Need to know
Most of us struggle after a night of poor sleep: we feel groggy, tired, irritable – there’s a general sense that we’re not firing on all cylinders, or like we’re going through our day in a ‘fog’. Insomnia sufferers know these symptoms all too well.
Individuals who experience insomnia often describe it as a debilitating, distressing, deeply frustrating condition that affects all aspects of their life. The negative impact of just one night of poor sleep can weigh heavily on us, so for those who are consistently sleeping poorly it can feel like torture. Sleeping should be easy, right? Why can’t I just close my eyes and fall asleep like everyone else? – a question I’ve heard many times in the sleep clinic. Insomnia can be such a cruel condition. The desperate desire for sleep and the increasing frustration that comes with being unable to sleep actually makes it even harder to get to sleep. Breaking this vicious cycle is one of the keys to overcoming insomnia.
Securing good sleep is essential for physical and mental health. When sleep is healthy, it helps the body recharge, fuels its natural ability to heal, and plays a vital role in helping the brain process the day’s events. Most adults need between seven and nine hours of sleep to feel sufficiently rested, though the exact duration needed varies from person to person. People with insomnia often report not getting sufficient sleep; some report just five or six hours. Others get more, but it is typical for people with insomnia to have highly fragmented sleep – in other words, they don’t sleep solidly and have long periods of wakefulness in their sleep.
Broadly speaking, insomnia involves persistent difficulty with getting to sleep and/or staying asleep, at least three nights per week. For those with chronic (vs short-term) insomnia, this goes on for a period of at least three months. These difficulties are accompanied by daytime symptoms such as fatigue, memory or concentration problems, or irritability. There also has to be some degree of dissatisfaction or distress about one’s sleep. Importantly, for the problem to be classed as insomnia, these issues have to be occurring despite adequate opportunity for sleep (so the sleep problems are not caused by factors such as shift patterns, late-night partying or noisy neighbours). And, the symptoms aren’t better explained by other conditions that can lead to poor sleep, such as circadian rhythm disorders or sleep apnoea.
Insomnia can have a serious impact on a person’s quality of life and day-to-day functioning. It can affect performance at work, relationships, and motivation to exercise and keep a healthy diet. People with insomnia often stop doing the things they enjoy as they no longer have the energy or drive to do them. As a result, they can often feel unhappy, powerless and trapped.
Insomnia is common, but treatable
It’s estimated that around one-third of the general population experiences one or more insomnia symptoms. By some estimates, approximately 10 per cent of people meet criteria for chronic insomnia, making it one of the most prevalent medical conditions. Despite how common it is, accessing evidence-based treatment for insomnia remains a challenge for a number of reasons, so it goes untreated in too many people.
Insomnia is still imperfectly understood by many health professionals – research has found that, on average, medical students receive only 2.5 hours of sleep education – and its signs are often missed or minimised. Furthermore, relatively few people actually seek out support for their sleep problems. It can be hard to know where to turn. Sleep as a specialist field is unregulated, meaning anyone can claim to be a ‘sleep expert’, even if they don’t have any clinical training. People with insomnia are often desperate for a solution, which makes them more vulnerable to unfounded promises and quick-fix ‘sleep solutions’.
In my experience as a clinical psychologist working with insomnia clients, by the time someone has contacted me, they’ve often already tried various supplements, remedies and treatments from an eclectic range of unqualified individuals. They might have also seen their GP and been prescribed sleeping medication. While sleeping pills can provide some short-term relief, they don’t deal with the underlying cause of the insomnia and there’s a risk of dependency, so GPs tend to prescribe them only for a brief period of time. Insomnia sufferers often end up feeling pessimistic about their chances of recovery and sceptical about any further sleep advice.
Thankfully, there are highly effective treatments for insomnia that are supported by solid scientific evidence. Cognitive behavioural therapy for insomnia (CBT-I) is considered the ‘gold standard’ treatment for insomnia by the leading authorities on sleep disorders. CBT-I is a type of psychological therapy that focuses on the role that behaviours and thoughts have in perpetuating sleep problems.
Insomnia is often the result of a period of stress or changes in routine – due to things such as illness, having a baby, changing jobs, relationship issues or bereavement – that causes a disruption in sleep. This in turn can affect how we think about sleep, and so we start to make changes in our sleep behaviours in an attempt to solve the sleep issue: loading up on caffeine, going to bed earlier, consuming alcohol, taking sleep supplements, sleeping on the sofa, etc. Over time, these changes can actually make matters worse. In CBT, we call them ‘maintaining factors’ as they fuel continued sleep problems. By the time someone is seeking help for their insomnia symptoms, the stressful life event has usually long since resolved, yet the sleep problems remain.
CBT-I is a very practical therapy, with the therapist helping the individual to identify, understand and then break the cycles that contribute to insomnia. This is achieved by learning some basic sleep science, making changes to your sleep schedule and habits, challenging common ‘sleep myths’ and other unhelpful beliefs about sleep, learning relaxation strategies, and following good sleep hygiene principles. I tell my insomnia clients that it’s helpful to think about CBT-I as a form of training rather than a therapy, as it requires a lot of self-discipline and hard work; but, the more you put into it, the more you will get out.
After completing treatment, my insomnia clients often say things such as: ‘I feel like the old me again’ and ‘I have my life back’. They have told me that their thinking is sharper and their memory and attention have improved, so they’re performing better at work; that they no longer feel irritable all the time and they’re getting on better with the people in their life. Clients have said that their life looks and feels different, like someone has switched on a light.
If you think you are experiencing symptoms of insomnia, you might benefit from working with a clinician directly. But if you’d like to start by making some changes on your own, this Guide presents a number of strategies, based on CBT-I principles, that you can try at home. Following these steps can help alleviate your insomnia symptoms and set you on the right path to start sleeping well again.
What to do
Identify behaviours that could be fuelling your insomnia
One of the main culprits behind insomnia tends to be going to bed early in an attempt to give yourself more opportunity for sleep. Perhaps you’ve tried this many times before and it rarely, if ever, leads to more sleep. You might think: If I don’t sleep, at least I’m resting, which must be good, right? Sadly, no. It can actually make things worse because spending excessive time lying awake in bed confuses the brain: it starts to associate your bed with wakefulness, making it harder for you to fall asleep.
Another strategy that people sometimes turn to when they are desperate for a good night’s sleep is drinking alcohol. Sleep myth: it helps you to sleep. Sleep truth: it might help you fall asleep more quickly, but it wreaks havoc on your sleep quality as the sleep you get is less restorative, your heart is working harder, and you’re more likely to wake up in the night and have fragmented sleep.
Compensating with caffeine in the daytime is an understandable strategy that many people use when struggling with feeling groggy and fatigued in the day. But because caffeine is a stimulant, it increases brain activity and blocks a chemical called adenosine, which delays the normal process of feeling drowsy. Drinking coffee or consuming other forms of caffeine in the afternoon or evening poses a risk to sleep.
Something else I hear a lot about when supporting people with insomnia is how hard they ‘try to sleep’. Without realising it, they are actually putting huge psychological pressure on themselves. People who are sleeping well don’t ‘try’ to sleep; in fact, they give little thought to how they get to sleep. It just happens. Naturally, it makes sense that people with insomnia start to fixate on trying to sleep, as their desire for sleep will be off the charts. However, the more pressure you put on yourself to sleep, the less likely you are to be able to sleep. This is because it causes a stress response (much like performance anxiety) that wakes up the brain and leads to anxiety and racing thoughts. As hard as it is, learning to let go of the need to sleep and taking the pressure off sleeping can help you to fall asleep more quickly.
Practise good sleep hygiene
Most people with insomnia have probably already been told about sleep hygiene at some stage, as it’s the standard sleep advice provided by health professionals. Interestingly, while sleep hygiene is part of CBT-I treatment, relatively little emphasis is placed on it by clinicians; other components have been shown to be more effective at targeting insomnia. Even so, there are some sleep hygiene principles that I think everyone should know about. The way I explain it to my clients is that we want to eliminate anything that might be affecting their sleep, so they need to aim to get their sleep hygiene ‘squeaky clean’ to increase their chances of making progress with the other strategies.
With this in mind, I recommend sticking to the following principles if you have insomnia symptoms, and I encourage my clients to be really strict with themselves about these:
- Avoid caffeine after 2pm.
- Significantly limit (or ideally avoid) alcohol and nicotine, especially within three hours before bedtime.
- Have a 60- to 90-minute winding down routine before you go to bed every night. This means doing things to help your body and mind feel relaxed and calm, and avoiding anything that overly stimulates the brain. Reading, light exercise, meditation, listening to relaxing music, having a bath, and self-care routines can all help. Avoid checking work emails, turn off notifications, don’t start planning or strategising, no gaming or social media. Think: gentle, relaxing, calm.
- Make your bedroom a sleep sanctuary: get the best bedding and mattress you can afford, make sure it’s dark, use ear plugs if it’s noisy, and keep the temperature pretty cool.
- If you wake up at night, do not check the time.
- Stay hydrated during the day and avoid consuming too much liquid just before bed.
- Get up at the same time every morning, even on non-working days. This will strengthen your body clock.
- Get outside and soak up the daylight as much as possible, especially in the morning. Even if it’s overcast. If you can’t get outside, sitting by a window is the next best thing.
Improve your stimulus control
Stimulus control is all about keeping your bed and bedroom for sleep (and intimacy) only. If you have insomnia, that ideally means no eating, reading, working, watching TV, gaming, online banking, to-do lists and so on when you’re in your bedroom. This is because we want your brain to form a strong association between your bedroom environment and sleep. This is based on the Pavlovian principle of classical conditioning, where stimuli are repeatedly paired and this eventually forms a strong association. We want your brain to be producing melatonin – which increases in response to darkness – as soon as you go into your bedroom, as this will help you fall asleep. What we don’t want is for your brain to associate your bedroom with strategising, planning, working, worrying, playing, checking the time and so on.
My insomnia clients will often ask if they can read or listen to music in bed. Fair question. I explain that, while we’re working on their insomnia, we need to strengthen the link between bed and sleep as much as possible, and to do that means doing all of that pre-bedtime activity in a different room. Once their sleep is back on track, they can experiment with doing these things in bed again and see how it goes.
You can further strengthen the link between bed and sleep by getting out of bed when you’re unable to sleep. Try the ‘20-minute rule’: get up if you think you’ve been awake for around 20 minutes or so. If you’re not sure how long you have been awake, you can just get up at the point when you think sleep is not happening – when you feel awake and perhaps frustrated or restless. Rather than staying in bed and being tortured by not sleeping, it is better to get out of bed, go to a different room (somewhere cosy, warm and comfortable, with low lighting) and do something that is gentle on the brain until you start to feel sleepy-tired (that drowsy, heavy feeling in the eyes), at which point you go back to bed. Reading a book, doing a crossword, listening to music or a podcast – any of that is fine, as long as it isn’t too stimulating and doesn’t involve looking at a bright screen. But don’t lie down! We don’t want you falling asleep on the sofa; we want your brain to associate feelings of sleepiness with bed – so remember to get back into bed as soon as you feel sleepy.
Challenge unhelpful beliefs about sleep
The beliefs you have about sleep can play a key role in fuelling insomnia. I have met lots of people who, over time, have become convinced that they cannot sleep well and that they will never sleep well again. People often start to believe that the only way they can sleep well is with medication. Many tell themselves that they won’t be able to function at work if they don’t sleep well (even when they’ve managed to hold down their job for years amid chronic sleep problems). People with insomnia can feel that they have no control over their sleep and that there is nothing they can do to improve it.
These beliefs are totally understandable, as insomnia can leave people feeling hopeless. However, because insomnia has a negative impact on our mood and cognitive functioning, people who are sleeping poorly often struggle to think flexibly, their beliefs become much more pessimistic, and they feel less capable of overcoming their difficulties.
If you think that your thoughts about sleep might be making things worse, try working through them in this way (tip: it’s best to try this exercise in the daytime):
- Notice: what are my thoughts about sleep right now? How true do they feel?
- Spot the trigger: what is happening right now that might be causing me to think this way?
- Practise self-compassion: it’s understandable that my sleep problems would make me think this way.
- Step back and question: am I willing to be wrong about this? Is there another way of looking at this? Is it possible that I’m not seeing the whole picture right now?
- Rebalance: what’s the actual evidence for this? When I’m feeling less tired/stressed/fed up, how would I be thinking about this?
- Recognise your needs: what can I do for myself right now to feel a little better?
Try a ‘brain dump’ to alleviate racing thoughts
Lots of people struggle with racing thoughts, where, as soon as they wake up, their brain suddenly switches on and their head is full of things they need to do, worries, memories and so on. This is often a result of daytime stress, and feeling overworked and having a lack of downtime.
A strategy that can reduce the impact this has on your sleep is the ‘brain dump’ exercise – you might want to try doing this at least an hour or so before bedtime. Jot down everything that is swimming around in your thoughts. This doesn’t need to be detailed; it can be a list of brief bullet points. The idea is that getting it out of your head and onto something physical, like a notepad, can help to ‘declutter’ the brain, and can even give you new insights and perspectives (eg, I don’t need to figure this out now, or This isn’t as bad as I thought).
Use a relaxation technique at bedtime
Progressive muscle relaxation is a great way to help the body relax, which in turn can help the brain feel calmer and quieter. It’s a simple technique that you can practise when you first get into bed. Here’s how to do it:
- Get yourself into a comfortable position in your bed. Lying on your back is probably best for this exercise.
- Close your eyes and breathe calmly for about 30 seconds in a way that feels natural to you.
- While continuing to breathe calmly, imagine slowly scanning your body from the top of your head down to your toes. As you do this, check for any feelings of tension in any of your muscles.
- When you find some tension in your muscles, focus your attention on that muscle group (whether it’s your shoulders, neck, facial muscles or others) and gently tense and hold it until it just starts to feel a little uncomfortable. Notice the feeling in those muscles and then release, letting the muscles fully relax and go soft. Notice the sensation of relaxing your muscles.
- Repeat this with the same muscle group, then continue your body scan, and move on to another muscle group.
- This is particularly effective with your hands. Try making your hands into fists, hold until it starts to feel uncomfortable, and then gently release, noticing all the tension flow out of your hands. Repeat this, while continuing to breathe calmly.
Consider cautiously experimenting with sleep restriction
Sleep restriction involves reducing the total time spent in bed (sometimes by hours), which initially can result in getting even less sleep. It works by dialling up the biological pressure to sleep (the sleep drive) and improving overall sleep efficiency as less time is spent in bed awake. It can take a few weeks before people start to feel the benefit, which means it is often the most challenging part of CBT-I, though it’s often very effective if one can persist with it. It tends to result in more consolidated sleep and people often start to feel more satisfied with their sleep. Although it can be effective, it is not something I would recommend trying without professional support as it requires careful monitoring and analysis of sleep diary data. Also, it is not suitable for everyone due to the short-term sleep deprivation it can cause.
If you’re experiencing insomnia symptoms and want to try a gentler form of sleep restriction, then a safe way to do so is to experiment with delaying the time that you go to bed while getting up at the same time every morning, regardless of how you slept. Ideally, you want to be switching your lights out for sleep only when you’re feeling really sleepy. Trying to get to sleep before your body and brain feel ready is a common trap that people with insomnia fall into, so delaying your bedtime can help reduce the time it takes to fall asleep.
Get professional help if needed
If your insomnia symptoms are causing distress and disruption, and are generally reducing your overall quality of life, then it’s best to get professional support from a qualified sleep specialist trained in CBT-I.
Most sleep specialists tend to be medically trained doctors, as most treatments for sleep disorders are medical/pharmacological rather than psychological. However, insomnia is a rather different type of sleep disorder because the main factors driving it tend to be psychological (eg, worry, anxiety, stress, behavioural habits, trauma), and so people with the condition can greatly benefit from the expertise of professionals who are trained in psychological treatments. In the Learn More section, you’ll find further details on CBT-I, medication and other tools that you might consider using in addition to the various at-home behavioural and cognitive approaches described above.
Key points – How to sleep well again
- The impact of insomnia is wide reaching. Persistent trouble with getting to sleep and/or staying asleep not only causes distress and frustration, it can lead to fatigue, irritability and other daytime symptoms.
- Insomnia is common, but treatable. About a third of people experience one or more insomnia symptoms. CBT-I is a specialised treatment that uses psychological principles to help break the cycles that sustain insomnia.
- Identify behaviours that could be fuelling your insomnia. Attempted fixes such as going to bed early or drinking alcohol before bedtime can actually backfire and make insomnia worse.
- Practise good sleep hygiene. This includes avoiding caffeine and alcohol late in the day, creating a wind-down routine before bed, and making your bedroom as dark and comfortable as possible.
- Improve your stimulus control. If you have insomnia, it’s important to save your bed for sleeping – not working, worrying or playing – to reinforce the association between the bedroom environment and sleep.
- Challenge unhelpful beliefs about sleep. Pessimistic beliefs related to sleep are understandable if you’re struggling with insomnia, but you don’t have to accept them as facts.
- Try a ‘brain dump’ to alleviate racing thoughts. Jotting down worries and other thoughts can help you mentally declutter before you lie down.
- Use a relaxation technique at bedtime. Progressive muscle relaxation, in which you tense and then relax different muscle groups, can calm your body and mind.
- Consider cautiously experimenting with sleep restriction. A gentle approach is to delay bedtime until you’re very sleepy and then rise at the same time each morning.
- Get professional help if needed. If your symptoms are affecting your overall quality of life, it’s best to seek a qualified sleep specialist trained in CBT-I.
Working with a therapist and other sources of support
Cognitive behavioural therapy for insomnia (CBT-I) is usually provided by clinical psychologists and cognitive behavioural therapists, as they have the necessary skills and knowledge to help facilitate change, and their specialist therapeutic training equips them to work with motivational issues, barriers to change, comorbid mental health problems and therapeutic process issues. Additionally, they can draw upon psychological theory to help make sense of the multiple factors contributing to someone’s insomnia. As a result, people often say that CBT-I helps them to understand and deal with the root of the issue and the factors that are making it worse, rather than just managing the symptoms. The usual treatment model for CBT-I includes an assessment followed by around six to eight follow-up sessions.
When looking for a CBT-I therapist, make sure to ask about the therapist’s credentials and any specialist training they have in sleep, and about their experience and successes in treating insomnia. Check they have completed specialist training in CBT-I. They should also have completed formal therapeutic training (eg, as a qualified CBT therapist, or registered clinical psychologist) and be registered with a recognised professional body (eg, in the UK, organisations such as the Health and Care Professions Council, the British Association for Behavioural and Cognitive Psychotherapies, or the General Medical Council).
Pharmacological treatment is another option, and it remains a common form of treatment for insomnia. However, medication is generally unable to address the underlying causes of the sleep problem, it usually offers only short-term relief, and can risk negative side-effects and psychological dependency. In the UK, ‘z-drugs’ (hypnotic medications such as zopiclone and zolpidem) are commonly prescribed for insomnia, though other medications including the antidepressant mirtazapine may be prescribed. Long-term use of hypnotic medications has been shown to increase the risk of health issues and (ironically) sleep problems. If you feel that medication might be for you, your doctor can provide advice about the pros and cons of sleeping pills and common side-effects.
As mentioned above, there are lots of other remedies, substances and treatments that are advertised as helping with sleep problems. As sleep problems are common, sleep is big business. However, only CBT-I and pharmacological treatment are formally recommended for insomnia.
I am often asked about sleep-tracking devices and apps, and whether they can help you improve your sleep. Many popular fitness trackers now include some form of sleep monitoring functionality, and I think that sleep tech is doing a great job of getting people interested in their sleep. It can certainly provide some really useful insights.
However, it’s important to hold in mind that these trackers are limited in what they can measure. They often overestimate how much sleep a person gets, they tend to be less accurate for people with sleep disorders, and their ability to measure sleep staging is not yet that reliable. The level of accuracy varies between devices, so if you want to invest in one, it’s worthwhile finding out if the device has been scientifically validated. As a general rule, wearable sleep tech devices (eg, watches, bands, rings) tend to be more accurate than ‘nearables’ – sleep tech that is not physically attached to the user, such as sleep apps or smart mattresses – though this could change over time as technology continues to improve.
Lots of people (myself included!) become a little obsessed with checking their sleep scores on their devices. If you have a sleep tracker, it’s helpful to try to see a sleep score as your device’s estimate, based on certain factors the device is measuring (eg, heart rate, movement), rather than a scientific fact. This is important due to the power of belief. I’ve known plenty of people who feel deflated when they see how ‘bad’ their sleep score is, and the belief that they have slept badly can actually change how they feel and function during that day. My advice is to check your sleep score later in the day, not first thing. Then, when you check it, compare the score to how you actually feel: are you alert? Refreshed? Are you functioning at a pretty good level? And how does your sleep score compare with that?
Links & books
The digital program Sleepio is grounded in CBT-I and developed by leading sleep researchers. It’s free to trial but requires a subscription for full access. It covers key CBT-I principles and has been shown to be beneficial for some people. It might be more suitable for individuals with mild or recent-onset insomnia, whereas people with chronic insomnia would likely need a more individualised approach with a qualified sleep professional.
Keeping a sleep diary can be a helpful way of monitoring your sleep quality, including how long it takes you to fall asleep, total sleep time, number of awakenings, and what time you get up each day. The Consensus Sleep Diary has been approved by leading experts in sleep research and is freely available to download.
The National Sleep Foundation website provides lots of useful information about different types of sleep disorders and treatments, sleep hygiene advice, and the science of sleep.
The book Overcoming Insomnia: A Cognitive-Behavioural Therapy Approach (2nd ed, 2014) by the psychologists Jack D Edinger and Colleen E Carney is a comprehensive self-help guide to tackling insomnia. It contains plenty of helpful exercises and practical tips, as well as the full CBT-I protocol if you want to try to work on your insomnia yourself.