Show Notes

Welcome back to The Designer Practice Podcast, and I’m your host, Kayla Das.

In today’s episode, Pamela Young, registered psychotherapist and clinical director of Hope Harbour Psychotherapy, will share what sleep tells us about clients and how to support early on.

Hi Pamela. Welcome to the show. I’m so glad to have you here today.

Thanks Kayla. I’m glad to be here.

Yes, I’m a registered psychotherapist in Ontario and the clinical director of Hope Harbour Psychotherapy, which is based in Belleville, Ontario. So my clinical work, originally began working with children and with teens. So I did play therapy and sand tray and have been trained in EMDR. So I even did EMDR with the kids.

Now I no longer work with kids, but I’m primarily focused on trauma therapy. Mainly EMDR. And in addition to that, I work with clients who are dealing with anxiety and overwhelm and also chronic stress because of being high-capacity leaders.

So over the years, one of the things that I’ve become especially interested in is how sleep shows up across many different clinical presentations that I see. And not as just a separate issue, but it’s something that interacts with the emotional regulation of my clients. So that curiosity really grew out of my own practice journey, but also personally just knowing how much sleep impacts myself and also impacts clients. And so that became really important to me and supporting my clients.

Amazing. So let’s talk about when you are meeting a new client, how do you think about sleep as a part of the overall assessment and case formulation when working with that client?

Yeah, so early on with my work with a client, my goal isn’t to fix sleep. It’s more about understanding it and how it’s not showing up for a client. What are the patterns that are happening? So for example, how long it takes for a client to fall asleep, and how much time they spend awake at night. How rested do they feel in the day? How much are they in bed? Awake. And the challenge is that when clients come, their memory about their sleep is often skewed by just how long their last night went. So I’m more interested in the trends rather than just one bad night.

I want to know about what is the problem that they’re noticing and how is it maintaining over time? So something stressful or traumatic may have triggered this, but often they change and are different from what started it. And it’s also important to say that sleep concerns aren’t only about not getting enough sleep. Sleeping too much can be just as clinically meaningful.

So for some clients, especially for those who are depressed, long periods of sleeping can function as a way of coping or escaping. And for others who may be struggling with chronic pain or illness their increased sleep needs may reflect some genuine physical fatigue or the body trying to recover.

So the key isn’t judging the amount of sleep, but it’s understanding what the function of sleep is serving. Is it restorative? Or is it avoidant? Is it compensating for something else that’s depleted? And that can give a lot of information especially as you start to think about that treatment plan and case conceptualization understanding it early can help me to support the client for the rest of the therapy and help to make that therapy more effective.

The case conceptualization tells us if this nervous system is regulated what are coping strategies and what might be maintaining symptoms, and then that can help us to pace and plan the work.

It’s also important to acknowledge that how we assess and conceptualize the sleep is going to look different depending on the type of modality that we use for a client. So sleep becomes part of the treatment planning across different approaches and the lens can change depending on that approach.

For example, a CBT therapist may focus on beliefs and behaviors that maintain sleep problems, where someone who’s doing DBT will think of it in terms of more of the emotional regulation and the vulnerability factors. And for myself as an EMDR therapist, I’m listening for sleep as a marker of that nervous system activation and the readiness for the trauma processing.

But what’s consistent as I begin work with a client and cross modalities is that the sleep can give us information about the capacity and factors that a client is going through in their life at this time as they come to see us.

I love that. What do you listen for in session that might tell you sleep could be an important place to focus early on with a client.

I’m listening for patterns around their sleep timing and the quality. Is there challenges with falling asleep? The frequent awakenings, as I was talking about. And also what’s really can be important is do they feel like refresh.

I wanna be attentive, and I’m listening to the daytime impact. So if they come in saying I have brain fog, or I can’t concentrate really well, or I’ve just so angry all the time, or I feel depleted some of these symptoms that clients bring in as they say, this is why I’m here. This is around my goals for therapy. I am listening for is there a piece of the lack of sleep that is impacting what’s happening? So I’m listening for the signs of the nervous system being aroused at night.

Which as we know, like with PTSD, you know, lack of sleep or nightmares is part of some of the symptoms that are connected to that. So I’m paying attention to where it’s showing up for them. And if a client is coming in and saying that they’re napping a lot or they sleep for 12 hours. But they’re not feeling rested. Of course, encouraging the clients to go and get medical attention or asking around, is there a physical thing? ‘Cause we’re not doctors, we can’t know that per se. But if there’s nothing there that was suggest a physical reason for that sleep struggles. That’s really important cues.

And another thing that I’m listening for and I’m curious about is their dreaming. So I’ll sometimes, I will ask clients, do they have dreams? Do they remember their dreams? Do they have a recurring dream? Or do they struggle with nightmares. Nightmares in particular, especially as we know with trauma can suggest that their experiences in life, whether it’s small traumas or big traumas that they haven’t been fully integrated.

So I’m not as concerned about the content of the dream per se, but I’m more interested in the emotional tone the client feeling in that dream. And then that can give information to me as a therapist, that there could be emotions that the brain is trying to process or the brain is trying to make sense of experiences that are happening.

And so when someone is having these repetitive dreams or nightmares. It’s important information that we can use for where we’re going to target and what might be in the subconscious space the client’s not consciously aware of.

So the sleep it’s not just a side issue it’s about how the client’s coping and also maybe their readiness for doing the therapy.

I love that. So why can working with sleep early on be so helpful for clients, especially when they’re feeling overwhelmed or unsure where to start?

When clients are really feeling overwhelmed, it’s can be hard for them to, know what therapy is going to do for them. Sometimes this is the very first time they’ve come into therapy and there’s that anxiety, and so it can give something that’s very concrete and manageable to focus on.

When someone is exhausted, everything feels harder. And emotions are louder and the concentration is lower, and so even small tasks can feel really overwhelming. So the sleep work often allows for really small but specific shifts rather than big changes. A client can leave like even in a first session with a gentle adjustment or one piece of education that can help them to start to feel a little bit more settled.

It can create that early sense of okay, this is something I can do. I can have control with this. And an early win can matter because that helps the clients to feel that there is change possible. And in that way too, it can be confidence building. When clients notice like even a slight improvement and it’s not like perfection, but there’s maybe a little shift that can happen then that helps them to realize that there is possibility. We can engage in this therapy, I can tolerate some harder conversations later on with it.

It also really helps with emotional regulation with clients and that window of tolerance. And I’ll talk to clients about this, when we’re gonna introduce that window of tolerance, that space where they can have some difficult stuff happening, but they’re not swinging into having anxiety or panic attacks, or their system isn’t just shutting down. It’s that space where they can stay present. And that just getting even a little, 10 or 15 minutes more sleep or making sure they get up at the same time each morning can really help to just even make that window a little bit bigger.

One of the first places I start with a client is just having them choose a consistent wake up time. I don’t focus on getting to bed or how many hours or any of that. It’s just saying, Hey, let’s find a time where you can consistently wake up each morning and get outta bed. That can help your brain to just create some rhythm and some stability. Because when there’s trauma, when there’s anxiety, the system is so disorganized and having something like anchoring your morning and when you get up can start to give the nervous system and that time clock that’s in the brain there some stability with it, which can help to make it feel safer.

Of course, we all know this not everybody can control their mornings and all the parents in the group or caregivers are saying, yeah, or, if a person’s doing shift work that might not be a realistic starting point.

But in these situations, another place I’ll go is just even some psychoeducation around sleep environment. We know it and, the sleep hygiene things like making your room as dark as possible, making sure there’s not stimulation before bedtime, having a sort of bedtime routine. A lot of times I’m amazed that clients don’t really even know some of those beginning sleep hygiene things. And so that education is really important. And I just again, wanna emphasize that this isn’t about perfection. Sleep can be a really hard thing to navigate through. So we just wanna make these really small shifts that can feel and be doable. Just a small adjustment so that clients can just even notice how their body responds and just have a sense of a little quick win for themselves as they are getting launched and starting off in their therapy.

Amazing. So what are some simple and practical ways therapists can explore sleep with clients without turning it into a separate or specialized treatment Right away.

I usually begin with an open-ended question about sleep. So just even something as simple as how has your sleep been lately? And then I listen, if a client tells me their sleep is good and it doesn’t feel like a concern for them, I respect that and I just move.

So if sleep doesn’t need to be the focus for every client that’s coming in. But when a client is describing sleep as a struggle, and especially if it’s connected to how they’re functioning during the day and what they want help with, or what their goals are for coming in, I become more curious. Rather than jumping in to fix it, I might ask a few follow up questions like we talked about, such as the patterns or how the sleep has changed with stress.

I’ll ask, has sleep always been a struggle with you? Some people just either more sensitive to noises and sounds, and I know with one of my kids, any small little thing, they were awake, their system heard it, and so it’s just been a pattern for their whole life. Or have they been good sleepers, but something happened in that pattern changed for them. So I just be curious and ask more. And I just try to normalize things for them. That, oh, it makes sense that you struggle with that. We’re gathering this information.

And so that’s where the psychoeducation can come in. That’s where we can talk about how sleep is connected to emotional regulation. They’re very closely linked and, a lot of clients just, they start to get anxious. About this lack of sleep, and then that creates more anxiety. And so we’re just trying to make the mountain a little bit smaller that they have to climb with normalizing it. And have some self-compassion and be not as critical of themselves.

And if the goal for the client is to improve their sleep, if they know that they’re needing that, then I will use a sleep assessment to start to go into deeper, what are the patterns what is it that’s happening, rather than just guessing at it.

But it helps ’em to think through the different components that are connected to sleep. And that allows that collaboration with the client. So rather than turning sleep into this separate treatment or this thing that we have to get all right at the beginning, it’s more just how does this fit in with a bigger picture in what you’re coming for therapy.

Absolutely. And this kind of brings me to my next question of can improving sleep support the deeper, say emotional or trauma work, that can sometimes come later in the therapy process.

Yeah, improving sleep really supports that deeper emotional and trauma work because the sleep is foundational to how the brain regulates emotion and processes experience and stay stable under stress. When we look at the stages of sleep, if you have a watch or a ring or something that is tracking your sleep, it’ll look at, how much REM sleep a person is getting, how much of deep sleep, how much of that lighter sleep.

So we know that from a brain perspective when there is a lack of sleep. Especially in that REM sleep where the REM is, of course, that space where the brain is streaming, that’s the rapid eye movement stage and the brain is processing challenging situations, the emotions that are happening. And if the brain is not able to go into that, place or does not have that space to do that type of work, then that’ll be playing out in the nervous system and how it regulates itself. So sort of the alarm systems of that fight flight freeze are overactive. There’s gonna be a lot more like false alarms or, putting it again into that sort of window of tolerance. That window becomes a lot smaller. And so the clients are gonna be more reactive or more overwhelmed and also more likely to misinterpret sort of neutral experiences as being threatening.

And so when sleep improves, that balance begins to shift and clients can have more emotional steadiness and can present with more difficult material. Because as we know in doing trauma work or doing some of this work in therapy can be difficult in and of itself too. And if a person isn’t ready yet to go into that really deeper kind of stuff because their brain is not safe to do that, or their system isn’t safe, then we wanna really move slowly with it too.

So that’s something that I’m always considering too with working with a client. Now. It’s a little bit of a tricky situation because it’s not necessarily linear. So for example, for some clients, especially if trauma’s involved the sleep challenges or the nightmares aren’t gonna fully improve until the trauma has been processed work through. So we can’t necessarily wait till sleep is perfect before we continue. It just becomes that balancing act.

If sleep is very disrupted, then they might not have the emotional regulation to begin to do the difficult work. But then if we don’t do the difficult work, then they won’t get that relief in their sleep. The improvements might come later. I think of it like this. It’s a little bit like trying to rebuild a house during a storm, so it technically is possible to be rebuilding this house. But it’s a lot harder when there’s a storm going on. And it’s less stable. So we wanna maybe have more like structures in place, more scaffolding to ensure that unless we are building this house it’s not going to collapse. In that we want the conditions to make sure that it is safe and that the work is effective, or maybe we need to slow down the work with that capacity for it. So that’s I know it’s hard to answer that question just because of that push pull that we’re working with anxiety, depression all of those things.

I think that’s a really great analogy though, and I think it really puts into perspective that cycle of sleep really, sleep is contributing to the recovery, but then the reason that recovery is needed is also impacting the sleep. So balancing both sides to that coin. But I love that, Pamela, you have a free assessment you’d like to share. Can you tell us what it is and how it can help listeners?

Yeah. The assessment that I use is called The Better Sleep Self-assessment. It’s a brief non-diagnostic tool that I use to help therapists and clients to better understand those sleep patterns without turning the sleep into that separate treatment right away. So therapists who are trained in this CBT for insomnia are gonna recognize some of the structure of this assessment because it’s based on some of those core principles that are used in evidence-based sleep work.

But what I’ve done is adapted it into be a reflective format that can help therapists and clients adjust to whatever modality that they’re using without having to necessarily be following a sort of a CBT for insomnia type structure.

And what I like about it is that it’s a reflective, it gives a score that can also help clients to notice if they are having improvements in their sleep in the quality of it and like that nighttime arousal. Or maybe if it gets worse and so it can be used, maybe like once a month or that type of thing as just a way to look at what’s happening for them.

Sometimes, sleep is improving and then they’ll have one bad night and it’s oh, it’s all kind of been thrown out. But it can show them no there is something that’s happening here. And again, it just gives that conversation about these are the different components that we’re looking at when we’re looking at with sleep.

It’s not about becoming a sleep specialist or anything with that, but just giving some language and awareness to clients around how it impacts the work. How to pace things and how to move forward in a planned shared goal setting way.

So to sign up for Pamela’s better sleep self-assessment, check out hope-harbour-kit.com/sleep-assessment

Or you can simply scroll down to the show notes and click on the link.

Pamela, thank you so much for joining us on the podcast today to share what sleep tells us about clients and how to support them early on.

Thanks so much, Kayla.

And thank you everyone for tuning into today’s episode, and I hope you join me again soon on The Designer Practice Podcast.

Until next time, bye for now.

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