Behavioral sleep medicine practitioner Skye Margolies, PhD, DBSM, uses acceptance and commitment therapy to offer relief to those battling the dual challenges of pain and sleeplessness.
By Chaunie Brusie, RN, BSN
For most people, an occasional night of disrupted sleep is an inconvenient blip that leads to a tired day. But for those with chronic pain, insomnia can become a permanent—and tortuous—constant in their lives.
Along with the struggle of pain management, people with chronic pain often face insomnia from both their symptoms and the anxiety and stress that accompany the condition. Unfortunately, like so many other comorbidities, a lack of sleep becomes a vicious cycle of exacerbating chronic pain and further disrupting future sleep.
Clinical health psychologist Skye Margolies, PhD, DBSM, director of the pain division of the University of North Carolina’s School of Medicine, specializes in working with patients with chronic pain and insomnia. Through her work in behavioral sleep medicine, she advocates for a better understanding of the chronic pain-sleep connection and how sleep medicine professionals can recognize it and connect patients with resources.
‘Psychological Awareness of Sleep Problems’
Margolies’ career owes its start to her early work with veterans, in which she gained exposure to issues like trauma, non-combat-related PTSD, and pain from injuries. Through her post-doctoral work, she realized that sleep disturbances and pain often overlapped—and her focus on treatment integration was born.
Describing behavioral sleep medicine as the “psychological awareness of sleep problems,” Margolies notes that it can be used for everything from improving CPAP adherence to managing insomnia related to chronic pain.
And the first step? Awareness.
Margolies utilizes two main approaches in her work with chronic pain patients who also have insomnia: acceptance and commitment therapy (ACT) and cognitive behavioral therapy (CBT).
CBT-I Versus ACT for Insomnia
Most sleep professionals are familiar with CBT for insomnia (CBT-I), the gold standard firstline treatment approach for chronic insomnia. ACT is a newer approach that can be used as either an adjunct or alternative treatment to CBT-I in CBT-I nonresponders, patients experiencing an insomnia relapse, and other patients at the practitioner’s discretion.1
In the case of comorbid pain and sleep disturbance, an ACT-based approach highlights differences between actual “pain” and psychological “suffering.”2
In Margolies’ words, ACT starts with awareness and acceptance of the frustrations and fears surrounding sleep issues, as well as noticing when those frustrations become an issue on their own that can interfere with sleep. “That’s when ACT happens,” she says. “ACT is awareness and acceptance-based, while CBT is about changing the behaviors.”
Although both ACT and CBT can be applied across the spectrum of sleep challenges, Margolies adds that utilizing the therapies within the intersections of pain and sleep is especially interesting.
“More and more research is showing that poor sleep may have more of an effect on pain than vice versa,”3 she says. “There’s still this relationship, but there’s a stronger impact of poor sleep on pain. That what mediates that relationship is not necessarily the pain itself, but our thoughts about our pain.”
Using ACT, sleep professionals can work to change the thoughts surrounding the pain to improve sleep—which can be a pain management technique in and of itself.
“ACT with insomnia is not a one-size-fits-all intervention nor does it have to be a replacement for CBT-I,” says Colleen Ehrnstrom, PhD, ABPP, a licensed clinical psychologist with a specialty practice in ACT and a colleague to Margolies. “Rather, it is a complementary tool to increase willingness and adherence to support the sleep program that best suits the needs of the client.”
Treating Pain and Sleep Together
Viewing pain and sleep through a medical model lens can challenge practitioners and patients. “Even in treating pain, sleep is often treated as secondary to the pain problem. A medication is given, or patients are told to talk to primary care,” she says. “Sleep is often peripherally addressed with chronic pain.”
However, the work that Margolies and other behavioral sleep medicine practitioners do recognizes that sleep and pain are simultaneously standalone and intersecting issues. “People feel validated in that someone is addressing that both are there, that we can try to address them simultaneously,” she says. “Maybe the two can inform each other.”
Additionally, behavioral sleep medicine and approaches such as ACT for insomnia with chronic pain can provide the sort of immediate relief that medical approaches often offer. “It’s both a relief to patients to understand that they can get help that is maybe not medication-based, and at the same time, because we exist in such a biological model, not being able to sleep is stressful and frustrating, and if there’s something that can help right then and there, that’s really nice,” Margolies says.
The beauty of ACT, adds Ehrnstrom, is it can have an immediate impact. “It works,” she says. “When clients understand the proper implementation, sleep quality improves.”
Some of Margolies’ current and prospective work is focused on utilizing group therapy for pain and sleep problems, a methodology that has seen “promising” results so far. “Even when their sleep isn’t always perfect, they have a better understanding and a different relationship with it all. At the end of the day, that’s one of the big pieces we’re looking for,” she says.
Educating Others
Margolies presented at the 2023 Society of Behavioral Sleep Medicine conference about her work in the chronic pain-sleep space.
Kathryn Hansen, BS, REEGT, CPC, executive director for the Society of Behavioral Sleep Medicine, says the committee accepted Margolies’ presentation on ACT as a treatment for chronic pain and insomnia because it was a fresh approach.
“It’s a hot topic,” Hansen says. “Clinically, it’s new and innovative. It hasn’t been part of the conference before, and clinicians are interested in incorporating it into their practice.”
Margolies encourages clinicians seeking to learn more to turn to the Society of Behavioral Sleep Medicine as a resource. She hopes to see more sleep physicians looking to behavioral sleep medicine as partners in their practices.
For clinicians looking to connect patients to resources in the behavioral sleep medicine space, Ehrnstrom adds that Margolies serves as a “wonderful advocate” and is dedicated to building both evidence-based programming and educating clinicians on how to deliver optimal interventions for sleep.
“It is a privilege to watch her help clinicians find their confidence with this population,” she says. “Her specialized work with insomnia and chronic pain is leading the way for access to support and relief for so many people struggling to find quality sleep.”
References
1. Dalrymple KL, Fiorentino L, Politi MC, et al. Incorporating principles from acceptance and commitment therapy into cognitive-behavioral therapy for insomnia: a case example. J Contemp Psychother. 2010;40:209–17.
2. Saldaña KS, McGowan SK, Martin JL. Acceptance and commitment therapy as an adjunct or alternative treatment to cognitive behavioral therapy for insomnia. Sleep Med Clin. 2023 Mar;18(1):73-83.
3. Afolalu EF, Ramlee F, Tang NKY. Effects of sleep changes on pain-related health outcomes in the general population: A systematic review of longitudinal studies with exploratory meta-analysis. Sleep Med Rev. 2018 Jun;39:82-97.
Photo 165456926 © Fizkes | Dreamstime.com
