CBT treatment guidelines for insomnia
“It’s 3am and I can’t sleep! I have to sleep! I have a big meeting tomorrow! I’m never going to fall asleep!”
Sound familiar? When we are stressed, anxious or troubled, we usually experience sleep disturbances. Some struggle to fall asleep, while others wake up a few times during the night, struggling to get back to sleep. Sleep disturbances are common and not many can say that they haven’t been affected by insomnia at some stage of their lives. The challenge is that staying awake is often coupled with poor sleeping habits (the behaviours) and irrational “over-thinking” (the cognitions) about sleep (or lack there of!).
I recently presented at the Cognitive-Behavioural Therapy (CBT) bimonthly meeting on treatment guidelines for insomnia. I thought I’d share some of the main behavioural treatment approaches for those who suffer from chronic insomnia. These are guidelines and by no means a replacement for therapy. If you do suffer from insomnia that has a significant impact on your quality of life, consult with a registered Psychologist who treats sleep disorders.
Sleep Restriction Therapy
A basic strategy that most of us employ is to spend more time in bed following a bad night’s sleep. We think that if we get into bed earlier (or sleep in later), we’ll be able to “catch up” with sleep. While it may work for some, if you suffer from chronic insomnia, then this strategy only makes the association stronger between lying in bed and not sleeping. A CBT-trained therapist will help you determine how many actual hours of sleep you get each night and recommend how long you should restrict your time in bed. For example, if you average 4 hours of sleep a night (even though you’re in bed for 8 hours) it’s recommended that you only spend 4 hours in bed (add 30 minutes for falling asleep) until the quality of your sleep improves.
Stimulus Control Therapy
Now that you’ve restricted your time in bed (which a therapist will gradually increase as your sleep quality improves), it’s time to look at breaking associations of activities in bed other than sleep. Your bed needs to be a haven of tranquility, relaxation and sleep. If you’re playing on your phone, working on your laptop or even watching TV in bed, you’re associating your bed with wakeful activities. Your therapist will guide you on specific routines, but ultimately, you need to leave the bedroom if you cannot fall asleep within 30 minutes. Yes, that’s right – go to the next room! You’re free to do what you please there – read, write, text, browse Facebook, watch Walking Dead if you want to! As soon as you feel that you cannot keep your eyes open any longer, go back to bed. If you cannot fall asleep again within 30 minutes, then repeat! This may seem extreme, but you are:
- Breaking the link between lying in bed and tossing and turning
- Enhancing the link between your bed and sleep
Follow the instructions (pictured here) to change a few bad habits (and myths) about sleep. These work well together with sleep restriction and limiting activities in bed.
In addition to the behavioural strategies for insomnia, an important part of treatment is to look at changing your irrational or unhelpful thoughts around sleep. Worry about the daytime consequences of not obtaining enough sleep (associated with increased absenteeism and performance anxiety) results in more emotional distress and worsening sleep. The more you obsess about not sleeping, the more you struggle to sleep!
RESOURCES FOR THERAPISTS:
Bartlett, Delwyn. (2014). Managing Insomnia – What we have learnt in the last 10 years. InPsych Journal.
Edinger, J., & Carney, C. (2008). Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach Therapist Guide. Oxford University Press.
Perlis, M., Jungquist, C., Smith, M.T., & Posner, D. (2005). Cognitive-Behavioral Treatment of Insomnia: A Session by Session Guide. Springer.