Getting enough sleep is a key to maintaining good health. The Centers for Disease Control recommends the average adult get at least 7 hours of uninterrupted high quality sleep for optimal health1. On the other hand, a lack of sleep is associated with many types of chronic diseases. People who chronically do not get enough sleep are at a higher risk of developing: type 2 diabetes2, cardiovascular diseases3, obesity and inflammation4, and mental health problems like anxiety and depression5. The consensus is clear; good sleep is a critical part of good physical health.
However, some researchers are also interested in another potential benefit of good sleep. Can sleep actually enhance the positive effect of psychotherapy on a client’s mental health symptoms and quality of life? This is particularly important, because evidence suggests that nearly 50% of individuals who seek psychological treatments – for anxiety, or depression, or another mental health problem – do not improve6. This may be due to a variety of factors, such as the client’s attendance and engagement in the therapy, other stressful things happening in the client’s life, and the quality of the therapy being delivered. Therefore, finding innovative ways to enhance the benefit of psychological treatments is particularly important in order to help more people experience the benefits.
One potential target researchers are examining is called “treatment adherence,” and exploring if sleep before and after a therapy session can improve treatment adherence7. Treatment adherence refers to how well an individual understands the treatment, and also enacts the skills taught in treatment outside of session;8 it has been found to be associated with more positive outcomes in psychotherapy9.
Researchers from the University of California, Berkeley, wanted to understand if the amount of sleep a client gets while in treatment can impact treatment adherence, and therefore improve the client’s outcome in the treatment. This study is based on previous research that highlights that sleep problems are associated with impaired learning and encoding of new information,9 and worse emotional memory and consolidation of new information.10,11 Therefore quality sleep before and after treatment may enhance new learning in session, and the emotional memory of things experienced in session, and therefore improve treatment adherence and outcome.
The current study wanted to examine if sleep the night before and after a treatment session, is related to treatment adherence. Researchers recruited a sample of 188 adult participants (80% White, 63% Female) seeking treatment for persistent insomnia. When examining the relations between sleep over the course of treatment and therapist-reported treatment understanding, researchers found that longer total sleep time between sessions (and therefore shorter total wake time between sessions) predicted higher treatment understanding over the course of treatment.
Healthy sleep improves physical and mental health
Results indicated that clients with longer periods of sleep after sessions also predicted higher treatment understanding at the next therapy session, and over the course of treatment. These results are consistent with prior research suggesting that healthy sleep: 1) prepares the brain to encode and learn new information in the next day, as well as research that suggests that 2) healthy sleep supports the consolidation and retention of new information learned during the day, and in this case, in psychotherapy.
These findings suggest that getting adequate sleep both the night before and after a therapy session may help improve the client’s understanding and adherence to the treatment. The adherence to the treatment may then potentially help improve the client’s outcomes in the treatment. However, there are important limitations to this specific study. This study had a mostly White sample, and the presenting problem in the study was related to sleep difficulty. So, it is unclear if these findings would generalize to other presenting problems, such as anxiety disorders, and to more racially, culturally, and ethnically diverse clients. However, there is some evidence that sleep following exposure therapy for specific phobias, improves the therapeutic impact of exposure therapy, possibly by strengthening the new learning established during the exposures in therapy12.
This research study was not designed to examine if sleep actually causes an increase in treatment understanding. It only tested if the two were related. It could be that other factors are causing an increase in treatment understanding, such as the client’s motivation or expectancy for the treatment to be helpful, and that treatment understanding is actually causing an improvement or increase in the client’s sleep. Therefore, while these findings are not conclusive, they do provide additional research support for the benefits of sleep on psychotherapy understanding and adherence, and hopefully these questions can be researched in other types of psychotherapies and with anxiety and mood disorders.
1. Watson NF, Badr MS, Belenky G, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep. 2015;38(6):843–844.
2. Knutson KL, Ryden AM, Mander VA, Van Cauter E. Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus. Arch Intern Med 2006;166:1768–1764.
3. Kasasbeh E, Chi DS, Krishnaswamy G. Inflammatory aspects of sleep apnea and their cardiovascular consequences. South Med J 2006;99:58–67.
4. Taheri S. The link between short sleep duration and obesity: We should recommend more sleep to prevent obesity. Arch Dis Child 2006;91:881–884.
5. Schwartz DJ, Kohler WC, Karatinos G. Symptoms of depression in individuals with obstructive sleep apnea may be amenable to treatment with continuous positive airway pressure. Chest 2005;128:1304–1306.
6. Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), The efficacy and effectiveness of psychotherapy (5th ed., pp. 139–193). New York, NY: Wiley.
7. Dolsen, M. R., Soehner, A. M., Morin, C. M., Bélanger, L., Walker, M., & Harvey, A. G. (2017). Sleep the Night Before and After a Treatment Session: A Critical Ingredient for Treatment Adherence?. Journal of Consulting and Clinical Psychology, doi:10.1037/ccp0000184
8. Lichstein, K. L., Riedel, B. W., & Grieve, R. (1994). Fair tests of clinical trials: A treatment implementation model. Advances in Behaviour Research and Therapy, 16, 1–29. http://dx.doi.org/10.1016/0146- 6402(94)90001-9
9. Abramowitz, J. S., Franklin, M. E., Zoellner, L. A., & DiBernardo, C. L. (2002). Treatment compliance and outcome in obsessive-compulsive disorder. Behavior Modification, 26, 447–463. http://dx.doi.org/10 .1177/0145445502026004001
10. Abel, T., Havekes, R., Saletin, J. M., & Walker, M. P. (2013). Sleep, plasticity and memory from molecules to whole-brain networks. Current Biology, 23, R774–R788. http://dx.doi.org/10.1016/j.cub.2013.07.025
11. Stickgold, R., & Walker, M. P. (2013). Sleep-dependent memory triage: Evolving generalization through selective processing. Nature Neuroscience, 16, 139–145. http://dx.doi.org/10.1038/nn.3303
12. Kleim, B., Wilhelm, F. H., Temp, L., Margraf, J., Wiederhold, B. K., & Rasch, B. (2014). Sleep enhances exposure therapy. Psychological Medicine, 44(7), 1511-1519. doi:10.1017/S0033291713001748
Sarah Krill Williston is a PhD Candidate at the University of Massachusetts Boston, working in the Roemer lab. Her research centers on boosting mental health literacy and reducing stigma to encourage evidence-based care-seeking for anxiety and trauma-related disorders. Sarah specializes in offering evidence-based treatments like CBT and ABBT to individuals, particularly military families, active duty service members, and veterans with mood, anxiety, and trauma-related disorders.