Millions of people struggle with insomnia. In fact, some studies suggest that nearly one in three people experience at least one symptom of insomnia, such as difficulty falling and/or staying asleep, or waking up too early.
Most people are familiar with sleep medication, but there is less familiarity with the use of therapy (like cognitive behavioural treatments) in treating sleep problems.
The issue is that people are unlikely to make decisions when they are uncertain. This means that they are unlikely to go into therapy, which research suggests is just as effective as medication, and even more effective in the long-term. Moreover, the veils of therapy make it hard to obtain clarity about what goes on in the room and the idea of being vulnerable is scary.
In this post, I provide some information about what a CBT insomnia therapist like myself actually do in the room to support clients.
#1 Figure out goals and values
Therapy is a collaborative place. And one of the first things I emphasize is to figure out what it is that the client sleep goals and work together to come up with a game plane to accomplish this goal in therapy.
Common goals I hear with patients that struggle with insomnia are:
- Falling asleep with a normal range (e.g., 10-30 minutes a night)
- Staying asleep throughout the night
- Obtaining better quality sleep
- Having less concentration difficulties during the day.
Besides goals, one aspect I find very important is to understand how a patient’s values may play a role in therapy. I might ask the patient “why it is important for them to make a change?” This can sometimes increase motivation if I can link improved sleep to important areas in their life, such as family, health, and being better able to enjoy the present moment.
On the other hand, sometimes the recommendations are not consistent with a person’s values. For example, some folks want to have a variable schedule or read in bed. Sometimes, knowing how these behaviours can affect sleep can be helpful to understand that there can be consequences to actions (though I always recommend that a person follow their values). Insomnia is a subjective disorder, so if a person understands how their values can impact sleep and are willing to sacrifice sleep for their values, then this can reduce a feeling of distress. They are simply doing what feels right for them.
#2 Provide the right psychoeducation
Following building a strong relationship and figuring out a patient’s goals and values, there is information I like to provide to patients that is needed to understand the therapy recommendations.
For example, one of the most important pieces of information I provide is that not everybody is an 8-hour sleeper. Just like shoe sizes, we all have different sleep sizes for how many hours our body needs and what time our body prefers to sleep and wake up.
Besides dispelling myths, I also discuss the three main causes of insomnia:
1. Low sleep drive – we do not build up enough of an ‘appetite’ for sleep because we are spending too much time in bed or reducing activities because we are too exhausted.
2. Social jet lag – An irregular schedule creates variability in our circadian rhythm, which can create symptoms similar to jet lag.
3. Hyperarousal – There is a lot of anxiety about sleep, which then leads to a constant feeling of fight-or-flight. Over time, the bed becomes a place of wakefulness rather than sleepiness.
#3: Provide the right recommendations
The patient’s history as well as their sleep diary data gives me a better idea of the client’s sleep. II start to develop a formulation about what could be maintaining the person’s problem.
For example, if the patient is spending 10 hours in bed but only sleeping for 6 or 7 hours, then this might be a sleep drive issue. The patient is spending much more time in bed than they are sleeping, which could be reducing their ‘appetite’ for sleep. In this case, I might recommend that they actually spend less time in bed (and stay more active during the day), so that the sleep they do get is going to be higher in quality.
Another example is that the patient goes to bed feeling sleepy but then the moment their head hits the pillow, they are wide awake. In this case, I would want to help the patient start to associate the bed with sleep again by offering suggestions to get out of bed when they are not sleepy. They are tasked to do something pleasant (e.g., read a book, work on a puzzle) until they are sleepy again.
Interpreting sleep diaries is definitely an area where therapists like myself can be helpful. Sleep diaries are daily reports of a person’s sleep. For example, the sleep diary tells me how long it takes someone to fall asleep, how many hours they are sleeping, and how consistent their schedules tend to be. I can then interpret this data to understand what factors might be maintaining a person’s sleep problem and provide the right recommendations.
#4 Tackle beliefs that maintain sleep problems
There are sleep beliefs and anxiety about sleep that make following the recommendations more challenging. I think dealing with these anxieties this is where therapists really shine because anybody can read a book and learn about the skills. However, therapists can support the use of these skills by helping with implementation and dealing with barriers.
For example, some of my clients have worried that getting out of bed might make them never fall asleep again. However, I’ve generally been able to alleviate this fear by noting that their sleep appetite will build for the next night, and tomorrow will likely be better. In this case, we are focusing on prioritizing the next night, rather than saving the current night.
#5 Reinforce patient strengths
As a therapist, I am both a counsellor and a cheerleader. To take a strengths-based approach I try to reinforce what patients are doing well and help celebrate their great work they have done – whether it’s them trying out the recommendation in spite of being scared, or noticing improvements in their sleep quality.
#6 Help them to become their own insomnia therapist
I see the ultimate goal of CBT is to make the person their own insomnia therapist. This means working until the patient feels that they do not have to rely on me at all, and they have the tools needed to deal with possible insomnia symptoms returning. Life happens and insomnia symptoms are bound to come back from time to item. But this time the patient will have the needed knowledge and skills needed to figure it out themselves!
If you’re interested in becoming your own insomnia therapist, here’s a book I have written on treating insomnia and improving sleep!
Best wishes,
P
Simply mental health 