Changing minds: how CBT can break the sleepless cycle

Cog­ni­tive behav­iour­al ther­a­py (CBT) is well estab­lished as a means of help­ing peo­ple to man­age prob­lems by chang­ing how they think and act. It’s com­mon­ly used to treat anx­i­ety and depres­sion, but it can also be use­ful for sev­er­al oth­er con­di­tions, includ­ing bulim­ia, alco­holism and insom­nia.

The occa­sion­al night of poor sleep is noth­ing to wor­ry about. But, if it keeps hap­pen­ing, find­ing an effec­tive way to sleep well again can become an all-con­sum­ing task. Des­per­ate to drift off, many of us avid­ly fol­low sleep hygiene advice (see “Clean and serene”, page 6) and try herbal reme­dies and over-the-counter drugs such as diphen­hy­dramine, a sedat­ing anti­his­t­a­mine designed only for short-term use. But these mea­sures don’t always work.

I’ve expe­ri­enced long-term insom­nia since con­tract­ing Covid-19. Thor­ough­ly exhaust­ed after months of sleep­less­ness, I approached my GP for help. He prompt­ly offered me an anti­de­pres­sant that helps peo­ple to sleep. CBT was nev­er men­tioned. 

Per­haps my doc­tor didn’t feel that my con­di­tion was chron­ic (last­ing more than three months) at the time. Or maybe he was one of sev­er­al GPs who, accord­ing to behav­iour­al psy­chol­o­gist Ali­son Gar­diner, sim­ply haven’t yet realised that CBT is the treat­ment rec­om­mend­ed by the Nation­al Insti­tute for Health and Care Excel­lence. 

Gar­diner is the founder of Sleep­sta­tion, an NHS-approved online ser­vice that applies a set of tech­niques known as cog­ni­tive behav­iour­al ther­a­py for insom­nia (CBTi). It’s used by about half of the GP prac­tices in Eng­land. 

“We get 47% of our refer­rals from only 20 parts of the coun­try,” Gar­diner says. “When peo­ple know about the ser­vice, they use it. Some of the resis­tance to get­ting peo­ple into CBTi is down to the fact that sleep isn’t real­ly dealt with as a men­tal health con­di­tion. When some­one tells their GP that they’re depressed, say, the GP under­stands what to do and where to refer them. When some­one presents with a sleep prob­lem, the GP may not be aware that CBTi is a good approach. Patients are also unlike­ly to be aware of it.”

What is CBT for insomnia?

CBT is based on the con­cept that our thoughts, feel­ings and actions are all con­nect­ed, and that neg­a­tive thoughts and feel­ings can trap peo­ple in a vicious cir­cle of behav­iour. Dr Jason Ellis, pro­fes­sor of psy­chol­o­gy and direc­tor of Northum­bria University’s cen­tre for sleep research, describes how it’s being applied to insom­nia.

“CBTi is very focused on behav­iour­al con­cepts,” he says. “It aims to iden­ti­fy, chal­lenge and change any dys­func­tion­al beliefs, atti­tudes or acts that con­tribute to insom­nia. The ratio­nale behind it is that, when you have insom­nia, you try to com­pen­sate for it. All the effort you make to try to sleep, cou­pled with the addi­tion­al time you’re spend­ing awake in bed, leaves you feel­ing wor­ried, frus­trat­ed and angry – and that’s how we believe that insom­nia devel­ops. CBTi aims to address those issues.”

One of the first stages of the treat­ment is to analyse a patient’s sleep hygiene to help iden­ti­fy any lifestyle or envi­ron­men­tal fac­tors that may be play­ing a role in their insom­nia. 

“The inter­est­ing thing about this com­po­nent is that peo­ple with insom­nia gen­er­al­ly have good sleep hygiene,” Ellis says. “But we still incor­po­rate it, just in case.”

Teach­ing patients the facts about sleep is anoth­er ini­tial com­po­nent. Known as psy­choe­d­u­ca­tion, this aims to dis­pel com­mon myths – that every­one needs eight hours’ sleep a night to func­tion prop­er­ly, for instance – that may be con­tribut­ing to someone’s insom­nia.

How CBT for insomnia works

The CBTi pro­gramme will ask you to com­plete a sleep diary for a week or two. This involves not­ing down what time you went to bed and what time you tried to sleep, and esti­mat­ing how long it took you to drop off (check­ing the clock is not advis­able). You also keep track of whether you woke dur­ing the night and, if so, how long it took you to get back to sleep. Last­ly, you note what times you woke up and got out of bed.

Sev­er­al free apps offer a sleep diary func­tion. These include Sleep­ful, a CBTi pro­gramme devised by the clin­i­cal sleep research team at Lough­bor­ough Uni­ver­si­ty. 

From your diary entries, you’ll learn how long you were asleep as a pro­por­tion of the time you spent in bed, which gives a sleep effi­cien­cy score (the nor­mal range is 85% to 90%). This leads to one of the core tech­niques of CBTi: sleep restric­tion ther­a­py. This is suit­able for most peo­ple with insom­nia, but inap­pro­pri­ate for some patients, includ­ing those with a his­to­ry of bipo­lar dis­or­der, seizures and/or obstruc­tive sleep apnoea.

“The name of this ther­a­py is ter­ri­ble, because it doesn’t restrict anyone’s sleep,” Gar­diner says. “What it does do is fix a person’s sleep into a set time win­dow. For instance, if you spend 10 hours in bed but sleep for only five hours, there’s no point spend­ing all that time in bed. It works on some­thing called sleep pres­sure, one of the neu­ro­log­i­cal mech­a­nisms that con­trol sleep.”

Over the course of a day, every­one grad­u­al­ly builds up the need to sleep. After about 16 hours, the pres­sure to sleep will usu­al­ly be strong enough to help us to drift off. Sleep restric­tion aims to keep some­one with insom­nia up a lit­tle longer so that their sleep pres­sure becomes even stronger. 

“When your sleep pres­sure is at a very high lev­el, it won’t just help you to sleep ini­tial­ly; it will also enable you to get back to sleep quick­ly after brief peri­ods awake,” Gar­diner says. “What’s pow­er­ful about this tech­nique is that it works on the phys­i­cal func­tion of sleep and has a short feed­back loop. Peo­ple do see a dif­fer­ence quite quick­ly.”

Improving sleep efficiency 

As part of the restric­tion process, your sleep effi­cien­cy score is reviewed reg­u­lar­ly. Adher­ing to your sleep win­dow can help to improve your score. 

“The first week will be asso­ci­at­ed with a very brief, mild form of sleep depri­va­tion, as it takes a lit­tle while for your brain to recon­nect and get back into the sleep default posi­tion,” Ellis explains. “Once the amount of time that some­one can sleep for starts to increase, we give them an extra 15 min­utes in bed for the fol­low­ing week. We grad­u­al­ly increase the time in bed in incre­ments of 15 min­utes as their sleep effi­cien­cy improves.”

A fur­ther ele­ment of CBTi is known as stim­u­lus con­trol ther­a­py. This is designed to change how a per­son with insom­nia views their bed­room, as it’s easy to start assign­ing feel­ings of dread to the space when you can’t sleep. One idea is to get out of bed if you can’t sleep before any frus­tra­tion kicks in and do some­thing mean­ing­less for 30 min­utes before try­ing again. Anoth­er com­po­nent is the removal of behav­iour such as going to bed ear­ly to watch TV or read a mag­a­zine. This helps to des­ig­nate the bed­room as a space that’s sole­ly for sleep.

The var­i­ous anx­i­eties that can build up around the con­se­quences of insom­nia are also dealt with as part of CBTi. For instance, peo­ple may wor­ry that their con­di­tion could cost them their job. 

“We may have to deal with some cat­a­stroph­ic think­ing,” Ellis says. “A person’s thoughts can become irra­tional when they can’t sleep.”