How can cognitive behavioural therapy help people with insomnia get a better night’s sleep? Dr Lucy Maddox, senior clinical advisor at the British Association for Behavioural and Cognitive Psychotherapies, explains.
‘But [Pooh] couldn’t sleep. The more he tried to sleep the more he couldn’t. He tried counting Sheep, which is sometimes a good way of getting to sleep, and, as that was no good, he tried counting Heffalumps. And that was worse. Because every Heffalump that he counted was making straight for a pot of Pooh’s honey, and eating it all. For some minutes he lay there miserably, but when the five hundred and eighty-seventh Heffalump was licking its jaws, and saying to itself, “Very good honey this, I don’t know when I’ve tasted better,” Pooh could bear it no longer.’1
Sleeplessness is frustrating, lonely, and common. Approximately one in ten adults experience persistent and severe insomnia with daytime consequences, which means that 10% of people find it hard to sleep on three or more nights a week and have had this problem for at least three months, with effects of tiredness and moodiness the next day. In adults over 65 the figure rises dramatically, estimated at one in five. Lots of people experience sleep difficulties from time to time or to a less severe degree, so this really is a common problem.
What is insomnia?
Simply put, insomnia is when sleep at night is not good and this affects how you feel the next day. It might be that it’s hard to get to sleep, hard to stay asleep or both. The knock-on effects the next day can be sleepiness, irritability, teariness, poor performance at work or home, arguments with friends and family, and many more.
So whilst insomnia can feel like a nighttime problem it really is a 24-hour disorder. The effects it has stretch well into the daytime and can make life feel really miserable.
Anxiety and low mood are common bed-fellows of insomnia, and it’s easy to see why: poor sleep tends to make us feel more emotionally reactive, and feeling more emotional, in particular sad or anxious, makes us sleep worse.
Long-term sleep difficulties are associated with an increased likelihood of developing depression, so it’s definitely a problem that is worthy of attention.
But there is a psychological therapy with a good evidence base, and it’s not counting Heffalumps.
What do we mean by cognitive behavioural therapy (CBT) for insomnia?
CBT is a family of talking therapies based on the theory that our thoughts, feelings, behaviours and bodily sensations are all interlinked.
Cognitive behavioural therapy for sleep problems uses CBT techniques targeted towards helping challenge unhelpful thoughts about insomnia and looking out for inadvertently unhelpful behaviours which may be maintaining a poor sleep pattern.
Like all CBT, formulating or understanding the problem is the first step. Sleep problems can result from multiple causes, and trying to identify any longer term predisposing factors, shorter term triggers and accidental maintaining factors that keep the problem going can be helpful.
Understanding more about insomnia in general is also important, as it begins to let sufferers let go of the idea that lack of sleep is an insurmountable problem. The more we become upset or angry about lack of sleep the more we are likely to suffer from lack of sleep.
How can we tackle problematic thoughts in insomnia?
Evaluating our thoughts about insomnia
Recording the thoughts we have about insomnia in general, considering the impact these thoughts have on how we feel, reconsidering the accuracy of these thoughts and then considering how these new thoughts make us feel is one important part of CBT for insomnia.
Very often people find the thoughts they have about sleeplessness are catastrophic, leading them to feeling hopeless in the face of lack of sleep.
Evaluating our thoughts and trying to change our attitudes to sleep can really change how we feel and help to promote healthy sleep.
Dealing with racing thoughts at bedtime
Racing thoughts at bedtime are a common problem. Often people lie awake chewing over things that have happened that day or trying to problem-solve dilemmas.
Alternatively we might lie there overthinking our sleeplessness, worrying about what it will mean for us the next day, being hyper-alert to how our bodies feel, or thinking about how much we are thinking.
Instead, CBT approaches use a variety of techniques to help us to stop going round and round a helter-skelter of thoughts.
Journalling about your day before you go to sleep can help to leave the day behind, and paradoxical interventions like trying to stay awake can for some people have the effect of taking the pressure off sleep to an extent that it
What behaviours could we consider altering?
The ‘B’ in CBT stands for behavioural, and there are many behaviours we might accidentally get into which can inadvertently keep sleeplessness going. What can help?
Sleep hygiene and relaxation
Sleep hygiene refers to the basics of behaviour and environment that we can pay attention to in order to promote sleep.
Lifestyle factors we engage in during the day can be important, for example how much caffeine, alcohol or nicotine we have, what we eat and how much, and when we exercise. All of these things can be important to how we sleep.
Our routine just before bedtime is also important. CBT approaches recommend a wind-down routine 60-90 minutes before bedtime and that we pay attention to the comfort in our bedroom: noise, temperature, lighting, whether it’s stuffy or not, and how comfy our bed and pillows are.
Conversely, this does not mean that we should try so hard to make a perfect bedtime routine that we end up piling on the pressure on ourselves to sleep. Making sure our sleep pattern has a regular waking time and bedtime and doesn’t involve napping is also useful.
Behaviours in the bedroom are also important. We need to associate our bed with sleep, which means not reading, playing or chatting on our phones, or doing work-related tasks.
If we can’t get to sleep for longer than 15 minutes the recommendation is to get up! If we lie there stewing for hours on end we will associate our bed with sleeplessness.
Instead, we should get up and go into another room – read, make a hot drink or a hot water bottle, write some pages of a journal, something low activity that won’t make us feel really awake but will allow us to go back to bed when we start to feel sleepy again.
How effective is CBT for insomnia?
CBT for insomnia has a good evidence base. Whilst sleeping pills are not recommended for the long-term treatment of insomnia, CBT techniques can be used long term (although they require hard work and commitment). Online CBT for insomnia has also been shown to reduce anxiety and paranoia. This is likely to be because of the effects of lack of sleep on how we think and feel.
This isn’t to say that CBT for insomnia will automatically affect anxiety and paranoia, which can be influenced by a range of causes and have treatments in their own right, but it does mean that there are likely to be negative emotional and cognitive consequences of sleeplessness which are further reduced by the treatment.
1 AA Milne, Winnie-the-Pooh
2 Colin Espie, Overcoming Insomnia and Sleep Problems
This article will appear in issue 4 of Health Europa Quarterly, which will be published in February.
Professor Colin Espie, member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and an expert in this field, has written extensively on CBT for insomnia. His book, Overcoming Insomnia and Sleep Problems, is easy to read and outlines the approach comprehensively.2 Espie also founded the online CBT treatment package for insomnia Sleepio, which you can find at www.sleepio.com.
To find an accredited CBT therapist in your area, visit www.cbtregisteruk.com
Dr Lucy Maddox
Senior Clinical Advisor
British Association for Behavioural and