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.

Mindfulness: 5 ways to destress at Christmas

Christmas carries with it a lot of expectations. It's a time of year when the pressure to have the perfect holiday with family or friends can take its toll. Perhaps you are overloaded with tasks, or perhaps, for you, it's the opposite, you feel alone and as if everyone else is having the time of their lives. Wherever you are in the run-up to the big day, it's probably a good enough guess to say that it's not always the most relaxing time of year. Fortunately we can unwrap a few CBT and mindfulness cues to help us stay calm and prevent us from going off like a Christmas cracker!

Think of each of these are your very own mindfulness Christmas gifts to yourself and use them as reminders to tune in and watch your thoughts and how these relate to how you might be feeling over the Christmas period:

1. Christmas music

It's everywhere. Love it or loathe it, if you leave your home, you will hear it. You can use festive music as a reminder to check in with your thoughts, noticing what's going through your mind, noticing how you feel (your emotions and your body), before shifting your focus for a few minutes to focusing on your breathing, just noticing your breath going in and out. It's like a mini-timeout and can help to soothe stress, giving you a little space before choosing to move on to something new or continue what you are doing with fresh eyes.

2. Christmas wrapping

A necessary chore which can feel overwhelming when there's so much else to do, with a little mindful attention  wrapping gifts can become a way to bring you back to why you are wrapping these gifts, these tokens of love and appreciation for those people you truly value having in your life. You might even feel inspired to be more creative once you get focused in this way. To get mindful as you wrap up the presents, you can focus on the sounds of the paper as you unroll it, you can listen to the paper as you slice it with your scissors, feel the texture, notice the springiness of the ribbon as it curls, and notice the colours and shapes as you fold stick and pile the presents. If your mind wanders to other chores taking you away from your task, try to repeatedly bring your focus to the task at hand, tuning into what you can see, hear, feel and perhaps touch. No tasting though for now - the chocolates you bought were meant as a gift!

3. Mulled wine or mince pies

Food and drink are big features of the Christmas season, offering ample opportunities to be mindful. You can find out more on how to savour and notice the tastes, smells and sounds of Christmas food and drink here in this guided Christmas mindfulness exercise.

4. Christmas candle

Gifting yourself a Christmas candle can be a special way to mark the countdown to Christmas, filling your home with wonderful aromas. Lighting a candle can be symbolic of many things, celebration or a time for reflection, or even just a general sense of cosiness in your home. It also can mark the start or end of a mindfulness practice, when you might choose to set a small intention for yourself for your meditation or for the rest of your day. You can, if you choose not to close your eyes, use the candle as your mindfulness focus, and use it to gaze on the flickering flame, noticing the warmth coming from it, noticing the scent as it lingers in the air. Is there anything else that you notice?

5. Christmas compassion

Go easy on yourself and others. Maybe this is a difficult time of year for you - absent friends, stress, workloads. See if you can notice what it is like to experiment with being forgiving of yourself and others, or your own mistakes. Practise being aware of any tendency for too-high standards or expectations of a perfect day. Notice and be mindful of the times when you are demanding a lot of yourself and be flexible in your approach. Compassion could be the best Christmas gift you can offer yourself and others. If you find self compassion difficult, you can begin with a guided breathing exercise such as Soothing Rhythm breathing. Just a simple act of taking time to breathe can be the beginnings of self compassion.

I hope these five festive mindfulness reminders give you some inspiration to stay present over Christmas. As you practise being mindful, I'd like to encourage you to ask the following... What do you notice when you really pay attention? What do you miss when you don't?

Ali Binns is a CBT therapist in Bath. She supports clients with their emotional wellbeing, using a cognitive behavioural therapy approach combined with mindfulness techniques to support the process. 

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

Mindfulness for beginners: breathing exercise

Thinking is great, except when it's not! Our brains are wonderful things - our thinking brains enable us to plan, speak, connect, problem-solve, create, invent and imagine. Unfortunately our minds have a natural tendency to seek out the negative. Many of the thoughts that stick around are the ones that can lead to worry and rumination. These thoughts can seem to pop up out of nowhere.

If you've ever suffered from stress, anxiety or depression, you'll know the sort of thoughts. The ones that hang about and really get to you. Nobody's immune. Research suggests that we have between 50,000 to 70,000 thoughts a day and around three-quarters of these are negative. You can thank your brain for that too. In evolutionary terms, this tendency to seek out threatening messages was useful for survival. Operating on a better-safe-than-sorry policy, our ancient ancestors who survived were the ones who could best negatively predict that a long curving object on the jungle floor was a snake and so stayed safe. The understanding being that positively presuming the said object was a stick would have been a risk to our survival as a species.

We're all living with the legacy of these tricky brains which are hardwired to seek out threats in our environment. Once we're suffering from anxiety or stress, and our fight or flight reflex has kicked in, our minds begin to race in an attempt to quickly evaluate threats, negative thoughts increase and we can soon get caught up in spirals of negative thinking. Fortunately, we can learn to manage the rise of negative thoughts, simply by paying attention to them with mindfulness exercises. The simplest technique is mindfulness of breath.

This is an ideal mindfulness exercise for beginners as it's portable and do-able. All you need is a few moments and your breath - which you always carry with you! Mindful breathing helps you to distance yourself from the content of negative thoughts, as, over time, you come to notice and understand that thoughts are often nothing but thoughts, and certainly they're not always facts. Learning to notice and let go of unhelpful thoughts can be key to combating anxiety and depression.

Here's how to practise mindfulness of breath. (You may like to spend anything between 5 and 15 minutes for this exercise.)

Begin by finding a place to sit, and, close your eyes. Adopt an upright posture, alert yet relaxed to enable you to pay attention. The aim isn't specifically to relax (although this is often a welcome side effect).

Settle as you are, noticing your feet upon the floor, hands in your lap and any points your body makes contact with your seat. Bring your attention to your breath now. Simply follow the rise and fall of your breathing. There's no need to try to change your breath at all. Just allow it to be as it is, letting it do its own thing, accepting things just as they are. Notice and follow the breath in your abdomen. If you like, you can place your hand there to feel this gentle movement. 

Be curious about the sensations of your breath, in and out. Become aware of where else you notice the breath in your body. Perhaps you feel it in your chest, or the sensations of the breath entering your nose. Bring your attention to wherever you feel it most, and see what sensations you discover. 

If at any point during this exercise, your mind does wander, you might be relieved to know, this is completely normal. Simply make a note of where your mind has wandered and bring your focus back to your breathing. It can help to note with a simple word, such as 'thinking', 'feeling', 'planning', 'judging', 'remembering', what your mind was doing and return your focus to your breath. Every time you notice your mind has wandered know that this is part of the exercise - you've managed a moment of mindfulness. Treat your mind as if it were a bouncy puppy, who needs to be reminded to come back to heel, over and over again. There's no need to get cross with it, only gentle reminders are needed to begin to train your mind to stay present, instead of running back to the past or taking a wander into the future.

Continue paying attention to your breathing for your chosen time (some people find a timer helps). When you're ready to bring this exercise to a close, begin to notice the sounds around you, and the feeling of your feet on the floor, and your body in the chair. Slowly open your eyes, and take in the sights around you. Give yourself a couple of moments to take everything in, and move into the rest of your day.