Four Strategies to Get Some Zzzzzzz’s

By Ariel Campbell

Most adults have experienced symptoms of insomnia at some point in their lives. In fact, according to the National Sleep Foundation between 30-50% of adults have occasional difficulties falling or staying asleep, waking up early, or waking up not feeling rested. Lack of adequate sleep can negatively influence our daily functioning by leading to impairments in attention and concentration, increased irritability, and overall poorer mental health. However, for those of us who suffer from occasional insomnia there are a number of healthy habits we can incorporate into our daily routines to improve our quality of sleep.

In order to understand how and why these habits can be useful in promoting restful sleep, knowing some basics about sleep is helpful. Our sleep is regulated by our body’s natural circadian rhythm. This circadian rhythm is responsible for our feelings of sleepiness and wakefulness throughout the day and is controlled by light and dark signals that occur naturally in our environments. For adults, sleep proceeds in a predictable pattern that involves 4-5 repetitions of a 90-minute sleep cycle, with each sleep cycle including 5 sleep stages. During sleep, a number of changes happen in our bodies – our heart rate and breathing slow down, our blood pressure and body temperature drop, our bodies produce and regulate a number of important hormones including those that impact growth and hunger, and our brains cycle through varying levels of activity.

Now onto some of the daily habits that can promote and improve sleep…

First, developing a bedtime routine can be an effective strategy for helping our minds and bodies transition into a state of relaxation after a busy day. Having a structured pre-sleep routine that includes a relaxing activity, like reading or listening to music, can promote sleep by helping us to form habits that actually function to cue sleep. Stimulating activities and screens, on the other hand, should be avoided during the 30-60 minutes before bedtime and as a general rule of thumb the only activities that should be carried out in bed are those related to sleep and intimacy. Additionally, an essential part of any good sleep routine involves keeping regular sleep and wake times, even over the weekend, insofar as this helps to maintain a consistent circadian rhythm.

Second, attending to certain factors within our sleeping environment can help to ensure high-quality sleep. Since light is a powerful cue for our body’s internal clock, keeping the bedroom as dark as possible while sleeping and dimming the lights one hour before bedtime are helpful sleep habits. If fully avoiding screens before bedtime isn’t possible, switching your cell phone or computer screen into nighttime mode is advisable because the blue light of daytime mode (as opposed to the red light of nighttime mode) will actually delay the release of melatonin making it harder to fall asleep. Keeping the bedroom temperature between 60-70 degrees while sleeping is another useful strategy that works by helping our bodies to maintain the drop in body temperature that accompanies sleep. And lastly, since our brains are still active and responsive during sleep a final consideration when it comes to structuring our sleeping environment is to limit noise as much as possible. Noise tends to be most disruptive during the first and second stages of sleep and during the second half of the night. Additionally “peak” sounds, for example busy street noises, are more damaging to sleep than ambient background sounds. If it’s difficult to eliminate noise while sleeping, white noise can help to reduce disruptions in sleep due to sound. Today, there are many apps for white noise but a fan or air conditioner that produces a consistent sound will also do the trick.

Third, certain exercise and dietary habits have also been shown to impact sleep. Aerobic exercise, like walking, swimming, or biking, can aid in sleep by increasing the amount of time our body spends in the deeper and most restorative stages of sleep. 20 minutes or more of daily aerobic exercise engaged in 4-5 hours before bed is recommended. While your morning coffee can help energize you for the day ahead, drinking a second cup of coffee during the afternoon or evening hours can disrupt sleep. Additionally, alcohol has been shown to cause impairments in sleep – although it may initially cause drowsiness and induce sleep, consuming alcohol before bed is associated with significantly more sleep disruptions during the second half of the night.

And finally, the timing, size, and content of meals can play a role in getting a good night’s sleep. For improved sleep, it is generally recommended that your largest meals be eaten earlier in the day and that snacks consumed before bedtime include complex carbohydrates and avoid sugar. Complex carbohydrates like whole-wheat breads, vegetables, fruit, and nuts break down slowly and help to prevent sudden spikes and crashes in blood sugar that can interfere with sleep.

While occasional symptoms of insomnia are common and not a significant cause for concern, they can nonetheless be disruptive to our daily routines. By using the above strategies for managing bedtime routines and environments as well as diet and exercise, you can develop healthy sleep habits that will promote a full night’s sleep and help you to wake up feeling rested and refreshed.

Beyond Clinical Judgment: Using Progress Monitoring to Guide Treatment and Improve Outcomes

By Tonya Swartzendruber

A recent article in The Atlantic featured a topic near and dear to us at the Center for Anxiety: Using data to inform evidence based treatment. The author, Tony Rosmaniere, argues that the field of psychotherapy, and our clients, benefit greatly when therapists are willing to routinely look at progress through data generated from patient self-report assessments.

We know that assessing progress in treatment is essential. Evidence suggests that tracking progress in treatment through patient report increases therapist’s capacity to identify those patients benefiting (or not) from the treatment process and adjust their treatment plan accordingly. Just imagine if an oncologist or cardiologist or surgeon didn’t consider data when performing their clinical duties!

However, most therapists use a blend of experience, knowledge and intuition to determine how well treatment is addressing the problems of their patient. While general clinical judgment based on these factors is very useful, it is not always sufficient when dealing with the complexity of human experience and psychology. In evidence-based practice, established treatment methods, such as a Cognitive Behavioral Therapy, go a long way in organizing a treatment plan in the face of this complexity. Using progress monitoring in addition to evidence-based principles can make treatment even more flexible and responsive to individual and contextual factors that we know have a huge impact on treatment outcomes.

So, what is progress monitoring, and how should we use it? Progress monitoring is the ongoing use of data generated from the assessment of indicators that reflect progress in treatment: Quality of life, functioning, severity of symptoms and aspects of the therapeutic relationship. At it’s best, the patient and the therapist use reported information collaboratively to guide the treatment process and when necessary, address and prevent potential early termination of treatment and worsening of symptoms.

Progress and outcome monitoring increase accountability in the mental health profession, because it becomes clear when patients are and are not getting better. Accountability for therapists addressing mental health problems is extremely important. Other professional fields, such as medicine, demonstrate competence through good outcomes. The field of mental health should be no different. Using outcome monitoring helps ensure that mental health clinicians are aware of how their intervention is impacting their patients in an objective way.

Interestingly, just measuring outcomes can improve the effects of care. In a series of studies, Harmon, Slade, Whipple, Hawkins (2005), found objective feedback to therapists on patient response to treatment produced better patient clinical outcomes. That is, when patients had an opportunity to communicate indirectly with their therapists about how they were doing, they got better more often and more quickly. Of particular importance, when given information about when patients were worsening or the patient therapist alliance needed improvement therapists are able to adjust treatment as needed to prevent drop out or deterioration.

The Center for Anxiety has a rigorous progress-monitoring system in place. Using Mentegram software, patients complete a set of brief questionnaires assessing current symptoms related to mood and anxiety both prior to treatment and at each session. In addition to these routine questions, we regularly assess for risk items and if a patient reports a severe change in symptoms, their therapist and our patient care manager is notified immediately by email. The data generated from these questionnaires are routinely reviewed by therapists and can be viewed with the patient as well.

Center for Anxiety clinicians use this data for a wide range of purposes: To review data with clients on a regular basis; to discuss treatment termination when appropriate by pointing to progress; to encourage more engagement in therapy by showing that progress is slower than it could be; to demonstrate that a valued life can be created even when experiencing symptoms; to more accurately identify stressors and their relationship to increase or decrease in symptoms; and perhaps most importantly, to address any increase in symptoms through a possible change of the treatment plan.

In summary, progress and outcome monitoring is an essential and effective way to increase accountability, improve outcomes, augment clinical judgment when making decisions in treatment and more flexibly respond to the changing and dynamic needs of our patients.


When It’s More Than Just a Little Stress


Written by Talia Kaplan

Consider the following three people:

Joseph is a 35 year old married man whose father died from stomach cancer 5 years earlier. Recently, Joseph has begun to worry that he too may develop cancer. He has gone to several medical doctors and has had numerous scans, all indicating that he is healthy. Joseph continues to worry despite his doctor’s, his wife’s and his family’s reassurances. Any time Joseph feels nauseous or pain in his stomach he begins googling the symptoms to see if it is possibly stomach cancer. Joseph severely has limited the type of food he eats, stopped exercising, and stopped working due to his fear of stomach cancer. Recently, he has noticed that he is worrying about a hernia and other types of medical problems. When he went to see his general practitioner, he was referred to a therapist.

Nancy is a 60 year old divorced mother of three children who has a fear of flying on planes. Her three children live all across the United States, but Nancy has never been to visit her children due to her fear. She has never met her grandchild, and has become depressed as a result of her strained relationship with her children. Nancy’s daughter will be getting married in 2 months and she would like to be able to attend the wedding.

Michael is a 25 year old single male who obsessively worries about the remote possibility that he might kill someone, despite the fact that he has no desire to do so and zero history of violent behavior. Michael works as a barista in a coffee shop, but recently had to take a leave of absence because he kept thinking that he may have accidentally put detergent in a person’s coffee which might kill them. Michael would therefore re-do each cup of coffee he made three times before handing the cup to the customer. Michael’s supervisor noticed what he is doing and has threatened to fire Michael as a result of his inefficiency.

The three people listed above experience debilitating levels of anxiety. Their anxiety has moved beyond regular daily stress. It has moved beyond the frustration of frequently experiencing anxiety in difficult situations. For the people in these vignettes, anxiety has become the thing to fear, and a significantly inhibitory factor in their lives. The first person, Joseph, experiences hypochondriasis (health anxiety); Nancy has a specific phobia of airplanes; while Michael has OCD. While it is expected for all people to worry at times, anxiety can prevent people from living their life in the way they would want to. In cases like these intensive outpatient treatment involving exposure therapy, can help people make rapid gains in treatment over a short period of time.

Exposure therapy works on the premise of behavioral learning models. By avoiding the feared stimulus, people’s anxieties tend to get worse because their fears take over their life decisions. Exposure therapy re-teaches people that they can fully engage in life. Sometimes the feared outcome takes place, and sometimes it doesn’t, but their fear does not dictate whether it will happen. In intensive exposure-based treatment, the therapist and patient first work to ensure understanding of the core fear. For example, for some people the fear of flying in an airplane is that the plane may fall out of the sky, for others it may be that the airplane may hit turbulence and the passenger may experience nausea. Second, the therapist and patient collaborate to develop a hierarchy of feared situations. This hierarchy serves as a map for treatment progress. Patient and therapist then spend a series of half- or full-days together to move in a linear fashion to tackle areas of avoidance for each patient. An example of a first stage in a hierarchy for Michael might be thinking about a person spilling hot coffee on themselves and thereby slightly burning their hand because of a hot cup of coffee that he gave them. The therapist and patient work methodically to help the person re-engage fully in their lives despite feared situations. In many cases of intensive treatment, patients have seen significant improvement in their ability to live the life they want to be living within a week.

One important aspect of doing this type of short-term intensive treatment is attending to bodily sensations. For a patient like Joseph, bodily sensations are often interpreted as dangerous or scary. Through the use of mindfulness techniques, therapists work to teach patients how to re-interpret the daily aches and pains of daily life. Research suggests that intensive treatments can be used to help a person meet a short term goal that they have been struggling with for years. It can help a person reconnect and rebuild interpersonal relationships, allow a person to keep their job, and help people feel more satisfied with their lives.