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Key points
- Cognitive behavior therapy for insomnia (CBT-I) is an evidence-based approach for sleep concerns.
- You may be engaging in certain behaviors, such as going to bed early, that maintain or worsen insomnia.
- People with sleep problems tend to spend too much time awake in bed increasing sleep inconsistency.
Experiencing consistent trouble sleeping can be quite problematic. Long-term poor sleep can decrease mental and physical health and quality of life. It isn’t easy to feel satisfied with and enjoy life if you are chronically low on energy and your brain is foggy.
Cognitive behavior therapy for insomnia (CBT-I) is a short, structured, evidence-based approach to treating sleep difficulty that focuses on the connection between thoughts, behaviors, and sleep. You may be engaging in behaviors that you think will improve your sleep, such as going to bed early, yet often these behaviors maintain or worsen insomnia over time. Also, it is natural to worry about not sleeping when you can’t, yet worry worsens sleep. You can’t worry and fall asleep at the same time.
If you are interested in CBT-I, it may be helpful to work with a trained professional. However, below are some key components of CBT-I that you can start practicing to improve your sleep.
Stimulus control
When you spend long periods not sleeping, you create certain associations that make sleeping more difficult. For example, the bed itself may become a cue for being awake rather than asleep or you may engage in behaviors in bed, such as using your phone or watching TV, that hinder sleep. Stimulus control aims to change unhelpful associations so that your bed becomes a place for quality sleep.
Standard stimulus control guidelines include:
- Using the bed for sleep and sexual activity only.
- Getting out of bed when unable to sleep after about 20 minutes.
- Setting an alarm and getting out of bed at the same time daily.
- No napping unless you need to do so for your safety.
It is best not to look at a clock during the night, as doing so can lead to feeling more alert. So, if you are practicing getting out of bed if unable to sleep, just estimate how long you have been awake. When you get out of bed, go to another area, ideally outside your bedroom, and engage in an activity that is pleasant and not too stimulating. If you start to feel sleepy, you can return to bed.
Sleep consolidation (aka sleep restriction or sleep efficiency therapy)
People with ongoing trouble sleeping spend too much time awake in bed. This leads to sleep becoming more and more inconsistent over time. You may get into bed around 10 p.m. and get out of bed around 6 a.m., a total time in bed each night of eight hours, yet, on average, only sleep four or five hours a night. One of the reasons this is problematic is the longer you are awake in bed, the more your brain associates the bed with being awake, making it more difficult to sleep.
The goal of sleep consolidation is to reestablish consistent sleep (falling asleep and staying asleep) and increase your sleep drive (the biological desire to sleep, which gets stronger the longer you are awake). Sleep consolidation involves matching your time in bed each night with the amount of time you are sleeping plus about 30 minutes.
For example, if you are currently sleeping about six hours per night, your time-in-bed window would initially be six and a half hours a night. Once you are sleeping consistently throughout the night, your time in bed window can be gradually expanded until you are getting an amount of sleep each night that leads you to feel rested and function well during the day.
Cognitive restructuring
It is natural to start worrying about sleep when you are not sleeping well. You may get into bed at night and think, “What if I don’t sleep tonight? I am going to feel horrible tomorrow.” Or, “There is no way I am going to sleep tonight. I haven’t slept well all week.”
The more you worry about sleep, and the more pressure you put on sleep, the less likely you are to sleep. When you worry, you are alert and you can’t be alert and fall asleep. Also, worrying can lead to spending more time awake in bed which makes it more difficult to sleep.
Cognitive restructuring aims to identify, challenge, and change unhelpful thoughts about sleep. By creating and focusing on more neutral and/or balanced thoughts about sleep, you can decrease worry and pressure on sleep and set yourself up to have a better chance at sleeping.
You may practice telling yourself, “I am going to take things one night at a time and practice behaviors that support my sleep.” Or, “Not sleeping is unpleasant and it's not the end of the world. I can cope with this.”
Relaxation training
Relaxation exercises can reduce muscle tension and help ease an active mind making it easier to fall asleep. It is helpful to practice relaxation exercises as part of a daily routine, not just sleep-related. This helps them be more effective and takes a sense of pressure off of sleep. With that being said, it can be useful to practice a relaxation exercise for a few minutes upon getting into bed or upon waking during the middle of the night.
One of my favorite simple relaxation exercises is to lengthen the exhale breath and make the exhale about twice as long as the inhale. To practice this type of breathing, pause and for a couple of minutes, take slow breaths focusing on lengthening your exhale. You may slowly count 1,2,3 as you inhale, and then slowly count 1, 2, 3, 4, 5, 6 as you exhale. If you get distracted, gently return your attention to your breathing.
With regular practice of helpful sleep behaviors, it is possible to improve the quality of your sleep whether you have been experiencing sleep difficulty for weeks, months, or years.
To find a therapist, visit the Psychology Today Therapy Directory.
References
Walker, J., Muench, A., Perlis, M. L., & Vargas, I. (2022). Cognitive Behavioral Therapy for Insomnia (CBT-I): A Primer. Clinical psychology and special education, 11(2), 123.
