11.5 Sleep, Rest, Substance Use & Wellness Promotion

Sleep, Rest, Substance Use & Wellness Promotion

The COTA content outline names strategies for promoting wellness and mental health, and gives three examples: relaxation, sleep hygiene, and addiction management. These are not soft add-ons; sleep and substance use are among the strongest predictors of whether a client sustains any other gain the therapy team produces.

1. Rest and Sleep as an OTPF-4 Occupation

The OTPF-4 divides Rest and Sleep into three subcategories, which is a useful assessment structure in itself:

Assessments: the Pittsburgh Sleep Quality Index (PSQI) for sleep quality over the past month, the Epworth Sleepiness Scale for daytime sleepiness, and a sleep diary kept for one to two weeks. A COTA administers these under the OTR's direction once service competency is established; the OTR interprets them.

Sleep Hygiene and Stimulus Control

Sleep hygiene is the environmental and behavioral package:

• Keep a consistent bed and wake time, including weekends.
• Stimulus control — the highest-yield element: use the bed only for sleep and sex, and if awake after roughly 20 minutes, get out of bed, do something quiet and dim, and return only when sleepy. Lying awake in bed teaches the nervous system that the bed is a place for wakefulness.
• Stop screens 30–60 minutes before bed; blue light suppresses melatonin.
• Keep the room cool (roughly 60–67°F), dark, and quiet.
• No caffeine within about six hours of bedtime. Alcohol is not a sleep aid — it shortens sleep latency but fragments the second half of the night.
• Avoid large meals late; manage nocturia with fluid timing in coordination with the medical team.
• Get morning bright-light exposure and daytime physical activity; limit naps to about 20–30 minutes and take them before mid-afternoon.

[!NOTE] CBT-I (cognitive behavioral therapy for insomnia) is the first-line treatment for chronic insomnia and outperforms sleep hygiene education alone. Its components are stimulus control, sleep restriction, relaxation training, cognitive restructuring, and sleep hygiene. Occupational therapy contributes the routine, habit, environment, and daytime-activity components; the cognitive restructuring and sleep-restriction protocol are delivered by clinicians trained in CBT-I.

Sleep-related device management — CPAP desensitization and adherence, positioning wedges, hospital bed setup — falls under Personal Care Device Management within Health Management and is squarely an occupational therapy contribution.

2. Substance Use & Addiction Management

Occupational therapy's contribution to substance use treatment is not detoxification or counseling; it is the occupational restructuring that determines whether recovery holds. Substance use consumes enormous quantities of time, social identity, and routine. When it stops, an occupational vacuum opens, and relapse fills it unless something else does.

Screening: SBIRT

SBIRT — Screening, Brief Intervention, and Referral to Treatment — is the standard public health framework.

• CAGE — four items: have you tried to Cut down; are you Annoyed by criticism; do you feel Guilty; do you need an Eye-opener in the morning. Two or more affirmative answers warrants further assessment.
• AUDIT for alcohol and DAST for other drugs are longer, better-validated screeners.
• A COTA may administer a screener once service competency is established and reports results; the OTR and the team interpret and act on them.

The Transtheoretical (Stages of Change) Model

Matching the intervention to the stage is the entire clinical skill here.

Relapse is treated as part of the change process rather than as failure — the client re-enters the cycle rather than starting over.

Motivational Interviewing: OARS

Open-ended questions, Affirmations, Reflective listening, Summaries — delivered within a stance of expressing empathy, developing discrepancy, rolling with resistance rather than arguing, and supporting self-efficacy. Confrontation reliably increases defensiveness.

Occupation-Based Relapse Prevention

• Identify high-risk situations and triggers — people, places, times of day, emotional states.
• Fill the occupational vacuum. Map the hours previously occupied by obtaining and using, and build a concrete daily schedule to occupy them.
• Develop sober leisure and social participation — this is the intervention most specific to occupational therapy and the one most often skipped.
• Rebuild productive roles — work, volunteering, education.
• Connect to community support — 12-step programs, SMART Recovery, clubhouse programs, peer recovery support.
• Harm reduction where abstinence is not the current goal: reduce the damage of ongoing use while maintaining engagement.
• Basic ADL and IADL restoration — sleep, nutrition, hygiene, money management, and medication routines are frequently degraded and are direct COTA targets.

3. Relaxation, Occupational Balance & Physical Activity

Relaxation Techniques the COTA Teaches

Relaxation is a skill, not a handout. It requires rehearsal when calm before it can be deployed when distressed, and it is most durable when embedded in an existing routine — after the morning coffee, before the bedtime routine.

Occupational Balance

Occupational balance is the client's own satisfaction with the distribution of their time across self-care, productivity, rest and sleep, and leisure. A useful COTA exercise is a 24-hour time-use pie chart: have the client map an actual weekday, then map their ideal, and negotiate one concrete change between the two. Imbalance shows up as occupational deprivation (external barriers prevent engagement), occupational imbalance (too much of one category), and occupational alienation (engagement without meaning).

Physical Activity Guidance

The Physical Activity Guidelines for Americans recommend that adults accumulate at least 150 minutes per week of moderate-intensity aerobic activity plus muscle-strengthening activity on two or more days per week, and that older adults add balance training. Occupational therapy's contribution is making that achievable inside real occupations — walking to shops, gardening, dancing, active play with grandchildren — rather than prescribing an exercise program the client will not sustain.