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Nick Wignall is a clinical psychologist who specializes in cognitive behavioral therapy for anxiety disorders and insomnia. He’s also a writer interested in how we can use the tools and insights of behavioral science to better achieve our personal growth and development goals.
In this episode, we talk about insomnia as an anxiety disorder rather than as a sleep disorder, the pros and cons of acceptance and commitment therapy for insomnia, why sleep hygiene is rarely helpful, and why CBT-I is typically the best option for people with chronic insomnia.
Click here for a full transcript of this episode.
Martin Reed: I want to say thanks for being on with us today, Nick.
Nick Wignall: Sure, thanks for having me.
Martin Reed: So, just to get the ball rolling then, tell us how you got interested in the field of sleep, and insomnia in particular.
Nick Wignall: Mm-hmm (affirmative). I didn’t study it at all in grad school, which is strange it didn’t come up at all. But then, right as I was starting my first postdoc, I was asked to do a review of a book by a couple psychologists named, Colleen Carney and Rachel Manber who are big in the CBT-I world. I just thought it was … I didn’t know anything about sleep, but I was asked to do this review. So I thought, “Sure.” And I reviewed this book and I was just blown away by this whole world of CBT-I, cognitive behavioral therapy for insomnia. I was a trained cognitive-behavioral therapist, but I had never heard of CBT-I before.
Nick Wignall: Everything I read was like, “Wow, this makes so much sense.” It was almost too good to be true. It all made a ton of sense. So, when I started working I took on some insomnia clients, and thought, “Well, hey. Does this actually work? Let’s see.” So, that was kind of the start, and then I started going to conferences, and reading more, and taking on more insomnia clients. And of course, I learned a lot more. But it was that initial thing of reading that book which, kind of did it for me.
Martin Reed: So when you decided to try this out in the real world, how did it work? Was it straight away you were just thinking, “Wow! This really is getting results straight away”? Or was it more a case of trial and error as you were actually implementing it in the real world?
Nick Wignall: I think I lucked out, in that my first couple cases of insomnia were pretty … They weren’t super severe, and they were pretty straightforward, they didn’t have a lot of complicating factors along with them. So they went, frankly, just a pretty good dose of sleep restriction, and some stimulus control really just did the trick for these people.
Nick Wignall: And they got a lot of benefit really quickly. But then as I went on, I started getting more complex clients, with some stickier situations, which I learned a ton from, and eventually were successful with. But, it did take some time with some of those more complicated ones.
Martin Reed: So, go back to what you were saying earlier, about your initial training in your area of interest was CBT, Cognitive Behavioral Therapy.
Nick Wignall: Mm-hmm (affirmative).
Martin Reed: What’s the difference between regular, plain, vanilla CBT, and CBT-I? If someone has insomnia, and ultimately they want to find someone who’s familiar with CBT-I, what if they just find someone who’s unfamiliar with CBT-I, but they are a CBT therapist. I’m really just trying to grasp at what the difference is, because there’s so many acronyms in this industry, right? So, what does the addition of that, I, onto the end of CBT actually mean?
Nick Wignall: I think what it means is you understand how sleep works. Even on a physiological and psychological level, you understand how sleep works in the body. Really what that comes down to I think, is basically two points, which is these two concepts called, sleep drive, and arousal. The fundamental thing with sleep drive is, basically the longer you’re awake, the more sleepy you’re going to get. And, you can counter-intuitively, you can kind of harness that phenomena and use it to your advantage with people who aren’t sleeping well, right?
Martin Reed: Mm-hmm (affirmative).
Nick Wignall: So, if you understand that, which I think a lot of vanilla CBT providers were never taught anything about sleep and don’t really understand that. And then also the importance of arousal, which typically takes the form of sleep anxiety, or sleep effort, and how that can very quickly inhibit or disrupt normal levels of sleepiness. But once you really understand that those are the big two drivers of difficulty sleeping, I really think everything kind of falls into place after that. So to me, that’s the big difference.
Martin Reed: That’s brilliant. You know, to go onto this whole thing about the arousal, I’ve heard you suggest that perhaps insomnia shouldn’t necessarily be considered a sleep disorder. Perhaps it should be categorized … Or more appropriately categorized as an anxiety disorder. I’ve heard you say that. I don’t know? Maybe you want to deny it, or maybe you want to accept it. But, can you just tell us a little bit more about that, because I think it’s really interesting.
Nick Wignall: Yeah, sure. I’ll own that one. I think in general it’s … Understandably a lot of our diagnosis are descriptive in nature. For a long time, we didn’t understand the underlying mechanism behind a lot of common psychopathology. So the best we could do was describe it in terms that it looks like. Like, think depression. You know, with low mood, low energy, hypersomnia. But, in general, I think the better way to classify diagnosis is functionally, like, what’s the mechanism driving it underneath? When it comes to … Yes, insomnia looks a lot like a, you might call it a sleep disorder based on descriptive criteria because it involves sleep. But the fundamental mechanism, the thing that leads people into chronic insomnia is basically, hyperarousal, which almost always takes the form of some kind of anxiety.
Nick Wignall: So, something happens to someone. They start a new job that’s really stressful, the death of a loved one and a lot of grief. Something happens, and their sleep very understandably gets disrupted. They don’t sleep as well. They have acute insomnia, which is actually a pretty normal thing. Everyone experiences bouts of insomnia from time to time. But almost always if you look carefully, people who develop long term insomnia, they become afraid of having more insomnia. Which is a very understandable thing if you only sleep for a handful of hours per night, for a few nights in a row, you are going to feel pretty miserable. It’s rough, insomnia is rough.
Nick Wignall: But the problem is if you start worrying about it. You start researching why you’re having insomnia, and trying 101 different sleep hygiene techniques, and ruminating and worrying about your sleep. You’re increasing your level of arousal. You’re up-shifting mentally into a higher gear of activity, which unfortunately is the very opposite of the thing you need in order to fall asleep. You need to be relaxed in order to end up falling asleep, but if you’re constantly up-shifting into arousal because you’re worried about not sleeping, well, you’re not going to sleep very well.
Nick Wignall: So that’s why I say that insomnia is really more of an anxiety disorder. Because the fundamental mechanics of how insomnia develops, and actually how you get rid of it, I think, are much closer to what you see in typical anxiety disorders than in what you see in other sleep disorders. Which are more physiological, and not psychological in nature.
Martin Reed: Yeah, exactly. That’s exactly what I was going to say because if someone has insomnia, they can sleep. But, it’s this high-level of arousal that’s making sleep more difficult. Whereas in other sleep disorders that we see it’s more physiological like you say. If it’s sleep apnea for example, that’s a physical problem. But, with insomnia, it’s not really this physical problem with the sleep. It’s kind of this mental issue, whether it’s cognitive, or whether it’s behavioral.
Nick Wignall: But I think that’s good. We don’t want to stigmatize people, and imply that it’s all in your head, or there’s nothing wrong with you because it’s not physiological. But I think the way that I usually frame it to my clients is, it’s about habits. You can develop through no fault of your own, and often very counterintuitively. You can develop habits that seem like exactly the right thing to do but are actually are total counterproductive, and just made your sleep worse.
Martin Reed: Yeah, absolutely.
Nick Wignall: I like the word, habits a lot. Because it implies both agency. Like, you have control over … You can become aware of it. But, it’s not something that you’re doing intentionally to yourself.
Martin Reed: Yeah, I like that because also, I think most of us don’t recognize that it takes time to develop habits, too. So, just as it took time for insomnia to become more entrenched, and become a chronic problem, it’s going to take time for you to implement the techniques, the changes in the thought processes, the behavioral changes. It’s going to take time for you to develop those skills, or those habits, to reverse the process.
Nick Wignall: Exactly.
Martin Reed: So, that is a great word to use, I like that. What is it about CBT-I that you think is so effective for addressing this sleep related anxiety?
Nick Wignall: I think that the two active ingredients in CBT-I in some form or another, come down to what traditionally has been called sleep restriction. But, more people are moving away towards calling it sleep compression or time in bed restriction. Which doesn’t roll of the tongue quite as well, but is a little more accurate. You’re not technically restricting someone’s amount of sleep, you’re restricting how much time they spend in bed.
Nick Wignall: Then the other one is stimulus control, which basically is a fancy term for helping people not engage with the stimuli that keeps them awake and aroused. So, it could be a worry, or it could be too much noise in their bedroom, or whatever. But those two things, because they address the two fundamental variables in sleep, which are sleep drive, and arousal. So, I think it’s the one-two punch of hitting both of those. By compressing people’s sleep, by having people not spend as much time in bed, you’re increasing their sleep-drive so their more likely to be sleepy when they finally do get into bed, and they’re more likely to sleep deeply and get quality sleep throughout. You’re also preventing them from engaging in worry or things that would arouse them and inhibit their sleep drive.
Nick Wignall: In other words, if you’re lying in bed and you’re worried about not being able to fall asleep, instead of laying in bed and worrying, get out of bed and go watch a TV show, which will keep your mind off of worry, and allow your body’s natural sleep drive to build back up again, and help you fall asleep. So, I think those are the two big ones.
Martin Reed: What are your thoughts on this, when I’m working with clients some people will tell me right off the bat, “The idea of me allowing less time for sleep, or the idea of getting out of bed when I can’t sleep, that gives me more anxiety than the idea that I won’t sleep.” So, I’m sure you’ve experienced that yourself because I think it’s quite a common obstacle or a barrier that we face. How do you approach that?
Nick Wignall: With that in particular, with the getting out of bed thing, I, for the most part, try and encourage experimentation. So, what I’ll tell people is that, the standard approach is if you can’t fall asleep, get out of bed, do something relaxing until you’re sleepy again, then get back in bed. And, generally, if people are okay with that, we can try that. Even if they’re a little bit nervous, they’re usually willing to give it a go for a few times, and that often works.
Nick Wignall: But, if someone is really resistant to it, and doesn’t even want to experiment with doing it in little ways, I take in a sense, a harm reduction approach and say, “Okay, in general, it would probably be better to get out of bed if you’re not sleepy.” That’s kind of a basic staple of CBT-I. “But, it’s probably better that you listen to an audio book in bed, than lay in bed worrying about not sleeping. Or, you read on your Kindle a little bit.”
Nick Wignall: Sort of a general principle with insomnia is, stop trying so hard. Just across the board. You can’t worry your way into sleeping better. As a therapist, I can’t … Being too rigid with my recommendations almost always backfires, because it encourages more rigidity of thinking and behaving in my clients. I really try and be mindful of being flexible in my recommendations and approaches, and if something’s really not working for someone, to try to roll with it and come up with a more flexible solution.
Martin Reed: Mm-hmm (affirmative). What are your thoughts on acceptance and commitment techniques? This ACT for insomnia, which is, I think very similar to CBT-I apart from this idea about getting in and out of bed. Whereas the ACT techniques suggest that you stay in bed and accept your worries. Recognize that they’re thoughts, just welcome them in, trying not to engage with them. And that is the key to improving your sleep.
Nick Wignall: Yeah.
Martin Reed: Whereas with CBT-I, obviously as you just described is kind of the opposite. They’re saying as soon as you’re ruminating, and you feel those worries, that’s when you get out of bed. So, what are your thoughts on the differences here? Are you familiar with ACT, have you ever tried it?
Nick Wignall: Yeah, and actually I’m fascinated by it. I think ultimately whatever works, there’s a commonality among things that are going to work. And there are probably things in ACT that traditional CBT-I could incorporate and would be really helpful, and probably vice-versa to some extent. So, I definitely think it’s good that ACT for insomnia is becoming more of a thing, and people are thinking more about it. Because in my experience, there are some clients for whom that’s a better strategy. Especially people who are really more on the rigid side. They’re very hard-working, they’re very intense. A lot of times the structure of CBT-I just feeds into that and ends up being in that negative.
Nick Wignall: I really try and take it on a case-by-case basis, and there are certain people where I take a much more, what would look like acceptance commitment therapy style, approach. But, I think it really depends on the particular person. In general my approach is, if it’s pretty severe I think at first it helps to take the CBT-I route, get some of those habits, and some of those schedules under control, and get the intensity down a little bit.
Nick Wignall: Then I think the higher-level skill really is along the lines of ACT, which is … Just because you have an anxious thought doesn’t mean you have to do anything about it. Certainly not think more about it and worry on it. But, maybe you don’t even have to get out of bed or do anything, and just let yourself be. Accept those worries as worries, and not engage with them. In some ways I think that’s the ideal, but that’s a high-level skill. I’m all for going for that long-term, but I don’t think a lot of people are ready for that right off the bat.
Martin Reed: You just took the words out of my mouth. I was going to say this sounds way more skills-based, and it’s a high-level skill being able to not fear these thoughts, to kind of learn to welcome them in, almost like relaxation. Relaxation is a skill in itself. A lot of people who have never tried, let’s say meditation for example, they might just try it and, “I don’t feel relaxed.” And then never go back. They’re failing to realize it’s a skill that takes a lot of practice. I think if you’ve got a high-level of anxiety about sleep, trying to learn right off the bat as your first kind of strategy, to accept these thoughts, even just hearing that that’s what you’re being told to do I think is a very difficult obstacle.
Martin Reed: I would agree with you … Correct me if I’m wrong, but I interpreted what you said as, the idea of just getting out of bed is probably just a quicker way to start making progress, compared to something like ACT which does require a high-level of skill, and a high-level of practice.
Nick Wignall: I think for most people it’s the more gradual approach, and it allows them to really do the thing that I think all successful treatment for insomnia is based off of, which is building up people’s confidence that they can sleep on their own. That their body knows how to sleep, and that they don’t have to do anything about it, and then they will sleep.
Martin Reed: Absolutely.
Nick Wignall: I think that’s the key. So I think if you can boost that confidence by 50% by doing some basic sleep restriction and stimulus control, and get them feeling less anxious about their sleep, then maybe at some point they’re ready to do that higher-level stuff.
Martin Reed: Yeah, I’m seeing … In the forum on my website, I have people that I’ve worked with or have just tried CBT-I techniques themselves. They’ve seen improvements in their sleep, but they’ve still got these hold-out nights. Those one or two nights a week where they’re still having to implement stimulus control, and they’re getting frustrated by the idea that they still have to get out of bed.
Martin Reed: And then they’ve discovered ACT for example, through the sleep book, and they’ve read that, and now they’re trying that. And they’re finding it really helpful after going through a course of CBT-I, it’s like the next level. Like, CBT-I’s the Bachelors Degree maybe and then ACT is like the Master’s. You know?
Nick Wignall: Right.
Martin Reed: So they kind of graduate onto that, and they seem to be doing well. But, I think that you do need that basis of CBT-I really, to start making some progress, and start thinking about sleep a little bit differently before diving into ACT. That’s my personal opinion on it.
Nick Wignall: That’s been my clinical experience too.
Martin Reed: Let’s stick with anxiety, because I think it has such an important role to play in insomnia. When you’re working with clients who tell you that they’re anxious, how do you identify what the actual real thought is that’s creating the anxiety, and then work on addressing it?
Nick Wignall: Well, similar to you, I usually start with kind of a Socratic questioning and getting them to do a little meta-cognition, thinking about their thinking. And I’ll encourage them to keep a little journal or a thought record, or something around bedtime to try and get practice in noticing, “What are the thoughts that are going through my mind? What are those automatic thoughts that are happening?” In and around sleep because as you’re alluding to, it’s probably those thoughts that are producing anxiety, not sleep itself.
Martin Reed: Mm-hmm (affirmative).
Nick Wignall: For a certain percentage of people, that’s pretty productive. And we can get a record of what those typical thoughts are and then we can start to address those in different ways. Whether it’s traditional cognitive therapy and disputing distortions and all that kind of stuff. Or more of ACT approaches. There are a certain percentage of people who don’t do real well with that strictly cognitive approach. And I found there a lot of times you can look at it more behaviorally and say, Okay, “What are the environmental queues that are producing the anxiety?” Really what that means is, what are the environmental queues that are producing the thoughts that are then producing the anxiety?
Nick Wignall: But, if you can manipulate those environmental queues either by changing the environment itself, or by changing people’s state, emotionally and physically that they’re in when they go into that environment. Often you can get around the need to get into the thoughts in particular. So, that’s kind of high-level, but it might be the kind of thing where … I had a client recently who, the bathroom at night was the situation. That’s when they started getting anxious before sleep. Like, when they went to go brush their teeth and wash their face and stuff like that.
Nick Wignall: So what we did for a while is we switched up where they did all their evening routine stuff. I had them brush their teeth in the kitchen, and they would wash their face in the kitchen. So they avoided the bathroom all together. And amazingly when they went into bed, their level of arousal was significantly lower than it had been because they weren’t getting those classically conditioned arousal responses to that particular situation.
Martin Reed: That’s really interesting, because I think it’s almost connected to people in a way, with people who find they can sleep fine on the couch, but then they struggle as soon as they go into their own bed. So, it’s not really constructive for us to say, Well, okay, carry on sleeping on the couch.” Unless that’s their long-term goal. But when it’s something like what you said like, “Well just your teeth in the kitchen.” For example. You’re breaking that conditioned arousal but in a constructive way.
Nick Wignall: Then what it also does, I think importantly is, they get a few nights, or even a couple weeks of that under their belt, so to speak. Then they can go back to doing their regular routine, and they have more confidence that they can get to sleep. I think that’s so key. That that confidence then allows them to override some of that anxiety that comes up with the bathroom, or whatever it is.
Nick Wignall: The other thing I’m really big on is really getting pretty rigorous with people about basically the hour or two before bedtime. Different people call it, the buffer zone, or sleep runway, or different things. But, a lot of people are nominally good about not doing anything super stressful or anxiety causing before bed. But when really analyze it, they’re still doing a lot of what Colleen Carney would call striving activity. If they’re really goal oriented. If they’re checking emails or they’re doing chores around the house, or they’re getting ready for the next day.
Nick Wignall: All these things with someone with insomnia, even a moderate amount of goal-oriented thinking and behavior, is enough to kick you up into a high-level of arousal, to where your sleepiness gets overridden. Then they get to bedtime, and they start worrying that they’re not sleepy and that they’re not going to sleep. Then of course, if they’re not sleepy they’re not going to go to sleep.
Martin Reed: Yeah, I like to call it the buffer zone. It is hard, what do we tell people to do? We’re saying, “Okay, you should unwind like the hour or two before bed.” I like to just say, “It doesn’t matter what you do, just relaxing and enjoyable. That’s the only goal, relaxing and enjoyable activities. Apart from that it really doesn’t matter what you do.” But then people will tell me, “Well, if I read a book, I really don’t like reading anymore. Reading is boring, but it makes me sleepy.” You have to try and explain well, “If you don’t enjoy reading, then choose something else. It’s not the process of reading that’s generating s-”
Nick Wignall: Right.
Martin Reed: And it can lead down a slippery slope because one day they might read in their buffer zone, feel sleepy, go to bed and not sleep, and then you have this worry that this isn’t working anymore, when it was never really working in the first place. I’m a big believer in the buffer zone, and I just try and say, “Just stick to relaxing and enjoyable activities, and make that your focus. Because as soon as you’re striving for sleep, as soon as anything kind of hints at sleep effort, then you’re not really following a constructive path or process.”
Nick Wignall: One of the tricky parts I’ve found with that is that … And this is maybe a bigger cultural question, but I feel like a lot of my clients, they have two gears mentally. There’s work mode, like high-intensity work mode. And then there’s like, veg out, do nothing mode. Obviously if you’re in high-intensity work mode your mind is too revved up … That you’re in a too high state of arousal.
Nick Wignall: But, if you’re doing something that’s utterly boring, and uninteresting, you’re way more likely to end up worrying. You don’t have as much to hold your attention. What I actually tell people when they’re looking for activities that would be good for their buffer zone … And I think that this goes along with your point about enjoyable. Most people err on the side of things that are too boring-
Martin Reed: Absolutely.
Nick Wignall: You actually want to pick something that’s relatively interesting and enjoyable, right?
Martin Reed: Yep.
Nick Wignall: And probably more than you think. You don’t want to be watching a Transformers movie or something, but it should be something that when you think about that thing, you’re like, “Oh yeah, that’d be fun. Yeah, I want to do that.” Or it could be a book, it could be a TV show, whatever. But, I think that’s a common point that’s missed, is that people end up picking things that are too mellow, in a way.
Martin Reed: Absolutely, yeah, absolutely. You know, I was working with a client, and she just mentioned in passing, she was just like, “What I really miss is before bed I used to paint, and I used to do coloring. I used to do artwork.” And so I said, “Well, why aren’t you doing that now?” And her fear was that it would be too stimulating, that it would wake her up and make it harder to sleep. So, not only was she just going through this evening routine that she though was going to help her relax and sleep, but she was removing these enjoyable activities in her life, which was giving the insomnia even more of a negative outcome. So, I think that is a really important point. It’s not about something that’s going to switch off your brain, it’s more just something that you’re going to find relaxing, find enjoyable, and maybe it can just distract you from thinking about sleep.
Nick Wignall: Yeah.
Martin Reed: Excellent. All right, so this is the last thing I’m going to talk about on the anxiety topic. Do you tend to find that there’s a common thought amongst people with insomnia, like a specific thought that is behind much of the anxiety? For example, do you find that people worry that they’ve lost their ability to sleep? Or is it more about, “If I can’t sleep tonight I’m going to have a terrible day tomorrow.” What do you find is the big thought that is behind so much of the arousal, the anxiety?
Nick Wignall: I would say in people with mild to moderate insomnia, it’s usually that, “Tomorrow’s going to be awful because I’m not going to sleep.” Interestingly it’s not actually that tonight is going to be miserable, although it might be not fun. The more concerning thing to people is, “How am I going to feel tomorrow?” So with people like that, I actually do a lot of … I really try and work on when you have a poor night of sleep, really getting people to keep track of, “How do you actually feel after a really poor night of sleep?” And to really take a look at that.
Nick Wignall: But, in people that have really severe insomnia, almost always the biggest fear in my experience is that the big one’s going to come back. Usually, in their history, there was some period where they really were not sleeping well, really not well for an extended period of time, and it was pretty miserable and even scary. People thought there was something really wrong with them, and they were damaging their brain. And a lot of people have, almost like a trauma level of anxiety about the big one coming back. Like, “Yeah, I’ve been doing well for six months, but what if I go back to that big one?” So, those are the two that I think that I see the most commonly.
Martin Reed: Yeah, on that one, this fear that’s it’s going to come back?
Nick Wignall: Mm-hmm (affirmative).
Martin Reed: I see that too, so I really identify with that. You’ll have people that they could be sleeping well for like, six months. And then, they have one bad night, often to be expected. It’s like they had a stressful day at work, or an argument with their spouse just before bed, or something like that. So then they had a bad night, but, immediately that triggers this fear, it all just comes back. “Oh, I had this bad night, what if this means it’s coming back?” How do you deal with that? Do you just prepare people in advance? You say, “Look, you’re sleeping pretty well now, if you have a bad night in the future that’s to be expected.” Or do you just deal with it as and when it happens?
Nick Wignall: Yeah, this is a super good question. I don’t have a great snappy answer to that question. I feel like you can do a lot of traditional cognitive therapy stuff. You can look at the evidence and you can go back to your psycho-education about how sleep works, and if you get a really bad night’s sleep, you’re actually more likely to sleep well the following night, because your sleep drive is way higher. You can do all that kind of stuff, but I have found for people that have that borderline, traumatic level of insomnia somewhere in their past, not that they … Which by the way, it doesn’t mean that they objectively only slept only two hours per night or something for multiple nights. But it’s that their estimation, subjectively that was a major turning point in their life. Something really, really terrifying and scary.
Nick Wignall: I think it just takes time. They have to build up confidence that their body knows how to sleep, and that if they don’t get in their own way by doing these understandable, but counterintuitive things that end up making insomnia worse, that they will be okay with that. And in my experience so far … And I’d love to get your thoughts on this. But, that takes time for people who have that really entrenched almost traumatic level fear.
Martin Reed: Yeah, absolutely it does take time. I like to say, “Just as it took time for the insomnia to develop, and to become entrenched. It takes time to make it less of a focus of your life, and for you to regain that sleep confidence.” When I start to get to the end of working with clients, I like to explain to them that it’s normal to experience bad nights in the future, everyone has bad nights, and the key is to … What I like to say is first of all, just spend a very short amount of time, like 30 seconds. “Was there an external identifiable cause for that sleep disruption? So, if I had an argument, stressful work, got bad news … Okay, that’s why I had a bad night of sleep. My insomnia hasn’t returned, this is completely normal and to be expected.”
Martin Reed: But sometimes there isn’t an identifiable cause and you don’t want to spend time dwelling on it. So, then the next step is, try to avoid those compensatory behaviors. Don’t try and sleep … Don’t sleep in the next day. Don’t try going to bed earlier. Don’t cancel plans with friends.
Martin Reed: Then I tend to tell people that, “If you do that, normally you’ll find that your sleep does get back on track by itself, and if it doesn’t, the beauty of the CBT-I techniques …” Which is why I’m such a big proponent of them, is they’re with you forever. They’re just in your back pocket. So, you just pull them out again, and you know they’ve worked for you in the past. You’ve got your sleep back on track and slept well by implementing them.
Martin Reed: So, you can just go back and bring them back into your life again, for however long it takes, especially if you’ve kept a log of what techniques you found most effective, and kind of prioritize them. And then just implement them and see if your sleep can get back on track. Very few of them need more regular, intensive, ongoing coaching after that point.
Nick Wignall: I love it. I think that’s right on.
Martin Reed: All right let’s … Final thing, I just want to talk about sleep hygiene.
Nick Wignall: Yeah, one of my favorite topics.
Martin Reed: Everyone with insomnia has heard about sleep hygiene. I don’t think… I’d be amazed if someone who’s listening to this has never heard about it. But, just in case they haven’t, what do you consider sleep hygiene to be?
Nick Wignall: To me, sleep hygiene is what Google turns up when you question, “How do I sleep better?”
Martin Reed: Yeah.
Nick Wignall: It’s common wisdom about things you should do in order to sleep better. So it’s don’t check your email in bed right before you’re sleeping, or try and minimize the amount of noise in your bedroom. Or, don’t have your room be too hot, sleep in a cool room. So it’s all these common most … Frankly, not bad pieces of advice about what goes into good sleep.
Nick Wignall: The problem is that while most pieces of sleep hygiene are not bad pieces of advice. Yeah, all things being equal, a slightly cooler room is probably going to increase your odds of sleeping well. But they’re a distraction from the two really big things that do affect sleep which are, arousal and sleep drive. I think sleep hygiene as a broad category, is not a bad thing. But, it misses the two really big factors that do impact sleep. And it makes people think that, “Well, if I just drink the right kind of Sleepy Time tea, then I’ll get good sleep.” Or, “If I just figure out what the right temperature is, then I’ll sleep.” But those things are tiny in comparison.
Martin Reed: I like to think about sleep hygiene as more preventive in nature. So, if you’re sleeping well, then sleep hygiene techniques, or rules, or guidelines are good to observe. But once you’re at the stage where you’re living with chronic insomnia, it’s too late for that.
Martin Reed: Michael Schwartz who I’ve had on the podcast before, he says it’s like dental hygiene. We brush our teeth so that we don’t get cavities, but once you’ve got that cavity, i.e., once you’ve got the insomnia, no amount of teeth brushing is going to get rid of that cavity. That’s when you need something else in this case. It’s probably CBT-I.
Nick Wignall: Sure.
Martin Reed: Do you think that sleep hygiene should be included in a course of CBT-I? Or do you think it just has no place at all?
Nick Wignall: I don’t know. Sure, I think it’s fine, but it has to be contextualized. The idea that it’s more preventative, like you were saying. It’s more preventative, it’s not really going to help you if you’re in the throes of insomnia. The idea that any of those things, even if you’re doing them really well, those are tiny in comparison to, how high is your sleep drive, and how high is your arousal?
Nick Wignall: I usually draw a little pie chart for people, and explain it like, “Okay, here are the things that affect your chances of falling asleep. The one is like 45% and that’s sleep drive. There’s another one that’s 45 to 50%, and that’s arousal. And then, there’s a bunch of tiny little slivers. That’s like sleep hygiene.”
Nick Wignall: So, they’re not that important. The other really important thing about sleep hygiene I think that a lot of people miss, is that like with any kind of intervention, you can judge its merits based on its benefits alone. You also have to consider side effects. This is something that is really not talked enough about with sleep hygiene, which is yes, maybe your room being slightly cooler is good for your sleep, but is you constantly thinking about and worrying about the temperature in your room, how good is that?
Nick Wignall: Chances are the amount of anxiety and arousal that comes from you constantly thinking about and tinkering with your sleep hygiene regimen is going to way offset any potential benefit you could get from drinking the right tea, or having the right temperature in your room. So, I think that’s a really big problem that people miss with sleep hygiene, which is why it makes me wonder whether we wouldn’t just be better off if no one ever talked about sleep hygiene again?
Martin Reed: Yeah, connecting to what you just said, I think that another problem with sleep hygiene is that, for people with chronic insomnia, because that’s … Well, generally that’s the first thing they find out about and so they implement it. And, it doesn’t work which is to be expected. Then it leads to this worry, “Well everyone told me to do sleep hygiene, and this would get rid of my insomnia, but it hasn’t.” And it just leads you to become even more worried about your insomnia. Like, “I’m beyond help because sleep hygiene didn’t work.”
Martin Reed: And another problem that I have with it is that sometimes people can confuse sleep hygiene with more effective techniques like CBT-I. You’ll hear, “Oh I’ve tried that before.” Or when we’re talking about CBT-I, “I’ve tried CBT-I before.” And you say “Okay, well tell me about it.” Find out it was all the sleep hygiene stuff. And so, people then dismiss the more effective, the more evidence based options that are out there because they feel they’ve tried them because they confused sleep hygiene with these other techniques.
Nick Wignall: Yeah, that’s a great point.
Martin Reed: I think you told me in an email that you had a client that was really doubling down on the sleep hygiene, and it was really being counterproductive for them? Can you tell us a bit more about that briefly?
Nick Wignall: I had this guy come in and it was early-ish on in my history of treating insomnia. The first thing that was kind of stunning, was this guy came in and he probably knew four times as much about sleep hygiene as I did, and I was a clinical psychologist. The guy knew everything. He had read every article on sleep hygiene, had researched every little tip and tid bit, and had spent, frankly, years trying out every possible permutation and combination of different sleep hygiene strategies and approaches. And the guy had terrible, terrible insomnia.
Nick Wignall: So, I thought this was a great example of how the cost of sleep hygiene could easily outweigh the benefits. It turned out for this guy, the main driver of his insomnia was his sleep effort around sleep hygiene. He was constantly researching and tinkering with all these … In a lot of ways his life had become about sleep, and about how to optimize the perfect sleep hygiene routine. And what he was missing was, all this energy and decision making, and effort, and striving towards sleep hygiene, was the very thing that was keeping him aroused and making it hard to go to sleep. Because as soon as he laid down and wasn’t feeling sleepy, he’d start thinking, “Oh, hm, I wonder if I … Maybe I shouldn’t have taken this supplement, and maybe I shouldn’t have had those potatoes before bed, and maybe I-” And just, everything kept coming back to sleep hygiene. So, once I got a taste of what was going through this guy’s mind, I got him to buy into this program, which was: Set it and Forget it, is one of the things I say about sleep hygiene. Pick some routine, set your thermostat for 69 degrees, drink Sleepy Time tea an hour before bed, whatever. Do your routine, but leave it alone. Stop thinking about it and tinkering with it.
Nick Wignall: And that in itself was really helpful initially for this guy. And then the juicy piece of irony that I loved with this is … Maybe the biggest piece of sleep hygiene that you always hear about is no TV around bedtime. Don’t watch TV a half an hour before bed, or absolutely no TV in bed. That’s like the cardinal sin of sleep hygiene. But, this guy was constantly … He was getting into bed too early, so he was always aroused and thinking a lot in bed. And he was always worried about his sleep hygiene. So, I did something really blasphemous from his prospective, which is, I recommended that he watched TV in bed.
Martin Reed: How did he react to that when you first suggested it?
Nick Wignall: I wish I had a photo of this guy’s face, because it was like literally he thought, “My shrink has gone crazy. This guy doesn’t know what he’s talking about.” But I had him do it for a little while, and sure enough, he’d put on old reruns of The Simpsons, that was his thing. And pretty soon he just started falling asleep with The Simpsons, in bed.
Nick Wignall: So, this combination of him taking a “Set it and Forget it.” Approach to his sleep hygiene, and then watching The Simpsons and not worrying, which removed that association with worry and thinking in bed. Eventually he was able to stop watching TV and fall right back asleep. I loved that juicy irony of making the sleep hygiene expert watch TV in bed as a way to get over his insomnia.
Martin Reed: Yeah, I think-
Nick Wignall: One of my trophies that I hang up on the wall!
Martin Reed: I think that’s great. I can just imagine the face. When people get so entrenched in this belief, if anything then you go and suggest the exact opposite. The great thing is he was willing to try it, just to experiment with it and it worked out. I think that’s so much of the key to success. If you are concerned that something’s not going to work, or if you’re skeptical about something, is to just do an experiment. Because you don’t know for sure unless you try.
Nick Wignall: Great point.
Martin Reed: You might be right, but at least that way you’ll be proved right if you try it and if you get a bad experiment.
Nick Wignall: What … Just a quick little tidbit, because I’m sure you do this too, based on interacting with you. One of the best ways to get people to become a little more flexible and be willing to experiment is humor. I really try with most of my clients to be kind of funny, and try and be light-hearted, and to be kind of joking in a lot of ways. Because I think that helps foster an attitude that’s a little bit more lighthearted, and a little bit less doom and gloom which is always a good thing with insomnia, I think.
Martin Reed: Yeah, absolutely. I like to use the example of checking the clock during the night. I just say, “Try not to check the clock during the night.” Because I find that so much anxiety leads back to, “I checked the clock and it was X o’clock.” So I’m like, “Well, how about you just stop checking the clock? Just before you go to bed, that’s the last time you check the clock. Or, when your buffer zone starts, that’s the last time you check the clock. And then, you don’t check it again until your alarm goes off.” “Oh, I don’t know, just the thought of that gives me more anxiety.” So then I just say, “Well, when was the last time you checked the clock during the night, and you saw the time and decided to cheer and do cartwheels, and you’re so excited at three in the morning?” Chances are you’ve never looked at the clock during the night if you have insomnia, or felt good about the time.
Nick Wignall: Right.
Martin Reed: “But therefore, why not just give it a try, where you give yourself a week or two, just as an experiment, don’t check the clock, and just see how it goes.”
Nick Wignall: Yeah, I love it.
Martin Reed: All right, so I’ve taken a lot of your time Nick, and I really appreciate it, so I just want to ask you one final question-
Nick Wignall: Sure.
Martin Reed: … before I let you get away from me, okay? This is a question that I try and ask all the experts that I have on here. If someone with chronic insomnia is listening and feels as though they’ve tried everything. They’re beyond help, they can’t do anything to improve their sleep, what would you tell them?
Nick Wignall: That’s a good question. They’ve tried everything. I would say then, find a good cognitive behavioral therapy for insomnia provider. Because one of the things a really good … Because someone who’s really motivated, and can do the research and learn about sleep restriction and stimulus control. People who are bright and motivated, they can implement a lot of this stuff. And, if they’re still having trouble, what that probably means is there are some really subtle obstacles that are getting in the way that you’re missing. One of the benefits of someone who’s really trained and has a lot of experience is, we catalog all these little obstacles and points of resistance. We see so many people, that we’ve got this running list of really subtle, but powerful obstacles to getting good sleep.
Nick Wignall: So if you can find a good cognitive-behavioral therapy for insomnia provider, oftentimes they’ll be able to help you identify the thing that’s the glitch. They thing that you’ve tried everything, and it’s still not working for some reason. Maybe that’s, that’s not a very sexy answer I guess.
Martin Reed: I think it is a good answer because I think that we get good at reading behind the lines, when we’re talking to clients. They’re just kind of reporting things, how they feel, how they behave. Because we’ve heard these stories so many times, we can kind of pick things apart. Almost like the example I gave you of the person that gave up these enjoyable activities before. She never would have thought that that was having a negative impact on her process of improving her sleep.
Martin Reed: Though she just kind of mentioned it in passing almost. But, because she was talking out loud with me, we could identify that as something to work on. And also, another thing is having that person looking over your shoulder to make sure you are consistently implementing these techniques. I think you have to be so self-disciplined when you’re working by yourself, on sleep restriction. Getting out of bed by the same time every day, getting out of bed when you can’t sleep. I think it’s hard to do unless you’re really, really self-motivated. And so, it can just help to have that person that keeps you honest, gives you that accountability to check in with you and help reassure you and just keep you on the right track.
Nick Wignall: And to find someone you like. I think that’s really big, it’s not to be underrated … yeah, find someone who’s an expert, who knows what they’re doing with CBT-I, and who has experience. But find somebody you actually enjoy working with. I think that’s key, because you’re going get much more out of it, and you’re going to be more motivated to do some of those difficult things. So, don’t be afraid to go on some test drives and, try and find someone who you really click with in addition. Sorry, just one last little point there.
Martin Reed: No, that’s great! Thank you so much for being on Nick. I think we covered a lot, and I really appreciate your time, and I think everyone listening to this is going to find it really helpful. So, thanks again.
Nick Wignall: You bet. Thanks for having me on.
Martin Reed: Thanks for listening to The Insomnia Coach Podcast. If you’re ready to implement cognitive behavioral therapy for insomnia, CBT-I techniques to improve your sleep but think you might need some additional support and guidance, I would love to help. There are two ways we can work together. First, you can get my online coaching course. This is the most popular option. My course combines sleep education with unlimited support and guidance and is guaranteed to improve your sleep. I will teach you and help you implement new CBT-I techniques over a period of eight weeks. This gives you time to build sleep confidence and notice results without feeling overwhelmed. You can get the course and start right now at insomniacoach.com/online.
Martin Reed: I also offer a phone coaching package where we start with a one hour call. This can be voice only or video, your choice. And we come up with an initial two week plan that will have you implementing CBT-I techniques that will lead to long term improvements in your sleep. You get unlimited email based support and guidance for two weeks after the call along with a half hour follow up call at the end of the two weeks. You can book the phone coaching package at insomniacoach.com/phone.
Martin Reed: I hope you enjoyed this episode of the Insomnia Coach Podcast. I’m Martin Reed, and as always, I’d like to leave you with this important reminder. You can sleep.
Mentioned in this episode:
The Sleep Book by Dr. Guy Meadows.
If you’re ready to improve your sleep using evidence-based cognitive behavioral therapy for insomnia (CBT-I) techniques, click here to get my online insomnia coaching course. We can get started right now.
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