Sleep Strategies for your Toolbox!

 This is a handout from a recent presentation I did for the APNA New England Chapter Conference on Sleep Strategies for your Toolbox! Reducing Arousal & Improving Sleep by Applying CBT and Mindfulness Strategies.  I hope you find them useful.  

Meditation for Nurse’s Week May 2023

Happy Nurse's Week!

I updated my mindfulness video for Nurses - I hope this offers you a quick break... 

those who provide caregiving to others may also like this...

Combating stress & the mental health problems that arise from it…  including anxiety, depression, insomnia

Stress is often a trigger to or perpetuates many mental health difficulties, including feelings of anxiety, low or depressed mood, and sleep problems.  Common symptoms that relate to daily acute or chronic stress include worrying (about relationships, work, responsibilities, sleep, stressors), negative thought patterns and rumination, as well as hyperarousal.  Anxiety disorders and insomnia can be seen as states of hyperarousal. 

Mindfulness (MF) is an intervention that can be effective in reducing states of hyperarousal, negative thought patterns and worrying.  Some aspects that help these problems include the principles of MF…

·       Present focused awareness (vs. automaticity or responding automatically);

·       Control of our attention; and

·       Non-judgmental, self-compassionate acceptance. 

Practicing MF using meditative exercises (ex: body scan, breath focused, sitting or walking meditations) or Yoga can help us to cope with the arousal and other patterns associated with our individual stress responses.

I will refer you to a source that I think could be helpful as you work to develop new ways to manage stress.  I suggest you visit this website: Cognitive Behavioural Therapy (CBT) Skills Workbook (Hertfordshire Partnership NHS Foundation Trust) – Breathe Education (breathe-edu.co.uk) They offer a CBT skills workbook that I will refer to in this post – you can either view the workbook on that site or download a copy for your own files.  The workbook offers 'Tools' that I will mention, which consist of some of the standard CBT strategies that can help to reduce symptoms of anxiety and depression as well as improve insomnia.  Where the tools from the workbook are mentioned, you should go to the workbook and work thru the section and activities associated to learn more about them. There are other free workbooks that offer similar activities and tools, although I suggest you use care to choose a site from a reliable and verifiable source (you should not have pay for tools like this, they are widely available on sites from reliable mental health and academic organizations).  Here are some steps to take to work on reducing the stress and anxiety you experience:

·       My Stress Symptoms: As you recall feeling stress and anxiety, try to identify your experience or the symptoms you feel that tell you this is happening (See Tool 1: Anxiety in the CBT Skills workbook on page 8 - 10).  This also offers important information about the ‘Fight or Flight’ response and the symptoms of this reaction to threats we commonly face in life. 

·       ‘Target’ Symptoms: Note the stress related symptoms you experience –write them as a list or check them off on the pages of your workbook - think of these as some of your ‘target symptoms’  which help us to both recognize when we are in an anxious state, and to remind us to use some of our coping skills to work on reducing the anxiety we are feeling.

·       Triggers to Anxiety: When you are feeling stressed or experiencing distress, consider the things that occurred prior to the symptoms arising (or at a later time reflect on the situation)…  begin to identify your own personal list of ‘triggers’ to your target symptoms of anxiety.  They may be things like, an interaction with someone that was difficult, an upcoming event, not feeling well physically in some way, not having slept well last night, hearing about a news story, learning of problems someone close to you is experiencing… there are many different things that each of us responds to with worry or anxious feelings – As you identify ‘triggers’ you can begin to use tips and problem-solving techniques to manage and reduce triggers or at the least plan some self care activities when you know you will be facing a difficult experience.

·       Worry Management: For some tips on managing worry see Tool 7 in CBT Skills workbook – you might start a worry diary and schedule some time daily to reflect on the worry identified (or worries that you identify).

·       Activity Scheduling: Using an activity schedule can be an important tool to help improve mood, reduce anxiety, and build our ‘need for sleep’ or sleep drive by having physical activity daily which helps us sleep better at night.  See Tool 5 Increasing Activity Levels for Low Mood, which uses principles of Behavioral Activation (see post from March 14^th: The Importance of Daily Structure and Activity).

·       Problem solving is an important tool in coping – Problem focused coping helps us to face stress directly and make a step to resolve the cause.  See Tool 8 in the workbook on problem solving.

o   Do something to change the source of the stress

o   Identify and manage the trigger to stress and anxiety

o   Distancing yourself from the source of stress (while this may sound like avoidance (which could actually worsen anxiety), there are times we can decide that a particular situation or activity is not required and an alternative is available).  For example if you stop at a particularly busy coffee shop daily where lines are long and the clerks are often rude, you could find a different place to get your coffee. 

·       Emotion focused coping helps us regulate our feelings and emotions in reaction to a problem or to work thru difficult emotions that may be painful.  Examples include: (Or visit this website which I used as a resource for more information: https://www.healthline.com/health/emotion-focused-coping#therapy)

o   Talk to others! – it can help to talk about the feelings you had in a situation with someone it might help you discover a solution or different way to think about it or the act of talking it out helps to release some emotion and get emotional or social support.  Consider seeing a therapist when you have difficult feelings that you need to work through...

o   Try to see things differently... – using the technique of 'reframing' helps us look at things from a different perspective.  This may help you to see the context of a situation differently as well as details we might get stuck on.  Positive thinking or trying to see the optimistic view challenges negativity, recognize your ability and success vs focus only on the negative or feelings of failure, and being willing to try again.  See the workbook section on managing Negative Automatic Thoughts (NAT’s) – Tool 9 – or Cognitive Restructuring.

o   Compassion and Forgiveness – we often cannot change or do anything about pain or losses we have experienced.  We often have difficulty offering ourselves the same compassion we would offer others.  We can work to forgive and move forward although it may take time and require coming to terms with our pain before we can forgive.  Practicing forgiveness (and self-compassion) benefits our emotional wellness, increases our compassion and empathy, reduces stress and anger and can improve our interpersonal relationships.  

o  Write about it! – writing down your thoughts helps you to begin to work thru them, by un-jumbling the feelings we have and helping us process our experiences.  Some like to keep a journal - while others prefer to write down the thoughts without a serious form or format... there aren't any rules on this, except that it can help you to sort through your thoughts and feelings by putting them in written form!

o   Meditation – allows you to acknowledge and be with your thoughts, feelings and experiences, to accept them rather than stewing over them or judging yourself for having them.  The principles of Mindfulness (Present Focused Awareness, Attentional Control, Acceptance) are helpful to our applying many of these emotional coping strategies...  There are many great sites to learn more about Mindfulness - I suggest: UCLA Mindfulness Center; There are also apps available (both free and some have a fee).

·       Social support – may take many forms and be based within various kinds of relationships.  Consider the importance of having some regular social interaction -it offers us different perspectives and points of view, gives us enjoyable experiences, and helps us release some of the pent up feelings and sort thru our thoughts about the situations we face regularly.

·       Religious or spiritual coping – Using prayer and spiritual practices provides many benefits to those who participate – some enjoy the ritual associated with services they attend or saying certain prayers or engaging in certain activities or meetings – others benefit from the social supports, engagement and sense of belonging.

·       Good Self Care – work to assure that every day you attend to your own health and wellness thru activities like:  improving your diet, engaging in daily exercise, rest and relaxation breaks, planning a fun activity daily, engaging in a hobby regularly, using meditation or mindfulness exercises. 

The Importance of Daily Structure & Activity...

Having regular activity and structure in our lives is very important...

Studies show us that increasing our daily activity (using Behavior Activation therapy) can be effective in combating depression.  For example this treatment directly improves the withdrawal, avoidance and isolative behavior that are very commonly found in depression (Dobson et al, 2008; Xie et al, 2019).  Often with transitions in life one stressor is the change in our normal patterns of activity that structure our lives (like with retirement, moving, a pandemic!).  We may not reflect on it much, but a daily schedule is important to both our physical and mental health...

Part of the activity we do daily should involve getting natural light (even on a cloudy or rainy day) preferably early in the day to 'reset' our biologic clock which regulates our circadian rhythm and our sleep-wake cycle.  

Even better is when we get some physical exercise daily - now that many of us work remotely, it is too easy to end up sitting and looking at a screen all day long - don't forget to get up regularly and move around - take a short (or long) break to walk outside or engage in your favorite physical activity - your sleep will likely improve as a result...  Exercise and activity help to build our 'need to sleep' or homeostatic sleep drive...  think of it as filling the tank for your need to sleep tonite!

Here is  a handout that may help you in establishing a schedule of daily activity.

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Scheduling Daily Activity

Activity is important for both physical and mental health, and quality of life

How do you develop a Schedule of Activity?

•       Set your daily schedule with set times to start and end your day

•       Include some regularity in your routine

•       Cultivate daily activities you enjoy

•       Include daily Self Care Activities

•       Rate your mood before and after an activity to learn more about how your mood is impacted

Develop a ‘Menu’ of Activities you enjoy –use them both in your weekly schedule as well as to add ‘extra’ activities to your day, particularly when you are struggling with overwhelming thoughts, ideas or emotions and need a distraction

Do what you love…

•       Anxiety, depression, and other mental health struggles have a way of stripping away the activities that matter to you in life, either because you become fearful of them or lack the motivation you once had to pursue them. Maybe you loved to read but now feel tired all the time. Or maybe you used to like going out with your friends but now fear being away from home at night.

•       As hard as it may be, try to do things that matter to you, even if you have to force yourself. Doing activities that make you happy, that connect you with others and that give you a sense of mastery or competence are important for mental well-being.

•       Make a point of taking time to do one or two things on a regular basis that always used to bring you joy and do your very best to be present instead of distracted about the past or worried about the future. Afterwards, ask yourself how you feel now after that activity - Did it make you feel better?

How Avoidance Intensifies Your Anxiety?

Escaping situations that are anxiety-provoking may offer immediate relief - but the downside is the message sent reinforcing that you can’t tolerate the situation --> which increases anxiety further and leads to avoiding more situations in the future. People end up limiting themselves to avoid more and more situations.   Gradually work to stop avoiding and start facing situations. In other words, act against urges to avoid things that trigger your anxiety.

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Daily Activity Schedule

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Mid-Day
Afternoon
Early Evening
Night

Don’t Forget to Include:  Self Care, Social activities, Activities you enjoy, Responsibilities. 

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References:

Dobson, K. S., Hollon, S. D., Dimidjian, S., Schmaling, K. B., Kohlenberg, R. J., Gallop, R. J., Rizvi, S. L., Gollan, J. K., Dunner, D. L., & Jacobson, N. S. (2008). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology, 76(3), 468–477. https://doi.org/10.1037/0022-006X.76.3.468

Xie, J., He, G., Ding, S., Pan, C., Zhang, X., Zhou, J., & Iennaco, J. D. (2019). A randomized study on the effect of modified behavioral activation treatment for depressive symptoms in rural left-behind elderly. Psychotherapy Research, 29(3), 372-382.  https://doi.org/10.1080/10503307.2017.1364444 

Mindful awareness of the hands

Responding to Stress Handling Emotions

This exercise is based on work from Diana Winston's exercises at the UCLA MARC center - I encourage you to check out their center! Here's a link: UCLA MARC center

Hearing & Thinking Meditation

Cultivating Awareness

Capturing the Moment

Here is information about the book, Wherever You Go There You Are (1994) by Jon Kabat-Zinn that is mentioned in this podcast.  The inspiration for this mindfulness session came from pages 11 -17 of this text.  If you find this post meaningful, I encourage you to purchase your own copy!

A mindful moment