Chronic sleep problems such as insomnia do not go away without appropriate treatment1. Once people start to sleep poorly, they tend to develop ways of thinking and behaviours around sleep that worsen their problems over the long run2. Fortunately, cognitive behavioural therapy for insomnia (CBT-I) can improve your sleep, as it directly targets these unhelpful thoughts and behaviours around sleep3. This chapter will go into the different components of CBT-I and introduce the instructions for many of the recommended sleep strategies included in CBT-I.
Cognitive Behavioural Therapy for Insomnia (CBT-I)
CBT-I is an effective treatment for insomnia, with many studies showing it to be similar to sleeping pills in improving sleep in the short term4. However, it is much more helpful than sleeping pills at improving sleep in the long run4.
Research shows that CBT-I consistently reduces the time taken to get to sleep3. In addition, it decreases the amount of time spent awake during the night3. CBT-I also improves sleep quality and efficiency5. Most of these improvements persist after treatment finishes5. Conversely, sleeping pills typically lead to sleep difficulties once people with insomnia stop taking them4.
Medical Practitioners do not recommend sleeping pill use beyond 2-4 weeks at a time. It is because sleeping pills can stop working as well after a while7. You may need to start taking larger doses to get the same effects when this happens. Sometimes doctors prescribe sleeping pills because they think they will work faster for patients than psychological therapy. However, even two sessions of CBT-I can make a significant difference to one’s sleep at night8.
Let’s look at the four main components of CBT-I. What are the sub-skills or individual strategies in each component, and what scientific research supports these strategies?
Component One of CBT-I: Psychoeducation
Psychoeducation provides people with helpful information about sleep, including sleep hygiene recommendations, homeostatic pressure, circadian rhythms, and hyper-arousal. Sleep hygiene means having a comfortable bedroom environment, minimising light exposure before bed, exercising during the day, minimising caffeine and alcohol and doing things to wind down or manage worries before bed.
Sleep hygiene recommendations were first developed in 1977 to educate individuals about the possible factors that promote and inhibit optimal sleep9. Your improved sleeping practices should improve how well you sleep by following these recommendations. However, there is no standard prescription for optimal sleep hygiene and no weighting of the most critical factors.
In 2003, researchers reviewed seven studies that attempted to define sleep hygiene recommendations and found 19 different rules10. Nineteen rules are way too many to have to think about or follow at one time. It could cause a lot of stress for you, and we know from the last chapter that we are trying to avoid hyperarousal. It is one of the reasons why I do not talk too much to my patients about them in general. I prefer only to mention the particular ones that could help that individual.
See if any of the below sleep hygiene recommendations may be worth you trying:
- Try to get up at the same time, seven days a week
- Only be in bed for the amount of time you need to sleep
- Only use the bed for sleep and sexual activity
- Minimise alcohol, especially in the evenings
- Minimise caffeine intake after 2pm
- Exercise regularly during the day
- If you have any, write down your problems a few hours before bed and how you will address them.
- Do not try to force yourself to fall asleep when you are in bed10.
The lack of a standard sleep hygiene definition means it is tough to determine its efficacy. It may explain why a 2006 review found that sleep hygiene is not a scientifically supported intervention for treating insomnia3. The psychoeducation component of CBT-I is also not an empirically supported individual intervention for insomnia.
In 2002, researchers found that improving sleep hygiene knowledge has little impact on improving sleep quality12. However, they did find that changing sleep practices in line with sleep hygiene recommendations does12. In addition, changing your behaviours to be more conducive to sleep can improve your sleep and overall health. Just don’t focus too much on every single sleep hygiene rule.
Any helpful psychoeducation intervention needs to teach you the main factors contributing to your particular sleep difficulties. Every case of insomnia is related to issues with homeostatic pressure, circadian rhythms or hyperarousal. Then, we need to recommend specific behavioural and cognitive strategies for you to address these factors. Administering a questionnaire such as the Sleep Hygiene Index13 at your baseline assessment could also help you target appropriate sleep hygiene factors in your individualised sleep plan.
Component Two of CBT-I: Sleep Scheduling
Sleep scheduling provides you with helpful information on when to be in bed at night. It can inform you when to go to bed at night and get out of bed in the morning. It can also tell you about your ideal amount of time in bed at night.
I recommend introducing both stimulus control and sleep restriction therapies after the psychoeducation component of a CBT-I treatment. Stimulus control and sleep restriction eliminate the behaviours that commonly disrupt sleep. They are great at breaking conditioned responses at night-time, increasing homeostatic sleep pressure, and strengthening circadian rhythms. In addition, research indicates that sleep scheduling improves sleep quality and efficiency over time, improving the perception of a refreshing night’s sleep14.
Stimulus control therapy was developed in 197215 to break the conditioned response of the bed, bedroom and bedtime in patients with insomnia. Any stimulus can produce several reactions in people, depending on their conditioning history with the trigger. For example, individuals with insomnia are so used to being awake and frustrated in bed that the bed and bedroom become conditioned with being tense, worried, annoyed and alert over time rather than feeling calm, relaxed, sleepy and asleep14,16. Has this happened to you at all?
The stimulus control instructions aim to limit the time in bed awake so that you can recondition the bed with the feeling of sleepiness and the behaviour of well-consolidated sleep.
The stimulus control instructions are as follows17:
- Only go to bed when sleepy,
- Wake up at the same time every day,
- Only use the bed/bedroom for sleep and sex,
- Avoid naps during the day, and
- Sit up or get out of bed if you cannot fall asleep within about 20 minutes of retiring to bed.
- If you have to get up during the night, do something calming or relaxing until you feel sleepy again, and then lie back down in bed for sleep. Ideally, this activity during the night should not involve bright light, rigorous exercise or be too cognitively demanding.
Stimulus control therapy is a supported behavioural treatment for chronic insomnia, according to the American Academy of Sleep Medicine (AASM)3. Furthermore, it has reliable and robust effect sizes in the available research in the field18,19,20.
The main difficulty with stimulus control is adherence to the instructions21. A good friend wanted me to emphasise how difficult he found it was to follow the instructions. Many stimulus control guidelines seem counter-intuitive, especially the waiting until you feel sleepy before going to bed and getting up if you can’t sleep. Individuals with sleep problems also have many preconceived notions about the cause of their insomnia that do not involve instrumental conditioning.
It is essential to highlight how important getting out of bed after 20 minutes if sleep doesn’t feel close. If you do not get out of bed when you are awake or frustrated for extended periods, your bed cannot be reconditioned with feeling calm, sleepy and sleeping well. It is also essential to explain why you need to wait until you feel sleepy before bed. The aim is for the bed to equal being asleep, and it is much easier to fall asleep in bed if you are already feeling sleepy before going to bed. Finally, it is important to say why you need to get out of bed at the same time each morning, no matter how badly you have slept. Your sleep pressure will be even higher for the following night, and it will become even easier to fall asleep quickly once you get in bed over time.
If people do not follow the stimulus control guidelines, their bed does not become reconditioned with sleep. Their circadian rhythms also fail to strengthen, and their sleep is unlikely to improve22.
Introducing cognitive and relaxation techniques alongside stimulus control instructions can help overcome unhelpful beliefs about the strategy’s risks. Relaxation strategies can also reduce the likelihood of engaging in safety behaviours that limit your willingness to adhere to stimulus control instructions.
Sleep restriction therapy was developed in the mid-1980s to take advantage of the positive benefits of short-term sleep deprivation31. By spending less time in bed, sleep restriction temporarily induces sleep deprivation, which increases homeostatic pressure. This increased homeostatic pressure then decreases sleep fragmentation and consequently improves sleep efficiency16.
Sleep restriction instructions are as follows31:
- Determine your average total sleep time over the past 1-2 weeks. If it is less than five hours per night, say that it is five hours.
- Add 30 minutes to this amount. The total is your new time in bed prescription. For the next two weeks, only spend this amount of time in bed every night.
- Figure out which time you would like to wake up, seven days a week. It is your rise time or time to get up each morning. Set the alarm to help you wake up at this time. When the alarm goes off, get out of bed and try not to sleep again until the next night.
- Minus your time in bed allocation from your rise time to figure out your bedtime. For example, if you wake up at 6 am and are meant to be in bed for 6 hours and 30 minutes every night, aim to go to bed around 11:30 pm.
- The bedtime should be approximate rather than absolute for the restriction to be maximally effective. For example, if it is 11:15 pm and you notice many sleepiness signs, go to bed rather than wait until 11:30 pm. On the other hand, if it is 11:30 pm and you are wide awake, wait until you feel a bit sleepier. Then go to bed.
- Once you have your bedtime, rise time and time in bed prescription, track your sleep for the next two weeks using a sleep diary or activity tracker. Then figure out your sleep efficiency, which is the percentage of your time in bed spent sleeping.
- If your sleep efficiency for the next two weeks is under 85%, cut down your time in bed by a further 15 minutes each night.
- If it is between 85-90%, keep your time in bed prescription as it is.
- If it is above 90%, extend your time in bed by 15 minutes each night.
Keep tracking for another two weeks and repeat until your sleep efficiency is between 85-90% regularly.
The AASM also recognises sleep restriction as a supported intervention for chronic insomnia3. Sleep restriction is similar to relaxation in reducing how long it takes to fall asleep and how much time you are awake during the night. However, it is more effective in maintaining these improvements in the long-run23. For example, in one study, time awake during the night had increased 12 months post-treatment with relaxation but continued to decrease with sleep restriction24. In addition, sleep restriction produces enduring insomnia improvements, even a year after treatment finishes. Other research has shown that these sustainable improvements would reduce the risk of you developing depression26.
The downside of sleep restriction is that it temporarily increases daytime somnolence and reduces vigilance in the initial phases of treatment27. It makes adherence to sleep restriction therapy difficult if you are already concerned about the daytime consequences of your sleep problems21.
It is also essential to prescribe time to bed and rise times consistent with your circadian rhythms and usual lifestyle14. Trying sleep restriction like this is likely to increase your adherence rates.
If you have excessive daytime sleepiness, please be cautious regarding driving or operating machinery during sleep restriction therapy. If daytime sleepiness is a big concern, you may require some time off work in the first 1-2 weeks of trying this strategy. However, as long as you are not endangering yourself or others, the increased sleepiness will prevent you from lying in bed at night, ruminating or worrying. It can also significantly improve your sleep initiation and increase your overall sleep quality17.
Sleep scheduling is the empirically most robust component of a CBT-I intervention. At 12 months follow-up, both stimulus control and sleep restriction adherence were the most significant predictors of ongoing improvements in the time taken to fall asleep and time awake during the night22. Thus, as long as you know the long-term benefits and address adherence issues, sleep scheduling is the best strategy to try if you want to improve your sleep.
Component Three of CBT-I: Relaxation techniques
Because hyperarousal plays a massive role in most sleep problems, it is vital to develop strategies to quieten the mind and calm the body. Relaxation strategies reduce excessive physical tension and calm pre-sleep cognitive activity, fostering a more positive outlook and reducing overall concerns about sleep disturbances28. They can also help you transition to sleep quicker and have a deeper, better quality sleep29.
Relaxation techniques sometimes included in CBT-I include:
- Progressive muscle relaxation30,
- Imagery training32,
- Thought-stopping or autonomic suppression34,
- Biofeedback training35,
- Diaphragmatic breathing36, and
- Autogenic training37
These relaxation strategies all have at least one study showing that they can effectively improve sleep. For example, in one study that treated individuals with insomnia with relaxation techniques, sleep efficiency or the percentage of time in bed spent sleeping increased from 67.0% to 78.8% over six weeks of treatment25. In addition, anxiety and depression levels also reduced after practising the relaxation techniques for six weeks25.
Relaxation techniques are most effective for sleep when you practise them initially during the daytime. It helps to focus on lowering arousal rather than trying to fall asleep28. Once you have practised relaxation techniques sufficiently, you can reduce the time taken to fall asleep at the start of the night more than if you try to follow sleep hygiene education38. CBT-I is typically superior to relaxation alone39, but relaxation strategies have additional benefits on depression40, stress41 and anxiety42. Therefore, it is worthwhile to learn relaxation alongside other effective sleep strategies if you have chronic sleep problems or daytime stress, anxiety or depression.
Progressive Muscle Relaxation
Progressive Muscle Relaxation (PMR) is CBT-I’s most commonly used relaxation technique. The AASM considers it an effective stand-alone treatment for insomnia3. PMR involves tensing and releasing different groups of muscles throughout the body to reduce physiological arousal.
PMR instructions are as follows30:
- Tense the muscles in your arms, bringing your hands towards your shoulders to feel your biceps tighten. Then take in a deep breath through your nose down into your stomach. Then relax your arms as you breathe out all the air through your mouth. Next, let your hands hang down by your side and give them a shake. Then repeat one more time by tensing, breathing and relaxing your arms.
- Then tense the muscles in your face, including the ones in your forehead, nose, jaw and around your eyes. Notice the tension. Then take in a deep breath through your nose and into your belly. Relax all the muscles in your face as you breathe all the air out through your mouth. Let your face muscles droop as your jaw hangs loose. Then repeat one more time.
- Tense the muscles in your neck by bringing your shoulders up to your head. Hold this pose tight for a few seconds. Then take in a deep breath through your nose into your stomach. Pause for a second or two. Then breathe all the air out through your mouth as you relax your neck and let your shoulders drop. Next, move your head around slowly in a circular motion if this helps you to relax your neck. Then repeat once more.
- Tense the muscles in your stomach and back, bringing your abdomen closer to your spine. Hold this for a second, then take a deep breath into your belly while still keeping your stomach and back tense. It may make it a little harder to breathe in as deeply as with the other muscle groups. Then breathe all the air out of your mouth as you slump down and push your belly out. Repeat one more time.
- Tense the muscles in your buttocks and thighs, squeezing them tightly. Take a deep breath in, pause, and relax these muscles as you breathe all the air out. Shift back and forth from left to right a little in your seat, then repeat.
- Lastly, stretch out your legs and tense your calves and feet, bringing your toes back towards your body. Breath in, pause, breathe out and relax your calves and feet. Shake out your legs, and then repeat one last time.
PMR may have some additional cognitive benefits by helping you focus on and pay attention to particular body areas. However, PMR focuses more on reducing bodily tension than imagery training, thought stopping, or meditation. I, therefore, recommend it if you feel physically tense at the end of a long day and want to learn how to reduce it.
Studies comparing relaxation techniques have found that PMR does not produce significantly better results than autogenic training or biofeedback training35,37. However, cognitive relaxation techniques such as imagery training are more helpful in reducing how long it takes to fall asleep at the start of the night43.
One particularly beneficial mental relaxation technique is imagery training, which aims to distract you from intrusive and pre-occupying sleep-related thoughts by using visualisation. Imagery involves visualising an engaging situation that is pleasant and relaxing immediately before sleep44.
I try to imagine a beach I often visited when I was younger or hiking in the Austrian Alps. Still, you can try to imagine whatever you find calming and peaceful. Imagery can distract you from your worries and bring on the feelings of relaxation you initially felt when you visited these places.
The more you can engage all your senses in the visualisation exercise and explore the space, the more effective it is. For example, if it is a beach visualisation, try to hear the seagulls flying around and the waves crashing in. See if you can feel the breeze and warm sun on your skin and the touch of your toes in the warm and soft sand. Thinking in the form of images resolves worry more efficiently than thinking in the form of words, and this may be one of the reasons it can help us fall asleep in bed45.
Researchers have compared imagery to PMR and sleep hygiene education across four weeks of treatment and found significant improvements in sleep efficiency and time awake during the night in the imagery and PMR groups by post-treatment46. Furthermore, the imagery group exhibited 16 minutes less time awake during the night than the PMR group. They also had increased self-efficacy, and reduced depression severity by the 6-month follow up46. I, therefore, recommend imagery as both a relaxation strategy before bed and a cognitive distraction technique in bed.
The most popular form of meditation these days is mindfulness. If you are interested in learning mindfulness meditation, I recommend starting with 10 minutes a day, either in the morning or night. Several meditation apps are mentioned in the previous chapter. After a few weeks of daily practice, you will hopefully begin to see some of the benefits. You will then know if it is something that you would like to continue to do or not.
Several studies have found modest improvements in sleep through mindfulness meditation as an individual intervention for sleep47,48. However, recent findings have been more promising49, especially when combined with other sleep interventions50,51. Another study also found that mindfulness improved self-regulation of sleep by allowing it to occur naturally rather than forcing it, which subsequently predicted greater well-being52. Adding mindfulness to other recommended sleep strategies can reduce insomnia severity and improve daytime functioning.
Component Four of CBT-I: Cognitive Therapy
Cognitive therapy can provide you with the skills to challenge your unhelpful or unrealistic beliefs about sleep. For example, many individuals with insomnia attribute all of their tiredness, mood difficulties or poor performance at work to their sleep difficulties. It puts way too much pressure on them to get a good night’s sleep. It is vital to see the other factors that may contribute to how you feel during the day. You can also look at data that challenges your fears and helps you to develop realistic expectations about your sleep.
Cognition refers to all mental activities you experience in verbal thoughts or visual images. Many cognitive processes are critical in differentiating individuals with sleep problems from ‘normal sleepers’, including attention, perception, memory, beliefs, attributions and expectations53. These differences contribute to higher anxiety levels and increased cognitive arousal in individuals with chronic insomnia54.
You can implement specific cognitive techniques alongside or after the behavioural interventions in CBT-I.
Cognitive techniques for insomnia include:
· Cognitive restructuring55,56,
· Cognitive control57,
· Constructive worry55,
· Paradoxical intention59, and
· Mindfulness and acceptance of thoughts50.
Out of all the cognitive strategies, the paradoxical intention intervention is the only cognitive intervention that the AASM considers an effective stand-alone treatment for insomnia3.
The instructions for paradoxical intention are as follows59:
- Go to bed at your usual bedtime
- Lie down in bed with the lights off.
- Don’t read or look at your phone or anything else.
- Try to see if you can stay awake for “just a little bit longer” without doing anything to force yourself to stay awake.
- If you are still awake, congratulate yourself for successfully achieving your goal. Then, don’t look at the time on the clock and keep focusing on staying awake for “just a little bit longer”.
- Keep this up all night if you have to. But, whatever you do, do not try and force yourself to sleep and keep trying to stay awake “just a little bit longer”.
It can take a little time to fall asleep using paradoxical intention initially. Still, once you do, you are much more likely to stay asleep and sleep well during the night.
A cognitive model of insomnia
Through research on the cognitive processes involved in insomnia, Allison Harvey and colleagues developed a cognitive model that identified the five main aspects that are likely to be perpetuating insomnia60.
The model proposed that individuals with insomnia typically:
- Spend excessive time ruminating about why they have not slept well in the past. They also spend a lot of time worrying about not sleeping well in the future.
- Misperceive their sleep to be worse than it is. They tend to overestimate how long it takes them to fall asleep at the night’s start. They also overestimate how much time they spend awake during the night. Because of this, they underestimate their total sleep achieved, which makes their anxiety and arousal worse.
- Pay more attention to external and internal threats to sleep in bed at night. They also focus more on their functional impairments and tiredness during the day than good sleepers.
- Have many unhelpful and unrealistic beliefs about sleep, including hours of sleep needed, consequences of poor sleep, causes of their insomnia, and what they should do about it, and
- Maintain these attentional biases and unhelpful beliefs about sleep through safety behaviours. These may include not going to work after a poor night, napping during the day, and spending extra time in bed to catch up on ‘lost sleep’.
The researchers then developed a cognitive therapy for insomnia, which consisted of Socratic questioning and carefully planned behavioural experiments to address all aspects of their cognitive model60. They found significant reductions in time taken to fall asleep (over 50%) and time awake during the night (37%). They also improved total sleep time by 11% post-treatment, with findings maintained by follow-up one year later. In addition, significant improvements occurred in work and social adjustment, unhelpful beliefs about sleep, worry, depression severity and anxiety severity60.
Although these findings were promising, it did take a lot more sessions than a typical CBT-I intervention61. A 2012 study by Roane and colleagues found that behavioural and cognitive sleep interventions change cognitions around sleep but do so in different ways62. Both strategies can help create long-term changes to sleep-related beliefs and behaviours. Combining behavioural and cognitive sleep strategies is likely more beneficial than just one.
To target worry and rumination that is often present in sleep problems, you can use both the constructive worry55 and the cognitive control57 techniques.
The constructive worry technique instructs you to spend time a few hours before bed to write down whatever your worries or concerns are at the moment. You are then encouraged to solve any issues you believe may keep you awake or cognitively aroused in bed that night55. By having a plan to address these worries, you will likely feel more in control and less concerned, even if the goal is to focus on something else.
Cognitive control also instructs you to spend 20 minutes reflecting on the day that has been a few hours before going to bed. Then write a to-do list about what you need to address the next day57. By targeting these worries or concerns earlier in the evening, you have less information that you need to process in bed, resulting in less cognitive arousal and frustration. If something new pops up that you have not thought about before, you can also quickly write this down on a notepad next to your bed and then continue to relax and allow sleep to come57.
Either the constructive worry or cognitive control intervention can be helpful alongside stimulus control. Both strategies would help you recondition the bed with sleepiness instead of fear about not sleeping.
Out of all the cognitive processes, individuals with insomnia tend to use thought control strategies more frequently than normal sleepers58. The aggressive suppression and worry approaches appear to be particularly unhelpful, with their use predicting increased sleep impairment, anxiety, and depression58. Conversely, ‘normal’ sleepers use cognitive distraction more frequently, and this strategy predicts better sleep quality44. Thus, mental distraction techniques are likely to help you reduce your cognitive arousal levels in bed at night. As long as what you distract yourself with isn’t too energising, it can help you not worry about things until you drift off to sleep. Try not to look at the phone too much or watch TV in bed, though, and put a timer on the device if you need one so that it switches itself off once you are asleep. I’ve spoken to different people who have found white noise, relaxing melodies, nature sounds, audiobooks, or even stand-up comedy helpful as a distraction in bed. You could also think about good things that happened during the day or what you are grateful for in your life.
Highlighting sleep-state misperception
Another critical area to challenge is a harmful sleep-state misperception. To challenge this, you can compare your objective sleep data (provided by a fitness tracker or sleep study) to your subjective sleep data (collected by a sleep diary). If you find a significant discrepancy between objective and subjective sleep, you may perceive yourself to be awake during the light stages of sleep when you are asleep60. It means that you are probably sleeping more than you realise and spending less time awake during the night.
Seeing evidence that highlights the inconsistencies between objective and subjective sleep can reduce your anxiety about sleeping if you sleep longer each night than it feels like you are. It can also result in better subjective sleep and feelings of a more refreshing night’s sleep.
Stimulus control can be a helpful behavioural intervention for sleep state misperception. The instruction about getting up after 20 minutes if you can’t sleep is beneficial. It will show you that you are sleeping more than you realise because it is impossible to get up from bed if you are asleep17. If you do get up and check the clock, more time is likely to have passed than you realised, which indicates that you must have been asleep for at least a little bit. Cognitive restructuring56 techniques can then help you challenge the validity and utility of your thoughts around being awake when you might be sleeping.
Cognitive restructuring aims to elicit, identify, discuss, appraise, and correct any unhelpful thought processes that may be maintaining any catastrophic beliefs you have about sleep.
Cognitive restructuring questions ask the following56:
- What are you thinking?
- Are these thoughts accurate?
- Is there any evidence to support these beliefs?
- Are these thoughts helpful to have?
- Are there any alternative explanations for these thoughts?
- What do you fear will happen if these beliefs are correct?
- Do you underestimate your ability to cope with these problems? and
- What can you do to address the issue?
In CBT-I, cognitive restructuring is introduced after sleep scheduling to address and challenge any unhelpful beliefs and attitudes about sleep that may worsen your insomnia. For example, the Dysfunctional Beliefs about Sleep Scale (DBAS-1663) can determine how negative your thoughts about sleep are. A reduction in DBAS-16 scores predicts better outcomes for individuals after CBT-I treatment64.
Mindfulness or acceptance-based techniques
Individuals with insomnia also exhibit an attentional bias for sleep-related threats during the day and night. One way to target this is by introducing mindfulness or acceptance-based techniques65,66,67. These techniques involve a non-judgmental, present-focused awareness, which means being aware of any thoughts, feelings or sensations that arise without changing them. It also consists of bringing attention to the present moment and getting in touch with whatever is occurring. Being mindful and in the present is considered more helpful than being caught up in the past or future65,66,67.
Mindfulness and acceptance-based therapies theorise that the content of thoughts is not problematic but rather the judgments or evaluations you make about these thoughts. By remaining in the present and practising ‘defusion’ and acceptance techniques68, the perceived impact of sleep threats should diminish over time. It could result in lowered arousal, more restorative sleep, and fewer impairments in your daytime functioning65,66,67.
The last aspect of insomnia to challenge on a cognitive level is safety behaviours. Safety behaviours are habitual sleep-related behaviours or routines that you may have developed because you think it helps with your insomnia, even if it does not60.
Safety behaviours often lead to reduced adherence to the behavioural interventions of CBT-I, such as stimulus control or sleep restriction. Therefore, you need to address safety behaviours through behavioural experiments, followed by reflection and cognitive reappraisal of the effectiveness of the safety behaviour.
Earplugs and eye masks are two examples of safety behaviours. Once you realise that you can sleep well without an eye mask and earplugs, your need for them may diminish over time. However, unless you challenge yourself to sleep without them, your beliefs about their necessity remain intact. If you can sleep without them and sleep well, you can use this positive example to help try other strategies that could be more effective.
Paradoxical intention can be implemented as a behavioural experiment to reduce pre-sleep arousal and sleep effort. People with lower pre-sleep arousal and sleep effort reduce their likelihood of insomnia relapse following CBT-I treatment51. When I have first instructed individuals to try paradoxical intention, they often tell me that I am crazy. However, if you try it for a few nights, research indicates you will generally obtain a more restorative night’s sleep59. It is then possible to reflect on the relationship between sleep effort, performance anxiety, pre-sleep arousal and poor sleep quality. Once you understand from experience that trying less to sleep in bed leads to better sleep, permanent cognitive change is possible. You will also be able to benefit more from any subsequent sleep strategy that you try to implement.
When thinking about changing your sleep, remember back to the lesson of sleep hygiene recommendations. We should not just try to change everything all at once. We first need to figure out what we want and need to improve. We then need to have a proper baseline assessment to determine how things are. Finally, we need to develop an individualised plan to improve these areas and track progress over time. By tailoring your strategies to your specific sleep problem and unique lifestyle, it becomes possible to achieve optimal outcomes for yourself.
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