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In our previous blogs about sleep, we’ve looked at why sleep difficulties can happen (sleep-and-mental-health), and how they’re sometimes linked to depression and anxiety. We’ve also shared some top tips for improving your sleep. This week we delve more deeply into how cognitive behavioural therapy (CBT) can help.
CBT is based on the idea that thoughts, feeling, emotions and physical symptoms are all interconnected, and we often experience these in a ‘vicious cycle’. For example, if we have anxiety and we think about being anxious, the more we worry, and the more we experience physical symptoms of anxiety. This then feeds our anxious thoughts.
Insomnia tends to work in a similar way – and if you have trouble sleeping you may well recognise this cycle. It might look something like this: you go to bed, and can’t get to sleep. You start having negative thoughts, for example “I won’t be able to sleep, and I’ll be in a bad mood all day tomorrow”. This may lead to physical symptoms of anxiety, making it less likely that you’ll sleep and more likely that you’ll continue to worry!
This might then affect your behaviour; you might check the time, work out how many hours’ sleep you can still get, or check your schedule for the next day. This will probably trigger even more worry.
You might try really hard to make yourself drop off, perhaps thinking “I must sleep” or “I must not think about tomorrow”. This can have the opposite effect! It’s the ‘white rabbit’ effect: if we ask you right now not to think about a white rabbit, what happens? You’ve probably just pictured a white rabbit – perhaps twitching its nose or munching on lettuce. So the more you try not to dwell on something, the more you’re likely to worry about it. And the harder you think about sleep, the less likely it is to happen!
Difficulties with sleep are not just limited to night-time. Someone with insomnia can experience another vicious cycle when they wake up. They might feel very tired, and think “I barely slept, I cannot cope with today”. They may then cancel their plans, which could lead to other difficulties such as low mood and frustration. The lack of activity could also make it harder to sleep the following night.
This is known as a ‘safety behaviour’ – in this case, the person believes they’re helping themselves cope. But they’re missing the opportunity to learn something: that they can have a poor night’s sleep and still function the next day, or that being active is important for sleeping well.
Understanding and addressing what people believe about their sleep plays an important part in CBT treatment. Sometimes people believe they’ve barely slept when in fact they’ve had an adequate amount of sleep, and this influences their thoughts and behaviour accordingly. CBT is about changing thoughts and behaviours – in this case to improve the patient’s sleep by changing the way they react and respond to their sleep.
If you decide to treat your sleep problems with CBT, the therapist will start by thoroughly assessing your sleep difficulties to check there are no other factors that need addressing first.
If you both agree to focus on insomnia as the main difficulty, you’ll spend some time formulating your sleep difficulties – discussing examples of what you experience, to work out what your own unique vicious cycle looks like. You can read what is a formulation in this blog.
Understanding sleep and why we do it is also important. For instance, if you wake up feeling sluggish and with sore eyes you may believe you haven’t had enough sleep – but it may be down to something called ‘sleep inertia’, which happens when we’re transitioning from being asleep and being awake. Someone with anxiety around sleep may see this as evidence they’ve had a bad night’s sleep, which fuels their vicious cycle.
Next comes the main part of treatment, when you and the therapist will work together on breaking the cycle. The exact techniques used will be individual to each person and their formulation, but one effective approach is the ‘behavioural experiment’.
These are scenarios that a patient and therapist design together to test out the beliefs they have, often by doing something different. The white rabbit experiment is a simple example; from doing it you learned that trying to not think about something makes you think about it more! Such experiments provide evidence that helps you challenge a belief – in this case “If I deliberately don’t think about something the worry will go away”.
Someone who’s slept badly may believe the only way they can get through the day is to drink coffee – and that if they stop before 7pm this won’t affect their sleep. As an experiment, they might gradually reduce the amount of coffee they drink and see what impact this has. Chances are they’ll notice they can survive the day without it – and they’ll probably sleep better as well. You may well need to practice behavioural experiments like this over a period of time.
If you’ve tried the tips we suggested in our sleep hygiene blog and you’re still experiencing insomnia, you might benefit from trying CBT. Find about more about what CBT involves here.
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