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Wellness Series Part 1 – Don’t Sleep on it: An Urgent Call for MFTs to Attend to Sleep in Therapy

 

The global COVID-19 pandemic, political uncertainty, and racial tension over the last few years has undoubtedly taken a toll on our psychological, physical, and social relationships. One of the more impactful and important mechanisms through which this manifests is through sleep quality, particularly poorer sleep. Indeed, both the global/national events (e.g., Targa et al., 2021) and circumstances in our own environment greatly impact our sleep (Caddick, Gregory, Arsintescu, & Flynn-Evans, 2018), greatly exacerbating health disparities (Curtis, Fuller-Rowell, El-Sheikh, Carnethon, & Ryff, 2017). Research has shown a bidirectional relationship between family relationships and sleep quality (El-Sheikh, Hinnant, & Erath, 2015; El-Sheikh & Kelly, 2017; Hasler & Troxel, 2010). Despite the growing knowledge of the impact of sleep on cognitive, emotional, physical, and social relationships, marriage and family therapists (MFTs) may not incorporate sleep assessment and education in treatment. The following article presents the biopsychosocial (BPS) implications of sleep, recommendations for assessment, psychoeducation, and treatment planning, and finally, three case vignettes in systemic therapy.


The biopsychosocial importance of sleep

Just like family systems, sleep has a homeostatic mechanism, where neurochemicals accumulate in our brain producing sleepiness, and sleep therefore clears out these neurochemicals (Walker, 2017). Both environmental factors (e.g., noise, light, temperature, stress) and lifestyle factors (movement, food, and beverage intake) all affect these neurochemicals and dictate our sleep quality (Caddick et al., 2018; Kredlow, Capozzoli, Hearon, Calkins, & Otto, 2015; O’Callaghan, Muurlink, & Reid, 2018; Zhao, Tuo, Wang, & Zhao, 2020;). In addition, sleep occurs in stages throughout the night with each having vital functions for our brain and body (Walker, 2017).

Importantly, short or poor-quality sleep (sleep fewer than 5 hours or disturbed erratic sleep) is implicated in nearly every mental health condition, worse mood, poorer memory, increased aggression, amplification of the amygdala, and heightened fight/flight/freeze response (Goldstein & Walker, 2014). Poor and inadequate sleep changes the way we perceive and interact in social situations by affecting the recognition and expression of emotion (Goldstein & Walker, 2014). In addition, sleep deprivation and poor sleep impairs emotional empathy (Guadagni, Burles, Ferrara, & Iaria, 2014; Guadagni et al., 2017). Thus, sleep is an important mechanism that impacts how we relate to our partners, children, siblings, parents, and social relationships (Novak & Gillis, 2021). Finally, not only can conflict and distress in our most important relationships disrupt sleep quality, but even witnessing conflict can disrupt sleep (El-Sheikh et al., 2015; El-Sheikh & Kelly, 2017).

As such, it behooves clinicians to discuss, assess, and relay important information about sleep to our clients. Clients with sleep issues are at risk for higher psychological, relational, and physical health outcomes; poorer outcomes can create worse sleep. This can create a vicious and reinforcing cycle that can even show up in therapy. Clients may not be progressing, as learning, memory, and attention are dampened making it difficult to retain information in the therapy room. In addition, some relationship conflict may be avoided and even prevented: children (and really all people) are more irritable with poorer sleep, parents fight with adolescents about bedtime and school readiness because of a shifting biological clock, even couples may engage in more conflict because mood and empathy are hampered. It is surprising that sleep has not received more attention in the field of marriage and family therapy. As an extratherapeutic factor (in the common factors of change) that plays a major role in client functioning, perhaps MFTs will begin to take our clients’ sleep more seriously and attend to it in therapy.

Systemic sleep assessment and education by MFTs

Although sleep intervention is beyond the scope of our practice, MFTs are in a uniquely poised position to assess and discuss sleep issues with clients from a systemic lens. In a recent paper, I outline what couple and family therapists can do in therapy regarding sleep (Novak & Gillis, 2021), including: 1) how to assess, 2) provide proper psychoeducation, 3) how to apply this knowledge in clinical settings, and 4) how to collaborate with other healthcare providers. I encourage readers to review that work for more information, but below I provide a few quick tips.

  1. Assess sleep and how it might be related to client’s presenting concerns

Clinicians can include a number of validated sleep quality measures in initial intake packets, but should also verbally assess for a client’s sleep habits and outcomes, including length/duration, onset, naps, bedtime routines, and anything related to difficulty falling asleep or staying asleep. Clinicians can also have clients use apps to measure and keep track of sleep and then report back. Importantly, MFTs must be considerate in addressing sleep in regard to developmental, sociocultural, and practical considerations. Changes in sleep across the lifecycle naturally occur, but these may be more pronounced in both the adolescent (shifting of circadian rhythms and school start times) and older adults (less REM and slow-wave sleep and fewer hours of total sleep) (Walker, 2017). Socioculturally, minority and intersectional identities tend to have poorer sleep in the United States (Curtis et al., 2017). Geographic (US times zone) and social location (neighborhood safety and urban/rural status) can play a role, and finally, practical issues like job status (working night shifts), poverty, financial insecurity, and a multitude of socioeconomic issues that simply improving sleep health cannot address (nor therapy, for that matter). MFTs must be cognizant and socioculturally attuned to these areas which require a good therapeutic relationship and proper assessment.

  1. Screen for the presence of DSM-5 sleep disorders

There are 10 sleep disorders listed in the DSM-5 (American Psychiatric Association, 2013): insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders, circadian rhythm sleep-wake disorders, non-rapid eye movement (NREM) sleep arousal disorders, nightmare disorder, rapid eye movement (REM) sleep disorder, restless legs syndrome, and substance/medication-induced sleep disorder. If any of these are suspected, referral to a medical doctor or sleep scientist for a polysomnographic exam (i.e., sleep study) and/or psychopharmacological intervention.

  1. Refer and collaborate with other specialty providers

For insomnia related disorders, sleep psychologists are specifically trained in Cognitive Behavioral Therapy for Insomnia (CBT-I), the gold standard of helping to address difficulties in falling or staying asleep. MFTs can also become certified in CBT-I. Outside of this protocol, other mental health providers can list sleep if they work with sleep issues on Psychologytoday.com. In addition, MFTs should coordinate with MDs on sleep adherence issues (CPAP use or medication) for other sleep disorders.

  1. Deliver individual and systemic psychoeducation on sleep hygiene

Importantly, parents set the habits and rituals for their children’s sleep quality (Buxton et al., 2015) and couples influence each other’s sleep habits and rituals, even if they have different chronotypes (morning lark vs. night owl). As such, the implications for changing sleep hygiene and habits should occur on a systemic level and include relaying psychoeducation about sleep to individuals in therapy as well as both the parental and couple subsystems. This information should include recommendations for sleep across the lifespan: 11-14 hours for toddlers, 10-13 hours for preschoolers, 9-11 hours for school-aged children, 8-10 hours for teenagers, 7-9 hours for young adults and adults, and 7-8 hours for older adults (Hirshkowitz et al., 2015). MFTs should also discuss helpful Rituals and Routines established by the National Sleep Foundation (https://www.sleep found ation.org/articles/sleep-hygiene), other environmental and lifestyle factors impeding sleep (summarized in Novak & Gillis, 2021), as well as recommending reading and helpful resources, such as Why We Sleep (Walker, 2017) and Sharing the Covers: Every Couples Guide to Better Sleep (Troxel, 2021).

  1. Address underlying BPSS comorbidities with sleep

As mentioned, MFTs can help address sleep issues by attending to psychological (mental and emotional health) and relational (relational dynamics, couple conflict cycles, adolescent-parent troubles) issues in therapy during treatment as usual with the therapists’ preferred therapy model. Addressing these while also addressing sleep hygiene and sleep problems can be particularly fruitful.

Clinical vignettes

Below are clinical examples in systemic therapy of clients across the lifespan. These vignettes provide a snapshot of how sleep assessment and education in therapy are tied to clients’ presenting concerns.

Children and sleep

I saw a father of four who, among other presenting issues, wanted to discuss some problem behaviors with his 3-year-old son. He described how Sunday afternoons were particularly rough for the family when his son would throw tantrums and show aggressive behavior—hitting his siblings and destroying things around the house. After further assessment, I learned that his son was not getting a nap during the mid-to-late morning. I knew that the developmental course of sleep at his son’s age meant that his child was still in the biphasic stage and still needed daily naps. We discussed implementing naps on a consistent schedule. When we met three weeks later, he happily reported that his son’s problematic behavior had drastically diminished. We then set off to discuss other strategies of emotion regulation and emotion coaching.

Adolescents and sleep

A colleague, Dr. Brian Gillis, worked with a family whose chief complaint was verbal conflict between a 15-year-old son and his mother. Their arguments began nearly every morning when the mother attempted to wake the son at 6:30 a.m. for school, and the boy resisted (an understatement—in fact, he once threw an alarm clock at his mother!). The therapist performed a short sleep assessment and found that the son was sleeping only five or six hours per night—much less than needed. He then provided psychoeducation to the family about the delayed schedule of teenage sleep as a way of validating and normalizing the boy’s irritability upon waking. They then brainstormed ways to adjust the son’s evening routine—such as by showering and packing his lunch—so that he could sleep for 30 extra minutes in the morning, and made a plan for him to get into bed at the same time every night. While his morning grouchiness did not dissipate completely, the family reported more positive interactions as a result of the reduced conflict between mother and son before school.

Couples and sleep

I was seeing a couple for some marital problems a few years ago. On one particular session, the female partner was describing her partner’s lack of presence when she was talking about their relationship. She indicated he had trouble staying awake, and how it hurt her deeply because she felt she was not important to him. He would either become defensive or dismissive, triggering a pattern of pursue–withdraw between them. I knew that, in addition to de-escalating and helping them understand their cycle, I had to assess for the husband’s sleep duration and efficiency (the percentage of the night that one is actually asleep) and daytime sleepiness, which is a sign of poor sleep. We then spent a session with his wife discussing sleep hygiene habits and how both could improve their sleep habits and rituals. I presented some psychoeducation to his partner, while also holding her pain so that she could understand the importance of my discussion of sleep. After implementing sleep hygiene habits and rituals to both partners, we then set out to address their typical pattern and relationship dynamics.

Conclusion

This article discusses the biopsychosocial importance of sleep, easy-to-implement tips for clinicians to incorporate systemic sleep hygiene in treatment, and what providers can look for when collaborating and referring for sleep disorder. As sleep problems continue to pervade society, MFTs can play a pivotal role in improving clients’ lives through addressing sleep and its correlates in therapy. Our focus on systemic change, attention to wholistic (BPSS) care, and attunement to our clients’ background and context, make MFTs ideal providers to attend to sleep in the therapy room. Ultimately, more research and clinical experience is needed to help identify: 1) how parallel treatment of sleep assessment and education impacts therapy outcomes, and 2) how systemic therapy as usual can impact sleep outcomes for all attending clients and their families. Likewise, we as clinicians ourselves should practice good sleep hygiene habits which may also impact both therapy outcomes, and our own biopsychosocial well-being.

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MFTs can play a pivotal role in improving clients’ lives through addressing sleep and its correlates in therapy.

Josh R. Novak, PhD, LMFT-S, is an AAMFT Professional Member and holds the Clinical Fellow designation. He currently serves as an assistant professor in the MFT program at Auburn University. He is the director the Relationships & Health Lab, an interdisciplinary collaborative team of faculty and students across many fields, including Dietetics/Nutrition, Sleep Science, Kinesiology, Nursing, Pharmacy, Psychology, and Human Development and Family Science. His program of research focuses on the nexus of relationships and health, within and across disease contexts, and how partners and families influence health and health behaviors.


REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Buxton, O. M., Chang, A. M., Spilsbury, J. C., Bos, T., Emsellem, H., & Knutson, K. L. (2015). Sleep in the modern family: protective family routines for child and adolescent sleep. Sleep Health, 1(1), 15-27. https://doi.org/10.1016/j.sleh.2014.12.002

Caddick, Z. A., Gregory, K., Arsintescu, L., & Flynn-Evans, E. E. (2018). A review of the environmental parameters necessary for an optimal sleep environment. Building and Environment, 132, 11-20. https://doi.org/10.1016/j.build env.2018.01.020

Curtis, D. S., Fuller-Rowell, T. E., El-Sheikh, M., Carnethon, M. R., & Ryff, C. D. (2017). Habitual sleep as a contributor to racial differences in cardiometabolic risk. Proceedings of the National Academy of Sciences, 114(33), 8889-8894. https://doi.org/10.1073/pnas.16181 67114

El-Sheikh, M., Hinnant, J. B., & Erath, S. A. (2015). VI. Marital conflict, vagal regulation, and children’s sleep: A longitudinal investigation. Monographs of the Society for Research in Child Development, 80(1), 89-106. https://doi.org/10.1111/mono.12146

El-Sheikh, M., & Kelly, R. J. (2017). Family functioning and children’s sleep. Child Development Perspectives, 11(4), 264-269. https://doi.org/10.1111/cdep.12243

Goldstein, A. N., & Walker, M. P. (2014). The role of sleep in emotional brain function. Annual Review of Clinical Psychology, 10, 679-708. https://doi.org/10.1146/annur ev-clinpsy-032813-153716

Guadagni, V., Burles, F., Ferrara, M., & Iaria, G. (2014). The effects of sleep deprivation on emotional empathy. Journal of Sleep Research23(6), 657-663. https://doi.org/10.1111/jsr.12192

Guadagni, V., Burles, F., Valera, S., Hardwicke-Brown, E., Ferrara, M., Campbell, T., & Iaria, G. (2017). The relationship between quality of sleep and emotional empathy. Journal of Psychophysiology, 31(4), 158-166. https://doi.org/10.1027/0269-8803/a000177

Hasler, B. P., & Troxel, W. M. (2010). Couples’ nighttime sleep efficiency and concordance: Evidence for bidirectional associations with daytime relationship functioning. Psychosomatic Medicine, 72(8), 794-801. https://doi.org/10.1097/PSY.0b013 e3181 ecd08a

Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, L., Hazen, N., Herman, J., Katz, E. S., Kheirandish-Gozal, L., Neubauer, D. N., O’Donnell, A. E., Ohayon, M., Peever, J., Rawding, R., Saschdeva, R. C., Setters, B., Vitielo, M. V., Ware, C., & Adams Hillard, P. J. (2015). National Sleep Foundation’s sleep time duration recommendations: Methodology and results summary. Sleep Health, 1(1), 40-43. https://doi.org/10.1016/j.sleh.2014.12.010

Kredlow, M. A., Capozzoli, M. C., Hearon, B. A., Calkins, A. W., & Otto, M. W. (2015). The effects of physical activity on sleep: A meta-analytic review. Journal of Behavioral Medicine, 38(3), 427-449. https://doi.org/10.1007/s10865-015-9617-6

Novak, J. R., & Gillis, B.T. (2021). A primer on sleep for MFTs: Implications and practical considerations. Journal of Marital and Family Therapy, 48(2), 543-559. https://doi.org/10.1111/jmft.12528.

O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, 11, 263-271. https://doi.org/10.2147/RMHP.S156404

Targa, A. D. S., Benítez, I. D., Moncusí-Moix, A., Arguimbau, M., de Batlle, J., Dalmases, M., & Barbe, F. (2021). Decrease in sleep quality during COVID-19 outbreak. Sleep Breath, 25, 1055-1061. https://doi.org/10.1007/s11325-020-02202-1

Troxel, W. M. (2021). Sharing the covers: Every couple’s guide to better sleep. New York: Hatchette Book Group.

Walker, M. (2017). Why we sleep: Unlocking the power of sleep and dreams. New York: Simon and Schuster.

Zhao, M., Tuo, H., Wang, S., & Zhao, L. (2020). The effects of dietary nutrition on sleep and sleep disorders. Mediators of Inflammation, 2020, 1-7. https://doi.org/10.1155/2020/3142874

 

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