Therapy for Sleep Disorders
CBT and Other Treatment Alternatives
If you regularly experience sleep problems that interfere with your daily life, you may be suffering from a sleep disorder. But you don’t have to suffer the vicious cycle of sleepless nights and daytime fatigue that takes such a toll on your mood, energy, and overall health. For many sleep problems, cognitive behavioral therapy (CBT) can be more effective than sleeping pills—but without the unpleasant side effects or long-term health concerns. CBT can help to relax your mind, change your outlook, improve your daytime habits, and set you up for a good night’s sleep.
Why therapy for sleep disorders and not medication?
When you’re desperate for sleep, it can be tempting to reach for a sleeping pill or over-the-counter sleep aid. But sleep medication won’t cure the problem or address the underlying symptoms—in fact, it can often make sleep problems worse in the long term. That’s not to say there’s never a time or a place for sleep medication. To avoid dependence and tolerance, though, sleeping pills are most effective when used sparingly for short-term situations—such as traveling across time zones or recovering from a medical procedure. Even if your sleep disorder requires the use of prescription medication, experts recommend combining a drug regimen with therapy and healthy lifestyle changes.
Cognitive-behavioral therapy can improve your sleep by changing your behavior before bedtime as well as changing the ways of thinking that keep you from falling asleep. It also focuses on improving relaxation skills and changing lifestyle habits that impact your sleeping patterns. Since sleep disorders can be both caused by and trigger emotional health problems such as anxiety, stress, and depression, therapy is an effective way of treating the underlying problem rather than just the symptoms, helping you to develop healthy sleeping patterns for life.
A recent study at Harvard Medical School found that CBT was more effective at treating chronic insomnia than prescription sleep medication. CBT produced the greatest changes in patients’ ability to fall asleep and stay asleep, and the benefits remained even a year after treatment ended.
What defines a sleep disorder?
A sleep disorder is a condition that frequently impacts your ability to get enough quality sleep, leaving you feeling exhausted or sleepy during the day. The most common sleep disorders include insomnia, sleep apnea, narcolepsy, restless legs syndrome (RLS), and circadian rhythm sleep disorders often triggered by shift work or jet lag.
Cognitive behavioral therapy (CBT) for sleep disorders
Cognitive behavioral therapy is the most widely-used therapy for sleep disorders. It may be conducted individually, in a group of people with similar sleeping problems, or even online. Since the causes and symptoms of sleep disorders vary considerably, CBT should always be tailored to your specific problems. Cognitive behavioral therapy for insomnia (CBT-I), for example, is a specific type of therapy designed for people who are unable to get the amount of sleep they need to wake up feeling rested and refreshed.
The length of therapy also depends on the type and severity of your sleep disorder. While CBT is rarely an immediate or easy cure, it is relatively short-term. Many CBT treatment programs for insomnia, for example, report significant improvement in sleep patterns following a course of 5 to 8 weekly sessions.
How does CBT work for sleep disorders?
CBT addresses negative thoughts and behavior patterns that contribute to insomnia or other sleeping problems. As the name suggests, cognitive behavioral therapy involves two main components:
Cognitive therapy teaches you to recognize and change negative beliefs and thoughts (cognitions) that contribute to your sleep problems.
Behavioral therapy teaches you how to avoid behaviors that keep you awake at night and replace them with better sleep habits.
Using a sleep diary in CBT
To identify patterns in your sleeping problems and decide on the best treatment approach, your therapist may start by asking you keep a sleep diary. The details can be important, revealing how certain behaviors are ruining your chance for a good night’s sleep. You can download or print HelpGuide's sleep diary (PDF) and take it to your therapist to help pinpoint your specific problems.
Thought challenging in CBT
The cognitive aspects of CBT include thought challenging—otherwise known as cognitive restructuring—in which you challenge the negative thinking patterns that contribute to your sleep problems, replacing them with more positive, realistic thoughts. The idea is that if you change the way you think, you can change the way you feel, and ultimately how you sleep.
This involves three steps:
1. Identifying your negative thoughts. If you have a sleep disorder such as insomnia, you may perceive the obstacles that prevent you from getting a good night’s sleep to be greater than they really are. For example, you may keep telling yourself that you cannot fall asleep unless you take a sleeping pill. The more you tell yourself that, the more anxious you’ll become if you don’t take a pill and the harder you’ll find it to sleep.
2. Challenging your negative thoughts. In the second step, your therapist will teach you how to evaluate your sleep-disrupting thoughts. This involves questioning the evidence for your thoughts, analyzing unhelpful beliefs, and testing out the reality of negative predictions.
3. Replacing negative thoughts with realistic thoughts. Once you’ve identified the negative distortions in your thoughts, you can replace them with new thoughts that are more accurate and positive. Your therapist may also help you come up with realistic, calming statements you can say to yourself as you’re preparing for sleep.
|Challenging negative thoughts that fuel sleep problems|
Negative thought: I should be able to sleep well every night like a normal person.
Sleep-promoting comeback: Lots of people struggle with sleep from time to time. I will be able to sleep with practice.
Negative thought: It’s the same every single night, another night of sleepless misery.
Sleep-promoting comeback: Not every night is the same. Some nights I do sleep better than others.
Negative thought: If I don't get some sleep, I'll tank at work and jeopardize my job.
Sleep-promoting comeback: I can get through work even if I’m tired. I can still rest and relax tonight, even if I can’t sleep.
Negative thought: I’m never going to be able to sleep well. It’s out of my control.
Sleep-promoting comeback: Sleep problems can be cured. If I stop worrying so much and focus on positive solutions, I can beat it.
Negative thought: It’s going to take me at least an hour to get to sleep tonight. I just know it.
Sleep-promoting comeback: I don’t know what will happen tonight. Maybe I’ll get to sleep quickly if I use the new strategies I’ve learned.
Since negative thoughts are often part of a lifelong pattern of thinking, replacing negative thoughts with more realistic ones is rarely easy. But with practice, you can break the habit. That’s why it’s important to practice the techniques you learn in therapy on your own at home.
Behavioral techniques used in CBT for sleep disorders
As well as changing the way you think about sleep, CBT also works to change the habits and behaviors that can prevent you from sleeping well. Depending on your specific symptoms and needs, your therapist may employ some of the following techniques:
Sleep restriction therapy (SRT) reduces the time you spend lying in bed awake by eliminating naps and forcing you to stay up beyond your normal bedtime. This method of sleep deprivation can be especially effective for insomnia. It not only makes you more tired the next night but builds a stronger association between bed and sleep rather than bed and lying awake.
Stimulus control therapy helps to identify and change sleep habits that prevent you from sleeping well. This means training you to use your bedroom for just sleep and sex, rather than working or watching TV, and maintaining consistent sleep-wake times, even at weekends.
Improving your sleep environment and sleep hygiene. Your sleep environment should be dark, quiet, cool, and comfortable, so your therapist may recommend blackout shades, earplugs, or a sound machine to block out noise. Sleep hygiene involves improving your daytime habits so you exercise regularly, avoid nicotine and caffeine late in the day, and learn to unwind at night.
Remaining passively awake, also known as “paradoxical intention”. Since worrying about not being able to sleep generates anxiety that keeps you awake, letting go of this worry and making no effort to sleep may, paradoxically, help you to unwind and fall asleep.
Relaxation training. When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, and breathing exercises can help you relax at night, relieving tension and anxiety and preparing you for sleep.
Biofeedback uses sensors that measure specific physiological functions—such as heart rate, breathing, and muscle tension. Biofeedback teaches you to recognize and control your body’s anxiety response that impacts sleep patterns.
Hypnosis can also sometimes be used in CBT for sleep disorders. While you’re in a state of deep relaxation, the hypnotherapist uses different therapeutic techniques to help you change negative thought patterns or unhelpful habits and promote restful sleep.
Relaxation techniques for insomnia
Abdominal breathing. Breathing deeply and fully, involving not only the chest, but also the belly, lower back, and ribcage, can help relaxation. Close your eyes and take deep, slow breaths, making each breath even deeper than the last. Breathe in through your nose and out through your mouth.
Progressive muscle relaxation. Make yourself comfortable. Starting with your feet, tense the muscles as tightly as you can. Hold for a count of 10, and then relax. Continue to do this for every muscle group in your body, working your way up to the top of your head.
Mindfulness meditation. Sit quietly and focus on your natural breathing and how your body feels in the moment. Allow thoughts and emotions to come and go without judgment, always returning to focus on your breathing and your body.
Making therapy work for you
Making improvements to your sleep often takes time and commitment. It’s essential that you find a therapist who’s right for you: someone who you can trust, someone you feel comfortable talking to, someone who will be a partner in your recovery. Once you’ve found the right therapist, the important thing is to stick with treatment and follow your therapist’s advice. If you’re feeling discouraged with the pace of recovery, remember that therapy for sleep disorders is very effective in the long run. You’ll reap the benefits if you see it through.
You can also support your therapy by making positive lifestyle choices that benefit your ability to sleep.
Add more physical activity to your day. Exercise relieves stress and anxiety and improves sleep, so make time for regular exercise. Aim for 30 minutes or more on most days—but not too close to bedtime.
Be smart about what you eat and drink—and when. Avoid late meals within two hours of bed. Stop drinking caffeinated beverages at least eight hours before bed. Like caffeine, nicotine and sugary foods are stimulants, and while alcohol can make you sleepy, it interferes with the quality of your sleep and can make sleep disorder symptoms worse.
Reduce stress and anxiety in your life. If the stress of work, family, or school is keeping you awake, you may need help with stress management. By handling stress in a productive way, and maintaining a calm, positive outlook, you’ll be able to sleep better at night.
Resources and references
Improving Sleep: A guide to a good night's rest – Harvard Medical School Special Health Report
Cognitive Behavioral Therapy – Sleep Education
Cognitive Behavioral Therapy for Insomnia (CBTI) – Stanford Health Care