CBT for Insomnia: Sleep Hygiene and Sleep Efficiency

The behavioral element in Cognitive Behavioral Therapy for Insomnia (CBTI) has two components, sleep hygiene and sleep efficiency. Sleep hygiene involves developing habits and routines that reduce insomnia. And we also create an environment that is conducive to sleep and helps us sleep better.

Our sleep is also better when we have a consistent sleep schedule. Going to bed and waking up at approximately the same time every day improves sleep. But sometimes that’s not enough, and we need to improve our sleep efficiency.

Sleep efficiency refers to the amount of time we spend in bed compared to the amount of time we’re actually asleep. People with insomnia often spend a great deal of time lying in bed awake, trying to fall asleep. And this leads to very inefficient sleep and contributes to insomnia. In order to increase sleep efficiency, we reduce the amount of time we spend in bed. This is known as sleep restriction therapy.

In sleep restriction therapy we decrease our sleep windows, by either going to bed later or getting up earlier, until our sleep becomes more efficient, and we spent a greater proportion of our time in bed actually sleeping. So at first we may get slightly less sleep than we’re used to (hence the term sleep restriction therapy), but we also spend considerably less time lying in bed awake. And then as our sleep becomes more efficient, we can increase our sleep windows, allowing ourselves to get more sleep, while still spending less time in bed.

This video presents an overview of the CBT for Insomnia program developed by Dr. Gregg Jacobs at Harvard Medical School. For more detailed information about his online CBT-I program, please visit www.cbtforinsomnia.com.

Sleep Hygiene and How to Sleep More Efficiently

This transcription was auto-generated by YouTube. I’ve only added minimal editing, so I apologize for any errors, run-on sentences, etc.

Struggling with insomnia or having difficulty sleeping can have a really negative effect on our quality of life. This video presents an overview of the cognitive behavioral therapy for insomnia program developed by Dr Greg Jacobs at Harvard medical school For more detailed information about his online cbt for insomnia program please visit cbtforinsomnia.com.

In this video we’re going to learn how to sleep better through sleep hygiene techniques and with sleep scheduling strategies that help us sleep more efficiently. And in my other video on insomnia we learn how to improve our sleep by quieting our minds and reducing our negative sleep thoughts. And you’ll find a link to that video in the description.

Sleep hygiene involves modifying our behaviors to create an environment and establish habits that make it easier for us to fall asleep and to stay asleep. One of the main goals of sleep hygiene is to learn to associate being in bed with being asleep. And so the first rule of sleep hygiene is to only use your bedroom for sleeping and intimacy.

You want to train your mind to associate the bedroom and especially your bed with sleeping and nothing else, because most people who sleep poorly associate being in bed with lying awake not being able to fall asleep. And we really want to train our bodies to associate being in bed with sleeping because that makes it much more likely that we’ll fall asleep when we go to bed.

So don’t bring your laptop or phone to bed. Don’t study or work in your bed. Don’t have a long problem-solving session with your partner in bed. And don’t laze around in bed once you wake up. If it helps you to fall asleep you can read or watch tv in bed for up to 30 minutes before you go to sleep but no longer than this. If you like to read or watch tv for longer than half an hour to help you wind down at night then start off somewhere else in the living room on the couch and then only move into your bedroom and bed once you’re ready to fall asleep.

And only go to bed once you’re already feeling drowsy otherwise you’ll just lie there in bed unable to sleep. And then if you’ve been in bed for more than 20 to 30 minutes without having fallen asleep lying in bed any longer is unlikely to bring on sleep anytime soon. You’re just teaching your body to associate being in bed with lying awake rather than falling asleep. So after 20 to 30 minutes of being in bed unable to sleep get up and move to a different room and do something relaxing for 20 to 30 minutes—like reading a book or listening to some quiet music; or doing a relaxation exercise like the one i link to in the description— and then return to your bed only once you’re feeling sleepy.

And try to keep your bedroom dark quiet and relatively cool. Our bodies cool down at night as we prepare for sleep so if we keep our bedrooms too warm it interferes with this process and most people find they sleep best at a room temperature in the mid to high 60s.

And sleeping well isn’t just about what happens once you go to bed the hours leading up are important as well. Try to stay off your computer or phone for 30 minutes to an hour before bed and use a blue light filter on any devices you can as bedtime approaches. And don’t eat a big meal drink alcohol or caffeine close to your bedtime. And nicotine is a stimulant so avoid smoking right before bed.

And try to have a night-time routine that involves some relaxation before you get into bed: doing some yoga or meditation, or taking a bath, or just reading or watching tv, or even cleaning up the kitchen if you find that relaxing. We all need something to help us unwind before bed. If you’re working right up until bedtime, or dwelling on things that went on during the day, or worrying about tomorrow when you get into bed, you’re probably not going to be able to quiet your mind enough to fall asleep.

And now we’re going to look at sleep scheduling and how that can help us sleep better. One of the most important things we can do to promote good sleep is to keep a regular sleep schedule. Our bodies rely on a consistent 24-hour routine or circadian rhythm to regulate our sleep wake cycle. Our bodies get used to going to bed at a certain time and waking up at a certain time, that’s why if we get up at the same time every day we often wake up just before our alarm goes off—our body knows that it’s time to wake up it doesn’t need an alarm to tell it.

The more we can stay consistent and let our bodies get into the habit of knowing it’s time to go to sleep and it’s time to wake up the better our sleep will be. The less regular our sleep schedule is the less we can rely on our body’s internal clock to help us sleep, and the more we start fighting against it. And so keeping a consistent sleep schedule is one of the best things you can do for your sleep. And that’s one of the things that makes sleeping so difficult for shift workers, or new parents whose sleep schedules are constantly getting disrupted, or when we travel across time zones, or experience the effects of daylight savings time.

And it’s important to try to maintain the same sleep schedule even on weekends. If you’re so tired at the end of the week that you need to sleep in try to limit it to no more than half an hour. If you’re sleeping in a few extra hours on the weekend, when you try to get back to your regular routine on sunday night you’re probably going to find it hard to fall asleep. And difficulty sleeping sunday night is one of the reasons we can be so cranky on monday mornings.

And if you need to take a nap these are fine earlier in the day but try to keep them to under 45 minutes, otherwise it can disrupt your sleep at night. And having a nap later in the day makes it more difficult to get to sleep at night, so a nap in the morning or after lunch should be fine, but a nap after work or after dinner can make it harder to fall asleep when you go to bed.

So maintaining a consistent sleep schedule is the first aspect of sleep scheduling but there’s another element and this involves sleep efficiency. Sleep efficiency refers to the amount of time you spend to sleep compared to the amount of time you spend in bed. So if you fall asleep as soon as your head hits a pillow and then sleep right until your alarm goes off, your sleep efficiency is 100%.

If you go to bed at 11 and set your alarm for seven you’ve allotted eight hours for sleep, and if you sleep seven hours that’s 7/8ths efficiency or 87.5%

Good sleepers average 95% sleep efficiency. The average person has about 90% sleep efficiency which would be allotting eight hours of sleep and then sleeping for seven and a quarter.

Poor sleepers average only about 65% sleep efficiency which would be, for example, only about five and a half hours of sleep over a period of eight and a quarter hours allotted for sleep.

Now as we talked about with sleep hygiene we want our beds to be strongly associated with sleeping and for good sleepers being in bed is a strong cue for sleep, but for poor sleepers who might spend two or three hours or even longer lying awake in bed each night that becomes a strong cue for being awake. So in order to overcome insomnia we need to find ways to sleep more efficiently and to make our beds a stronger cue for sleep.

Now if you practice better sleep hygiene and sleep scheduling and learn to quiet your mind and reduce negative sleep thoughts like i talk about in my other video on insomnia, your sleep efficiency will improve. But sometimes it still doesn’t improve enough, in which case we can further improve our sleep efficiency by reducing the amount of time we spend in bed.

Now usually when people have trouble sleeping they increase the amount of time they spend in bed, which makes sense, you want more sleep so you spend more time in bed. But unfortunately this has the opposite effect of what’s desired, because now you’re spending more time in bed, and your sleep is even less efficient, and you find it even more difficult to fall asleep once you’re in bed.

And spending too much time in bed interferes with our body’s natural rhythm. The longer we thin awake the stronger we feel the pressure for sleep due to increased physical activity and exposure to light, and due to increased accumulation of adenosine, which is a chemical our body produces that makes us sleepy. And our levels of adenosine increase the whole time we’re awake, and so if we sleep in or go to bed earlier, by spending more time in bed we find it more difficult to sleep because our bodies haven’t had enough time to do all the things they need to do in order for us to start feeling sleepy again.

So paradoxically if we’re having trouble sleeping, instead of spending more time in bed, we need to start spending less time in bed. And we start by giving ourselves one hour longer in bed than we tend to sleep. So if you’re averaging six hours of sleep a night, then give yourself seven hours of time for sleeping. And this may result in having a little less sleep at first as your body adjusts to having less time in bed. So if you’re tired during the day you can take a nap as long as it’s before 4 pm and lasts less than 45 minutes.

And if after a week your sleep efficiency hasn’t improved you can reduce your allotted sleep time even more, but don’t ever give yourself less than five and a half hours to sleep so you always have enough time to get your core sleep. And then once your sleep efficiency has reached 85% for at least two weeks you can increase your allotted time for sleep by half an hour a week as long as you’re still maintaining 85% sleep efficiency.

Now i understand that reducing the amount of time you spend in bed when you’re already having trouble sleeping can sound a little ridiculous and can be a hard thing to convince yourself to try, so you can always use a more gradual approach and try going to bed just 15 minutes later at night, or getting up just 15 minutes earlier in the morning so just decreasing the amount of time allotted for sleep by 15 minutes and you’ll probably find that you’re still getting the same amount of sleep overall. And then you can further reduce the amount of time allotted for sleep in 15 minute increments until your sleep efficiency has improved to at least 85%. And if you follow the sleep hygiene and scheduling guidelines as well as the strategies for quieting your mind and reducing negative sleep thoughts that i talk about in my other video on insomnia, it probably won’t be too long until you start to notice at least some improvements in your sleep.

If you have any questions or comments, please leave them on the YouTube video page.