Searching for a good night's sleep: what mental health counselors can do about the epidemic of poor sleep.
Subject: Epidemics (Case studies)
Epidemics (Care and treatment)
Behavioral health care (Case studies)
Mental health (Case studies)
Insomnia (Case studies)
Insomnia (Care and treatment)
Author: Puterbaugh, Dolores T.
Pub Date: 10/01/2011
Publication: Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2011 American Mental Health Counselors Association ISSN: 1040-2861
Issue: Date: Oct, 2011 Source Volume: 33 Source Issue: 4
Topic: Canadian Subject Form: Behavioural medicine
Organization: Government Agency: United States. Food and Drug Administration; United States. National Center for Biotechnology Information Organization: National Sleep Foundation; American Psychiatric Association
Accession Number: 270461805
Full Text: Sleep problems are epidemic in the United States. Many adults complain of poor sleep yet engage in behaviors that are counterproductive to sleep. This article briefly reviews recent research on the treatment of insomnia and discusses application of mental health counseling strategies for treatment. Case studies illustrate the application of current research within counselor areas of expertise in cognitive behavioral therapy and behavioral counseling.

INTRODUCTION

Sleep is essential to physical and mental well-being. The critical interplay between sleep, physical health, and mental functioning is difficult to overstate. Yet though the professional literature and popular media emphasize the importance of sleep, the behavior of many people is detrimental to high-quality, restorative sleep.

Sleep deprivation at its worst is literally torturous; even mild chronic sleep deprivation changes brain chemistry and physiology, leading to deterioration of cognition, memory, and mood (National Institute of Neurological Disorders and Stroke [NINDS], 2007). Published studies support the use of cognitive-behavioral and related strategies to improve sleep quantity and quality (Adachi, Sato, Kunitsuka, Hayama, & Doi, 2008; Ebben & Spielman, 2009; Edinger, 2009; Jacobs, Pace-Schott, Stickgold, & Otto; 2004; Whitworth & Crownover, 2007). The expertise of mental health counselors in techniques considered best practices for many mental disorders corresponds with many interventions for effective treatment for insomnia. Counselors are trained in addressing the intersection of cognition, behavior, and emotional distress; their code of ethics also emphasizes the importance of interdisciplinary consultation in treating complex client problems whenever that is appropriate (American Mental Health Counselors Association, 2010).

THE SLEEP DILEMMA

Sleep problems chronically affect 40 million Americans yearly and another 20 million a year intermittently (NINDS, 2007). Though there is plenty of information available to the public about sound sleep practices, difficulties with sleep persist. This brief review of recent research provides the basis for the interventions described in the case studies.

Sleep Problems and Practices of American Adults

American adults, who tend to report many sleep problems, are often contributors to their own insomnia. The National Sleep Foundation (2010) provides a snapshot of the attitudes, challenges, and habits of American adults regarding sleep: About 40% of those surveyed believe they get "a good night's sleep" most of the time (p. 19), but of these, many rely on alcohol, sleep medications (prescribed or over-the-counter), or both several times a week. During the first decade of this century, the annual number of prescriptions for sleep aids rose at more than twice the rate of total prescriptions (Piskora, 2007). In 2006 more than $4.6 billion was spent on these prescriptions (Piskora, 2007). While prescription drugs are helpful for many, their benefits must be weighed against the possibility of serious side effects and potential interactions with other medications or alcohol (Food and Drug Administration [FDA], 2007). The FDA, which generally approves nonprescription sleep aids for up to two weeks' use, warns that these medications can have varied effects, e.g., sleepiness may persist into the next day, and there is risk of psychological dependence even though they are nonaddictive (FDA, 2007).

The risks of mixing prescription or over-the-counter sedatives with alcohol include dizzy spells, potentially dangerous breathing problems, reduced motor control, and impaired memory (National Institute on Alcohol Abuse and Alcoholism, 2007). The FDA has also emphasized that prescription sleep aids carry the risk of bizarre behaviors while sleeping, a problem that may be exacerbated by alcohol. These behaviors may include leaving the home, driving, eating, and engaging in unusual behaviors (FDA, 2007).

Behaviors that are occasional side effects of prescription drugs for insomnia are not the only behavioral concern related to sleep. The personal habits of American adults often undermine the ability to fall asleep. The National Sleep Foundation (2010) findings highlight the frequency with which survey respondents routinely engaged in stimulating activities within an hour before attempting to fall asleep. While some behaviors are recognized as arousing, such as attending to job-related activities or physical exercise, others, such as watching television, are often believed to be soothing and helpful in achieving sleep. In fact, 76% to 89% of American adults watch television in the last hour before sleep, with African Americans citing the highest rate of use and Asian Americans the lowest (National Sleep Foundation, 2010).

Although people often use television and computers to relax, any source of blue light stimulates the hypothalamic system, suppressing production of the natural sedative melatonin (Dijk & Archer, 2009; Holzman, 2010). Natural midday lighting, fluorescent lights, computer monitors, and televisions are strong sources of blue light waves. The effect of these light waves on alertness is not related to sight; visually impaired persons whose eyes do not respond to visual light can still respond and transmit responses to blue light that result in circadian rhythm changes via the pineal gland (Dijk & Archer, 2009; Holzman, 2010). Thus, though television and computer use may be thought of as an escape and relaxation before bed on a cognitive-emotional level, it may simultaneously heighten the alertness of the physical brain for hours after the activity ceases.

Sleep and Health

Occasional sleeplessness or difficulty falling or staying asleep is normal, but sufficient sleep is essential to physical and psychological well-being (N1NDS, 2007). While what is sufficient varies by individual, seven to eight hours a night is usually "best" (NINDS, 2007, para. 11). The relationship is reciprocal: physical illnesses impact sleep, and poor sleep contributes to physical problems. Physical difficulties, such as asthma, and life phase issues, such as menopause and prostate enlargement, can contribute to insomnia (Holcomb, 2007). And insufficient REM sleep can result in daytime sleepiness, poor concentration, weight gain, and diabetes (Holcomb, 2007; Watenpaugh, 2009).

Watenpaugh (2009) explored the interlocking relationships between obesity and sleep. Obesity has critical implications for the quality and quantity of sleep. Both lifestyle and physiological factors related to obesity interfere with adequate and restorative sleep. Inactivity leads to obesity, which interferes with sleep, which leads to fatigue, which leads to more inactivity. More subtle factors, such as metabolic changes due to inactivity and poor diet, exacerbate this distressing vortex, compounding difficulties with both sleep and body mass (Watenpaugh, 2009).

Common medications, including those used for psychiatric purposes, may confound efforts to achieve deep and restorative sleep. Prescriptions for diagnoses such as attention deficit disorders (National Center for Biotechnology Information [NCBI], 2011) and depression (NCBI, 2010a) may contribute to poor sleep, as can over-the-counter cold medications (NCBI, 2010b). Abused substances, such as amphetamines, cocaine, and mixed substances like Ecstasy, also interfere with sleep (American Psychiatric Association [APA], 2000). Some medications prescribed for sleep difficulties may contribute to weight gain, thus complicating the sleeping problems found among obese patients (Watenpaugh, 2009).

Sleep disruption and poor sleep are primary symptoms of many disorders, including depression and bipolar disorder (APA, 2000). REM sleep is critical for reorganization of memory and neuroplasticity. In depressed persons the REM stage is often overly long because their right frontal lobe is more active and their hippocampus receives less input, which interferes with achieving deeper stages of sleep. Anxious patients may have difficulty sleeping or maintaining sleep due to raised levels of norepinephrine (Arden & Linford, 2009). Complicating the situation is the damage to the hippocampus caused by chronic stress and sleep disruption (Arden & Linford, 2009). Sustained periods of stress and poor sleep increase levels of cortisol, which in turn leads to loss of cells in the hippocampus. Exercise and mindfulness meditative practices, which are palliative and preventive for depression, anxiety, and insomnia, help the hippocampus to recover (Gage, 2000).

Insomnia may be due to health or lifestyle habits (Arden & Linford, 2009). It is also possible to develop a conditioned insomnia: worry about whether this will be another night of tossing and turning results in anxiety, which contributes to poor sleep (Holcomb, 2007). Thus, insomnia may be due to biological factors, psychological factors, or emotional distress; but a pattern of poor sleep can itself become a source of stress sufficient to interfere with sleep.

APPLICATIONS FOR MENTAL HEALTH COUNSELORS

Because of the interplay between sleep and mental health, whether a client is seeking assistance for anxiety, depression, posttraumatic stress disorder, adjustment issues, or other difficulty, interventions to normalize sleep may help relieve symptoms and build confidence from self-efficacious action. Like exercise for depression (Doyne, Ossip-Llein, Bowman, Osborn, McDougall-Wilson, & Neimeyer, 1987; Rethorst, Wiplfi, & Landers, 2009), cognitive-behavioral interventions for sleep are actions the client takes that may bring improvement (Jacobs, Pace-Schott, Stickgold, & Otto, 2004).

Cognitive-behavioral strategies have been shown to be effective for sleep problems and provide long-lasting positive outcomes, as opposed to medications, the effectiveness of which is short-lived and which carry significant risk of overdose, dependency, and side effects (Ebben & Spielman, 2009; Harvey, 2005; Passarella & Duong, 2008; Whitworth & Crownover, 2007). Cognitive-behavioral therapy (CBT) as a solo treatment was found most effective even in direct comparison with medication, placebo, and combination (medication plus CBT) treatments across most areas of assessment in the treatment of insomnia (Jacobs et al., 2004).

Other research highlights education and simple behavioral changes to improve sleep: brief correspondence courses, information brochures, and coaching in sleep hygiene all have significantly improved the quality of sleep. Adachi et al. (2008) measured a reduction in sleep latency (the period between going to bed and falling asleep) of over 50% and an increase in sleep time of 30 minutes a night using correspondence courses in sleep hygiene. Brown, Buboltz, and Soper (2006) created an educational program for college students that incorporated pre- and post-test assessments of sleep habits and knowledge, and the treatment group also received a 30-minute presentation on good sleep habits and an informational brochure. Within six weeks this intervention yielded improvements such as fewer daytime naps, less use of caffeine, and less time falling asleep than the control group. Wickwire, Schumacher, and Clarke (2009), working with a small sample of adults (n=7), found the participants reported improved sleep after a four-week treatment of weekly sessions plus guidelines on rendering the sleeping area a "sacred" space (p. 71), devoted only to sleep and sexual activities, with a self-designed ritual to use when entering the space.

Psychoeducational, cognitive, and behavioral interventions for sleep appear to overlap with the skill sets common to mental health counselors. Despite the possibility of using counselors' skills to implement research-based treatments for insomnia, however, very few training programs teach how to apply counseling techniques to insomnia. Yet, as can be surmised, counselors have much to offer clients in terms of psychoeducational and therapeutic interventions for insomnia.

Assessing Sleep Difficulties

It appears that every man's insomnia is as different from his neighbor's as are their daytime hopes and aspirations.

~F. Scott Fitzgerald

Simple questions during intake and thereafter can help the mental health counselor assess whether the client has sleep problems and create an opening for dialogue about quality and quantity of sleep, sleep hygiene, the relationship between sleep problems or insomnia and simple interventions to improve quality of life.

Drawing on the findings of the National Sleep Foundation (2010) and APA diagnostic criteria for insomnia (2000), here are suggestions for ways to begin assessing client quality of sleep, whether or not the client has presented insomnia as a primary complaint:

* How many hours of sleep do you get, on average, each night? Has this changed in the past year?

* Do you regularly take daytime naps? If so, how many, and for how long?

* Do you regularly experience daytime sleepiness?

* Do you feel you get sufficient sleep most nights?

* Do you have difficulty falling asleep?

* If so, how long does it typically take to fall asleep?

* Do you wake at night and have difficulty falling back to sleep?

* Do you wake up early in the morning and are unable to return to sleep?

* Do you sleep alone? If not, does your partner suffer from insomnia, hot flashes, snoring, or sleep apnea?

* Do animal companions share the sleeping space? If so, how do allergies, animal sleep/wake patterns, and cats' nocturnal behaviors affect your sleep?

A client's responses to these questions can guide the therapist in providing feedback about normal sleep patterns, such as acceptable amounts of sleep (seven to eight hours average for adults, for example; N1NDS, 2007) and time spent in bed awake. In treating insomnia Ebben and Spielman (2009) consider 85%-90% of time in bed spent sleeping as a sign of success. The mental health counselor can also explore client beliefs and behaviors regarding sleep.

Applications: Cognitive and Behavioral Interventions

Cognitive strategies are effective for insomniac clients who have inaccurate and unhelpful beliefs about sleep (Jacobs et al., 2004). One mistaken idea is the impression given by advertisements that it is normal to fall asleep almost immediately upon going to bed and sleep throughout the night without waking (AmbienCR, 2010; Lunesta, 2010; Unisom, 2009). This may explain the assertion of so many adults that they sleep poorly (National Sleep Foundation, 2010). The APA (2000) definition of primary insomnia, on the other hand, describes a range of normal patterns of sleep, including variations in the time spent in different stages of sleep, that may evolve over an individual's lifetime. Cognitive strategies involve working closely with the client to discover inaccurate beliefs about sleep, provide education, and help the client rehearse more accurate and constructive thoughts about sleep. The client-friendly worksheet, The Daily Mood Log, created by David Bums (1980/1999; 2006), is an excellent example of how to help clients identify irrational negative beliefs and restructure those beliefs to be more helpful and realistic. The client is asked to write down upsetting beliefs and automatic thoughts, which are then explored and challenged.

Cognitive therapy directly intervenes in brain function at both chemical and structural levels, helping clients make the initial steps toward what may be efficacious and lasting change. Through the use of language, therapy activates the left hemisphere of the brain, counter-balancing the tendency of the right brain, in its default mode of negative emotions, to become increasingly distressed, which creates more anxiety and despair over being awake when it is thought one should be asleep (Arden & Linford, 2009).

Stimulus control therapy (Adachi et al., 2008; Bootzin, 1972; Passarella & Duong, 2008) uses the underpinnings of classical conditioning to help clients associate being in bed only with sexual activity and sleep. Clients are advised not to use the bed for work, reading, eating, watching television, or lying awake worrying. They are to get out of bed if they cannot sleep within 10 to 20 minutes of bedtime and to rise within 10 to 20 minutes of awakening in the morning. The regimen includes rising at the same time every day, even weekends and holidays, and daytime naps are prohibited (Adachi et al., 2008; Bootzin, 1972; Passarella & Duong, 2008).

Sleep restriction therapy (Ebben & Spielman, 2009) is, as the name implies, a technique of limiting the client's time spent either sleeping or seeking sleep in order to begin regulating sleep patterns; it combines cognitive strategies with behavior techniques. Deliberately reducing the amount of time spent in bed lessens the association of being in bed with worrying about lack of sleep. This challenges irrational client beliefs about the negative effects of a few poor nights' sleep, e.g., the fear that tomorrow will be a terrible day because of a poor night's sleep. Time in bed and time sleeping are carefully logged and the client is permitted to slowly increase the time spent in bed once the percentage of time spent sleeping meets or exceeds 90% of the time in bed (Ebben & Spielman, 2009).

Applications: Sleep-Related Safety Behaviors

Sleep-related safety behaviors are behaviors that have become intrinsically linked in the client's mind with falling or staying asleep. The client has developed habits, referred to as sleep-related safety behaviors, that he or she has come to believe are essential for sleep (Harvey, 2005). Mental health counselors can help clients to differentiate between helpful and dysfunctional safety behaviors. Dysfunctional safety behaviors emerge as clients attempt to reduce the anxiety that poor sleep or delayed sleep onset produce; they tend to disrupt the quality or quantity of sleep. Alcohol use is a prime example of a sleep-related safety behavior: it may depress the central nervous system enough to alleviate some anxiety and shorten sleep latency, but invariably it contributes to poor sleep quality and waking during the night (Ebben & Spielman, 2009; Harvey, 2005).

Conversely, some safety behaviors are appropriate and effective, giving clients a sense of control and facilitating relaxation and sleep (Adachi et al., 2008; Brown et al., 2006; Ebben & Spielman, 2009; Harvey, 2005; Passarella & Duong, 2008; Wickwire et al., 2009). These include formally marking the end of daytime activities and the beginning of evening and relaxation activities with a client-defined routine (Wickwire et al., 2009). This routine should include avoiding highly stimulating activities before bedtime (Wickwire et al., 2009), and not going to bed until feeling sleepy (Bootzin, 1972; Ebben & Spielman, 2009).

Sleep hygiene comprises a sizable number of commonly recognized behaviors that both encourage relaxation and sleep and are known to interfere with the quality of sleep. Sleep hygiene suggestions for clients include:

1. Exercise regularly, but not within a few hours of bedtime (NINDS, 2007).

2. Minimize the use of electronic media for about one hour before bedtime (Adachi et al., 2008).

3. Minimize the use of very bright lights before bedtime and regularly expose yourself to bright morning light or very bright artificial light indoors during morning hours to help regulate circadian rhythms (Lack, Wright, & Payntor, 2007).

4. Use progressive relaxation techniques before bedtime to help alleviate any tension. Gentle movement will also help reduce stress by activating the parasympathetic nervous system (Ebben & Spielman, 2009).

5. Restrict use of the bed and bedroom to sleep and sex to avoid the bed becoming a conditioned stimulus for work, anxiety, lying awake, etc. (Wickwire et al., 2009).

Cross-Disciplinary Concerns and Referrals

Many mental health complaints, including insomnia, may be rooted in physical illness, medications, or physical health habits. It is sound practice for mental health counselors to recommend that clients consult with the primary care physician to rule out basic health concerns and seek clearance for exercise and referrals for any needed specialist care, nutrition, etc. If insomnia, for example, is not due to habits or emotional issues but rather to sleep apnea, it is vital for the client's general health to seek immediate medical care (Mayo Clinic, 2010).

COMBINING COUNSELING STRATEGIES FOR INSOMNIA: CASE STUDIES

The following examples blend several cases. Details have been changed to protect privacy.

Case Study 1

A patrol officer reports he cannot fall asleep after returning from work. He works the second shift, returning home at 12:30 AM or later, often after a stressful night on the job. The client has a routine that he asserts helps him relax: He has a large meal watches television crime dramas, has a beer or two, and then lies down to sleep, though he often watches television in bed. He routinely becomes frustrated because he takes a long time to go to sleep; he either lies awake worrying about how he will function on patrol the next day without sleep or gets up to surf the Internet, watch more television, and have a snack.

Clearly, a number of the client's behaviors and cognitions contribute to his insomnia. Interventions to help him develop an evening ritual to shorten sleep latency and improve the quality of sleep included cognitive therapy and behavioral interventions including safety rituals, stimulus control, sleep restriction, and application of research about the effects of light, caffeine, alcohol, and stress on quality of sleep. The following treatment plan was agreed on.

Client will:

1. Use no caffeine for at least three hours before returning home for the evening. If necessary this period will be extended to facilitate sleep.

2. Take a short walk with his dog to alleviate stress and enjoy his animal companion.

3. Plan to have food available that is good-tasting and neither overly heavy nor so light that he wakes from hunger during the night.

4. Abstain from alcohol at this time.

5. Turn off the television and computer and reduce ambient light for 30 minutes before bedtime.

6. Mark the preparation for bedtime after turning off electronic devices by bedtime hygiene processes (wash face, remove contact lens, brush teeth) and use progressive muscle relaxation techniques to mark the transition.

7. Review accurate replacement thoughts about sleep from a list developed in therapy, e.g., "Resting without sleep is still good rest; I don't need eight hours of sleep every night to function."

8. Read or listen to quiet music for 30 minutes or until sleepy.

9. Go to bed only when sleepy. If he lies awake more than 15 minutes, he will get out of bed, go into another room, put on a soft light, and resume reading or listening to quiet music until sleepy.

10. Review replacement thoughts as necessary to challenge old negative beliefs about sleep and insomnia.

11. Immediately upon waking in the morning, get out of bed and shortly thereafter take the dog for a walk outdoors for morning exposure to bright light, which has proven to have positive effects on night-time sleep quality.

Case Study 2

Client is a 45-year-old married female whose husband snores heavily. She is entering perimenopause and experiencing occasional night sweats. She com plains of difficulty falling asleep, waking during the night then having difficulty returning to sleep, and daytime sleepiness. To minimize the effects of daytime sleepiness, she has been consuming considerable caffeine and snacks. The client works long hours indoors, and under economic duress she has cut back on expenditures, including gym membership. The client's last hour before bedtime is generally spent attending to such tasks as checking children's homework, paying bills, and responding to e-mails. Directly after completing these tasks, she prepares for bed," in bed she catches up on work-related reading until she decides to turn out the light. By that time, her husband has generally fallen asleep and is snoring. She often lies awake for an hour or more before she falls asleep.

This client's lifestyle is fairly common: employed and with a second shift of home-related duties, lack of exercise, over-reliance on junk foods and caffeine, and using the bed for work-related activities. The recommendations for her included referral to her physician for consultation about perimenopausal symptoms; information about research on the effects of light, caffeine, and nutrition on circadian rhythms and quality of sleep; cognitive-behavioral strategies to address inaccurate and unhelpful beliefs about sleep; and sleep hygiene practices. The treatment outline:

1. Consult with her primary care physician or gynecologist about recommendations for dietary and medicinal treatments for early stages of perimenopause.

2. Either cease using caffeine altogether (it is implicated not only in poor sleep but also in increased hot flashes during change of life) or abstain for at least six hours before desired bedtime.

3. With physician's approval, set up an exercise routine that can be followed daily or nearly daily at home. Exercise can also help with perimenopausal symptoms.

4. Modify diet to minimize reliance on non-nutritive/high-sugar prepared foods.

5. Use moming exposure to bright light to help normalize circadian rhythms and improve nighttime sleepiness. This will also help reduce daytime sleepiness.

6. Cease use of electronic media for about one hour before bedtime.

7. Use bed and bedroom only for sex and sleep; read in a separate quiet room.

8. Use relaxation and meditative practices to help reduce tension, including the tension that arises when sleep latency seems overly long or client awakens during the night.

9. Review replacement thoughts frequently to challenge old negative beliefs about sleep and insomnia.

10. Keep the bedroom at a comfortable temperature and adjust as needed for comfort.

11. Consider use of a white-noise machine or noise-reducing headphones to cope with husband's snoring. Husband should seek a medical consult in case what wife describes as severe snoring is actually sleep apnea or another serious medical condition.

Clients are not necessarily amenable to making these changes. After all, safety behaviors such as drinking alcohol and watching television to relax (despite its actual effect on the brain) have been built up over time, and clients may be convinced that these behaviors are all that stand between sleep and lying awake all night. Empathic and compassionate encouragement may be necessary to encourage skeptical clients to truly invest in experimenting with behavioral changes to relieve insomnia.

CONCLUSION

There is a growing body of research regarding the efficacy of cognitive-behavioral, psychoeducational, and behavioral interventions in treating insomnia. Modern research using brain imagery supports the efficacy of psychotherapy in creating change. Training in sleep hygiene and application of research to practice is a continuing need. The American Academy of Sleep Medicine provides training, testing, and its own certification in CBT for insomnia but limits certification to physicians and clinical psychologists. This budding specialization highlights the increased demand for nonpharmacological interventions for insomnia as well as the applicability of mental health counseling expertise to the problem (Edinger, 2009). Continued research of specific protocols can help the counseling professions to define best practices supported by scientific research. In the interim, counselors' current skills, enhanced by insights from the psychological and medical literature, are invaluable assets in addressing the national crisis of poor sleep.

APPENDIX A

AUTHOR'S HANDOUT ON SLEEP AND INSOMNIA FOR CLIENTS

Based on substantial research and the frequency of insomnia as a presenting or corollary problem for clients, the author has printed the following on a postcard-sized client handout.

Ten Tips for a Better Night's Sleep

1. Keep regular hours, even on days off.

2. Avoid caffeine, nicotine, and other stimulants for about 6 hours before bedtime. Skip sugary snacks and drinks before bedtime, too.

3. Get regular exercise, but avoid strenuous activity for at least one hour before bedtime.

4. Have a light snack before bed, not a heavy meal. For your snack, choose foods such as dairy or turkey, which contain high amounts of tryptophan, an amino acid that your body uses to manufacture melatonin, a brain chemical that helps you relax and sleep.

5. Your brain naturally increases its melatonin production as the sky darkens and then decreases it as the morning sky brightens. Artificial light interferes with this natural sleep/wake process. You can prepare for sleep by using dimmer lights as you near bedtime. Lower-wattage bulbs and lamps rather than bright overhead lights are strategies to help your brain begin preparing for sleep.

6. Television, movie screens, and computers emit a type of light that is very similar to sunlight at noon. These media may help distract you from concerns from the day, but they send your brain messages to be alert because it looks like daytime. Avoiding television, movies, computers, and handheld electronic devices for an hour or more before bed will help reduce brain stimulation.

7. Quiet prayer or meditation practices not only reduce stress chemistry, they help rebuild brain structures damaged by stress and help you sleep better. They also help you build a stronger memory! Taking some time at day's end for quiet prayer and meditation is an excellent sleep habit.

8. Be a little boring! Make your preparations for bed a regular routine. If you always have a light snack, brush your teeth and wash your face, say your prayers, and then go to bed, your brain will begin to recognize the pattern and start preparing you for sleep each time you begin that pattern.

9. Alcohol may help you fall asleep through its brain-depressing chemistry, but it also contributes to middle-of-the-night sleep disruptions and/or waking. It's better to avoid alcohol before bedtime.

10. Don't get upset if you have difficulty falling asleep. If relaxation strategies don't help, either relax and close your eyes and reassure yourself that occasional sleeplessness, as long as you're getting physical rest, won't hurt you; or get up and read in a low-lit, quiet room until you feel sleepy. Don't turn on the television, computer, or hand-held electronic device; it will stimulate your brain and make achieving deep sleep more challenging.

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Dolores T. Puterbaugh is in private practice and also serves on the faculty of several universities. Correspondence concerning this article should be addressed to Dolores T. Puterbaugh, Ph.D., LMHC, LMFT, 13910 86th Ave. N., Seminole, FL 33776. E-mail: puterbaugh@mindspring.com.
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