Adding some ‘worry time’ to your day could beat pills.
It’s the end of the day. You pull back the duvet, dive into bed and let your head hit the pillow. Your eyes shut and your mind lets go within seconds or minutes. But for some of us, bedtime is that grim, worrisome chore at the end of a day.
There are countless ways to encourage and improve sleep, but whether they work is entirely subjective; Soothing herbal teas, warm milk, scented oils, candles, vigorous exercise, yoga, hot baths, massages and, as a last resort, sleeping pills. Yet the UK’s National Health Service (NHS) will only prescribe one week’s worth of pills due to their addictiveness. So what is the next best thing? One method quickly gaining popularity is Cognitive Behavioural Therapy (CBT).
An image of someone laying on a couch dispersing their feelings and then being guided through some psycho-babble and exercises shoots across my mind. After further investigation I learned that the UK NHS prescribes CBT as a 6-week group workshop whereby each week a different part of the unhelpful cycle of sleeplessness is tackled.
The unhelpful cycle of sleeplessness starts with thoughts and worries regarding the inability to fall asleep flooding your mind, resulting in feelings of anxiety, stress and frustration. This in turn emanates into physical signs such as increased heart rate, sweating and muscle tension followed by behaviours such as tossing and turning and clock-watching. The last phase feeds back into the first, resulting in a vicious, worsening cycle. Can insomnia really be improved by thought alone?
Sleep cycle tactics
CBT targets these four different phases of the cycle using various techniques. Below is a summary of the 5 main tips given by CBT psychologists.
Allocate half an hour a day to worry about anything and everything, preferably not too soon before bedtime. If worries pop up throughout the day then just write them down for ‘worry time’.
Getting to sleep
Here are a few rules: Only go to bed when you are feeling sleepy (even if that means staying up until 3 am), do not use the bed for anything except sleep and sex, get out of bed if you have been lying awake for 20 minutes (and repeat throughout the night if necessary) and get up at the same time every day (even on weekends).
It’s crucial to wind down before bedtime, sleep isn’t something that you can switch on and off. Dim the lights in your room, put away all your gadgets, and spend the last few minutes before bed doing some reading or relaxation exercises. Ensure you get enough sunlight in the morning too as this will help reset your body clock. Exercising will also improve sleep but do this no later than late afternoon.
Coping after poor sleep
Tiredness and lethargy can take over after poor sleep, but energy levels are like a generator rather than a battery so you should try to stay active and carry out the plans you initially wanted to do. Act as if you have had a good night’s sleep and notice how well you are able to carry out tasks. Naps are not recommended but it may help some people if they are kept to no more than 20 minutes.
Training your body to associate your bed with sleep is crucial. Watching TV, working, worrying and using your phone in bed makes your body think that it’s a good place to stay awake and get things done. Avoid all these activities in bed and find a new place to do them, even if it’s only as far as your bedroom desk. Another important point to mention is bathroom lighting. We often brush our teeth straight before bed, exposing ourselves to bright bathroom lights. This suppresses the production of melatonin, a hormone involved in the sleep/wake cycle, delaying the natural onset of tiredness. It is recommended to brush your teeth no earlier than 30 minutes before bedtime.
Learning to relax is a key life skill but takes practice. Relaxation soundtracks, including Yoga Nidra, can guide you through gradual muscle relaxation. You should practice this every day for the next 7 days, and preferably when you are already feeling relatively calm.
An example of such tracks can be found here.
Better than pills
Earlier this year, a review of 8 published studies on the efficacy of CBT was carried out by Koffel and colleagues from the universities of Minneapolis and Pennsylvania in the U.S. They found that group CBT sessions improved sleep efficiency (this is the percentage of time you spend in bed whereby you’re asleep) and the time it takes to fall asleep, and these changes persisted post-treatment.
Other studies have also shown that CBT may work just as well as sleeping pills, or even better. In 2006 a research group based at the University of Bergen in Norway conducted a randomised, double-blinded, placebo-controlled trial and found that insomniacs who underwent CBT for 6 weeks improved on most sleep outcome measures when compared to those who took zopiclone, a sleep medication, and the placebo medication group. The CBT group also exhibited better sleep management 6 months later. Clinical trials have shown that short-term use of zopiclone, like the older benzodiazepines, improves sleep but they did not investigate beyond 4 weeks of treatment so the participants in this Bergen study may have developed tolerance at 6 weeks.
Mind over matter
Change is certainly not easy. Obstacles inevitably exist, be they our work patterns, living arrangements or our own thoughts. The efforts to knock down these hurdles, albeit a pain, will be worth it. Sleep deprivation has been associated with a range of health problems including heightened prevalence for heart disease and dementia, so it is in every sufferer’s best interest to fight it.
Keep a sleep diary to record how many of the hours you spend in bed are attributed to being asleep and this will help you establish whether your sleep efficiency improves. Anything below 85% is considered abnormal. Not all of the CBT tips may work, but all you may need is one or two and you’ll be on your way to sleeping like a baby and, most importantly, saving your health.
Koffel EA, Koffel JB, & Gehrman PR (2015). A meta-analysis of group cognitive behavioral therapy for insomnia. Sleep medicine reviews, 19, 6-16 PMID: 24931811
Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, Nielsen GH, & Nordhus IH (2006). Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA, 295 (24), 2851-8 PMID: 16804151