- The value of sleep may change according to cultural beliefs, social practices, and scientific data.
- Focusing on negative effects of insufficient sleep may be unhelpful for people with chronic insomnia.
- The need for sleep is best met with a consistent practice, which is established over time.
One busy NYC morning, dozing off standing inside a subway car after an all-nighter at the City College sleep and electrophysiology lab, I overheard a startling conversation between two suit-clad professionals. One was raving about a book that explained how to reduce sleep to just a few hours so as to accomplish more. The other was asking for practical tips, eager to get in on the secret of reaching for the stars in the city that never sleeps. This was almost three decades ago.
Since then, sleep has turned from an annoying nuisance into a coveted commodity. The change was brought about by years of research and public health advocacy spearheaded by Harvard physicians Charles Czeisler and Judith Owens. Today, nearly everyone can cite benefits of good sleep, including cardiovascular and neurological health, cognitive and athletic performance, emotional and immune resilience. Nonetheless, insufficient sleep is still an occupational hazard in professions demanding quick high-stakes, sometimes life-and-death, decisions. Sleep curtailment due to schedule pressures remains common in medicine, law, transportation, business, and finance; it affects people in uniforms, shift workers, and students. For this reason, sleep specialists and the media have been on the quest for a well-rested society, promoting better individual choices and safer policies.
An unintended consequence of this quest is the catastrophizing attention its messages can draw from people afflicted by chronic insomnia, who comprise 10-15% of the adult population. It is not uncommon for an insomnia sufferer to spend eight to 10 hours in bed, netting only four to five hours of fragmented sleep. The remainder of the time is typically occupied by ruminations featuring imminent effects of sleeplessness, from a heart attack or a stroke to an emotional breakdown or a job termination letter. These concerns increase anxiety antithetical to sleep.
An electronic device is often employed as an immediate distractor. The most empirically supported recommendation—to take wakefulness out of bed—is frequently met with skepticism: If lack of sleep is so detrimental, how would staying out of bed help me get the recommended eight hours? Unfortunately, the sleep duration recommendations developed for good sleepers apply to a person with insomnia about as much as the daily food intake recommendations apply to a person with food poisoning. Trying harder does not lead to the desired effect.
You may wonder if it matters whether the lack of sleep is due to insomnia or externally induced deprivation. Four hours are four hours, any way you count them. However, there are important differences. A person who allocates little time for sleep usually falls asleep quickly, sleeps deeply, and does not think of sleeping as a challenge. The very idea of borrowing time from sleep is based on taking sleep for granted. A client with behaviorally induced insufficient sleep once confessed to falling asleep multiple times during a daily drive by putting the car in park at a traffic light and closing the eyes, only to wake up seconds later from honking. Anyone dealing with insomnia would consider this feat of falling asleep intentionally, promptly, and repeatedly a superpower.
Consequently, the question “How much sleep do I need?” is imbued with different meanings. For some, it’s “What’s the minimum I can safely get away with?” For others, “What’s the ideal I’ve long lost hope to attain?” The same numeric answer elicits different responses. Like having sex three times a week may seem “all the time” to one spouse and “hardly ever” to the other (Annie Hall), the standard eight hours can mean “I’ll pencil it into my calendar for the next holiday weekend” or “I’d give up all the riches to experience it once in a lifetime.” The real answer is not so much a number, but a sustainable and satisfying practice, which leads to the question, “How?”
If you are reading this, chances are you know all about sleep hygiene and behavioral methods: getting up at the same time and using sunlight in the morning; staying active during the day; avoiding caffeine, alcohol, and blue screens in favor of chamomile, warm bath, and lavender in the evening; leaning on various forms of meditation and sleep-promoting audios instead of work emails, news, and thrillers at bedtime; reading War and Peace on the couch if sleep just doesn’t seem to grace with its presence at 3 a.m. This is all good and true. “But is there anything else (other than medicine)?” is a question commonly heard in behavioral sleep practice. And another common question is, “How long do I have to do this for?” Below is an attempt to summarize several points that may help make a personal quest for better sleep a success.
1. Make a commitment to a long-term change.
If sleep has not been your forte for a while, it will take time to change. And changing a whopping third of your life will necessarily involve rethinking the other two-thirds. If you accept data showing that sleep relates to many waking functions, it’s as important to appreciate that many waking habits, in turn, relate to sleep. So improving sleep is less like removing a rock from the road and more like building the road. If you think you shouldn’t have to work so hard on something as natural as sleep, consider other natural functions, e.g., cardiovascular or digestive, which also rely on intentional lifestyle support.
The good news is that you don’t have to do it all at once. Focusing on incremental changes removes the pressure to make it or break it on a single night, helps one to accept normal day-to-day variability in sleep and alertness, and fosters the ability to come back to better habits even if something throws you off. As a client recently observed, when positive changes start to take root, the initial time investment does not seem that long in retrospect.
2. Work with your body clock.
Perhaps this should be #1. Biologically, sleep is determined by the homeostatic pressure (waking metabolic processes that after a time beget sleep) and the circadian system (the near-24-hour fluctuations in many physiological variables linked to the environmental light-dark cycle). The same physical and mental functions that are associated with the amount of sleep are just as closely related to the circadian regulation. Moreover, a varying sleep schedule can produce jetlag-type symptoms and tiredness regardless of the hours slept. Therefore, aiming for the hours and ignoring the timing is like trying to solve a puzzle with half the pieces missing. A daily exposure to sunlight is the main tool to reinforce circadian rhythms. A bright light therapy box may be a good substitute for people without history of a bipolar disorder or retinal conditions. Three key points are brightness, duration, and timing: at least several thousand lux of UV-free light need to hit your eyes for at least 30 minutes at approximately the same time every day.
In figuring out the timing, you need to carefully consider your natural sleep pattern, personal and professional commitments. Generally, morning bright light adjusts the circadian cycle earlier, and evening light pushes it later (this is called the phase-response curve). However, for a strong “night owl” chronotype, the natural morning may be 12 p.m., and the light should be timed accordingly and then gradually adjusted. Also, for a strong “morning lark” chronotype, someone who gets hit by drowsiness at 8-9 p.m. and wakes up at 3 a.m. fully alert, morning bright light would not help sleep longer, but an evening light may be recommended by a health care professional to boost alertness in the early evening and extend sleep into a later morning. Other than light, the tools of circadian regulation include properly scheduled melatonin, nap, meal, and exercise times.
3. Approach sleep more like a system, less like a science experiment.
While the process of isolating variables is great for making a lab discovery, trying to do so in real life, with multiple uncontrollable and often unknown factors, can leave you bewildered and exasperated. Building a system based on well-established knowledge is usually more fruitful. In this process, strategies most likely have to be combined. Limiting caffeine for a week while maintaining a habit of watching videos in bed may not lead to a noticeable improvement, but that does not negate a wealth of data on caffeine affecting sleep, and does not suggest increasing caffeine again.
If removing the phone from the bed suddenly leaves you more alert, it does not mean that interactive screens help sleep but points to the need for an additional tool, such as a mindfulness practice. On the other hand, there are individual differences in response to standard methods, and some behavioral experiments may be warranted. For example, some people (“morning larks”) may benefit more from exercising in the late afternoon rather than the morning. If you engage in such a trial, please remember that sleep is a once-a-day behavior and give yourself a couple of weeks to collect data before making a judgment.
4. Rethink your beliefs and assumptions.
When sleep is challenging, we may develop thinking patterns that can be counterproductive. Lack of sleep may be viewed as the cause of daytime tiredness and anxiety, but excessive worrying by itself can make you both tired and sleepless. A long recovery night after several poor nights may fuel the belief that nine hours of sleep are best for the daytime alertness; however, once a more consistent pattern is built, seven hours may feel more like the sweet spot. The belief that being in bed for as long as possible is the only way to ensure sufficient sleep can turn the bed into a stressful place and undermine both the homeostatic and the circadian mechanisms of sleep. What do you believe about your sleep that may be holding you back? Try writing down a few short statements and then see if you can take one or two that sound negative and fixed, and rephrase them in a way that offers an opportunity for a positive change. For example, “If I don’t get to sleep by 11, my night will be ruined,” can be replaced with, “I look forward to my winding down routine and embracing sleep when it comes.”
5. Think of sleep as a good friend.
Personifying your sleep may help evade bedtime negativity, such as fear, anger, or frustration, if things don’t happen quickly enough. Negative emotions trigger alertness and the desire to do something immediately to alleviate the discomfort. Such a state, instead of a peaceful slumber, leads to a self-defeating conclusion that “nothing works.” Alternatively, thinking of sleep as an old friend who just may be moody at times makes less-than-comfortable compromises (like reading on the couch to gather drowsiness) worth the relationship you are trying to foster. If the long-term goal is to reconnect with sleep, replacing “I may as well do something productive since I’m up anyway” (which has an “I-don’t-need-you” ring to it) with a pleasant winding-down routine sends a welcome message to your desired ally, and makes you feel more in control of the process.