Transcript for Episode 96: Sleep Health is a Social Justice Issue

Cat McDonald:
Hi, I'm Cat McDonald, and this is NASW Social Work Talks. And today we're talking about sleep health. Sleep is as important to humans as food and air, and a lot of people, especially Americans, tend to not get enough sleep at night. Sleep hygiene is so important because when you don't get enough sleep, that can have a lot of negative effects on your body and your brain. So today we're speaking with Jessi Pettigrew. She is a licensed clinical social worker and a PhD candidate at the Graduate School of Social Work at Colorado State University. Working with clients, Jessi became curious about the intersection of sleep and mental health. So I'm excited to speak with Jessi to share what she's learned about improving the sleep health of clients and practitioners alike.

Jessi Pettigrew:
Absolutely.

Cat McDonald:
Welcome, Jessi.

Jessi Pettigrew:
Thank you. Thanks for having me.

Cat McDonald:
So can you talk about what made you interested in the topic of sleep?

Jessi Pettigrew:
Absolutely. So I noticed that there was a huge need among the clients that I was serving, both in my inpatient experience in an outpatient therapy, and I didn't feel like I had a lot to offer them at the time. So that kind of motivated me to research and kind of learn more about sleep. Also, I had a mentor and supervisor at our outpatient clinic at the University of Kentucky, and she noticed that there was a clinic-wide need. A lot of people were calling to try to get treatment for insomnia and other sleep disorders. And at the time, we didn't have a therapist who was trained to provide any sort of behavioral sleep interventions. So those things really motivated me to get trained in cognitive behavioral therapy for insomnia, which is where I started. And I feel like once I learned a little bit, I wanted to just keep learning because sleep is so fascinating. So I'd say I kind of became obsessed with all things sleep.

Cat McDonald:
Yeah. So how did you learn more? What are kind of things did you do?

Jessi Pettigrew:
Absolutely. So I found some training opportunities in cognitive behavioral therapy for insomnia, and really I just found an online certification course through PESI, and I can share that resource for your listeners if that would be helpful. And then after that point, I did get some additional training and some supervision in treating other sleep disorders. So I was working toward a behavioral sleep specialist certification and then decided to get a PhD. So I put that on hold for now, but I would love to go back to it at some point.

Cat McDonald:
So it's recommended that adults get between seven and nine hours of sleep every night.

Jessi Pettigrew:
Yes.

Cat McDonald:
Can you talk about why our bodies need sleep and why sleep is so beneficial for our bodies?

Jessi Pettigrew:
Absolutely.

Cat McDonald:
And what can happen when we don't get enough sleep?

Jessi Pettigrew:
Absolutely. So I'm glad that you gave that range because I think a lot of people get stuck on this idea that we need eight hours of sleep every night. And that's not true for every person. Every person really has their own sleep need. So you have to pay attention to your own body and figure out what that is for you. Also, it can change just based on activity levels and things that we do throughout the day. So sleep is absolutely crucial for our bodies. So what happens when we're sleeping is we go through a process of physical restoration. There's also some memory consolidation and emotion regulation that happens when we're sleeping.

So when we don't do those things, then as you can imagine, there are consequences from that. So there are physical and mental health consequences of not getting enough sleep. Now, I also want to provide the caveat that it's normal to have a bad night of sleep here and there, and that happens to everyone. So you can have a bad night of sleep without having severe consequences from that. But generally, even short term consequences from sleep deprivation include decreased emotion regulation, distress tolerance, increased negative affect, problems with memory and concentration. And that can be even from just a few nights of sleep deprivation, which tends to be compounding. And then chronic sleep deprivation has a whole host of mental health disorders that are associated, and also physical health consequences. So in terms of mental health things that we see, depression, anxiety, ADHD, especially in children.

So children tend to have kind of a paradoxical effect from sleep deprivation, which is that they look hyperactive during the day. And so that could actually be a sign of sleep deprivation. And then in terms of physical health consequences, chronic sleep deprivation or untreated sleep disorders alter the body's ability to regulate itself because it's unable to go through those processes that are really important while we're sleeping. So that can lead to chronic health conditions. So there are links between, again, sleep deprivation and untreated sleep disorders and cardiovascular disease, heart attacks, stroke, cancer, dementia, increased risk of accidents, so workplace accidents and car accidents. So a lot of things to be concerned about. I do want to say, I'm sure we'll talk a little about insomnia disorder later, but we don't see as dire of health consequences with insomnia disorder. And I want to say that as a point of reassurance because people suffering from insomnia disorder are terrified of having these consequences, which is actually part of what makes it harder for them to sleep. So I do also want to provide that caveat.

Cat McDonald:
One thing you said that's interesting is that kids can become more hyperactive when they don't get enough sleep. So it's possible that kids are maybe getting misdiagnosed with ADHD.

Jessi Pettigrew:
Absolutely.

Cat McDonald:
Because they demonstrate these tendencies.

Jessi Pettigrew:
Absolutely, absolutely. And I think it's more common that primary care doctors and family practitioners are trained in recognizing that, but not everyone is. So it's also a good thing for parents to be aware of. And also, kids can have sleep apnea, and so it could be something that's extremely treatable. So it could be scheduling and the fact that they're not getting enough sleep or it could require a medical intervention.

Cat McDonald:
And that's such a challenge because schools start so early.

Jessi Pettigrew:
Absolutely.

Cat McDonald:
And if they're hyperactive and then they don't fall asleep and then they have to get up early, it's like this cycle.

Jessi Pettigrew:
Absolutely. And that's especially a problem with our teens. So teens naturally have a more delayed sleep schedule, which is completely natural biologically. And again, some places have done a good job of doing later school start times, but places that don't, our teens are extremely sleep deprived.

Cat McDonald:
Yeah, I see it. Yeah. Yeah. So researchers have found that sleep deprivation sort of disproportionately undermines the health of communities of people and communities of color. Can you talk about some of these disparities that you are finding?

Jessi Pettigrew:
Absolutely. So first I just want to say that there's no biological reason why Black folks and people of color have worse sleep outcomes. So researchers believe that this is because of the effects of systemic racism. So things like living in neighborhoods with more exposure to light and noise pollution and air pollution also can cause increased rates of sleep apnea. Also, the impact of racism itself is stressful, obviously. And we know that prolonged stress exposure is not good for our sleep. So it's for these reasons and others that we see those differences in sleep based on race and ethnicity. And researchers believe that sleep disparities may be at least one of the mechanisms that are contributing to poorer health outcomes generally and lower life expectancy, especially in the black community. If you think about it, we have to have some level of privilege to be able to achieve healthy sleep. So we have to have the opportunity, the timing, lack interruptions. Lack of stress. Not that any of us have lack of stress, but it's a huge issue.

Cat McDonald:
So yeah. So how can social workers help people who are in a situation where there're all these barriers to getting a good night's sleep?

Jessi Pettigrew:
That's a great question. I think first we have to recognize that and then that can put us in a position where we can better advocate for communities, especially built environment. So when low income neighborhoods are being built, if we can kind of intervene at that point, that would be ideal because then we can advocate for things like exposure to natural light, green space. So all the things that we know are good for our health generally also tend to be good for our sleep. And I think just awareness. And then things like light and noise pollution, on an individual level you can try to counteract some of those things, but I think really the work that needs to be done is just the bigger advocacy in the macro level, systemic changes that need to take place.

Cat McDonald:
So why do you think social workers should be concerned about sleep health, even if they're not working in a clinical setting?

Jessi Pettigrew:
Yeah, absolutely. I think that, again, in order to sleep in a healthy way, it requires some level of privilege. And so access to healthy sleep is a social justice issue in my mind. Everyone does not have the same access. And there are so many layers to that, but just to name a few, there's the environmental issues that we discussed, but I also think about individuals who are unhoused, who are incarcerated, living in any other type of sub-optimal situation. And you think on top of dealing with everything else that they're dealing with, imagine trying to sleep in those conditions, in environments. And of course, your sleep is terrible because you're concerned with safety and survival on a basic level. So then imagine how you feel, I guess, when those compounding consecutive days of poor sleep, sometimes years of poor sleep.

And I just think about trying to feel at all like a healthy human being when that's your sleep situation. And it's not just how you feel. I mean, we know that that lack of sleep is doing real damage to people's bodies and minds. And then we expect people to rise above the situation that they're in, and we're really putting them in an impossible situation.

Cat McDonald:
Wow. Yeah. So can you talk about cognitive behavioral therapy and how that might help people who are experiencing some insomnia or sleep deprivation?

Jessi Pettigrew:
Absolutely. I love talking about cognitive behavioral therapy for insomnia. So I think that a good place to start is talking about a little bit about insomnia generally. So insomnia is interesting because it really doesn't follow all the same rules of other sleep disorders and sleep deprivation. So a person suffering from insomnia has what we call an adequate opportunity for sleep. So they have the space, they have the time, but they still have trouble falling asleep or staying asleep or both, despite having that opportunity. They tend to be extremely dissatisfied with sleep. And I commonly came across individuals in clinical practice who felt very dismissed when talking about their symptoms of insomnia. Often they're kind of assumed to be part of another mental health diagnosis like depression or anxiety.

But what we know about insomnia is that once it exists, even if there's another mental health disorder on board, then it's really hard to resolve on its own. So CBTI or cognitive behavioral therapy for insomnia is fabulous and works really well in my experience. So CBTI itself is a cluster of behavioral approaches. So what we would do first is we would have our client just track their sleep for a couple of weeks, so usually two to three weeks just to get a baseline of what is happening with sleep. And we do this with sleep diaries. So everyone always asks about the watches. And the watches don't do as good a job capturing our sleep as sleep diaries do.

Cat McDonald:
Oh, like Fitbits?

Jessi Pettigrew:
Yes.

Cat McDonald:
Or Apple Watch?

Jessi Pettigrew:
Yes, absolutely. It gives you a good idea, but they aren't always super accurate. And also I like the sleep diaries because then the individual is kind of engaged in thinking about, "Well, how did I sleep last night? What time did I go to bed? What time did I wake up?" So then we would look at those together in probably our second session. And what we're looking for is how much time is the person in bed versus how much sleep are they actually getting while they're sleeping? So a lot of times with insomnia, there's a mismatch of those things. So someone might be in bed for much longer time than they're actually sleeping, and we call this sleep efficiency. So we would look at that sleep efficiency, and we would match the time in bed with the time that they're actually getting.

And then over time we can extend that. They con would continue to do sleep diaries. And then once they start to fill up that time with sleep, then we start to extend that. The other strategy that I think more people have probably heard of is called stimulus control. And this is the idea that when I'm in bed, I'm sleeping, and if I'm not sleeping, I'm not in bed and sometimes not even in my bedroom. So the only things that you should be doing in your bed are sleeping, the only exception to that is sex. So what we tell people with insomnia is remove everything from your bedroom. Do not watch TV, do not read in bed, do not eat in bed. And to go even beyond that, if you're not sleeping, then the recommendation is to get up. So even if this is your time to be sleeping and you're not sleeping, then you get up. And what the stimulus control does is it conditions your brain that, "Okay, if I'm in bed, I'm sleeping." So over time, that can help to improve your sleep efficiency as well.

Cat McDonald:
Yeah, yeah. Hanging out in bed, watching TV, eating popcorn.

Jessi Pettigrew:
Exactly.

Cat McDonald:
Talking on the phone. Yeah.

Jessi Pettigrew:
Yeah, it's lovely. And if you don't have a problem with sleep, some of those things might be fine, but if you have a problem with sleep, you need to cut it out.

Cat McDonald:
Yeah, yeah. Separate the two activities.

Jessi Pettigrew:
Absolutely.

Cat McDonald:
Sleep is for sleep, bedroom is for sleep, everything else happens outside the bedroom.

Jessi Pettigrew:
Absolutely.

Cat McDonald:
Nice calm environment.

Jessi Pettigrew:
Yes, yes. It's a sanctuary for sleep.

Cat McDonald:
Yeah. So what are some of ways that social workers can help folks? I know that there's some tools that you use in your practice. Can you talk about some of those?

Jessi Pettigrew:
Yes, absolutely. So I think that for clinical social workers specifically, the highest impact and lowest effort thing that we can do is to simply be screening our clients for sleep problems and talking to our clients about sleep. So I usually start with just some general questions about sleep, and I do that on purpose just to kind of get a feel for how someone is feeling about their sleep and what might be going on. So I would start with things like, "How would you describe your sleep? What time do you usually go to sleep? What time do you usually wake up? Any problems that you've noticed with your sleep? Do you feel refreshed upon waking and throughout the day? Do you require naps throughout the day?" That's a sign that someone is not getting enough sleep or has an untreated sleep disorder. So I would say if you only have time to do one sleep assessment for the sake of safety, I would do the Epworth Sleepiness Scale.

And this is really impactful because the sleep disorders that are causing daytime sleepiness are the most dangerous. So things like sleep apnea, hypersomnia disorders, which is a little less common. Circadian rhythm disorders, which are pretty common. And a lot of these are really easily treatable once they're diagnosed, but they have to be diagnosed and assessed by sleep medicine specifically. So the scoring is really simple, and if you see the Epworth, you would just get kind of a basic score. If your client scores over 10, which is the threshold for concern, then your next step would be to refer them to your local sleep center or sleep clinic. You can also refer them back to their primary care doctor and just kind of help coach them of this is what you need to talk to your doctor about. This is the concern you have what we consider excessive daytime sleepiness.

Now a side note, since we were talking about insomnia disorder, your clients with insomnia disorder won't always have a high score on the Epworth. They sometimes do, but it's less common, but it doesn't mean that they're not suffering as well. Treatment would be really different though because there's that kind of extreme desire to sleep and almost like too much effort to sleep. So you could refer them specifically to a behavioral sleep specialist or a clinician who's trained in CBTI. Or I would love if everyone just gets trained in it and can help clients through that themselves, that would be fabulous. But a sleep clinic or sleep center may or may not be able to help with that. I know more sleep centers are hiring people who can do the behavioral sleep interventions, but you would have to ask them 'cause they don't always have the professionals to do that.

Cat McDonald:
So what kinds of treatments can people expect if they are coming with high scores on these assessments?

Jessi Pettigrew:
Absolutely. That's a great question. So you could expect if you meet with a sleep medicine provider that they would do kind of your typical appointment where they would ask lots of questions about your sleep. If you're having excessive daytime sleepiness that's not explained by keeping yourself up every night to study or to work. If it's kind of an unexplained problem and you seem to be getting enough sleep, then they would do, it's called polysomnography or a sleep study. So I know a lot of people are familiar with, you have to go to a lab and sleep overnight and that is what it is. But a lot of sleep centers now seem to have a take home test. So don't let that stop you if you're worried that you won't be able to sleep in a lab, because that's a pretty common concern. They do have the ability to send you home with some of those devices. Not every place does. And it kind of depends on your specific presentation, but that's essentially what I would expect if I were referred to a sleep center.

Cat McDonald:
And then if somebody has this assessment and then yes, you have an issue, what can we do? What could they expect?

Jessi Pettigrew:
Absolutely. So the most dangerous kind of sleep disorder, and I'd say the one that's most commonly assessed and diagnosed by sleep centers is sleep apnea. And the treatment for sleep apnea is generally a CPAP, which you would wear at night. A lot of people are also resistant to CPAPs for good reason. And it's especially scary if you don't know what to expect. So you can talk to your sleep medicine provider about what that looks like. They've improved significantly, even in the past 10 years. So they're not as cumbersome as they once were. And there are other things, but potential interventions, even things like sleep positioning and an oral device now that you can wear. So please don't let that stop you because untreated sleep apnea is extremely dangerous and causes all these other horrible health consequences that we talked about and ultimately a shorter life expectancy. So please, please go and get assessed if you believe that that's a problem for you.

Cat McDonald:
Right. Okay. So is there anything that you wanted to add to the conversation that I didn't ask?

Jessi Pettigrew:
I think you've done a really good job and we've covered a lot of ground. I think the takeaways are just understanding why sleep is so important. And when you have that understanding as a social worker, whether you're in a clinical setting or you're a macro level social worker, then that knowledge is power and that can help you to advocate for individuals, for things like housing first and shorter sentences. And the things that we care about anyway, it can just kind of be another tool to help with advocacy. And then in a clinical setting, it's important for the reasons that we talked about when there's an untreated sleep disorder, then it's also really hard to treat mental health symptoms like depression, anxiety, bipolar disorder. Those things tend to get better if we treat also a sleep problem.

Cat McDonald:
Good. Thank you, Jessi Pettigrew. I really appreciate you coming and chatting with us about this important topic.

Jessi Pettigrew:
Thank you.

Cat McDonald:
And yeah, for everyone watching and listening, I will put links to resources for social workers in the description and in the show notes. Thank you so much, Jessi, and thank you for watching and listening.

Jessi Pettigrew:
Thanks for having me.