Sleeping to CHANGEpain

On this page, you will find all the resources for the virtual group medical visit Sleeping to CHANGEpain.

Session 1

This session:

Highlighted the importance of addressing sleep issues in the face of persistent pain,
Provided an overview of the approach we will take in this program,
Introduced stimulus control techniques (AKA bed = sleep),
Discussed possible reasons for keeping a sleep diary,
Reviewed resources for different forms of non-sleep deep rest
And, introduced the self-compassion break exercise.

Actions for the Week

After each session, you will need to determine the steps you want to take over the next week to work on your sleep. There will be time at the end of each session to reflect on what you have learned, to consider what amount of change is feasible over the week to follow, and to make a plan that you are 80% likely to succeed with over the next week.

Practice some form of non-sleep deep rest daily.

Recommended Interventions from this Session

1. Stimulus Control, or more simply, BED = SLEEP

Don’t go to bed until your sleepy
Get out of bed if you are not sleeping
Get out of bed when you wake up in the morning
(And try to get up at the same time every day)
Keep your sleep efficiency (time asleep/time in bed) to 85-95%

2. Sleep Diary

Consistency helps sleep. By keeping a sleep diary, you can start to better understand the average amount of sleep you are getting and move your sleep toward a more regular schedule.Start your sleep diary using the CBT-i Coach app or one of the templates below. CBT-i Coach app is helpful because it will give you a sleep prescription (recommended bedtime and wake-up time). Click here to watch a short video introduction to using the app Sleep Diary Template – CHANGEpain – PDF
CBTforInsomnia.com Template
National Sleep Foundation Template
American Academy of Sleep Medicine Template

3. Self-Compassion Break exercise

When you notice that you are fretting about your sleep, practice the self-compassion break exercise
Use this tool to calm your physiology and develop more emotional awareness
Written instructions for this exercise

4. Non-sleep deep rest

Helps to reduce stress and improve sleep
Examples of non-sleep deep rest: restorative yoga, yoga nidra, self-hypnosis for sleep, body scans, etc.
- Here are some links to practices:
  - Yoga Nidra for Sleep
  - Body Scan for Sleep
- Many meditation apps have a range of guided practices for sleep — click here for 30 days free access to the Ten Percent Happier app (which has guided practices for sleep), the Calm app also has “Sleep Stories” which are quite popular (click here to access some of them on YouTube)
- The self-hypnosis app Reveri has a 7-day free trial
- Also see the bottom of this page for non-sleep deep rest resources recommended by other CHANGEpain patients

Additional Resources

Highly Recommended Online Video: Cognitive Therapy for Insomnia (1hr-presentation)

More on self-compassion
Self-Compassion Guided Practices & Exercises
10 Self-Compassion Practices for COVID-19

Session 2

This session:

Introduced sleep scheduling/restriction intervention
Discussed the psychophysiology of emotions and relevance to sleep
Provided a structured exercise for exploring emotion regulation
Thoroughly reviewed behaviours that support sleep
And, discussed the value of tracking and reflecting on sleep-enhancing behaviours

Recommended Interventions from this Session

1. Sleep Scheduling (or Sleep Restriction) – for insomnia

Sleeping on a schedule that restricts your time in bed
If you use the CBT-i Coach app, you will have a sleep prescription made for you through the app
Alternatively, revisit the Cognitive Therapy for Insomnia video at the 35-minute mark and follow the same process Dr. Korol outlines to set your schedule.
Here are very brief instructions for doing it yourself:
- Use the information from your sleep journal to figure out how much sleep you get per night on average
- Add 30 minutes to your average sleep hours. (This will be your sleep window unless it is less than 5.5hrs. You will give yourself a minimum of 5.5hrs in bed.)
- Set your wake-up time
- Set your bedtime based on your sleep window (For example, if you are sleeping 6hrs on average and setting a 7am wake up time, you would set a 12:30am bedtime.)’
If you think this intervention would help you, but you are worried about the sleep deprivation, this article might help: Putting the Fear of Sleeplessness to Rest

2. Sleep-enhancing behaviours

There are many things we can do (and not do) throughout the day and night that have a significant impact on our sleep
The Sleep Hygiene Reading from Empowering You to CHANGEpain lists many important sleep-enhancing behaviours: Empowering You to CHANGEpain – Sleep Hygiene Reading
Use one of the forms below to track and reflect on your sleep-enhancing behaviours
- Sleep Enhancing Behaviours Tracking & Reflection Form
- Sleep Enhancing Behaviours Tracking & Reflection Form BLANK

3. Emotion Regulation

Emotion regulation skills help us influence our emotional state for the better
The ability to move out of emotions like frustration and anxiety can be very helpful for sleep
Cognitive reframing techniques and mindfulness practice are good tools for developing these skills
This reflective exercise introduced in the session can support emotion regulation and awareness of unhelpful thoughts: Fear of not sleeping reflection exercise template

Additional Resources

Diet
Caffeine and Adenosine (article)

Stress
Cortisol and its Effects on Your Sleep (article)

Light/Dark Exposure
The importance of early-day light for improved sleep (12-minute video)
Why screen time can disrupt sleep (article)
Evening screen time can sabotage sleep (article)
Light Therapy Lamps — brand sold at Costco for a reasonable price

General
Huberman Lab podcast episode – The Science and Practice of Perfecting Your Sleep
The Matt Walker Podcast

Session 3

This session:

Discussed the importance of identifying and challenging unhelpful sleep thoughts
Introduced the Thought Record exercise and plan for habituating helpful thoughts
Highlighted some strategies for supporting success with stimulus control and sleep scheduling
Discussed the foundational importance of stress management
And, practiced an exercise to support falling and returning to sleep

Recommended Interventions from this Session

1. Cognitive Reframing

Cognitive reframing (or cognitive restructuring) is a process where we discover, challenge, and modify or replace unhelpful thoughts
One type of unhelpful sleep thoughts are thoughts that bring about an aroused emotional state (such as anxious or frustrated) that decrease our chances of falling asleep
Thoughts that forecast a difficult day because of our sleep are another type of unhelpful sleep thoughts
Cognitive therapy techniques (such as the Thought Record Exercise) and mindfulness practice are both tools that can help us become more aware of our unhelpful thoughts and change them to more helpful thoughts
As you progress in challenging your thoughts, use this Record of Helpful Sleep Thoughts to remind yourself of these new ways of thinking. There are also additional resources below that may help you with this work.

2. Stress Management/Relaxation Training

To sleep well, your system needs to be in a relaxed state. You may have heard terms like parasympathetic, relaxation response, or rest & digest to describe this state.
Attending to the calm state of your system involves more than doing a relaxation practice. It is about how we live our lives.
If you don’t already have a daily relaxation practice, make this commitment moving forward. Here are our recommended guidelines:
- Minimum 20-minute relaxation practice during the day
- Attending to calming your system through mini-relaxations and cognitive reframing throughout the day
- Relaxation practice before bed
If you need more support in this area, consider CHANGEpain’s GMV’s: 9-week Relaxation program and Restorative Yoga classes

3. Develop a Return-to-Sleep practice

Waking up at night is normal and not something we can completely control, but waking up is not a significant issue if one is able to get back to sleep
The cognitive reframing tools (including positive sleep thoughts) and relaxation practices that we looked at in this session are particularly helpful tools for supporting return-to-sleep.
Over time, try different things and learn more about what helps you to get back to sleep.
When you wake up at night, work with your return to sleep practice, and if you are still unable to sleep, get out of bed

Example of a self-guided Return-to-Sleep practice

Here is a list of the steps of the return-to-sleep practice discussed in class:

Acknowledge your surroundings with a quality of acceptance
Notice how you are feeling physically, mentally, and emotionally
Set an intention to let go of anything that does not support sleep (e.g., I am ready to let go of this tension and fall asleep. I am ready to let go of these thoughts and fall asleep.)
Scan through your body and for each part:
- Make adjustments to increase comfort
- Encourage the release of tension with each exhale breath
- Silently repeat for the appropriate body part: “My ____ are safe and ready to rest.”
After completing the whole body scan, bring your awareness to your whole body. Encourage your whole body to soften into the support beneath you with each exhale breath. Silently repeat to yourself: “My body is safe and ready to rest.”

Things that are Hard to Do

Stopping sleep procrastination
- The root of changing this behaviour is understanding it. What are you avoiding?
Get out of bed when you are not sleeping
- To support stimulus control interventions, write down 5-10 things you can do when you get out of bed at night. Try to think of activities that are more enjoyable than tossing and turning in bed. (For ideas, see the CBT-i Coach app: Tools > Create New Sleep Habits > Get Out of Bed When You Can’t Sleep)
Stay up until a scheduled bed time when you are exhausted
- If you are working with sleep scheduling, write down 5-10 things you can do to keep your self awake. For each idea, consider how likely it is to work and whether it might prevent you from getting sleepy (e.g. screen use). (For ideas, see the CBT-i Coach app: Tools > Create New Sleep Habits > Go to Bed Only When Sleepy)

Additional Resources

Challenging Thoughts
CBTforInsomnia – Positive Sleep Thoughts
CBTforInsomnia – Challenging Negative Sleep Thoughts

Session 4

This session:

Offered on-going support for recommended interventions
Introduced the basics of sleep physiology
Discussed the key sleep issues being addressed through this program: insomnia and non-restorative sleep
Provided an introduction to mindfulness and discussed its relevance as a sleep intervention

Actions for the Week

1. Review this page and any notes you have taken. Identify any unanswered questions and bring them to the final session.

Recommended Interventions from this Session

1. Sleep Education

Click here for summary notes
Learning about sleep can help us to let go of unrealistic sleep expectations: it is normal to wake up at night and it is normal to go through periods of insomnia when stress is higher.
The Sleep Solution: Why Your Sleep Is Broken and How to Fix It, by W. Chris Winters is a good book for learning about sleep, but be sure to ignore what he says about pain

2. Mindfulness Practice

Mindfulness can be described as being aware of what is arising in the present moment and letting go of resistance to what is. This skill can be incredibly helpful in the face of sleep issues.
To explore this practice more deeply at CHANGEpain, consider the 9-week Relaxation program

Additional Resources

Mindfulness
Mindfulness meditation helps fight insomnia, improves sleep
How Mindfulness Improves Sleep
Mindfulness Coach App (free)
UCLA Mindful App (free)
Waking Up App (free to those who can’t afford it)

Session 5

This session:

Offered on-going support for recommended interventions
Discussed of sleep medications, including guidelines for use and guidelines for tapering (click here for notes from this portion of the session)
Overviewed possible areas to seek further professional support
Highlighted role of the microbiome in sleep
Emphasized importance of brief action planning and goal setting moving forward

Recommended Interventions from this Session

1. Supporting gut health

Poor sleep has been found to disrupt the health of our gut microbiome, and an unhealthy state of our gut microbiome has been found to disrupt sleep.
Research looking at the relationship between the gut and sleep is new, but given the various ways supporting gut health has been found to support our health, it is great area to explore.
In her 12-week Central Sensitization program, CHANGEpain’s Dr. Alexandra Perel-Winkler discusses gut health

2. Further professional support

If you haven’t done so already, you may want to consider the following:
- Physician assessment for possible undiagnosed sleep issues
- Pharmacist review of medications (including OTC) for possible contributing factors to disrupted sleep
  - Click here for information about UBC Pharmacy Medication Reviews
- Support from various other clinicians navigating conditions, such as depression, anxiety, and PTSD, that may affect sleep
- Physician or pharmacist guidance and support tapering sleep medication use
- Functional medicine or naturopath support for gut health, hormones, and more

3. Brief Action Planning & Goal Setting

This 5-week session recommended far more interventions than is realistic to work with in this short window of time
Continuing to work in the direction of improving sleep will require forethought
Consider setting goals and using Brief Action Planning (reading from Empowering You to CHANGEpain)
Explore habit change strategies to support this work