CBT for sleep
Cognitive behavioural therapy (CBT for sleep) is an effective treatment for chronic sleep problems. According to many experts it’s the most effective treatment for persistent insomnia but not everyone agrees. Casey Adams (Ph.D) thinks cognitive approaches can cause harm to our self-esteem and mental stability when (for example) we are being told that we need to change or even stop thinking in order to get to sleep. According to Adams this can create an endless loop of self-doubt and over-thinking.
CBT for insomnia is a structured program that helps you identify and replace thoughts and behaviours that cause/worsen sleep problems with habits that promote sound sleep. Unlike sleeping pills (that focus on treating the symptoms), CBT helps you overcome the underlying causes of your sleep problems.
The cognitive side of CBT teaches us to recognize and change beliefs that affect ability to sleep. The behavioural side of CBT helps you develop good sleep habits and avoid behaviours that keep you from sleeping well.
The first step in evaluating one’s insomnia is to do a careful self-analysis of one’s sleep pattern and the factors that affect it. This will help rule out potential other sleep disorders and help identify behaviours and cognitions that are negatively affecting sleep. For example, if the primary problem is the presence of negative thoughts that result in over-arousal, then it will be more effective to focus efforts on challenging these negative thoughts and replacing them with more positive sleep thoughts (as opposed to focussing on sleep hygiene issues that may not be the problem). The right combo of ‘techniques’ must be tailored for each patient.
While sleeping medication is big business, some research has shown that the most effective treatment for insomnia is actually cognitive behavioural therapy. These methods have been tested in rigorous clinical research and are used daily in the US and Europe, either as part of a self-help program or in formal therapy to manage and overcome insomnia for many weary people seeking relief from this persistent and potentially debilitating sleep disorder. This said, there’s plenty of other support and aid that haven’t been tested so the big picture remains unclear.
This approach to psychotherapy was originally pioneered by such leading researchers as Albert Ellis and Aaron Beck. Beck’s outstanding research, theoretical formulation and clinical techniques were first published in a series of significant books and articles in the 1960′s and 1970′s.
CBT can be combined with medication management for patients who need rapid relief or to help initially break a pattern of insomnia.
Key CBT sleep methods
CBT treatment can cover various following methods and the treatment is typically tailored for the patient. The most effective treatment approach may combine several of these methods.
- Sleep education. To make effective changes, it’s important to understand the basics of sleep — for example, understanding sleep cycles and learning how beliefs, behaviours and outside factors can affect your sleep.
- Cognitive control and psychotherapy. This type of therapy helps you control or eliminate negative thoughts and worries that keep you awake. It may also involve eliminating false or worrisome beliefs about sleep, such as the idea that a single restless night will make you sick.
- Sleep restriction. Lying in bed when you’re awake can become a habit that leads to poor sleep. Limiting the amount of time you spend in bed can make you sleepier when you do go to bed. That way you’re more likely to fall asleep and stay asleep.
- Remaining passively awake. This involves avoiding any effort to fall asleep. Paradoxically, worrying that you can’t sleep can actually keep you awake. Letting go of this worry can help you relax and make it easier to fall asleep.
- Stimulus control therapy. This method helps remove factors that condition the mind to resist sleep. For example, you might be coached to use the bed only for sleep and sex, and to leave the bedroom if you can’t go to sleep within 15 minutes. Stimulus control helps with 3 key areas. 1) It strengthens the link of being in bed with sleeping – by only getting into bed when you feel tired, and only using your bed for sleep and sex. 2) It weakens the link of being in bed with doing things that are likely to keep you awake – like watching exciting TV programs, doing work, or organising things. 3) It weakens the link of being in bed with worrying – if you can’t sleep, instead of lying in bed worrying, you get up and do something for a while until you feel tired again.
- Sleep hygiene. This method of therapy involves changing basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, drinking too much alcohol, or not getting regular exercise. You may be told to avoid napping and taught to maintain a consistent sleep schedule. It also includes tips that help you sleep better, such as ways to wind down an hour or two before bedtime.
- Relaxation training. This method helps you calm your mind and body. Approaches include meditation, hypnosis and muscle relaxation. Progressive muscle relaxation helps you to relax your muscles deeply. One by one, you tense and then release the muscles of your body, working up from your feet to your legs, arms, shoulders, face and neck.
- Biofeedback. This method allows you to observe biological signs such as heart rate and muscle tension. Your sleep specialist may have you take a biofeedback device home to record your daily patterns. This information can help identify patterns that affect sleep.
- Sleep diary. To understand how to best treat your insomnia, your sleep therapist may have you keep a detailed sleep diary for one to two weeks. In the diary, you’ll write down when you go to bed, when you get up, how much time you spend in bed unable to sleep, total sleep time and other details about your sleep patterns.
CBT vs Sleeping pills
Some newer sleeping medications have been approved for long-term use. But they may not be the best long-term insomnia treatment.
Sleep medications can be a very effective short-term treatment — for example, they can provide immediate relief during a period of high stress or grief.
Cognitive behavioural therapy for insomnia may be a good treatment choice if you have long-term sleep problems. You may want to try it if you’re worried about becoming dependent on sleep medications, if medications aren’t effective or if they cause bothersome side effects.
Unlike pills, cognitive behavioural therapy for insomnia addresses the underlying causes of insomnia rather than just relieving symptoms. But it takes time — and effort — to make it work. In some cases, a combination of sleep medication and cognitive behavioural therapy for insomnia may be the best approach.
Who benefits from CBT?
Cognitive behavioural therapy for insomnia can benefit nearly anyone with sleep problems. The therapy can help older adults who have been taking sleep medications for years, people with physical problems such as chronic pain and those with primary insomnia, a condition that exists in its own right. What’s more, the effects seem to last. There is no evidence that the therapy has negative side effects.
Cognitive behavioural therapy for insomnia requires steady practice, and some approaches may cause you to lose sleep at first. Stick with it, and you’re likely to see lasting results.
Note: there are limited number of certified experts and you may not live near a practitioner.