Cognitive Restructuring & Stimulus Control

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1 Cognitive Restructuring & Stimulus Control What is Cognitive Restructuring? Cognitive restructuring is a useful technique for understanding unhappy feelings and moods and for challenging the faulty "automatic beliefs" that can lie behind them. As such, you can use it to reframe the unnecessary negative thinking that we all experience from time to time. The purpose of cognitive restructuring for insomnia is to learn ways of reducing the mental alertness, repetitive thoughts and anxiety which interfere with sleep. Why will my mind not turn off? Research has shown that people with insomnia complain about an overactive mind in bed. They may or may not be the kind of people who are like that in the daytime too. Some say that they feel physically exhausted at bedtime, but can t get their mind to stop being energetic! Others say that they feel both physically and mentally exhausted, but still they can t stop that racing mind! Many people use their time in bed as a time to think things through, but for people who have trouble sleeping, thoughts and worries can keep them awake. Some people do their thinking at night because of their busy daytime lives, but that may not be a good solution. Others may have more time during the day, but are just in the habit of using bedtime as a time to think. Also, it is difficult to keep your mind empty when it is quiet and you can t sleep! First of all, let s consider the kinds of things that we think about when we are in bed and unable to get to sleep. There are several types of thoughts that are common. Rehearsing and planning thoughts This is when you think back over the day or recent events or when you look ahead to things that are about to come up. It is quite natural to reflect on things, and to plan ahead but your thoughts can keep you awake! Problem-solving thoughts You may have things on your mind because you think this or that needs to be done. It may be something simple or something complicated. You may not have come up

2 with a solution, or perhaps there is no easy solution. In this type of thinking your mind is actually working quite hard, which makes sleep difficult. Thinking about your health After a period of illness, it is natural to find that there are more things on your mind. Some of the thoughts may be worrying and others simply repetitive. Thoughts about your health may involve rehearsing and planning or problem-solving as mentioned above. Thinking about sleeping More likely, thinking about the fact that you re not sleeping! When sleep doesn t come quickly or naturally you may become pre-occupied with your insomnia and how you are going to get through the next day. But, as you probably know, trying too hard to get to sleep keeps us awake! Listening to your body This is a bit like the last one. You start to focus inwards and notice how tired you are, or how awake you are. Maybe you can t stop listening to your heart beat, or some other body sensation like hot or cold or an itch or muscle tension. This kind of thinking can make us very restless. Thinking about thinking In other words thinking about nothing in particular! Your mind may buzz around, darting from idea to idea. With these types of thoughts you may feel you can t control your thinking, even though you are not really worrying about anything! Thinking about things that go bump in the night! We don t really mean ghosts and ghouls! But, sometimes people can t get to sleep because of noises they hear, or think they hear!! The wind outside, people in the street, an unfamiliar sound that we seem to home in on and wonder what it is and so on. It is hard to sleep if you are feeling uneasy. What are the kinds of things that go round and round in your head at night? Do emotions play apart? They certainly do! This can happen in different ways: Maybe there are worries in your life at the moment about family, work, health, money or whatever. So when you are having rehearsing, planning type thoughts, or problem-solving thoughts you probably get strong emotional feelings. Of course,

3 the thoughts plus the feelings with them keep us even more awake. Disappointment, sadness and worry in our thoughts make sleep more difficult. Often people say that they have nothing to worry about, maybe even lots to be grateful for! Like a family to be proud of, and so on. Your mind might go round and round planning or problem-solving, but at the same time you re feeling that these things are unimportant and that there is no cause for you to be thinking so much! You may not be unhappy or anxious in your life, but frustration is another emotion that helps to keep us awake. In other words, it may be because there is no real problem that all this thinking about thinking is so upsetting! Not being able to get to sleep does get us emotional. At times your frustration may even turn to annoyance and anger! You lie there thinking that you can t get to sleep, perhaps knowing that you are keeping yourself awake. You are actually winding yourself up emotionally. It can be pretty frustrating thinking that sleep comes so easily to other people maybe like your partner snoring away beside you! How do your thoughts make you feel? Is it possible to control my thinking? There are a number of things that you can do that will help to overcome the racing mind. First of all though, let s think through some things that might help. Beliefs and good sleep A lot of worry and concern over sleeplessness is based on information and beliefs that are not accurate. Negative or faulty beliefs are faulty because they simply are beliefs - that is, they are not based on fact. Faulty beliefs can be changed, and in changing they can affect your attitudes to sleep which in turn can help to promote sleep! Are your thoughts, and your feelings about them justified? Negative and faulty thoughts can be challenged with correct self-statements. Here are some examples that might help to guide you. You may recognise some of your own beliefs in the list below or you may have ones that are not listed. Whatever the case, you can use the strategy of challenging beliefs to examine and correct your own faulty thoughts.

4 Faulty I will get sick if I don t sleep. Everyone else is sleeping. I m never going to get to sleep tonight. I won t cope well tomorrow. Correct Insomnia does not cause illness. As many as 1 in 5 adults have insomnia. There are many people who are not sleeping right now. I always fall asleep at some point. Sleep is natural and my body will slip into it eventually. I can cope with relatively little sleep. I may be tired but I have done it before and I can do it again Relaxation How often have you thought, If only I could relax, I would be able to sleep? We want you to be able to get your body nice and relaxed in preparation for falling asleep. One way of achieving this, without using any kind of medicine, is to learn how to relax. Therefore, we would like to offer a practical guide to learning relaxation. Relaxation is not just a technique; it is a principle and the principle is of letting go. This letting go is achieved by doing what is called Progressive Relaxation Training. Progressive Relaxation Training is based on the tensing and relaxing of the main muscle groups, and leads to decreases in muscle activity, blood pressure and heart rate. Relaxation can, of course, start in the early evening, but a relaxation routine at bedtime can help you to relax even more, eventually carrying you off to sleep. Your Relaxation Programme Here are the steps you should follow for your relaxation programme: 1. Wind down during the second half of the night. 2. Slow down or stop doing work/activity 90 minutes before bed. 3. Practice the relaxation routine while in bed: 1) Concentrate on breathing

5 2) Tense and relax muscles and breathe 3) Take exercises slowly - do not over tense muscles 4. Practice, practice, practice. We will provide you with an audio relaxation programme which you can listen to at night when you are ready to go to sleep in your bed. This means that you would only turn it on when you are sleepy and in your bed. It is recommended, however, that you also listen to the programme at other times during the day to practice and learn the techniques suggested. When you listen to the programme at other times during the day, please make sure that you do not fall asleep!. and please do not listen to it while driving the car!! Remember to use your relaxation programme every night! Imagery Imagery involves creating a mental image, a kind of picture story in your mind. The imagery story should be: Vivid and clear in your mind s eye Pleasant and enjoyable to follow through Relaxing (of course!) - the main thing is to avoid strong emotion Planned ahead - don t just wait until the time comes Practised - regularly until you are good at it The old idea of counting sheep and watching them jump the gate is an example of imagery. You should choose one image to use each night soon after you go to bed. The image you choose can be a place that you like or find relaxing, like a holiday or a favourite walk. Once you have chosen your image, you should take yourself through the image by imagining each step clearly and in detail. For example, if your image is a beach then you may imagine walking down a beach, stopping and watching the sea and wildlife, feeling the sand under your feet, the gentle breeze and so on. Going over every detail can be soothing and can be strong enough to distract your mind from flitting thoughts. What kind of imagery story might be good for you?

6 Write down a story-line that you can practise:- Putting the day to rest You may find this technique particularly useful for thoughts that have to do with the past day and planning about the following day. The aim is to put the day to bed, along with all your plans for the next day so that you can get to sleep! If you can manage to stop the thinking you usually do in bed before it happens, then you should sleep better. To put the day to rest you need to follow these simple steps: Set aside 20 minutes in the early evening (say around 7 pm) Sit down with a pen and paper Think of what has happened during the day, how it has gone and how you feel about it - put it to rest! Write down anything you still need to do on a to do list with steps that you can take to complete any loose ends Try to use your 20 minutes to leave you feeling more in control When it comes to bedtime remind yourself that you have already dealt with things If new thoughts come up in bed note them down on a piece of paper at your bedside to be dealt with the next day.

7 Remember that the thoughts that interfere at bedtime will be easier to dismiss if they have already been dealt with at a time when you were more awake! Thought-blocking Another way you can deal with repetitive thoughts in your mind is called thoughtblocking. This works best with trivial, unimportant thoughts rather than with more worrying problems. Sometimes these thoughts come to people when they wake up in the middle of the night. When this happens, it is best to start the thoughtblocking immediately upon wakening before you get too wide awake! To use thought-blocking follow three simple steps: Repeat the word the every 2 seconds in your head with your eyes closed Don t say it out loud, but it sometimes helps to mouth it Keep up the repetitions for about 5 minutes (if you can!) Thought-blocking works by stopping other thoughts from getting in. The word the is of course meaningless, so when you repeat it into yourself it doesn t have any emotional effect, except maybe to bore you and that might actually help! Giving up trying Sometimes people are unable to sleep because they are simply trying too hard! Trying to fall asleep actually keeps you wakeful and may lead to irritability when you don t succeed. It is understandable that you want to sleep and then try to make it happen. The drawback is that, unlike many other things in life, sleep is not something that you can make happen by sheer force of will. In fact, the harder you try, the less likely it is to happen. The good sleeper does not do anything in particular to get to sleep! This cornerstone of good sleeping is something that we all have inside of us. At one time, you, too, had this cornerstone of sleep. Now it is time to re-learn it! It is possible and will help you to regain a natural sleep. Here are the steps you can take: Lie comfortably in your bed with the lights off but keep your eyes open Give up any effort to fall asleep Give up any concern about still being awake

8 When your eyelids feel like they want to close, say to yourself gently Just stay awake for another couple of minutes, I ll fall asleep naturally when I m ready. Don t purposefully make yourself stay awake; but if you can shift the focus off working to fall asleep, you will find that sleep comes naturally This technique helps you to stop forcing sleep and relieves the anxiety that goes along with that. If you are tired, sleep will come naturally. It will be good to waken in the morning knowing that you fell asleep even though you gave up trying! This will help to build up your confidence that the normal sleep drive is returning. What is Stimulus Control? Stimulus control is a term used to describe situations in which a behaviour is triggered by the presence or absence of some stimulus. For example, if you always eat when you watch TV, your eating behaviour is controlled by the stimulus of watching TV. If are sleepy when sitting in your armchair, then alert and awake when you get into bed, then you have a poor bed/sleep connection. Can I strengthen the connection between bed and sleep? Yes! Sleep will come more quickly and it will be easier to stay asleep if your mind and body can respond to an important cue: your bed. If you always sleep in your bed and only use your bed to sleep in, you can rebuild a strong link between your bed and sleep. This connection will help promote sleep. There are a number of things you can do to make a strong connection between sleep and the bed. Bedtime activities It is important not to use your bed for anything except sleep. This means that activities like watching TV, reading, using your ipad, eating, and talking on the phone are out! When you go to your bed, you should put the light out straight away and put your head down intending to sleep. Sexual activity is the only exception to this rule; it actually helps us sleep afterwards! The 15 minute rule Of course, there will be nights when you put your head down and sleep will not come quickly. If sleep does not come within 15 minutes, you should get out of bed and go into another room. As with staying up when everyone seems like they are sleeping, getting out of bed when you want to sleep is very, very hard! It may be hard because you feel cosy and don t want to leave the warmth of the bed. It may be hard to know what to get up and do! But there are things you can do to make getting out of bed easier - you could leave the heating on and a table lamp on in your living room. You could prepare a flask of a warm milky drink or a decaffeinated

9 drink before you go to bed. You could read or listen to music, or do something else that is relaxing while you have your drink. After a while of being up, you should go back to bed when you feel sleepy again. If you still cannot sleep, you will need to get out of bed yet again! You should follow these same rules if you waken up in the middle of the night for 15 minutes and cannot fall asleep. Feeling sleepy tired All of us know what being tired feels like: itchy eyes, lack of energy, aching muscles, yawning and so on! People who do not sleep well at night can feel tired during the day. Feeling tired while living from day to day can be exhausting! Although you may feel tired a lot of the time, tiredness is not the same as feeling sleepy tired. Sleepy tired is a signal from our bodies that it is time to sleep for a long stretch of time that is for our night s sleep. We cannot make sleep come on. Unlike eating when we are not hungry, it is quite difficult to get to sleep or to stay asleep when we are not sleepy tired. Even if we can fall asleep it does not mean that we will remain asleep. For example, some people find that they fall asleep quickly when they go to bed, only to wake up as early as an hour later. It is important that you only go to bed when you feel sleepy enough to sleep through the whole night. If you are lying awake in your bed, you are breaking down the connection between bed and sleep, and you are building up a lot of frustration! Try and stay up until you feel sleepy tired. That way you will be more likely to go to sleep quickly, and less likely to lie awake thinking about not sleeping! Avoid napping Another thing to do to strengthen the connection between night-time sleep and the bed is to avoid napping during the day, not even for very short periods. This includes not napping in the evening! Stopping naps will not only better prepare you for a continuous, longer sleep at night but will strengthen the connection between the bed and sleep. Sleeping in a chair in another room weakens that important link. Bedtime wind-down People normally do other activities in the bedroom, such as reading or watching TV, because they have gone to bed before they are ready for sleep. There are things you can do to prepare yourself so that you feel like sleeping when you go to bed. A pre-bed routine is one thing that you can do.

10 Your pre-bed routine should start about minutes before bed when you can start relaxing and preparing for sleep. Your pre-bed routine could include things like slowing down work/activity, brushing your teeth, putting your pyjamas on, setting your alarm clock. Your routine may be a bit more involved: you may sit down an hour or so before bedtime with a hot decaffeinated drink, read or watch TV or listen to relaxing music. This time before bed should help to start your unwinding. For many people, this may be the one time of the day when they have some time to themselves. If this is the case for you, you can make this time into a special time when you do something that you like but which has the purpose of relaxing you and getting you ready to sleep. Think of some ways that you can strengthen your bed-sleep connection. Can I really make these changes? Changes take time so please be gentle with yourself if you do not find improvements occurring as quickly as you would like. They say that old habits die hard and you will need to coax new habits to develop!. and to encourage yourself! Let s pause and spend a few moments considering motivation. You are possibly being asked to make quite big changes to your sleep routine. Also it may be hard to think about getting up during the night, or not having your favourite book in bed. But remember, our aim is to establish a new and much improved sleep pattern. Changes can be difficult to put into practice and be even harder to keep going. You may find that the first few nights are not too bad and that you manage without great difficulty. However, with the arrival of the weekend, your new routine may become more of a challenge! It is at times like these that you have to make that extra effort and stick to the programme. Only by maintaining these changes can your sleep pattern be improved permanently. You may have made great efforts in the past to improve your sleep, efforts which have failed. These experiences can make getting motivated to make new changes all the more difficult. Dwelling on these experiences may make it hard for you to try again, and giving up may be an easier option. It is important, then, that negative thoughts such as, I am never going to get a good night s sleep, are replaced with more positive ones like, This problem is hard to break, but I am going to keep on trying. Keeping motivated is the key to achieving permanent changes in your sleep pattern.

11 Our motivation can come and go; that is to be expected. Relapses can occur and these are times when you experience a strong feeling of disappointment in yourself and think that there is no point in trying again. Please don t let relapses discourage you. The best thing to do is to get right back on that horse and try again! You may never have a better chance to sort out your sleep problems than right now. Good luck and sleep well!