Sleep confidence: what to work on before another sleep technique

The thing patients are working hardest at

I spoke with Dr. Sarah Silverman, a Stanford-trained sleep specialist who uses a mindfulness-based approach to insomnia, about what she works on with patients before anything else.

Her answer was sleep confidence.

Sleep confidence is, in a nutshell, confidence in your own ability to sleep. Even after a bad night, you trust that the next night is likely to be better.

Most people who struggle with sleep have lost that. Sleep has become stressful, and then it becomes a fear.

Why trying harder makes it worse

Sleep is one of the few health behaviors that is involuntary.

We can do everything to set the stage for good sleep. We can promote it. We cannot force it.

Dr. Silverman put it this way: you are teaching the patient to be inviting to sleep, not smothering to it.

The harder a person tries to sleep, the more elusive sleep becomes. Gillian Flynn wrote in Gone Girl that sleep is like a cat, it only comes to you if you ignore it. It describes the problem exactly.

So the work is not another technique for falling asleep. It is helping the patient let go of the need to control it.

What that looks like in a session

Acceptance is the principle that builds sleep confidence.

You are helping the patient acknowledge that sleep is a biological process that cannot be forced, and to be open to being awake during the night and tired during the day.

Nobody has to be happy about being awake at 3am. Neutral is enough. The goal is being open to whatever the night brings, rather than resisting it.

This takes time, in the same way that any change in health behavior takes consistency and patience. It is a skill, not a switch.

One assessment tool worth adding

Alongside the Epworth Sleepiness Scale and the Insomnia Severity Index, Dr. Silverman uses the Dysfunctional Beliefs and Attitudes about Sleep scale.

What it gives you that the others do not is a view of how the patient is thinking about their relationship to sleep, statement by statement.

That makes it a useful tool for building sleep confidence, because you can see which specific belief needs the work.

A sleep diary over a couple of weeks remains the easiest place to start, and gives you a good baseline.

Grounding techniques you can hand a patient

Grounding is an umbrella term. Dr. Silverman uses it for frustration during the night, and for daytime nervous system regulation.

Physical grounding is walking in grass or sand, stepping into water, getting natural light. Connecting back to nature.

The 5-4-3-2-1 technique works through the senses: five things you can see, four you can feel, three you can hear, two you can smell, one you can taste. It brings a patient back to the present moment and away from frustration.

Category grounding is picking a category, such as movies or animals or countries, and spending a minute or two listing as many as you can.

Mental exercises do the same job. Counting backwards from 100 by sevens, or saying your full name backwards and then three family members’ names backwards.

Deep breathing is the one most patients already know. Breathing in for four and out for four, with attention on the body, slows the heart rate and grounds them.

These are also useful for rumination and anxiety outside of sleep.

What to tell patients about their mornings

Good sleep begins in the morning. Dr. Silverman’s three starting points:

• Wake at the same time every day, including weekends and non-work days. This anchors the circadian rhythm.
• Get natural light within the first 30 to 60 minutes of waking. A walk outside without sunglasses gets light and movement at once.
• Practice a stress reduction technique earlier in the day, not just at night.

That last one is the one clinicians tend to skip. A patient who is overwhelmed and running all day, and then expects to switch off at bedtime, is asking the nervous system to do something it does not do.

Starting small is the point. One or two minutes of breathing, practiced regularly, does more for the nervous system than a 30-minute practice nobody sustains.

When to refer

Dr. Silverman’s threshold: difficulty falling or staying asleep on more than three nights a week, with daytime consequences, for more than about three months.

That is where short-term insomnia has become chronic. Short-term insomnia, sometimes called adjustment insomnia, tends to run a few nights to a month around a stressful event.

She also makes the case for referring earlier, before the three month mark, when things are clearly heading that way. Intervening at a few weeks can stop adjustment insomnia from becoming chronic.

Two other referral triggers worth having in mind:

• A patient using an over-the-counter sleep aid regularly, such as diphenhydramine or melatonin, for a sustained period.
• Suspected mineral or vitamin deficiencies, including low iron, that may be contributing physically.

Clinical pearls

• Sleep confidence is the target, not another sleep technique. Confidence that the next night will be better is what breaks the cycle.
• Teach patients to invite sleep rather than force it. Acceptance is the mechanism.
• The Dysfunctional Beliefs and Attitudes about Sleep scale shows you which belief to work on. The Epworth and the Insomnia Severity Index do not.
• Grounding techniques belong in the daytime, not only at 3am.
• A fixed wake time and morning light are the two highest-yield instructions most patients can start immediately.
• More than three nights a week, for more than three months, is the referral threshold. Earlier is fine and often better.

Patients arrive believing they are bad at something everyone else does easily. Sleep is a self-regulating system, and a good part of the treatment is helping them trust that it still works.

Many of the symptoms these patients have been living with are highly treatable. Most of them have simply never been told that.

Disclaimer: This information is for educational purposes only and is not intended to replace individualized medical advice, diagnosis, or treatment.