Treatment for sleep disorder (insomnia)

Therapeutic relationship: The relationship between the client and the psychotherapist represents a significant active factor in treatment. The therapist supports coping and tries to maintain a balance between change and stabilization.

Sleep restriction: This method aims to ensure that the patient falls asleep more quickly, awakens less often, and that sleep overall becomes deeper. The patient is instructed to keep a sleep diary. Each day she should note how many hours she spends in bed at night and how many of those hours she actually sleeps. After about one week of documentation, the average sleep duration is calculated. If she slept on average 5 hours, a sleep window of 5 hours is set — i.e., if she has to get up at 7 a.m., she may only go to bed at 2 a.m. The patient is further instructed to document daily her sleep duration and her time in bed. After another week the therapist calculates from these values the so-called sleep efficiency (time in bed / sleep time x 100). If this value is at least 85%, the sleep window may be extended by 15 minutes per night. If this value is below 85%, the sleep window is reduced by 15 minutes per night, with the sleep window not falling below a duration of 4.5 hours. After another week the value is recalculated. The more time the patient actually spends asleep of her time in bed per night, the higher the sleep efficiency. This procedure is continued until a result satisfactory to the patient is achieved. During the day the patient must not sleep, because this would reduce sleep pressure. Realistically, sleep restriction takes about 8 weeks. During this therapy phase sleep times must be strictly observed and should under no circumstances be changed on weekends. Therefore this therapy method is not suitable for patients who work shifts. By initially reducing the sleep window (e.g., from 2 a.m. to 7 a.m.), sleep pressure increases; consequently the patient falls asleep more quickly and spends less time awake and ruminating in bed. In the long term this leads to the patient no longer associating the bed with anger, worries, rumination, etc. Thus the bed becomes increasingly a place of recovery rather than a place of dread. In addition, the patient gains the feeling of being able to influence or control her sleep again, which also has a positive effect on wellbeing. Before, during and after the intervention, sleep quality is assessed using questionnaires.

False assumptions about the nature of sleep (e.g.: regular nightly sleep is essential for life, daytime wellbeing is solely dependent on nighttime sleep, sleep before midnight is the most important, one must sleep at least 8 hours to feel rested) are corrected through knowledge transfer ("Psychoeducation") and replaced with realistic expectations.

Rules of healthy sleep (sleep hygiene) are taught: e.g., no alcohol should be consumed in the 2 hours before going to bed, daytime naps should be avoided, and it is advised not to look at the clock at night.

With a persistent disorder, patients associate the bed with being unable to sleep, ruminating, watching TV, reading, tossing and turning in bed, etc. These associations are to be dissolved again in therapy by following the rules of so-called stimulus controlare taught. This includes: The bed should be used only for sleeping and for sexual activity, one should only go to bed when sufficiently tired, ruminating in bed should be avoided — in that case it is usually better to get out of bed again — get up at the same time every morning, when you go to bed turn the light off immediately, etc.

Learning a relaxation method (progressive muscle relaxation, diaphragmatic breathing, autogenic training, etc.) and their regular practice.

Addressing the Underlying problems, e.g. grief work in the event of a separation, perfectionism, fears of failure, etc.

Cognitive therapy: Maladaptive (dysfunctional) thoughts / catastrophic thoughts related to the sleep disorder (e.g., fear of failing at work, never being able to sleep again, losing one’s job, becoming unable to work, being left by one’s partner, etc.) are identified, subjected to reality testing (i.e., questioned), and replaced by constructive, realistic thoughts. The patient gradually learns to confront her catastrophic thoughts more critically.

Mindfulness meditation helps to distance oneself from ruminations and anticipatory anxiety.