Sleep coaching (®Klösch & Holzinger) outlined
Part 3: Cognitive Behavioral Therapy for Insomnia (CBT-I)
We reach now the second main element of the sleep coaching(®Klösch & Holzinger) method: cognitive behavior therapy, abbreviated as CBT. After the success of CBT, several specialized methods have been developed on the basis of CBT, for sleep related topics we now refer to CBT-I: CBT for Insomnia.
The sleep education element of our methodology, which I have described in part 2 of this article, can be seen as a diagnostic element of sleep coaching(®Klösch & Holzinger). Now, in part 3, we will supplement it by the many practical steps offered by CBT-I. As already explained, our method is based on Gestalt therapy. In this open framework of the Gestalt, it is important to know the elements of the CBT-I, to internalize them, but not to see them as an obligation or as irrevocable measures, rather you can choose which of the measures suit you and could be implemented in your daily life.
CBT-I works particularly quickly, which has the huge advantage of offering fast improvement of the quality of life of people suffering from unhealthy sleep. It is important to analyze your own behavior and your own attitude towards sleep and to recognize which habits of your daily life might have a negative impact on sleep. Once the problem has been identified, the harmful behavior can be reconsidered and modified in order for it to no longer prevent sleep but instead, to replace it by a sleep-promoting behavior and a more positive attitude.
There is no need to implement each of the measures proposed in CBT-I into the daily routine. Each person can choose among those measures which one fits best to support their sleep, to get rid of habits that led to unhealthy sleep and to replace those bad habits with new ones that could promote a better sleep pattern while fitting into their way of life. To make this choice it might be helpful to first understand what CBT-I is based upon and why it works as efficiently as it does.
I would like to go back to the roots of CBT-I, without going into too many “technical” details. Most people will know Ivan Pavlov, the Russian physiologist who won the Nobel prize for his research on conditioning and involuntary reflex actions. He found out through his experiments with dogs, that it is possible to condition a dog to salivate when hearing the sound of a metronome. To condition the dog for achieving this result Pavlov proceeded as follows: the dog got its food every day only after hearing the metronome. Once the dog got used to it, food was not needed anymore to make it salivate, the sound of the metronome was enough to trigger the reaction. From this experiment, following equation can be extrapolated: Conditioned Stimulus (Metronome) leads to Conditioned Response (Salivate). From this equation, behavioral therapy classical conditioning, was founded.
Years later, behavioral therapy merged with cognitive therapy, which until the merging in the 60ties, was even considered as being opposed to behavioral therapy. A.T. Beck was considered the founder of cognitive therapy, which can be described best with an application example within patients suffering from depressions. The way in which the patients perceived, interpreted and attributed meaning to what happened in their daily lives, was the core of the problem and the path to a solution by using what is now called cognitive restructuring. This has not much to do with the very fashionable and unscientific “positive thinking” so many people like to quote nowadays. Cognitive restructuring does not deny that negative events happen and there is not necessarily something good in all negative events, but some of our thought patterns turn everything into negativity. We all have some automatic thoughts which we need to identify. I will give you an example from the world of sleep, as this is our topic. People having difficulties to fall asleep, when seeing the bed, immediately has negative thoughts in their minds that could translate like this “I will now go to bed and for sure will stress out instead of falling asleep” or “I am pretty sure, as soon as I will go to bed, my neighbors will start making noises and I won’t be able to fall asleep.” Once a person realizes, that those negative thought are the ones leading to the problem of falling asleep, those thought patterns can be addressed and corrected.
Cognitive Behavioral Therapy (CBT) is the merging of both those methods: classical conditioning and cognitive restructuring. CBT-I also is used in relation to Insomnias related to Post Traumatic Stress Disorder (PTSD). The basic idea of CBT-I is to make the patient/client have a more relaxed attitude towards sleep. Sleep occurs naturally, we all were born with the ability to sleep well. As it is set in the core of our being, we can find back to it.
In the 80ties, A. Spielmann has largely contributed to the development of treatments based on CBT and addressing chronical insomnia. He introduced a model of 3 factors which are: predisposing factors, precipitating factors and perpetuating factors. The predisposing factors are the ones that make us vulnerable to get insomnias, an underlying health condition for example. I would like to mention one predisposing factor in particular: children who suffered from sleep disorders, even if just for a while, are more likely to also develop sleep disorder as adults. The precipitating factors are the ones that lead to the first nights of bad sleep. Those can be traumatizing events, a health issue, negative stress (distress) and so on. The perpetuating factors are the one that make the insomnia stay even if the precipitating factor has been resolved. As an example: if you had a few weeks of increased problems at work, you might have had problems sleeping, because you were trying to find a solution to those problems. Maybe this led to you waking up, going back to your laptop to write some ideas down, in the process you had a drink and to calm down, you started surfing the internet or playing some computer games. Weeks later, the work problem got solved, but you still wake up in the middle of the night feeling very much awake, unable to fall asleep again. The insomnia came out of behavioral habits, which need to be detected and addressed.
Emotions, behaviors and thoughts (cognitions) are all interconnected and influence each other. Emotions are very difficult to control, which is why CBT addresses the thoughts and the behaviors, which as a result automatically influence the emotions.
D. Riemann and C. Espie, both are among of the leading insomnia experts and managed to make CBT for Insomnia a now widespread treatment method, which I will now describe in the simplest manner possible. I will include elements of sleep hygiene, stimulus control, cognitive restructuring, but in the text below, I will avoid often naming these measures like that, as I believe that a less scientific sounding approach will be more helpful in fulfilling the main goal: getting a relaxed attitude towards sleep.
Sleep: a matter of attitude
As a first step, it is important to develop awareness of how valuable our life companion sleep actually is. Considering sleep as an important element, rather than a by-product of life that just happens and consumes time, is essential. In most of our societies, sleep is currently demonized as THE unproductive time of the 24 hours long day. The development towards this kind of thinking is not that old, it only came with the age of industrialization and the pressure to perform. Sleep has such a bad reputation that the US Department of Defense has been busy researching how to keep soldiers awake for two weeks without loss of performance. The fact that people are meant to compete with tireless machines — with no concern for health and mental well-being — is clearly a mistake and as such, it should be rejected. Our human nature is adapted to the circadian rhythm, we live in harmony with the world in which we were born. If we live with it, we promote our health and our well-being: if we go against our own nature, we commit an act of violence to ourselves.
Sleep is a precious miracle, as we know in detail thanks to sleep education. If we allow ourselves to sleep, it works wonders for us and not only it will create fascinating dream worlds, it will also keep us dynamic, fit, healthy and happier.
Once we have acknowledged the value of sleep, we are ready to learn more about it, to pay attention to it, and to give to it the importance that our modern, hasty, performance-based world took away from it. Why not even celebrate sleep?
Before going to bed, many of us take a look at the clock, ponder if something could still be done before bedtime, such as checking e-mails, hanging up the laundry, or … stop! With such considerations, an inner restlessness builds up that cramps sleeping between two tasks and labels it guilty in advance for each task we did not manage to fulfil. We should learn to recognize such arising thoughts and stop them right away.
Instead, let us celebrate our sleep, let us welcome it.
Sleep is a part of us, we should not set it aside, unnoticed at the edge of our being, like an uninvited guest. We should absorb it, or as a Gestalt therapist would say, integrate it into us.
What does our sleep need in order to develop freely?
Let’s take a look at the bed, the blankets are soft and cozy. Let’s imagine how nice it will be to lie in it, close your eyes and let your mind wander. The most beautiful moment of the day can be the one when we leave the day behind us, when we don’t have to deal with anything from the outside world. We are allowed to immerse ourselves in our oasis of peace; our bedroom and our bed welcome us; they offer peace and wonderful adventures in dream worlds.
Healthy sleep is a question of attitude and our attitudes are influenced by our language. So, if we only say good things about sleep and celebrate going to bed, as I did in the previous paragraph, we have already come closer to healthy sleep. Paying attention to language usage, avoiding negative words and repeating positive ones are the next steps towards healthy, restful sleep. This method is used in behavior therapy, but, like so much else, it comes from Gestalt therapy. A direct student of Laura Perls, my esteemed colleague Bud Feder, described this wonderfully in his manual “Peeling the Onion”.
How you speak is how you feel: this is not just related to sleep, but can be applied to all sorts of subjects in life.
The Gestalt goes even further in this way of thinking than the CBT. It assumes that we shape our environment or the field. Everything that surrounds us is the field, we are influenced by the field, our entire behavior is shaped by the field, but we can help shape it. How we dress, behave, how we think, what friends we have, how we treat our family, how we perceive the street, the city, the country we live in is how we interact with the field. We can take the field in us and also change our perception of it through the use of language.
For example, let’s say: “I can’t sleep because this horrible street I live on is so loud.” Then we have already increased the level of stress caused by the noise through the formulation alone. But let’s say: “The familiar sounds of my street surround me, so I know: I have arrived in my safe haven, I am at home and can relax.”
Another good example would be one after a night spent with bad sleep: instead of telling yourself how bad this is, be happy about it, because you now know that your sleep pressure will grow, in the evening you will feel tired and fall asleep way more easily, probably even sleeping all night through. What a pleasure to go to bed when you are feeling really sleepy!
If we allow ourselves a positive attitude towards sleep, we grant it a place in our field, a place in ourselves, we cherish this part of us the same way we do all of the aspects of who we are.
Sleep hygiene: our surrounding in the evening
Let’s integrate our sleep … OK, but then what? Our positive inner attitude goes hand in hand with external conditions, some of those we can influence. We already know a lot about sleep, so now it’s time to pay attention to sleep hygiene. What do I mean by that?
Implementing our knowledge about sleep in concrete measures we can set.
For example, we know about the effect of light on our melatonin release. It is not unimportant to bear in mind that we sleep an hour less on average since we have electric light. Artificial light has postponed our working hours, but also redesigned our free time: we can literally turn the night into day. That may sound good at first glance, but our sleep suffers from it, as it is simply being suppressed by too many activities.
Let us analyze the sleep thief called light.
Televisions, computer screens, laptops, smartphones and bright lighting suppress the release of melatonin, as mentioned before. If we turn off the light sources an hour before going to sleep, we have already taken an important step to promote our sleep.
TV, computer games and social media chats are also nerve-wracking because of the content. We are tense while chatting, trying to give the right answer, we are annoyed or happy, we are planning something… If we check e-mails again, we are mentally back to work, planning the next day, thinking about how to react to this e-mail. When we watch a movie, we drift away mentally, we sink into a state of apathy, sometimes so severe that we no longer want to get up to go to sleep properly. We stay seated, let ourselves be lulled by a random movie or TV show, possibly nodding off but not getting any real sleep.
Computer games are sometimes even more stressful, often they are thematically related to wars or battles. The body switches to danger mode, even if it is only a mental, imaginary danger we are facing, the hormone release still takes place: adrenaline and cortisol do their work and keep us alert and awake. In addition, we often find it difficult to escape the virtual worlds that simulate a utopia in which we like to dwell.
All the activities just described are unsettling and at the same time stultifying. They take us away from the essential: we move away from real life and from our present. We move away from ourselves. They are not really relaxing, they do not help us to peacefully end the day, but rather they are an often-pointless delay of real relaxation. Only within reality we can end the day properly. Relaxation means to let your mind wander, to feel life and its intensity, to allow ourselves to take the time, time with our family, with people who surround us and who just like us want to end the day before diving into dream worlds.
By the way, dreams are often much more creative than any computer game! Dream worlds did not arise from bits and bytes, instead, they are born from our deepest longings, they connect our conscious to our unconscious self, they create worlds of unlimited possibilities. Aren’t they much more exciting than games that only reflect desires that others want to force upon us in order to do business?
An essential factor in enjoying the evening is to reduce the stress level, or rather to avoid building up stress, because, as already mentioned, the negative effects of it on our health and sleep are terrifying. Very often we are not even aware of our inner stress level: we find ourselves living in a state of constant tension, this state of hyperarousal needs to be identified and there is no better way of doing so, then to get rid of it for a while in order to feel the difference between “being relaxed” and “being stressed”. I like to compare it with people living in a big city: when they happen to go to the countryside for a week end, they suddenly realize what real silence is. They were not aware anymore that they were living with a constant background noise, just like many of us are not aware anymore of living in a constant high stress level. Only when confronted to real silence start the awareness of background noises, just like the awareness of hyperarousal only can be started by finding a moment of full relaxation.
We all can only decide for ourselves what will reduce stress for us. I can recommend sport, which also strengthens the cardiovascular system. If the person suffering from stress is not very active, a long walk can also achieve the desired effect. In the evening you shouldn’t do exciting sport, this is something for the day, right after work, for example, to get the job off the thoughts, to stay fit and to make the body tired. As a reminder: Those who are physically tired in the evening experience more sleep pressure, followed by more deep sleep, thus they regenerate better and strengthen their immune system.
Gardening also contributes to relaxation. It is even said to be effective against depressions when the hands dig into the earth to plant something or to pull weeds, but this form of therapy for depression has not yet been scientifically proven. It is sure though, that the contact with nature contributes to relaxation and the fresh air provides oxygen, and again: breathing, providing the brain and body with enough oxygen, is promoting healthy sleep.
Let’s enjoy stress-free evenings, turning off all bright lights and all screens, returning to our own world in order to shape it with joy. Let us give our body the rest and the darkness it needs.
What else can we do to celebrate our sleep before bed time?
Let’s go a step further into the evening, it is now time to open the windows! We need oxygen in the bedroom in order to really relax during sleep. Our body can only do all of its nightly tasks when provided with enough oxygen. The ideal bedroom temperature is below 19 degrees. It’s warm and cozy under the blanket, but the air we breathe is fresh and full of oxygen, it’s dark: these are the perfect sleeping conditions. Or almost…
You could add a lavender scent in the room, the mattress should be ideally adapted to your body, possibly the frame of your bed is made of pine wood, which also promotes sleep.
A little note about the bed: it’s there to sleep, or for sex, but not for working, chatting or watching TV. If you can’t fall asleep, the best thing to do is to get up for a moment, drink a glass of water, read a page from a book or write down some thoughts that still are on your mind… The important thing is not to stay in bed when you are still stressed. Turning from one side to another, tormenting yourself with questions or wondering why you cannot fall asleep: all this actually prevents sleep. Sleep does not come from stress. In addition, you may soon associate bed with not being able to sleep, which is particularly harmful. Not using the bed when you are awake, helps you to associate it with sleep and then, when you lie down in it, the body automatically sets to sleep mode. The same is true of the bedroom: it is not a workplace, no place to debate, to argue or to discuss things: a bedroom is intended for relaxation. If you have a one-room apartment, you can turn the living room into a bedroom with a pull-out sofa: the evening looks of the room can trigger sleep, making the bed can even be seen as being part of a sleep ritual.
Bedtime ritual and additional tips
What is a bedtime ritual? Everyone can create their own: it’s a set of actions that are always taken before going to bed. If the ritual is carried out every day, the body and psyche gets used to it and drift towards sleep mode during the ritual. With children, you can start with bathing and brushing teeth, then you could make them put on their pajamas, read a bedtime story and turn off the lights.
As an adult, you can organize the evening more freely, for example take a short walk in the evening, meditate, read a few pages from a book: the important thing is that it should be the same every evening, only then is it a bedtime RITUAL.
One of the most common sleep disorders is not being able to fall asleep or waking up frequently and then not being able to go back to sleep. Often it is because one thought is stuck in our mind, we start to brood, our thoughts go in circles, cause stress and prevent sleep. In these cases, the CBT-I provides two methods that can be used in addition to a bed time ritual.
On the one hand, the thought “stop”. As the name suggests, you stop the thought by forcing yourself to visualize something else. It even can be a simple stop sign, or a peaceful landscape, a painting that you know well, etc. It has to be something visual, something you can focus your inner eye on. The subject that previously was stuck in front of the inner eye is suppressed by this picture, you can mentally hold onto this still picture and come to rest. Note: an abstract thought would be less helpful, as it does not take as much attention as picturing an image does, thus, an abstract thought would not busy your brain enough to keep your mind off the recurrent disturbing thought.
The second method, the worry chair, can be used if the first method does not help. The worry chair method is as follows:
Outside the bedroom you set up a chair and a table that you use every time your thoughts are trapped by a topic that would not let your mind come to rest. Keep a diary or a sheet of paper and a pencil ready on the table in case you need them. Of course, you can replace them by a recording device but, if possible, one without a screen because of the disturbing blue light. Have only a little lamp near it, if you need to switch on the light make sure the light shines only on the paper, not on yourself. You can go to sit in this chair to think over a topic that wouldn’t let you go. Think for a while about the problem that is on your mind, write down what you have to say about it and what you don’t want to forget. If you get up to go back to bed, you leave the problem in the chair and on the paper, you don’t take it back into the bedroom. Such a worry chair can also be used during the day to calm yourself down when you are upset.
We mentioned positive attitudes and good sleep hygiene: these measures are part of the cognitive restructuring in the CBT-I.
Our sleep ritual and our bed design are what the CBT-I calls stimulus control. We also explained the thought stop and the worry chair. All of these terms are technical terms of the CBT.
Often, we therapists allow ourselves to be misled into using these technical terms, but the scientific-sounding names for these extremely powerful methods are not intended to detract from the fact that they are easy to use. The CBT attaches great importance to simplicity, which means easy internalization and a quick solution to the problem.
If sleep is already severely disturbed, another cognitive-behavioral treatment method can be used.
Although this is also uncomplicated, it cannot be performed without a therapist, so I will only briefly describe it to draw attention to this possibility.
This is a method you might know by instinct if you traveled abroad into a different time zone. Some people experience Jet Lag, which is a difficulty to adapt to a new time zone. The circadian rhythm is adapted to the time zone we usually live in and a sudden change can prevent from falling asleep at a time when at home is daytime, while in the new location it is night and thus, bedtime. To adapt more quickly to the new time zine, many people chose to just skip sleep for one night which leads to them being very tired the next evening. This increases the sleep pressure and they fall asleep quite fast: next day, their bodies giving in to the new time zone and adapt. This rather drastic measure to overcome Jet Lag can be compared to the method of sleep restriction, but of course, this is on a one-day scale, while sleep restriction can be used over several weeks of targeted sleep deprivation.
Sleep restriction has first been introduced by W. Schulte in 1966. The aim was to use it as a treatment against depression, as sleep deprivation leads to serotonin levels rising. Treating depressions through sleep deprivation (SD) works on a short term, but not on a long term. “In more than 80% of responders to SD, a relapse into depression occurred after the recovery night.” according to an in-depth study by U. Hemmeter et al. in 2010.
Sleep restriction is practiced and very useful in sleep coaching and CBT-I especially when the circadian rhythm is disrupted or when most other methods failed to have enough effect to reach a healthy sleep pattern. The goal is to increase sleep pressure and sleep efficiency (the time spent in bed and actually sleeping) through sleep deprivation. During sleep restriction therapy, the time in bed is reduced until the hours spent in bed (no less than 5 hours) are actually mostly spent sleeping. The time spent in bed is progressively increased, as slowly as necessary to still keep a good sleep efficiency level.
This is a rather drastic method of “setting the internal clock” and increasing sleep efficiency for clients who are initially already overtired and suffering from sleep deprivation. This method should therefore only be carried out with the support of a medical doctor or a therapist and preferably during a vacation period.
Putting negative attitudes aside, integrating sleep, enjoying it, welcoming it, if possible, with the help of a ritual, are key elements of the CBT-I. These measures once well integrated can keep stress at bay. As stress always can come back, the next time it overwhelms us, we can stop it with an internal stop sign, or we carry it into another room and leave it alone in the worry chair while we return to our well-deserved sleep.
If stress returns frequently, then we may need additional, more powerful weapons, namely meditation techniques and hypnosis, in order to regain control. Those techniques will be addressed in the next chapter of our sleep coaching method(®Klösch & Holzinger) before reaching our last chapter, dream work, the one that makes our method effective over the long term and that also addresses nightmares as sleep depriving elements.
At the end of the day, we have to be able to think for ourselves and say: I’m going to sleep now and I’m looking forward to it!