CBT for insomnia - solve your sleep problems in a safe and natural way

Have your nights become a nuisance - tossing and turning with a good night’s sleep seemingly out of reach? Perhaps it might be a relief to learn that help is at hand; cognitive behavioural therapy can offer a safe, side-effect free alternative to medication to help you recapture your natural sleeping patterns.

Since, on average, we spend a third of our lives asleep, disrupted sleep can feel very troubling indeed. Insomnia affects an estimated 30-50% of people at some point in their lives, and 10% experience chronic insomnia (technically, sleep disturbance which lasts for longer than three weeks). In short, insomnia is a common problem - you are definitely not alone.

In this post, I’m going to take a look at how we approach insomnia in therapy using a CBT approach. Obviously this is only a snapshot of how we can use techniques from mindfulness, Acceptance and Commitment Therapy (ACT) as well as classic CBT methods to get back to bedtime bliss.

Typically, a series of sessions of CBT for insomnia will cover a range of approaches to help you achieve a realistic sleep goal. To start, you’d be building up an accurate picture of your sleep problem with your therapist. In CBT we look at four distinct areas - thoughts, emotions, behaviours and symptoms. We will be focusing on how all of these areas can be contributing to a difficulty in falling asleep or getting back to sleep when wakened.

How much sleep do you need?

Experts agree that on average an adult requires between 7 and 9 hours of sleep per night. Sleep needs do change during the course of our lives, babies and toddlers sleep far more, for example. If you have a very physical job, you exercise a lot, or perhaps you have recently been poorly, then your needs may change. There’s no gold standard set amount, but the guideline of 7-9 hours holds true for most.

Insomnia is associated with an increased tendency to feel anxious or experience other mood difficulties. Here it can get a little chicken and egg, as sleep disruption can also be part of depression and anxiety, but whichever came first, we know that if we improve the quality of our sleep then we can see all-round benefits.

Benefits of a good night’s sleep

• Improves mood

• Helps with immune system function

• Regulates hormones - including keeping a healthy weight

• Helps with focus and productivity

• Improved energy

• Helps with rational thinking

• Increases our ability to deal with whatever life throws at us

• And last but not least: it’s actually quite nice, to be able to snuggle down at the end of a long day, and appreciate the cosy, safeness of your own comfortable bed

Tracking your sleep

The first steps in therapy for insomnia involve tracking your sleep - the number of hours, what you were doing before bedtime, any remedies you may have used, caffeine or alcohol consumption and so on. There are plenty of apps on the market for this, but we don’t have to get too snazzy… pen and paper will do and probably more easily shared with your therapist. This sleep diary from The Sleep Foundation is comprehensive and will help to establish your current pattern and is a way for you to monitor your progress if you choose to.

What’s sleep hygiene?

Of course, sometimes sleeplessness can be down to modifiable factors, which can be easily remedied, so the next steps in insomnia treatment would be to take a look at your ‘sleep hygiene’. Contrary to how it sounds, this doesn’t mean keeping your sheets clean - although downy duvets and laundry-fresh sheets might assist! Sleep hygiene means taking a look at your bedtime routine, sleeping arrangements and bedroom environment. You can then take practically address areas which are in your control.

When we talk about sleep hygiene, we are ensuring we have some healthy habits in place. eg.

• Reducing alcohol at bedtime (can lead to night wakening)

• Reducing caffeine consumption

• Ensuring your room is a comfortable for sleep: temperature, light levels, comfort, noise

• Reducing over-stimulating activity at bedtime: playing video games, using phone in bed, reading news, going on social media etc

• Eating too late in the evening

• Introducing an effortless healthy wind-down routine

By setting up sleep-welcoming habits, we begin to set the body up for relaxation and sleep. If these simple strategies are still not bringing the progress you would like, then it’s time to move on to look at how your thinking and the very quest itself to get a good night’s sleep can make it increasingly out of reach.

Your sleep beliefs

While a period of interrupted sleep (due to a specific trigger, perhaps illness, a difficult period at work, a loss, relationship problems, having a new baby) might trigger an episode of sleepless nights, when this persists, it can be because our own thoughts about our lack of sleep can keep us locked into sleepless nights of tossing and turning. Paradoxically, the harder we try to get to sleep and the more we might be telling ourselves that we HAVE TO get to sleep, the more we might be getting ourselves stirred up, so preventing sleep from happening when we want it to.

The truth is, sleep will happen whatever we do or don’t do, but in insomnia it ends up happening at the wrong time, perhaps in short snatched bursts. We might find ourselves catching up one night after a sleepless night, or in naps, or at weekends. Just as we can’t force ourselves to stay awake, we can’t truly prevent sleep. Our body has inbuilt sleep regulation - if we’re in a sleep deficit, then we will fall asleep, even if that is during the day when we need to be awake. This isn’t ideal, as not only could it be outright dangerous if we are driving or operating machinery, but it may not suit you to be dozing off at random moments!

Don’t try too hard

Once we find ourselves in a cycle of overnight sleeplessness, we can get into a cycle of behaviours and thought patterns which become fixated on the idea of getting a good night’s sleep. In the case of sleep, there’s a paradox here. The more we try to get to sleep, the more this escapes us. This is called the Law of Reversed Effort. Have you ever tried to stop yourself from laughing where silence was required? Remember when you learnt to swim, how hard you tried and how now, well, really it’s effortless… There are many activities where trying harder does not work, and so it is with sleep. Because sleep comes naturally, we don’t need to be taught how or to strive to do so, it’s more about letting go of everything. It’s all the things we do in our minds and the physical actions we might carry out which keep our body alert, and in a state which isn’t conducive to sleep.

Sleep beliefs

Working out your beliefs about your sleep and challenging these during your waking hours can be helpful and supportive. As can educating yourself about sleep itself. The more you understand about sleep is that you’ll see that it is a natural process, which in reality needs no effort. It is often our thinking about the lack of sleep which keeps insomnia going. Common beliefs might be:

I won’t be able to cope or function without sleep

I have to fall asleep now, I can’t stand not being able to sleep (while watching the clock)

I can’t bear it when I haven’t had a good night’s sleep

I have to ensure my mind is empty before I go to bed, or I won’t fall asleep

I have to have silence to sleep, I can’t bear not having silence

I must have a perfect night’s sleep

If you’re an insomniac, do any of these resonate with you? There are others, but those are some of the typical themes I come across among my clients. These beliefs about your sleep can be addressed and helpful beliefs can be developed which are more conducive to helping your body to wind down for the evening.

A modern CBT approach for insomnia is Acceptance and Commitment Therapy (ACT) which takes a mindful approach towards the thoughts, rather than getting into a bedtime battle. Acceptance and Commitment Therapy is a third wave CBT approach which uses, among other things, mindful awareness to accept thoughts rather than try to wrestle and wrangle with them at the very time we could be drifting off to dreamland. ACT techniques are particularly helpful at bedtime when we don’t want to be getting into increasing mind activity by trying to rationalise thoughts away. Being able to disengage with worry thoughts and let them go, while focusing on the present moment can help. Mindfulness training to accept and allow thoughts, feelings, external distractions to come and go can be of benefit. Imagine your thoughts as clouds in the sky which drift in and out, or as leaves on a stream which bob off into the distance. There’s no need to get into the river with the thoughts, you can learn to allow them to float away without attending to them.

Sleep behaviours to tackle

Aside from the basics of sleep hygiene, unhelpful habitual sleep patterns can be addressed.

There are two tried and tested methods of breaking the sleep pattern called Stimulus Control Therapy and Sleep Restriction Therapy which may be of help. Stimulus Control is for those who may have conditioned themselves to associate their bedtime as something negative. Sleep restriction Therapy aims to improve the ratio of sleep to time spent in bed (sleep efficiency), by restricting your sleep to begin with. It’s not quite as brutal as it sounds, and can get you quickly back on track if you are feeling highly motivated.

Any activities you undertake with the sole purpose of getting to sleep may keep the focus too much on the lack of sleep and give you extra pressure. It’s as if sleep becomes some kind of performance for which you must be ready. Reducing the amount of props or aids to sleep may also take the pressure off.

Helpful behaviours at bedtime might include relaxation techniques, a mindful body scan or simple mindfulness of breath. The key to success here is not to carry them out with an explicit goal, but to practise just accepting and being curious about what you find and what happens, rather than having an expectation that these must work for you. These exercises can be helpful to switch off and to engage the parasympathetic nervous system (our relaxation response) but their effectiveness may be affected by worry about your lack of sleep and focusing on striving for sleep.

Managing general anxiety or stress

Often being able to explore your everyday stressors can go hand-in-hand with insomnia. If you’re at the end of your tether and stressed to the max at the end of the day, it’s no wonder that you’ll find it harder to drift off to sleep. As CBT is a therapy which helps you to help yourself, many of the approaches we use to manage your insomnia can be cross-pollinated into everyday life.

Sleeping beauty. Sounder sleep could be just a few steps away with CBT for insomnia.

As I hope you can see from this introduction to treating insomnia with CBT, we have lots of options to get you back to sounder, more refreshing sleep. If I can be of support, please reach out.

Ali Binns is a CBT therapist in Bath specialising in anxiety problems. Feel free to get in touch using the contact form on the main menu if you’d like support and help in working through your particular problems.

Breathing exercise: Box breathing

When emotions run high and we can feel our emotions getting the better of us, it’s not so easy just to think ourselves out of it with immediate effect, so it can be useful to have a variety of techniques at our fingertips to help to soothe our emotions. Then can we step back and see things differently. This post is going to focus on a simple breathing technique called Box Breathing which we can use to help to soothe our emotions when we need to.

Albert Einstein, a clever sort, we can all agree, once said, “We can not solve our problems with the same level of thinking that created them”. This makes a lot of sense when you get into a tricky spot and you find yourself hijacked by your emotions. Please don’t beat yourself up about this, it happens to everyone - it’s just that some people have learned strategies to cope better and some have yet to learn.

When our emotions are triggered, our brain has already begun to send out messages to protect us from imminent threat and has set in motion the body’s fight, flight or freeze reflex. The sympathetic nervous system becomes activated (all systems go!), to fight or to flee the scene, or, if all else fails, to freeze. This is your body’s survival mechanism at work.

The difficulty with being able to think differently when our emotions have been triggered is that the thoughts become threat-focused, with a distinctly negative bias. This would have had a clear benefit to us when our lives depended on it, but in the modern world, the attentional bias causes more problems than it solves. We can’t think differently, as old Albert says, unless we create a slightly different space for ourselves to think in. So what to do?

Fortunately we have our own breath at our disposal to engage the parasympathetic nervous system (a calming response). By breathing in a way that signals safety, you can begin to activate the brain’s soothing systems, and start slowly and surely to reverse the cycle. As you calm your breath, you are in a better position to begin to access your rational thinking and assess how best to proceed in the difficult situation you may have found yourself in.

This post is focusing on the simple technique of Box Breathing. I’d encourage you to give this a try for a week or two and see what benefits it might bring for you.

A guide to box breathing

Begin by imagining you can see a square shape in your mind’s eye - a simple geometric box shape if that’s easiest, or if it helps, imagine a perfectly square window looking out over a relaxing scene of your choice. Now beginning in the top left corner of the box shape, take a deep breath in as you trace your way across the top edge for an approximate count of four, hold for a count of four as you travel down the right hand side of the box shape, breath out for four as you trace along the bottom edge, and hold once more for four, as you head up to the top left corner again and repeat. Repeat for as long as you need.

Don’t try to force the count, if this seems at first unnaturally too long or too short. Feel free to adjust it, but ensuring as best you can to keep the breaths even. Fill your lungs in the in-breath and breathe out all the air on the out-breath. This way you will succeed in slowing down your breathing, enabling your body to begin to relax and slow. Just keep a focus on the idea of the box shape to assist you with keeping the breaths even and smooth.

Other breathing techniques are of course available. You could also practice a beginners mindfulness of breath practice or soothing breathing.

Ali Binns is a CBT therapist based in Bath. She takes an integrative CBT approach, helping you to discover evidence-based approaches which will work for you and your unique situation.

Breathing exercise: Soothing rhythm breathing

Using our breath can be a helpful way of settling our mind and body when we are experiencing negative emotions such as anxiety, anger, depression or general stress. It can help to create a more secure and grounded feeling and reduce the impact of the body’s natural fight or flight reflex. By deliberately using our breath, we are helping our mind to receive the message that we are safe.

Soothing rhythm breathing is a breathing exercise designed to soothe body and mind. There are other breathing exercises where you can just allow the breath to be as it is, but this technique is about discovering a breathing rhythm that is supportive and calming for you. The counting element can help to focus your mind on your breath.

The rate and rhythm of breath which you find soothing may vary from the count here, so please feel free to adjust your counting if need be. Your natural soothing rhythm may even vary from day to day, so initially it is worth taking a little time to find your rhythm before settling into a pattern which feels soothing and natural for you. There’s no rush to find the right pace; just keep your in and out breaths of equal length, with a brief pause between each.

You can experiment with the sequence below until you find the rate which feels most beneficial for you. There’s absolutely no pressure to do this right or get it right first time, just set aside a few minutes a day to practice and you will soon get the hang of it.

As with other mindfulness based practices, if you find your mind wandering off onto other concerns, that’s okay, just bring your attention back to your counting and your breath.

Instructions

• First sit in a way that you feel supported, yet alert, in an upright posture with feet flat on the floor, and head facing forward.
• To begin with, slowly take a steady and long in-breath for a count of four.
• Pause there for a moment…
• Then gradually release the breath for a count of four, keeping it steady, long and slow.
• Repeat this count for three minutes.

As with any breathing exercise, these are best practised in a quiet relatively calm environment to begin with, and as you become used to doing them, you will be able to use them while going about your day when you feel the need to give yourself some time to reset.

If you would like to try a different mindful breathing technique, you can go here to find a Beginners Mindfulness of Breath exercise.

Ali Binns is a CBT therapist in Bath. She regularly teaches clients to use these simple breathing techniques as part of their general care plans. These exercises help clients to work with their emotions in a more helpful way. 

Progressive muscle relaxation

Progressive muscle relaxation is a classic exercise which has stood the test of time and is helpful to reduce tension and relieve the symptoms of stress and anxiety. Often clients wonder why I’m teaching them another relaxation exercise, so I hope the following helps to explain the why as well as the how.

When we are under pressure and our fight or flight system is being regularly activated by threats in our environment, one of the physical symptoms we can experience is a build-up of muscle tension. This muscle tension arises because of the impact of adrenaline, the way we are holding our bodies, and the way we are breathing. The fight or flight reflex prepares our muscles to act in face of a perceived threat in our environment. The threat doesn’t have to be real, even an imagined threat will do!

Our threat system is rather like an overhelpful friend, at times, pointing out threats, much of the time are not an actual danger at all. Nevertheless, as humans we get to live with a brain which responds to everyday situations and threats in much the same was as it would to a sabre toothed tiger. Our mind is working hard to protect us, and while we’ll all have our unique combinations of triggers, when the adrenaline hits our bodies, we all react in the same biological way. Our heart rate rises and our muscles are being prepared to take action – to fight and defend ourself, or to run away and take cover.

The benefits of progressive muscle relaxation

Whether we react with fear or anger to threats, muscle tension can be a feature. Muscle tension is one of the physical symptoms which forms part of the unhelpful cycle when the fight or flight system is activated, so this progressive muscle relaxation is a way of breaking into that vicious circle, creating a helpful loop instead. Because muscle tension as a symptom is linked to our thoughts, feelings and actions, if we can actively reduce muscle tension, it can have a positive impact on stress as a whole. (This, fact fans, is one of the reasons why therapeutic massage can help to relieve the symptoms of stress.)

Take the time to practise regularly and PMR can help to release and reduce muscle tension. Persistence is key. It would not be enough to do progressive muscle relaxation just once, although, you may experience an immediate benefit. It is best if you can run through this at least once per day. Most people start to notice a difference after 2-3 weeks of practice.

In time, you might be able to run through this as a brief body scan to look for areas of muscle tension in your body and take action to relax those areas. The exercise will also give you the knowledge to notice when muscle tension may be building for you. This can serve as an early warning sign to you to take action to reduce stress levels and ensure you are looking after yourself with appropriate self care.

How to practise progressive muscle relaxation

Find a comfortable and quiet place to sit or lie down. If you can, try to ensure that you can get 15-20 minutes without interruptions. So phones off, door closed, and ask anyone you may share a house with to give you a little time alone.

Close your eyes and bring your attention to your breathing. Try as best you can to keep your breathing slow and even, lengthening on the out breath. Try saying the word ‘relax’ to yourself a few times as you breathe out to encourage this lengthening of the out breath.

You are going to work through your main muscle groups one at a time, starting with your right foot. Begin by tensing your right foot, squeezing your toes together and pointing them downwards. Focus on that tension. Slowly release that tension as you breathe out, saying the word ‘relax’ to yourself. Notice the different sensations as you hold the tension and release the tension. Notice what it is like as the muscles relax. How does it feel different?

Now do the same with your right calf muscle. Tense your right calf and hold this tension for a while. Slowly release the tension as you breathe out.

Move slowly through the parts of your body as follows, working through the muscles of your right leg, left leg, buttocks, back, abdomen, chest, shoulders, left arm, left hand and fingers, right arm, right hand and fingers, neck, jaw, lips, eyes, and forehead. With each group of muscles create tension followed by releasing and relaxing for each group of muscles.

Once you have worked your way through the different areas of your body, scan through your body and make a note to see what, if anything, feels different now. If some areas are still tense, spend extra time focusing on those muscles.

When you’re finished, you can open your eyes and see if you can take some of this feeling of relaxation into the rest of your day. If you have used this before bed, let yourself drift into a sleep naturally.

Ali Binns is an accredited CBT therapist in Bath. If you'd like to find out more about how she works, feel free to browse the site. Or if you would like to book an appointment or find out more about how CBT might help you, you can get in touch via info@alibinns.co.uk