleep deprivation. To explain this, we can compare two people: one person has their alarm at 7:00am but presses the snooze button every 10 minutes until 7:30am. The other person sets their alarm at 7:30 am and wakes up naturally at that time.
In this case, person A would have slept less because they were woken up every 10 minutes and took a bit of time to fall back asleep. On the other hand, person B would experience more consolidated sleep and likely feel more refreshed.
Therefore, if your goal is to get the sleep you need, then setting your alarm clock a little later instead of snoozing may be the better option!
Snoozing can disrupt our circadian rhythm
Our circadian rhythm is the internal clock that governs when we tend to feel sleepy and when we tend to feel alert. When we do not have a strongly set circadian rhythm, we get sleepy and alert at random times (also known as ‘circadian misalignment’ or ‘social jetlag’) (Baron & Reid, 2014).
Social jetlag happens when we sleep and wake up at different times throughout the week because of irregular light exposure. Therefore, hitting the snooze button may lead to more irregularities throughout the week and contribute to circadian problems (which may lead to chronic insomnia).
Snoozing can worsen sleep inertia
For some people, their snoozing may lead to more rest, but not sleep. Unfortunately, staying in bed can actually make us feel more tired because of sleep inertia.
Sleep inertia is the process by which sleep chemicals in our body is being flushed out (Hilditch & McHill, 2019). During this time, we tend to feel a lot groggier even if we don’t need much more sleep. Sleep inertia can be reduced through activating behaviours like getting out of bed and getting light exposure (among other strategies).
When we are lying in bed, however, resting behaviours can make sleep inertia last longer and reduces our ability to generate momentum and energy throughout the day. Although it’s much tougher in the short-term, getting out of bed will make us feel better quicker.
Jetlag can happen even when we are not traveling! Benefits of snoozing
Although snoozing is not great from a sleep perspective, there may be personal reasons to snooze regardless of what the science says. Perhaps the most important one is that snoozing is simply an enjoyable activity. Some people find the act of snoozing to be comfortable and enjoy spending the extra time in bed snuggling up in their cozy sheets.
As we discussed, we are not the sleep police, and you should be able to choose the behaviours that are most comfortable for you. Now, you have the knowledge to determine whether it is ‘worth it’ to snooze.
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,P
-
4 Evidence-Based Strategies To Stop Racing Thoughts At Night
Racing and intrusive thoughts at bedtime
Some people go to bed feeling right and ready for sleep. However, when their head hits the pillow, racing thoughts start enveloping their minds and they begin to feel wide awake.
To counter these thoughts, they may engage in a bunch of different strategies: suppressing thoughts, distracting themselves, counting sheep, among dozens of other tips and tricks. However, these strategies are generally ineffective to subdue their frenzied minds.
In this post, I provide a few different evidence-based strategies based on research and clinical practice (e.g., cognitive behavioural therapy for insomnia) to work through different types of racing thoughts.
Counting sheep aren’t always helpful for racing and intrusive thoughts! 1. Worry Logs for everyday worries
One category of racing thoughts that people can experience are worries in their daily lives.
What do I do about my car’s flat tire? Who is going to take the kids to school tomorrow? I need to plan my sister-in-law’s baby shower.
When we notice our sleep is being impacted by daily concerns, then a worry log can be a helpful tool (free workshop developed by Dr. Colleen Carney).
The way to use a worry log is by taking a piece of paper and folding it vertically into two columns. One column will be the ‘worry’ section and the second column will be the ‘solution’ section.
In the evening, you would write in the ‘worry’ section some worries that may keep you awake at night. On the other side, you would then write the solution for that worry. If the problem requires several steps (e.g., planning a baby shower), then write the next step that you need to take. If there is no solution, then simply write ‘there is no solution, so I don’t have to worry about it’.
Once you’re down, place the worry log next to your bed on a nearby drawer. When you find yourself worrying, you can think to yourself: “I’ve already thought about these issues, so I don’t have to worry about them anymore”.
2. Thought records for scary beliefs about sleep
Although worry logs tend to be helpful for general worries, sometimes our racing thoughts are about the sleep itself. What if I don’t fall asleep again? I’m not going to be able to fall asleep and tomorrow will be a disaster.
If our thoughts are more insomnia-specific, then we may need another tool.
Thought records are a great way to evaluate our negative thoughts about sleep in a fact-based manner.
The idea is to take a scary thought, such as “I’m not going to be able to function at all tomorrow”, and really evaluate both the evidence for and against this thought.
You will likely end with a more balanced thought after this practice, such as “although I won’t be at my best, I have been able to do all the things I needed to do in the past, such as take my kids to school, get through work, and finish the chores”.
Here’s a helpful article on developing thought records if you’re interested!
3. Regular mindfulness practice to let go of thoughts
Besides changing our thoughts as in the case of thought records, another possibility is to simply notice the thoughts and let them go.
Mindfulness practice works by helping facilitate our ability to simply observe our thoughts and not give power to them. We notice different thoughts, emotions, experiences, and then let them go. Mindfulness has been found to treat many conditions, including sleep problems.
Paradoxically, our willingness to engage with the thoughts and not forcefully push them away can actually help to get rid of thoughts faster. It’s like the Chinese finger trap, where the contraption is designed in a way that the more we struggle, the harder it is to get out of the trap.
Beyond mindfulness practice, relaxation exercises can be helpful to reduce stress and anxiety generally speaking. This can also have a beneficial impact on racing thoughts and create a more conducive environment for sleep. That being said, it’s encouraged to practice these exercises outside of the bedroom, so they don’t become a direct effort to fall asleep. This is important because we don’t want these practices to be a crutch to get sleep.
Relaxation or mindfulness practices in the day time can be a great way to improve sleep (and other areas of your life) 4. Stimulus control to break the association between worry and the bed
Sometimes, the reason why our thoughts tend to race particularly excessively at nighttime is because we have associated the bed with worry.
When we spend a lot of our time in bed awake and in distress, our brain becomes conditioned to start worrying the moment our head hits the pillow (known as ‘conditioned arousal).
To break this association, there is an effective evidence-based strategy for insomnia called ‘stimulus control’. Stimulus control has been found to be a key strategy to break conditioned arousal in insomnia (Bootzin et al., 2016).
The idea is that we need to make our bed an environment solely for sleep. To do so, we would only go to bed when sleepy, and get out of bed (doing something pleasant and relaxing) when sleep is not coming. This process can be very tough, but also very effective over time.
Concluding thoughts
All the strategies discussed can have their unique benefit in reducing racing thoughts. Please feel free to pick the ones that feel right for you and work best. Hopefully, one – or more – of these tools are helpful to you!
If you found this post useful, please consider subscribing to the mailing list for more evidence-based strategies on mental health!
Best wishes,P
-
6 Ways To Get The Most Out Of Therapy: A Therapist Perspective
Introduction
As a therapist, I have worked with a number of patients in the past. With that experience, I have that there are certain mindsets that some patients come in the door with that serve them well during the course of treatment.
None of these strategies require an excessive amount of time or preparation. For example, there’s no need to read up on twenty books on different therapies or anything like that.
Rather, they are simply specific mindsets and behaviours that help ensure that time in therapy is positive, fulfilling, and gets you closer towards your goal. Below, I list six different ways to get the most out of therapy.
#1 Be open and honest with your therapist
To get the most out of therapy, being open and honest with your experience and feedback with therapist is essential.
The therapist needs to have a good sense of your presenting problems and your goals to understand what may be causing your psychological challenges and how to best get you to where you want to be.
In doing so, you and the therapist may actually have a stronger and more positive working relationship, and they may be able to reinforce your strengths and validate your struggles better. This outcome is perhaps contradictory to how some patients might feel – which is that the therapist will not understand them or will judge them if they told the truth.
Moreover, being honest about feedback (whether positive or negative) about the therapy can be helpful for the therapist to work with you to adapt the treatment in a way that feels right for you. A good therapist will never judge you for being honest with them; if anything, they will encourage it.
#2 Be curious and open-minded about therapy
A second tip to get the most out of therapy is to be like a scientist – curious and open-minded about the potential benefits of therapy. Generally speaking, you have little to lose and a lot to gain!
Therapy can sometimes challenge previously held worldviews and can be quite illuminating in terms of how psychological challenges are maintained. Therefore, going into therapy with an open mind can be a great way to really get as much out of it as you can.
#3 Give the strategies an earnest attempt
Cognitive behavioural therapy (CBT), among other types of therapies, typically ask the patients to engage in some form of intersession practice (a fancy term for homework) between sessions to consolidate the skills they learn in therapy.
Sometimes, patients are somewhat reserved or unwilling to try out the recommendations: “I don’t think it’ll work”, “It doesn’t seem like it would be helpful for me”, “It might be too tough”.
Although it’s the clinician’s job to make the home practice or technique right for the patient, it’s up to the patient to really apply these strategies to their lives. Their negative beliefs about the effectiveness of the strategy may be correct, but it’s important to give them a chance to see if they will work. When it comes to therapy, ‘what you put in is what you get out of therapy’. Give the strategies an earnest attempt knowing that we are just experimenting to see which strategies are most helpful. If they work – great! If not, let’s put them by the wayside and pick something else that feels better.
#4 Clarify your reasons for change
To successfully get the most out of therapy, it’s important to figure out your own reasons for change. That is, why is it important to put yourself through therapy and its associated work to change from where you currently are?
Reasons for change can be based on our values – life-concepts that are important to us. For example, a person who is depressed may see a reason to fight their depression to be able to enjoy meaningful activities again, spend more time with their friends and family, and/or find employment.
Ultimately, the most important value is completely up to you. It’s much harder to have intrinsic motivation when we are doing something because other people think we should or because society tells us we should live in a certain way. Reflect on your own values and what is important to you in your own life.
It should also be said that it’s okay to be ambivalent about whether you should change or not when you go to therapy. Your therapist will be very helpful in working with you to talk through the pros and cons of change (also known as motivational interviewing)!
#5 Reinforce small victories
For many patients, their attentional processes make them focus on the negatives rather than the positives. In depression, this type of ‘thinking error’ could be called discounting the positives – we notice the bad and explain away the good.
For example, a patient being treated for their insomnia may have improved their sleep substantially over treatment. However, they may hone-in on one day where their sleep was not the best and disregard all the improvements they have made. One bad apple spoils the bunch.
Although it’s important to notice areas to continue working on, laser-focusing on these areas can make you neglect all the great work you have done. Therefore, it’s important to reinforce victories (big or small) as evidence that the work you are doing is moving you along the right direction.
#6 Give therapy a shot!
Many people are skeptical about the usefulness of therapy. Because of that, they may decide to avoid therapy and potentially missed out on a positive experience.
Although therapy is certainly not for everyone, the experience itself should be generally positive if you are working with an empathetic, compassionate, and knowledgeable clinician.
That being said, I recognize that therapy is not always an available option and can be financially burdensome for many people. There are some practices that operate on a sliding scale or treatment that can be provided in a medical setting for reduced/less cost. Alternatively, self-help books on therapy can also be another more accessible avenue.
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,P
-
What To Expect In Cognitive Behavioural Therapy As A First Time Patient
Introduction
Starting therapy as a new patient can be an anxious experience. People often have a lot of worries. They wonder what their therapist is like and if the therapist will judge them. They worry about what therapy is like and what is expected of therapy. And they may worry about what they need to do to prepare for treatment (if anything).
All of these concerns can make going to that first therapy appointment a lot more nerve-wracking. In some cases, it may even deter some people from going to therapy and getting the help that they need.
To reduce stress and uncertainty, I developed this post to shed some light into the first therapy session and to expect before, during, and after a session. Although the information provided is likely generalizable to many types of therapies, I have tailored the information specific to cognitive behavioural therapy since this is my area of expertise in terms of my own clinical training.
What to expect before the session
First and foremost, don’t stress about preparation in terms of knowing about CBT or how the process will go! All you have to do is dress comfortably and get to the clinic (if it’s in person) at the pre-determined time. Perhaps sometimse a little earlier if the clinic asks you to complete a couple forms beforehand.
At the clinic, you’ll check-in at the reception and likely complete a few forms to get some patient information. You may also complete a couple questionnaires about your health and wellbeing to establish a baseline and to get a sense of your progress throughout treatment.
Oftentimes, waiting in clinics can be a stressful experience because we’ve associated this process with medical procedures like waiting for your medical doctor or going in for a teeth cleaning at the dentist. It makes sense that we would be a little bit nervous to go into an office to be prodded by a cold stethoscope or a pointy needle!
When it comes to therapy appointments, this fear is less substantiated. After completing the forms, the therapist will welcome you into a room with a comfortable and supportive atmosphere to start the therapy session.
And if you’re still a little afraid, it can be reassuring to know that the therapist is often has a bit of anticipatory anxiety as well to do a good job working with their new patient. You’re both meeting each other for the first time after all!
What to expect during the session
1. Introductions and housekeeping. The first session is very low pressure. The main goal of the first treatment is really just to learn more about each other, start developing a positive working relationship, and understand more about your specific goals for treatment.
The therapist will likely start the session by introducing who they are and their experience, in addition to going over some housekeeping. Housekeeping includes information such as confidentiality (and limits to confidentiality), structure of the treatment, and some therapist/patient responsibilities. The therapist may also provide some information at this time (or a little later on) about CBT and what therapy will look like.
2. Learning more about your presenting problem. After initial introductions and housekeeping, the therapist will ask to learn more about why you came for treatment. This is a period of exploration for both you and the therapist and can be beneficial for both sides. This should not feel like an interrogation; if the therapist is doing their job right, you should feel listened to, validated, and may even gain further insight into your own challenges.
3. Collaborating on therapy goals. After understanding more about the reason why you are coming to therapy and your current specific problems, you and the therapist will then collaborate to develop goals for treatment.
I would like to emphasize the word ‘collaborate’ here because that’s exactly what it is. You should never feel like the therapist is completely directing the treatment or bulldozing your desires in lieu of theirs. What the patient wants out of the treatment is always the most important thing.
The therapist’s role should be to guide the patient to developing goals and help mold these goals into specific and actionable that is consistent with what the therapy can provide (i.e., SMART goals). For example, ‘sleeping better’ is a great goal but may be hard to quantify in therapy. The therapist could help to develop SMART goals based on this initial desire by querying what the patient would like to see change in their sleep based on this goal (e.g., falling asleep quicker, keeping to a regular sleep schedule, etc.).
4. Setting home practice. In a typical 50-minute session (and depending on your comfort levels), setting a goal this week for home practice may not be part of the first session. This is because developing positive rapport, providing psychoeducation about treatment, learning more about your presenting problems, and developing of therapy goals is already quite a packed schedule!
However, it is helpful to know that home practice may be assigned in the future to support you in your goals. As helpful as therapy can be, I am a firm believer that what you get out of therapy is what you put into it. And engaging in consistent home practice developed by you and your therapist can be helpful to move closer to your ultimate goals. It’s also a way to consolidate the skills you learn in therapy to take with you after treatment completion!
What to expect after the session
At the end of treatment, you and your therapist will agree on frequency and timing of future appointments and they will likely ask you to reflect on how treatment was. Here, you can provide open and honest feedback about the session (the therapist will not be offended!).
If the therapist has assigned home practice or readings, then you might practice those new skills. If not, I simply hope you had a positive experience and that you are feeling hopeful for what’s to come in the future!
Additional recommendations when starting therapy
Here’s a few additional recommendations for when you are working with your therapist.
1. Be open and transparent with your therapist. It can be a little nerve-wracking to open up with your therapist about your struggles. And for some, it can be even tougher to provide negative feedback if there was something about treatment that bothered you. However, being honest with your therapist will allow them to better support you in terms of delivering therapy and changing how therapy is being conducted if it’s not working well for you. Moreover, if you find that this specific therapy isn’t working for you, then they will be able to help provide resources to seek different avenues of treatment that is a better fit.
2. Take a curious and non-judgmental approach to therapy. As discussed before, therapy works best when you give it a shot and take a curious, non-judgmental approach to seeing if this treatment works for you. I would encourage you to take an earnest shot with the therapist and the specific treatment recommendations before writing it off. However, it’s okay if the therapy doesn’t work well for you – it may not always be the best fit. Again, you and the therapist can work together to determine other strategies or treatments that might be more helpful.
3. Take ownership of your progress and goals! Although therapists can be wonderful, kind, and intelligent human beings, they are not necessarily miracle workers. The therapists helps to understand your problems, create a safe and supportive space to work on your mental health goals, and provides research supported skills to help you along in your goals.
However, the bulk of the work will remain on you to earnestly learn from therapy and try out the recommendations. It can be a very empowering experience to become your own therapist and recognize that there are things you can do yourself to improve how you think and feel!
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,
P -
Why Mondays Are So Hard: From A Sleep Science Perspective
A case of the Monday mornings
Mondays are tough. It can feel like we have been hit by a truck when we wake up in the morning. Usually we’re a lot more tired, it’s harder to get up out of the bed, and we are particularly irritated seeing others’ cheery smiles.
But why is this? Certainly, the fact that many of us are transitioning from a pleasant and free weekend into starting a new week of work probably does not help. However, this is only a part of the equation.
We can also explain why many of us experience a bad case of the Mondays from a sleep science perspective.
Irregular schedules and social jetlag
When we travel across time zones, we often experience something called ‘jet-lag’. We tend to feel a lot more groggy and tired, our hunger signals are all over the place, and we sleep and wake up at irregular times.
This phenomenon occurs because our internal clock is not well-aligned with the new clock on wall. Our body might still be in San Francisco time even though we are currently living in New York time.
What’s interesting is that ‘jet-lag’ symptoms can occur even when we don’t travel at all. It can happen just by virtue of having an irregular schedule, especially when we decide to go to bed and when we get out of bed.
Take for example: Betty goes to bed on Monday at 11:00pm and wakes up at 7:00am. The next day, she goes to bed at 2:00am and wakes up at 10:00am. This creates a 3-hour variability in bed/rise times between Monday and Tuesday. This shift can lead to the same jet-lag effect as traveling from Vancouver to Toronto!
If we were to apply this example to weekends, people often keep a fairly consistent rising time during the week because of work. However, they may be prone to sleeping in on Saturdays and Sundays. The shift back to Monday can lead to what we sleep researchers call “social jetlag’ – the change in schedule creates substantial jetlag symptoms that make Monday more of a monster than it already is.
A nice visual demonstration of ‘social jetlag’ at work. The person gets out of bed at around 7am on weekdays, but gets up near noon on Sunday. This is equivalent to travelling from London, Ontario to London, UK! Sleep pressure build-up on weekends
Sleep pressure, or sleep drive, is our propensity to fall asleep at any given moment. We build up more sleep drive the more we are active and awake throughout our day to day. The more sleep drive we have, the deeper our sleep is likely to be.
Throughout the week, some people may be in a slight state of sleep deprivation, because of work, chores, taking care of kids, among everything else. In this case, sleep pressure is high.
On Friday and Saturday, people may get a chance to truly refresh themselves by expending all the built-up sleep pressure and get a good night’s sleep.
For those who sleep in, however, this can be a bit troublesome because they may wake up later than usual (e.g., 10am instead of 7:00am). This gives a person less time to build-up sleep drive for the day before going to sleep on Sunday night. As deep sleep is related to the amount of time we spend awake and active, our sleep drive is unlikely to be as high on Sunday night.
The result is less refreshing sleep compounded with the jetlag symptoms from an irregular schedule.
Taking a brisk walk in the morning is a great way to increase sleep drive, break out of sleep inertia, and get some light exposure for our circadian clock! A few evidence-based strategies to deal with Monday mornings
Keeping to a regular schedule can be a great way to reduce social jetlag. That being said, I understand the joy of being able to sleep-in (a little bit of relaxing the schedule is completely okay!) – just try to keep it reasonably consistent.
Besides waking up a bit earlier, staying active (e.g., taking a walk, jogging, cycling) throughout your day can be a good way to increase sleep pressure, so the Sunday night sleep is more restorative.
Beyond these sleep strategies, there are fatigue management strategies that can break sleep inertia and get you up and running as soon as possible. Alternatively, stress management strategies can be a good way to reduce the impact that potential stress and worries about work and life can have on your sleep.
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,
P
-
Five Benefits Of Cognitive Behavioural Therapy For Insomnia
CBT for Insomnia as the first line treatment
Cognitive behavioural therapy for insomnia (CBT-I) is considered the gold standard for treatment of insomnia. It is the preferred first-line treatment method compared to medication for chronic insomnia for reasons discussed in the post
CBT-I works by leveraging our sleep systems to address the causes of insomnia. Below, I discuss 5 benefits of CBT-I in treating chronic insomnia.
1. CBT-I is effective
Perhaps the simplest – and important – benefit of CBT-I is that it is effective. Meta-analysis continue to support efficacy of CBT-I in treating insomnia. Specifically, CBT-I improves both objective (e.g., how long it takes someone to fall asleep) and subjective sleep outcomes (subjective feelings of insomnia). Beyond sleep, CBT-I has been found to also improve other health outcomes, such as depression, anxiety, pain, and overall quality of life.
2. CBT-I improves confidence in being able to sleep well
From a more meta-cognitive perspective, CBT-I not only improves sleep but it improves our relationship with sleep. People who have been treated with CBT-I typically report that they feel more confident in their bodies natural ability to produce high quality sleep even if they have bad nights. This is called sleep self-efficacy.
3. CBT-I focuses on quality over quantity
CBT-I works by consolidating our sleep. Instead of taking a lot of time to fall asleep and wake up numerous times throughout the night, CBT-I ensures that our sleep is deep and restorative with minimal wake time in the night.
The treatment recognizes that our individual sleep needs are different. Some people may require more sleep and other may function well with less sleep. By focusing on quality, CBT-I ensures that each person meets their sleep needs and feels well-rested for the day.
4. CBT-I has relatively fewer side effects
Besides a bit of sleep deprivation for a few nights during the active parts of therapy, CBT-I is generally safe in terms of potential side effects. This is because CBT-I primarily relies on specific changes in the way we think or behave in response to a bad nights, rather than any outside influence.
This finding contrasts with medication, in which people can experience side effects, such as drowsiness, headache, or nausea according to an article by MayoClinic.
5. CBT-I is durable in the long-term
One other difference between CBT-I and medication is that CBT-I is durable even after treatment is completed. Research has found that the positive effects of CBT-I can last for at least 3 years after treatment. Moreover, research from our lab suggests that we don’t have to follow the rules of CBT-I forever to keep our treatment gains. You can have your cake and eat it too!
Final thoughts
There are numerous benefits to CBT-I when it comes to treatment of insomnia. That being said, there are limitations to all treatments of course. CBT-I can be a lot of work and take commitment to successfully benefit from this treatment. From a logistical perspective, CBT-I takes longer to work compared to medication, and is relatively expensive and inaccessible. There are self-help books on CBT-I should therapy from direct treatment providers not be an option.
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,P
-
The Different Types Of Insomnia In Adulthood
Insomnia: An Overview
According to a study by Ohayon (2002), anywhere from 5 to 50% of the population suffers from some form of insomnia depending on your define insomnia. Insomnia can be short-term or long-term, and people can experience specific sub-types of insomnia.
As a general definition, insomnia can be defined as difficulty falling asleep, staying asleep, and/or waking up too early. This issue is usually related to feelings of unrefreshing sleep and daytime impairment (e.g., feeling more irritable, loss of concentration, and being more tired).
In this post, I provide brief information on different operationalizations of insomnia to shed light on some of the different types of insomnia that can exist in adulthood.
Acute Insomnia
Acute insomnia is a short-term type of insomnia that usually lasts a few days to a few weeks. Acute insomnia is typically a result of a stressor that disrupts sleep for a short period of time. For example, preparing for an exam, transitioning into a new job, or having a baby.
Usually, acute insomnia resolves itself when the stressor is no longer present. However, for some people, their sleep problems persist and may become chronic insomnia.
Chronic Insomnia
Chronic insomnia, otherwise known as insomnia disorder, is a longer-term type of insomnia that persists for at least 3 months and occurs 3 days of the week.
Chronic insomnia is a diagnosable disorder because of how persistent, pervasive, and impairing the disorder is to a person. Typically, chronic insomnia occurs because a person becomes excessively worried about their sleep and counterproductively engages in behaviours that further impact their ability to produce sleep. For example, they may spend a lot of time in bed worrying about not being able to sleep, which creates an association between the bed and wakefulness.
Here’s a post if you’re interested in learning more about the difference between acute and chronic
Beyond length of insomnia, there are specific subtypes of insomnia that people can experience.
Sleep Onset Insomnia
Sleep onset insomnia refers to when a person has difficulty with falling asleep. Good sleepers usually take between 10-30 minutes to fall asleep on average.
In our clinical work, we usually use a 30-minute threshold for what is considered elevated sleep onset. This means that if a person takes on average more than 30 minutes to fall asleep, then this could be considered a problem with sleep onset.
Interestingly, acute pain (e.g., a sore tooth, a bruise) can lead to problems with sleep onset.
Sleep maintenance insomnia
Sleep maintenance insomnia is when a person has difficulties with sleeping soundly throughout the night. Although awakenings in the night are very common, people with sleep maintenance issues will spend more time in the middle of the night awake. They may take hours to fall back asleep in some cases.
As an interesting fact, the use of alcohol or cannabis at night can lead to quicker sleep onset but more frequent awakenings, as the chemicals in the body are being broken down which can lead to higher arousal levels.
Terminal Insomnia
Terminal insomnia refers to waking up earlier than planned. For example, a person may typically sleep at 11pm and wake up at 7am. If they were to start waking up earlier than their body usually plans to frequently (e.g., 4 or 5am), then they may be experiencing terminal insomnia symptoms.
On the other hand, if a person who is a morning bird consistently sleeps at 9:00pm and wakes up around 4 or 5am, then that would not be considered terminal insomnia. That’s just their natural circadian rhythm at work.
Comorbid Insomnia
Comorbid insomnia is simply a fancy term when insomnia exists with another disorder (e.g., chronic pain, depression, anxiety, cardiovascular diseases).
Not many years ago, insomnia was seen as generally secondary to other disorders. For example, people would consider depression to be ‘primary’ and insomnia as a ‘secondary’ effect of depression.
We now know that these relationships are bidirectional and insomnia can exist before depression and stick around even if depression is treated (e.g., Stepanski & Rybarczyk, 2006). Moreover, treating insomnia can also improve the other condition, such as in chronic pain and depression.
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,P
-
How To Treat Seasonal Affective Disorder: A CBT Perspective
Seasonal Affective Disorder: An Introduction
As the days grow colder and shorter, and the nights grow longer during the transition from summer to the autumn and winter period, it is unsurprising that people experience a worsening in how they feel. As individuals from House Stark like to say – “Winter is coming”.
Seasonal Affective Disorder is quite common – studies have found that about 5% of the U.S. population experiences seasonal affective disorder, with symptoms present about 40% of the year (Kurlanski & Ibay, 2012). However, I expect that a much more significant number experience a general reduction in mood (though perhaps not meeting diagnostic criteria).
When thinking from a cognitive behavioural therapy perspective, there are certain environmental and behavioural changes that occur that is likely to affect mental health.
In this post, I provide a few hypotheses on why changes in seasons are leading to issues with mood and sleep. Importantly, I’ll also provide a few CBT strategies for depression and insomnia that might be helpful to stave off seasonal affective changes.
Seasonal changes and depression
The change in seasons leads to shorter and colder days. With these changes, the result is a lot less light activity and our days become a lot more empty. Both of these changes can impact our mood.
In summer, we are often a lot more active in our daily lives: we may spend more time outside; exercise more often; hang out with friends, among other reinforcing activities. The reduction in activities in our lives during the seasonal shift reduces the amount of positive reinforcement in our lives, which can impact our mood. Moreover, energy is like a generator, rather than a battery. Therefore, we may also feel more fatigue as a result of the reduction in activity. Both of these factors make us feel worse for wear.
Second, the lack of light exposure can lead to a general reduction in mood. Light activity is associated with mood (Dumont & Beaulieu, 2006) and the lack of light exposure could be a contributing factor to depressive symptoms.
Seasonal changes and sleep
Depression and sleep are very related. Factors that impact our mood can impact our sleep (and vice versa).
Importantly, the reduction in activities in a person’s day can reduce the build-up of sleep pressure. Sleep pressure is what provides us the deep and refreshing sleep that we need. Without sufficient build-up, our sleep pressure dwindles, and our sleep becomes light and unrefreshing. Poor sleep can of course lead to poor mood. Secondly, the lack of light exposure may also be impacting our circadian rhythm. Our internal clock plays a big role in pretty much every area of our physiological functioning. Light is the primary factor that helps synchronize our clock and the lack of light can impact our body’s ability to regulate our sleep/wake cycle. We may also be more inclined to sleep-in, which can lead to more REM (rapid eye movement) sleep – this is associated with depressive symptoms
CBT strategies to combat seasonal affective disorder
Now that we have talked about causes of mood and sleep issues in seasonal affective disorder, here are a few CBT strategies that may be helpful to support a proper transition into the wintery times.
1. Schedule activities into your daily life. Although certain activities, like going to the beach, may be somewhat limited due to inclement weather, adding season-appropriate activities into your life can increase the amount of positive reinforcement in your life. Activities could be something small (e.g., making yourself a nice coffee in the morning or taking a warm bath) to something more active (e.g., doing yoga, taking a 15 minute walk on a treadmill). The latter examples have the added benefit of increasing our sleep pressure, which can be very helpful to stave off problems with sleep and increase our sleep quality. Here’s a post on scheduling activities in your life if you are interested!
2. Wake up at consistent times. Getting out of bed at a similar time every day can be a great way to set our circadian rhythm and ensure that we are not experiencing symptoms of jetlag and low mood resulting from a poor sleep schedule.
3. Getting regular exposure to light. Although opportunities for light exposure aren’t as plentiful, taking actionable steps to get some light in the morning and throughout the day can be helpful to improve our mood. In some cases, some people may find benefits using a light box to increase exposure to light activity, though research is limited (Nussbaumer et al., 2015).
4. Increasing social support. Look for opportunities to spend time with friends and family can be a protective factor for mood. Although opportunities for outdoor activities may be challenging, there may be other ways to engage with loved ones (e.g., phone calls, house gatherings, lunches, movies) to support mood and wellbeing.
5. An acceptance approach. Given all these changes, it makes a lot of sense that we don’t feel at our best all the time. Taking a mindful attitude to the natural changes in our mood can be helpful to protecting ourselves from a depressive spiral. What we resist, persists. However, if we accept the fact that sleep and mood might take a small hit (while also doing our best to reduce this as much as possible), we are much more likely to handle this transition well.
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,P
-
Why Does Chronic Fatigue Cause Insomnia: A CBT Model and Strategies To Help
The relationship between chronic fatigue and insomnia
Chronic fatigue syndrome is a challenging disorder to deal with because research has yet to determine the cause of chronic fatigue syndrome to any specific medical cause. Moreover, along with being a severely impairing disorder by itself, chronic fatigue can also lend itself to other comorbid challenges.
One common comorbid condition of chronic fatigue is insomnia – difficulty falling asleep, staying asleep, and/or waking up too early – with unrefreshing sleep being a big part of chronic fatigue. Studies have found that approximately 90% of people with chronic fatigue syndrome also present with unrefreshing sleep (Mariman et al., 2013).
It’s important to recognize that fatigue and insomnia are very interrelated and – when left unchecked – can lead to greater symptoms of both problems because of how they affect one another. At the same time, understanding this cycle can identify potential solutions to tackling both fatigue and insomnia.
The vicious cycle between chronic fatigue and insomnia
When we are constantly tired, our body naturally pulls for rest. We may reduce our physical activity, spend less time with friends and more time on the couch or the bed, and take naps when possible.
Although this makes perfect sense given how exhausted we may feel, there are a couple problems with this resting approachthat affects our sleep and how we feel. First, our ability to develop deep sleep is based on the build-up of sleep pressure. Sleep pressure is built throughout the day, and we build more when we are active and awake. High sleep pressure is what gives us restorative and refreshing sleep.
Unfortunately, when we spend the day resting, we build-up significantly less sleep pressure, which has significant effects on our ability to produce high quality sleep. We get trapped in a cycle of shallow sleep that makes us more tired the next day.
Moreover, we often think of energy like a battery (where the more active we are, the more energy we use), but energy is more like a generator. Sometimes, we have to give a little to get a little. But when we spend the whole day resting, our generator has no input to create momentum.
The relationship between insomnia and fatigue can also lead to further problems. For example, it may lead to muscle atrophy, which can affect chronic pain, and lack of positive reinforcement in everyday life, contributing to depression.
Breaking out of the fatigue-insomnia cycle
Fortunately, research cognitive behavioural therapy has been found to be helpful for both chronic fatigue and chronic insomnia (e.g., Malouff et al., 2008; Wu et al., 2015). Below, I discuss a few strategies from CBT that can be employed to tackle chronic fatigue and insomnia to break this cycle.
1. Built up sleep drive. Increasing sleep drive, or pressure to sleep, will increase the amount of deep restorative sleep. This may have a beneficial impact on fatigue and support overall recovery. Sleep drive can be built by reducing amount of time spent resting prone (i.e., lying down), reducing naps, and generally trying to stay a bit more active throughout the day.
2. Gradually scheduling activities. Although it can be incredibly tough in chronic fatigue, scheduling activities in a gradual way can be helpful to get the generator going in terms of energy. This can be done in a slow and steady manner, beginning with activities that feel manageable (e.g., light yoga, short walks, stretches) and moving up to more challenging tasks. SMART goal setting can be a helpful way to add activities into your life in a specific, achievable, and time-bound manner.
3. Fatigue management strategies. Beyond activity, there are also many other factors that go into fatigue management. Examples include keeping to a consistent rise time, getting regular light exposure, staying hydrated and eating a balanced diet, and avoiding substances. Here’s a post on fatigue management if helpful!
4. Tackling self-defeating beliefs. Our thoughts can be our worst enemy when it comes to mustering up the energy to engage in activities associated with daily living. A grad student at our lab is an expert in fatigue and one of her main findings is that the way we perceive a task directly affects our energy levels. For example, let’s say you’ve been watching a lecture for 2 hours. The professor then says to the class “the lecture has just 5 minutes before the end”. You’d probably feel pretty energetic to know that because you perceive your resources to pay attention to 5 more minutes to be sufficient. On the other hand, if the professor said that the lecture still has 2 more hours, you might feel significantly more exhausted, because you don’t feel like you can handle that much more dry lecturing!
This can also apply to specific thoughts about chronic fatigue. For example, if our thought is “I can’t do this. I’m too tired”, we will naturally focus on our feelings of tiredness, which only seek to exacerbate these feelings. Using thought records to tackle these negative thoughts or mindfulness practices to lessen the impact of these thoughts may be helpful strategies from a cognitive perspective.
Concluding thoughts
Fatigue and insomnia can be a very challenging set of symptoms to deal with because our motivation is fighting against us. Both insomnia and fatigue pull for rest, but the problem is that excessive resting can lead to further problems. Accepting that fatigue may be a constant challenge while making a commitment to engage in a lifestyle that supports you in being able to manage this condition.
If you found this post helpful, please consider subscribing to the mailing list for more evidence-based information on mental health!
Best wishes,P
