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Sleep Is Intertwined With Physical—and Mental—Health
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Sleep Is Intertwined With Physical—and Mental—Health


By Lori (Dolores) Puterbaugh, PhD, LMHC, LMFT, NCC, Largo, Fla.



Truth or dare: Do you do any of these activities in the hour before going to bed?

  • Watch television.
  • Use your computer or smart phone.
  • Have serious conversations with your partner or family members.
  • Exercise.
  • Use alcohol or cigarettes.
  • Do job-related work.
  • Watch television in bed.

Once you go to bed, if you haven’t fallen asleep within 15 minutes, do you give up on falling asleep and then resort to television or the computer until you get sleepy?

If you answered “yes” to any of these questions, you are normal, but that’s not necessarily good in this case. The truth is that Americans are experiencing an epidemic of poor sleep habits, poor sleep, and not enough sleep. The results of all this sleep deprivation may be the reason underlying some of the problems that send people to your practice. The dare is that with the right intervention, your sleep-deprived clients—and you—can learn how to get a good night’s sleep.

Since sleep is intertwined with mental and physical health, mental health counselors need to take notice. Which came first, a client’s depression or the lack of sleep? The client’s anxiety, or the lack of sleep? It can be next to impossible to parse the relationship between poor or insufficient sleep, and a client’s complaints about depression, lack of energy, anxiety, and other difficulties.

For many of our clients, sleep is a problem, a problem that contributes to the challenges in their lives. Listen to adults talk about sleep, and, you’ll see they sound like teenagers exaggerating their love lives. Most people are convinced everyone else is getting more, or better, sleep … and they resent it. At the other extreme are those who sacrifice their well-being by forgoing sleep and then bragging about needing less. 

Talk to Your Clients About Their Sleep Habits

Sleep deprivation is literally tortuous. Even mild chronic sleep deprivation changes brain chemistry and physiology, leading to deterioration of cognition, memory, and—no surprise—mood, according to the National Institute of Neurological Disorders and Stroke. 

We mental health counselors need to address sleep habits with our clients, provide information on normal sleep patterns, and guidance on how to achieve a regular, good night’s sleep. 
Adults generally need seven to nine hours of sleep per night, though some research points to middle-aged women needing about six hours. Many people do not reach this ideal. In order to be helpful, counselors have to elicit the truth from clients about their regular sleep habits, and then the facts about their behaviors surrounding bedtime. 

Bear in mind that people often lie or exaggerate about sleep habits, just like they do about exercise, church attendance, and how depressed or anxious they really are. I find clients skip the sleep section of my intake paperwork because they don’t think it’s important, or they think that it doesn’t have anything to do with “why I’m here [in counseling].” What they don’t know is hurting them. (For 10 sleep-related questions to ask new clients during the intake, see page 317 of my Oct. 2011 Journal of Mental Health Counseling article, “Searching for a Good Night’s Sleep.”)

A 2010 National Sleep Foundation (NSF) study found that a majority of Americans have poor sleep hygiene. They are doing, in effect, exactly what you would do if you wanted to have a bad night’s sleep. Many of our clients fall into this category, and they are reluctant to give up doing what they believe helps them relax and unwind. These unproductive behaviors have become what are called “sleep safety” behaviors, meaning the client is so convinced that these actions help bring about sleep that going without them provokes anxiety and is disruptive (at first). 

These nearly ubiquitous counterproductive habits include watching television or using computers just before bedtime, and even in bed. Waiting until late in the day to have serious discussions (or even arguments) with partners and spouses. Rushing around doing chores or exercising, and then trying to do effect a rapid wind-down with a drink or two just before bedtime. For these people, their bed is a desk/sofa/conference table and not a sanctuary for sleep and affection. 

They find the notion of a routine, however brief, that signals the end of the work/chore day and the beginning of preparation for sleep to be old-fashioned and quaint. They are sure they need that television on a timer to unwind and fall asleep. (The NSF study reported that 76 percent to 89 percent of American adults watch television in the last hour before sleep, with African Americans citing the highest rate of use and Asian Americans the lowest.) They use the drone of the television to drown the buzz of their anxious forebrains, unaware that the blue lightwaves of the television stimulate their hindbrain with the brightness of the noonday sun. 

Give Your Clients Information to Help Them Improve Their Sleep Hygiene

Our job is to educate, coach behavior and cognitive-behavioral strategies, and encourage the client to work towards behaviors that actually encourage quality sleep. In fact, cognitive-behavioral therapy as a solo treatment was found most effective in the treatment of insomnia, even in direct comparison with medication, placebo, and combination (medication plus CBT) treatments across most areas of assessment, according to research reported in the Sept. 27, 2004, issue of Archives of Internal Medicine.

We mental health counselors must convince clients to turn off the television or computer a full hour before bedtime, so the brain stimulation caused by that quality of light does not interfere with proper melatonin (and thus serotonin) production. We have to be willing to bear more bad news: a client’s nightly nightcap or two actually will interfere with sleep quality after the initial depressing effect passes. Likewise, exercise, a benefit for sleep when done earlier in the day, may be overstimulating just before bedtime.

Clients who have trouble falling asleep become anxious and upset, triggering the sympathetic nervous system and making sleep ever more elusive. Frustrated, the client gets out of bed, turns on the television, takes a sedating medication or drink, and takes a step or two into a pattern that reinforces the belief that sleep doesn’t come easily, is a “problem,” and that perhaps the client needs a prescription sleep aid. They are also unaware that normal adults often wake briefly during the night, and that these times of resting in bed, semi-awake, often increase with age as the time spent in very deep sleep naturally shortens. 

Advertisements for sleep medications make it seem as if middle-aged adults are dozing peacefully as soon as their heads hit the pillow. Sleep latency, the time between hitting the pillow and entering sleep, may be 15 minutes in young adulthood and 30 minutes or longer by the 50s. If clients spend this time relaxing, breathing easily, and perhaps using some visualization and relaxation techniques, and they know this is normal, this time can help smooth the way for a good night’s sleep.

Be aware, however, that sleep problems are not limited to adults. I have visited 2nd grade classrooms where the teacher—a religious sister—and I were the only two people in the room without a television in the bedroom! It’s clear we are passing on our poor sleep habits to our kids. Instead of being in quiet, 40-watt soft light, reading and relaxing before going to bed, children as young as 7 and 8 are now routinely watching televisions, surfing the ’Net, and using handheld electronic devices, all with that same quality of light that disrupts the brain’s sense of time of day. 

Good Night!

Mental health counselors are ideally trained to help clients, and the general public, understand what real sleep patterns look like across the lifespan, how to achieve a better night’s sleep, and how behaviors that Americans think of as normal bedtime routines are actually interfering with good quality sleep. 

Use the list of 10 tips in sidebar < > to help yourself and your clients get a good night’s sleep. In my own practice, I print these tips on a postcard-size sheet and give them to clients so they will have the tips handy.

Since poor sleep contributes to anxiety, depression, memory prob-lems, academic problems, and and increases risk of accidents, helping clients learn to sleep better can be an important part of mental health counseling.

Author’s note: Lori (Dolores) Puterbaugh, PhD, 

Editor’s note: A variation of this article appeared in the Oct. 2011 Journal of Mental Health Counseling.

LMHC, LMFT, NCC, is in private practice in Largo, Florida and an adjunct instructor for the Psychology & Mental Health Counseling Program of Troy University, and for St. Petersburg College. She is a member of AMHCA, the Florida Mental Health Counselors Association (FMHCA), SMHCA—the District III Affiliate for FMHCA, ACA, and AAMFT. Puterbaugh will give a presentation at AMHCA’s Annual Conference in Orlando in July on “Searching for a Good Night’s Sleep: Research-Based Treatments for Insomnia.”