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
Helps with immune system function
Regulates hormones - including keeping a healthy weight
Helps with focus and productivity
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.
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.
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.