Treating clients who can’t sleep? Here’s what Dr Colleen Carney, a leading expert in psychological treatments for insomnia wants you to know.

One of the biggest battles therapists face when treating insomnia is knowing whether someone is actually suffering from it, says Dr Colleen Carney, director of the sleep and depression lab at Toronto Metropolitan University. “Insomnia is a very specific thing. One of the trickiest things is where we have a client and they say, ‘I only sleep four hours a night’. But then they might have always been a short sleeper, and when you ask them how they feel during the day they tell you, ‘I actually feel fine, I just notice that I sleep less than everyone else’. Trying to fix these problems with CBT-I (cognitive behavioural therapy for insomnia – the gold standard for insomnia disorder) isn’t appropriate. Or if a client has what you would consider terrible habits, and they go to bed really, really, late and wake up really, really, late, that’s not insomnia disorder. I think there’s a tendency for trainees (and beyond) to see anything with sleep they think is out of the ordinary and say, ‘let’s get into CBT’. It’s an excellent treatment, but it’s for a specific disorder, insomnia disorder – that’s the key thing.”

Tired but wired

So, what exactly is insomnia disorder? “It means that you have difficulty falling asleep, staying asleep, or both for at least half the nights of the week,” says Dr Carney, who is the co-author of Overcoming Insomnia, part of the Treatments That Work^TM series available through Psychology Tools. “It’s causing some sort of daytime problem, and this has been going on for over a month. It’s a chronic issue.”

And while it may sound strange, someone with chronic insomnia may look very alert. Dr Carney explains that when someone is newly sleep-deprived, they will be “falling asleep at their desk, but within a few weeks, several systems upregulate so that they become hyper-aroused. That gets rid of the sleepiness, which eliminates that danger of falling asleep in the day. This is why people with insomnia disorder usually perform well on cognitive tasks even though they feel like they can’t. They are ‘tired but wired’. If you have a client with sleep apnea in the waiting room, when you go to get them, you have to wake them up, and they’ll tell you they can ‘sleep anytime, anywhere’. A person with insomnia disorder will tell you ‘I’m so tired I feel like I could fall asleep right now’ [and yet] they can’t.”

Derailing our drive to sleep

One way an acute sleep problem can turn into a long-term one is due to the coping mechanisms we use for the initial sleep loss. We might cut back on activities, rest more or try to nap because we feel really tired. And while they may seem like sensible things to do, they can derail the body’s sleep-drive system. Dr Carney says: ”When the system that makes up for lost sleep – that sleep-drive system – is fed a lot of rest, it goes ‘oh, you don’t need to compensate’ and so what you’re given is light sleep and low sleep drive. It adjusts its set-point down.”

Another way it can become a chronic problem is that we stop associating our bed with sleep. “When you’re struggling and spending all this time awake in bed, it strengthens the pairing of the bed with wakefulness, which is conditioned arousal,” says Dr Carney. “If you’re someone who is in menopause, the bed becomes the place you have hot flashes. If you have PTSD (post-traumatic stress disorder) it might be the place where you have nightmares or panic attacks. Your bed becomes a place where you don’t sleep well, no matter what you do, even if you take a medication. Some people feel completely ready for bed but as soon as they get into it, they’re wide awake. It’s very frustrating.

“And when you’re chasing sleep, the time you get in and out of bed starts to become highly varied, and it creates a jetlag without traveling. When you have jet lag, it's difficult to fall asleep or wake up when you want to; you feel tired, moody, and cognitively ‘off’. That’s what happens in insomnia without people knowing.”

Then worries often start creeping in. “Am I going to become ill? Have I lost control?” This adds further fuel to the fire of insomnia.

Restricting time in bed

To treat insomnia disorder, then, the client has to break the association between bed and wakefulness, and make sure they have enough activity and time out of bed to build a drive for deep sleep.

With the help of a sleep diary, clients can work out how long they are spending in bed – and how much of that is spent asleep. They then commit to spending that amount of time in bed – and no more – for the next two weeks. It’s a technique that’s commonly referred to as sleep restriction, but Dr Carney prefers the term ‘time-in-bed restriction’ as it’s not actually reducing the amount of time the client is sleeping. If clients don’t feel sleepy at the scheduled bedtime, they stay up later until sleepiness appears. If they get into bed and no longer feel sleepy, they should get out of bed. This is called stimulus control and it addresses the problem of the bed becoming paired with wakefulness. With both techniques combined, “The body clock is regulated, the sleep drive will build, so it will become, ‘oh bed equals sleep’,” they said.

And for some, these behavioral techniques will solve the insomnia on their own. “Many people, when you teach them about their sleep system and how to hack it, respond in the first two weeks, between the first and second session,” they said.

But sometimes cognitive therapy (the ‘C’ in CBT-I) needs to be added, for example if the client is scared that the techniques will make them even more tired, or if they think they “need to do something in order to sleep as opposed to understanding that your sleep system isn’t letting it do its own thing.”

Dr Carney explains: “If a client’s fear or belief is really strong… [as their therapist] you’re not going to try and steam-roll the person and say ‘well, just do it’. Of course not. You’re going to sit with that belief, explore what’s behind it, and devise an experiment. [You might say,] ‘we’ll do one week testing my idea that if you had a high sleep drive, it would get rid of the noisy mind. Is this something you’re willing to do for a week and collect the data?’ When people do that and they’re allowed to test it, when you give them the space, it works.”

‘Insomnia plus’

Dr Carney specialises in insomnia with co-occurring conditions – ‘insomnia plus’. It was originally an interest in depression during their undergraduate years at the University of Toronto that sparked a passion for treating sleep issues. “I was reading research about depriving people with depression of REM sleep and it was as powerful as an antidepressant,” says Dr Carney. “I became very interested in trying to understand why sleep is so important for depression.”

So, what are the relationships between co-occurring conditions such as depression and insomnia? “Insomnia disorder is reliably predictive of developing mental disorders,” says Dr Carney. “And it’s not like you can’t have a mental disorder that can cause insomnia disorder – but more often than not it’s insomnia disorder first. I remember one of the first epidemiological studies I ever read was in 1989, by Ford and Kamerow. It showed that at Point A, if you had insomnia disorder only, within the year a quarter of those people would develop major depressive disorder, about 20% would develop anxiety disorders, and 10% went on to develop some sort of substance use disorder. So, there’s something about it that predisposes you to mental disorders. And treating insomnia has a positive impact on treating these other disorders as well, whereas treating the other disorders often doesn’t get rid of insomnia disorder.”

Treatment priorities

With that in mind, should therapists treat insomnia before any comorbid conditions? This is a complicated issue without a lot of research guidance. “People are worried about depression, so they go right for the depression,” says Dr Carney. “Insomnia is an independent predictor of suicide, independent of depression, so insomnia is important clinically. There are clinical trials, including mine, using this [CBT-I] protocol that have produced antidepressant effects on the same order as antidepressant medication. And these are people who were not treated for depression – we treated their insomnia. That said, we do not have the studies to suggest who would benefit the most from which approach.”

One consideration is finding out how the client wants to proceed. “Many people will say, ‘I don’t want my depression treated. I’m constantly being thrown an antidepressant, I just want this insomnia to go away’ – in which case I would have no qualms about treating the insomnia disorder and then revisiting the depression.”

And often, not treating the insomnia can also mean that the depression treatment doesn’t work.

“So, I think targeting the depression automatically is not always the best move,” says Dr Carney. “ I think it really would depend on the case and the person’s preferences.”

Another co-occurring condition, psychosis, is currently garnering a lot of interest from researchers. For example, a team at the University of Oxford is looking into whether sleep treatment can actually prevent its onset.

“I think this is exciting work, but we do need to understand for whom this works,” says Dr Carney. “It’s exciting that this can be helpful in people with psychotic disorders.”

As for Dr Carney, one of their current focuses is the treatment of adolescents, two thirds of whom report some kind of sleep problem. They have launched a free app, Doze: Goodnight Mind for Teens, which treats the specific issues teenagers face.

“Teen problems tend to be transdiagnostic, so they can have insomnia and hypersomnia, they can have a circadian rhythm disorder, and they can have subclinical [insomnia, where they’re not meeting the criteria for a disorder, but they are getting insufficient sleep. And so this uses a transdiagnostic treatment."

If you're interested in learning more about CBT-I for the treatment of insomnia, Treatments That Work^TM manuals by Dr Carney are available from Psychology Tools.