3: Targeting the Systems
Now that we know how these three main systems work to regulate sleep, let’s talk about what we need to do in order to target them effectively. In other words: how can we, using behaviors, put pressure on these three systems in order to get the desired sleep outcomes?
You have to re-train your sleep
If you’ll remember from our behavioral lens, insomnia can be understood as your body getting stuck in a pattern of poor sleep, which self-perpetuates indefinitely instead of getting better. Thus, a period of focused ‘sleep training’ is needed in order to learn to sleep better. During this training period, your goal is not only to undo this pattern of poor sleep but to actually get stuck in a pattern of good sleep which then self-perpetuates. The training period necessitates consistency and discipline in the short term, for the purpose of re-calibrating your sleep system so that good sleep becomes the default setting for the long term. Parents who have had to go through sleep training with their infants often point out the similarities they see as they learn about adult sleep training, like paying attention to sleep cues, schedules, and bedroom environments [and can always attest to the results being overwhelmingly worth the effort]. Let’s revisit each of the three sleep systems and focus on what strategies we can take to put the right pressure on each of them.
How to target the systems
Our goal is to have a consistently high sleep drive each night.
- Initially adopt a (much) later bedtime. In order to ensure high-enough sleep drive, you will need to wait until the time your body consistently tells you you’re sleepy, not just tired. Many people cope with poor sleep by starting to go to bed earlier in order to try to get more sleep. For reasons already discussed, this only perpetuates the sleep problems and needs to be stopped. For some, this may mean going to bed at 10:30 instead of at 9:30 – for others it might mean going to bed at 1 am instead of 11 pm.
- Don’t take naps. Our sleep drive builds steadily throughout the day while we’re awake and gets depleted while we’re sleeping. Taking a nap “burns off” some of the sleep drive that you built during the day, leaving you with not enough sleep drive at the end of the night when you get into bed. Avoid napping as best as you can and save that sleep drive for the evening. Caveat: if for safety’s sake you need a nap, like getting drowsy behind the wheel, absolutely take a nap.1
Our goal for the biological clock is to reinforce a consistent rhythm of alertness and sleepiness.
- Wake up at the same time, seven days a week. Research has shown that the most important behavioral factor for properly aligning your biological clock is keeping a consistent wake up time. Break that habit of sleeping in on the weekends or after a rough night, so that you train your biological clock to work predictably and to interrupt the pattern that keeps the sleep problems going.
Our goal is to use the principles of behavioral conditioning to cause the bed to trigger sleepiness as an automatic conditioned response.
- Use the bed for sleep only.2 Seriously, you need to stop anything else you’re doing in bed, like reading, watching TV, using your smartphone, working on a laptop/tablet, browsing social media, etc. These are common ways people cope with not being able to sleep, but they only further reinforce the bed being a place where you’re awake and not asleep.
- Don’t be in bed unless you’re sleepy or asleep. This is similar to the previous point but actually takes it one step further. In addition to working on un-pairing the bed=awake connection, you need to work on strengthening the bed=asleep/sleepy connection. Therefore, you should not be in bed unless you are sleepy or asleep. This means that if your bedtime rolls around but you are not sleepy, you hold off on going to bed until you feel sleepy. This also means that if you are ever in bed but wide awake or unable to fall asleep within about 20 minutes, whether you just got into bed or woke up in the middle of the night, you have to get out of bed.
Where the magic is
In my experience as a treatment provider, I have found this approach – first learning about the three sleep systems and then exclusively targeting those systems – to be the very best way to treat insomnia. It helps us focus all of our resources on what we know to be the most effective techniques and gives behavior changes a very concrete physiological basis. I have also found that there is a unique effectiveness to targeting all three systems at the same time. There seems to be a synergistic effect that can’t be replicated by just targeting one system at a time. That’s why when a client tells me that he/she has already tried getting into bed later or cutting out naps or waking up at the same time every day, but with no results, I emphasize this point and challenge them to target all three systems for a few weeks – which almost always results in significant improvements and a pleasantly surprised client.
Another important point to note is that the guidelines discussed above work complementarily. There is overlap as you target the multiple systems. For example, by not getting into bed until you feel sleepy, you’re not only promoting proper behavioral conditioning, you’re also ensuring a high sleep drive. Waking up at the same time every day, even after a poor night of sleep, not only properly cues your biological clock, but also encourages a higher sleep drive the next night.
What is your sleep goal, anyway?
Finally, none of this really matters unless you think about them as tools to help you get to where you want to be with your sleep. In other words, these are less like restrictions you must abide by and more like techniques that achieve a certain outcome – predictable, consolidated, and restorative sleep. Also, following these guidelines is part of a training period intended to help you to get “stuck” in a pattern of good sleep, but this is a temporary, time-limited training period. Once you beat the insomnia, you don’t have to be so disciplined about following the guidelines strictly.
Before I walk my insomnia clients through the concrete next steps for behavior changes, I usually like to ask them to verbalize what their sleep goals are. This is really important to me because I don’t see myself as some kind of rule-giver that doles out and enforces strict bedtime rules, I see myself as a coach that helps people reach their sleep goals by providing the right tools and support. In fact, if your current sleep patterns are working fine for you – say you get poor sleep during weekdays and make up on weekends by sleeping in – then I personally have no problems with you staying this way. If daily naps are how you’ve always coped with poor night-time sleep and you’re okay with keeping this pattern going, then by all means continue. There is nothing inherently wrong with naps, just like there is nothing inherently wrong with sleeping in. However, if your goal is to get consolidated sleep and fall into a consistent sleep pattern, you’ll probably benefit from following the methods that research has shown to be the best way to get there.
If you’re ready, learn how to create a new sleep schedule that targets these systems.
- Guideline for napping: If you must nap, either for safety reasons (like feeling sleepy while driving or operating machinery) or to make it through a difficult day, favor naps that are shorter and earlier. Those are much less likely to affect your nighttime sleep. Rule of thumb: 20 minutes or less, and 2pm or earlier.
- Yes, since you asked, intimacy is an exception we generally allow for. But nothing else! Bed is for sleep and intimacy only.