Sleep‘We’re built for sleep,’ according to the psychologist Aric Prather, yet many of us still struggle to overcome insomnia. He talks us through his ‘prescription’
Many of us are hoping for a happier, healthier life in 2023. We may already be trying lifestyle changes (daily meditation, giving up dairy), but for most of us the greatest gains to be had are in sleeping better. Regardless of your specific goal – whether it be to lose weight, reduce stress, get fitter, advance at work, or be a better friend or partner – it is hard to achieve anything when you have had insufficient sleep.
On the flipside, everything seems more possible when you are well rested. Sleep boosts the immune system, regulates mood and metabolism, and can make you more productive, patient or creative. It sharpens the mind and can prolong your life.
“Sleep is one of the most powerful things you can do for your body. It’s just critical to make that a priority,” says Aric Prather, author of The Seven-Day Sleep Prescription. A psychologist and professor of psychiatry and behavioural sciences at the University of California, San Francisco, Prather practises cognitive behavioural therapy for the treatment of insomnia (CBTI).
In his book, he shares his strategy for “unlocking your best rest”. He says: “Life is hard, there is always stress, sleep is disrupted, but there are things we can do.”
Better yet, the effort pays dividends. “The more work you put into it, the better you’ll sleep,” says Prather. Here are his tips on how to get started.
Start keeping a sleep diary
The aims of Prather’s practice are to regulate our internal clock and to address any anxieties or hangups we have developed around sleep. Reliably restful nights take both, he says.
It may be that you have unwittingly formed bedtime habits that promote wakefulness, but before you can change your behaviour, you must become aware of it.
Prather asks his patients at the UCSF insomnia clinic to start keeping a handwritten “sleep diary”, recording facts such as how long it took them to fall asleep, the number of times they woke during the night, their wake-up time and estimated sleep quality. The aim is to highlight patterns and possible areas for improvement. “Sleep is universal, but it’s also really personal,” says Prather. The diary is the first step towards an approach that will work for you.
Manage your expectations
Often Prather’s patients have had one “terrible” night, and worry about it happening again. They may go to bed early to make up for it, then lie there fretting that sleep won’t come, which exacerbates their insomnia.
Sometimes, he says, they are chasing a unicorn. “They have maybe had one fantastic night when they’ve fallen asleep and woken up in the same position, feeling great, and that’s become what they’re shooting for … You can savour that experience, but that can’t be your goal.”
Accepting that sleep will sometimes elude you, for reasons outside your control, helps to relieve the stress, frustration and anxiety around drifting off, perhaps making it more possible.
“It’s really about teaching people that one bad night won’t ruin your life,” says Prather. “We’re resilient, we’re built for sleep.”
Wake up at the same time each day
If you are struggling to sleep, it is tempting to “catch up” with a lie-in at the weekends or when you can, but this can backfire by further confusing our internal “drivers” of sleep, says Prather. “Our brain is always taking on information, trying to keep us alive, making predictions about what’s going to happen next – so the more things can be stable and consistent, the better those predictions are.”
Striving to go to bed at the same time every night can pile on pressure that is not conducive to sleep, says Prather. Instead, he advises waking up at the same time (or within a half-hour window) every day to regulate your circadian rhythm, which governs your bodily processes and whether you are a night owl or an early bird.
What time you choose is up to you, says Prather; the key is consistency. If it is a challenge to begin with, he suggests anchoring it in a ritual that you look forward to such as making a cooked breakfast.
After a while, you should naturally start to feel sleepy around the same time every night. “It’s like restarting your sleep drive … all that can be anchored to one time in the morning.”
Let yourself wind down
Your brain needs time to decompress from the pressures of the day and prepare you for sleep – if possible, about two hours before your ideal bedtime.
“Often people treat their brains and their bodies like laptops: ‘Well, turn it off!’” says Prather. “I wish it was that way … but we need to have an adequate transition.”
The optimum post-work, pre-bed activity will be different for everybody: some people clean, others listen to a podcast, some might write in a journal or do some gentle stretching.
These rituals can become environmental triggers, encouraging us to shift gears into sleep. Even television can help us wind down, says Prather (though he advises against watching it in bed).
But, he adds, there is a big difference between starting a nail-biting new drama, and zoning out to reruns of a familiar show such as Friends. Likewise, the anxiety-inducing content of your Twitter timeline is probably more harmful to sleep than the blue light being emitted by your phone.
If, after two hours of winding down, you are still wide awake, it may be that your routine is too stimulating. Prather recommends meditating before bed (“If that’s your thing”) or listening to gentle music.
To sleep better at night, start with your days
“Sleep and your daytime experience are intimately intertwined,” says Prather.
If you go full tilt from dawn to dusk without taking any breaks, the pent-up stress will inevitably catch up with you come bedtime – and, once chronic, it is hard to shut off.
For this reason, Prather says, it is vital to manage your workload, build downtime into your schedule and actively strive to manage stress.
He challenges his patients to take five “microbreaks” of five to 15 minutes every day, preferably without reaching for a caffeine boost every time. He suggests meditating, phoning a friend or even – if you’re really flagging – sticking your head in your freezer. “There are ways to get through the midday doldrums without an extra cup of coffee: that cold exposure is absolutely alerting … You can also do a brisk walk outside.”
If you are concerned about being seen to be shirking, or you feel you are just too busy to step away, Prather suggests reframing it as an investment in your health. “There’s just such a long history, at least in western culture, around the merits of productivity. You have to really make the case that by investing in sleep, it actually improves your productivity in the day.”
Our thoughts likewise need to be managed, with dwelling on problems or replaying past regrets believed to be one of the major factors in insomnia. CBT techniques such as learning to observe your thoughts from a distance, without engaging with the content – as though they are faraway clouds, or passing cars – can be helpful in shutting them off at night. Prather suggests setting aside 15 minutes each day for “intentional worry time”. Set a timer and list the things you are worried about, without attempting to solve them.
It helps to relieve latent anxiety, he says. If those worries do crop up again at night, tell yourself you will deal with them in tomorrow’s “worry window”, or write them down.
Test your sleep drive
Once you have at least a week’s worth of data in your sleep diary, Prather says, you can work out your “sleep efficiency” score. That is the approximate number of minutes that you spent asleep, divided by the number of minutes you gave yourself to sleep (including how long it took to drift off, and any time spent out of bed due to insomnia).
The threshold that Prather aims for with his clients is average sleep efficiency of at least 85% for adults aged up to 65, and about 80% for those over 65.
If you routinely fall short, you may have become conditioned to associate being in bed with being awake. Start by restricting your bed to sleep and sex only, and don’t go to bed until you are sleepy. If you are still very much awake after 20 to 30 minutes, get up and continue to wind down elsewhere, with a cup of tea or a book, until you feel like drifting off again.
If this doesn’t produce results, Prather’s next suggestion is perhaps counterintuitive: go to bed late. He rarely tells his patients to be asleep by a particular time, but he often tells them that they cannot go to bed any earlier.
The idea is that – by restricting their time spent in bed to the number of hours that (their sleep diary suggests) they are actually sleeping, plus 30 minutes in which to drift off – they reduce the time spent lying awake, and foster an association between the bed and sleep.
“With insomnia, people say they’re tired, but they’re often not sleepy – they just feel bad and fatigued,” says Prather. “That feeling of sleepiness is rare. So that’s why pushing on that drive, that biological need, is so powerful … Then, as they get some success, it helps shift their mindset: ‘Oh, I can sleep. It’s not broken.’”
After a week, many of Prather’s patients report falling asleep almost instantly and sleeping through to their alarm. That late bedtime can then be gradually brought forward, in 15-minute increments every few days.
Investigate other possible issues
Prather urges against pharmaceutical sleep aids, especially for long-term insomnia. “It just masks the symptoms … People can become really psychologically dependent on them.”
If your sleep troubles persist despite your best efforts, he advises consulting your doctor. It may be that you need personalised support for CBTI to be effective.
Insomnia could also be indicative of another sleep disorder, or underlying medical issue. Obstructive sleep apnoea, for example, often goes undiagnosed but is disruptive to sleep.
“Often, people will wake up in the middle of the night, feeling anxious, and it’s due to the fact that their airway was obstructed,” says Prather.
A sore jaw or headache might suggest night-time teeth-grinding, which can be alleviated by wearing a mouthguard. Another potential cause of low-quality sleep is depression, with both oversleeping and waking up early possible symptoms.
Sleep is such a fundamental building block, seeking to improve our routines can be “a great entry point” to better overall wellbeing, says Prather. “Most people don’t want to talk about their depression or anxiety or trauma, but they’ll talk about their sleep.”
Fight for your right to sleep
We may be built to sleep, but the modern world isn’t. Our schedules are tethered not to the sun but technology. We are awash in artificial light every hour, we feel that we can’t afford to switch off.
In truth, not everyone has equal opportunity to sleep, with race and socioeconomic status often connected to less or lower-quality rest.
Prather advocates for sleep to be recognised as a human right: to be promoted in and of itself, and enshrined with social and policy change.
In his dream world, this could mean greater protection for night-shift workers; later school start times allowing for teenagers’ need for sleep; and “right to disconnect” laws restricting work emails. Employers could promote the importance of switching off after work.
The post-pandemic shift to hybrid working was a chance for greater flexibility; instead, says Prather, “people have shifted to being available at all times – really impinging on opportunities for rest”.
This has led to what has been termed “revenge bedtime procrastination”, where people stay up late just to claw back a few hours for themselves. “People feel like their time isn’t theirs any more,” Prather says. “It’s this constant struggle.”
The solution to that resentment and time-pressure is not to deny yourself rest, he argues, but to fight for it. “It may seem like you’re kind of shortchanging that time, but actually, it’s doing an incredible thing to try to enhance your wellbeing, your creativity, your cognition, your ability to deal with stress. All of those things will serve you well in living your best life – when you’re awake.”
The Seven-Day Sleep Prescription by Dr Aric Prather is out now.
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