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Behavioral Interventions with Sleep Disorders
10 CEUs Behavioral Interventions for Night Terrors and other Sleep Disorders

Section 20
Clinical and Non-Clinical Interventions for Sleep Disturbances

Question 20 | Test | Table of Contents | Sleep Disorders CEU Courses
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

Non-clinical treatments
Sleep Hygiene. Prior to beginning an educational endeavor focusing on sleep habits individuals need to be aware of their current sleep habits and how those habits may be related to current difficulties they are experiencing. Research has indicated that individuals overestimate their knowledge about proper sleep habits and how they actually apply that knowledge to themselves (Hicks et al., 1999). If individuals are working on false knowledge then one general way to improve sleep quality is to provide individuals with proper information on good sleep practices. The commonly used term for this is ‘sleep hygiene’. Sleep hygiene is providing educational information about good sleep habits, foods to avoid, and lifestyle elements that can contribute to, or interfere with, a good night sleep. Information and instructions typically given to individuals as part of a sleep hygiene program include: effects of poor sleep; consistently maintaining a sleep/wake schedule; foods to avoid at night (e.g. caffeine); increased exercise, except for three hours prior to bedtime; and information about a good sleep environment (bed is only for sleeping, noise in room, light, etc.).  A large majority of individuals suffering from mild to moderate non-chronic sleep difficulties show improvement through the use of sleep hygiene. For specific details on sleep hygiene and areas that may be beneficial to cover refer to Dement (1999).

Exercise. Another non-clinical treatment for sleep difficulties is regular exercise. Exercise has been demonstrated to decrease the reporting of sleep difficulties and decrease the amount of time that it takes individuals to fall asleep (Duncan et al., 1995: Matsumoto et al., 1984; Youngstedt et al., 1999), as well as increasing the time spent in stage 3 and 4 sleep (deep sleep) (Dement, 1999). In general, any exercise that is practiced regularly appears to have beneficial effects on sleep; however, a few types of exercise seem to have a greater effect. Exercises that involve a large cardiovascular component have a greater effect than exercises that do not include a cardiovascular component (Trinder et al., 1985). Hence, vigorous stationary cycling would be expected to have greater effect than weightlifting. However, it should be noted that all exercise appears effective in reducing sleep difficulties and time to fall asleep, at least to some extent. Based on this, it behooves interventionists who are working with individuals suffering from sleep difficulties to encourage their clients to develop regular exercise schedules since it will not only improve their general health, but also reduce attendant sleep difficulties.

Bright Light Therapy. Another suggested non-clinical treatment is bright light therapy. Bright light therapy has been demonstrated to be an effective treatment for disturbed sleep schedules, especially for individuals who have shifted their sleep and wake times out of phase with the norm (Campbell and Murphy, 1998; Rosenthal et al., 1990). While many studies use between 1000 to 10,000 lumens, artificial light as low as 250 lumens has been found to significantly impact circadian sleep rhythms (Trinder et al., 1996). The application of bright light therapy is actually easy, very affordable and is very conducive to the treatment of early morning or late night insomnia. To conduct bright light therapy only one piece of equipment is needed, a bright light that emits a broad light spectrum (a 500-Watt Halogen lamp is usually sufficient). The individual is instructed to place the light in a position where they can get full exposure to the light while they are doing their normal activities of the day. For most individuals, exposure to the light should last for 30–60 minutes and the timing during the day will depend on the particular phase syndrome the individual is suffering from. The exposure to the bright light will enable the person's circadian rhythm to begin to shift into a more normal mode. Continued repetition of this procedure over time will help shift the circadian rhythm to match the day and night cycles that are natural in the environment. Once the circadian rhythm is in line with the natural cycles the individuals should begin experiencing more normal sleep schedule and have fewer difficulties with sleep. In summary, bright light therapy is simple to use and affordable. With minimal instruction individuals can conduct bright light therapy at their residences immediately.

Clinical treatments
Although informed about proper sleep habits and treatment options such as exercise and bright light therapy, many individuals continue to experience sleep difficulties. Reasons may be biological or psychological. As a result, it is important that psychologists, counselors and therapists become aware of effective clinical treatments for sleep difficulties and disorders. While providing actual training for these treatments goes beyond the scope of this article, creating awareness of treatment options can assist helping professionals in case-conceptualization and treatment planning.

Behavior Therapies
. Stimulus Control Therapy consists of a set of instructional procedures that involve the context of sleep and the bedroom. Instructions to clients usually include: going to bed only when sleepy;  using the bed room solely for sleep and sex;  moving into another room if unable to fall asleep after 15–20 minutes, returning to bed just when sleepy;  maintaining a regular rising time in the morning regardless of sleep onset time and duration; and  avoiding daytime napping.  The purpose of this approach is to associate bedtime, the bed, and bedroom with rapid sleep onset and encourage a more consistent circadian sleep-wake cycle (Morin and Wooten, 1996). Sleep restriction therapy focuses on limiting the amount of time in bed to actual sleep time, or increase the proportion time in bed as sleep time. For example, if a person complains of acquiring only 4 hours of sleep, the amount of time in bed is limited to 4 hours. When the sleep efficiency exceeds 85–90% one increases the amount of time allowed in bed by 15–20 minutes. If efficiency falls below 80% one reduces the amount of time in bed by 15–20 minutes. Adjustments in sleep are made until the person achieves optimal sleep. This approach tends to be the opposite of the response of many insomniacs, which is to increase the amount of time in bed to get more sleep (Morin and Wooten, 1996). Both stimulus control and sleep restriction therapies have psychoeducational components. However, it is important that treatment go beyond providing merely education. Therapists who use these interventions need to monitor the individual's behaviors. Further, clients should be encouraged to keep a log of their sleep changes. One of the key components in both interventions is to help individuals learn they can control their sleeping habits, an important consideration since a common complaint of many is that they have no control over their sleep.

Relaxation. Relaxation therapies focus on decreasing arousal level to ease sleep onset. Specifics include behavioral relaxation therapy such as progressive muscle relaxation and deep breathing, as well as cognitive imagery. The latter may entail imagining oneself on a beach or other pleasant place like lying in the sun, if a positive situation for the client. Imagining a feeling of warmth also helps. Behavioral approaches tend to work well with simple physical restlessness, while imagery is effective for people who have both mental and physical restlessness, such as ruminating about the day's events (Morin and Wooten, 1996). For all relaxation approaches it is beneficial for the therapist or counselor to first instruct the client how to relax using the chosen technique in session. Homework geared toward between-session practice with a review at the next session for fine-tuning and feedback can facilitate effectiveness. In each instance close monitoring on the part of the therapist tends to increase compliance and effectiveness of relaxation techniques. Counselors are encouraged to help clients create their own relaxation tapes. Making a tape encourages individuals to import their interests and ideas into their treatment. For deep muscle relaxation audio-taping the client session exercise and giving the tape to the client for home practice can be beneficial. Listening to a tape when attempting to fall asleep takes less cognitive effort than trying to remember the steps to relaxation taught by a therapist. Further, expecting those with sleep difficulties to spend hours in therapy learning relaxation techniques may simply create a situation for non-compliance, whereas creating a relaxation tape enables them to continue treatment with less professional monitoring. No matter what approach to relaxation that is used by the therapist and client, it is important that the individual consistently apply the approach on a regular basis. Without consistent applications, effectiveness of relaxation techniques to reduce sleep difficulties diminishes.

Cognitive Therapy. Cognitive therapy often focuses on patients' expectations. Often a key component is to help clients change their views from believing they are out of control and are victims to thinking they are capable of coping with situations. Refuting irrational beliefs and thought stopping have been demonstrated to be effective in treating sleep difficulties (Bootzin and Perlis, 1992). Frequently, small successes experiencing control facilitates further expectations of success. For example, if the client can learn to control bedtime and related circumstances with the help of the therapist, two expectations are encouraged. The therapist is validated as a legitimate source of help and, once small successes are experienced with the help of the therapist, larger ones become a logical progression and are anticipated. Another final method of changing the way in which clients view their sleep difficulties is paradoxical intent (Bootzin and Perlis, 1992). Paradoxical intent consists of instructing clients to do the opposite of what they have been doing. Many clients try very hard to fall asleep and can become anxious about it, especially those for whom sleep concerns are sufficient to seek professional help. As a result, clients' sleep becomes more difficult and quality worse. For example, a paradoxical prescription may be to ask the person to attempt to wake up at least 3 times throughout the night for the next 7 nights. Success indicates the person does have control over his or her sleep, while ‘failure’ would mean the person woke less than 3 times during the night—a significant improvement for some clients. While this treatment may sound counterintuitive, a meta-analysis of over 100 sleep treatment studies found that paradoxical intent is slightly more effective than most psychological interventions for reducing unwanted night time awakenings, but less effective in reducing sleep-onset time (Murtagh and Greenwood, 1995).
- Buboltz Jr, Walter C.; Soper, Barlow; Brown, Franklin; Jenkins, Steve.; Treatment approaches for sleep difficulties in college students; Counselling Psychology Quarterly, Sep2002, Vol. 15 Issue 3

Personal Reflection Exercise #6
The preceding section contained information about clinical and non-clinical interventions for sleep disturbances. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Arditte Hall, K. A., Werner, K. B., Griffin, M. G., & Galovski, T. E. (2021). The effects of cognitive processing therapy + hypnosis on objective sleep quality in women with posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 13(6), 652–656.

Azza, Y., Wilhelm, I., & Kleim, B. (2020). Sleep early after trauma: A target for prevention and early intervention for posttraumatic stress disorder? European Psychologist, 25(4), 239–251.

Kelly, W. E., & Mathe, J. R. (2019). A brief self-report measure for frequent distressing nightmares: The Nightmare Experience Scale (NExS). Dreaming, 29(2), 180–195.

Sell, C., Möller, H., & Taubner, S. (2018). Effectiveness of integrative imagery- and trance-based psychodynamic therapies: Guided imagery psychotherapy and hypnopsychotherapy. Journal of Psychotherapy Integration, 28(1), 90–113.

Walters, E. M., Jenkins, M. M., Nappi, C. M., Clark, J., Lies, J., Norman, S. B., & Drummond, S. P. A. (2020). The impact of prolonged exposure on sleep and enhancing treatment outcomes with evidence-based sleep interventions: A pilot study. Psychological Trauma: Theory, Research, Practice, and Policy, 12(2), 175–185.

What are three nonclinical treatments for sleep difficulties? Record the letter of the correct answer the Test.

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