CBT-I: Fix For Insomnia And Depression
Are you feeling sad and tired? It's common knowledge that when you are depressed, disordered sleep follows – either sleeping too much or too little. Many of you have seen the much discussed article in the New York Times on the research that shows how addressing sleep deprivation through cognitive behavioral techniques or CBT, also helps resolve depression. This is very good news for the depressed and sleepless -- fix the insomnia and sleep issues and the fog of depression may lift.
Therapists can help individuals with depression and sleep difficulties by offering effective and simple ways to improve sleep. We call this sleep hygiene support. When you find a psychotherapist who understands how to address sleep problems, you may also discover that stress, anxiety, physical illness, poor concentration, job problems, marriage difficulties, parenting, transitions, resiliency and other problems are eased somewhat.
The American Psychological Association has now recognized sleep psychology as a specialty. What exactly is insomnia? Insomnia is defined as at least three months of poor sleep that causes problems at work, at home or in relationships. The treatment called CBT-I is based on the concept that chronic insomnia is sustained by a variety of factors and poor sleep hygiene such as:
- Napping during the day
- Going to bed too early
- Lack of adequate sunlight
- Sleeping in
- Excessive caffeine use
- Late-night heavy meals
- Late-night liquids
- Exercising close to bedtime
- Watching TV in bed
- Reading books, Kindles or iPads in bed
- Working and using a laptop in bed
- Upsetting, emotional conversations too close to bedtime
- Less than optimal sleep environment (temperature, bedding, etc.)
- Using alcohol to sleep which is ultimately disruptive
- Worrying about falling asleep
Treatment using CBT-I includes tracking sleep times and practicing sleep hygiene to address unhelpful patterns. Many insomnia patients who lie awake worrying and thinking actually learn to associate bed not only with sleep but a place to be awake, and even begin to dread their beds. CBT utilizes stimulus control instructions such as using the bed only for sleep and sex. That means no internet or work in bed, sorry! Another helpful technique includes using a sleep diary, as well as the concept of sleep restriction which limits the time in bed thus increasing the body's drive to sleep.
Another important piece of the CBT cognitive therapy model helps insomnia patients recognize and modify unhelpful, inaccurate thoughts that affect one's ability to sleep. For instance, many patients hold the belief that they "cannot function well without 7 or 8 hours of sleep" which puts additional pressure to fall asleep. This results in escalating tension and anxiety, and of course, no sleep! Patients using CBT will be taught "worry control" and learn to exchange rigid beliefs with more accurate evidence-based thoughts such as "I once flew across the country, slept 2 hours and was focused and effective during my meetings." Will you feel your best? No, probably not, but you will be fine. It won't be your best day (or maybe it will), but you'll survive. Should worry creep in the next night, try a sleep mantra like -- you know how to sleep, you've slept before and you'll sleep again, as well as pre-bed meditation and sleep relaxation and guided imagery. When I work with insomnia patients in my psychotherapy practice, I like to weave in some EMDR bilateral stimulation using mantras and guided imagery, as well as previous positive sleep experiences to help get more corrective and helpful sleep images uploaded into the nervous system. I've had great success using some creative EMDR techniques for sleep and worry.
Relaxation training is used to help quiet the mind and relax the body. There are a number of techniques that can be taught such as muscle relaxation, deep breathing and biofeedback. Find what works for you. I often teach diaphragmatic breathing and progressive muscle relaxation and suggest helpful relaxation CD's that I've had good success with. Patients who feel tense before bedtime benefit the most from these strategies.
It is not necessary for patients to discontinue sleep medication to benefit from CBT-I, however many patients are able to gradually taper off their sleep medications once they have learned alternative techniques to manage their insomnia.
Self-help books offering CBT-I are also available. Some suggestions are: “The Insomnia Answer,” by Paul Glovinsky and Art Spielman, and “Quiet Your Mind and Get to Sleep,” by Colleen E. Carney and Rachel Manber.
Practice acceptance, try compassion and change what you can. Take care, KS