I know what you’re thinking: Yet another sleep book. And you’ve heard it all before. From friends, family, a stranger in the health food store. A tip, a quick fix. Follow good sleep hygiene. Don’t drink coffee, get more exercise, don’t eat junk food, keep your light at night very dim and your room at exactly 67 degrees. Drink the juice from the whatever fruit on the whatever island in the whatever ocean that only grows in the whatever season during even numbered years. If so many simple remedies for poor sleep exist, then why do so many people STILL struggle with their sleep?! Getting consistent, deep, restorative, natural sleep is rarely accomplished by ingesting something, or by good sleep “hygiene”. It’s usually not that simple. But words of wisdom from a snarky sleep guy like me just might help your sleep. I promise you: My take on sleep is very different.
Everyone wants to sleep well/enough, consistently. Some people do sleep well/enough but just don’t realize it. Some sleep poorly or not enough and know they have a problem, but they exaggerate the problem and, more importantly, the perceived consequences. Treating physical and/or mental health conditions often improves sleep, but at the same time, treating poor/insufficient sleep usually improves overall health. But please keep this fact in mind: at the time of this publication, no research studies exist that show that insufficient sleep causes any chronic health condition. Yes, you read that correctly. All mental and physical health issues get worse with insufficient sleep, but insufficient sleep does not cause any of these health issues – it is associated with these issues. But it’s still very worthwhile to work on sleeping better because let’s face it, who wants to feel tired, exhausted, grumpy, irritable, impatient, sluggish, foggy, achy, out-of-sorts, depressed, or anxious all the time? And who wants to spend the time and money on desperate searches and experimentation to find the nonexistent magic sleep solution? Not me, and hopefully not you!
This is a good point to inform you that if you struggle with your sleep, or struggle to stay alert during the day, TELL YOUR DOCTOR. As I mentioned earlier, ANY physical or mental health condition can adversely affect your sleep. Overall health must be addressed WITH YOUR DOCTOR before deciding to work on your sleep. Additionally, if you implement some of the sleep strategies described in this or any other sleep health publication, and you continue struggling with your sleep (or experience excessive daytime sleepiness), INFORM YOUR DOCTOR. I am not a doctor, which means I am not your doctor. I don’t play on on TV. I didn’t sleep in a Holiday Inn Express last night either! This publication is for your personal interest only.
After over 30 years educating patients with clinical sleeping disorders, I am keenly aware of the torturous effect that insufficient sleep has on a person. Let’s be honest: In horrible places around the world, when bad people want to traumatize someone, it often involves such things as a hard surface, bright light and loud noise, aka, sleep deprivation. People (in the civilized world) struggling with their sleep experience a little bit of this trauma too. Poor sleep is no laughing matter. I have found over the years, however, that I am much more successful helping someone overcome poor sleep by a bit of a lighthearted approach. Suggestions, not rules, presented in a doable way.
When it comes to prescription sleeping medication, your doctor is your best guide. Sleep specialists usually do not recommend sleeping medication as a long-term “cure” for poor sleep, but studies show that sleeping medication is widely prescribed in primary care settings and often used long term by patients. Many medications (e.g., antidepressants, antihistamines) are prescribed “off-label” for insomnia due to their sedating effect. And then there are all of the over-the-counter supplements that purport to improve sleep, most with little or no science behind their claim. Medications can have dangerous interactions, and some studies have shown long-term use of certain medications used for sleep are strongly associated with serious physical and/or mental health deterioration. Some sleeping medications can produce adverse side effects such as nighttime wandering (big risk for elderly), eating, or nightmares, and some are associated with significant morning grogginess. And of course alcohol is used by many around the world as a sleep aid. The numerous risks and dangers of using alcohol for sleep are discussed later in this book.
Sleeping medication, prescription or over-the-counter, may seem to work well initially, but then start to lose effectiveness. Most of this is thought to be a placebo effect. This can then lead to a person taking more of the medication (“dosing”) to maintain a perceived effect. And an interesting thing about sleeping medications: none have been shown to improve falling asleep much faster or sleeping much longer/better than people taking a placebo.
Aside from the risks associated with sleeping medications, the biggest problem is the erosion of confidence in one’s sleep. For that matter, relying on ANYTHING for sleep erodes sleep confidence. Why? Simple: nothing produces natural sleep except being awake. Similar to hunger/satiety, sleep/wake are “homeostatic”, an ongoing balancing act. Sleepiness and hunger both build while awake, but most healthy people do not rely on medication to get hungry.
Learning better sleep strategies is not rocket science, but it is more than scanning a simple list like you see in a magazine at the checkout line at the grocery store. Those of us in the sleep health field all have our own unique ways of helping those with struggling with insomnia, ideas and concepts that go beyond a simple list. Learning to sleep better requires an understanding of not just the “what”, but also the “why” and the “how” of certain morning, day, evening, and night activities. Here’s a simple example of what I mean: Wearing a seatbelt is a good thing (the “what”). But increasing the chance of someone actually wearing a seatbelt requires the “why” (you’ll be safer in an accident) and the “how” (click the buckle when you get into the car).
Over the years, sleep experts have come up with highly effective and safe ways to help people with insomnia, together called Cognitive Behavioral Therapy for Insomnia, or CBTI. CBTI came to prominence in the 1970s and 1980s and usually involves some combination of these traditional components:
- Sleep Restriction (limiting time in bed)
- Stimulus Control (associating the bed with sleep)
- Relaxation (calming the body and mind)
- Cognitive Restructuring (addressing negative attitudes and unrealistic beliefs about sleep)
- Sleep Hygiene (what you eat and drink, exercise, your bedroom environment, etc.)
Although CBTI is the recommended approach to overcoming chronic insomnia, few sleep professionals are formally trained, and few primary care providers have had much training in sleep disorders at all. The problem seems to be twofold: sleep is still only minimally covered in medical schools, and most healthcare providers simply do not have the time necessary to teach the “what’s”, “why’s” and “how’s” of effective behavioral sleep strategies. And I don’t know about you, but some of the CBTI components sound a little scary. Restriction? Control? Restructuring? Yikes!
And that brings me to the reason for this publication. I wanted to share my take on effective sleep strategies, based on CBTI techniques, in a simple, straightforward, regular-person sort of way. My way. There are many sleep books and websites that can give you all the methods and statistics of the research behind these strategies – I’ll save you the eye-bleeding. Heck, reading some of that research might actually put you to sleep! Just ask my wife, who has seen me fighting to stay awake many a late night while reading research about insomnia. She just rolls her eyes at me and goes back to sleep!
So I hope you enjoy this easy read. It’s chock full of “what’s”, “why’s” and “how’s” about great sleep strategies, developed over the many years I’ve spent educating patients with clinical sleep disorders, presented with a few “Mike-isms” (my pearls of sleep wisdom!). My goal is to keep you interested (and awake) while reading it, not to make you feel like you’re studying for a final exam. I also might point out that I myself do most of the things I will be writing about, and I’m a pretty good sleeper. 😊
“Trying” to Sleep
Before we get into specific things you can actually do to work on your sleep, you must first be reminded of something: natural sleep cannot be forced. Ever. Sleep is a passive event. It happens – you can’t make it happen. You allow it to happen. And as you probably know by experience, the harder you try, the more elusive sleep becomes. So when it comes to better sleep, the key is to learn how to never “try”. Thus the title of this book 🙂
The experience of allowing something as important as sleep to just “happen” may be a very different experience from other parts of your life. Maybe you are/were a successful business person, a high-achieving student, or a high-achieving athlete. Maybe you are used to controlling things – taking charge to make sure things go according to plan, a real Type A personality. Sleep is different, a bit of a paradox. Actively trying to “will” yourself to sleep (or back to sleep) only leads to frustration and makes sleep less likely to happen.
My best analogy for this idea of not trying involves our half-wild cat Sally (15 y/o at the time of this publication). Even as a kitten, when we approach her to pick her up, she gives us a look of utter terror, like she’s never seen us before. (Wait, no, we’ve fed her, cleaned her litter box, provided her a warm bed for her for her whole life, treated her like a queen! We love our pets!) At first we thought, “What the heck? Why would she be so elusive?”. But soon we realized that if we just sat down on the couch, Sally would eventually, at the right time and under the right conditions, cautiously hop up next to us on the couch, lie down and start to purr. And then it struck me: Sally is just like sleep: elusive by nature; elusive when you “try”.
So to get started, join me in a sleep mantra:
“Natural sleep cannot be forced.”
“The harder I try, the worse it gets.”
“So from now on, I’ll never try.”
Call it our first Mike-ism. Try saying it to yourself before you go to bed or in the middle of the night if you are awake.
Not trying to force sleep is perhaps the most important key to sleep. Much of the remainder of this publication will teach you simple strategies that can help prevent you from trying to force your sleep.
Ok, time to start in on some specific behavioral changes for working on your sleep. And oddly enough, the starting point for better sleep begins after the night is over, in the morning. I like to say, “Good sleep starts in the morning”. Specifically, I’m talking about the time that you start your day. While you can’t control precisely when you fall asleep at night (sleep is a passive event, remember?), with a little effort you can definitely start your day at about the same time each morning, no matter how the night went. In fact, the time you decide the night is over and you are starting your day is one of the few things you directly control regarding your sleep. And just to clarify, starting your day is more than just waking up. You can wake up, check the time, make a quick bathroom trip, check social media while having a little snack, then go back to bed. You are awake, but you have not started your day. Starting your day is the purposeful act of getting out of bed, turning on lights, and being active.
In my years of helping people with their sleep, I have found that people who rise roughly when the sun comes up tend to sleep better. This is anecdotal and often situational for people who work or go to school. The main thing is general day-to-day consistency, not specifically the time per se.
A consistent morning start-the-day time helps to establish a stable sleep/wake rhythm, something called your “circadian rhythm”. Most people have heard of this rhythm, but don’t know what “circadian” means. The word “circadian” is Latin and it means “about” or “approximately” (“circa”) a day (“dian”). It works behind the scenes to make us more alert sometimes and more sleepy sometimes. For example, ever stay up all night? (Yes Mike, it happens a lot, that’s why I’m reading your book!) Even after a night of little or no sleep, you may experience a slight increase in alertness in the morning, followed by some relatively strong sleepiness in the afternoon. This fluctuation is your natural sleep/wake circadian rhythm at play, and we’ll have more to say about it later.
So what do I mean by a consistent start-the-day time? I might suggest no more than a one hour morning-to-morning variance. In other words, if you normally get up for the day at 7:00am, I would suggest never sleeping-in later than 8:00am. I know, the bed is the warmest, most comfortable place in your home. Why would anyone leave it? And I agree! In fact, I get jealous watching the grandparents in the movie Willy Wonka basically living in their bed. Ahhh, looks like pure bliss. But did you see the jar of sleeping pills on their bedside table?!? Just kidding – it was a feel-good family movie after all. I digress…
Like with any other body rhythm, we function best when the rhythm is stable. For example, most of us eat at roughly the same times so we feel/function better. By anchoring the circadian sleep/wake rhythm with a consistent morning start-the-day time, you will feel naturally more awake during the day and more sleepy at night. Even if you don’t get enough sleep right now, start with a firm commitment to start each day around the same time. Every morning. Your brain doesn’t care if it’s your day off.
How can you establish a more consistent morning start-the-day time? Even though you may have joyfully crushed it with a sledge hammer when you retired, an alarm clock (or cell phone alarm) works well. Spouses and dogs can work well too, but they can be prone to human or canine error. And some people sleep with their windows uncovered so the natural morning sunlight emerges in the bedroom. (You might warn your neighbors about this first though!) And more about light exposure in the next section.
Starting each day at about the same time, no matter how the night went, can take some effort. But it is well worth it in the long run. It’s the tangible start of sleeping better. Getting up for the day too early or sleeping-in later essentially gives us something like jet lag, which is the circadian rhythm being pulled earlier or pushed later. Jet lag is not fun. Set your alarm and obey it!
Different things can be used as time cues. Meal times for example. Or activity/rest patterns. In German, external time cues are called “zeitgebers”, literally a “time-givers” (I impressed my German-speaking future spouse with this bit of trivia). Of all zeitgebers, light level is our main time cue.
The sun goes up, the sun goes down, and as humans, we have lived our lives around this pattern for most of our existence. In humans, light level is detected by certain cells in the retina that do only that – detect light. From there, light information is sent to a small group of cells (uh oh, this sounds like some boring science) in your hypothalamus (hippo what?) that sends a signal to the pineal glad (eww sounds gross) to make melatonin (ok… melatonin… heard of it… I’m back).
So, because naturally changing light levels during the day historically have been the strongest time cue for the human brain, it is no surprise that light level, specifically lack of light, is also our strongest sleep cue. Simply put, light suppresses the sleep hormone melatonin. Darkness promotes melatonin.
As we discussed earlier, the first and most important way to anchor your circadian rhythm is to start each day at a consistent time. Getting good light exposure soon after you start your day is the next most important thing to do to anchor your circadian rhythm. In addition to shutting-down your natural melatonin release, morning light has also been shown to help with improving mood.
Let me shed some light on light: The sun has been around a lot longer than 1879, the year that Thomas Edison invented electric light. (I think that was the year the first case of insomnia was diagnosed too, but I could be wrong) We now have light on demand 24/7, as well as lots of electronic gadgets with back-lit screens. These screens emit some high-frequency light, which make it look bright and cheery (yep, so you’ll buy it). Back-lit screen devices are great for daytime use, but perhaps not the best thing for your brain late at night. Why not? It has very little to do with the light frequency issue. Studies have shown that the amount of light is far more impactful on sleep than frequency of light. The main issue with using back-lit screens at night is the engagement with material on the screens. Read on.
Modern society offers convenient, constant illumination and information 24/7. Our old human brains change after a prolonged period of wake, and one of the ways it changes is how it processes information. The big energy-gobbling front part of your brain, a main factor in what makes humans the top of the animal world, keeps us thinking relatively logically and rationally. It keeps the emotional centers of the brain (e.g., limbic system) in-check during the day. We are generally more patient and calm during the day, relatively more emotional and impulsive when awake at night. However, because most people in a modern society have the time and ability to engage in their information-bombarding back-lit screens at night, sleep suffers. But again, the main problem is not the frequency light from your back-lit screens.
Ok, now the “how”. First and foremost, as the evening progresses, try to simulate the natural dusk-night transition by gradually lowering house lights. Remember dusk? I know, it sounds so 1970s. Dusk is that time when our brains should know that the day is over. Maybe go outside for a few minutes (if it’s safe) and experience it. Doesn’t cost anything, and probably not too difficult to do. With your eyes open and little or no light exposure to your eyes, you send your brain a powerful message: sleep is imminent. You see this effect when camping in the outdoors. Ever notice how everyone starts yawning right after sunset while sitting around the campfire? Even a camper who is struggling with their sleep at home often falls asleep easier and sleeps better in a chilly tent on a lumpy air mattress. How is this possible? Natural light exposure is a big factor, but there are other factors at play too, and we will talk about them later as well.
Ok, I know earlier I may have seemingly dismissed the whole sleep hygiene thing, so please forgive me. But sleep hygiene tips/instructions are what most people first hear about when they can’t sleep. And trust me, they’re sick of hearing it. And for good reason: sleep hygiene doesn’t work. They’ve tried it all! So let’s just clear-up this sleep hygiene thing here, now, and forever.
Hygiene prevents things, it does not “treat” things. You use good oral hygiene to prevent cavities. But if you have a cavity, does brushing make it go away? You use good hand hygiene to prevent catching a cold. But if you have a cold, does washing your hands make the cold go away? In sleep research studies, sleep hygiene instructions are often the “control” group, aka, the group with no treatment applied, so the scientists can measure the effect of an actual treatment.
Sleep hygiene is all about common sense living. The following is the “what”, “why” and “how” you should know to keep your sleep troubles at bay once your sleep starts to improve (important note: ask your doctor if you have any questions about your diet or exercise):
Caffeine. Ah yes, the evil cup of coffee! Caffeine is one of the world’s most popular drugs. It’s a fairly powerful, long-acting stimulant. In fact, if caffeine were discovered today, my guess is that it probably would be available by prescription only. A cup of coffee can disrupt sleep for a few hours afterward because the half-life (the time it takes for half of the ingested caffeine to be metabolized) is thought to be around 3-4 hours in most adults. Even while you’re actually sleeping, if you have enough recently-consumed caffeine in you, it can make your sleep a bit less deep and less restorative, more shallow and fragmented. And caffeine is in more than coffee: chocolate, teas, sodas, energy drinks, even certain medications contain caffeine. Often it’s the other unhealthy stuff in caffeinated products that are really bad for you.
If you’re feeling a little sluggish in the late afternoon, try a glass of cold water, a brisk walk outside or even a short nap (more on that later) instead of more caffeine. If you are someone who consumes caffeine all day, do not stop cold-turkey! I usually suggest dropping the last one first, wait a day, then drop the next last one, and so on until the last caffeine is consumed maybe with lunch or mid-afternoon depending on how it affects you. For most healthy adults, caffeine is nothing to fear. Common sense.
Alcohol is the world’s most popular sleeping substance. In fact, it works a lot like some sleeping medications do in our brain. Besides being something that should be minimized for good health in general, here are four things that alcohol does to wreak havoc on your sleep. First, alcohol is a central nervous system (CNS) depressant, which can “knock you out” and put you into an artificial/sedated non-restorative type of “sleep”. Second, alcohol is a carbohydrate, which means that it is converted it into a sugar, a particularly stimulating type of sugar. And since alcohol is usually consumed in the evening, this conversion often happens during sleep. More sugar at night means a more wakeful brain and less restorative sleep. Third, alcohol is a diuretic, which means more bathroom trips during the night. And fourth, because alcohol is a CNS depressant, it relaxes your muscles more than usual and thus makes snoring worse (more on snoring later).
Too much alcohol is not a “nightcap” but rather a “night-hack”! But if you enjoy an occasional adult beverage at night with friends, with some food, and not too late, the positive social aspects of enjoying time with others probably outweigh any negative effects of drinking responsibly. Be safe and enjoy life. Common sense.
As far as food, the most important things are quality and quantity. No surprise here: try to eat the right amount of good quality food to be healthy and to be comfortable at bedtime. Food you eat before bed may be the most impactful on your sleep because digestion/food metabolism during sleep is not as efficient as it is while awake. Studies come out now and then trumpeting the benefits this food or that food (or drink) on sleep. Caution is needed here. No food or drink will put you into a natural sleep.
A note here about tryptophan, an essential amino acid that our body uses to make serotonin and ultimately the sleep hormone melatonin. Everyone knows that turkey has a lot of tryptophan and everyone falls asleep after Thanksgiving dinner, right? Of course, it could also be the glass of wine at noon, the 2000 extra calories consumed at an irregular time of day, or the comfortable couch after dinner with Uncle Sal going on about his gall bladder issue again. Yes, poultry is moderately high in tryptophan, but lots of other foods have higher amounts. Dairy products, bananas, seeds, nuts, honey and eggs have a lot for example. If you’re a little hungry at bedtime, maybe instead of finishing off the cheesy dinner casserole (digestion slows during sleep), how about plain yogurt with sliced banana or almonds? Or a glass of milk with cheese and crackers? Or a banana? Green leafy vegetables have a lot of tryptophan, but most people don’t want to eat a salad for a bedtime snack. A specific food or drink will not cure your insomnia, but a tryptophan-rich bedtime snack will work with your natural sleep system. Falling asleep (or back to sleep) is a passive event, remember? Like sleeping pills, you might try a certain “miracle” food or drink you’ve read about and sleep great for a while, but then it stops “working”. This can be a slippery slope of expectations. Eat right but enjoy life! Common sense.
Next is exercise, and (surprise!) exercise is good for your sleep. It seems to be good for everything, physically and mentally. Exercise tends to make sleep deeper and more restorative. And not just exercise – being socially or mentally more active has been shown to be good for sleep too. Evidence of this can be seen in people who are depressed, whose sleep is almost always poor. In fact, the onset of insomnia is considered a strong predictor of clinical depression.
When to exercise? Most sleep experts recommend not exercising at night close to bedtime because this can raise the level of certain chemicals in your body (e.g., cortisol) that can keep you awake. Moderate exercise will also raise your core body temperature, which naturally falls when you fall asleep. Even a small increase in core body temperature can take a little while to return to normal. Morning exercise can also be a third anchor for your circadian rhythm (along with consistently starting each day and getting morning light exposure). Check with your doctor about whether exercise is ok for you, and if you get the green light, then go for it! Use your body, use your mind. Common sense.
Another thing I consider part of sleep hygiene is the sleeping environment. Here’s the message: cool, dark, quiet, comfortable, clean, and uncluttered. That’s it. No specific room temperature, lux level, external decibel level, cotton thread count, air humidity level, or Feng Shui will put you to sleep or keep you asleep every night. If you sweat at night, cool the room. If you are bothered by a light source, take care of it, or try an eye mask. If traffic noise happens during your normal sleep time, try ear plugs. If you hate your lumpy old mattress, get a new one. If you get congested at night from allergies, keep your bedroom cleaner. If you have a piles of junk all over your bedroom, tidy up a little! Common sense.
There are other things to consider for a good bedroom: bedpartners with different sleep schedules, bedpartners who snore, bedpartners that like to watch TV in bed, dogs and cats in the bedroom, etc etc. Each situation is different, and it just requires taking a moment to evaluate your sleeping environment.
I do however have one little silly mental tip that actually seems to help: rename your bedroom. Call it your “sleep-room”. You use it primarily for sleep, so calling it your sleep-room gives it a purpose. Think of it like this: you happen to have a bed in your sleep-room just like you happen to have a couch in your living room. I’ve seen this help! No harm in trying.
Sleep hygiene is like any other hygiene – it helps only to prevent a problem, not to cure one. Don’t obsess over it because it’s mostly just common sense living!
Beliefs About Sleep
Studies have shown that attitudes and beliefs about sleep can affect sleep. In particular, irrational, rigid or negative thoughts about sleep can perpetuate your insomnia (keep it going). Ideas like staying in bed longer helps you get more sleep, or that you need at least eight hours of sleep each and every night or you’ll get sick, or if you don’t sleep well you’ll get fired from work. These are highly irrational attitudes and beliefs about sleep, and focusing on them can be like gasoline on your insomnia fire. To understand, let’s unpack these three examples:
Many people who struggle with chronic insomnia tend to go to bed earlier, stay in bed when awake at night, and/or sleep-in in the morning. This just perpetuates the insomnia. Being in bed a lot longer than you actually sleep can lead you to become more easily awake in bed instead of asleep through a process called “classical conditioning”. Remember research about Pavlov’s dogs from high school psychology class? The dogs learned to associate the sound of a bell (Dr. Pavlov entering his laboratory) with food, so they salivated (Dr. Pavlov gave them meat to get saliva samples for his research on digestion). Same thing can happen with sleep (not an icky salivating thing fortunately!): As you spend more time in bed awake trying to force your sleep, your big human brain begins to associate the bed, bedroom, even bedtime with alertness/anxiety. You become conditioned to become more awake/alert in bed. For some, even just the thought of going to bed can cause anxiety. We’ll talk about how to un-condition this conditioned alertness and anxiety later.
Want to wreck someone’s sleep? Tell them they need a certain number of hours of sleep each night or they will probably get some terrible disease. Humans are pretty good at coping with even moderate sleep loss. No need to panic about occasional poor nights of sleep. Your goal is to allocate enough time, and not much more, to get as much sleep as you need to feel reasonably well the next day. Period. No guarantee with natural sleep. And studies of adult sleep around the world find that average sleep duration is a little over 6 hours, for good sleepers and for people experiencing insomnia alike. In fact, it is just as likely that any one adult sleeps 5 hours as it is that he/she sleeps 8 hours. What’s really interesting to me is that good sleepers tend to OVER estimate their sleep a bit while a person with insomnia tends to UNDER estimate their sleep, despite both being just as likely too ACTUALLY sleep a little over 6 hours. Perception of sleep is a fascinating thing.
The normal human experience with sleep is also far from perfect: All humans wake a bunch of times each night. I was really fascinated by this in my early years as a Sleep Technologist in the 1980’s. Most of these awakenings are brief and not remembered in the morning. As we move through our adult years, sleep can naturally become segmented (happen in chunks), we tend to get sleepy a bit earlier, we’re awake a bit more during the night, and we be more likely to take a nap during the day. A variety of non-sleep factors are at play here, but it is thought that the circadian rhythm changes as we age. So expecting to sleep all night long, at least 8 hours without waking up, is completely unrealistic.
And for our third example, how many rough nights have you had? And how many times have you been fired because of sleepiness? You can do the math. This is simply not likely to happen.
Sleep and wake are one big continuous 24 hour cycle, so it’s important to be flexible. Each depends on the other, and since each day is different, each night is too. People ask me how much do I sleep, and my answer is, “I don’t know.” (yes I get some strange looks) I don’t try to monitor it. I really don’t even want to know! I try to allocate enough time, and not much more, to get as much sleep as I need to feel reasonably well the next day. Period.
The key to better sleep is to understand what has been consistently shown to help, learn how to implement these things for yourself, then just do your best. Life throws curveballs I like to say, and sleep will be affected. But a solid understanding of good behavioral sleep strategies will serve you well!
Humans are not very good at going full speed, and then quickly shutting down for sleep. You need to wind down at the end of the day. Think about the sun: Does it “fall” out of the sky at the end of the day? No, it “sets”. So at the end of your wakefulness, gradually wind down. Teach yourself how to relax.
It is very important to understand that relaxing yourself does not “put” you to sleep – sleep is a passive thing, right? Becoming relaxed is the first initial step to becoming sleepy, a pre-requisite to feeling sleepy, and there is a long list of ways to relax. A couple of “tried and true” ways to relax are tummy breathing and progressive muscle contractions. (Note: Check with your doctor to see if purposeful relaxation exercises are safe for you)
Tummy breathing, also called abdominal or diaphragmatic breathing, is perhaps the oldest relaxation method around. It’s used in most Yoga and meditation techniques. It is also used in singing, playing wind instruments, public speaking, etc., anything which requires slow, deep, controlled breaths. This type of breathing also tends to relax us. For the basic core maneuver, lie down or recline in comfortable clothes, put one hand on your chest and one on your tummy, and take a slow breath in and out. Which hand moved the most? The goal is to breathe in a way that makes the hand on your tummy move up and down and the hand on your chest remain still. To me, the simplest way to do this is to just let your waistline go when you inhale. This is counter to how popular culture tells us to breathe (tummy in, chest out), so it can feel a bit strange at first. Take your time, expand your tummy with each slow breath in, and passively exhale, all at a comfortable pace.
When you have the basic maneuver learned, you might try pausing a moment before and after each inhaled breath. Then as you exhale, you might consciously relax your jaw, neck and shoulder muscles (I call these three areas the Bermuda Triangle of stress). A few minutes of this in the evening can be a great way to relax, a pre-requisite for sleep.
The other relaxation technique I like which has been shown to be very effective is progressive muscle contractions, sometimes called the “Jacobson Technique”. This technique starts the same way as tummy breathing by putting yourself in a comfortable position wearing comfortable clothes. When you’re ready, slowly and systematically go through your body contracting, holding, and releasing different muscles. You might start with your hands. Make tight fists for about five seconds, relax about five seconds, then repeat, five seconds on and five seconds off. Take a moment to notice the different feeling in your hands and forearms. Warm and tingly perhaps? Relaxed? Next, maybe do your biceps – contract and hold, relax, repeat. How do your upper arms feel? When ready, choose another muscle and so on, working your way all through your body. (Tip: Go gently or skip any muscles that are not comfortable doing this. For example, my calf muscles cramp easily, so I usually skip them.)
Progressive muscle contractions release muscle tension. They also cause our body to release a little bit of endorphin. Most of us know endorphin as the stuff that gives those crazy long-distance runners their “runner’s high”. The effects of endorphin can be found in the word “endorphin”, which stands for “endogenous morphine”. It is a natural chemical that makes us feel relaxed. And by doing progressive muscle contractions in the evening, you can generate a bit of natural endorphin for relaxation without raising your heart rate or body temperature as with aerobic exercise.
One other idea for relaxation is to consider a hot soak during the colder months or a cool shower in the warmer months. This can be a great way to relax, but (like exercise), a hot soak probably should be done at least an hour before bedtime. This is so your body temperature has a chance to fall, which is necessary for sleep. I’ve even suggested to some people who have ongoing trouble falling asleep (and who have the time) to do a warm soak midday, or even in the morning. It can help get that circadian rhythm anchored!
Like I said before, there are many ways to relax. Tummy breathing and progressive muscle contractions are just two of my favorites, and they are simple to learn. If purposeful relaxation is new to you, I strongly suggest (after an OK from your doctor) starting slowly. Maybe try it first in the afternoon or early evening for a few minutes. I like to encourage people to “explore” relaxation. No big time commitment, no performance anxiety.
Relaxation does not put you to sleep – remember, nothing does. It’s just required for sleep. I know you’re probably sick of hearing this, but it needs repeating: Sleep is a passive event. Never try to force it.
In bed in the dark of night, you are alone with your thoughts. Added to this is the fact that the parts of your brain that help with your rational, organized thinking start to go “off-line” when you get tired. During the night, the mind can get expansive and the emotion control center loses proper functioning. In sum, the tired/sleepy brain can become a breeding ground for worry.
Most worry has roots in lack of information or understanding of the worry. The whole “fear of the unknown” thing. The more you know about something, the less you worry about it. Even for something that you cannot directly do anything about, gathering information and learning about the worry reduces worry.
What to do? Address nighttime worries during the day, when you’re thinking more clearly. Literally schedule a time to worry.
Writing thoughts down has been used for a long time as a way to help organize them. Worrying at a scheduled time (e.g., for 15-20 minutes after lunch) is designed to reduce worry outside of this time. Try listing a couple worries that tend to be on your mind at night. Then, for each each worry, write a couple ideas you could do to learn about (not formally resolve) the worry. Most worry has an element of the “fear of the unknown” thing. Time to go to school with your worries and concerns.
Keep your “solutions” brief, practical and rational – a step in the right direction. For example, if you write “I am worried about my finances”, I would not recommend “play the lottery everyday” or “start a Ponzi scheme and invite all my friends”. Instead, you might put down “review last month’s expenses and try to save $20 this month” or “talk with Uncle Dave about how he manages his finances”, or something like that. Then at night, remind yourself that you did some productive worrying. It’s all safely documented in your kitchen drawer. You don’t need to worry about anything now. You can worry more tomorrow. Heck, you can worry longer tomorrow. You may begin to take control of those worries swirling around in your head at night, keeping them literally “off your mind” while in bed. Now and then, actually do one of the things you wrote down. Make the phone call, go to the website, etc. Learn about the object of worry.
You may be thinking, “I am worried about my sleep”. This is common, and likely, given that you’re reading this publication. To me, worry about sleep is actually sort of logical. Sleep happens at night, when it’s dark, when you’re unconscious. It’s mysterious. Maybe it used to be easy but now you struggle with it. Nothing you try seems to work. Your doctor may not really know much about it (it’s not covered much at all in most medical schools). Plus there are weird dreams sometimes. And your spouse snores! Etc, etc. So…learn about sleep. First, talk with your doctor about your sleep concerns to see if something treatable is directly causing your sleep trouble. Then, maybe read about the discovery of the circadian rhythm (a very interesting story starting with a French botanist with a VERY long name studying a heliotrope plant in the 1600’s). Then maybe learn about sleep stages – cool stuff!
And then of course, finish reading this publication!
When people tell me, “I always go to bed at the same time”, I usually ask “why?”. Every day is different, so why would anyone expect to fall asleep at the same time naturally? In nature, the time that a mammal falls asleep at night is variable. Sleep and wake are the two parts of the a 24 hour cycle, and because every day is different, why would you expect sleep to begin at the same time every night? An endless list of factors determine when you fall asleep each night: how active you were, what you ate, how much stress you experienced, light exposure, medications, etc. etc. etc. The best time to go to bed, especially if you have ongoing trouble falling asleep, is when you are sleepy. Not when you’re just tired, bored, exhausted, because the late show is over, or simply because it’s just your normal bedtime. Sleepy. As in struggling to stay awake. You want to increase the chance that sleep will happen easily, so being truly sleepy when you go to bed is the goal. But how do you really know when you’re truly sleepy enough to go to bed? It’s all about paying attention to sleep cues.
It is very common for people to watch TV or be on their computer or mobile device in the evening. We have busy lives, and evening/night is when most people have time to use these devices for entertainment (or extra work). They can distract us, and distraction can actually be good for drifting off to sleep (more on that in the next section). But as we learned earlier, engagement with backlit screens can keep us awake sometimes. Plus, have you noticed how TV shows just roll on, one right after the other? In the past, commercials were shown for a few minutes between programs, and this gave us time to consider going to bed. Not the case anymore. It’s easy to stay put and keep watching. Computers and mobile devices offer social media, email, online banking, etc., activities that can eat into sleep time. The “time drain” aspect of electronic devices is probably at least as bad for your sleep as any light exposure aspect.
But perhaps the main reason that backlit screen time around bedtime is bad for our sleep is that it can make us forget what it feels like to get sleepy. You may not notice your sleep cues getting stronger. Let me explain. Let’s go back to nature and our camping example come earlier. Outside of our modern society, we are much more keenly aware of the onset of night. The transition from day to dusk to night is salient, unavoidable. Removed from our modern living, this change in ambient light engulfs us. We have no choice but to get sleepy, and we feel it. On the couch at home in front of the TV you may get sleepy, but you may not notice the start of sleepiness happening. It just happens. In fact, one of the more commonly heard experiences from people with insomnia is that they fall asleep on the couch, get woken up by their partner or a noise on the TV, drag themselves to bed, and then Zing! Alert. No sleep. The feeling of getting sleepy before going to bed must be experienced on a nightly basis for sleep to be easy.
So learning what getting and staying sleepy feels like may take some re-learning. At the end of this booklet, I encourage you read about my iPhone app that can greatly help with this.
And to finish this section, a Mike-ism:
If you want to know if you’re sleepy enough to go to bed, don’t look at your clock, look at your mirror.
Distraction with Imagery
As I mentioned, the best way to avoid trying to force sleep is to distract yourself. In the “old” days, when someone couldn’t sleep what were they told to do? Count sheep. Count backward by 3’s from 1,000. Read War and Peace. These were the gold standards of boring, monotonous activities, and the hope was to bore ourselves to sleep. Ever try this? I did once. Made it to about 11 sheep and wanted to scream. (I’ve also wondered if sheep with insomnia count jumping humans. Again, I digress.)
When you lie down to sleep, it is very important to understand something: You can’t think about nothing. The human brain (even mine) is too big. Humans are always thinking about something, all the time, so the “blank slate” approach in bed doesn’t work very well. Boring monotonous mental tasks like counting sheep may work once or twice for some people, but they are not a long term solution. For some people, boring monotonous thoughts can become worrisome ruminations, leading to more insomnia.
So what works well? Once you are relaxed and sleepy enough for bed, the best strategy is to use the amazing, limitless theater of your mind to distract yourself through pleasant imagery. And it’s simple because as a human you do this all the time. When you go to bed (or back to bed), in your mind just picture a pleasant scene, a memory, a part of a favorite book or movie, a project you’re working on that you enjoy, a “happy place”, etc. There is no end to material. And don’t just let your mind drift there – mentally take it there. Concentrate, focus. The secret is the more you focus on pleasant imagery, the less you focus on sleep, and this is exactly what sleep needs. It needs you not to focus on it. Don’t remember everything about an image, scene, memory, etc.? Who cares, make it up – it’s your mind after all! You might look through an old photo album before bed to jog your memory of a great time from your past. Or leaf through a magazine about a favorite hobby or a distant land you’d like to visit. Then at night, when you climb into bed and close your eyes for sleep, take yourself there. Really get into it, recalling all the sights, sounds, smells, the whole experience.
Reading before bed is perhaps one of the best ways to get sleepy. When you read, what are you doing in your mind? You are visualizing everything. You are literally making the movie based on the book (which is why we are all disappointed when we watch a movie made from a book we’ve read – it’s not OUR movie!). Reading distracts you, taking you somewhere mentally. It keeps you from focusing on bedtime and sleep. Personally, I like historical novels with places, characters, etc. And to clarify, I’m talking about reading a paper book or magazine of some sort (not a backlit screen) in low incandescent light. You remember paper books, those things in boxes 10 for a dollar at garage sales? Who would have thought they could help the world sleep better!
If reading in low light is difficult visually, audio stories are a great option. Most libraries have them on loan for free. Pop in a story and put on your headphones and away you go. You might even flip through a magazine at the same time to keep yourself even more distracted. Later, when you feel the strong waves of sleepiness, turn it off, go to bed, and play the movie clip you created.
Lastly, the simple technique of distraction through mental imagery can also do one amazing thing for someone struggling with insomnia: It can make going to bed enjoyable. This can be huge for some people who “dread the bed”. And keep this in mind too: if distraction through pleasant mental imagery is difficult, it might not be time to be in bed. Everyone has read that you should get out of bed in 20 minutes if you’re still awake. I don’t like this instruction at all. Yes, leave the bed if you can’t sleep, but don’t count the minutes. Instead, ask yourself a simple question: “Is distraction easy?” If no, leave the bed. If yes, stay in bed.
With distraction through pleasant mental imagery, you get to think about whatever you want to think about. I do this every night, and dare I say it can be fun! A great memory. A year from your life. A great movie you’ve seen recently. Where can you take yourself tonight?
Do you frequently check the time at night? Look at the clock, sigh, then roll over, again and again? Guess what – some smart researchers found that when people don’t check the time at night, they are less anxious about being awake, and they tend to be awake less. For most people, the clock is a cue for worry at night. Checking the time also makes you do math, and (for most) that’s not fun. Do you really NEED to know the time at night, or just WANT to know the time? Think about that. In nearly every situation, it’s the latter.
The solution is quite simple logistically: arrange things so you can’t check the time. You might take a moment to look around and locate your time devices. Maybe move your alarm clock (and/or cell phone) across the room and position it so you can’t see the time display. You don’t need to look at it for it to wake you up in the morning, right? Look for other places you might get a peek at the time: on the way to the bathroom, in the living room if you’re reading at night, the microwave clock, etc.
Want to take it to the next level? Avoid the clock even before you go to bed. I do this. I honestly don’t know what time I go to bed. I do know it’s different each night because each day is different, as I discussed above. And because I don’t know exactly what time I go to bed, I don’t know when I fall asleep, or how much I sleep. And I think this helps me sleep.
Not knowing the time at night is one of those sleep gems that can really make a big impact. And it’s simple – it just takes some willpower to not peek at the time.
So here is a “time-tested” Mike-ism for you: The first step in dealing with being awake at 2am is to not know that it’s 2am.
Awake at Night
Awake in the middle of the night – oh joy. Waking early and not being able to return to sleep is perhaps the most frustrating and challenging type of insomnia. Here’s the deal: Just like you can’t force ourselves to fall asleep or back to sleep, you also can’t force yourself to STAY asleep. So once again, the key is not to “try” to force sleep. When you know you’re awake, or perhaps more accurately “alert”, and you feel that returning to sleep easily is just not going to happen easily, try this: Shrug. Mentally and literally. A healthy indifference to being awake at night can help keep worry in check. Next, repeat your sleep mantra (see earlier section on “trying”). Then, if your mobility allows, leave the bed (yep, classical conditioning and Pavlov’s dogs again). Just take a deep breath, remind yourself that you can’t force sleep, put your foot on the floor, and go to another room. If it’s cold, maybe wear a robe, slippers and maybe use a heating blanket. Maybe a cup of warm decaf tea or milk. Have a fireplace that’s easy to use? Turn it on. (Note: If your mobility is limited, maybe sit in a chair near the bed, or at least sit up in bed.)
What to do? Don’t stare at the wall or pace the hall. Do something that does not involve much activity or light (no TV or quick peek at email!). The list is endless and personal to your preferences. Maybe read, write, draw, knit, paint, color, lie down and breathe for a moment, have a light snack, listen to music, listen to an audiobook, play a card game, do a crossword puzzle, do a jigsaw puzzle…everyone has different things they like to do. Maybe you can rediscover an old hobby?
It is important to find something you actually like to do, not something really boring, and have it set up and ready to go before you go to bed. You don’t need to be fumbling around your closet in the middle of the night. Be patient – allow your natural sleepiness to return. It will if you let it. Go back to bed only when you’re truly sleepy (struggling to stay awake). If you become alert back in bed, even if it happens right away, repeat the process: Shrug, mantra, leave the bed, quiet low light activity until sleepy.
This is insomnia bootcamp. Clinically it part of “stimulus control”, and it’s one of the most effective strategies for overcoming chronic middle of the night awakenings. Over time, leaving the bed if/when you become alert strengthens the association between your bed and sleep. But it takes some effort and a few nights to have an effect. For long-lasting improvement for the difficult experience of being awake at night, it’s recommended by nearly all sleep experts.
Important note: Frequent short awakenings at night can be caused sleep apnea, restless legs, medications, or any one of countless other things. So as always, talk with your doctor about your sleep.
If you noticed someone having difficulty breathing while out in town one day, would you avoid them, walk away, get irritated at them, or laugh at them? Of course not. You would likely help the person struggling to breathe any way you could. For Pete’s sake, their airway may be blocked by something! When someone is snoring during sleep their airway is also restricted, but bedpartners or anyone else nearby usually get annoyed, smack the person on the arm or sharp elbow to roll over, put in earplugs to ignore the noise, or move to another room to sleep. Many people I’ve helped with snoring report that their bedpartner goes to bed early to try to be asleep when they (the snoring person) climbs into bed. And when someone is snoring at the movie theater or in church, others nearby usually chuckle.
People who snore a lot are often more tired during the day. This is thought to be caused by the brain not allowing itself to stay in a stable sleep pattern because it is detecting the body working harder to breathe through a narrowing or blocked airway. So sleep can be less restorative. Through hormonal changes, shallow/fragmented sleep can also lead to weight gain, less exercise, even personality changes. The risks of heart disease and stroke also increase the longer that loud snoring goes untreated. And as body weight increases, snoring usually gets worse, which makes sleep quality worse, which leads to adverse changes in hormones that regulate hunger, which can lead to further weight gain. A vicious cycle.
But there are two things that can significantly worsen snoring that (theoretically) can be modified. The first is alcohol consumption before bed. I mentioned this earlier in the Sleep Hygiene section. As a CNS depressant, alcohol makes muscles relax more than normal. There are muscles supporting the tissues at the top of our airway, an airway which can be narrow to start with in some people. Alcohol can be something that causes the airway to get even more narrow, which makes snoring louder as airflow becomes more restricted. Reducing or eliminating alcohol in the evening can really help reduce snoring.
The other behavior that can worsen snoring is sleeping in the supine (back) position. People who snore usually snore loudest while sleeping on their back. In fact, some people snore only while sleeping on their back. This happens because gravity pulls back on the tongue and jaw, making the airway more narrow, which increases snoring. A possible solution? If possible, don’t sleep on your back. How, you ask? Try putting a couple of tennis balls in a tube sock, then clip or sew the sock to the back of your sleep shirt vertically down the middle. Then during the night, if you roll onto your back, you’ll feel the lump. This will be your cue to roll to one side or another. Over time, the tennis balls may train you to stay off your back while you sleep. If you cannot sleep on your sides (e.g., due to physical ailments), you might try a foam wedge to prop up your upper body a bit while you sleep, reducing the effect of gravity on your airway. In fact, there is a whole industry of gadgets and devices designed to help people stay off their back during sleep. Crazy backpacks, electric vibrating collars, etc. As with anything, research any sleep-related product thoroughly before purchasing.
Very important note: If you snore loudly, or if you have been told that you stop breathing at night, tell your doctor right away. You may have sleep apnea, a dangerous and potentially life-threatening, but very treatable, sleep disorder. Snoring and sleep apnea tend to go hand in hand, so if you are witness to loud snoring (or worse, silent pauses in breathing), do not avoid, ignore, or laugh at it. Get that person to the doctor!
A lot of people try to take naps, but can’t fall asleep. (There’s that “try” word again!) Aside from children and the elderly, the rest of us are probably best to avoid naps most days. However, an occasional, short, early-afternoon nap can be restorative, especially after a rough night of sleep.
A short nap (e.g., 15-20 minutes) means that if you do fall asleep, you likely will not quite get into a deep state of sleep. This may seem strange: Why wouldn’t you want to sleep deeply in a nap? It is sleep, right? Yes, but when you wake out of a deep state of sleep, you can feel groggy and disoriented, sometimes worse than we felt at the start of the nap. And if the nap goes over an hour, you will likely not only experience some deep sleep but also some Rapid Eye Movement (REM) sleep. A full, complete deep + REM cycle, especially if done later in the afternoon, will reduce your sleep drive that night, making getting to sleep and staying asleep more difficult.
What’s the best way to take a short nap in the early afternoon? First and foremost, make sure you’re sleepy. Not just bored, tired or exhausted, but sleepy. Struggling to stay awake. Make your sleeproom cool, dark, quiet, and comfortable, and set your alarm. Maybe breathe with your tummy a few times. Relax. Take your mind somewhere pleasant. And just see what happens. When your alarm goes off, get up. Don’t worry if you fell asleep – you may not know if you did, and that’s ok. Maybe sip a glass of ice water and get some light to get your alertness back.
Some famous people in history (like Thomas Edison and Salvador Dali) used to hold small objects (such as ball bearings or a spoon) in their hand when they were sleepy during the day. If they fell asleep briefly, they dropped the object(s). Apparently Edison knew the restorative value of a short nap – I mean, the guy invented just about everything (we’ll forgive him for the light bulb thing). And from what I understand, Dali took brief naps to get his creative juices flowing too. Maybe that’s how he got the idea for his signature stylish mustache. Who knows.
A short nap can be a great supplement to insufficient sleep at night, especially as you age, if have an irregular work schedule, or if you have caregiving duties at night. And anyone could have a rough night for any reason: a windy night, an emergency phone call in the middle of the night, a neighborhood cat fight, etc. In those cases, a longer “recovery” nap may be in order. So decide the purpose of your nap: take the edge off a little daytime sleepiness (short nap), or recover from an exceptionally rough night for reasons out of your control (longer nap). When in doubt, keep the nap short just to be safe.
Do you struggle frequently with getting to sleep or do you wake up for long periods of time at night and have difficulty returning to sleep? Are you working with your doctor to get off sleeping medication? Or convinced you’ve tried everything to help your sleep?
In 2007 and validated again in 2012, sleep scientists in Australia discovered a clever way to help people with chronic sleeping difficulty. In a sleep laboratory (with expensive equipment), they gave a group of people suffering with chronic insomnia a series of short sleep opportunities (“trials”) to fall asleep. Each short sleep trial was ended if either 1) sleep began, or 2) if the sleep trial time ended with no sleep. The subjects were then immediately asked if they thought they had fallen asleep, and then told whether or not they were correct. Subjects were asked to get out of bed for a few minutes, then returned to do another sleep trial. It was sort of like “practicing” falling asleep. And it worked!
Over a number of these sleep trials, the subjects “learned” what it took to fall asleep. After one long session of this sleep training, all of the research subjects were able to get off (and stay off) their sleeping medication, and the majority of them rated themselves as “good” sleepers for months afterward.
So, can you do this type of research-validated sleep training at home? Yes! Assuming you don’t have a complete sleep research laboratory at your disposal, all you need is my Sleep On Cue™ iPhone app to do sleep training at home. Instead of fancy machines and wires attached to your head, the Sleep On Cue™ iPhone app uses a precise call/response method to tell if/when you fall asleep during each sleep trial. Sleep training with the app can be done around bedtime for an hour or two (or longer) the night after any rough night of sleep. Sleep training can help you relearn what it feels like to fall asleep, enhancing your awareness of those sleep cues I talked about earlier. And sleep training can lead to much greater confidence in your sleep, which reduces worry and anxiety about sleep, and for many, reduces or eliminates reliance on sleeping medication.
The Sleep On Cue™ iPhone app not only offers sleep training, it also allows you to take a custom nap. Select how long you have for your nap (e.g., 45 min) as well as how long you actually want to sleep if you do fall asleep (e.g., 20 min), then away you go! If you are looking to enhance your efforts to get better sleep and quickly, learn to sleep on cue with my Sleep On Cue™ iPhone app!
As sleep trouble can be a very personal thing, I am happy to offer online sleep coaching. This is easy, convenient, affordable, but most of all effective! With over 30 years helping people with sleep troubles, I can usually help you make significant progress in just one or two coaching sessions. Another option is an on-site sleep health workshop for your company or group. Just drop me a note if you’re interested in either!
All For Now
I sincerely hope you got some helpful information from this reading! Sleep and wake are one big 24-hour cycle, so remember to take a long-term approach when working on your sleep. Behavioral change is effective for better sleep, but it can take some time and some effort. But is it oh so worth it!
This publication is for general interest and education only. This publication is not a medical treatment nor is it meant to modify or replace medical advice you have been given. Always talk to your doctor about your health, including your sleep and your medication. Never drive or do anything that would be dangerous if you’re sleepy.