You may remember from chapter 2 that your internal body clock and your sleep drive are your body’s two big players in healthy sleep, and they are both impacted by what you do. Sleep hygiene guidelines are largely focused on what you can do—or refrain from doing—to positively impact your body clock and its synchronicity with the sleep drive. Sleep hygiene also includes guidelines for creating optimal conditions for a sleep-promoting environment, such as a comfortable bed and room. The questions about sleep hygiene practices that you answered in chapter 5 should have illuminated which guidelines you follow closely and which may be targets for change. We encourage you to assess your sleep hygiene from the perspective of “What am I currently doing to support my sleep?” and from that of “What am I currently doing that may disrupt my sleep?” Considering both perspectives can be helpful in uncovering well-intentioned but sleep-disruptive behaviors.
Sleep hygiene is analogous to oral hygiene practices—such as flossing, brushing, and minimizing sugary foods—that support healthy teeth and gums. You can do a great job with oral hygiene and still get a cavity. When you go to the dentist, you expect the dentist to tell you to keep flossing and brushing, but you do not expect the dentist to tell you that the cavity will be fixed by continued or improved oral hygiene. The cavity is a separate issue that requires additional intervention. Chronic insomnia and other sleep problems are the same. You will want to engage in effective sleep hygiene, but your chronic sleep problems need additional components of CBT-I, such as stimulus control or sleep restriction.
It is interesting to note that people who have trouble sleeping typically also have a hard time with sleep hygiene and are more likely to engage in behaviors that disrupt sleep, such as napping or drinking alcohol before bedtime (Jefferson et al., 2005). Though there is no definitive answer as to why this is true, we have come to believe that poor sleepers are more reactive to sleep concerns, paying more attention to, and feeling a greater urgency to “fix,” any sleep disruption they experience. Though well intentioned, these efforts to fix the problem or compensate for lack of sleep tend to be counter to sleep hygiene guidelines and actually create more problems. This notion supports our discussion in chapter 2 about the value of a paradigm shift: we invite you to take this opportunity to shift your focus from fixing or avoiding your immediate sleep issues, to promoting and optimizing your healthy sleep over the long term.
In this chapter we will review the most common sleep hygiene guidelines and help you assess your willingness to change your behaviors or sleep environment to be more consistent with these guidelines. Some of these changes will involve adding behaviors (such as establishing a bedtime routine) and others will involve removing behaviors (such as cutting out alcohol before bed). Either way, we are talking about change, and behavioral change can be challenging. Therefore, we also offer some general tips to help you succeed.
Understanding the rationale behind any suggestion can help you make and maintain a behavioral change. This is why we believe it is so important to learn about sleep physiology—our understanding of the physiology of sleep provides the rationale for all of the behavioral programs in this book, including sleep hygiene. Therefore, as we review each sleep hygiene guideline, we also will explain why it is important. The core message is this: if you get out of your own way, your body will naturally self-correct, leading to reliable, restorative sleep.
A consistent schedule supports your body clock by giving it environmental cues, such as your first exposure to light, at the same time each day. An inconsistent schedule, on the other hand, confuses your body clock and makes your body work harder to maintain consistent wake and sleep cycles. A sleep schedule is important to your body clock not just this night but the next night and the next night as the body clock forms this rhythm over weeks and months.
It is most important that you have a consistent wake time. If you wake up at the same time regardless of what time you went to sleep the night before, this will help your body stay in rhythm. If you always get up at 7 a.m., for example, then your sleep drive will be at the same place at 11 p.m. each night, making it more likely that you will have a consistent bedtime when life does not interfere. We encourage you to stay within thirty to forty-five minutes of your target wake time, no matter how sleepy you are, even on weekends. Of course, during a stimulus control or sleep restriction program, you will have even less variability in your wake time.
A consistent bedtime is also useful, but you likely will have some variability here. For example, you may have an evening engagement that keeps you up later than usual; we do not want you to become a slave to sleep, and prefer that you enjoy meaningful activities even if this creates variability in your bedtime. Also, we generally suggest that you not go to sleep at your target bedtime if you are not sleepy, since this is a setup for lying in bed awake. Thus, we encourage you to establish a target bedtime, and to strive to maintain consistency, while accepting some variability. Remember, if you wake up at your normal time even after a late night, this will help your body stay in rhythm.
It is helpful to make the transition from sleeping to waking as quickly as possible. You can liken this to pulling a Band-aid off your skin quickly; the faster you make the transition the faster you adjust and move through any discomfort. This means resisting the urge to hit the snooze button. It also means that it is better to get up than to doze in and out, even if you wake up before your desired wake time. It also helps if you get natural light within the first hour of waking. Light will cue your body clock to start your wake cycle for the day; for example, it will suppress your body’s production of melatonin, a hormone that provides a cue for sleepiness. If you cannot get bright natural light at your wake time, consider using a light source that mimics the spectrum of natural daylight. We discuss these types of resources in appendix A (Circadian Rhythm Disorders).
Napping can confuse your body clock and weaken your sleep drive, leading to trouble falling asleep as well as trouble staying asleep. We have found that, for some people, even nodding off briefly seems to interfere with the body clock: brief snatches of sleep seem to signal to the brain that it is now time to be awake, even though you are far from rested. If you choose to nap, consider napping for no more than twenty to thirty minutes, and no later than midafternoon. If you tend to nod off before bed, we strongly encourage you to problem-solve to decrease the risk of this; for example, you may choose to sit on a more upright chair rather than reclining on a plush couch in the early evening, or you may walk briskly to the water fountain if your eyelids get heavy as you sit at your desk.
Stimulants are any substance that activates your nervous system. Some typical stimulants are caffeine, sugar, and nicotine. If ingesting these, it is best to do so early in the day, before noon. Be conscious of both the obvious sources of caffeine, such as coffee, tea, soda, and energy drinks, and also less obvious sources such as medicines (for example, Excedrin, Midol, or decongestants) and smoothies with “energy boosts.” Eliminating or reducing stimulants allows your body clock to follow its natural rhythms. Using stimulants impacts your body clock by increasing the amount of time your nervous system is activated, and may get your body clock out of sync with your sleep drive (look back at figure 2.1 for a better understanding of this).
We have already mentioned medications that contain caffeine, but even medications without caffeine can have an effect on your wake and sleep patterns. Perhaps the most common over-the-counter culprits are decongestants, which have an activating effect. We also have worked with people who were taking a stimulating antidepressant (such as Wellbutrin) or stimulant (such as Adderall or Ritalin) too late in the day. A medication that makes someone else sleepy may make you alert, and vice versa. Check the common side effects of your medications and consult your medical provider to determine if you can move potentially stimulating medications to earlier in the day, and more sedating medications to later in the day.
Although alcohol may help you fall asleep, it interferes with the structure of sleep because your body is busy digesting and processing the alcohol rather than restoring your body and brain. Also, because alcohol is a muscle relaxant, your airway may be more likely to soften, which is especially concerning if you have sleep apnea.
Aim for going to bed with a balanced appetite. A bedtime snack can be helpful. Although we most commonly see recommendations for a high carbohydrate/low protein snack, some of our clients find that the reverse—high protein/low carbohydrate—helps them sleep through the night. Whether you snack or have a late meal, be careful not to go to bed too full; you want enough food in your small intestine to help your body relax into sleeping without having to work at heavy digestion. In addition, acid reflux can be caused or made worse by lying down right after eating, and acid reflux can disturb your sleep even if you are completely unaware that you have it.
Regular physical exercise is an important anchor for sleep. Exercise helps you to get rid of excess stress hormones such as adrenaline and cortisol which, in excess, can interfere with your body clock’s ability to initiate and maintain sleep. Exercise also raises your internal body temperature, and timing exercise to coincide with your natural rise in body temperature can further support your body clock. For optimal support with sleep, exercise around four or five hours prior to your bedtime. If you exercise at a different time of day, consider some light movement (such as jumping jacks or stairs) four or five hours before bed to provide this core heat. It is recommended that you avoid exercise close to your bedtime so as to avoid a temperature spike that may interfere with your sleep.
In contrast to our suggestion that you quickly transition from sleep with a brisk wakeup, it is crucial that you dedicate time to support the transition from wake to sleep. We often encounter people who expect too much of their brains: they think they should be able to go, go, go all day and evening, and then fall asleep at a moment’s notice. Our brains need a more gentle slowing. A wind-down routine that lasts twenty to sixty minutes will support your body clock in cueing your body to sleep. We encourage you to choose activities that are calming and to do them in low light. Some examples include listening to soothing music, doing some gentle stretching, reading, or engaging in a quiet hobby such as knitting. If you are not willing to turn off your screens (phone, tablet, television, or computer) during your wind-down routine, consider blocking the blue light on your screen (see below). As with everything we discuss in this book, there are a lot of individual differences; we encourage you to think carefully about what activities are most likely to help you wind down and set you up for sleep. Doing crossword or Sudoku puzzles or reading an engaging novel may be just the thing to clear your mind, or it may activate you too much. Journaling may be a nice way to review your day and put it behind you, or it may stir you up.
Before electricity, humans spent most of their evenings in relative darkness. Now we spend hours after sundown in spaces illuminated by artificial light, which throws off our internal body clock. Lights send the wrong message to the brain, telling it to stay awake and stay active. For example, darkness cues your body to produce melatonin, a hormone that creates a sense of sleepiness and contributes to the architecture of your sleep cycle. Dimming or darkening your environment before bedtime will facilitate this process.
Electronic devices are sleep’s nemesis! They produce bright light and stimulating images, both of which are counterproductive to what your body needs to fall asleep and to stay asleep. The most optimal choice is to use these devices only during your daytime hours. If you are not ready to take a (temporary) break from electronic devices before bedtime, take precautions to block the blue light rays from your device, since blue light suppresses melatonin more than other light wavelengths. You can download apps that remove these specific light wavelengths, purchase an orange gel to put over your device, or wear blue-blocking sunglasses.
Comfort is a lens that will change as your body’s needs change over your lifespan. Assess your bed in terms of the softness or firmness you prefer in a mattress as well as whether the mattress and your bedding provide your preferred level of warmth or coolness. Pay attention to your comfort when you sleep on other beds (such as at a hotel or at a friend’s or family member’s home) to identify helpful changes regarding your bed or bedding. If it isn’t practical to purchase a new mattress, you may be able to add a less expensive “topper” to achieve your desired sleep surface. We do not mean to suggest that you need a “perfect” mattress; remember that we want to encourage flexibility and an ability to sleep in varying circumstances. However, we have worked with some people who were trying to sleep in a chair or on a couch, and this level of discomfort was clearly disruptive to their sleep.
For most people an optimal bedroom will be dark, quiet, and well ventilated, and have a comfortable temperature. However, if you lived for years in a city, complete quiet may be so unfamiliar that you may sleep better with white noise. Notice, though, that we encourage you to use “white noise,” which is consistent. If you sleep with the television or radio on, the volume will change many times a night as the broadcast moves between programs or between programming and commercials; these volume changes can pull you out of deeper stages of sleep even if they don’t fully awaken you, leading to less restorative sleep.
If your environment is too noisy or light, you may want to consider using earplugs, a noise machine, or an eye mask. These inexpensive tools can be very helpful, but they can also backfire—we have worked with people who had so much ritual around creating an ideal sleep environment that this increased their stress and arousal, especially when something went awry, such as if they forgot their eye mask when traveling. Try to find the sweet spot: aim for desirable, even if not ideal, conditions, while trying to have a flexible, accepting attitude so that you will be able to adapt as conditions change.
Finding a balance between your sleep needs and those of your significant other, your children, or animals is an important piece of sleep hygiene. If your partners snore, kick, are restless, hop in and out of bed, or (in the case of animals) sleep on your head, consider a trial period of sleeping alone to see if your sleep improves. You can then make an informed decision about whether the benefits of sleeping with your partner (or partners) outweigh the costs.
We commonly learn that our clients’ sleep is being disturbed by their partners’ snoring. If this is true for you, you may want to wear earplugs. Or, an often overlooked option is for your partner to remedy the snoring directly if this hasn’t already been attempted. For example, he or she may benefit from a sleep study to assess for sleep apnea, a decongestant to treat a stuffy nose, or a modified diet to address foods sensitivities. Or perhaps you have observed that your partner only snores when sleeping on his back; he can use a positional device to help him stay on his side. Finally, if nudging your snoring partner has the desired effect, but you are hesitant to do this too often so as not to disturb his sleep, please talk to your partner; you will likely get his reassurance that it is okay to nudge as many times as you need to.
Although we have been focused on how to keep bed partners from disturbing your sleep, you also can consider asking your human bed partners to help you; getting their support to stick to your treatment program can make all the difference.
Knowing what you “should” do and doing it are two very different things. Here are some of the things we want you to keep in mind as you work to improve your sleep hygiene.
We strongly encourage you to think of sleep hygiene as a set of guidelines and not rigid rules. The impact that any particular behavior has on your sleep is unique to you. The guidelines are based on what we know to be true generally, or on average; they also are based entirely on what we understand about the physiology of sleep, without considering the impact of your thoughts and feelings. For example, although it is generally recommended that you not exercise strenuously in the hour before bed, one of our clients found that this was one of the best ways to prepare for bed. He told us, “I know that I am taking care of myself. This calms my brain which then calms my body.” For him, the calming effect outweighed any negative impact the exercise might have had on the rhythm of his core body temperature. Similarly, it may be worth having your sleep disrupted by your cat because of the greater ease with which you fall asleep when she keeps you company in bed.
We are not encouraging you to defy the sleep hygiene guidelines just because it is easier or preferable to not change. Rather, consider each guideline and how following it more closely may impact your physiology, thoughts, and feelings, given your personal set of circumstances. Then, if you are willing, do an experiment. The client we referenced above already had sleep log data with his normal late-night exercise; he then moved his exercise to earlier in the day and continued to track his sleep. After a couple of weeks he could confidently say that moving his exercise earlier in order to be more consistent with sleep hygiene guidelines did not help his sleep—and may even have hurt it. Similarly, even if you think the benefit you derive from sleeping with your cat outweighs the cost, your cat may be disturbing your sleep more than you think, and we encourage you to collect data by doing a trial without the cat in your room.
In addition to encouraging flexibility to allow for individual differences, we also are encouraging you to remain somewhat flexible because we know that being very rigid about following a list of prescribed rules can backfire. Your life starts to revolve (even more) around your sleep and you put even more pressure on yourself to do everything “right” and to sleep tonight! This is counter to the work we did in chapter 4 to increase your willingness to not sleep. Remember, we want to help you hit the “sweet spot,” being strict enough with yourself that you are actually doing the treatment and it has the time it needs to work, but not so strict that your anxiety increases or you cannot adapt to new situations, such as sleeping in less ideal conditions while traveling. Seeing sleep hygiene for what it is—a set of guidelines rather than rules—will help you to not respond with alarm if you “break a rule.” Set some specific goals for yourself, but also remember to be flexible, based on your situation. It is likely that your priorities will shift based on whether you are at home or on vacation, under a deadline, or managing a stressful life event.
One of the biggest obstacles to changing behavior is not wanting to. The good news is that you do not have to want to do something in order to do it. For example, you may be willing to give up caffeine even though you love the boost it gives you; you may be willing to dim your lights as you approach bedtime even though you prefer a bright space. Why would you be willing to do things that you do not want to do? Usually it is because you expect to gain something. Hopefully our explanation of how sleep works and of the 3P model of insomnia (chapters 2 and 3) helped you understand that changing your behavior can break the spiral of insomnia: even though poor sleep hygiene is not likely to have caused your sleep problem, it may be maintaining it over time.
In order to increase your willingness to follow the sleep hygiene guidelines, you may want to revisit the questions we posed in chapter 4 for each behavior you are thinking of changing:
It is important to have this conversation with yourself before you are faced with making a change. That way, when your mind is feeling the urge to do what you have always done, you are prepared to do something different. Be prepared to face and refute convincing language such as I can’t give up my caffeine until I am sleeping again. It is the only thing that helps me get through my day. This circular thinking is a common barrier, and you will be more likely to succeed if you are prepared for these types of thoughts. A helpful response could be: Maybe this is true, but I would like to find out. I am going to give up the caffeine for three weeks to see what happens to my sleep.
Be patient. The brain is designed to make changes over time, not in a knee-jerk fashion; it may need two to four weeks of consistent data and practice (such as waking at the same time) to make a shift. In addition, you may need to follow most of the sleep hygiene guidelines before your sleep improves. If you create a wind-down routine and establish a consistent wake time, that is a great start, but it is unrealistic to expect great progress if you continue to consume energy drinks late in the day and try to sleep in an uncomfortable armchair. A comprehensive sleep hygiene program will likely be more effective than a single-component program.
Another aspect of managing expectations is to not expect sleep hygiene alone to cure your insomnia. Most people in the field of behavioral sleep medicine agree that although good sleep hygiene is important in maintaining healthy sleep, it is unlikely on its own to fix a long-standing sleep problem. This is why we encourage sleep hygiene as a way to support either stimulus control therapy or sleep restriction therapy, rather than as a stand-alone treatment. However, if your habits are very inconsistent with the sleep hygiene guidelines, it would certainly be reasonable to try sleep hygiene on its own if this is the program that you are most willing to do. We have had a few clients who needed only this treatment; they have tended to be people with very poor sleep hygiene and recent, rather than long-standing, sleep problems.
Keep track of what you are doing. This is an experiment, so treat it like any scientist would by keeping an objective daily record. The sleep log is an ideal tool for this. If you are working on decreasing alcohol use or having a more consistent sleep schedule, or want to see what happens if you change the time you take a medication or exercise, the sleep log will give you all the information you need to track your progress and look for any relationship between these behaviors and your sleep patterns. For other guidelines, you may need to expand on the basic sleep log directions. For example, if you implement a wind-down routine, you can create symbols to track when you engaged in your wind-down and what you did; if you experiment with having a snack before bed, you can mark when you last ate. We generally find that it is best to do this in either the “Medications” or “C-A-N-E” row, leaving the “Sleep Cycle” row uncluttered so that it is easier to see your time in bed and time asleep.
For each change you are considering, make a specific plan. Your plan should include a clear definition of your goal (for example, no caffeine at all; or no caffeine after noon; or no caffeinated beverages after noon, but small amounts such as in chocolate are okay); any obstacles you anticipate (for example, craving, or lack of decaffeinated options); a plan for how to overcome those obstacles (for example, remind self of reasons for making this change; purchase decaffeinated coffee and herbal teas); and how you will track how closely you followed the guideline and the impact on your sleep (for example, using a sleep log).
Worksheet 9.1 will help you develop your personal sleep hygiene plan and use the implementation tips we reviewed. You will need to refer back to the sleep hygiene questions you answered in chapter 5. You may notice that we had you write the number of days in a week that you follow the guideline, rather than just whether you do or do not follow the guideline. This is because behavior is on a continuum. If you drink alcohol before bed every night, this is different than drinking before bed once a week, for example.
This more fine-tuned measure also allows you to see incremental progress. If you drink before bed on two nights instead of your previous seven, you can see that you followed the guideline on five nights, rather than only seeing that you did not follow the guideline exactly. We hope this helps you maintain your motivation to change, and helps you strive for even greater adherence to the guidelines.
You may be wondering how many nights is “good enough.” For example, if you have a consistent wake time five out of seven mornings, is that good enough? In general, we encourage you to strive to hit your target every day, especially in the beginning. Once you have established a new pattern or habit, you can experiment and collect data to see if small variations have a negative effect on your sleep. Remember to use effectiveness (what works), rather than rigid rules, to guide you.
Worksheet 9.1: Your Sleep Hygiene Plan
Use your responses to the questions in chapter 5 and the explanation of the sleep hygiene guidelines in this chapter to complete this worksheet.
STEP 1: Rate how IMPORTANT you think it is, how WILLING you are, and how CONFIDENT you are that you will be able to continue to follow the guidelines you already are following. Then do the same for the guidelines you are not closely following. Use a scale of 0–10:
|
0 |
5 |
10 |
||
|
Not at all |
A little |
Somewhat |
Quite |
Extremely or completely |
Sleep Hygiene Guidelines I Am Already Following Closely:
|
How I Feel About Continuing to Follow This Guideline |
|||
|
Guideline |
Importance of |
Willingness to |
Confidence I Can |
|
Sample Consistent wake time |
8 |
10 |
10 |
|
How I Feel About Continuing to Follow This Guideline |
|||
|
Guideline |
Importance of |
Willingness to |
Confidence I Can |
|
Sample Consistent bedtime |
9 |
6 |
4 |
STEP 2: Next, make a plan for each guideline you rated as IMPORTANT but (a) are not now following, or (b) have low confidence you will continue to follow. If you need more room, you can download additional copies of this worksheet from http://www.newharbinger.com/33438. Here is a sample.
|
Guideline |
Wind-Down Routine |
|
My Goal |
Listen to music on back porch with lights turned down. Start with fifteen minutes; increase to thirty minutes after three to four days. |
|
Will quiet my mind, relax me, and help my body clock transition from wake to sleep. |
|
|
Willingness |
What will I have to give up? Time to get something done; spontaneity What will I have to experience? Guilt (So much to do. How can I just relax?) Why am I willing despite this? Insomnia is costing me a lot, including being unproductive and inefficient at times. If I give up fifteen to thirty minutes for a wind-down period, I may get more, not less, done. I don’t actually believe I’m bad for relaxing for fifteen to thirty minutes, so I don’t have to listen to my guilt. I’ll do this as an experiment. If it costs me too much, I can always go back to my old habit. |
|
Obstacles and Solutions |
O: Will lose track of time and suddenly it will be bedtime. S: Set alarm for forty minutes before target bedtime. O: My mind will tell me to do “just this one thing.” S: Remind myself why I am willing; remind myself that I already know how things have been going without a wind-down, and want to try something different; I’ll do that “one thing” tomorrow. |
|
How to Track |
Write in C-A-N-E row of sleep log. |
|
Guideline |
|
|
My Goal |
|
|
Why Important |
|
|
What will I have to give up? What will I have to experience? Why am I willing despite this? |
|
|
Obstacles and Solutions |
|
|
How to Track |
|
Guideline |
|
|
My Goal |
|
|
Why Important |
|
|
Willingness |
What will I have to give up? What will I have to experience? Why am I willing despite this? |
|
Obstacles and Solutions |
|
|
How to Track |
|
Guideline |
|
|
My Goal |
|
|
Willingness |
What will I have to give up? What will I have to experience? Why am I willing despite this? |
|
Obstacles and Solutions |
|
|
How to Track |
|
Guideline |
|
|
My Goal |
|
|
Why Important |
|
|
Willingness |
What will I have to give up? What will I have to experience? Why am I willing despite this? |
|
Obstacles and Solutions |
|
|
How to Track |