Dr Robert London

Helping Patients Conquer Insomnia

Clinical Psychiatry News - Volume 32, Issue 2, Page 49 (February 2004

I can't sleep, I can't concentrate anymore. I'll lose my job if I don't sleep. Doc, please give me a pill or something.

Who of us in medicine is not hearing such laments with alarming frequency? All too often, we are quick to prescribe medication to patients with insomnia or to spend months—sometimes even years—dealing with the underlying causes of anxiety leading to insomnia. But behavioral alternatives are available for the kind of insomnia that stems mainly from the anxieties of daily life. And if successful, these techniques incorporate the patient into the treatment process.

To those of us who have been schooled to think inside the “medical box,” these techniques may sound like new-age mumbo jumbo. But they involve cognitive skills that you can learn and offer to your patients as a quick, effective alternative to medication, over-the-counter sleep aids, and herbs.

The techniques are simple enough to be taught in one or two sessions. I encourage you to run through the techniques several times with your patient during each visit so that the skills can be mastered under controlled conditions. I suggest, too, that you urge your patients to practice these techniques as often as possible over the next couple of days after the initial visit, modifying them to suit the patients' lifestyles.

The techniques involve guided imagery and are based on the age-old “counting sheep” method of falling asleep; through guided imagery, the patient focuses his concentration, enabling him to redirect anxieties or stressful thoughts.

Below I have outlined three visualization techniques that I have used in my clinical work and teaching. I teach my patients more than one technique, to increase their self-help options.

Each technique begins with the induction of a relaxed state of mind to help patients release muscle tension and prepare them to focus on learning concrete exercises that might help them deal with insomnia.

Have the patient sit in a chair and get comfortable. Then tell the patient:

? Close your eyes and take a deep breath.

? Continue to take five or six deep breaths, exhaling slowly.

? Let your body relax while taking these breaths, concentrate on a state of drifting into relaxation, and let your whole body just drift away. When you feel your muscles become tension free, you will start to realize that you are in a relaxed state.

After a state of relaxation has been achieved, introduce one of three visualization strategies:

1. The split screen technique.

2.The 20 heavily carpeted stairs technique.

3.The red balloon technique.
The Split Screen Technique
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Picture in your mind a large movie screen or a giant TV. Imagine a thick line down the center of the screen dividing it in two. Project all your worries, fears, daily problems, and unpleasant thoughts onto the left side of the screen. This enables patients to look at all the unpleasant thoughts that are at the root of their sleeplessness without experiencing them.

Then, shift to the right side of the screen, where you will project any pleasant scene or experience of your choosing. As you put the unpleasant thoughts onto the screen and concentrate on viewing a pleasant sea of experiences, your body and mind relax, and you can fall into a restful sleep.
The 20 Heavily Carpeted Stairs Technique
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Picture 20 heavily carpeted stairs. Imagine that the carpet, woven in your favorite color, is thick and luxurious. Then proceed to walk very slowly down the stairs one step at a time. As you walk down the stairs, count them 1 …, 2 …, 3 …, etc., until you get to 20; feel yourself sinking deeper and deeper into the thick plush of the carpet. When you reach the last step, you will feel completely relaxed and fall into a restful sleep.
The Red Balloon Technique
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Imagine a huge red balloon attached to a wicker gondola. Put all your worries into the gondola, and let it float up into a blue, blue, blue sky. Relax your body as you watch this red balloon float away, getting smaller and smaller in the sky, taking your worries and anxieties away and making it easier to relax and fall into a restful sleep.

It is also a good idea to encourage your patients to come up with their own scenarios or to put their own personal stamp onto those that you are offering. This in itself is empowering, leading to a sense of mastery. Also, you might want to suggest simple, less-abstract concepts when dealing with children. For example, I know of a woman whose mother helped her get to sleep at night when she was a child by having her imagine that she was throwing a party and could invite every person she had ever met. The visualization consisted of her sending invitations to all her friends starting with the names that began with A, moving on to B, and so on. She told me that she could never remember getting past the B's.

Psychiatrists should be able to learn these three techniques and teach them as an alternative approach to dealing with insomnia. Imagery techniques and mind-diversion approaches coupled with relaxation are nonintrusive. They have proved to be rewarding to my patients and are a wonderful alternative to pills and gadgets.

Feel free to write to me at cpnews@elsevier.com and let me know what you have done to treat this complex medical/biologic/mental problem. I will try to pass it on to my readers.

PII: S0270-6644(04)70913-3

© 2004 International Medical News Group. Published by Elsevier Inc. All rights reserved.