design for insomnia

M154ID Research for Design and Reflective Practice

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Supporting

Document Title: Design for Insomnia How can design encourage the mind and body to recognize the time to sleep in relation to sleeping disorders? Author: Lily McGarry Module: M154 ID Design for Research And Reflective Practice Date: 13.01.2012

Abstract 30% of the UK population suffers from a sleep problem, with 10% reaching a diagnosable level of insomnia. There has been nothing specifically designed for insomnia sufferers to recognize the time to sleep and manage their problems. The purpose of this report is to identify key factors that drive insomnia and recognizing the time to sleep, and to then use that data to inform a design specification for a product to aid insomnia sufferers in improving there sleeping efficacy.


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Insomniac.

“There are some nights when Sleep plays coy,

Aloof and disdainful. And all the wiles

That I employ to win Its service by my side

Are useless as wounded pride, And much more painful.”

-Maya Angelou.


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Acknowledgments I would like to convey my gratitude to the following for their assistance and support in the development of this document:

The staff at Coventry University’s School of Art & Design:

All members of the Coventry University Industrial Design staff that have been consulted during this research project must be thanked for their judgments and suggestions throughout the duration of the project.

Dr. Kevin Morgan, School of Sport, Exercise and Health Sciences, Loughborough University:

Professional and theoretical expertise was provided via an interview with Dr. Kevin Morgan. This allowed further insight to be made into the mentality of someone suffering with insomnia and was a crucial element of the research process.

All focus group and sleep diary study participants:

All research participants have to remain anonymous due to ethical restrictions however it must be said that their involvement with the empirical stage of the research process was essential in the development of this project. The completion of the project would have been unattainable without the involvement of all research participants.


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Contents Glossary of Terms …………………………………………………………..……..5 Figures…………….…………………………………………………………..…….6 Research summary..…………………………………………………..…………...7 References..………………………………………………………………..……….8 Bibliography……..…………………………………………………...….……...9-10 Conceptual Framework…………………………………………………………...11 Desk Space Research Summary……..……………….……….……….…...12-14 Empirical Research Summary……..…………………………………….…...15-17 Appendices: -Interview Content & Findings…………………………………………….…18-24 -Full Interview Transcription………….………………………………………25-34 -Focus Group Content & Findings……….………………………………….35-39 -Sleep Diary Study Content & Findings……………………………………..40-43 -Design Brief……….……………………………………………………………..44 -Interview Ethics Forms..……………………………………………………..45-52 -Focus Group & Sleep Diary Study Ethics Forms…………………………..53-71


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Glossary of Terms Acute Insomnia: Transient Insomnia is the inability to consistently sleep well for a period of less than a month.

Circadian Rhythm (body clock): The circadian rhythm tells us in relation to sleep that the time of day will trigger whether or not we feel like going to bed.

Chronic Insomnia: Chronic Insomnia is the inability to consistently sleep well for a period of longer than a month.

Homeostatic Drive: Homeostasis refers to the conservation of balance within the body. In reference to sleep homeostatic drive means that the longer one stays out of your bed, the sleepier one feels.

Insomnia: Insomnia is defined as a problem getting to sleep, a problem remaining asleep or disappointment frequently with the quality of sleep. It can be classified as transient, acute or chronic.

Sleep restriction therapy: This signifies a component of cognitive behavioral therapy for insomnia, in which sufferers limit the amount of time are allowed in their bed to exactly the number of hours they spend sleeping. Once their sleep efficacy improves they can gradually spend more time in bed.

Transient insomnia: Transient Insomnia is the inability to consistently sleep well that for a period of less than a week.


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List of Figures Figure 1. McGarry, L. (2011) Blurred time image [by L.McGarry] Coventry December 2011 Figure 2. McGarry, L. Knowledge of sleep relative to knowledge of diet and exercise [by L.McGarry] Coventry December 2011 Figure 3. McGarry, L. Maslow’s Hierarchy of needs and sleep [by L.McGarry] Coventry December 2011 Figure 4. Daytime impact of sleep (2011) mental health foundation reveals impact of poor sleep on the health and happiness of the UK [online] available from < http://www.mentalhealth.org.uk/our-news/news-archive/2011/2011-01-27/> Figure 5. Zeo Sleep Manager (2011) zeo [online] available from < http://www.myzeo.com/sleep/> Figure 6. Sleep Buddy (2011) sleep buddy product details [online] available from < http://sleepbuddy.com/soft-blue-light/> Figure 7. McGarry, L. Comparison of time spent in bed with time spent asleep graph for insomnia sufferer [by L.McGarry] Coventry December 2011 Figure 8. McGarry, L. Comparison of time spent in bed with time spent asleep for normal sleeper [by L.McGarry] Coventry December 2011 Figure 9. McGarry, L. Comparison of bedtimes between insomnia sufferer and normal sleeper [by L.McGarry] Coventry December 2011 Figure 10. McGarry, L. Comparison of time taken to fall asleep between insomnia sufferer and normal sleeper [by L.McGarry] Coventry December 2011 Figure 11. McGarry, L. Sleep Diary Framework [by L.McGarry] Coventry November 2011 Figure 12. McGarry, L. Focus Group Participants [by L.McGarry] Coventry November 2011


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Research Summary Project Outline Sleep is essential. Without it life would be impossible. According to the mental health foundation up to 30% of the UK population have either insomnia or another related sleep disorder. Action must be taken. The research question derives from personal on-going insomnia experience. It was observed that amongst many specific problems that prevent people with insomnia from good sleep, a key difficulty is recognizing through a blur of perpetual tiredness and chaotic sleep/wake times, the time to attempt sleep. The purpose of this report is to identify factors that drive insomnia and recognizing the time to sleep, and to then use that data to inform a design specification for a product aiding poor sleepers. Research Methodology Various qualitative and quantitative research methods were used. This included literature reviews and related studies, an interview, a focus groups and a sleep diary study. The Focus Group was undertaken with participants categorized according their insomnia severity: chronic insomnia, acute insomnia and transient insomnia. An Academic and industry professional was interviewed to gather insights into more specific parts of the project. A sleep diary study was used to underpin data acquired during the focus group and interview to add an element of objectivity and quantitative data. These pieces of research satisfied the key research objectives: What are the fundamentals of sleep/insomnia? What are the existing solutions to treating insomnia and how can they be improved? What are the triggers for sleep and how can design innovation be associated with them? Limitations

This study relates to a context that limits the conclusions. It was only possible to conduct a Focus Group using family members. This affects generalizability. It would have been beneficial to use a larger amount of participants to optimize the generalizable data.

Research Conclusions There is no quick and easy solution to insomnia. As designers we cannot aim to cure but we can influence. As well as cueing sufferers in for the right time to sleep the most beneficial product addition to the current climate surrounding sleep would be one that works with existing therapies to promote the maintenance of healthy sleep. (Morgan 2011) The objective of the product should be to remove the “blur” around the signals for the body to sleep. The promotion of routine and regularity of sleep/wake times should be at the heart of the solution. Clarity of routine is essential. Insomnia spans across the generations affecting 5% of the 18 to 25s and 30% of the over 60s and 70% of the blind population. Inclusiveness will be a key theme for the final product. (Morgan 2011) Insomnia has a negative impact on perceived level of control and motivation. This lack of motivation perpetuates the problem. Through the application of self-determination theory (Deci & Ryan 2000) we can increase perceived levels of control and motivation and in turn have a positive effect on sleep efficacy for sufferers. Design Recommendations The final solution should be a desirable product that transforms sleep into something less socially inconspicuous. The core of the final design should focus on encouraging and cueing routine and regularity of sleep/wake times for the sufferer. Key words: Evaluate/Respond, Routine, Clarity, Intuitive, Relatedness, Personalized, Effectiveness


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References Cooper, R. (1994) Sleep London: Chapman & Hall Medical Employee Wellness Magazine (2011) sleep deprivation costs the UK £1.6 Billion per annum [online] available from <http://www.employeewellnessmagazine.com/news/sleep-deprivation-costs-uk-economy-1-6-billion-per-annum/> [2010] Espie, C. (2011) ‘The Psychological management of sleep problems [online] available from <http://jnnp.bmj.com/content/82/8/e2.40.short > [2011] Kazantzis, N. (2006) Handbook of homework assignments in psychotherapy: research, practice, and prevention New York: Springer Maslow, A, H. (1954) Hierarchy of needs [online] available from <http://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs> Morgan, K. (2011) Recognition of the time to sleep and insomnia [interviewed by L. McGarry] Coventry December 2011 Mental Health Foundation (2011) mental health foundation reveals impact of poor sleep on the health and happiness of the UK [online] available from < http://www.mentalhealth.org.uk/our-news/news-archive/2011/2011-01-27/> [2012] National Institute of Neurological Disorders and Stroke (2007) brain basics: understanding sleep [online] available from <http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm> [n.d] NHS (2011) Insomnia treatment [online] available from < http://www.nhs.uk/Conditions/Insomnia/Pages/Treatment.aspx> [2011] Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and facilitation of intrinsic motivation, social development, and well being. American Psychologist


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Bibliography Beil, L. (2011) In eyes, a clock calibrated by wave lengths of light [online] available from <http://www.nytimes.com/2011/07/05/health/05light.html?_r=4&pagewanted=all> [July 5, 2011] Cooper, R. (1994) Sleep. London : Chapman Hall Medical Employee Wellness Magazine (2011) sleep deprivation costs the UK £1.6 Billion per annum [online] available from <http://www.employeewellnessmagazine.com/news/sleep-deprivation-costs-uk-economy-1-6-billion-per-annum/> [2010] Healthcare (2010) sleep easy with help of the sleep clinic [online] available from <http://www.studiotalk.tv/show/sleep_easy_with_help_from_the_sleep_clinic > [2012] Holzman, C. (2010) What’s in a color? The unique human health effects of blue light [online] available from <http://ehp03.niehs.nih.gov/article/info:doi%2F10.1289%2Fehp.118-a22> [January 01 2010] Journal of neurology, Neurosurgery & psychiatry with practical neurology (2011) The psychological management of sleep problems [online] available from <http://jnnp.bmj.com/content/82/8/e2.40.short > [2011] Loughborough University (2011) Loughborough sleep research centre [online] available from <http://www.lboro.ac.uk/departments/ssehs/research/behavioural-medicine/sleep/popular-articles/today-survey.html > [n.d] Mental Health Foundation (2011) Mental Health foundation report reveals impact of poor sleep on the health and happiness of the UK [online] available from <http://www.mentalhealth.org.uk/our-news/news-archive/2011/2011-01-27/ > [2012] Michael S. Leff, R.N. (2010) train your brain to sleep: recognizing the circadian rhythm [online] available from <http://www.mylocalhealth.com/stress_less/train_your_brain_to_sleep_recognizing_the_circadian_rhythm_448 > [n.d] NHS (2010) treating insomnia [online] available from <http://www.nhs.uk/Conditions/Insomnia/Pages/Treatment.aspx > [2010] NHS (2010) sleeping pills [online] available from <http://www.nhs.uk/Livewell/insomnia/Pages/treatment.aspx > [2010] NHS (2010) Insomnia- Expert view [online] available from <http://www.nhs.uk/Conditions/Insomnia/Pages/Questionstoask.aspx > [2010] Scienceline (2008) what happens to your body when you fall asleep? [online] available from<http://scienceline.org/2008/02/ask-peretsman-sleep/ > [2011]


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Sleep buddy (2011) Sleep buddy: how it works [online] available from <http://sleepbuddy.com/how-it-works/> [2011] Sleepio (2009) stepped care meets technology [online] available from <http://blog.sleepio.com/2009/08/25/stepped-care-meets-technology/ > [2011] Rice-Oxley, M. (2011) How I cope with insomnia [online] available from <http://www.guardian.co.uk/lifeandstyle/2011/jan/29/sleep-problems-insomnia > [2012] Zeo (2011) Zeo sleep manager [online] available from <http://www.myzeo.com/sleep/> [2011]


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Conceptual Framework

Above is the final draft of the Conceptual Framework. Many iterations of this were made during the initial stages of the project, notably because as the knowledge base of insomnia increased it became clearer which avenues of exploration would be of more benefit to the project and increase the likelihood of a product solution. An example of such iteration can be observed in the research objectives. Initial thoughts were that it would be beneficial to analyze existing products on the market in order to see what has been done already and where there is a gap. However after an Interview with Dr. Kevin Morgan it became abundantly clear that an exploration into existing methods of treatment that are effective and do not yet have products associated with them would be of greater benefit.


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Summary: Desk-space Research In order to verify initial observations derived from personal ongoing experience with insomnia and to strengthen the insight into the knowledge and understanding surrounding it- it was crucial to conduct desk-space research. This stage of the project aided in the completion of key research objectives- notably, to “understand the fundamentals of sleep/insomnia” and to “research existing products/solutions”. This consisted of literature reviews, case studies, existing solutions/products analysis and a statistical analysis. The results are discussed. There is a growing health concern surrounding sleep. In the UK alone roughly 30% of people suffer with some form of sleeping problem. 10% of which have reached a diagnosable level. Research has shown that 75% of the UK workforce gets less than the recommended eight hours of sleep per night. (Employee wellness magazine 2011) It was found that sleep deprivation within the UK costs the economy £1.6 billion per annum. (Employee wellness magazine 2011). This emphasizes the growing health concerns surrounding sleep. There is a definite need for action to be taken to help in the management of this problem. New data from the Great National Sleep Survey 2011 (the largest sleep survey taken from the UK) indicates the extent to which sleep affects poor sleepers in comparison to good sleepers:

Area Good Sleepers

Insomnia

Low mood 561 (27%)

1,633 (83%)

Low energy 888 (42%)

1,841 (94%)

Relationship difficulties 279 (13%)

1,088 (55%)

Problems staying awake 251 (12%)

898 (46%)

Poor concentration 555 (26%)

1,537 (78%)

Decreased ability to get things done

475 (23%)

1,331 (68%)

Figure 1. Daytime impact of sleep (Mental health Foundation 2011)

If we consider Maslow’s Hierarchy of needs relative to the data taken from this survey- sleep falls into the first level of the pyramid, which relates to physiological components. Therefore it is very difficult for insomnia sufferers to reach the levels above- safety, love/belonging, esteem and self-actualization. (Maslow 1954) This data serves as quantifiable evidence of the theory. Case studies confirmed that people with insomnia truly lack quality of life. There is a case history of a 42 year old woman becoming socially isolated because she felt that she would become over stimulated by going out and therefore unable to sleep and an example of a 54-year-old business executive feeling fatigued during the day and falling asleep in his office. (Cooper 1994: 600-601) Insomnia in the Blind It was found that out of the £2 million people who are blind in the UK, 70% experience life-long sleeping problems because their retinas are unable to detect light meaning that they fail to recognize the time to sleep. These people have a kind of perpetual tiredness and intermittent insomnia because their circadian rhythms follow their innate body clock rather than a 24-hour one. (NINDS 2007) Medication is prescribed in the form of melatonin for the problem. However the long-term use of medication for insomnia has been proven ineffective. Therefore there is need to cater for the blind population in the design of the final product due to the large number of people


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within that group that the problem of recognizing the time to sleep affects. The final concept must be truly inclusive. Current Treatment Methods Traditionally, insomnia has been treated using pharmacotherapy. The efficacy of pharmacological methods in the treatment of persistent insomnia is very questionable. Long-term use of such treatments invariably to works to the sufferer’s detriment- creating a tolerance/dependency. (NHS 2011) The most effective widely known evidence based, long-term treatment for insomnia at the moment is Cognitive Behavioral Therapy. This therapy is focused around modifying patterns of detrimental behavior and negative thinking, which perpetuate the insomnia disorder, and is a cooperative method between the patient and the therapist. (NHS 2011) The problem with this method according to Professor Colin Espie, key sleep researcher and head of Psychological medicine at the university of Glasgow, is in its execution on a large scale. (Espie 2011) It was highlighted that 50% or more people with insomnia rarely or never consult their doctor about it. “There is, therefore, an important public health agenda around insomnia, much in the same way as there was historically around diet and exercise”. This is indicative of a lack of drive from the public to rectify problems with their sleep. Motivation from the public to solve problems with sleep therefore needs to be increased and become as socially conspicuous as diet and exercise. (Espie 2011)

What could be done? Within this context the Self Determination Theory can be applied (Deci & Ryan 2000). This pertains to the extent to which our activities are both Self Motivated and Determined. The theory holds that there are two key elements- ‘extrinsic’ motivation and ‘intrinsic’ motivation. Extrinsic motivation signifies taking part in an activity for the sheer purpose of an external purpose- where as intrinsic motivation signifies taking part in an activity for its own rewards. In order to encourage people suffering with poor sleep to take control of their problems, this needs to be self-motivated. This type of motivation has three essential components in order to work, autonomy- the need to be one’s own self, competence- being effective in a task or situation and relatedness- the need to connect and interact with others. If these intrinsic motivation factors are met there will subsequently be an improvement in sleep efficacy. Through the application of this theory, it is expectant that troubled sleepers will feel encouraged to feel motivated to take control of their sleeping habits and engage in healthier more productive behaviors. Cognitive Behavioral Therapy was explored. The effect of self-monitoring within this therapy was considered. “Monitoring can provide an “a-hah!” experience for clients: “no wonder I felt that way or did that”. This kind of understanding can help clients feel more in control and creates a stage for testing and responding. Self-monitoring helps to serve as an essential precursor to intervention within insomnia as it helps clients to learn to evaluate and respond in a productive way. (Kazantzis 2006: 54-56) This kind of self-monitoring could be incorporated into a product solution to work in conjunction with cognitive behavioral therapy. In order to tackle the problem of insomnia and lessen the impact of sleep deprivation on the UK, the Mental Health Foundation has advised a number of recommendations. Amongst this list was a recommendation relevant to this project- to conduct “Further research into low cost CBT-based interventions for sleep problems, such as self-help books and online courses, should be carried out.” (Mental Health Foundation 2011) This is consistent with the advice Dr. Morgan gave in the interview- that the most benefit would be gained from designing a product that works within the structure of theories that encourage the promotion of sleep, such as cognitive behavioral therapy. There is definitely room here for a product solution.


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Analysis of exist ing products:

Fig 5. Zeo sleep manager Fig 6. Sleep Buddy There has not yet been a product designed specifically for the recognition of the correct time to sleep in relation to sleeping problems. The leading sleep aids generally serve to monitor sleep in an iPhone app type way that would not be beneficial to the insomnia sufferer. The kind of feedback that such products provide would only serve to state a problem that the sufferer is already aware of- that they aren’t sleeping enough. In this sense the products are not insomnia specific and that is where the gap in the market is. The feedback that the poor sleeper would need in order to benefit from such a product would be information that tackles a key component of wakefulness e.g. recognizing the time to sleep. A product that was related to the type of thinking that will be harnessed to the final design is a sleep buddy for children. This product serves as a reminder to children regarding when they should be asleep and when they should wake up. It is likely that this product would lack the mature design language necessary to motivate the sufferer in a realistic way- however the basic concept is very interesting and something that will be taken into consideration. The modesty of the product as Dr. Kevin Morgan stated in his interview, is key. A simple and intuitive final design is the aim.


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Summary: Empirical Research In order to increase the strength of research and validate findings derived from desk-space research and initial observations, it was vital to generate empirical research. This element of the research project consisted of both qualitative and quantitative data collection methods including a focus group, an interview with an expert and a sleep diary study. These components of the research process were particularly helpful in satisfying two Research Objectives: gaining a deeper understanding of the fundamentals of sleep/insomnia and learning what the triggers for sleep are and how design innovation can be associated with them. Focus Group A focus group was undertaken with user participants who were categorized as following according to the severity of their sleeping problems: chronic insomnia, acute insomnia and transient insomnia. Participants were questioned on regular sleeping habits, perceptions and experiences of methods of treatments, awareness of what is considered healthy sleep and recognition of the right time to sleep. Several research conclusions arose as a result of this study: There is a lack of perceived control amongst poor sleepers. Participants who suffered with more severe cases of insomnia stated that they felt “powerless” over their sleep and that it was out of their hands. To increase motivation amongst poor sleepers there needs to be an increased level of perceived control. There is a need for a more accessible treatment method. When questioned on whether participants would consider CBT to tackle their problems with sleep it was not viewed as an accessible method of treatment. It was stated by those in full time employment that CBT, while beneficial, is not a convenient method. Fitting it into daily life when there are other demands to deal with is not always feasible. Overall awareness and knowledge of sleep needs to be increased. There seemed to be a lack of overall awareness and general knowledge healthy sleep behavior. For example, participants with more severe cases of insomnia had significantly poorer estimates of a healthy amount of time to spend asleep. It is not surprising that sleep habits go awry when there is no concept of what is considered healthy sleep and knowledge of the state of personal sleeping habits. It can be inferred from this that there is a gap in knowledge around sleep that needs to be filled to effectively promote and in turn aid in the practice of healthy sleep Interview Academic and Industry professional Dr. Kevin Morgan, School of Sport, Exercise and Health Sciences, Loughborough University was interviewed in order to gather further insights into more specific components of the project. This interview served to be extremely valuable to the research process. Morgan Was very positive to the approach that had been taken to the project. It was stated that what would be beneficial in the current climate surrounding sleep problems and insomnia would be a product that works within the construct of evidence based long-term treatments to encourage the promotion of good sleep (Morgan 2011).


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Morgan was questioned on the triggers for entering the sleep process. It was stated that there are two drivers for sleep. Homeostatic drivers and circadian drivers and the harmonizing of these two processes, which is key to inducing sleep- along with challenging a set of, learned intuitively plausible behaviors that work to the sufferer’s detriment. Emphasis placed on behavior in the treatment of insomnia. He confirmed that the most effective, long term, evidence based solution for insomnia is Cognitive Behavioral Therapy. Cognitive Behavioral therapy for insomnia uses a variety of devices including cognitive restructuring. Where while users are thinking negative thoughts that will perpetuate their problem, they learn to evaluate their thoughts and realize that the problem isn’t as bad as they thought. An increased awareness of the right time to sleep would be beneficial for someone suffering with insomnia. Poor sleepers fail to recognize/blur the distinction of those experiences before falling asleep and they adjust their lifestyles in detrimental ways as a result of this. People who have a normal and regular sleeping routine have experiences preceding sleep that match each other night after night, therefore it becomes easy for them to recognize when they have reached this internal state. Poor sleepers lack this regularity and lose the intrinsic confidence that they can recognize the internal state preceding sleep. Therefore regularity and routine is key in restoring intrinsic confidence. Since sleeping disorders increase with age- affecting 5% of the 18-25s and 30% of the over 60s the product should be accessible across the generations. The design language and interface should appeal to both younger and older audiences. He noted that there are a number of devices on the market that claim to cure sleeping problems. However these products have an extremely poor evidence base. He advised that the final product shouldn’t claim to induce sleep for people suffering with insomnia- rather it should work within the structure of evidence-based therapies that encourage the promotion of sleep- for example cognitive behavioral therapy. The product should aim to raise people’s knowledge and awareness of sleep as at the moment there is a distinct lack in the society’s knowledge of sleep. Morgan highlighted the preoccupation that society currently has with diet and exercise and the lack of knowledge surrounding sleep. He noted that there are three domains of health: Diet, exercise and sleep. In our society there is a distinct pre-occupation with the former two. People are able to go into explicit detail about nutritional concerns and exercise regimes etc. Knowledge/awareness of sleep is neglected. Aside from cueing people in for sleep, Morgan advised that raising the public’s general sleep knowledge would be extremely beneficial given the current situation. This interview inspired a number of ideas with regard to the final product. For example the final design could indicate where people with sleeping troubles currently are relative to their homeostatic drive and circadian rhythm in order to prevent them from engaging in seemingly helpful behaviors, which will ultimately put them in a worse position. “We don’t have a sophisticated conceptualization of our sleep, it’s crude and one of the reasons for this- sleep is socially inconspicuous”. - (Morgan 2011)


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Sleep Diary Study The sleep diary study served to underpin findings from both the interview and Focus Group in an objective quantitative manner. The findings of this study indicated a disordered bedtime pattern relative to the bedtime pattern of the normal sleeper. It can be concluded from this that poor sleepers have a lack of regularity in their sleeping routines, which makes it hard to anticipate the time to fall asleep and thus hinders attempts at recognizing the correct time for bed. This in turn could encourage damaging behaviors that seem intuitively plausible at the time. An example of a detrimental behavior can be observed in the comparison of time spent in bed versus time spent asleep between the insomnia sufferer and the good sleeper. The good sleeper’s time spent in bed and time spent asleep was invariably similar, meaning that their beds serve the sole purpose of sleep and no other behaviors are associated with it. It delivers exclusively on that functionality. Whereas poor sleepers spent generally more time in bed than the normal sleepers and most of that time was spent awake. Thus blurring the association between the bed and the time for sleep. This type of behavior can seem like a way to improve sleep but it only perpetuates the problem. This type of problem could be prevented if the person suffering with insomnia had an increased amount of knowledge surrounding sleep and an awareness of the right time to attempt entering the sleep state. The sleep diary emphasized the importance of routine in the maintenance of a healthy sleeping routine, as the participant with healthy sleep had sleep/wake times that were consistently similar give or take an hour, whereas the participant with insomnia had chaotic sleep/wake times. This made it difficult to anticipate the next time the participant with insomnia should be feeling sleepy and attempt to enter the sleep state.


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Appendices Interview Content Interview: Dr. Kevin Morgan Framework: Introduction of the project and explanation of the question… How can design be used to encourage the mind and body to recognize the time to sleep in relation to sleeping disorders?

What are the triggers for the body to enter sleep?

What in your experience are considered good and bad sleep habits?

As someone who suffers with insomnia I have often found that I have lost the ability to recognize when my body is tired and I should try to sleep. Do you believe that an increased awareness of the right time for the body to sleep would be beneficial for someone suffering with insomnia?

Do you know of any long-term treatments for insomnia?

What is your opinion of Cognitive Behavioural Therapy in the treatment of Persistent insomnia?

Are there other effective treatments for insomnia and why do they work?

How big a problem is insomnia in the UK? I have come across some statistics stating that insomnia affects 30% of the population is this correct?


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How are people typically treating insomnia at the moment?

Do you know of any unorthodox methods for treating insomnia?

Do you know of any physical products that are related to persistent insomnia?


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Interview: Key Findings Research Aim: The aim of this activity was to pursue detailed information around the research topic in question through direct contact with the interviewee and to expand the researcher’s understanding of the topic. Research Objectives: What you wanted to find out Method: The research participant was chosen because of his professional and theoretical expertise surrounding the subject area. An audio recording was made of the interview to mitigate the misrepresentation of responses. To ascertain the reliability, generalizability and validity of the interview, further desk-space research was conducted. To obtain the optimal amount of qualitative data the researcher did not use fixed categories for responses and was open to different and new knowledge other than what had already been researched.

Question 1: What are the triggers for the body to enter sleep? Dr. Morgan attributed the cue to enter sleep to two processes: -Homeostatic Drive. This refers to the conservation of balance within the body. In reference to sleep homeostatic drive means that the longer one stays out of your bed, the sleepier you feels. -Circadian Rhythm. Otherwise known as the “body-clock”. The circadian rhythm tells us in relation to sleep that the time of day will trigger whether or not we feel like going to bed. “Homeostatic drivers make you feel sleepy relative to the last time you had a sleep and circadian drivers, will tell you you’re sleepy relative to the time of day.” It was stated that the “harmonizing” of these two processes is the key in cueing the body to fall asleep. It was then indicated that there was also a psychological factor that impinges on this process. In order for the process to work there is a requirement for an element of recognition that you are sleepy. What is linked to this recognition is the “conditioning that usually accompanies feeling sleepy at a particular phase of your day” i.e. ritual. We participate in a series of behaviors that are exclusive to falling asleep- putting pajamas on, turning the lights off, and becoming horizontal etc. Conditioning means learning and all of these behaviors are learned. He went on to say that it is “axiomatic that what is learned can be unlearned”. People with sleeping disorders unlearn these behaviors. Insomniacs engage in behaviors, which seems intuitively reasonable, when in fact they only serve to the detriment of the individual. An example of this is that most people who suffer with insomnia tend to spend more time in bed than someone without sleeping problems. But they spend most of that time awake. It seems that there is a certain element of sleep that is programmed. He indicated that what people with insomnia do is “replace a series of very helpful, conditioned behaviors with another set of very unhelpful behaviors.” It can be concluded from this that what triggers sleep is the conditioning of a set of rituals, the end point of which being sleep and the harmonizing of homeostatic drivers and circadian rhythm drivers. People with insomnia have trouble with this because they have replaced helpful behaviors with unhelpful behaviors.


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Question 2: What in your experience are considered good and bad sleeping habits? Morgan linked bad sleeping habits to environmental factors. People with insomnia fill their sleeping environment with things that anticipate a sleepless night- computers, games, books, food, music players etc. A room built for passing the time. In doing so they enter the bedroom with a mindset that this is not the place for sleep. People who are “normal sleepers” have bedrooms that are designed for the purpose that they serve, which is falling asleep. “It is designed to deliver on that functionality”- and once the time for sleep is over normal sleepers leave the room or make the bed in order to make it a “transposed space”. It was also mentioned in the previous question; which is also applicable here- that spending too much time spent in bed is a detrimental sleeping habit. These specified habits are both directly related to altering the association between the bedroom and sleep. These are learned behaviors.

Question 3: As someone who suffers with insomnia I have often found that I have lost the ability to recognize when my body is tired and I should try to sleep. Do you believe that an increased awareness of the right time for the body to sleep would be beneficial for someone suffering with insomnia? Morgan felt positive that an increased awareness of the right time to fall asleep would be beneficial for an insomnia sufferer. He explained that people who live regular lifestyles relative to the circadian rhythm, condition their bodies- so experience informs their sleeping routine. What happens is that night after night these experiences match each other; and they learn to recognize that this is the internal state that precedes falling asleep. Whereas, what happens for people with insomnia is that they lose that sense of intrinsic confidence that they will fall asleep- and as a result of this begin to adjust their lifestyles. For example: Someone might think, “It’s not going to be tonight that I’m going to bed so why go to bed at 11 o’clock if I’m probably just going to stay awake and stare and just think? I’ll just stay up and go to sleep at 1 or 2am”. So people with sleeping problems begin to mix the messages to their body because of the effort they make to rectify their troubles. People fail to recognize/blur the distinction of those experiences before falling asleep. It becomes hard to identify whether you are in that state that precedes sleep or whether it is just more of that perpetual tiredness that people with insomnia feel throughout the day- and fighting that feeling becomes a habit that is transported into the night; which is only working to the sufferer’s detriment. Feelings about whether or not you go to sleep can be as blurred as feelings of appetite- and there’s research that shows that x amount of Americans mistake feeling thirsty for feeling hungry because they are constantly eating. They fail to discriminate. “It’s not difficult to confuse. To use a gestalt therapy expression- it’s not difficult to mishear what your body is telling you”. His response to this question served to confirm that an increased awareness of the right time for the body to sleep would indeed be beneficial in the maintenance of a healthy sleeping routine for someone suffering with insomnia.

Question 4: Do you know of any long-term treatments for insomnia? Treatments for insomnia broadly fall into two categories. There are pharmacological treatments for insomnia, which are both effective and safe. However they work best in the short term. Otherwise they fail to work. -People build up a tolerance to them -They develop a dependency on them -They experience withdrawal symptoms if they don’t take them


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Short term is defined by the national institute for health and clinical excellence as three to for weeks long- however most diagnosed insomnia cases are persistent and therefore last for longer than three to four weeks. Pharmacological treatments for insomnia create more problems than they solve when used in the longer term. What are needed are safe long-term treatments and the safe long-term treatment for insomnia is Cognitive Behavioral Therapy. This involved addressing the style of a person’s thinking around insomnia and addresses the organization of somebody’s behavior. For insomnia sufferers this would include sleep restriction therapy and stimulus control therapy. Simply a repertoire of tricks/devices that help people control the style of their thinking before they fall asleep. This is important for someone with insomnia because before when they fall asleep they think and it can be the style of their thinking that keeps them awake. This is due to cognitive arousal, which refers to a racing mind that struggles to shut down- the sense that “my thoughts are beyond my control”. CBT helps to control these thoughts. Within CBT there is cognitive behavioral restructuring where while sufferers are thinking they negative thoughts they review these things while they think about them to conclude that things aren’t so bad. About 80% of treated participants report long-term benefits from this treatment. The accessibility of insomnia was then questioned. In that in order to get what you need out of the system you need to have an awareness of how to work the system first. The right path of treatment for insomnia is not made obvious. You have to learn the right path for yourself. There is also still a training barrier; many practitioners know about CBT but are unaware that it can be used for treating insomnia. “The system is benign- well meaning but it’s horribly inefficient”.

Question 6: How big a problem is insomnia in the UK? I have come across some statistics stating that insomnia affects 30% of the population is this correct? This isn’t entirely true. What is true is that 30% of the UK suffer with a sleep problem, but only 10% of that portion of the population have reached a diagnosable level if insomnia. This is not evenly distributed across all age groups or all genders. The big drivers for insomnia are age and gender. Insomnia increases steadily with age- from around 5% of 18-25 year olds to 30% of those over 60. Women invariably report higher levels of insomnia than men and this is true across their whole lifespan.

Question 9: Do you know of any unorthodox methods for treating insomnia? There is a whole range of high street alternative medicine approaches- from herbal techniques, acupuncture to chiropractic’s aromatherapy, osteopathy, reflexology etc. Many of them advertise as solutions for insomnia and most of them have a pretty poor evidence base. Insomnia doesn’t have a simple solution. If it were simple then it wouldn’t be a problem anymore.

Question 10: Do you know of any physical products that are related to persistent insomnia? There are products out there. For example, Morgan mentioned a white noise generator to block noise out, and other kinds of noise generators that produce soothing noises e.g. the sound of the ocean. They’re effectively noise generators, which block out extraneous sounds.


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Everything hinges on evidence, whether it works or not. With no evidence there’s no confidence. But you can’t go wrong with things that raise people’s knowledge/awareness or cues them in. He advised to look at the evidence-based therapies and how they work and to ask the question “where could I insert a simple product?” Something modest that did something a person would have done if that product hadn’t had been there. Things like cues. Products that guarantee to induce sleep are invariably ineffective. There aren’t products that make you fall asleep. The devices that are effective work within the structure of theories that encourage the promotion of sleep. That’s’ where things like cueing people in come into play. Morgan went on to describe the state of the population’s knowledge (or lack of) surrounding sleep: At the moment we do not have a sophisticated conceptualization of our sleep. If we consider what we know and what we value as part of our health behaviors at the moment, in truth there are probably three domains of health activity that drive our levels of well being for the rest of our lives. Our diet, our level of exercise and our sleep and any one of those and seriously impinge upon our health quality. We know almost everything about diet. People can confidently speak about calorie intake, energy balance and nutrition etc. This is similar for exercise; people can talk about high and low intensity exercise, their weight and BMI measurements. This knowledge level is not evident in the health domain of sleep. This is because sleep is socially inconspicuous. Any small contribution could at this point in time have quite a substantial impact simply because people “don’t get i t” with sleep.

Conclusions: There are two drivers for sleep. Homeostatic drivers and circadian drivers and the harmonizing of these two processes, which is key to inducing sleep- along with challenging a set of, learned intuitively plausible behaviors that work to the sufferer’s detriment. Cognitive behavioral therapy for insomnia uses a variety of devices including cognitive restructuring. Where while users are thinking negative thoughts that will perpetuate their problem, they learn to evaluate their thoughts and realize that the problem isn’t as bad as they thought. The product could encourage people to learn a set of helpful sleeping behaviors to replace the unhelpful behaviors that they have learned. An increased awareness of the right time to sleep would be beneficial for someone suffering with insomnia. Poor sleepers fail to recognize/blur the distinction of those experiences before falling asleep and they adjust their lifestyles as a result of this. The product could indicate where people with sleeping troubles currently are relative to their homeostatic drive and circadian rhythm in order to prevent them from engaging in seemingly helpful behaviors, which will ultimately put them in a worse position. People who have a normal and regular sleeping routine have experiences preceding sleep that match each other night after night, therefore it becomes easy for them to recognize when they have reached this internal state.


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Poor sleepers lack this regularity and lose the intrinsic confidence that they can recognize the internal state preceding sleep. Therefore regularity and routine is key in restoring intrinsic confidence. Since sleeping disorders increase with age- affecting 5% of the 18-25s and 30% of the over 60s the product should be accessible across the generations. The design language and interface should appeal to both younger and older audiences. The product shouldn’t claim to induce sleep for people suffering with insomnia- rather it should work within the structure of evidence-based therapies that encourage the promotion of sleep. The product should aim to raise people’s knowledge and awareness of sleep as at the moment there is a distinct lack in the society’s knowledge of sleep. There are three domains of health: Diet, exercise and sleep. In our society there is a distinct pre-occupation with the former two. People are able to go into explicit detail about nutritional concerns and exercise regimes etc. Knowledge/awareness of sleep is neglected.


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Interview: Full Transcription (LM)- Author: Lily Mcgarry (KM)- Interviewee: Dr. Kevin Morgan The following transcript is near a word for word account of the Kevin Morgan interview. Minor steps have been taken to ensure grammar and clarity. An effort has been made to guarantee that this transcript is a true account of the participant’s views and the background in which it was shared.

(LM) I ’m looking at how design can be used to encourage the mind and body to recognize the t ime to sleep. Something I have observed as an insomnia sufferer is that I often lose track of when the best t ime to sleep would be and this problem is what I ’m basing my project around… First question: What tr iggers the body to enter sleep? (KM) At what level do you want an answer? Do you want a physiological answer? The easy answer is: when you’re sleepy. If we keep it at the level of behavior, because it’s simpler and it’s intuitively accessible at that level, if you start going into deeper levels it sounds like science but it doesn’t actually connect with anything people experience. So let’s just think about people’s experiences of triggers for going to sleep. Why do people generally go to sleep? Well you have to come down to what drives sleep in general. Sleep is driven by two big processes hence the name of the theory that holds this to be the case “the two process theory”. The two drivers are circadian drivers i.e. the time of day and homeostatic drivers. In physiology and biology homeostasis means the “maintenance of balance. So for example, if you stop eating, homeostatic drive encourages you to eat. It does so through the mechanism of appetite and hunger. So hunger is a mechanism that’s constructed to maintain homeostasis with energy balance. So if you don’t eat, your body tells you “it’s time to eat” and when you’re full another mechanism kicks in and says “you’re full, stop eating”. That way most of us manage to maintain a relatively stable energy balance. Sleep works in much the same way. The longer you stay out of your bed, the sleepier you feel. The greater the drive to go to sleep, and if you “spend” that “debt” to sleep you wake up feeling refreshed and you don’t feel like going to sleep. So that’s called homeostatic drive and homeostatic drive works for everyone. If follows the relatively simple principle: the longer since your last sleep the greater the pressure to go to sleep. So in answer to your question, homeostatic drive must trigger the body to go to sleep. Now, I assume you’re an art type person, so you’re probably a free runner, that when you get an idea in your head and it has to be seen through you will keep going, so if the homeostatic drive might say to you “you’re feeling a bit sleepy now”, you’ll just make another cup of coffee and you’ll just hammer on and run past homeostatic drive and we can do this. So homeostatic drive works at one level and we can adjust it. But there’s another driver for sleep that’s almost independent of homeostatic drive and that’s the circadian drive. Circadian means “round the day”- circa-dian. It basically tells us that irrespective of homeostatic drive, the time of day will trigger whether or not we feel like going to bed. Why is that the case? Evolution has created sleep as much for inactivating people during darkness as for restoring levels of energy. It’s not an accident that we sleep at night; it’s an evolutionary imperative that we sleep at night. So irrespective of how sleepy you feel, you’re more likely to go to sleep at bedtime, than you are at mid morning. It’s just the way things are.


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How can we prove that? Imagine that you did stay up all night. You’re doing an all nighter. You’ve got to finish some coursework. By two or three o’clock in the morning you feel terrible. Your body temperature is at its lowest, you’re feeling extremely lacking in energy, you’re making more coffee and you’re really forcing your way through the paces. If the only thing that mattered, Lily was homeostatic drive then as each hour passed you should feel more and more tired. But that’s not what happens. What happens is, as three and four and five o’clock passes, you start feeling less tired. By the time you get to six or seven o’clock you can actually feel quite elated. Now how does that work with homeostasis? Homeostatic drive ought to predict if that was the only process that the longer it was since your last sleeps the sleepier you should get. This isn’t what happens. What happens is the circadian driver kicks in, and the circadian driver says feel sleepy at bedtime and feel alert at waking up time. Driving that is your temperature rhythm. As we approach bed time the body temperature starts to fall and will keep falling until about three 3am and at that point you will be at you’re lowest and then it will start to rise again and you arousal level will rise with it. My point here is that you have these two processes. Homeostatic drivers, which will make you, feel sleepy relative to the last time you had a sleep and circadian drivers, which will tell you you’re sleepy relative to the time of day. If you want evidence of this then fly to Japan, fly to America it will be mid day and you will feel desperately sleepy because the circadian driver is kicking in. If you want to work with the circadian driver, just stay out of bed long enough and then go to bed that night in New York etc. when your body thinks it’s morning you will go to sleep, why? If you’ve been out of bed for 35 hours your homeostatic drive will kick in and force you to sleep. Now we come back to your question: What triggers the body to go to sleep? It is usually the harmonizing of the circadian and the homeostatic processes. Most of us who live boringly regular lives will condition our bodies to expect to be in bed sometime between 11 and 1am. This coincides with it being dark and it being the end of a long day. So when homeostatic and circadian drivers come together an individual goes to sleep. Ok. That’s easy. Now you have something that complicates things. That is what do people experience before they go sleep? The experience that should drive sleep is sleepiness. Not fatigue, but sleepiness. Ok they’re quite different, and in order to recognize that you’ve got to go to bed you’ve got to recognize that you’re sleepy and not just fatigued. How can you discriminate between sleepiness and fatigue…? Well, are you a runner? Do you exercise? (LM): Well, yes I walk a lot. (KM): Ok so let’s say you’ve just finished a 3 or 4-hour walk. You feel great but you don’t feel like walking much further. What do you do, do you fall asleep? No. Do you feel fatigued? Yes! Do you feel lethargic? Yes. Do you feel sleepy? No. It’s a completely different feeling. Do you see athletes falling asleep after a race? No. Do they feel energetic? No. Sleepiness and fatigue are very different. Now back to your question. It seemed like a simple question a lecture ago! What triggers people to go to sleep is the harmonizing of circadian processes with homeostatic processes and then the psychology of the whole thing, the recognition that you’re sleepy and that you ought to go to bed. And what maps onto that- the conditioning that usually accompanies feeling sleepy at a particular phase of your day and you say, “It’s time for me to go to bed”. Then ritual kicks in, we engage in a ritual set of stylized behaviors which nearly always involve activities which are unique to going to bed i.e. winding down, cleaning your teeth, taking your clothes off, turning the light off, and becoming horizontal. These are all unique signals to your body that sleep is about to happen. So the signals that you are due some sleep now are heavily conditioned. Conditioning means learning. It’s axiomatic that what is learned can be unlearned, and when it becomes unlearned to the point that what seems to work for everybody else doesn’t work for the person with insomnia then you have problems. Because there are then lots of things that then start to happen to the person with insomnia, which seems intuitively plausible solutions and in fact they are completely counterproductive. I’ll give you an example, most people who suffer from insomnia tend to spend more time in bed than someone without insomnia, but they spend most of that time awake. Ok.


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If I was to go back on my earlier statement and stay that what triggers sleep is the conditioning of a set of rituals, the end point of which is falling asleep it seems that there are certain element of your sleep that are programmed, they are learned. Just watch someone that’s got a baby. No baby is born knowing that they’ve got to fall asleep on their own in their cot, that’s what you’ve got to crack as a parent. You crack it by teaching it. You put them in there and now an again you’ve just got to let them cry and sooner or later they get the message that their job is to fall asleep alone in their cot. But what they’ve learned they can unlearn. What people with insomnia unlearn is the association with their bed and the triggers for falling asleep. And then they go one step further and they replace those triggers with what’s called a “conditioned emotional response” that instead of lying in your bed like…well, ask someone without insomnia what they do to fall asleep and the answer is nothing. They don’t do anything; it’s not an active process. It’s automatic. They will go to bed and the bedroom itself will trigger sleep. (LM): Yes, it’s called falling asleep for a reason! You fall into it… (KM): Yes, exactly. Good metaphor. However people with insomnia start worrying about going to sleep from the minute they get up from the arm chair and by the time they get into bed it’s not uncommon for their level of arousal to be above baseline because they’re just wondering- Is tonight the night? Then they get into bed, and what do they associate their bed with? It’s a place where they feel frustrated, cross and depressed. What they do is they replace one set of very helpful conditioned behaviors with another set of very unhelpful behaviors and they teach themselves that the bed is a place of hostility and we work with that therapeutically. We have programs and we have therapies. One is called stimulus control therapy and the stimulus control therapy rule is if you’re not asleep in fifteen minutes then get out of bed. Keep this up for weeks. Then bit-by-bit you will re-learn that your bed is somewhere that you go to sleep. It’s crude but it works. We couple this with sleep restriction therapy. You spend less time in bed- we calculate how much time you sleep and we create a sleep window i.e. you got to bed at that time/wake up at this time. Sleep windows are anchored at getting up times, that’s because it’s the best driver of your circadian rhythm as opposed to your bed time. If you’re going to vary one of those times vary the bed time, that way the signal to your body “things start now” is much clearer. And what we basically do it we mildly sleep deprive people for weeks at a time. If you mildly sleep deprive people they get sleepy and sleepier people whether they’re an insomniac or not are more likely to fall asleep in their beds. It’s not rocket science. It works! Ok, now, back to you...

(LM): Ok next question, what in your opinion are considered good and bad sleeping habits? (KM): This depends on whether or not you have a sleep problem. I have some joke drawings that I show people at presentations, one of my favorites is Van Gogh’s bedroom, (pictured below) It’s got a bed and a few paintings on the wall and everything you need to fall asleep. If you ever look at a person’s bedroom that’s had insomnia for a couple of years it’s full of stuff that anticipates being awake- food, something to read, a lap top, TV- something to invariably pass the time. If you look at someone’s living room it looks like the bedroom of someone with insomnia. However if you look at the bedroom of somebody who doesn’t have insomnia not only as I was saying earlier is the rituals and behaviors that involve going to bed are unique to bedtime. If you look around the environment of your bedroom it’s probably got what you need for bedtime. If you live in a very small house it might have the odd exercise bike but in general it’ll be an environment that is designed for the purpose that is serves which is sending someone to sleep. For example it will be colder than other rooms because we don’t like to be warm in bed. So it’s designed to deliver on that functionality, and when we wake up we generally leave the bedroom or we cover the bed up so it becomes a transposed space. So, what are bad habits and good habits? Well if you’re a good sleeper and don’t’ have a sleep problem, you don’t have bad sleeping habits, whatever you’re doing obviously works, so if you find somebody who has no problems with their sleep- chunky sleepers- it’s pointless telling them to drink less coffee, do more exercise, have a better pillow etc. It


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means nothing because there’s nothing wrong with their sleep. If you have someone who has a sleep problem then you start looking at what they’re doing only because you’re looking for targets for intervention, you’re looking for things to fix. Now some of these are going to be design features of bedrooms and it’s easy to assume, especially in our society that privileges biochemical models of dysfunction e.g. you don’t drink the right tea or do the right exercise- it might be just as relevant to say take the radio out of the bedroom. Use your bedroom for going to sleep. If you have a sleep problem then start learning that your bedroom is somewhere that you go to sleep. Everything that isn’t to do with sleep, get it out. Everything -the TV, the books, the ashtray and the Xbox. Everything! Simply say, if I need to listen to the radio during the night then I get up, I leave this room and I go to where everyone else goes to listen to the radio. If I need to eat then I’ll go to the kitchen, if I need to smoke then I’ll go outside- in the garden. Where ever! Do you see what I mean? (LM): Definitely. (KM): You create in the bedroom the unique environment of sleep, in other words in answer to your question- the bad habits here are bad associations you’re learning with your bedroom. What you want to do is increase the number of times you fall asleep in an environment that is so unique that the environment itself ultimately starts to trigger the feelings that precede falling asleep. Ok.

(LM): Ok thanks! Next question: As someone who suffers from insomnia I have often found that I have lost the ability to recognize when my body is tired and I should try to sleep. Do you believe that an increased awareness of the right time for the body to fall asleep would be beneficial for someone suffering with insomnia? (KM): Yes. This is to do with cueing. What happens is, almost certainly people who live regular lifestyles, I mean regular relative to the circadian rhythm. Regular lifestyles with no sleep problems, just train themselves so experience tells them…they start yawning at the same time every night with the expectation that the same set of rituals will kick in. If you’re not doing coursework and battling the demands of the semester, back-loading stuff or juggling then you can do this stuff. When your life is a bit more on the edge it’s a bit more difficult. But the nevertheless that regularity becomes a guardian of sleep quality. What happens when somebody is living so regular a lifestyle is that their experiences night on night match each other and they learn to recognize- this is the internal state that precedes my falling asleep. You can label it sleepiness, tired sleepiness, weariness, fatigue, you can call it what you like, that fact is that you recognize it as an inner state that makes going to sleep probably quite likely. If you don’t trust your sleep to happen the way it seems to happen for everyone else, if you start adjusting your lifestyle, so you might think “it’s not going to be tonight that I’m going to bed, so why go to bed at eleven o’clock if I know that I’m going to stay awake and just stare and think…I’ll just stay up until 1 or 2am”. You start mixing the messages to your body. You fail to recognize…you blur the distinction of those experiences before you go to sleep. So it becomes difficult to recognize- is this the state that precedes falling asleep? Or is this the state that is just that endless weariness that I feel during the day that I’ve got so used to fighting during the day, other wise I’d be dysfunctional- and fighting it has become a habit, I’m now taking it into the night which is not doing me any favors. So you’re absolutely right that along with the therapy the setting of our sleep window serves a very important function, it’s rigid in as much as we contract with the individual e.g. “this will be your bedtime and this will be your getting up time” and they have to agree that they will stick to this and part of the principle here is that they will re-learn to associate those pre going to sleep experiences with a time of night. It’s difficult at first- they will do it because they have agreed to do it and they will have little faith in the therapy. After about a week when they start falling asleep and the days are wretched they really do start to see the benefits and it makes a bit more sense. But you’re right! Feelings about whether or not you go to sleep can be as blurred as feelings of appetite and there’s wonderful research showing that x percent of Americans mistake feeling thirsty for feeling hungry because they just eat all of the time! They have long since failed to discriminate, you know you always have your coke with your burger so you never actually discriminate- “am I hungry or am I thirsty”… (LM): Just “in” basically! (KM): Absolutely in! So you see it’s not difficult to confuse. It’s not difficult- to use a gestalt therapy expression- it’s not difficult to mishear what your body is telling you. Next question


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(LM): Ok, Do you know of any long-term treatments for insomnia? (KM): Yes. Well I assume what you mean is, I know what you mean is- are there any long-term evidence based treatments. Yes, broadly treatments for insomnia fall into two categories there are the pharmacological treatments for insomnia which are effective, which are safe, which are best in the shorter term and create more problems than the solve in the longer term. The reasons for this are manifest and one of them is simply the way these drugs work, people build up a tolerance to them and they stop having such a powerful effect, they can become dependent on them and the can experience withdrawal if they don’t take them. But in the short term as defined by the national institute for health and clinical excellence are three to four weeks and during that period it is very effective and very safe, highly recommended. The problem is that most insomnia cases are not three to four weeks… (LM): I’ve tried it didn’t work! (KM): Yes! It just goes on for a long time, so what we need is safe long-term treatments and the recommended evidence based safe long-term treatment is called cognitive behavioral therapy for insomnia. Cognitive behavioral therapies are a generic style of talking therapy that combine from a psychological perspective almost opposites- cognitive and behavioral approaches but they’re called a pragmatic combination and they work very well together even through the theories that drive them are pretty much poles apart. Cognitive behavioral therapy is broken up into components and those components involve what at CBT involves: addressing the style of a person’s thinking and addressing the organization of somebody’s behavior. Behavioral components of CBT are what we talked about- things like sleep restriction therapy and it would include stimulus control therapy, the cognitive elements of the program are derived from cognitive behavioral therapies in other areas but they’re largely a repertoire of devices, tricks if you like that help people control the style of their thinking before they fall asleep. Why should that be important? Well when you put the lights out and you are lying in bed, and you eyes are closed people think and the style of their thinking can be the thing that keeps them awake. For a couple of reasons but the demon of the piece here is something called cognitive arousal, and it’s important to realize that cognitive arousal doesn’t really mean the same thing as anxiety although anxiety is a form of cognitive arousal, and it doesn’t mean physiological arousal- it doesn’t mean your heart is pumping or your blood pressure is that high it simply means- well it means what the patients I speak to all of the time tell me, I say to them “what are you thinking about or what stops you from going to sleep?” They say, “My mind’s racing, I can’t shut down”. This sense of- my thoughts are beyond my control, the just race along, is a characteristic experience of people trying to get to sleep and cognitive behavioral therapy can help because cognitive therapy is about controlling thoughts and it works in all kinds of effective ways. It’s crude; you can block thoughts and say stuff in your head that just stops you thinking about anything. At its most sophisticated you can challenge thoughts, there’s a style to the way we think and quiet a lot of the thinking around insomnia is projected consequences e.g. “I’m going to be wretched tomorrow, I’m going to fail my exam, I’m going to perform badly in class, I’ll miss the aero plane to go on holiday and look awful… and damn here I go again”. One way to deal with this is to challenge it e.g. “how long have you had this problem, has your life fallen apart yet?” Speaking personally about you- “you’ve managed to get yourself into university, that was a challenge, you haven’t disintegrated yet, you’re looking pretty bright and you’ve made it here. You function properly. But you could probably do with feeling a bit better sometimes than you do. Ok. So if you were to review these things while you were thinking about how awful you’ll feel we can introduce what is known within cognitive behavioral therapy as cognitive restructuring, you can put your mind in a different place and conclude that things aren’t so bad. “Ok I can’t get to sleep but it’s not the end of the world.” Or one of the things that I really like doing and it’s something that my patients really like is creating worry buffers, worry buffers are scheduled times for worrying during the day. Six o’clock, note pad, light, sit down, by appointment and worry for half an hour. Just write them down, write down what you’re worried about- your relationships, your coursework, your income, all of the things that everybody worries about. Write them down and think about them, really think about them and think about why they’re worries and what could possibly be done about them. If you think of the odd thing that could be done then write that down as well. Be constructive, don’t just be ruminative and just amplify these things. Think strategically. Then at 6.30 put your


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pen down and that’s it! Then that night you go to bed and what do you do if worrying sets in? You think, “no I’ve done that, I’ll do that tomorrow, I’ve done the worrying”. It works for some people! They’re given permission not to think about things, which aren’t going to be particularly helpful anyway. Then of course there are also relaxation procedures, now years ago it used to be believed that the reason people couldn’t go to sleep was because they were physiologically aroused, their body’s were effervescing with activity and relaxation was found to help some people with sleep onset insomnia- problems going to sleep. But it turns out that people aren’t that physiologically aroused at all, that they’ve got more problems with controlling their thoughts. Which begs the question, why would relaxation have helped people who are cognitively aroused? The answer is that it’s almost certainly a meditation. Usually we use what’s called progressive muscle relaxation, you tense and relax and tense and relax systematically and it takes about 25 minutes and you’ve got to think about it all of the time, you can’ think about your income and how your money is running out and what the bank manager is going to say. You can’t think about this stuff when you’re doing it- all you can think about it tightening your muscles, working your way up your legs, your trunk your upper limbs etc. It fills your head up and almost certainly for that reason it helps people to get to sleep, it’s a cognitive strategy although it looks like a physiological strategy. So there we go, that’s the answer to the question are there long-term things. Who does this work for? About 80% of treated patients report long term benefits from this treatment. We’ve run trials here- I’m just working on one now. Really ill people, old people, people with cancer, people with arthritis, and people in pain- it works for them. It’s a very robust treatment. Ok, next question!

(LM): Ok thanks! Just on the subject of Cognitive Behavioral Therapy; in terms of accessibility are there a lot of sufferers that are in need of CBT that can’t necessarily get access to it? - Is it very expensive to do? (KM): Yeah. Ok 10% of the adult population experience treatable insomnia, serious insomnia. That percentage increases with age, one of the reasons for that is that people like you don’t die with insomnia, you just get older with it. So in 20 or 30 years time someone might ask you in a survey “do you have sleep problems?” and you might say “yes” and they might think it’s because you’re 40 and they’ll be wrong. It’s because you had it as a young person and never got better and you didn’t die with it. So my point here is that we have a fixed population of people with insomnia, we know now what’s best for them (CBT). The problem is that it’s competing. It’s competing rather unfairly with hypnotic drugs, because hypnotic drugs are a lot easier to get hold of. They take minutes to sign off a prescription and they seem to solve the problem, but they actually make the problem worse. Cognitive Behavioral Therapy has long been a problem in its service delivery because it’s a talking therapy, in England over the last three years it’s never been a better time to access cognitive behavioral therapy and that’s because of the department of health in England’s IAPT program which stands for improving access to psychological therapy program, as a result of the IAPT program which started with investment by the labor government 3 year ago and was picked up and continued by the current coalition there are now trained cognitive behavioral therapists in every PCT area in England. Wherever you live, you can go to your general practitioner and asked to be referred to the IAPT service- and if you want some strategic advice, many of the people in those service know about CBT and don’t know that CBT can be used for treating insomnia and don’t know how to do it. If I was telling somebody how to use systems I would say insist, you pay your taxes, it’s your service and it’s the health service. Ask for the referral and you are obliged to receive an assessment and you can say that it is driving your anxiety levels up and then when you get into it then say “well if you don’t know how to do cognitive behavioral therapy for insomnia then contact Kevin Morgan- he trains IAPT practitioners in how to do this”. It’s easy, well it’s easy if you know how to do CBT, but many of them don’t know that CBT can be used for treating insomnia. So, the conduit is there. There’s still a training barrier, but we’re working on that and it’s more optimistic now than it’s ever been. But you’ve still got to learn how to use the system. How to get what you need out of the system, the system is benign, it’s kind of well meaning- but it’s horribly inefficient. It’s just not obvious to anybody what is the right path; you have to learn this yourself- even some of the GPs won’t know what the answer is. There you go…


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(LM): So once you’ve got that referral how long does it take to get to the stage where you’re seeing a therapist and it’s actually happening? (KM): In an IAPT service they are time limited, you’ve got to see somebody, I think within three weeks for an assessment. Then they do the stacking business…

(LM): Ok next question, although I think you may have already answered this one. How bigger problem is insomnia in the UK? I’ve come a across numerous statistics stating that it effects roughly 30% of the population, is that about right? (KM): No, that’s far too many. I don’t think we’re going to get very far by inflating the statistics. I gave you a number of 10% earlier. That’s 10% who had reached a diagnostic level. Now if you want to know how to diagnose insomnia, it’s relatively straight forward, it’s got some critical bits that must be included. Insomnia is defined as a problem getting to sleep, a problem staying asleep or dissatisfaction repeatedly with the quality of your sleep i.e. you wake up feeling rotten. It’s got to happen at least two or three times a week for a month. But critically, two things have got to be there as well. You’ve got to experience that given adequate opportunity to sleep. The recreational abuse of your sleep is not insomnia and it must have daytime consequences, so being a constitutionally short sleeper isn’t insomnia. If were asleep for three hours you’d find it utterly boring if you wake up at 3am, but you’re bright and alert throughout the day until you get your three hour sleep- then it’s not insomnia, for sure. You’ve got to have daytime consequences. In diagnostic manuals you’ve got to have what is described as social or occupational dysfunction and it’s characterized by fatigue. People go into the day feeling fatigued. Not sleepy. People insomnia not always falls asleep. Our own research shows a counterintuitive finding- we’ve been looking at the occupational impact of insomnia in lots of people and we’ve been trying to design metrics that captured just what insomnia does to people in the work place. Being fatigued is one thing, but what does it affect? It affects our abilities to hold meetings and maintain proper workplace relationships, concentrate on your work etc. Does it affect absenteeism? Does it affect punctuality? Now punctuality is interesting because it often gets overlooked in favor of absenteeism and absenteeism received attention because it’s easy, because records are kept by organizations so you can count off the people but being late for work is slightly different, being tardy, being unpunctual. Yet the research shows that if you can identify people with insomnia they’re the least likely people to be late for work. Why would that be? It’s obvious, obsessional people end up getting there early! That same psychological driver that is taking them albeit fatigued to work is the same driver that’s keeping them awake at night. The current thinking about insomnia is that it a deregulation of attention and that means that some people just find it really easy to switch off and focus on falling asleep and some people find it very difficult to reign in their attention from those daytime things that concern them. So that’s why the psychological therapies, which aim to contain that, are successful. What you can’t make out of insomniacs is “non-insomniacs” what you can do is teach them skills for lifelong management and get them to stop beating themselves up, it just makes it worse. So that’s what it’s about, it’s about understanding it. 10% of the population, it rises with age. Do you know what epidemiology is? It’s the study of conditions within populations. It was known that smoking caused lung cancer long before anybody understood the genes or the pathology of carcinoma of the lung. Simply because the epidemiology showed that if you looked at smokers and non smokers almost no non smokers developed lung cancer and almost all smokers developed lung cancer and you could just draw the conclusions Well we have no idea what causes this disease but we know that if you stop doing that you’re more likely to live. What we know about insomnia is that overall it affects about 10% of the population but this is not equally distributed across all age groups or all genders. The big drivers for insomnia are age and gender, insomnia increases steadily with age for around 5% of the 18 to 25s to around 30% of those over 60. The other driver is gender; women invariably report higher levels of insomnia than men. Age by age more women in the 18 to 25 year old age group will report than men and that tracts right across the lifespan, always women more than men, even into old age.


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There’s a couple of ways of looking at this, one of them is to assume that women’s sleep is fundamentally different and you can look at two systems- you can look at the sleep system itself and say- is the way that women sleep different? And you can look at what challenges sleep and you can start to argue that maybe… If you’re a psychologist- here’s a good rule of thumb- it’s a message for life: when people talk about gender differences in anything the question to ask first is not “why do they differ?” The question to ask first is “why would you expect symmetry?” Why would you expect men and women to differ? We have different bodies and lifespans; they work differently, why on earth would you expect them to sleep the same? So you’ve got all of those hormonal things that are going on for women that don’t go one for men. You’ve got all of those social things that go on for women. Men, generally don’t feed babies, they don’t have babies, they don’t have pregnancies they’re not care givers the way women are, they don’t go through menopause, men don’t live as long as women. Men fall off the edge in their seventies and women go on! So you’ve got very different trajectories, things that challenge sleep level. Then you got these kinds of sociological differences. If you look at the epidemiology of pain, more women report pain. This starts to tell a story of…well, do men say anything about themselves frequently that make them look vulnerable? The answer is no they don’t. Ask men questions to which the answer will imply a personal vulnerability, you may well get suppressed responses. So that’s one way of looking at the data that there’s a results bias in the questions. The other way of looking at it that used to be the case that’s much less so now is are men doing something that makes them not recognize that they’ve got insomnia? I.e. do they drink too much? It used to be the case that women drank much more than women anyway, so you’d have to ask questions about whether they even knew that they had insomnia. Now things have moved in the other direction. So there are big differences there, nevertheless gender is an interesting issue here. So what has this got to do with design? How does this take us to design? Where do you want to go with this? I’m going to ask you the questions now… (LM): Well I’m trying to create a link between the sleep triggers we talked about and a product. (KM): This product will be conceptualized as a space? A gadget? (LM): Well I’m not entirely sure at the moment but I suppose the overall aim is some kind of sleep aid. So remember you talked about the blur and not being able to know when the right time to sleep is? Well I’d like to remove that blur and enable sufferers to say “Ok this is the optimal time for me to fall asleep, I could try it now and it could happen”. (KM): Ok, ok. Yes! A reminder! A sleep memoir… (LM): Yes, remember we talked about sleep debt. So you would be able to know how much you’d “spent” and know when you’re at the end of your tether and it’s about right for you. (KM): A sleep manager… (LM): Possibly… (KM): Yes, this could work! I tell you what could work to you advantage, at the moment the gains to be achieved in this field are inflated simply because sleep literacy is so low. Most people don’t know anything about their sleep. Now here’s a message for you, if you think well in a kind of men health, women’s health obsession that characterizes our society now, this relationship we have with our bodies- we want guarantees and we want to sue people if the don’t look after our bodies properly and this kind of moral ethic is that you’ve got to look after your body i.e. if you’re too big and if you smell of smoke or something- suddenly you’re in the lower end of things. If you think about what do we know and what do we value about our health behaviors at the moment, in truth there are probably three domains of health activity that drive our level of wellbeing for the rest of our lives. Our diet, our level of exercise and our sleep and any one of those can really seriously impinge our quality of life. If we eat too much food or we don’t’ eat enough food then we know where it takes us. Exercise, well you can probably get away with it at your age I can’t at mine ok, you’ve got to keep moving. And sleep! You lose sleep and it’s all you think about! It’s like toothache, it’s the most important prioritized thing in your life all of the time, ok.


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Ok what do we know about diet? Almost everything, people can talk about energy, you could get anybody off a bus and they’ll tell you about calories and calories are like physics measurements! People know about exercise, high intensity and low intensity, people have sophisticated views of these things, most people have electronic weighing scales that measure their weight to within grams and they know about BMIs. Any body going to weight watchers will ask what is your body mass index? What do they know about sleep? Nothing! They can’t even discriminate between the problem of getting to sleep and staying asleep and if they’ve got a sleep problem. We don’t have a sophisticated conceptualization of our sleep, it’s crude and one of the reasons for this- sleep is socially inconspicuous. It’s invisible unlike everything else. For example, as I said insomnia increases with people’s age. As people get older they’re more likely to report insomnia. What do you know about ageing? Probably lots, you know what happens to people’s skin when they age; you know what happens to their hair color when they age, how come? Because you see it! It’s public, but what do you know about what happens to people’s sleep as they age? Nothing, it’s invisible because people don’t talk about it. So what I’m getting at here is that any small contribution could at this point in time have quite a substantial impact simply because people don’t “get it” with sleep. Ok.

(LM): Ok do you know of any unorthodox methods of treating insomnia? (KM): Well there’s a whole lot of complimentary and alternative medicine approaches or CAMS, this would include all of with those therapy in the high street, everything from acupuncture to chiropractic’s aromatherapy osteopathy, reflexology etc. Many of them would actually advertise as solutions for insomnia and most of them have a pretty poor evidence base. If it was simple to solve insomnia then hypnotherapists would be millionaires, but is doesn’t. It isn’t simple. There are devices, there are pyramids you can stick your head in at night, which capture the wisdom of the ancients…yeah. There are magnetic beds you can buy and vibrating mattresses and all kinds of expensive beds containing water, oil. All kinds of stuff that makes your body do things that will initiate the sleep state. There are suggestions that you must align yourself with east and west of course etc. You Google sleep aids and you get all kinds. Then of course there are the traditional herbal things, the main ones amongst which are valerian based. Herbal remedies like hop pillows. There are products our there.

(LM): Have you come across any designs recently that have contributed to the management of insomnia? (KM): Ok, yeah. Well there are two ways of doing this. Some of the more exotic gadgets; they come out of design schools. I was recently looking at what was effectively a white noise generator. Basically if you have a noisy bedroom it would block noise out- this is a nice idea some people like noise in their bedroom. There are other noise generators that actually produce soothing noises e.g. wind or the ocean. Kind of murmuring noises but they’re effectively white noise generators which just block out the frequencies that create extraneous sounds, there are aromatherapies etc. Everything hinges on evidence of whether or not it works. Not on the attractiveness of the product idea, what really matters is to not dismiss anything however strange it sounds. Let’s just ask the question “is there evidence that it works?” Where there’s no evidence there’s no confidence. But you can’t go wrong with things that raise people’s knowledge or cues them in. If you look at how therapies work. How do evidence based therapies work and ask yourself the question “where could I just insert a simple product? Something modest that did something that a person would have done if that product hadn’t had been there”. Things like cues. The trick is to try and find linkages between products and need and they’ll fall into either “this product will make you fall asleep”. In which case you can guarantee that it will be rubbish at the moment. There aren’t devices that make you go to sleep. Or there are devices that work within the structure of theories that encourage the promotion of sleep, that’s where


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things like cueing people in come into play. Even if it was a handful of questions for example a quick 1,2,3 then go to bed. When you feel like this then go to bed. Ok.


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Focus Group Content Introduction of the project and explanation of the question… How can design be used to encourage the mind and body to recognize the time to sleep in relation to sleeping disorders? “The purpose of this study is to gain a deeper insight of insomnia and some of the perceptions around it and some of the common problems…”

Introductory question to help part icipants feel used to speaking and sharing information: 1.How much sleep would you say you get on a daily basis? 2.How much sleep would you says is a healthy amount of sleep per night?

3.Have you ever used a sleep aid before? / How effective would you rate it?

4.Did it help your troubles with sleep in the long term?

5.What are your opinions on the current methods of treating sleep troubles?

6.Have you ever considered cognitive behavioral therapy to treat your problems with sleep?

7.Do you know specifically when it’s time for your body to sleep?

8.What kind of signals does your body give you to fall asleep?

9.Do you have a set time for falling asleep?


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10.Do you think that an increased awareness of the right time for your body to sleep would be beneficial? Project aim: The aim of this study was to gain a deeper insight into the mindset of people suffering with insomnia and their feelings around the subject of recognizing the time to sleep and their own sleeping patterns, solutions for sleep troubles and their effectiveness. This study aided with the key research objective of gaining a deeper understanding of the fundamentals of sleep and insomnia. Objectives: The primary objective for this piece of research was to gain a deeper understanding of the fundamentals of insomnia and sleep through direct interaction with poor sleep sufferers. This was to provide a rich amount of qualitative data on perceptions surrounding insomnia and the research question. Method: Focus Group Characterist ics of Part icipants: Five individuals with varied sleep troubles participated in the Focus Group. In order to ensure generalizability to the wider population there had to be a variety of participants of different age groups, genders and types of sleep troubles. The group included three females and two males. Ages were 65, 47, 50, 24 and 20. Participants were chosen on the basis of having suffered with a sleep problem at one time or another throughout their lives. The participants collectively suffered with a range of sleeping problems: Two participants had Chronic Insomnia, one participant had acute insomnia, another participant had transient insomnia and there was one currently “normal sleeper” (however this individual had reported at one time to have had brief sleeping troubles). Figure 12. focus Group Participants Participant Age Sex Disorder Type

LG 65 Female Chronic Insomnia SM 50 Male Chronic Insomnia

JM1 47 Female Transient Insomnia JM2 24 Female Normal Sleeper WM 20 Male Acute Insomnia A Focus Group was selected as the tool for collecting this data in the hope that it would result in rich data through direct interaction between the researcher and the participants. There are a number of limitations to consider with reference to this type of study i.e. participants misrepresenting their sleeping habits and it is hard to analyze such rich qualitative data as it has no definitive structure. To lessen these limitations this study was to work in conjunction with a sleep diary study, which would underpin the Focus Group findings. Content The focus group covered regular sleeping habits, perceptions and experiences of methods of treatments, awareness of what is considered healthy sleep and recognition of the right time to sleep.


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Focus Group Transcription How much sleep would you say you get on a regular basis? Participants were unable to accurately recall the amount of sleep they would get on a regular basis. Participants who were ‘good sleepers” were more able to recall this- whereas the participants who were suffering with sleep problems were less certain of this and stated that there was a lack of regularity in their sleep and that attributed to the inability to recall their amount of sleep. This is indicative of a lack of awareness of sleep. It could be suggested that this lack of awareness helps to perpetuate the sleep problem.

How much sleep would you say is a healthy amount per night? Participants reported a variety of different answers. “Normal sleepers” gave answers that were similar to the recommended amount of sleep for adults by the National Sleep Foundation (8 hours). However participants suffering with poor sleep gave responses that were either too high (10-12 hours) or too low (5-6 hours) relative to the recommended amount. This suggests a distorted perception of what a healthy amount of sleep looks like on behalf of the poor sleepers. It is clear that poor sleepers could benefit from an increased amount of knowledge in regards to sleep. If their perception of a healthy amount of time to sleep is distorted then it is difficult to achieve a productive sleeping routine.

Have you ever used a sleep aid before and how effective would you rate it? The general consensus from the group was that they had all used pharmacological methods to help with their sleep troubles at one time or another. Nytol was the common solution mentioned. The effectiveness of this method was negatively reported. Participants noted that it was effective as a short-term solution however after a longer period of time they built up a tolerance to it. There was a reference of possible addiction and a growing dependency on the medication if it was used for a long period of time. There was also mention of fatigue the day after its use. It was noted that subsequent to the use of sleeping tablets that participants ended up feeling in a worse position than when they started. This question indicates that sleeping medication is a successful short-term solution however since the cases of insomnia within the group are longer than what is considered short term it seems that sleeping medication ultimately serves to be detrimental.

Did it help your troubles with sleep in the long term? Methods that they had used to help with their troubles were not considered long-term solutions.

Have you ever considered Cognitive behavioral Therapy to help with your sleep problems? When questioned on possibility of cognitive behavioral therapy for sleep troubles, which is widely known as the most effective method of treatment, participants displayed a low level of enthusiasm and willingness. They felt that it would prove to be beneficial however there was an issue with accessibility- as it is only available after a referral from a GP etc. and fitting it in with their lives was not convenient. It is something that has to have time devoted to it and this


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is not always fitting for someone who leads a 9-5 job and has to cope with the demands of family life. There is not a lot of time for it in their day-to-day lives.

Do you know specifically when it’s time for your body to sleep? Responses were varied. Notably the normal and transient sleeper had a distinctly firmer idea of the correct time to sleep and attributed this to a regular daily routine, which informed their sleeping pattern. Since every day was the same their homeostatic drive would be the same at the same point of their circadian rhythm every night. A participant with chronic insomnia stated that out of a routine it was much easier to confuse the correct time to sleep, especially while going through a bout of sleepless nights. This indicates that routine and regularity is an essential component in recognizing the time to sleep. Lack of routine seems to perpetuate sleeping problems.

What kind of signals does your body give you to fall asleep? Participants struggled pair the recognition that it is time to sleep with specific signals. The general response was that an overwhelming feeling relating to an inability to stay awake triggers sleep. Not surprisingly the good sleeper felt more able to link the feeling of sleep with some changes in the body i.e. a deepness of breathing, tired eyes, heavy muscles etc. which demonstrates that knowledge of sleep cues is stronger in good sleepers.

Do you have a set time for falling asleep? Two participants were able to state that they had fairly set falling asleep times, however this was attributed to a routine set by the demands of work as the time they would have to wake up everyday would be the same- so generally speaking their homeostatic drive to fall asleep would be the same everyday at the same time. Poor sleepers indicated a distinct lack of set times for sleep

Do you think that an increased awareness of the right time for your body to sleep would be beneficial? When participants were questioned on the possibility of increasing awareness of the right time to sleep there seemed to be an air of uncertainty amongst the group. The general consensus was that it was an interesting idea that could work. The principal response that rose from this question was that participants had a low perceived level of control over sleep and this seemed to be a factor that perpetuated their sleeping troubles. It was mentioned that participants- specifically those with poor sleep- felt “powerless” over their sleep and that feeling more in control and organized with sleep would be helpful.


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Conclusions Control: It can be concluded from this study that there is a distinct lack of perceived control over sleep with insomnia sufferers. Thus an increase of perceived control and intrinsic confidence over sleep could be beneficial in the management of sleeping disorders. Routine: It is evident that routine and regularity is key in maintaining a healthy sleeping practice. Participants who had firmer sleep and wake times were more able to keep to a healthy routine and maintain healthy sleeping hours, whereas those lacking in routine (poor sleepers) found it more difficult to keep to a sensible sleeping pattern. Awareness: There seemed to be a lack of overall awareness and general knowledge of sleep. It is not surprising that sleep habits go awry when there is no concept of what is considered healthy sleep and knowledge of the state of personal sleeping habits. It can be inferred from this that there is a gap in knowledge around sleep that needs to be filled to effectively promote and in turn aid in the practice of healthy sleep.


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Sleep Diary Study Figure 11. Sleep diary Framework

Below is a framework of the sleep diary distributed to both participants. They were instructed to answer the questions as accurately as they could. Each participant was assessed in the same way and the results of each diary were compared. Sleep Diary: To be filled out the morning after the night in question. Don’t worry about making your answers exact. Approximations are fine. Name: __________________________________________ Other comments on sleep this week: ……………………………………………………………………………………………………………………......

1 2 3 4 5 6 7 Note the day of

the week (Mon, Tues, Wed..)

1 What time did you fall asleep last night?

2 What made you decide to go to sleep?

3 Once settled, how long did it take until you to fell asleep?

4 Once asleep how many times did you wake up during the night?

5 What time did you finally wake up?

6 How did you feel the next day on a scale of 1 to 5 (1=fine 5=horrible, include description if applicable e.g. sleepy, irritable)?

7 How long did you spend in bed last night? (From first getting into bed to when you finally got up)


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Research aim: The aim of this activity was to record and compare the habits of a relatively normal sleeper with the habits of a person suffering with chronic insomnia for the duration of a week. This was designed to work in conjunction with the Focus Group and interview to underpin the responses given and add en element of objective quantitative data to the project. Project Objectives: The objective of this study was to gain further insight into what behaviors promote poor sleep and what behaviors promote good sleep and to look for targets for intervention. Participants were assessed on sleep and wake times, time spent in bed, day-time wellness, time taken to fall asleep and drivers for sleep. Method: Two participants were chosen to take part in this study; one male-aged 50 suffering with chronic insomnia and one female-aged 47 with a relatively normal sleep pattern. They were both given a Results: The significant results of the sleep diary study are compared and discussed. Comparisson of time spent in bed with time spent asleep Participant SM (Insomnia Sufferer) Participant JM (Normal Sleeper)

Figure 7. Comparison of time spent in bed with time spent asleep graph for insomnia sufferer It is evident that the insomnia sufferer was consistently spending more time in bed than the time they spend actually sleeping. This data is consistent with the observation Morgan made in the interview that people with insomnia engage in detrimental behaviors- in this instance it is spending too much time in bed. This behavior will no doubt serve to blur the sufferer’s association with sleep.

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Figure 8. Comparison of time spent in bed with time spent asleep for normal sleeper Comparatively, the normal sleeper’s time in bed against time spend in bed does not indicate much difference. In this instance the bed serves the sole purpose of sleep. Therefore the only thing that this participant associates with their bed is sleep. It delivers that functionality. Comparison of bedtimes

Figure 9. Comparison of bedtimes between insomnia sufferer and normal sleeper The graph indicates a clear consistency in bed times for the normal sleeper and an inconsistency in bedtimes for the poor sleeper. This study was completed during a working week so wake times through Monday to Friday were invariably similar due to the demand of working hours.

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Comparison of time taken to fall asleep

The graph indicates a very distinct difference in time take to fall asleep. The poor sleeper invariably takes no longer than an hour to fall asleep- whereas the poor sleeper clearly takes a longer amount of time to fall asleep and these amounts of time are varied. This lack of regularity works to hinder intrinsic confidence that sleep is imminent. The variation of bed times also serves to blur the time that sleep is expected. It is evident here that night after night the good sleeper’s experiences of sleep are relatively similar while the poor sleeper’s schedule is quite chaotic. This would make it hard to judge when the body has reached the time to sleep- and might trigger behaviors that worsen the problem.

Conclusions: What can be concluded from this study is that poor sleepers have in comparison to normal sleepers a chaotic sleeping pattern that makes it difficult to judge when they should be tired and expect to fall asleep. If they had an indication of there sleeping pattern it could increase their awareness of when they should attempt to sleep and prevent them from engaging in damaging however intrinsically plausible behaviors. The final product could provide an objective overview of their sleep, and cue them in at the optimal time relative to the circadian rhythm and homeostatic drive.

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Design Guidelines Project Title: Design for Insomnia: How can design encourage the mind and body to recognize the time to sleep in relation to sleeping disorders? January 2012 Introduction: There is currently a public health concern surrounding sleep. According to the mental health foundation up to 30% of the UK population have either insomnia or another related sleep disorder. Professor Colin Espie, Key sleep researcher, highlighted that 50% of people rarely if ever consult their doctor about sleep and that this problem is developing in a similar way to the problems surrounding diet and exercise (Espie 2011). Action must be taken. Project Aim: A key problem within the insomnia disorder that prevents sufferers from practicing healthy sleep is recognizing through a blur of perpetual tiredness and chaotic sleep/wake times, the optimal time to attempt to enter the sleep state. The aim of this project is to remove that blur and create a product that promotes personalized awareness of sleep and provides a cue for the optimal time to sleep. Project Objectives: Human Factors With regard to users- Insomnia increases with age, affecting approximately 5% of the 18-25s and 30% of the over 60s and 70% of the people who are blind in the UK suffer with a sleeping problem due to an inability to recognize the time to sleep. Therefore the final solution should aspire to be very inclusive concerning age and disabilities. Tangible feedback within the final design should be considered. The product should pertain to relevant anthropometric data. Engineering As designers we have a responsibility not just to design sustainably but also to consider the system as a whole. The final concept should be designed using the most applicable sustainable processes. Aesthetic The form of the final design should be of an aesthetic that has an appeal that spans across the generations. It should be simple and intuitive; emphasis should be placed on accessibility. Clarity is a key word here. Consider the construction of a brand/style around these key values to aid in the conceptualization of the final design. Build on the need for organization and routine that is delivered in a simple and accessible manner. Explore a variety of methods in which people can be cued in to recognize the time for sleep. The final design should be a functional and desirable product. The mindset Sleep is a problem that can leave sufferers feeling isolated, unmotivated and powerless. Explore techniques in which sufferers can relate to one another and transform their problem into something that is less socially inconspicuous. Consider methods in which sufferers can be reminded of their successes and in turn have an increased perceived level of control and effectiveness in treating their sleep. Explore ways in which sufferer’s can personalize the product to their meet individual needs. The core of the final design should focus on encouraging and cueing routine and regularity of sleep/wake times for the sufferer.


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Ethics: Interview

ETHICS CHECKLIST

Applicant Details

Name: Lily Mcgarry

E-‐mail: [email protected]

Department: Art and Design

Date: 08/11/11

Course: Consumer Product Design

Title of Project: Can design help to encourage the mind and body to recognize the time to sleep in relation to sleeping disorders?

Project Details Summary of the project in jargon-‐free language and in not more than 120 words: Research Method: Interview with Dr Kevin Morgan The aim of this project is to analyse the “triggers” of sleep to create a useful design innovation to enhance the lives of those suffering with sleeplessness. Research objectives: -‐Define the user group and their characteristics / characteristics of the disorder i.e. user needs: To research this I will conduct a series of literature reviews, review user case studies and analyse relevant statistics. -‐Researching the current design solutions for sleeping disorders: This will involve desk-‐based research / analysing the current treatments and products available.

-‐Researching the triggers for sleep and how design can be associated: this will involve a focus group study involving those suffering with sleeping disorders and a sleep diary study of someone with chronic / acute insomnia.


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Participants in your research

1. Will the project involve human participants? Yes 2. Will the project involve human patients/clients, health professionals, and/or

patient (client) data and/or health professional data? No

3. Is there a risk of physical discomfort to those taking part? No 4. Is there a risk of psychological or emotional distress to those taking part? No 5. Is there a risk of challenging the deeply held beliefs of those taking part? No 6. Is there a risk that previous, current or proposed criminal or illegal acts will be

revealed by those taking part? No

7. Will the project involve giving any form of professional, medical or legal advice, either directly or indirectly to those taking part?

No

Risk to Researcher

8. Will this project put you or others at risk of physical harm, injury or death? No 9. Will project put you or others at risk of abduction, physical, mental or

sexual abuse? No

10. Will this project involve participating in acts that may cause psychological or emotional distress to you or to others?

No

11. Will this project involve observing acts which may cause psychological or emotional distress to you or to others?

No

12. Will this project involve reading about, listening to or viewing materials that may cause psychological or emotional distress to you or to others?

No

13. Will this project involve you disclosing personal data to the participants other than your name and the University as your contact and e-‐mail address?

No

14. Will this project involve you in unsupervised private discussion with people who are not already known to you?

No

15. Will this project potentially place you in the situation where you may receive unwelcome media attention?

No

16. Could the topic or results of this project be seen as illegal or attract the attention of the security services or other agencies?

No

17. Could the topic or results of this project be viewed as controversial by anyone?

No

Informed Consent of the Participant


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18. Are any of the participants under the age of 18? No 19. Are any of the participants unable mentally or physically to give

consent? No

20. Do you intend to observe the activities of individuals or groups without their knowledge and/or informed consent from each participant (or from his or her parent or guardian)?

No

Participant Confidentiality and Data Protection

21. Will the project involve collecting data and information from human participants who will be identifiable in the final report?

No

22. Will information not already in the public domain about specific individuals or institutions be identifiable through data published or otherwise made available?

No

23. Do you intend to record, photograph or film individuals or groups without their knowledge or informed consent?

No

24. Do you intend to use the confidential information, knowledge or trade secrets gathered for any purpose other than this research project?

No

Gatekeeper Risk

25. Will this project involve collecting data outside University buildings? Yes 26. Do you intend to collect data in shopping centres or other public

places? No

27. Do you intend to gather data within nurseries, schools or colleges? No 28. Do you intend to gather data within National Health Service premises? No

Other Ethical Issues

29. Is there any other risk or issue not covered above that may pose a risk to you or any of the participants?

No

30. Will any activity associated with this project put you or the participants at an ethical, moral or legal risk?

No


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Participant Information Sheet: Consumer Product Design Project You are being invited to take part in research that will inform a student coursework submission. The student concerned is in the final year of a MDes in Product, Transports or Automotive Design within the Department of Industrial Design, Coventry University. Your participation in this research is entirely voluntary. What is the purpose of the research? The aim is to understand the different triggers and starters for sleep in relation to sleeping disorders in the hope that valuable product design can be associated and implemented. Why have I been chosen? You have been selected because of your expert knowledge on the subject the researcher is analysing. Do I have to take part? It is up to you to decide whether or not to take part, and you are free to withdraw at any time without giving a reason. If, after completing the research you wish to withdraw your data from the study you may do so for a period of two weeks after participation. After this point your data will have been added to that of other participants for the purposes of analysis. If you wish to have your data removed please contact Lily McGarry at the earliest opportunity. If you agree to take part please sign the attached consent form. What will this involve? You will be asked if the student can involve you in an interview on the topic in question. It will consist of questions and discussions. This will include a recording of the conversation, which will be used later purely for research purposes and will only be viewed by the researcher. You do not have to answer any of the questions nor be recorded unless you wish to do so. You can decide to finish at any time and no other involvement would be required from you. If you would like any more details about the nature of this work or how the information will be used please contact Louise Moody or Karen Bull the staff members who have set this piece of work (see contact details below). What are the possible disadvantages and risks of taking part? The staff and students are not aware of any risks or disadvantages to you of taking part in this study.


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What are the possible benefits of taking part? It is hoped that the information the student gains from this research can be used to provide the students with a valuable learning experience. What if something goes wrong? If you have a complaint regarding how the research has been carried out or how the student has behaved, you are requested to inform Louise Moody or Karen Bull who will try to resolve the matter (see contact details below). What will happen to the results of the research? The research will be used to inform the student’s coursework submission and may in the future form part of their professional design portfolio. Please let the student concerned know if you are interested in seeing a summary of their research findings. Please note: This written consent form will work in addition to a verbal consent that will appear on an audio recording of the focus group. Student contact details: Lily McGarry e-‐mail: [email protected] Telephone: 024 76 418 284 Mobile: 07982053006 Staff contact details: If you would like to discuss this further, or have any questions, please contact Karen Bull on [email protected] or Louise Moody on [email protected] / 02476 795601


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Ethics: Focus Group & Sleep Diary Study

SLEEP DIARY ETHICS CHECKLIST

Applicant Details

Name: Lily McGarry



Date: 14/11/11


Title of Project: How can design encourage the mind and body to recognize the time to sleep in relation to sleeping disorders?

Project Details: Summary of the project: Sleep diary The aim of this project is to analyse the “triggers” of sleep to create a useful design innovation to enhance the lives of those suffering with sleeplessness. Research objectives: -‐Define the user group and their characteristics / characteristics of the disorder i.e. user needs: To research this I will conduct a series of literature reviews, review user case studies and analyse relevant statistics. -‐Researching the current design solutions for sleeping disorders: This will involve desk-‐based research / analysing the current treatments and products available. -‐Researching the triggers for sleep and how design can be associated: this will involve a focus group study involving those suffering with sleeping disorders and a sleep diary study of someone with chronic / acute insomnia.


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No

Risk to Researcher


sexual abuse? No


No


No


No


No


No


No


No


No


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consent? No


No



No


No


No


No

Gatekeeper Risk


places? No




No


No


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Participant Information Sheet: Product Design Project You are being invited to take part in research that will inform a student coursework submission. The student concerned is in the final year of a MDes in Product, Transports or Automotive Design within the Department of Industrial Design, Coventry University. Your participation in this research is entirely voluntary. What is the purpose of the research? The aim is to understand the triggers for sleep in order to improve the lives of those who suffer with insomnia. Why have I been chosen? You have been selected on the basis that you are have at one time or another / are currently suffering with some form of insomnia. Do I have to take part? It is up to you to decide whether or not to take part, and you are free to withdraw at any time without giving a reason. If, after completing the research you wish to withdraw your data from the study you may do so for a period of two weeks after participation. After this point your data will have been added to that of other participants for the purposes of analysis. If you wish to have your data removed please contact Lily Mcgarry at the earliest opportunity. If you agree to take part please sign the attached consent form. What will this involve? You will be asked if you could fill in a sleep diary to log the details of your sleeping pattern for two weeks. You do not have to complete any of the specified tasks, answer any of the questions nor have your photo or measurements taken unless you wish to do so. You can decide to finish at any time and no other involvement would be required from you. If you would like any more details about the nature of this work or how the information will be used please contact Louise Moody or Karen Bull the staff members who have set this piece of work (see contact details below). What are the possible disadvantages and risks of taking part? The staff and students are not aware of any risks or disadvantages to you of taking part in this study.


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What are the possible benefits of taking part? It is hoped that the information the student gains from this research can be used to provide the students with a valuable learning experience. What if something goes wrong? If you have a complaint regarding how the research has been carried out or how the student has behaved, you are requested to inform Louise Moody or Karen Bull who will try to resolve the matter (see contact details below). What will happen to the results of the research? The research will be used to inform the student’s coursework submission and may in the future form part of their professional design portfolio. Please let the student concerned know if you are interested in seeing a summary of their research findings. Student contact details: Lily McGarry E-‐mail: [email protected] Mobile: 07982053006 Telephone: 024 76 418 284 Staff contact details: If you would like to discuss this further, or have any questions, please contact Karen Bull on [email protected] or Louise Moody on [email protected] / 02476 795601


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FOCUS GROUP ETHICS CHECKLIST

Applicant Details

Name: Lily Mcgarry



Date: 08/11/11


Title of Project: Can design help to encourage the mind and body to recognize the time to sleep in relation to sleeping disorders?

Project Details Summary of the project: The aim of this project is to analyse the “triggers” of sleep to create a useful design innovation to enhance the lives of those suffering with sleeplessness. Research objectives: Focus Group -‐Define the user group and their characteristics / characteristics of the disorder i.e. user needs: To research this I will conduct a series of literature reviews, review user case studies and analyse relevant statistics. -‐Researching the current design solutions for sleeping disorders: This will involve desk-‐based research / analysing the current treatments and products available. -‐Researching the triggers for sleep and how design can be associated: this will involve a focus group study involving those suffering with sleeping disorders and a sleep diary study of someone with chronic / acute insomnia.


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No

Risk to Researcher


sexual abuse? No


No


No


No


No


No


No


No


No


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consent? No


No



No


No


No


No

Gatekeeper Risk


places? No




No


No


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Participant Information Sheet: Consumer Product Design Project You are being invited to take part in research that will inform a student coursework submission. The student concerned is in the final year of an MDes in Product Design within the Department of Industrial Design, Coventry University. Your participation in this research is entirely voluntary. What is the purpose of the research? The aim is to understand the different triggers and starters for sleep in relation to sleeping disorders in the hope that valuable product design can be associated and implemented. Why have I been chosen? You have been selected on the basis that you have having suffered/are suffering with the condition the researcher is analysing (insomnia/sleep troubles). Do I have to take part? It is up to you to decide whether or not to take part, and you are free to withdraw at any time without giving a reason. If, after completing the research you wish to withdraw your data from the study you may do so for a period of two weeks after participation. After this point your data will have been added to that of other participants for the purposes of analysis. If you wish to have your data removed please contact Lily McGarry at the earliest opportunity. If you agree to take part please sign the attached consent form. What will this involve? You will be asked if the student can involve you in a focus group on the topic in question. It will consist of questions and discussions. This will include a recording of the conversation, which will be used later purely for research purposes and will only be viewed by the researcher. You will also be asked during the recording for verbal consent. You do not have to answer any of the questions nor be recorded unless you wish to do so. You can decide to finish at any time and no other involvement would be required from you. If you would like any more details about the nature of this work or how the information will be used please contact Louise Moody or Karen Bull the staff members who have set this piece of work (see contact details below). What are the possible disadvantages and risks of taking part? The staff and students are not aware of any risks or disadvantages to you of taking part in this study. What are the possible benefits of taking part?


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It is hoped that the information the student gains from this research can be used to provide the students with a valuable learning experience. What if something goes wrong? If you have a complaint regarding how the research has been carried out or how the student has behaved, you are requested to inform Louise Moody or Karen Bull who will try to resolve the matter (see contact details below). What will happen to the results of the research? The research will be used to inform the student’s coursework submission and may in the future form part of their professional design portfolio. Please let the student concerned know if you are interested in seeing a summary of their research findings. Student contact details: Lily McGarry e-‐mail: [email protected] Telephone: 024 76 418 284 Mobile: 07982053006 Staff contact details: If you would like to discuss this further, or have any questions, please contact Karen Bull on [email protected] or Louise Moody on [email protected] / 02476 795601


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design for insomnia

Documents

m154id research

research project

research participants

research process

design specification

design brief

empirical research summary

chronic insomnia