DR DAMON ASHWORTH is a clinical psychologist and sleep researcher. Here he describes the benefits of Cognitive Behavioral Therapy for overcoming insomnia, and also offers many solutions to help with sleep problems.
Sleep difficulties are a feature of nearly every mental health problem, including depression, anxiety, trauma, substance abuse, bipolar disorder, psychosis and schizophrenia. Take depression for example. Up to 90% of individuals with depression have sleep difficulties, and two out of every three have significant enough sleep problems to also have a diagnosis of insomnia.
Worse still, insomnia does not tend to go away on its own without appropriate treatment. This is because once people start to sleep poorly, they tend to develop ways of thinking and behaving around sleep that make their problems worse over the long run.
Fortunately, there is a treatment out there that can improve your sleep. It’s called Cognitive Behavioral Therapy for Insomnia (CBT-I), which directly targets these unhelpful thoughts and behaviors around sleep. Many studies show CBT-I is an effective treatment, similar to sleeping pills at improving sleep in the short-term, and much more effective than sleeping pills at improving sleep in the long-term.
Research shows that CBT-I consistently reduces the time taken to get to sleep, decreases the amount of time spent awake during the night, and improves sleep quality and efficiency, with improvements persisting after the treatment finishes. This is unlike sleeping pills, where sleep difficulties typically come back once people with insomnia stop taking them.
Sleeping pills are also not recommended for use beyond 4 weeks at a time, because they stop working after a while and people need to take bigger doses over time to get the same effects. Often doctors prescribe them because they think they will work faster for patients, but even one session of CBT-I has been shown to make a significant difference to one’s sleep at night!
CBT for Insomnia consists of four main components:
Helpful information around sleep, including homeostatic pressure, circadian rhythms, hyper-arousal and sleep hygiene recommendations. Sleep hygiene means having a comfortable bedroom environment, minimizing light exposure before bed, exercising during the day, minimizing caffeine and alcohol, and doing things to wind down or manage worries before bed.
2. Sleep scheduling
Helpful information on when to go to bed at night, when to wake in the morning, and the ideal amount of time for sleep. Stimulus control and sleep restriction are the two main interventions included in sleep scheduling, and both are scientifically supported for improving sleep quality and sleep efficiency if done properly.
3. Relaxation techniques
Because hyper-arousal plays a huge role in insomnia, it is important to help people develop strategies to quiet the mind and calm the body during the day, both before bed and in bed. Relaxation techniques may include imagery training, meditation, biofeedback training, deep and slow breathing and progressive muscle relaxation.
4. Cognitive therapy
Skills to challenge unhelpful or unrealistic beliefs about sleep. A lot of individuals with insomnia attribute all of their tiredness, mood difficulties or poor performance at work to their sleep difficulties, and this puts too much pressure on them to get a good night’s sleep. It is therefore important to get them to see the other factors that may contribute to how they feel during the day, present them with data that challenges their fears, and help them to develop realistic expectations about their sleep.
BEST SLEEP INTERVENTIONS OVERALL
In 2017, I ran 26 two-week experiments on my sleep to determine which interventions were most helpful. Here are all the sleep interventions I tested, ranked from best to worst based on their overall score out of 100:
SLEEP RECOMMENDATIONS (Stepanski & Wyatt, 2003):
1. Decrease time in bed
Sleep efficiency is a better predictor of satisfaction with sleep and daytime mood than total sleep time. So if you only get 7 hours of sleep per night, spend 7.5 hours of time in bed. This will allow for better sleep over time.
2. Regular bedtime and waking time
Reducing variability in your sleep can make a huge difference in how long it takes you to get to sleep, how restful a sleep you have, and how refreshed you feel in the morning. Have a set bedtime, and whenever you feel sleepy around this time, go to bed. Then set an alarm so that you can wake up at the same time each day. If you want to sleep in on weekends, allow yourself no more than one hour later than you usually wake up. Following this, regardless of how much sleep you get, helps to strengthen your circadian rhythms and build up your homeostatic pressure to ensure better sleep over time.
Vigorous exercise prior to bedtime is actually unhelpful for sleep, but expending more energy during the day is likely to lead to better quality of sleep at night. The earlier in the day it is done, the greater the effect it will have.
4. Less caffeine and alcohol
Minimize these substances where possible, especially within 4 hours of bedtime as they both have significant effects on sleep quality. Alcohol can reduce worries and result in getting to sleep quicker, but results in poorer sleep quality in the second half of the night. Alcohol can also lead to more snoring due to the loosening of the throat muscles. Caffeine boosts cortisol levels, a.k.a. stress, and results in less deep sleep and more awakenings.
5. Do not try to sleep
It is something that has to come naturally. The harder you try to get to sleep, the less likely it will happen, as trying activates the autonomic nervous system, which also increases how stressed you feel. The more you allow yourself to relax, the more likely sleep is.
6. Do not keep looking at your phone or alarm clock during the night
If your alarm is set, then there is no need to know the time in bed. This will only increase performance anxiety if you look and see that you have not slept for very long. Put it in a drawer, cover it with a shirt, or face it the other way.
7. Keep naps short
Napping during the day reduces your pressure for sleep by the time you go to bed at night. If you have to nap, keep it less than 30 minutes so that you don’t go into a deep sleep, and do it before 4 p.m. so that sleep pressure can build up again by the time you go to bed that night.
8. Engage in relaxing activities before bed
Just like waking up, going to sleep is a transitional process. Don’t expect that your mind will shut off immediately as soon as you get into bed. Whatever it is, do something relaxing as a pre-bed routine. Read a book, listen to some music, have a hot bath, practice Yoga, mindfulness or relaxation techniques. Then maintain that relaxed state in bed and allow sleep to come.
9. Use the bedroom only for sleep and sex
This means no reading, eating, Internet surfing, game playing, phones, TV, planning, worrying etc. in bed. Bed = sleep.
10. Make a worry list before bed
To prevent your mind from racing in bed, reflect on the day about 2 hours before you want to sleep, write down any worries, concerns or problems you may have, create a to-do-list, or plan for the day ahead. Then if thoughts come up in bed, remind yourself that you have already sorted them out or that they can wait until tomorrow.
11. Leave the bed if awake
Sometimes, no matter what you try, you may find yourself awake in bed. If you do not fall to sleep within what feels like 20 minutes, get up, go to another room and do something relaxing until you are sleepy before returning to bed. Over time this will recondition the bed with sleepiness rather than frustration, and allow you to fall asleep quickly. Give it a try for a week. It may be the most difficult recommendation to follow initially, but it produces long-lasting results quickly.
For more details on these interventions and strategies, go to www.sleepdetective.com.au.
Article by DR DAMON ASHWORTH
Damon is a clinical psychologist who currently volunteers as a mental health specialist with the Vanuatu Government in Port Vila, Vanuatu, under the Australian Volunteers Program. His sleep research was the first to show that four sessions of CBT-I can significantly improve depression and insomnia severity in people who had previously failed to remit through... Read more