In recent years, I have not read much on the subject of sleep. I could explore the books about it on my shelves, but instead I will post this email because I am curious what insights my colleagues have regarding interventions to overcome insomnia.

What I tell my clients is that it is very hard to think oneself to sleep, but that some people can, in essence, hypnotize or lull themselves to sleep by doing some kind of mental repetition. In many cases, however, what is required is that the insomniac, especially those plagued with a repetitive tune or worrisome thought, move. Any body movement, it seems to me, increases the possibility that the "tape" in one's head gets broken. This might be parallel to the observation that dreams are more likely to be forgotten ("erased") once we move, even roll over.

The "movement" that seems to most promote sleep for me is a yawn. That is, if I have been lying in bed for an hour or two, and I manage to force myself out of bed (rather than simply turning over, which does sometimes aid sleep), then my best option is to get in the shower, lean my head against the wall, and let the rather hot water beat down on my neck.  Within a few minutes, I start to yawn, maybe at first in a constricted manner but eventually I enter into a full out yawn. After I do this yawning several times, I feel ready to return to bed, which I do. Almost always I fall asleep within ten minutes.

There are of course many other "movements" that seem to help clients, eg., a certain tea or hot drink, watching tv or reading, walking a dog, etc.

But I have no recollection of yawning ever being mentioned in "How To" sleep books.



Although I have not read the book by Paul Green, I have the following observations about the TOMM (Test of Memory Malingering, by Tom Tombaugh)

I recently finished a med/legal report for a tort claim. Again I was faced with a defence psychologist or psychiatrist concluding that my client's responses on the TOMM suggest malingering. With respect to some of my long-term clients who I know are not malingering and who for the most part are not intentionally exaggerating symptoms, this misinterpretation of the TOMM is having devastating consequences on their lives. For instance, sometimes their income benefits are cut off, and so are my services.

There are legitimate interpretations regarding why these clients did not score above the cutoff of 45 on the second administration, and in some cases scored no better than chance. The common denominator among them is some kind of cognitive deficit stemming from test anxiety, distraction, blanking out, etc.

The TOMM, in being named a test of Memory Malingering, lends itself to this misinterpretation. If it was instead named a Test Of Memory Motivation, then a more realistic and less prejudicial name is employed. But for some of my clients the TOMM is not even a test of memory motivation, that is, of the desire/willingness/energy to respond to items on a memory test with as much conscientious effort as possible.

On grounds that memory cannot be tested until a percept is actually formed and can then be retrieved, for some of my clients the TOMM becomes first of all a test of attention and concentration. In his manual Tombaugh himself indicated that he wanted to ensure that the TOMM did not become a test of attention and concentration, as he wrote on page 17 that the administrator is to do things to make sure the subject is attending to each picture. But for my most traumatized and depersonalized clients with little self confidence, this is what the TOMM becomes... a test of concentration.

Although I am admittedly not knowledgeable about the literature reporting on research involving the TOMM, I find it difficult to believe that any research I might read would change my reality, which is that my legitimate clients who are "failing" the TOMM are doing so because of trauma- or anxiety-related difficulties. As well, it is clearly outside my reality that any clients who have been meeting with me regularly for more than a year or so and who do poorly on the TOMM are intentionally misrepresenting their abilities and somehow malingering.

These clients come back after their assessments and tell me what was happening to them during the administration of the TOMM. Generally they are not focussing on each picture at all. After a few, they start thinking about their "brain fog" and, for instance, are worrying about how they will ever get a job again, given how poorly they are doing. By contrast, in at least one instance, the psychometrist, it seems, was misinterpreting the test anxiety behaviour of the client to be a product of the effort to malinger. Our colleague, I surmise, was informed of this effort, and wrote the report accordingly... or simply signed it, whichever the case.

In my opinion one interesting variation on the standard way of administering the TOMM gives me more information regarding the lack of an initial percept of the fifty items. On the second administration, I ask a person who is obviously doing poorly to indicate after giving a response whether he or she guessed at the answer or rather felt certain that he or she gave the correct response. The more they report guessing, the more I have evidence that many of the fifty stimuli did not register in the first place.

A reading of the above might lead some listserve members to conclude that as a treating psychologist I am naive about the intentions of these clients of mine who perform poorly on the TOMM. I acknowledge a vulnerability in this area, as I tend to trust clients until proven otherwise. But I also have very honest referral sources, so do not expect to get a malingerer. and form very positive relationships with these clients. The "proof" regarding who is right, I believe, is in the results. That is, my reality sets the conditions for the client to heal, whereas the message that they are malingering stresses them further, both emotionally and financially, and interferes with their efforts to recover. But of course if some professional is already committed to the premise that this client is malingering, then seemingly no evidence can be presented to reverse this belief.