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Sleep: nutrition for the mind
Stephen
Introduction: work, play, sleep, repeat
Of all the things in this book we are writing about, I have come to the conclusion there is one factor most instrumental in self-care, well-being and productivity – and that is sleep. I have heard the same phrase time and time again: ‘If only I could get a good night’s sleep, I feel I could face anything.’ I have heard this from practitioners, and I’ve heard it from family carers struggling to maintain their caring role. Sleep seems to be the cornerstone of any attempt to keep things together and on track. As we shall see, not only does a lack of sleep affect things like concentration, planning and analysing, it also has a profound physical effect on our bodies, making us more susceptible to ill health. Walker (2018) comments that for too long we have seen poor sleep as a symptom of conditions rather than the possible cause. We need to give that careful consideration.
Before the industrial revolution, workers were more attuned to night and day. We now understand how our bodies are locked into a circadian rhythm that relies on dark and light, as this helps the production of chemicals in our brains. The cues of it getting dark or light, along with other factors, initiate our sleep and waking. Picture our earlier lifestyles, living off the land, working while it was light, sleeping when it was dark. Without wanting to paint an idyllic picture of life in previous centuries, it is clear the trappings of modern life, and the opportunities that go with it, can get in the way of a good night’s sleep.
The pattern culturally associated with how we sleep has changed since the advent of artificial light. We can now extend the daylight into the hours of dusk and brighten up early winter mornings at the flick of a switch. We used to have a bi-modal sleep pattern, sleeping for four or five hours early in the evening, usually after our last meal of the day, followed by one or two hours awake, and concluding with four or five hours of further sleep to get us to morning. This was also supplemented by an afternoon nap just like the siesta some cultures continue to enjoy today.
This pattern of sleep, particularly the afternoon nap, has been shown to be healthy for us, ‘promoting greater life satisfaction, efficiency, and performance’ (Levitin, 2015, p 189). Companies at the cutting edge of this kind of knowledge, such as Nike and Google, provide nap rooms for employees. They know from NASA research that a 25-minute nap boosts performance by 34 per cent and alertness by 54 per cent (Webb, 2017). I suspect as busy practitioners you could do with that lift, but, equally, we are unlikely to see nap pods as a universal reality any time soon, which is a shame.
We have lost our bi-modal and afternoon nap pattern because we are locked into hours of working and ways of thinking about work and life outside of work. Using artificial light to extend our hours of activity means in some way we are working against our body’s natural, instinctive way of functioning.
I am constantly amazed by the restorative nature of a good night of sleep. In so many circumstances I find myself thinking late on an evening, ‘I can’t do any more, I’m so tired I can barely move.’ I find myself physically exhausted. I could regale you with stories of epic bike rides or marathon runs that have left me physically with nothing left but I will save you that. Equally I can find myself psychologically or emotionally drained from the rigours of the working day and feel I just can’t muster the energy to think about anything. But then, a good night’s sleep, and we’re fit to go again. Or at least should be.
The language of sleep
Sleep is embedded in our cultural psyche. When my wife and I wake up on a morning we invariably ask, ‘How did you sleep?’ This is closely followed by ‘Who is walking the dog?’ ‘I slept like a baby’ is the response I love to hear to the ‘How did you sleep?’ question. Because then I can say, ‘What? You were up three times during the night crying and during two of them you had something to eat?’ and laugh at my own amazing sense of humour (because I’m a dad and that’s what dads do).
‘I slept like a log’ is good response I often use myself. You didn’t move, you fell asleep and didn’t stir until the next morning. You were an inanimate object. This is interesting as it alludes to sleep being something in which there is nothing going on. As we shall find out, there is so much happening that is crucial to our well-being and that impacts on our productivity the next day. In some ways, being asleep is just as much an active time as being awake, except… you’re asleep. Indeed, one well-used phrase we hear when we are pondering a difficult conundrum or big decision is ‘sleep on it’. This seems to suggest something is going on while we are asleep as that decision somehow gets made, or that knotty issue resolved, while we are oblivious to the world around us.
The importance attributed to a good night’s shuteye cannot be overestimated. You don’t really need a chapter in a book to tell you how important it is because you know how you feel when you don’t get a good night’s sleep. Yet, lots of us often forgo what we know is good for us and that’s a recurring theme every time we talk about any sort of self-care. So, keep reading… there’s good stuff coming that will help you see the importance of this element of self-care and give you some ideas around promoting good sleep. We want to avoid the sluggish feeling that has you reaching for the coffee pot by mid-morning or sooner. We want to avoid you being no good to neither man nor beast by mid-afternoon.
Personally, for most of my life at least, I have been very lucky, and could ‘fall asleep on a clothesline’. This fascinating phrase comes from the days of the workhouses of early twentieth century London where people who were homeless and couldn’t afford the price of a bed for the night had made available to them a bench to sit on and a clothes line to lean over in order to sleep. Many people are less fortunate than me, however, and have problems with sleep. Matthew Walker (2018), drawing on his 20-year research career into sleep, suggests half of us are not getting as much sleep as we need. For most people who fall into the ‘not sleeping well’ category I’d imagine you are going to bed feeling tired and are unable to get to sleep because of what I refer to as the ‘churn’ of the day’s activities. Or you may be thinking about tomorrow’s tasks and have them going around and around in your head keeping you awake. ‘Open loops’, as David Allen (2015) refers to them. Things that you don’t have recorded anywhere that you are trying to hang on to and remember. For me, having a ‘trusted system’ as outlined in the productivity chapter (Chapter 7) can help me to manage this to a large extent by knowing everything is captured, nothing is forgotten, and it’s all just waiting there in an organised format, for me to get to it the next day. There are other people who fall asleep without problem but wake up in the early hours of the morning only to start to ‘churn’. When I’ve got a lot going on this is what happens to me. I find some sort of mantra-like mindfulness exercise can help. I repeat ‘there’s nothing to be done now, this is my time’ over and over again until I drop off. It’s a bit like counting sheep. (More on mindfulness in Chapter 5.)
Think about how you sleep
What time do you usually go to bed?
What time do you usually get up?
Do you find it difficult to get to sleep?
Do you wake up during the night?
How do you feel when you wake up the next morning?
Do you usually wake up naturally or does the alarm clock always wake you? Do you sleep differently on a weekend?
What is sleep?
In his lectures about dreams in 1915 Sigmund Freud asked the question ‘What is sleep?’ and suggested that:
Sleep is a state in which I want to know nothing of the external world, in which I have taken my interest away from it. I put myself to sleep by withdrawing from the external world and keeping its stimuli away from me. I also go to sleep when I am fatigued by it. So when I go to sleep I say to the external world: ‘Leave me in peace: I want to go to sleep.’
(Freud, 1991 [1915], p 117)
Here Freud tells us, very simply, a few truths I feel are worthy of note. He talks about a state in which you have taken your interest away from the external world. I’ve already mentioned that what stops us getting to sleep is our attention on the external world, so we need to consider how we take our attention away from it in order to achieve rest. He also makes going to sleep a very personal responsibility. When I talk to people about self-care there is often a backlash, with people telling me, no matter what solutions I propose, that the problem is their workload or the nature of the work and is not about them wanting to disengage from it. I understand and accept this argument; however, I don’t wholly agree with it. There are ways we can achieve distance, a ‘settledness’ about how we have left our work, in order to give us the space to engage in rest and recuperation, of which sleep is one part. Only the individual can take such actions. Many people work in stressful jobs and a proportion of them sleep well. So, while the job undoubtedly has an impact, and I am not denying workplace stress, I’m a great believer in doing something in the areas you can take responsibility for. My philosophy here is that I’m trying to be part of a solution rather than part of the problem. Only you can take action to work towards good sleep and good self-care, while you and others continue to make the case for organisational change around the other realities of professional practice.
Freud also talks about keeping the world’s stimuli away. This proves so difficult with late night television, emails, smartphones and more. Part of having a good night’s sleep is looking at how you prepare for sleep. There is compelling evidence that the light from our ‘always-on’ devices stimulates our brains and overturns the chemical process going on internally to facilitate sleep. The blue light (traditionally the sky when we were outdoors more) that sends an ‘it’s daytime’ message to our brains is evident in such devices and has a negative impact on melatonin release essential for sleep. It has been discovered that melatonin release can be suppressed for 90 minutes after exposure to bright light (Webb, 2017). The number of people with sleep problems is increasing and for many it is the exposure to these bright artificial light sources that could be causing the problem. Exposure to a light level of 10,000 lux, which is approximately equal to being outside on a clear day, was shown to increase the length of time it took people to get to sleep in a Japanese study (Nakamura et al, 2019).
Getting to sleep
The desire to sleep is driven by the pineal gland’s production of melatonin in your brain; the gland reacts to diminishing light by flooding your brain, making you feel sleepy and less alert. Melatonin starts to increase at around 9pm, then stays in your brain through the night for about 12 hours. It begins to fall to low levels when daylight seeps through your eyelids, ‘instructing’ the pineal gland to stop its production of melatonin, with levels being at their lowest around 9am. This cycle goes on in your body over a near to 24-hour cycle irrespective of what you are trying to push your body to do. In fact, this process is so chemically locked in that even in the absence of light the body continues this cycle.
Over 80 years ago in 1938, Professor Nathaniel Kleitman and his research assistant Bruce Richardson from the University of Chicago became their very own research project. They took a trip to Kentucky and entered Mammoth Cave with enough supplies to last them six weeks. Mammoth Cave is one of the deepest caves on the planet, so no light penetrates its depths. In the cave they set about living in darkness to see what happened. Their work established that we have a biological, circadian rhythm of about 24 hours, and it showed that in the absence of the external stimuli of light we do not descend into a chaotic random sequence of waking and sleeping. They discovered that they were awake for about 15 hours and then asleep for about nine hours. Does that sound familiar? They did, though, find that the human ‘rhythm’ is not precisely 24 hours. Later research building on their own showed that on average, if left alone, we work on a ‘clock’ of about 24 hours and 15 minutes. Thankfully, our in-built chemistry and our pineal gland keep us on track by utilising our reaction to light and dark and working alongside other factors such as a drop in core body temperature to get us to sleep. This gives us some clues to the ideal sleep pattern we are searching for.
Quantity and quality
The World Health Organization and the National Sleep Foundation tell us something I suspect you already know. We should be aiming for about eight hours of sleep per night. Certainly, we should be within the region of seven to nine hours. The World Health Organization has stated that sleep loss is now an epidemic in the industrial world and Walker (2018) states that:
Routinely sleeping less than six or seven hours a night demolishes your immune system, more than doubling your risk of cancer. Insufficient sleep is a key lifestyle factor determining whether or not you develop Alzheimer’s disease. Inadequate sleep – even moderate reduction for just one week – disrupts blood sugar levels so profoundly that you would be classified as pre-diabetic…
(Walker, 2018, p 3)
A lack of sleep doesn’t only affect your physical health; it also takes effect on your mental state. It can make you sluggish, prone to poor decision making and procrastination, and can impact on creative problem solving (Tuck, 2018). In professional practice clear decision making and effective problem solving are crucial to the role. Walker (2018) also suggests that lack of sleep doesn’t necessarily throw us into a negative mood state but may well lead to a see-saw of emotions. He points out that any extremity of emotion, positive or negative, can be dangerous, stating that negative emotions can lead to feelings of worthlessness and a questioning of the value of one’s life.
Surely, as professionals, we need to value ourselves first and value our contribution so that we can value the lives and contributions of others? While working with people often in a crisis themselves we need to be maintaining our own emotional stability, drawing on our emotional intelligence to facilitate a professional intervention. Howe (2008) notes that if our emotions are negative, we can become psychologically defensive, which can lead to us being absorbed in our own distress, potentially creating a lack of compassion.
It’s not only the quantity of sleep we need to get right but also the quality of that sleep. During the night we go through different stages of sleep, all of which are essential. As we have seen above, our bodies are ‘programmed’ by the chemical reactions going on inside. If our brain chemistry is responding to the light–dark cycle, then we should sleep in tune with this cycle. As the level of melatonin is on the rise in our brains from about 9pm we should be trying to achieve a bedtime of between 10 and 10.30pm. Our eight hours of sleep would then take us to 6 to 6.30am, perfectly in sync with the rise and fall of melatonin governed by the available light. This needs to be developed as a routine night after night, seven days a week.
One of the things that always puzzles me is the way as parents we completely understand how giving babies and children routine is good for them. I remember as a parent, for my children, it was bath at 7pm, supper at 7.30, story at 7.45, bed at 8. And it works wonderfully for many. For some reason when we become adults, we laugh in the face of routine; yet intuitively I feel we know it works. This seems to be another one of those things we have knowledge of but do nothing with and then wonder why we are cranky in the morning.
Throughout the night we establish a pattern of two sorts of sleep – non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep – which do different things. What is notable here is that throughout the night, in an approximately 90-minute cycle, we move between the two (there are actually four stages of NREM sleep but that’s a little technical for what we need to know here). NREM sleep dominates the early part of the night and REM sleep dominates the later part of the night, or early morning, depending on how you want to look at it. These two forms of sleep are crucial to memory storage.
Walker (2018) describes the need for this pattern beautifully, using the metaphor of a sculptor working a block of clay. To start with, all of the raw material is available to him, the same way all of our memories from the day are stored in our short-term memory. The sculptor then starts by deciding what superfluous matter can be removed, what pieces of clay are not required. During this period, early details are made. Finer structures are then worked on to reveal details and ‘store’ those details in the beauty of the finished sculpture. If we apply this to sleep, the early part of sleep (NREM) helps us with the processing of information and making the big decisions about what is important. Unnecessary information is discarded with a little transfer of details. REM sleep, which comes later in the night, deals with the details and the storage of these memories. It is the REM sleep that does the work of forging connections with older memories and it is during this period we dream.
Your brain is trying to achieve this process whether you are awake or asleep based on the biological rhythms controlling your brain. Being awake gets in the way of this being successful. So, as we have seen, your brain is ready to start work on this at around 10pm and needs to be done by about 6am. If you decide to stay up until 2am to binge watch the latest TV series, you have lost that early NREM heavy/REM light sleep, meaning there’s been no culling of the big information to leave you with the finer details. If you need to get up at 4am to get the train for a meeting at 9am then your brain hasn’t finished achieving what it needs to do in the REM heavy/NREM light sleep period. Either of these scenarios is compromising your ability to store memories and make connections with older memories. This process, in Walker’s words, is like pressing ‘save’ on your computer and is therefore crucial. This was shown to great effect in a study by Ji and Wilson (2007) from MIT’s Picower Institute for Learning and Memory. He showed that rats presented with a maze that led to rewards repeated the same patterns of brain activity when asleep as they had when engaged in the task, encoding this important memory from the day so it could be recalled.
What this also shows is that sleeping less during the week and trying to catch up on a weekend doesn’t work. Trying to buy back sleep by having a lie in on a weekend doesn’t offset those lost hours. ‘The brain can never recover all the sleep it has been deprived of’ (Walker, 2018, p 297).
Productivity impact
Lack of sleep leads to lack of productivity, with typically lower work rates and therefore slower completion of tasks. It is estimated that lost productivity in America costs between $2,000 and $3,500 per sleep-deprived employee per year. This is as a consequence of being less happy and lacking in motivation. Sleep-deprived people can be volatile, rash and prone to making poorly conceived decisions, because lack of sleep impacts on the frontal lobe, the part of the brain that manages our emotional impulses and mediates our self-control. Broken or disturbed sleep is also problematic and can lead to lower activity in the prefrontal cortex of the brain according to Schilpzand et al (2018). The impact of this is poor cognitive processing, planning and problem solving. Moreover, Schilpzand et al (2018) discovered that sleep-deprived workers shy away from setting themselves proactive goals in terms of complex work, defaulting to easier options. The risk, I’d suggest, here is that difficult tasks are deprioritised repeatedly until finally they must be done. This is often last minute, at the end of the day when our brain resources are at their lowest and needing to be ‘recharged’ by sleep. Not the best way to be working on important tasks!
We can understand then how lack of sleep is a dangerous business… and dangerous for our business (Walker, 2018). Our ‘business’ is work with vulnerable people often in a state of heightened emotions themselves, needing us to be in charge of our own emotions to be effective practitioners.
Think about a time when you had not had much sleep
How did it make you feel?
What strategies did you use to get through the day (positive or negative)?
How productive were you?
Chronotype
It’s worth mentioning here that how we respond to the onslaught of the day is different for all of us, as we are all a particular chronotype. We respond to the relentless march of the clock differently. Some of us are morning larks and some of us are night owls. Thinking about what chronotype you are can have a dramatic effect on your productivity and how you work. I’m a morning person. I’m good from about 6am to about 11am when I tend to get a slump. Getting outside and having some lunch invigorates me then I’m good from about 1pm to 3pm. But after 3pm… don’t ask me to do anything that requires me to think!
Some people are the opposite and take a lot of time to get going. Now, I can’t simply leave work at 3pm, citing my chronotype as the protagonist in my early departure, but what I have done is constructed a way of working that plays to my strengths. I try, as far as I can, to do my writing and thinking work on a morning in the 6am to 11am window. Then, less challenging tasks that still require thought I do from 1pm to 3pm. When I hit 3pm then it’s simply routine admin tasks like printing documents ready for tomorrow and the week ahead, straightforward phone calls and appointment making, photocopying, or data entry type tasks. I do a lot of planning in the later part of the day as this means I leave with everything in order ready for the next day. I’m not saying planning is easy but it’s not as difficult as writing a report or reading complex information. More on productivity in Chapter 7.
Caffeine and alcohol
If the statistics are right, every second person reading this is sleep deprived to one extent or another. One remedy we tend to turn to is caffeine. Caffeine disrupts the ability of a chemical called adenosine to latch on to receptors in your brain. Adenosine’s job is to create what is termed sleep pressure, a force determining how sleepy you feel. The caffeine stops this chemical effect by latching on to the receptors instead. The problem is the adenosine in your brain continues to accumulate just waiting for its chance to invade the receptors. Once your body has removed the caffeine, using enzymes in your liver, the adenosine rushes in and you get that almighty mid-afternoon coffee slump. So, to offset this, as you feel it taking place, you drink more coffee, or tea (normal or green), or caffeinated drinks, or eat chocolate – all of which usually include caffeine. This can have a knock-on effect later when you are trying to get to sleep. The half-life of caffeine (the amount of time it takes your body to deal with 50 per cent of the drug) is five to seven hours. So that cup of coffee you have at 6pm is only halfway out of your ‘system’ by midnight. And be warned, ‘decaff’ is not ‘no caff’. There is still about 15 to 20 per cent of the amount of caffeine in there compared to a standard cup.
Alcohol is not helpful in promoting good quality sleep either and falling asleep after a few drinks is not giving us the quality of sleep we need. While many of us can report falling asleep easily after a few alcoholic drinks the reality is alcohol is a sedative. So, you are sedated rather than asleep, and this disrupts the NREM and REM pattern we’ve already explored. Alcohol makes sleep fragmented so it ‘is therefore not continuous and, as a result, not restorative’ (Walker, 2018, p 271).
The impact of good sleep
Sleep helps to maintain both physiological and psychological function. Here again we see the link between the three elements of the self-care triangle. In order to exercise effectively we need to be maintaining adequate sleep. In order to maintain focus on sound nutritional intake we need to have the psychological energy to do so. In terms of the overarching concept of ‘being organised’ we need to be able to apply all of our psychological functioning to the mental effort of the day.
The result of a lack of both the right quantity and the right quality of sleep is poor attention, poor planning, diminished cognitive functioning and poor judgement. The impact on our productivity as a consequence of poor sleep cannot be overstated. Research has shown that just one night when you sleep for a maximum of four hours can make you so sleep deprived you are more likely to make errors and be less attentive (Nakamura et al, 2019). Now imagine the number of mistakes you’d make if you were having less than our eight hours of sleep night after night.
Many work-based cultures almost celebrate the sacrifice of sleep, applauding people who work late and turn in early. But a week of reduced sleep can create an impairment in functioning the equivalent of a 0.1 per cent blood alcohol level, similar to being drunk. You wouldn’t put yourself behind the steering wheel of a car under those circumstances, yet are left to make important decisions, about other people’s lives, while experiencing the same level of impairment as intoxication.
A bad night’s sleep can also affect your IQ level by a few points. On the other hand, a good night’s sleep has been shown in research at the University of California Berkeley to make people twice as effective at spotting complex patterns in information; the research has also shown that people are able to solve 30 per cent more anagrams after a period of rest that included REM sleep (Webb, 2017). Sleep improves our cognitive function and skills like analysis and critical thinking.
Barber et al (2014) found better sleep practices could reduce the negative feelings people experience when placed under stress. People may respond less negatively towards the circumstances of the day when well rested and respond better to the rigours of the job. Also, better sleep may actually increase how much people feel in control of the stressful situations they encounter. This is possibly as a consequence of how much energy they feel they have to confront the situation, be that either psychological or physical energy, or both.
Schulz and Burton (2018, p 1640) state that a study of nearly 600,000 adults in a range of industries showed ‘Employees who achieved optimal sleep levels of 7 to 8 hours per night had the lowest average number of health risk factors, the smallest productivity losses, and lower odds of having several health conditions compared to poor sleepers.’ Surely then there is a role for us on an individual level to take care of ourselves but also for employers to invest in education for their staff about sleep. Businesses and organisations need to take a careful look to see if the working environment they have established is impacting negatively on the sleep of their staff and consider changes to ensure it is supportive of good sleep practices. While I believe self-responsibility is so important to self-care, organisations need to accept the impact of professional roles and also support staff in appropriate ways.
If we can achieve good sleep what can we expect? Dr Rangan Chatterjee, in his ‘4 Pillar Plan’ (2018), gives us the following list of benefits of a good night’s sleep:
increased energy;
improved concentration;
greater capacity to learn;
better ability to make healthy food choices;
improved immune system function;
enhanced autophagy (the way the body clears out damaged cells);
better memory;
increased life expectancy;
reduced risk of being overweight;
reduced stress levels;
reduced risk of developing chronic disease eg type 2 diabetes and Alzheimer’s.
(Chatterjee, 2018, pp 206–7)
Sound advice
The National Health Service (NHS, 2016) offers some simple, straightforward advice to improve your sleep environment and practices that may help. It would be useful to look at each of the ideas in turn.
Keep to a regular bedtime routine
Remember it’s not just babies that need a routine, it’s any human being. Much as we kick against it as adults, we are creatures of habit and routine. Your body is programmed into a chemical routine that does its best to achieve sleep, rest and waking. And what do we do? We ignore it! We stop up late and wonder why we are tired the next day. We get up late and wonder why we then can’t get to sleep the next night. We self-medicate with alcohol and caffeine to get that little bit more out of the day and out of our social life. Someone once said to me, ‘Drinking coffee steals hours from later in the day and drinking alcohol steals hours from tomorrow!’ All we achieve is the disruption of our programmed chemical clock and when we don’t attend to it for long enough the situation becomes chronic. You should establish a pattern of sleep that fits your biological clock and you should maintain it seven days a week, 365 days a year.
Sleep at regular times
This will train your brain and internal body clock, aligning you to a natural sleep pattern. As we’ve seen, we need around eight hours of sleep a night and we should be sleeping from about 10pm to 10.30pm until 6am to 6.30am. These timings are in tune with our natural rhythm. So that’s your starting point.
Don’t go to bed hyped
While exercise is an important aspect of self-care (see Chapter 4) you should avoid it for two or three hours before bedtime. A good way to wind down is to have a warm bath – again, isn’t that part of the routine we give babies? There’s a drop in your core body temperature orchestrated by your circadian rhythm’s signal ‘time to sleep’, and it reaches its low point about two hours after sleep onset, which remember starts at about 9pm. This drop in temperature happens whether you actually achieve sleep or not, which is why people often feel cold when tired. Having a hot bath seems counter-intuitive and seems to be going against this tide your body is creating. But it’s not. The hot bath draws blood to the surface of your body and when you get out of the bath the dilated blood vessels on the surface disperse heat causing your core temperature to drop, which leads to feeling sleepy.
Write ‘to do’ lists for tomorrow
One of the main things that keeps people awake is trying to remember things they need to do tomorrow. Before you go to bed (or ideally at the end of your working day – see Chapter 7 on productivity), write down everything you need to do the next day, safely leaving your notes in a place you can find them when you need to, without having them going round and round in your head. Keep a notepad by your bed. If you think of something while in bed, write it down. There’s good evidence externalising memories in this way can help us ‘put them to bed’ to help put us to bed.
Do relaxation exercises such as yoga or listen to relaxation CDs
There is a huge range of yoga and relaxation CDs and apps available that might help you. Anything that calms your mind and distracts you from your racing thoughts. You could try audio books, or read a book, or maybe listen to the radio. You should avoid TV and smartphones as not only do they stimulate your brain, but the light they emit confuses your brain into thinking it is daylight. One way to improve sleep quality could be through mindfulness practice (see Chapter 5). Results from a study by Hulsheger et al (2015
