Improving your Sleep (Part 2)

Author: Diana Gordon, Psy.D.

In Part 1 of this series, we talked about some simple strategies for helping you get your sleep back on track. But for some people, those strategies might not be enough. If you’ve tried making changes to  your sleep hygiene and you’re still having trouble sleeping, you might want to consider seeing a CBT for insomnia specialist. Psychologists trained in CBT-I can teach you specific cognitive and behavioral skills for improving your sleep. If you’ve been having a lot of difficulty sleeping, there is hope! CBT-I is a safe and effective treatment for insomnia.  During CBT-I, your therapist will use a variety of techniques to help you sleep better, including stimulus control, sleep restriction, and modifying dysfunctional beliefs about sleep. We will describe each of these techniques in more detail below.

Stimulus Control

One of the fundamental principles of CBT-I is stimulus control. As human beings, we easily form associations between stimuli. You’ve probably noticed this in many areas of your life. For example, if your coworker has a candy jar on their desk and you stop by every day after lunch, it won’t be long before you crave a piece of candy every time you finish your lunch, even on weekends! You will learn to associate the end of lunchtime with a piece of candy. This is an association that you can easily break by simply not eating candy for a few days after lunch. In CBT-I, we look at all of the associations you have formed with your bed. Often people with insomnia associate the bed with wakefulness because they spend a lot of time in bed trying to fall asleep. They may also associate the bed with anxiety, frustration, or other negative emotions. A CBT-I therapist will help you take advantage of your brain’s ability to form associations by helping you form an association between your bed and sleep, while weakening associations between the bed and wakefulness.

Associations can be incredibly powerful, and breaking the association between the bed and wakefulness can also lead to powerful changes. Sometimes insomnia patients tell us that just seeing their bed fills them with dread and anxiety. It is very difficult to sleep in a bed that brings up those sorts of feelings. There are several techniques that CBT-I practitioners use for stimulus control, or forming new associations:

1. Go to bed only when you are sleepy. Many insomnia patients go to bed at a particular time because they believe they need to get a certain number of hours of sleep. The problem with this is that if you’re not sleepy, you’ll lie awake in bed and develop negative thoughts and feelings that make it more difficult to go to sleep. Commit yourself to going to bed only when you feel sleepy.
2. Wake up at the same time each day. In conjunction with #1, waking up at the same time each day can help you establish a regular sleep schedule. If you do this every day, over time your body will learn to fall asleep at night at a time that gives you enough high quality rest.
3. Get out of bed if you’ve been awake for longer than about 20 minutes. This can be very challenging for individuals with insomnia, because they believe that if they get out of bed they will lose out on precious time that they could be sleeping. The truth is, if you’ve been awake for 20 minutes you are unlikely to spontaneously fall asleep. Get out of bed and do something non stimulating (some slight stretching, reading, etc.) and get back in bed once you feel sleepy again. This will help break the association between bed and being awake, and will ultimately help you associate your bed with sleepiness. You should use this rule both when you are trying to fall asleep for the night and when you awaken during the night.
4. Avoid napping! If you nap during the day, you are likely to feel less sleepy at night. This will force you to go to sleep later and get less deep and restorative sleep during the night. For people with insomnia, disrupting the sleep/wake cycle in this fashion makes it very difficult to develop a consistent sleep schedule.

Sleep Restriction

Another important component of CBT-I is sleep restriction. Sleep restriction aims to improve your sleep efficiency. For example, a lot of people with insomnia notice that they’re spending a lot more time in bed than they are sleeping. They might spend 10 hours in bed, but only 5 hours sleeping. A CBT-I therapist will carefully review your sleep log and will set a “time in bed” window based on how much time, on average, you are spending asleep each night. After just a few days of sticking to your time in bed window, you should notice that you’re spending more time asleep. The goal is to train your body to sleep during the time it is in bed. Each week, your therapist will adjust the window as needed to help you achieve the amount and quality of sleep you want.

Modifying Dysfunctional Beliefs

Finally, another important component of CBT-I is identifying and modifying sleep interfering beliefs. Sleep interfering beliefs are untrue thoughts or ideas that make it more difficult for us to sleep soundly. They might include negative beliefs about our ability to sleep, such as “I never sleep well in hotel rooms.” They might also include beliefs that exaggerate the importance of sleep, such as “If I don’t get 8 hours of sleep I’ll never be able to function tomorrow.” Many people with insomnia have developed sleep interfering beliefs over the course of their sleep struggles. When untreated, these beliefs continue to contribute to sleep problems. For example, if you are lying in bed awake and you think “If I don’t sleep tonight I’m never going to be able to perform well in that work meeting tomorrow,” you likely are going to experience anxiety, fear, and maybe even sadness. These negative emotions can keep you awake. However, if you replace that thought with a thought like “No matter how much sleep I get, I know I’ll be fine during my work meeting tomorrow because I’m well-prepared,” you will likely feel much less anxious and sad. A CBT-I therapist will work with you to identify the sleep interfering beliefs that might be contributing to your problem, and will teach you a variety of strategies to modify these negative beliefs.
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When people hear about CBT-I and the work it requires, they often worry that it will make them even more tired than they already are. They feel afraid of making these big changes in their cognitive and behavioral patterns. The truth is, the first few weeks of CBT-I can be pretty challenging. Some people do report sleeping less than usual during the initial phases of treatment. However, rest assured that if you stay the course your sleep will steadily improve. About 80% of patients report seeing improvement in their sleep within the first four weeks of treatment. Your therapist can help motivate you to make these difficult changes, and can also monitor your progress to maximize the effectiveness of treatment. If you’re struggling with insomnia, please reach out to a CBT-I specialist who can help you figure out a path to recovery.