The Principles and Process for Reconditioning Good Sleep

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Author: Ron Cridland M.D.


It is interesting that the process of conditioning works very effectively whether you understand it or not.  You just have to do it for it to work.  However, a lot of people won’t do something unless they understand why they are doing it.  Therefore, in previous articles I have provided background information on a variety of behaviors and strategies such as relaxation techniques.  In particular, the article on Sleep Hygiene reviews in detail the rationale behind each behavioral component.  Some of these behaviors are more critical than others.  This article will more thoroughly integrate and organize the essential components into a more cohesive program to help you regain good sleep.  For some people, this will be enough information to regain good sleep.  Others will benefit from registering for the Interactive Online Insomnia Program to get a more individualized program and coaching.

If you take any kind of medication to help your sleep, make sure you read the article,  How to Use Sleep Medication While Training to Become a Better Sleeper  and Getting Off Your Sleep Medication before you start the program.

The process to recondition good sleep generally takes two to three months to work your way through.  Most people notice significant improvement in the first month.  The first two weeks are the most difficult because of the “hoops you must jump through” to change your conditioning.  However, if you can invest in this process, it usually pays off.  There are three components.

Conditioning

The first component is focused on “conditioning”.  You want to learn to associate the bed with good sleep.  In order to achieve this, you no longer want do anything else in bed but sleep or sexual activity.  You do not want to think, worry, plan, problem solve or even lie awake in bed for long periods of time because you will just reinforce the bed as a place to do those things.  You go to bed to sleep.  Obviously, that is easier said than done and there are a number of things you can do to help make this happen.


It does not matter what you used to do in bed to help you sleep such as read or watch TV.  Those are wakeful activities and you want to associate the bed with sleep not with wakeful activity.  Keep in mind that if those activities really worked well for you, you probably would not be reading this right now.  Obviously, you need to do something different than what you are already doing to become a better sleeper.

One of the most powerful, natural ways to immediately improve your ability to sleep is sleep restriction.  Let us say for example you typically go to bed at 10 pm, take an hour to fall asleep, wake up 4 times and take 15 minutes to return to sleep each time (total of one hour awake during the night), wake up finally at 6 am but do not get up until 7 am.  You would have spent 9 hours in bed but only have slept 6 hours.  That means there are 3 hours per night that you may be in bed awake, reinforcing the bed as a place to be awake.  This would make your conditioned insomnia worse.  Right away we can decrease the likelihood of you being in bed awake by reducing your time in bed to the number of hours we think you can sleep.  In this example you have the ability to sleep about 6 hours.  Therefore, there is not much point in you being in bed much longer than 6 hours otherwise you are “diluting” your sleep.  This is because the more time you spend in bed awake, the more you reinforce the bed as a place to be awake and make your insomnia worse.  Generally, I like to give you a little room to improve your sleep.  In this example I would have you restrict your time in bed to 6.5 hours which is still more than you are currently getting but you are much less likely to be in bed awake.  The way I normally do this is by having you go to bed later and get up at the time you would like to be able to wake up.  In this example, you would go to bed at 12:30 am and set your alarm for 7 am.

Going to bed later is difficult when you are tired from lack of sleep.  However, it is also very powerful.  If you can do it, it usually helps.  This is because when you go to bed later, your body is much more biologically sleepy based on your 24-hour biological sleepiness rhythm.   This extra sleepiness essentially “bulldozes” you into sleep and bulldozes you through the night, filling in the “holes” and “air-pockets” in your sleep.  What you are doing is “stacking the deck” physiological speaking, in favor of you not being able to stay awake during the night.  You do this long enough for you to experience “success” at sleeping well.  After a few weeks of sleeping well you start to feel more confident in your ability to sleep.  After a few weeks of confidence in your ability to sleep, you start to think of yourself as a good sleeper again.  Now you have changed your conditioning to that of a good sleeper.  The only problem now is that you are still sleep deprived.  However, once you are a good sleeper, you should have no problem gradually advancing your bedtime routine 30 minutes at a time until you are getting enough sleep to feel rested.

The other important component of conditioning is about what to do when you are unable to sleep.  If you cannot fall asleep either at the beginning of the night or during the night within an estimated 20 minutes (estimated because you should not look at the clock), you do not want to stay in bed not sleeping, reinforcing the bed as a place to be awake or frustrated.  You should get out of bed, go into another room, and do something relaxing until you start to feel sleepy.  Then you should go back to bed and repeat your relaxation technique to fall asleep.  No one likes getting out of bed when they are tired.  However, if you do not consistently get out of bed when you cannot sleep, you will continue to be tired because your insomnia will not get better.  If you get out of bed consistently when you cannot sleep, then you will learn to associate the bed with sleeping and more quickly resolve your insomnia.

Winding Down

The second component of this program has to do with taking enough time to wind down before bed to allow that adrenalin to wear off after pushing yourself through your day when you are tired.  You need to take at least an hour to wind down doing something you find relaxing and enjoyable.  Examples of relaxing activities include reading, listening to pleasant music or doing some kind of craft or hobby that is not frustrating.  Remember, you are not trying to “accomplish” anything.  You are not paying bills, answering emails, folding laundry or making lunches.  Preferably no TV, computer, video games or cell phones as these are bright, flashing lights that suppress your natural melatonin and stimulate the brain to some degree.  Even though some people may fall asleep watching TV, their nervous system is not as relaxed, and their sleep quality will not be as good.

Bedtime

As mentioned before, a lot of people go to bed and think, worry, plan or problem solve in bed.  I usually tell my patients that, from now on, “thinking in bed is illegal!”  This will usually get a laugh, but my point is made.  No thinking in bed anymore.  “How do I do that?” you may ask.  There are two things that are very helpful.

To begin with, set aside some worry time earlier in the evening before you wind down.  This is when you sit at a desk or a table (not the place you like to wind down) and think about all the things that need thinking about, worry about things that need worrying, plan the things that need planning, problem solve the things that need problem solving and “take care of business.”  Then you may want to write something down, make a list, put a note on a calendar or write in a journal.  Do whatever it takes so you can give yourself permission to “forget about it” for the rest of the night.  Then you take the next hour or two to wind down to allow the “adrenalin” to wear off, and to help “insulate your sleep” from what is going on in your life.

Then when you go to bed, you may still have some thoughts going through your mind.  Now you need to do a relaxation technique to help you turn your mind off.  The relaxation technique is very important for a number of reasons whether or not you have trouble falling asleep.  To begin with, relaxation helps you turn your mind off so you can fall asleep quickly and efficiently.  Second, if you go to sleep with “stuff” on your mind, “stuff” will “fuel” your dream content and disturb your sleep.  However, if you go to sleep with pleasant, relaxing thoughts, you are more likely to have pleasant, relaxing dreams and sleep deeper.  Third, if every night you do a relaxation technique you will get very good at it with practice.  Fourth, if every night you fall asleep doing a relaxation technique, you will learn to associate relaxation with falling asleep.  Then when you wake up in the night, remember your body is still tired and wants to sleep.  Typically, it is your mind that is active and keeping you awake.  If you repeat the relaxation technique and turn your mind off, it will help you fall back to sleep, especially if you have become conditioned to associate relaxation with falling asleep.

However, if you make the mistake of only doing relaxation when you have trouble falling asleep, you run the risk of learning to associate relaxation with trouble falling asleep!  Therefore, it is very important that you do relaxation every night, especially when you are falling asleep anyway, so that you learn to associate relaxation with falling asleep.  It is all about conditioning.

When you go to bed, it is very important that you set an alarm for the time you want to wake up.  This is particularly important even if you currently wake up without an alarm.

Most people think of an alarm as something to wake you up.  I think of the alarm as something to help you sleep.  This is because setting the alarm takes away the responsibility of keeping track of time so that you will know what time to get up without having to think about it during the night.

I have heard all the arguments and excuses from people who think they do not need an alarm.  The bottom line is that if you want to overcome your insomnia, an alarm is critical to your success for two reasons.  The first reason is that it will help reduce the number of awakenings during the night "to see if it is time to get up yet."   You may think you are waking up to go to the bathroom or some other reason.  However, the waking is usually a habit.  See if this sounds like you.  Just about every time you wake up and look at the clock you calculate in your mind how much time you have slept or how much time you have left to sleep.  You may think, “Oh, if I get to sleep now, I have two more hours left to sleep.  “Oh, if I get to sleep now I have one more hour left to sleep.”  “Oh, by the time I get back to sleep I am going to have to get up anyway.  I might as well get up now.”  Others will open their eyes and if it is dark, they can go back to sleep.  However, if it is starting to get light they wonder what time it is.

The problem is that every time you wake up and open your eyes you start gathering data.  Then you start processing data.  Then you start making decisions even if you are not conscious about it.  “Should I get up?”  “Should I go to the bathroom?”  “Should I go back to sleep?”  As I said earlier, “Thinking is illegal in bed.”  The whole process of gathering data, processing data, and making decisions about what to do during the night is ruining your sleep!  Training yourself to let the alarm wake you up will help you wake up less often.

The second reason for using the alarm is that it is critical to help train you to sleep longer.  Once you are programmed to wake up after a specific number of hours of sleep, if you try to get more sleep by going to sleep earlier, chances are that you will probably just wake up earlier.   If you try to sleep later into the morning you will probably continue to wake up earlier than you want.   Thus, it can be very difficult to get more sleep.  However, if you train yourself to wait for the alarm to wake up, that anchors your sleep to the alarm.  Then when you go to sleep earlier and sleep to the alarm, you can actually get more sleep. Or, if you set your alarm later you can sleep longer.

When choosing an alarm, it should be something gentle like a clock radio, wristwatch or cell phone.  Not an obnoxious electric buzzer that will startle you awake.

Using an alarm is like putting a cast on a broken leg.  It helps to create the framework for healing.  Once it is healed, you remove the cast.  Once you are a good sleeper, getting as much sleep as you need to feel rested, and you are off all your sleep medications, you can stop using the alarm if you want.

How to return to sleep during the night

When you wake up during the night, remember that your body is still tired and wants to sleep.  Typically, it is your mind that is active and keeping you awake.  If you repeat the relaxation technique and turn your mind off it will help you return to sleep.  You want to train yourself so that as soon as you become aware that you are conscious during the night, if it is not the alarm, your job is to repeat the relaxation technique and return to sleep before any other thoughts gain a foothold in your mind.  The idea is to practice this consistently until it becomes an automatic reflex.  You generally need to be awake at least 2 – 3 minutes to process the memory of being awake.  Eventually, you start returning to sleep so quickly you may not even remember being awake.

How to increase your sleep time

Before you try to increase your sleep time you need to be sleeping well for at least a week to establish the conditioning of good sleep.  To be “sleeping well”, three conditions have to be met:

  1. At the beginning of the night, you are falling asleep within 10 – 20 minutes (estimated because you are not looking at the time).
  2. If you wake up during the night you return to sleep in a few minutes using your relaxation technique. 
  3. In the morning you are waking up with the alarm, not before the alarm. 

If you are waking up before the alarm it means your mind is still keeping track of time waking you up after your usual, insufficient number of hours of sleep.  Then, if you go to bed earlier you are likely just to wake up earlier after the same insufficient number of hours of sleep.  However, if you can train your brain to “wait” for the signal of the alarm to wake up, this will anchor your sleep to the alarm.  Then when you start to go to bed earlier you will sleep to the alarm and actually get more sleep.

Although it may take a few weeks, once you can “sleep well” for at least a week to establish the conditioning of good sleep, then you can go to bed 30 minutes earlier.  Once you are actually sleeping 30 minutes longer (not just lying in bed awake 30 minutes longer) then you can go to bed another 30 minutes earlier and so on until you are getting enough sleep to feel rested.

Getting Off Your Sleep Medication

To be the most successful at weaning off your sleeping pill(s) it is best that you have first consolidated your sleep to make it as deep and consistent as possible.  Then you want to expand your sleep time until you are feeling fully rested.  If you are still tired and having to push yourself to get through the day, the resulting “adrenalin hangover” at the end of the day will make it hard to sleep without the tranquilizing effect of your sleeping pill.  However, if you are getting enough sleep to feel fully rested, then you are no longer living on adrenalin and therefore you no longer need the tranquilizing effect of your sleeping medication.  Then it is fairly easy to get off your sleeping pill.

You will reduce the sleeping pill gradually by ½ pill at a time.  Even reducing the pill by ½ may result in some withdrawal effects making it more difficult to fall and stay asleep.  If you happen to experience poor sleep during this withdrawal process you could undermine your good sleep conditioning all over again.  To prevent this from happening, you will also go to bed 2 hours later for the first 5 nights to increase your biological sleepiness.  This extra sleepiness will counteract the reduced sleepiness from medication withdrawal so that you will continue to be a good sleeper and not upset your sleep conditioning.   Because you will be feeling fully rested before you start this process, getting 2 hours less sleep will not feel as bad as when you first started the insomnia program.  You were probably much more sleep deprived in the past when your insomnia was at its worst.

After 5 nights of going to bed 2 hours later, as long as you are still sleeping fairly well, you will now start going to bed 30 minutes earlier every 1 – 2 nights until you are back where you were getting the full number of hours of sleep you need to feel rested.  After a couple of weeks to recover from this period of sleep deprivation, you repeat the process and reduce another half pill.


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