Part I: Behavioral Interventions for Insomnia

Do you lay in bed at night tossing and turning, unable to fall asleep?  Or do you wake up in the middle of the night, consumed by worrisome thoughts or the fear of not being able to fall back to sleep?  If so, you’re not alone. According to the America Insomnia Survey, one in four women struggle with insomnia.  

Here at CTWPS, we recognize the host of negative consequences insomnia may have on a woman’s emotional, physical, and cognitive health, and we specialize in developing targeted treatment plans to help women regularize their sleep patterns and, in turn, improve their overall sense of well-being. 

As cognitive behavioral psychologists, we understand insomnia to be caused by learned thoughts and behaviors that can be unlearned.  Whether you occasionally struggle to have a restful night’s sleep, or are battling with chronic insomnia, you may consider implementing tenants of the two behavioral strategies below into your sleep routine: 

1.  Schedule Appropriate Times for Sleep

When a woman first begins behavioral treatment for insomnia, we typically collaborate with her to obtain a comprehensive snapshot of her current sleep schedule: when she goes to bed and when she rises, how much time she spends in bed, how much time she spends sleeping, and her napping behaviors.  We find that many women attempt to compensate for a bad night’s sleep by taking naps or sleeping later on the weekends.  While these behaviors offer relief in the short-term, they actually cause insomnia to persist!

We would then help this patient set a regular rising time, such as 6am, which means getting out of bed at 6am each day (sorry, including weekends!), irrespective of how poorly she slept. We would also encourage her to temporarily reduce the time allowed for sleep.  We find that many women who worry that they won’t be able to sleep get into bed earlier than they otherwise would to “increase their odds” of getting quality sleep.  Problematically, though, the more time you spend awake in bed, the stronger the association between “bed” and “wakefulness” becomes.  

For this reason, we would coach this patient to either go to bed later or wake up earlier so that the time she spends in bed more closely reflects her average sleep time.  We would determine the maximum time she should allow for sleep by adding one hour to her average amount of nightly sleep for one week.  For example, if she averages six hours of sleep per night, we would encourage her to allow for no more than seven hours of sleep. To this end, we would also ensure that she knows when to go to bed by calculating what psychologists have termed her “earliest allowable bedtime.” To do so, we would subtract from her regular rising time of 6am her maximum time allowed for sleep (seven hours) in order to arrive at 11pm as the earliest time at which she should attempt to go to sleep.

Lastly, we would also encourage this patient to limit naps to no more than 45 minutes, beginning at no later than 2pm.  There are many well-evidenced benefits to short “power naps,” such as improved mood and focus. Research indicates, however, that longer naps, especially those taking place later in the day, often consist of “deep sleep,” which weakens your sleep system’s capacity to sleep deeply during the upcoming night.

2. Strengthen Your Brain’s Association Between “Bed” and “Sleep”  

The next area of focus in treatment with this woman would be to help make her bed a stronger cue for sleep.  To achieve this goal, we would first assess whether she does any activities in bed that are cues for wakefulness, such as chatting on the phone, watching Netflix, attempting to work through a conflict with her partner, or lying in bed for long periods of time trying to fall asleep.  While these activities may seem innocuous, they are actually counterproductive in that they strengthen the brain’s association between “bed” and “wakefulness.”  Thus, we would invite this woman to modify her behaviors so as to only use the bedroom for sleep and sex. 

Additionally, we would teach this woman to not stay in bed longer than 30 minutes, both before turning off the lights and after waking up in the morning.  We understand that many women are simply not interested in relinquishing their habit of reading or watching TV in bed before falling asleep.  In these instances, we coach women to start out by reducing the time they spend reading or watching to TV in bed to no more than 20 minutes. 

Importantly, we would also teach this woman to not lay in bed awake for longer than 30 minutes.  If you’re still not asleep after about 30 minutes have passed (and you likely won’t be at first!), get out of bed and engage in a quiet, restful activity for another 30 minutes, such as drinking a cup of hot tea, reading a book on the couch, or engaging in some gentle stretching or yoga poses.  Then, return to bed and repeat the cycle until you’ve fallen asleep. This practice has been termed the “½ hour – ½ rule,” and with practice, the number of cycles needed in order to achieve a state of sleep becomes fewer and fewer.  

We recognize that for some women, consistently implementing these behavioral techniques may not be enough to fully repair their sleep cycle.  While we do believe these behavioral interventions are critical prerequisites to healthy sleep hygiene, we also recognize that women live demanding, high stress lives with multifaceted responsibilities and, as such, have a lot on their minds! This is why we also make space in treatment to address the cognitive component of insomnia - the beliefs, thoughts, and worries - that tend to create distress and inhibit sleep.  For tips on how to obtain greater cognitive control so as to further improve your sleep, stay tuned for Part II: Cognitive Interventions for Insomnia.