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Sleep and CBT


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'I’ll Sleep When I’m Dead '

I think I first heard this phrase some time in the late 80s when the ability to function on very little sleep was seen as commendable and virtuous, suggesting that more hours awake could deliver greater levels of productivity - as if human beings were akin to assembly-line automatons. This culture of sleeplessness was famously personified by Margaret Thatcher who apparently managed her eleven year premiership on a mere four hours sleep a night, although some have speculated that this may have been a major factor in her rapid decline into dementia in later life. This prizing of work over sleep is seen as less fashionable these days, at least in the UK where many work places now embrace the culture of 'well-being'. However, the neglect of sleep is still prevalent in other parts of the world. Tech billionaire, Elon Musk recently lauded Chinese workers at his Tesla plant for "burning the 3am oil " (while neglecting to mention that those workers were literally locked inside the factory).


The culture of sleeplessness continued into the1990s, perhaps more fuelled by hedonism than work – and often aided by the use of illicit pharmaceuticals or at least large doses of caffeine. This zeitgeist-defining denigration of sleep eventually came crashing down (literally) in 2001 with the Selby Rail Crash, caused by a motorway driver whose lifestyle of caffeinated sleep denial led to a catastrophic event involving a land rover and two trains resulting in10 deaths and 82 serious injuries. This tragic episode was a wake up call (excuse the metaphor) to what happens to a society that fails to recognise the importance of sleep.


Although the motto of 'sleep when you’re dead' is less common nowadays, our hyper-commodified modern life is very much based on the principle of endless economic growth, fuelled by cycles of production and consumption - something that sleeping people are unable to provide. Netflix CEO, Reed Hastings acknowledged this when he recently said "we actually compete with sleep and we're winning". Sadly, these present day forces against sleep are perhaps more numerous and insidious than ever before. So, my first point regarding improving our sleep is this: Let’s celebrate sleep. Let’s welcome it with open arms when sleepiness manifests itself, let's build a positive relationship with it and allow it the proper space in our lives. Despite all the 21st Century’s promises of cybernetics, AI and bio-engineering, we humans are still essentially mammalian with a physiology and nervous system that dates back two hundred million years.


Mammals simply need to sleep. It’s non-negotiable. It’s part of the bargain we make for this incredible gift of human experience. Thankfully, over the past few decades, research has shown just how crucial sleep is for all aspects of self-regulation with regards to physical, mental and emotional health. If completely deprived of sleep, these systems unravel alarmingly quickly. Studies have also repeatedly shown how a good night's sleep improves productivity, creativity and problem solving abilities. Fairly recently, popular culture has caught up with this idea, leading to a deluge of articles, posts and blogs offering us helpful bite-sized simple fixes on how to get the holy grail of eight perfect hours every night. Are these helpful? Or do they lead to even more frustration in those of us who struggle to drift off, or who wake up in the early hours? So, rather than offering the usual ‘ten tips for a good night’s sleep’, I want to explore the wisdom of a more psychological approach that combines a bit of common sense, CBT and sleep research.


No ‘One size fits all’

Let’s start by not becoming fixated with those eight perfect hours or that sleep hygiene tick list (even though the ideas on it are probably worth a try). The most important point is to experiment and see what works for you. Here is an interesting experiment to try the next time you are lucky enough to have a week off work: After allowing a few days of sleeping in to get rid of any residual sleep debt, spend a few days going to bed at a reasonable time and make a note of what time you wake up in the morning. Do this for several days to work out the average hours you spend asleep. This should give you a baseline for knowing how much sleep you personally need. However, be aware that this number is not set in stone. It will give a general rule of thumb and may vary depending on the time of year (we tend to want to sleep more in Winter) and on your stage of life (teenagers generally sleep more and elders tend to sleep less).


Don't Panic

CBT suggests you don't panic if you can't sleep

Image by Mohamed Hassan from Pixabay


Sleep is a process that naturally occurs when enough ‘sleep pressure’ builds, caused by the accumulation in the brain of a molecule called adenosine. Essentially, the more time spent awake, the more this builds until the process of sleep allows for it to be recycled. Although daytime naps can work wonders for some people, be aware that these will release sleep pressure and may therefore effect your night time sleeping. Most sleep experts therefore advise against daytime napping for those who experience insomnia.


Having short periods of wakefulness during the night is quite normal. Most of the time, we don’t even remember them but they are part of our natural sleep cycles. If you have a prolonged period of wakefulness and genuinely can’t go back to sleep, remember that you cannot force yourself to sleep. It may be wiser to see this as some free time, leave the bed and go and do something enjoyable such as reading, writing or watching TV (whilst avoiding your phone, social media or emails.) Then, when you feel sleepy, go back to bed. There is considerable evidence that this type of ‘biphasic’ sleeping' was common in pre-industrialized societies when a lack of electric light meant going to bed earlier.


Take comfort that most people, at some point in their lives, will experience issues with sleep. Your sleep patterns will vary throughout life, related to the birth of children, stressful life events, medical conditions, hormonal changes or the process of maturing and ageing. So if you find yourself staring at the wall at 3am for the third night running, yes, it can feel very distressing – but it is unlikely to persist over the longer term. A few sleepless nights won’t harm you. Sometimes we perceive that we ‘have been awake all night’ when we’ve had more sleep than we realize. Research suggests that during nocturnal awakenings our mood regulation and cognitive functioning are impaired and this magnifies negative thinking. So be aware of this when you have catastrophic thoughts in the early hours. Traditional CBT for insomnia may help by spotting and changing such distorted thinking. Third wave CBT focuses on accepting and de-fusing from such thoughts by the use of cognitive exercises to experience how thoughts are just thoughts - they are the mind’s attempts to spin you a story. They are not necessarily true or wise and they cannot actually harm you.


Sleep is a self-regulating process and your body will ultimately compensate and deliver the type of sleep you most need, whether it be deep stage 4 physically restorative sleep or REM (dream) sleep for memory consolidation. The irony is that ‘insomnia’ is mostly a psychological phenomenon when anxiety about sleeplessness releases stress hormones that feed further sleeplessness - leading to a vicious cycle of conditioned behaviour, leading nicely to my next point…


Conditioning

As human beings, a great deal of what we do is conditioned and habitual. Often, chronic insomnia develops when patterns developed from primary insomnia become embedded. For example, let’s say you experience a very stressful life event such as divorce and this leads to an extended period of anxiety and sleeplessness. Then, after this initial situation becomes resolved, the sleeplessness remains. Now the insomnia, which was secondary, has become the main problem and we start to associate the bed with anxiety rather than sleep, so we need re-training from something like CBT-I (CBT for insomnia) therapy – which may initially restrict the time in bed to the time actually asleep to re-establish an association with bed and sleep. Here are some considerations about conditioning, sleep and habit:


  1. Human beings evolved to respond to 24 hour cycles of light and dark known as circadian rhythms. This is embedded into our biological functioning, right down to the cellular level. These cycles are triggered by hormonal responses to light and dark so try to work with these by immersing yourself in natural light as soon as you wake up, ideally by going outside. Similarly, a darker sleep environment correlates with better sleep. A sleep mask can be useful for this.

  2. Most importantly, create a regular getting up time and stick to it, even on weekends. If you find that you aren’t falling asleep within half an hour of going to bed, maybe consider staying up a bit later. Any later nights should soon trigger sleepiness on subsequent nights and prompt going to bed earlier, ultimately resulting in establishing a regular pattern.

  3. Do everything you can to build an association with your bed being used only for sleep (and sex) particularly avoiding an association with anxiety. So, if you are tossing and turning, it may be more helpful to just get out of bed, even if this seems counter-intuitive.

  4. Be mindful of the ‘cues’ you are giving your mind /body to sleep. Just lying down in the same darkened room at the same time every day is a cue, telling your mind it is time to sleep. What else could you build into your routine to suggest the winding down of the day? See what works for you: reading, audiobooks, music, sleep podcasts, stretching exercises, warm baths/showers and relaxation practices can all be helpful to different people. Avoid activities that are too physically or mentally stimulating and avoid going to bed on a full stomach.


Stress, CBT and Sleep

Image by Gerd Altmann from Pixabay


Stress and anxiety are the real enemies of sleep so, if you can tackle your stress, it can have a profound effect upon sleep. It can be a good idea to build stress-management strategies into your life generally whether these be communicating effectively with your partner or family to avoid conflict, regular exercise, learning breathing/meditation/relaxation techniques or even considering having counselling/talking therapy. If life is very full-on and stressful in general, one technique of CBT for sleep is keeping a ‘constructive worry’ journal where, before you go to bed, you write your concerns for tomorrow and how you plan to deal with them. Then, if those anxious thoughts pop up in the night, you can tell yourself that you have already made a note of how you will deal with them tomorrow.


Finally

Avoiding caffeine in the second half of the day and not drinking too much alcohol before bed are both advisable as they are both sleep disruptors, i.e. even if you do sleep, its quality will be impaired. There are different opinions about the use of technology that monitors sleep but some experts believe that these can lead to increased ‘sleep anxiety’.


So, in summary, prioritize and enjoy sleep, accept that sleeplessness will occur from time to time, develop healthy conditioned behaviour in relation to sleep, be aware of the vicious cycle of anxiety and work out what works for you. Always consider contacting your GP if you suspect you may have a physiological condition affecting sleep, such as sleep apnoea.


If think your insomnia has a psychological component, e.g. anxiety, worry or habit, then cognitive behavioural hypnotherapy may be useful in helping to develop strategies to help you cope and overcome your sleeping difficulties. When CBT is combined with evidence-based techniques of clinical hypnotherapy, there is a body of research to show that this can be an even more powerful form of talking therapy. It can change behaviour, alter thinking patterns and recalibrate an over-stimulated nervous system.


Contact neil@focusedattention if you would like to explore how I could help you with issues relating to anxiety or just click on the button below.



Further Reading


Foster, R (2022) Life Time: The New Science of the Body Clock, and How It Can Revolutionize Your Sleep and Health. London: Penguin


Tubbs, A. S., Fernandez, F. X., Grandner, M. A., Perlis, M. L., & Klerman, E. B. (2022). The Mind After Midnight: Nocturnal Wakefulness, Behavioral Dysregulation, and Psychopathology. Frontiers in network physiology, 1, 830338.


Walker, M (2017) Why We Sleep. London: Penguin







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