Trouble sleeping? Behavioral therapy can help
5/17/2021 by Craig Sawchuk, Ph.D., L.P.; Olivia Bogucki, Ph.D.; and John Mack, L.I.C.S.W., M.S.W.
If you're not getting a good night's sleep, you're not alone. Difficulty falling asleep, fragmented sleep, early awakening and nonrestorative sleep are common problems. As many as 30%–40% of adults experience sleep issues.
Sometimes your sleep cycle may get off track, whether it's due to stress or a change in sleep habits, or you're going through a medical issue. Thankfully, it usually rebounds on its own or after you make some minor adjustments in your habits, or the stress or medical issues are resolved.
However, for some, sleep problems can persist, leading to problems associated with insomnia. Approximately 10%–30% of people meet the criteria for insomnia, which usually is defined as disruptions in falling asleep, staying asleep or waking early for at least three nights a week over a three-month period. Unaddressed sleep problems can lead to difficulties functioning in almost every aspect of life and can have detrimental effects on your health. Sleep problems also tend to occur along with depression and anxiety disorders. These conditions can cause sleep problems or make them more difficult to manage.
When your sleep isn't restorative, you tend to change your habits to make up for this lack of restful sleep, such as:
- Increasing caffeine use during the day.
- Taking more frequent or longer naps.
- Going to bed earlier or trying to sleep in longer.
- Using electronics, such as TV, tablets or smartphones, during the night as distractions.
While these habit changes make sense, they quickly become part of the insomnia problem. Tossing and turning result in more time in bed without sleeping. Worry and frustration start to build about not being able to sleep. Unfortunately, the brain begins to associate the bed and nighttime with sleeplessness.
Cognitive behavior therapy for insomnia, also known as CBT-I, is a highly effective treatment that can lead to long-lasting beneficial improvements. The American Academy of Sleep Medicine and American College of Physicians recently recommended this therapy as the first-line treatment for chronic insomnia. It's a straightforward approach that can be delivered in various ways: self-help, internet, apps, individual or group therapy.
Cognitive behavioral therapy for insomnia doesn't necessarily focus on how insomnia started. Rather, it focuses on how sleep problems are maintained. It helps you learn skills and change habits to reassociate the bed with nighttime and sleep, with the goal of reducing the amount of wakeful time during the night.
Among the elements of cognitive behavioral therapy for insomnia are:
Sleep hygiene
Sleep hygiene involves changing your sleep habits and sleep environment to maximize the likelihood that your body is ready for sleep, such as:
- Making the bedroom dark, quiet and cool.
- Reducing daily caffeine use.
- Removing all electronics from the bedroom.
- Reducing or eliminating daytime naps and limiting sleep to nighttime.
- Establishing a routine time for going to bed and waking up.
Stimulus control
When sleep hygiene isn't enough, stimulus control can effectively help people reassociate the bed with nighttime and sleep using strategies such as:
- Using the bedroom only for sleeping and sexual activity — no reading, watching TV, using electronics or even spending time in your bedroom during the day.
- Going to bed only when sleepy rather than just feeling tired. When you're sleepy, your head tends to bob and your eyes are heavy. These signs tell you your body is ready to call it a night.
- Getting out of bed if you're lying awake for longer than 15–20 minutes. Go to another room, such as the living room, keep the lights low and only take part in quiet activities, such as listening to light music, practicing relaxation or reading something boring. Return to bed only when you're sleepy.
Keep a regular wake-up routine and get up at the same time each morning, even on weekends, holidays and days off.
Sleep restriction
Sleep restriction reduces the amount of wakeful time in bed and promotes a stronger association between the bed, nighttime and sleep by:
- Tracking the amount of time you spend in bed and the amount of time you spend asleep. For example, you may go to bed at 10 p.m., toss and turn from 2 a.m. to 4 a.m. and get up at 6 a.m. for a total of eight hours in bed. But you only had six hours of sleep.
- Moving your bedtime later and limiting the time in bed to the actual time spent sleeping. For example, you go to bed at midnight and wake up at 6 a.m., giving you six hours of sleep.
Wake up at the same time each day, while maintaining good sleep hygiene and continuing to practice getting out of bed when you're not sleeping.
Challenging negative thoughts
Lying awake in bed with a "busy brain" can be frustrating. Schedule thinking time so that it is less likely to come up while you are in bed.
This can be achieved by:
- Taking 10 minutes each night to write down your thoughts, worries or ideas that often come up while you are lying in bed.
- Give yourself at least two hours before your scheduled bedtime to give your brain time to settle down after this activity.
- The next morning, review the list within one hour of waking up. The act of reviewing the list each morning serves to build trust with your brain that you are not forgetting about what is on the list.
- This exercise allows your brain to unhook from your thoughts while you are in bed and pick them up again in the morning.
Relaxation training or stress management
A you start to sleep more solidly through the night, you can gradually start going to bed earlier. It may take some practice until you find the optimal sleep schedule.
Other cognitive behavioral therapy for insomnia skills include:
- Learning ways to challenge nighttime negative thoughts and worries, such as "I must get eight hours of sleep in order to function."
- Practicing relaxation skills, such as deep breathing, guided imagery, and passive or progressive muscle relaxation.
- Learning stress management techniques, including time management and problem-solving, to reduce stress during the day.
Resources to help improve your sleep
- Cognitive behavioral therapy for insomnia
Individual and group therapy is available through Primary Care in Rochester and Kasson. Ask your care team about your options. - "Overcoming Insomnia"
This self-help workbook by Jack Edinger and Collen Carney is a helpful resource for implementing cognitive behavioral therapy for insomnia independently. - CBT-I Coach
This free app was developed by the Veterans Administration to help users learn and apply cognitive behavioral therapy for insomnia skills. - Sleepwell
This website from Dalhousie University has useful information and resources to improve sleep.
Cognitive behavioral therapy for insomnia takes time and patience to be effective. The good thing is that nighttime always comes, so there is always an opportunity to practice, implement and refine these skills.
Olivia Bogucki, Ph.D., is a clinical health psychology fellow in Primary Care in Rochester and Kasson's Division of Integrated Behavioral Health.
John Mack, L.I.C.S.W., M.S.W., is a licensed clinical social worker in Primary Care in Rochester and Kasson's Division of Integrated Behavioral Health.
Craig Sawchuk, Ph.D., L.P., is a clinical psychologist in Primary Care in Rochester and Kasson's Division of Integrated Behavioral Health. He is the co-chair of the division and co-chair of clinical practice within the Department of Psychiatry and Psychology at Mayo Clinic in Rochester.