Sleep – so important to have, yet sometimes so hard to get (find out more in What Is… Sleep). Whether it’s depression where you’re exhausted but can’t sleep or mania where you have too much energy to feel the need for sleep, insomnia is something that spans across diagnoses.
For many of us, medications are important to get a decent night of sleep, but there are a variety of other measures that can be tried. A key non-medication strategy is cognitive behavioural therapy (CBT) specifically targeting insomnia. CBT for insomnia (CBT-I) focuses more on the behavioural aspect than the cognitive. Here is an overview of some of the main elements of CBT-I:
Most of us are familiar with recommendations like avoid caffeine/alcohol/screen time before bed, don’t nap during the day, and get regular exercise; you can read about my sleep hygiene here.
Do a sleep log
While you may think you’re aware of your sleep patterns, chances are keeping a log will give a better understanding. There’s a good example in the treatment manual that’s linked to below.
Increase sleep efficiency
Sleep efficiency is the ratio of time asleep divided by time in bed; to increase sleep efficiency, the initial goal is to spend less time in bed. Initially, this may mean less sleep, but in the longer term, it will result in an improvement.
Increase sleep drive
The drive to sleep comes from an accumulation of tiredness during the day. Napping during the day cancels out some of this accumulated sleep drive, making it harder to get to sleep at night.
Avoid negative associations with bed
Staying in bed awake for long periods can lead to the bed being associated with being awake and frustrated. This can be changed by going to bed onlywhen sleepy, only using the bed for sleep/sex, getting out of bed if you haven’t fallen asleep after about 15 minutes, and hiding the clock.
Wake up at a regular time
This is essential in CBT-I, and is counterintuitive in many ways. The idea is to get up at the same time regardless of how long or how well you slept. Getting up at a set time should happen even if it means disrupting a sound sleep. A consistent bedtime isn’t encouraged, as going to bed before you’re tired can mean more time awake in bed. Waking up at the same time every morning gets your sleep drive started at a consistent time each day.
Challenge thoughts related to sleep
Some common sleep-related myths, according to the University of Washington’s treatment manual, are:
- I need 8 hours of sleep to survive
- If I don’t get a good night’s sleep, then … (something bad will happen)
- If I’m having trouble sleeping, I need to try harder
- If I have a bad night of sleep I should try to catch up on sleep later
Thought patterns like these increase the level of anxiety around sleep and can push you into behaviours that actually worsen sleep.
While trying to increase sleep efficiency may feel like the opposite of what you should do, insomnia treatment guidelines consistently recommend CBT-I as on one of the most important and effective treatment measures.
The CBT-I Coach app from the U.S. Department of Veterans Affairs has some useful tools and trackers to apply this information.