How Integrative Intervention Alleviates Insomnia- Related Stresses: A Qualitative Study

  

    
Experiences of    insomnia-related stresses no “day and night”  
      
a. Life stressors    leading to insomnia  
      
1. “So many things (lead to insomnia),    it’s like mixed vegetable salad…I had sound sleep three years ago…all of a    sudden…I knew a big event would happen...my grandma got severely ill…after    that, my sleep had a rapid deterioration” (CLIENT D).  
      
2. “It may be attributed to loads of    work…so many deadlines…I need to get things done…these have been stressors    stored in me…even when I have completed one case, I still feel that something    is yet to be done…similar tasks would be assigned another day, generating    stress again and again. I did not know how to relieve it.” (CLIENT E).  
      
b. Physical    vulnerability  
      
3. “(The trouble of insomnia) is that I    am afraid of my body going wrong and it may be the onset of disease. If you    cannot sleep well, your internal organs will be affected. You will have a    greater chance to get heart diseases and hypertension... if I cannot sleep    for a whole week…I would become terribly weary and susceptible to disease.    When I am sick, I can sleep for a certain period of time… so that if one has    quality of sleep, the biggest thing is that he is definitely healthy anyways.    I have nothing to worry about but my health condition.” (CLIENT I).  
      
4. “The distress is that my body is    unwell in all respects. I would feel pain in my finger joints when I did not    get enough sleep… if sleep quality improved, joint pain would be alleviated.    You can rightly tell from differences of these fingers. (Showing swelling finger    to the interviewer) if I did not sleep well for a whole week, it would be    like this… I told my doctor but (he/she) did not believe me.” (CLIENT K).  
      
c. Poor emotional state  
      
5. “It has impaired my interpersonal    relationships. Because I did not have adequate energy, I cannot even handle    my own state. I do not want to talk with others” (CLIENT R).  
      
6. “I cannot confirm schedule of the    next day. This disturbs me a lot… I do not like it. I want to have my plan… I    even did not dare to meet others in the mornings because I worried I could    not get up on time… no regular arrangement... when you are exhausted, you do    not have enough courage to make any promises… I did not believe that I had    the capability of finishing it (I-BMS courses) before.” (CLIENT O).  
  
  

    
Ways of living with    insomnia: Mind-body practices and attitude changes  
      
a. Improvement in sleep    quality through mind-body practices  
      
7. “Abdominal breathing teaches us to    concentrate (on our own action of breathing) so that I would not ruminate on    other issues… less distracting thoughts… Counting sheep, one, two, and three…    other thoughts would come out anyways and disturb my sleep.” (CLIENT B).  
      
8. “After doing the gentle movement, I    can feel the circulation of blood and Qi inside my body. I began to feel warm    and have energy… for people who are in poor physical condition and in lack of    vitality, like me, these exercise really helps… I also taught them to my    friends and relatives.” (CLIENT O).  
      
b. Reduction in    sleep-related anxiety due to attitudes of acceptance and non-attachment  
      
9. “To which degree, do you think your    insomnia problem was resolved?” (Interviewee).  
      
“Not resolved, but improved… I did not    expect resolution. It was already rewarding as my sleep improved a lot after    attending the class. It is impossible to change immediately…only within a    couple of months…your life habit will not change in such a short time…let it    be if I cannot sleep. Not to obsess about it (resolution). If not, things    will get worse, right?” (CLIENT B).  
      
10. “I learnt how to relieve stress from    the course… even I only had sound sleep for three or four hours per night, I    felt refreshed the next morning… it was enough for me… if one is not too    nervous about things, he/she may live more lightly and happily” (CLIENT R).  
      
11. “When I cannot sleep at times, I    recalled the sentence. It was helpful. (Before attending classes) I worried a    lot about consequences of a lack of sleep. But, not now, by lying down and    closing my eyes, I also had a rest. I enjoy equanimity instead of tossing and    turning restlessly on bed. It was not troublesome anymore.” (CLIENT C).  
  
  

    
Beyond sleep    improvement: The integration of body, mind, and spirit contributing to    quality of life  
      
a. Shift from insomnia    to body-mind connection- a holistic perspective  
      
12. “It is the mind that matters. It was    hard to accept changes and that was why in the past I got stuck and failed to    move on… professionals (in I-BMS) have opened the door for me. I think it is    a right way.” (CLIENT A).  
      
13. “(Previously) I only focused on    exhausted feelings when waking up. Yet, I did not go back to the origin step    by step. My view was narrowed down to the negative results (exhausted    feeling)… we forgot some basic things. They are the origins. When taking    I-BMS courses, I noticed that I needed to unlock my heart… sometimes, I was    too harsh to myself. I have been changing it gradually… it is a reflection on    myself.” (CLIENT R).  
      
b. Centering of the    self  
      
14. “This course emphasized    self-exploration…in short, regarding self as an acting point… to explore    inside… most of the time, I focused on others outside… more introspection is    needed… for instance, to love myself and let go of the unpleasant in the past    are what you (I-BMS) have taught us so that I would really (think about it)…    why did not I let it go for my own good… I would not keep things in mind    which do not work.” (CLIENT C).  
      
c. Different    perspectives towards hardships through group support  
      
15. “I have learnt things from different    levels. I have gained more knowledge and practiced several good things    (exercises and energy flow)… not only on the theoretical level, but it was    quite experiential here (I-BMS group)… when I listened to others, I reflected    on their words and absorbed new ideas… I had no idea how others thought about    certain issues before… now, when I face some situations, what other group    members have said would come back to me. ” (CLIENT N).  
      
16. “It (small group discussion in I-BMS    class) was nice. I saw people different from me. I felt that things happened    to me were not special and minor when I compared myself to others who went    through more difficulties and hardships… It broadened my view and gave me a    chance to look at things happening around me. We shared similar predicaments…    many people tried to go through… I felt supported (by group members) and    motivated to change.” (CLIENT A).  
  

Table 2:  Themes, subthemes and verbatim from participants.

Experiences of insomnia-related stresses

From our informants’ perspective, persistent insomnia has never been a minor or trivial issue. Insomnia posed impact on their overall quality of life that was conceived as a behavioral pointer mirroring distress embedded in their life. Three sub themes emerged under this category: a. Life stressors leading to insomnia; b. physical vulnerability; and c. poor emotional state.

a. Life stressors leading to insomnia

Many of our informants identified critical life events as stimuli to insomnia. These events included relationship distress such as that from parenting, divorce, in-law conflicts or other familial and interpersonal conflicts, injury and sickness, decease of significant others, work stress, financial difficulties, or/and other life problems and affliction. Informants were aware of possible reasons for their insomnia that was not limited to medical problems. Thus some of them were unwilling to take hypnotics, but at the same time, they failed to find alternative ways to help themselves deal with stresses and struggles with insomnia. For instance, client D told that reasons of her insomnia were a mix of life stressors as well as her grandma’s illness since three years ago. For those who could not tell a specific critical event triggering their insomnia, chronic stressors were identified as potential causes for insomnia. Client E, an employee, attributed his insomnia to heavy work load. He suffered from severe stress due to endless work assignments and thus experienced insomnia.

b. Physical vulnerability

Worries about their own physical conditions, coupled with life stressors, were salient disturbance to participants’ everyday activities and interactions. Almost all participants worried about the negative impact of insomnia on their health conditions, including pain, fatigue, low levels of energy, and general weaknesses, which had been experienced within their bodies in different ways. Some informants reported that they were susceptible to illness after a couple of sleepless nights. Client I would easily get sick after certain period of insomnia and she regularly experienced this vicious cycle. This client also stated that she had nothing to worry about her insomnia but its adverse influence on her physical health. When being asked about whether her emotional state was influenced by insomnia, she repeated that “I really, really cannot feel it (emotional stress).” Yet, she knew that if she failed to sleep for several days, her physical conditions would severely deteriorate. Participants also mentioned that insomnia would make them extremely weary and uneasy about their body.

c. Poor emotional state

Some interviewees regarded poor emotional state as another major experience along with insomnia. Due to low level of energy after a “poor-sleep” night, they usually found themselves “not capable” of getting involved in various daytime activities and accomplishing things they wanted or needed to do. Lack of sleep resulted in an overwhelming sense of powerlessness for our informants particularly when it came to their interpersonal relationships, daily scheduling, and work performance. Poor concentration, memory loss, high levels of irritability, tendency to hide from others (self-isolation), negative thoughts, as well as reduction in problem-solving capacity were experiences shared by our informants with insomnia. Client R considered himself deficient in energy after insomnia. As a result, he felt incapable of communicating with others and building longlasting relationships. No matter if they were employed, retired, or housewives, they felt trapped in the poor emotional state in daytime triggered by insomnia. For those who were employed, work performance was their major concern. Three of our participants claimed that they never let sleeplessness influence their work. Meanwhile, by highly concentrating on their jobs, they experienced extreme fatigue after hours.

In short, the disturbing experiences triggered by insomnia were present together with various life stressors. Most clients did not regard insomnia as a purely medical issue. Not only did they identify their physical/bodily symptoms as major disturbing aspects of insomnia, but they also expressed that daytime consequences of insomnia, namely their poor emotional state and high irritability, were some of their major concerns. Thus, all these insomnia-related distresses undermined their overall quality of life, which called for an integrative approach to address their problems.

Ways of living with insomnia: mind-body practices and attitude changes

With respect to their current sleep quality, most informants reported a better quality of sleep at night and improved energy levels during the day after attending the I-BMS classes. Furthermore, they learnt to adopt attitudes of acceptance and non-attachment toward their sleep problems. The two sub themes are: a. improvement in sleep quality through mind-body practices and b. reduction in sleeprelated anxiety due to attitudes of acceptance and non-attachment.

a. Improvement in sleep quality through mind-body practices

One of the most frequently mentioned mind-body practices was abdominal breathing. Client B shared her experience of abdominal breathing that made her fall asleep more easily. Abdominal breathing probably relaxed autonomic nervous system related to pre-sleep bodily hyper-arousal, such as quickened heartbeat, cold/sweaty hand or shortness of breath. Common layman technique of counting sheep as a method for falling asleep will activate frontal cortex that may further sharpen cognitive hyper-arousal before sleep that is known as mind-racing. Thus, abdominal breathing helped participants to stay mindful and peaceful, and stopped them from ruminating over problems in the daytime.

Apart from breathing methods, informants also found acupressure and easy Qigong practices, such as Shoai-Shoou-Gong (hand swinging exercise) and clapping qigong, helpful. Participants practiced these easy exercises throughout the day and gradually developed it into a habit in their daily lives. According to our participants, these practices not only improved their sleep quality, but they also helped cultivate energy or Qi flow during daytime. For instance, these techniques made Client G feel warmth and energy flow due to blood and Qi circulation. In short, these mind-body techniques, including abdominal breathing, acupressure, and easy Qigong practices, filled our participants with vitality and hope that reinforce continuous practices of these self-help techniques.

b. Reduction in sleep-related anxiety due to attitudes of acceptance and non-attachment

Apart from actual improvement in sleep quality and daytime functioning, participants also developed an attitude of acceptance toward insomnia. They let go of “perfect sleep” expectations and learnt to embrace a more flexible attitude toward fluctuation of their sleep conditions. This perspective reduced their sleep-related anxiety and prevented things from going worse. For instance, Client B realized that worries about insomnia and obsession with perfect sleep could not help but worsen the situation.

In addition, participants also adopted an attitude of nonattachment toward interpersonal conflicts or other stressful events that might trigger their insomnia symptoms. Client R acknowledged that an easy and carefree attitude toward life worked well to alleviate sleep-related stresses. Most of our participants found one sentence learnt from I-BMS classes particularly useful which connoted meanings of acceptance and non-attachment. It was “lying in bed peacefully is also a kind of rest for my body. Falling asleep is not the only way to be tranquil.” Client C considered this sentence helpful because it changed her perception of insomnia and encouraged her to enjoy resting with equanimity. Our informants made good use of the meanings of rest and equanimity taught during the group sessions, coupled with sleep hygiene education and mind-body exercises, to alleviate their anxiety toward sleeplessness and let go of their unrealistic expectations for a “perfect sleep.” Consequently, a better quality of sleep and an overall better physical and emotional state in the next morning were achieved.

Beyond sleep improvement: the integration of body, mind, and spirit contributing to quality of life

In line with the goal of I-BMS model to improve clients’ overall quality of life, our informants further noted that they achieved improvement not only in their sleep quality but also in various aspects of their lives. Sub themes included: a. “shift from insomnia to body-mind connection- a holistic perspective”; b. “centering of the self”; and c. “different perspectives towards hardships through group support”.

a. Shift from insomnia to body-mind connection- a holistic perspective

Informants acquired different and broader views regarding their sleep issues. They achieved a better understanding of mind-body connection and its impact on sleep. Client A realized that the craving for desires and denial of uncontrollable changes would adversely influence sleep quality. Instead of getting preoccupied with their sleep problem per se, participants leant to “go back to basics, to the root source” which might lead to their insomnia. For instance, client R reflected on her narrow-minded attitude towards her experience of insomnia through which she could only sense the exhausted feelings resulting from insomnia. Many respondents acknowledged the important need and potential benefits to move beyond their sleep issue and reconnect their bodies with a positive mind. Moreover, they became more aware of interrelatedness between body, mind, and spirit. Informants were more likely to take initiatives to let go of their previous obsessions. Some of them realized that if no medicine could cure sleeplessness and it was every individual’s choice whether to let go of the past, to relieve stresses and strains.

b. Centering of the self

This term, “centering of the self,” was borrowed from Lee and associates (27. p204-207). It referred to the state in which participants went back to their inner world by nurturing their body, mind, and spirit when facing constant changes in the external world. They became aware of how unbalanced body-mind-spirit system impaired sleep, and at the same time, regained balance and inner strength. It is not unusual that individuals with insomnia tend to impute their sleeplessness to outside disturbances that cannot be easily changed. Yet, after the intervention, most of the participants learnt to resort to themselves to secure resources for dealing with insomnia. They also learnt to love and accept themselves. For instance, client C shared the benefits of self-exploration in classes and her reflection on self as an acting point. Client C noted that she embraced a renewed self and planned to make good use of her inner strengths re-discovered in the courses (Quote 14). After realizing the importance of centering of the self and reflecting on the self, Who?? cultivated not only selfacceptance but also a better connection with others in everyday life.

c. Different perspectives towards hardships through group support

Informants shared their experiences of mutual learning among group members in the I-BMS classes that allowed them to view issues and problems from different perspectives. Client N reported that he recalled his group mates’ words when he fell into difficult situations again (Quote 15). Through group sharing and discussion, participants realized that they were not alone. Instead of focusing on their own unpleasant experiences, participants expanded their perceptions of suffering and coping by learning the ways in which others dealt with hardships and overcame them through painstaking efforts. They learnt more, cared more about others, and provided support for each other. Client O used “a grain of sand” as a metaphor for her position among others of different age. This position offered her a new point of view to perceive issues and problems that had troubled her before.

Discussion

The current study revealed insomnia experiences among Hong Kong Chinese adults and their concerns regarding poor sleep quality. Major concerns were restless experiences at night and the lack of energy/spirit/vitality during daytime that can be deemed a manifestation of sleep-wake cycle disorder. Furthermore, insomnia also impeded their subjective health status. Informants reported that they were susceptible to diseases due to certain period of poor sleep and worries about deterioration of bodily functions. All of these experiences contributed to physical vulnerability and poor emotional state, which had far-reaching effect on critical aspects of their everyday lives. In accord with previous studies, individuals with insomnia presented lower levels of quality of life. It also found that energy/ vitality and “role-physical” dimension among other domains of SF- 12 were most useful predictors for severity of insomnia [35]. Given this pervasive impact of insomnia on patients’ life, management of insomnia should not solely focus on improvement of nighttime sleep. Alleviation of insomnia-related stresses during daytime should also become major treatment endpoints. Yet, it is not the whole story. Apart from insomnia symptoms and their daytime consequences, our informants also struggled with pressure from their own lives such as chronic pain, conflicts with family members, or persistent distress from work. Studies identified several precipitant factors of insomnia, among which, the most common ones were family, work, and health events [36]. Lundh and Broman included interpersonal conflicts and emotional involvement in the integrative model of sleep interfering and sleep-interpreting process [37]. It was suggested that a multidimensional view should be adopted to understand insomnia complaints, especially specific contexts within which sleeplessness was experienced [38]. Hence, the needs of patients with insomnia went beyond longer sleep and thus treatment should be extended to aspects of quality of life.

This study made the first attempt to explore how the I-BMS model benefits participants with self-reported insomnia and boosters their overall well-being. From a holistic view of care, I-BMS group work on insomnia and mood distress adopts an integrative approach. As informed by practices of Daoist and TCM, one of the critical therapeutic components of I-BMS is “nurturing body for balance and harmony” [27] that addresses the body as an agency in connecting mind and spiritual wellbeing. Our informants also noted that one of the benefits of rebuilding autonomic homeostatic from easy Qigong practices, acupressure, and abdominal breathing was to help them regain a sense of balance. Participants reported more tranquil state at sleep time and more energy and strengths in the morning. Emerging evidence has showed the benefits of acupressure and Qigong on insomnia, fatigue, and quality of life in different groups [39-43]. In addition, participants also learnt to cultivate acceptance towards sleeplessness as well as non-attachment to “unrealistic sleep expectation.” Thus, their worries were significantly reduced and their sleep quality was improved. Such findings are in consistent with our quantitative data that indicate I-BMS especially improve participants’ subjective sleep quality and sleep latency(unpublished). Ong and associates [44] argue that bias, rigidity, attachment and absorption to insomnia are second arousal or a meta-cognitive process involved in insomnia and they suggest “commitment to valued life” may help alleviating individuals’ preoccupation with insomnia. Studies have also found that reduced “sleep effort” can predict improvement on sleep conditions in treatment groups [45]. Sleep effort and safety behavior can also predict sleep disturbances among patients with mood disorder [46]. I-BMS classes also highlight the importance of acceptance of the undesirable and that of letting go of rigid attachment to the undesired things that may not be restricted to insomnia.

Instead of focusing on symptoms, the I-BMS model underlined strengths of participants by using “easy to grasp” practices and experiential activities. Through mind-body education and small group discussions, informants got more insights into the relations between stress, mind, and bodily signals of illness. “Puzzlement about cause” was found to be able to differentiate individuals with primary insomnia from good sleeper [18]. Thus, after experiential body-mind movement and education, clients were more likely to be aware of possible reasons for insomnia , the connections between stress, emotion and sleep and strike a balance in their sleep-wake cycle. Furthermore, they found more resources and wisdom inside themselves instead of resorting to the outside. In addition, the group modality provided them an opportunity to have a view from different perspectives as well as to be more humble and gratified. In fact, eudaimonic well-being (purposeful engagement with life) was inversely related to sleep problems after controlling the confounders, Hedonic and eudaimonic well-being can also buffer the adverse effect of psychosocial risk factors on sleep [47]. Wood found that traits of gratitude predicted better results of several sleep parameters [48]. In line with these studies, the I-BMS model adopted a strength-based approach by taking experiential activities, such as Qigong exercises and gratitude journal, as bottom-up pathways in cooperation with certain top-down methods, such as sleep hygiene education and mind-body education.

Limitation

Some limitations in this study deserve mention. Firstly, informants were selected from participants of an RCT intervention who were selfreferred with certain insomnia and mood symptoms and recruited from the community. Thus, no systematic diagnosis procedures were conducted. Instead, we used the score of symptom scale as inclusion criteria. More specific comorbidities need to be considered among particular clinic samples. Secondly, we failed to trace participants who dropped out but might help us better understand the advantages and disadvantages of the current intervention manual applied to different kinds of clients. Lastly, future studies should investigate interactions of various components involved in I-BMS program that results in a synergistic effect as well as further identify characteristics of patients who may respond to different components or respond through different pathways.

Conclusion

Given the complex nature of insomnia and its frequent cooccurrence alongside other life stressors, assessment and management of insomnia should be more comprehensive. Not only does I-BMS group intervention incorporate basic sleep hygiene education, but it also further targets the holistic well-being of participants. After attending the group, most informants reported a better sleep and enhanced energy during daytime. In addition, they became more aware of their own life as well as of the surroundings. They were more able to lead a life of equanimity by applying experiential learning from I-BMS to their daily lives.

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