Earlier this year, I underwent five weeks of CBT (cognitive behavioural therapy) courtesy of the NHS at the UK’s only dedicated insomnia clinic. In the first session, which was a group session of about 10 extremely tired people, the consultant informed us that CBT works for 80% of insomniacs. I pretended to look hopeful, but after a lifetime of sleep issues, automatically assumed I’d be in the 20%. Because I’m a negative thinker. Which, of course, was part of the problem.
It’s estimated that a third of adults are suffering from insomnia at any one time, and 10% from severe, chronic insomnia. My issues started young, at 6 years old. I was an anxious child and used to get scared of ghosts, witches, social situations at school, someone I loved dying, etc. Then as I grew up, the fear of ghosts and witches turned into generalised anxiety about work, relationships, family, the state of the world, death again… etc. After trying all sorts of sleep hygiene practices, meditation, anti-anxiety medications and sleep-specific medications like zopiclone (a hardcore sleeping pill which GPs are reluctant to give out because it’s addictive and also, stops working after a few days because you become immune to its effects), I was finally referred by a young GP at my practice who had heard about a specialist insomnia clinic in Holborn.
It took six months to get an appointment after the referral and by the time I sat in the first consultation in front of the doctor, I was on the brink of self-destruction. I wasn’t sleeping more than two hours a night, my GP wouldn’t give me any more zopiclone, I felt hopeless, frustrated and incompetent. The doctor (a psychiatrist) asked me lots of questions and listened to my answers, then prescribed me a new type of medication specifically designed for sleep and a course of CBT at the clinic. Spoiler alert: six months later, I don’t take any medication at all, and with the techniques I learned on the course, I’m sleeping naturally six hours a night, which is enough to make me very happy.
Unless there is a physical reason for the insomnia (e.g. narcolepsy, restless leg syndrome, sleep apnoea), the clinic treats insomnia as a psychiatric disorder. Most of the people in the group were also suffering from anxiety disorders or depression, but none of us knew which had come first – the insomnia or the mental health problem – because one exacerbates the other. A few were grieving lost partners or parents, or caring for ill partners or parents, and two worked night shift jobs which caused all sorts of sleep routine problems. From all walks of life, the one thing we had in common was that we were consistently failing at a basic human function.
I couldn’t imagine what the consultant would tell us that I hadn’t already read on the internet or in the tens of books about sleep hygiene I had by my bed. But what I learned in the sessions drastically altered my perspective on insomnia, which was really all I needed to sleep.
We all know the NHS is overstretched and under-resourced, and it’s not easy to get a referral to the clinic, so for the sake of public health and helping my sleepless sisters, here are some of the things I learned. Please note, this article is by no means a substitute for CBT, medication or any professional treatment for insomnia.
Forget what you think you know about sleep
Sleep has become a hot topic in the media over the last few years. There’s been a surge in books and articles about sleep, loaded with terrifying statistics about how lack of sleep takes years off your life, causes heart disease, cancer, obesity, diabetes, depression, Alzheimer's, you name it. Many of these studies, he told us, are done with small sample groups or on animals, rather than humans. Having read every sleep article and book going, I was convinced I was headed for an early grave and a miserable life. The consultant started by asking us about the conditions we thought lack of sleep could cause, and wrote down everything we said, then proceeded to cross most things off the list and provided evidence to support each elimination. That was a huge weight off my mind. Don’t believe everything you read, and don’t read everything.
On that note, we don’t all need eight hours
Another myth he debunked was that we need eight hours’ sleep. For some reason, we all think this is gospel, but the truth is that everyone needs a different amount. Some less than eight, some more than eight. Apparently Einstein said he generally needed 11, but 12 if he was to do physics.
Break the negative association with your bed
This was a big one for me. I’ve always hated going to bed and the second I get under the covers, I become hyperactive, I’m suddenly the most awake, engaging version of myself, much to the chagrin of my boyfriend who is an excellent sleeper. As the consultant explained, insomniacs hate their beds because they associate it with wakefulness, frustration and anxiety. One of the tips in breaking this habit was never to do anything in bed besides sleep and have sex. If you’re struggling to sleep, do not read in bed, watch TV in bed, use your phone in bed or have deep chats with your partner in bed. It’s for sleep and sex only.
No, really, don’t look at your phone
Blue light from your phone stops your brain producing melatonin, which is the hormone your body releases in preparation for sleep. We’ve all heard this before, and conveniently ignored it before. But if you’re serious about improving your sleep, put your phone outside your bedroom 20-30 minutes before bed and buy a good old-fashioned alarm clock.
The 15-minute rule
The consultant gave us a 15-minute window to fall asleep once in bed. If we weren’t asleep within 15 minutes, we were told to get out of bed, and leave the room. We were encouraged to create a 'nest', i.e. a comfy place outside the bedroom where we could sit in dim light and read or listen to an audiobook (nothing too gripping…). We could only go back to bed when our eyes were heavy and we were yawning. If we still weren’t asleep within 15 minutes of being in bed, we had to get back up and go to the nest again. This is another way of stopping the negative association with being awake in bed.
We were given a sleep diary every week, where we recorded the time we went to bed, the time we got up, and the amount of time we were awake in the night. The consultant then helped each of us calculate our individual sleep efficiency percentage. In order to get the most efficient sleep (i.e. not be lying awake for hours feeling frustrated in bed), I was instructed to go to bed at 2.30am and get up at 7.30am – and go to the nest in that time if I wasn’t asleep within 15 minutes. So I would read books or listen to audiobooks in my nest until 2.30am, then go to bed exhausted, and get up, exhausted, but hopefully having had an efficient sleep. It took a while, but it began to work.
Get up at the same time every day, no matter what
Including weekends, because if you sleep in on the weekend, you mess up the routine. And you cannot be messing up that routine.
Specialists are divided on naps, but our consultant said no naps. He wanted us to be awake all day, in order to be as tired as possible for the night ahead.
The Wheel was a pie chart we drew of things that contributed to our health and happiness. From spending time with partners, family and friends, to exercising, eating well, being creative, engaging in hobbies and yes, sleeping. The point was to show that sleep is just one component of a healthy, happy life. So if we didn’t sleep the night before, we were encouraged to look at The Wheel in the morning and remember there were lots of other things we could and should do that day to feel good. When you haven’t slept, the last thing you feel like doing is going for a run or socialising, but you should do those things regardless, because they’ll make you feel better overall, which will in turn help you sleep.
The Worry Tree
The Worry Tree is a sheet of paper divided into three columns: 'Good', 'Bad', 'To Do'. The first column is a list of all the things that went well that day, to remind you that things still go well regardless of whether you’ve slept well. The second is a list of all the things that went badly, or that you’re worried about. And the third is a to-do list, which should include practical, achievable goals that specifically address the bad stuff. So the bad stuff might include 'worried about presentation at work', and the to-do list might include 'spend 20 minutes practising the presentation at 5pm tomorrow'. When the bad stuff includes long-term problems like 'worried about my ill father', the to-do list should be a small thing you can do, like 'give Dad a call tomorrow night'.
Everyone says it, and it’s important. Preferably, you should exercise in daylight, and three hours before you go to bed, otherwise you’re all pumped full of adrenaline.
The consultant did a guided visualisation with us, which is where you visualise a happy, relaxing place you’ve been to before, and you go into great detail about what that place looks like, what it sounds like, what it smells like, what it feels like to the touch. Thinking this through while in bed helps you relax. You can find more information on how to do this here.
Long live, and god bless, the NHS.