Quieting Your Mind by Changing Your Thinking: Using Cognitive Strategies to Get to Sleep

Quieting Your Mind by Changing Your Thinking: Using cognitive strategies to get to sleep
Ashleigh Golden, PsyD

Dr. Ashleigh Golden is a licensed psychologist and an expert in cognitive-behavioral treatments for anxiety, depression, obsessive-compulsive disorders, and sleep disorders. Dr. Golden completed a 2-year sub-specialized postdoctoral fellowship at the Center for OCD and Anxiety-Related Disorders at the Saint Louis Behavioral Medicine Institute. Dr. Golden has supervised teams of clinicians across the country in intensive outpatient and partial hospital settings. She has a special interest for working with people who are ambivalent about accessing or participating in evidence-based therapy.

What is insomnia?

Insomnia is a common sleep disorder, estimated to occur in about 10-30% of the population worldwide, according to research. The Cleveland Clinic reports that the problem affects 70 million Americans every year. Insomnia can cause trouble falling asleep or staying asleep, and can make you wake up too early and not be able to get back to sleep. According to the Mayo Clinic, it can have a negative effect on energy level, mood, health, work performance, and quality of life. 

Insomnia can show up as a problem all on its own (primary insomnia), or as part of a coexisting medical or mental health condition (secondary insomnia.) 

What are some of the symptoms of insomnia?

The Mayo Clinic describes some common symptoms of insomnia:

  • Difficulty falling asleep at night
  • Waking up during the night
  • Waking up too early
  • Not feeling well-rested after a night’s sleep
  • Daytime tiredness or sleepiness
  • Irritability, depression or anxiety
  • Difficulty paying attention, focusing on tasks or remembering
  • Increased errors or accidents
  • Ongoing worries about sleep

According to the Cleveland Clinic, poor quality sleep or lack of sleep can negatively affect mental and physical health, contributing to diabetes, hypertension, and weight gain.

The Mayo Clinic notes that if symptoms of insomnia are making it hard for you to function during the day, it is important to visit your doctor to determine the cause of your sleep difficulty and potential treatment options. 

In some cases, doctors may prescribe sleeping pills for a short time to help you sleep. However, medications are not the first choice for treating chronic insomnia. Behavior changes are best to help you improve your sleep over the longer term.

What can I do if I have trouble sleeping? 

Using Cognitive Behavioral Therapy for insomnia (CBT-I) may help with insomnia. CBT-I is a brief, structured intervention that helps people use helpful habits to replace unhelpful thoughts and behaviors that worsen sleep issues. CBT-I assumes that the interplay between thoughts and behaviors are the key mechanism that keeps insomnia going.

The American Psychological Association’s Society of Clinical Psychology considers the research support for CBT-I to be strong, meaning that there is high-quality evidence that the treatment improves insomnia. 

CBT-I has several components, including:

  • Education
  • Behavioral strategies
  • Cognitive therapy
  • Relaxation training

We will be focusing on the cognitive therapy component, which helps patients “restructure” or reframe thoughts and beliefs that can get in the way of a good night’s sleep.

So how exactly does CBT-I work?

People with insomnia hold unhelpful or inaccurate beliefs about sleep, which can contribute to behaviors that make sleep more difficult. They also “catastrophize” or worry excessively about the consequences of poor sleep. 

The Sleep Foundation explains it this way: let us say that you have struggled with insomnia for a long time. This may lead you to worry about falling asleep. The worry may cause you to spend a lot of time in bed, trying to force yourself to fall asleep. But, paradoxically, spending a lot of time in bed and worrying about falling asleep can actually make falling and remaining asleep more difficult. This can spiral into an aggravating daily cycle that can be challenging to break.

CBT-I, according to the Sleep Foundation, uses cognitive restructuring to break this cycle by identifying, disputing, and changing beliefs and thoughts that contribute to insomnia. CBT-I helps patients re-evaluate how realistic or helpful their worries are, which lowers the anxiety that gets in the way of sleep as bedtime draws near. 

Common beliefs and thoughts that CBT-I addresses include:

  • Unrealistic expectations about sleep time and quality
  • Concern about fatigue during the daytime
  • Catastrophic consequences of missed sleep
  • Anxiety about past experiences of insomnia

As the Mayo Clinic notes, the cognitive component of CBT-I teaches you to identify and alter beliefs that impact your ability to sleep, which can help you manage negative thoughts and worries that keep you up.

How can I start changing my worries about sleep?Seth Gillihan, a clinical psychologist, lists common unhelpful thoughts about sleep, debunking the myths they contain and suggesting cognitive reframes.

Unhelpful thought Cognitive reframe
“I will not be able to function tomorrow. I will be miserable all day, I will fall asleep in meetings, and I will not be able to work.”
“It is true that insomnia is linked to lower performance on some tasks . . . but the effects are small. After a bad night’s sleep, most people say they have a rougher day, but it is not a disaster. I might feel sleepy at times, but I will get through the day.”
“I will have to cancel my plans.”
“Any effects on my enjoyment or performance will probably be small. I am going to keep my plans either way.”
“Insomnia is ruining my health.”
“It is unclear whether insomnia caused medical problems or vice versa. And it may not be great for me, but I am probably magnifying how bad it is. Worry does not help.”
“I have to get 8 hours of sleep every night.”
“The National Sleep Foundation recommends 7-9 hours per night. 8 is not a magic number. There is a wide range when it comes to optimal sleep. Some people are fine with 6 hours.”
“I have to catch up on the sleep I have missed.”
“Catching up on lost sleep by napping or sleeping in is counterproductive. The more time I spend in bed trying to chase sleep, the more likely I am to spend time awake and worry about not sleeping — which makes it harder to break out of insomnia. I will stick to my typical sleep schedule instead.”
“I must try harder to fall asleep.”
“More effort does not produce more sleep. It is best to create the conditions for sleep, then let go of the outcome.”

How can I challenge sleep worries in my daily life?

If you are worrying about falling asleep, the Anxiety and Depression Association of America recommends disputing your negative thinking. Write your worry down on a piece of paper or in the Notes section of your phone. Examine that thought the following day. What is the evidence for it? What is the evidence against it? Are there alternative thoughts or beliefs that are more accurate or helpful? 

Here is an example:

“I am going to lose my job if I cannot get to sleep at a reasonable hour tonight.”

Evidence for this thought:

  • “Meetings and presentations are generally a struggle when I am exhausted.”
  • “Colleagues have told me I seem to act tired and slow after nights of poor sleep.”

Evidence against this thought: 

  • “I have slept badly many times before and my performance reviews have been fine.”
  • “My colleagues and boss praise my performance, even when I am tired.”
  • “When I look back on the work that I have done when I am tired, it seems just as good as the work I have done when I am well-rested.” 

Does the evidence against the thought outweigh the evidence for the thought? What is a more accurate or useful thought that summarizes the evidence?

  • “The evidence against the thought is stronger. This thought is not very valid or helpful. A more accurate, useful thought would be, ‘Other people may notice when I have not slept well, but my overall performance does not seem to suffer. Best not to spend time worrying about it, since I will just do the best I can in the moment tomorrow.’”

Putting worry to rest

As bothersome as insomnia may feel at times, it does not have to take over your life. Losing sleep can feel bad, but worrying about it can make that feeling a lot worse. By challenging your thoughts about the consequences of sleep loss, you can use the power of cognitive-behavioral therapy to take control of your sleep worries.