Cognitive Behavioral Therapy for Insomnia Part 3: Cognitive Restructuring
Cognitive restructuring can be a useful approach to overcoming insomnia.
Posted June 14, 2009
In the last post I discussed the use of stimulus control methods to help manage and overcome insomnia. This post will discuss the use of cognitive techniques in the treatment of insomnia. Some very tired people believe they will never be able to leave behind "the scourge of insomnia" and feel good again. History says otherwise. Cognitive therapy has been used since the 1970's to treat a wide variety of behavioral and medical problems such as depression, anxiety, and chronic pain. This approach to psychotherapy involves identifying and changing dysfunctional thinking processes. It works by increasing awareness of the thinking patterns involved in dysfunctional behaviors, recognizing the nature of the dysfunction and challenging the distorted thoughts- thus bringing about lasting change in experiences, emotions and behaviors.
The first step in using these techniques to treat insomnia is to understand the power of cognitive processes in our emotional states and general health. Most likely anyone reading this blog will be familiar with the impact of belief on health. Common examples of this are the placebo and nocebo effects. A placebo is a pharmacologically inert chemical that has a positive health effect because of the belief of the person taking it. This effect is so strong that specific placebo control methods must be used in pharmacological research that tests new medications. Likewise, negative beliefs about substances or behaviors can lead to unhealthy outcomes. This has been referred to as the nocebo effect. An example of a nocebo is the rapid death of individuals who have been cursed by a sorcerer in certain pre-modern societies. This has been documented by anthropologists and is a very real phenomenon. In a less dramatic way, beliefs about sleep and insomnia can affect the quality and quantity of one's sleep.
Second, it is important to have accurate information about sleep and insomnia in order to be able to recognize and challenge negative, distorted thoughts regarding it. In a previous post I discussed how insomnia is actually a problem of over-arousal and that insomnia mainly affects daytime emotion and quality of life ratings and does not generally pose a health risk to the person suffering from it. Some additional facts are also important to know. People with insomnia tend to overestimate how long they take to fall asleep and underestimate how long they actually sleep. Negative thinking, especially the fear of the effects of not sleeping, increases arousal. This makes it difficult to sleep and causes the experience of trying to sleep, feel miserable. For example, thoughts such as "tomorrow will be terrible if I don't get enough sleep tonight" are likely to make it very hard to relax and then fall asleep. Stress tends to prevent cycling into deep sleep so the person may spend long periods of time in poor quality light sleep in which there may be an awareness of ongoing non-productive thinking. Little wonder that upon awakening it seems that no sleep has occurred as this light sleep is misinterpreted as wakefulness. Negative sleep thoughts can also affect daytime functioning as with the thought, "today is going to be very difficult because I didn't sleep well last night." This becomes a self-fulfilling prophesy and the day ends up being very difficult due to negative expectations and irritable mood.
Third, it is necessary to improve one's ability to be aware of these thought processes. Developing the ability to pay attention to the steady stream of negative cognitions is a step towards being able to challenge these thoughts. Just take a moment to notice your thoughts as you are lying awake in bed at night or are feeling fatigued and irritable during the day. Carefully note the thoughts and their emotional impact. This will set the stage for using cognitive restructuring to change your thinking about sleep and insomnia.
Cognitive restructuring will involve challenging negative sleep thoughts at night and during the day with accurate information. For example, the thought "tomorrow will be terrible and I won't be able to function because I can't sleep tonight" can be challenged with true statements such as "I probably am getting more sleep than I think and I have been unable to sleep like this many times in the past and have always been able to get through the day." During the day thoughts such as "this is going to be terrible because I got such bad sleep last night" can be challenged with thoughts such as "I may not feel that good but I will be able to function just as I have so often in the past."
With regular application of this process, inaccurate and unhelpful dysfunctional thoughts can be changed. As this occurs the stress related to not sleeping at night will be decreased making it easier to fall asleep and get a good night's rest. During the day the recognition that you don't have to feel terrible because of poor sleep can relieve some of the irritability and depression that are a regular part of insomnia.
With the use of cognitive restructuring, many people can begin to overcome their insomnia. If you find that these negative thoughts are especially entrenched, it may be necessary to work with a trained behavioral sleep specialist who can guide you through this process.
So, yes you can change your thinking habits, work to alleviate insomnia and feel good again. In the next post another technique, bed restriction, for managing insomnia will be discussed.