What people bring to therapy
Therapy for sleep problems
Most people arrive having already tried every sleep hygiene tip available. Those tips are fine and they are not usually what is maintaining the problem.
Written by Bhavana Bulchandani, Counselling Psychologist
MA in Psychology, Banaras Hindu University · · 6 min read
The first thing to understand is that whatever started your insomnia is often no longer what is keeping it going. A stressful month begins it; then anxiety about sleep itself takes over, and the original stress becomes irrelevant.
The effort paradox
Sleep is an involuntary process. You cannot will it, and trying activates the alertness system that sleep requires you to stand down.
So the sequence becomes: you cannot sleep, you worry about tomorrow, you monitor how long you have been awake, you calculate remaining hours, and each calculation raises arousal further. The effort is the obstacle.
What maintains it
- —Spending too long in bed. Going early or lying in to catch up weakens the connection between bed and sleep.
- —Bed as a place of wakefulness. Enough hours awake there and your body learns bed is where you lie and worry.
- —Clock-watching, which converts every waking into an arithmetic problem.
- —Catastrophising. "Tomorrow will be ruined" is both frightening and usually an overestimate.
- —Irregular rising times, which disturb the internal clock more than bedtimes do.
What psychological treatment does
Cognitive behavioural therapy for insomnia is the recommended first-line treatment for chronic insomnia in most clinical guidance — ahead of medication. It is structured and typically brief.
- 01Stimulus control. Rebuilding bed as a place for sleep: get up if awake, return when sleepy.
- 02Sleep restriction. Counter-intuitive and the most effective component — deliberately limiting time in bed to increase sleep pressure, then extending as efficiency improves.
- 03Cognitive work on the beliefs that drive the arousal, particularly about the consequences of a bad night.
- 04Reducing monitoring. Clock out of sight, tracker off for a while.
- 05Wind-down that is real, not a list of rules that becomes another performance to fail.
Sleep restriction should be undertaken with guidance, and is not appropriate for everyone — it is contraindicated in some conditions.
When to see a doctor instead
Where anxiety is driving the sleeplessness, therapy for anxiety addresses the same loop. Loud snoring with pauses in breathing, or severe daytime sleepiness despite adequate hours, may indicate sleep apnoea, which needs medical assessment. Sleep disturbance is also a core feature of depression and of thyroid disorders. Worth ruling those out.