Trouble sleeping? Behavioral therapy can help
12/5/2024 by Kyle Schofield, Ph.D.; Anne Roche, Ph.D., L.P.; Craig Sawchuk, Ph.D., L.P.
You're not alone if you're not getting a good night's sleep. 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, a change in sleep habits, or you're going through a medical issue. Thankfully, it usually rebounds on its own or after you make minor adjustments in your habits or the stress or medical problems 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 is usually defined as disruptions in falling asleep, staying asleep or waking early for at least three nights a week over three months. 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, anxiety and stress-related 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 results 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 the American College of Physicians recommend 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. Instead, 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 tired, your head tends to bob, and your eyes are heavy. These signs tell you your body is ready to call it a night.
- Get out of bed if you've been lying awake for more than 15–20 minutes. Go to another room, such as the living room, keep the lights low and only participate 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 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:
- Take 10 minutes each night to write down your thoughts, worries or ideas that often come up while 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 following day, review the list within one hour of waking up. Reviewing the list each morning builds trust with your brain so you do not forget what is on the list.
- This exercise allows your brain to unhook from your thoughts while in bed and pick them up again in the morning.
Relaxation training or stress management
As you start to sleep more solidly through the night, you can gradually begin to go 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 to function." For example, you might identify a more helpful thought such as “I’ve been able to get through the day on less than 8 hours before, even if it was tough!”
- Practicing relaxation skills, such as deep breathing, guided imagery and passive or progressive muscle relaxation.
- Learning stress management techniques to reduce stress during the day, including time management and problem-solving.
Resources to help improve your sleep
- Cognitive behavioral therapy for insomnia.
Individual and group therapy is available through Primary Care in Rochester and Kasson. In-person and video visits are also available. Ask your care team about your options. - Cognitive behavioral therapy for insomnia online interactive module.
This free online, self-paced, interactive skill-building module created by Mayo Clinic will guide you through implementing cognitive behavioral therapy for insomnia techniques independently. - Overcoming Insomnia.
This self-help workbook by Jack Edinger and Collen Carney is a helpful resource for independently implementing cognitive behavioral therapy for insomnia. - Insomnia 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 valuable information and resources on improving 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.
Kyle Schofield, Ph.D., is a clinical health psychology fellow in Primary Care in Rochester and Kasson's Division of Integrated Behavioral Health.
Anne Roche, Ph.D., L.P., and Craig Sawchuk, Ph.D., L.P., are clinical psychologists in Primary Care in Rochester and Kasson's Division of Integrated Behavioral Health.