Teaching patients to stop racing mind for restful sleep

Photo Cred: Annie Spratt/Unsplash

By Catherine Darley, ND

Many patients have intrusive thoughts during sleep time. This can occur after a stressful day, an eventful period in life, or could be a long-term habit. In my clinic, we are currently seeing complaints of insomnia soaring due to the unmitigated pandemic, economic downturn, and ongoing political uncertainty. These anxious thoughts can prevent the restful sleep patients need to cope with life’s challenges. However, there are several strategies that practitioners can employ with patients to help them quiet their mind and sleep more soundly.

First, help patients set the stage by purposefully adopting an attitude that enables peaceful sleep. A good way to think about sleep time is that it serves an entirely different purpose than wake hours. During the day, we take care of our roles and responsibilities, but at the night, we set them aside to rest and restore. We do not, and should not, take those wake time responsibilities to bed with us. However, when patients describe attending to their work email notifications in the middle of their sleep period, that is a good opportunity to empower them to prioritize their health over work. Adopting this attitude is foundational for the internal limit-setting and thought stopping that comes later.

The next step is to have patients intentionally put their thoughts to rest proactively before bed. Instruct them to write down those thoughts that tend to come up in the night, with the intention of “putting them to bed.” The goal is to ensure time to process worry during the day, so it’s been taken care of and does not need to emerge during sleep hours. The writing can take any format, from a full sentence narrative or problem-solution chart, to simple thought bubbles or even a drawing. Over time, people get more skillful in this, as they observe what thoughts tend to come up in the night, and learn how to more effectively address them. This journaling is best done an hour or two before bed, so they can then have an enjoyable wind-down for the remaining time. The common strategy of having a pen and paper by the bed to write down thoughts as they come up is totally contrary to this technique, and can even train people to further attend to their thoughts at night.

When considering children, it is important to remember that kids can also have insomnia due to thinking things through at night. One young patient comes to mind who came in at the beginning of second grade, having had insomnia since kindergarten. She said she would get into bed and “think about her friends and what happened on the playground.” Even young kids who are not yet comfortable with writing can do a version of journaling to set their thoughts aside. In my practice, some children have done a drawing or a clay model of their thoughts, which was then crumpled up to discharge the thoughts. This girl would whisper her worries into a “worry jar,” then she and her mom would ceremoniously dump the thoughts into the toilet and flush them away.

Older children have a circadian delay starting as early as 10 to 11 years old. Yet, they need to get up early for school. To get sufficient hours in bed, many teens go to bed before they are sleepy. This is a perfect set-up for developing the poor habit of thinking things through or worrying about why they can’t sleep. In the sleep community, we discuss the idea that early bedtimes before one is actually sleepy could actually promote the development of insomnia in youth.

The third step is to teach patients how to do some gentle thought-stopping if their thoughts get going in the night. Help them create an individualized phrase that really helps put their thoughts aside, something along the lines of “I already thought about that, and will have time tomorrow, so now’s time to rest.” People may want to simply thrust their thoughts away with a statement along the lines of “that’s not important.” I caution against this, as there is usually a valid reason those thoughts are coming up. This strategy is really about limit setting that sleep hours are not thinking time.

The final step now that their thoughts have been “kicked out of bed”, is teach your patients to do a sleep-promoting activity instead of thinking. Have them do this strategy any time they realize that they are awake in bed, either at the beginning or in the middle of the night. This is also a skill that takes time to develop, and different strategies will work better for different people. Help them choose the one that appeals the most and use it regularly for a week. Then if needed, they can try another strategy until they have an effective one.

Here are some strategies that I often use with my patients:

• Tell yourself a gentle story, maybe a favorite book or movie from childhood. Review the same story in your mind night after night. This is the strategy I personally use, and years ago made up a sweet story about a family going apple picking. Originally, the family would actually get to the orchard, but over time that story became more strongly associated with falling asleep. Now, I realize I’m awake, start thinking about the story, and barely get to the family packing lunch before I’m asleep.
• Do progressive muscle relaxation starting with the toes and working slowly towards the head. Tense an isolated muscle group for a count of seven, then relax heavy in the bed. Go slowly with the goal of being asleep before getting to your head.
• Visualize yourself falling asleep. Bring in as many senses as possible. You may use a time you recall falling asleep or create a visualization like falling asleep in the sun or in a hammock.
• Do a gratitude practice or prayer. Focus on the good things in your life, the things that make you happy and content. Avoid any problem solving or planning.
• If you wake from a dream, purposefully go back into the dream and let it carry you back into sleep.

These are skills, and like all skills people get better over time. When starting insomnia treatment, we incorporate these behavioral techniques into the overall integrative approach. It may take practice to learn what thoughts need to be discharged with the journaling, to learn this internal limit setting, and find the right sleep promoting strategy. Then, when their insomnia is resolved, at the last appointment we discuss whether these habits need to remain part of their daily lifestyle going forward, or if they want to simply have these strategies in their self-care tool kit to pull out and use when there are thought-provoking events. During these turbulent times, these strategies to calm the mind for sleep are more necessary than ever and can help empower our patients.