Psychological Therapy Techniques
Various types of psychosocial therapies have been proven to help individuals with insomnia and other sleep disorders associated with delayed circadian rhythms.
Cognitive therapy (CT). CT targets unhelpful thoughts surrounding sleep. When an individual is initially unable to sleep he or she may focus on the dilemma, ruminating on the negative consequences of not getting enough sleep. Ultimately, these repetitive, distressing thoughts about insomnia serve to make the condition even worse. Worrying makes the brain more active instead of relaxed.
An example of an unhelpful, repetitive thought may be, “I can’t fall asleep, I won’t fall asleep, what time is it?” Negative recurring thoughts can also take the form of disturbing content (e.g., death of a loved one) or represent other things that are particularly hard to put out of one’s mind during bedtime (e.g., images of a traumatic event).
As the symptoms of insomnia worsen over time, the person may develop beliefs of its consequences that interfere, not just with sleep, but with day-to-day functioning. A belief surrounding sleep may be, “not getting at least 6 hours is horrible for my health, and there is no way I can function at work tomorrow.” The pattern becomes cyclical over time, further inhibiting sleep. CT aims to intervene in this cyclical pattern through psychoeducation and having clients work with a therapist to “dial down” and alter their negative thoughts.
Stimulus Control & Sleep Hygiene. Stimulus control is a behavioral technique that has received strong research support. It involves teaching patients good sleep hygiene among several other techniques. Sleep hygiene involves treating the bedroom as a place solely for sleep so that the brain can associate going to bed as “time to sleep” and not “time to think.” A patient would be instructed to remove all non-sleep-conducive stimuli from the bedroom (e.g., TV, computer, video games, and reading material). This also includes avoiding substances that can interfere with sleep within 4 to 6 hours of going to bed (e.g., coffee, nicotine) and limit stimulating activities (e.g., watching a movie or something else involving bright lights).
Relaxation. In relaxation-based treatments, patients learn exercises to calm physiological states marked with tension and stress. Some common forms are progressive muscle relaxation, imagery techniques, and meditation. Progressive muscle relaxation involves gradually tensing then releasing each muscle group in the body. In addition to the exercise itself, which forces muscles to a relaxed state by the end, practicing this exercise regularly can enhance patients’ overall sensational awareness, helping them to notice and localize tension states.
The imagery techniques practiced for relaxation involve positive content (e.g., leaves floating along a river). Relaxation training often follows an intensive format, requiring multiple weekly or biweekly sessions. Patients are also urged to practice them at home. The whole range of these various relaxation techniques appear equally effective overall, which allows for a patient to choose their preference.
Paradoxical Intention Therapy. Unlike relaxation-based approaches, this cognitive strategy involves a person imagining their most-feared sleep-related outcome (i.e., staying awake all night). This is based on the premise that performance anxiety contributes to difficulty sleeping. Once one removes pressure on themselves to sleep and faces distressing thoughts through guided imagery with a therapist — during a session and on their own out-of-session (i.e., at bedtime) — the thoughts begin to hold less weight and occur less frequently, making room for sleep.
This approach has shown less adherence by patients than relaxation-based approaches even though it has modest research support. While it may work, patients may be averse to the technique. Therefore, despite the fact that it is indeed safe, its limited attractiveness and feasibility undermines its effectiveness.
Biofeedback. Biofeedback, which has received modest research support, aims to help patients become aware of their body’s stress response as means to learn to relax themselves. One reason biofeedback is helpful is because many individuals tend to be unaware of when their bodies are in an aroused or stressed physiological state. In theory, once a person can recognize when they are experiencing an exaggerated stress response, they can begin to adapt skills for minimizing the physiological reaction. Unsurprisingly, biofeedback is a commonly used adjunct to relaxation training.
Mindfulness-Based Therapy for Insomnia (MBT-I). Because problems with sleep often stem from stress, MBT-I has been adapted in Mindfulness-Based Stress Reduction (MBSR) treatment by Jon Kabat-Zinn. MBT-I is similar to relaxation training in its meditation component; to CBT in the way it targets both thoughts and behaviors about sleep; and to traditional medicine in its Eastern philosophical orientation. See more about mindfulness strategies.