What is cognitive therapy? How does it help improve sleep?
When people have had trouble sleeping for more than a couple of weeks, and shorter in some cases, it can change the way they think about sleep. Rather than being relaxed, or not caring about sleep, having trouble with sleep can make people think about sleep more than they used to. Over time this can develop to the point of being anxious about sleep and this in turn can make insomnia worse. Cognitive therapy aims to address this changed thinking about sleep to help settle insomnia symptoms.
How does thinking about sleep change in insomnia?
Think about someone you know who is a good sleeper. Have you ever tried to talk to them about your sleep? Were they interested, or did they just change the topic or just give some simple advice? Compare that to when you’ve talked to someone you know who has had trouble with sleep. Do they talk about their sleep through the day or readily engage in conversations about sleep? People who have had trouble with sleep tend to think about sleep more, not just at night, but through the day as well. This can be as simple as paying more attention to things related to sleep, but can evolve in to thoughts that recur through the day like:
- If I don’t sleep well tonight……
- I’m so tired, if only I was sleeping better, I wouldn’t feel like this..
Another way thinking about sleep can change is loss of belief or confidence in the ability to sleep. This can result in people feeling they can only sleep if they take measures to control sleep. So people start doing things with the specific aim of trying to improve sleep, like:
- wearing earplugs
- kicking snoring partners out of the bed
- developing a complicated routine preparing for bed
- carefully managing temperature of the bedroom, etc, etc
These changes in thinking about sleep are often evident if you listen to someone talk about sleep. In my role as a sleep physician, seeing people with insomnia and other sleep disorders, I find just listening to people talk about sleep one of the most helpful things I can do to understand their sleep problems and how their thinking about sleep has changed.
But how much thinking about sleep is too much?
We all think about sleep from time to time, so it can be hard to tell if you’re overthinking sleep and that is a factor getting in the way of sleeping well. A questionnaire that can help evaluate thinking about sleep is the Dysfunctional Beliefs and Attitudes about Sleep (DBAS) questionnaire. The original 30 question version was published in 1994 by Charles Morin. A shorter, 16 question version, was validated in 2007, and I find this a helpful tool when working with people on their insomnia.
If you want to assess your own thoughts around sleep, complete the DBAS-16 which you can find at this link, then score it according to the instructions at the bottom of the questionnaire.
How does cognitive therapy work?
Cognitive therapy works by identifying and targeting beliefs about sleep that may be contributing to anxiety and distress about sleep. It aims to address unhelpful beliefs about sleep such as the number of hours of sleep needed each night, over-estimating the power of sleeping tablets, under-estimation of actual sleep and fear of threats to sleep.
For many people I find that once they are aware of their thinking and beliefs about sleep they can begin to break them down and change their thinking. Often beliefs develop because of messages about sleep, such as needing 8 hours each night or being concerned about waking at night not being normal, which aren’t necessarily true. So education on what to expect as part of normal sleep is a big part of cognitive therapy. This is one of the reasons for developing the resource SleepHub, to provide information on sleep to dispel myths about sleep that can cause sleep problems. So posts like the ones below can be used to help better understand normal sleep:
Sometimes people have strong beliefs about sleep that result in emotions like getting angry or frustrated about sleep. Using tools such as the DBAS questionnaire (above) can help to identify those beliefs. Another tool that can help to identify and address those thoughts and beliefs is a cognitive restructuring worksheet like the one at this link. Listing thoughts about sleep and how they make you feel, then coming up with alternative thoughts to replace the negative thoughts can be helpful and is called cognitive restructuring.
How can I access cognitive therapy?
Cognitive therapy is best not seen as a stand-alone treatment, but as one of the five components of cognitive behavioural therapy for insomnia (CBT-I). It works best when combined with the other 4 components: sleep hygiene, sleep restriction, stimulus control and relaxation.
If you think you may benefit from cognitive therapy or CBT-I, talk to your health professional who may refer you to a sleep clinic for assessment and treatment. Psychologists experienced in the management of insomnia usually work with people on cognitive therapy and CBT-I over a number of sessions. There is also new research showing that online versions of CBT-I can be effective.
Cognitive therapy as part of CBT-I can be accessed via the links below:
- Melbourne Sleep Disorders Centre – individual and group CBT-I
- Towards Better Sleep – Brisbane-based group CBT-I
- Insomnia clinic at Woolcock Clinic – Sydney-based CBT-I program
- Adelaide Institute of Sleep Health – Adelaide-based, mixed group and individual CBT-I sessions
- Dr Melissa Ree – Perth based psychologist
- The Society of Behavioral Sleep Medicine has a provider directory where you can search for experienced CBT-I providers in your area.
There is research going on looking at how CBT-I can be made more accessible using online programs or developing treatment programs that don’t need the expertise of psychologists or doctors who specialise in managing insomnia and sleep disorders. Two examples of online CBT-I programs with good research showing they are effective are:
- Sleepio – UK-based online program developed with Prof Colin Espie
- Shuti – US-based program developed by University of Virginia with Prof Charles Morin
The US Department of Veteran’s Affairs have also developed an app, CBT-i coach, that is designed to be used in conjunction with working with a psychologist. This app allows people to work with psychologists that aren’t expert in CBT-I as the app provides a lot of the sleep-specific information.
Related posts & links:
- Cognitive behavioural therapy for insomnia
- Podcast on cognitive behavioural therapy for insomnia
- Sleep restriction
- Sleep hygiene
- Stimulus control
- Have a plan to manage insomnia
- How does insomnia develop?
- Why doesn’t insomnia just get better by itself?
Need more information about how you can sleep better?
At Sleephub we understand the struggle people endure with sleeping problems which is why we have created a comprehensive FAQs page with information for those seeking information about sleep disorders and potential solutions.