This chapter is about using acceptance-based cognitive tools to optimize your personalized sleep plan. Developing and implementing a personalized sleep program can be very challenging. You are tired of being tired and you want an immediate solution. Unfortunately, CBT-I programs are not geared toward immediate relief. You must tolerate additional discomfort before you see results. You must also change your current habits and patterns. You must convince your already frustrated mind to choose to do something different. You are required to complete worksheets and redesign your daytime and nighttime rituals.
Acceptance-based tools can help you to manage all of these challenges.
As the name implies, the basic premise is that there is benefit to being open and accepting of all of your experiences, including your thoughts. This is a paradigm shift, because our natural response to uncomfortable thoughts is to judge them, evaluate them, and react to them. Thus, the focus of acceptance-based cognitive skills is to train your mind to respond to your thoughts in a different way. We have found that these skills are complementary to the traditional cognitive skills that are taught in CBT-I.
Poor sleepers typically have a hard time turning off the “mind chatter” (Lundh & Hindmarsh, 2002). Busy brains interfere with falling asleep and staying asleep. You may experience this as being “tired but wired.” In fact, people with insomnia have more of this disruptive mental activity than healthy sleepers (Nofzinger et al., 2004). Additionally, poor sleepers worry more and work harder at trying to control their thoughts than healthy sleepers (Harvey, 2001). Acceptance-based tools address all of these challenges.
The acceptance-based tools of mindfulness training and cognitive defusion can help you to manage your busy, active mind. This is especially helpful when you are trying to sleep. It is also useful for decreasing your overall arousal during the day. Finally, these strategies can help you relate differently to thoughts that interfere with your willingness to change your sleep-related behaviors. Here are some clues that these acceptance-based tools will likely be useful for you:
You can use acceptance-based skills with all thoughts. These skills help us remember that thoughts are not facts. Thoughts are just thoughts; they may be true or false or something in between. Acceptance is not about liking or wanting particular thoughts. It is about allowing thoughts to be present without the thoughts influencing your choices in unhelpful ways. “Unhelpful” refers to anything that does not support your values and goals.
It can be helpful to think of acceptance-based skills as skills to improve your mental fitness. Fitness is your general state of health and well-being. Fitness provides the strength and endurance you need to achieve your goals. You can improve your physical fitness skills through cardiovascular exercise, weight-training, and stretching or yoga. Each of these practices contributes to your body’s ability to do the physical things you care about. Think back to our discussion about skiing trees and you will probably agree with us that your capacity to be successful is likely to be greater if you have been strengthening and stretching your body in preparation.
Mental fitness is just like physical fitness. It then follows that your capacity to be successful with a challenging and often uncomfortable sleep program is likely to be greater if you have been strengthening and stretching your mind in preparation. Mental fitness skills will help you tip your scale back toward the side of restorative sleep. These skills will help you quiet your busy mind. They will also help you stick with your sleep program.
There are countless mental fitness skills. Willingness is an example of a mental fitness skill because it encourages your mind to be open, or accepting, of your experiences. We covered this in chapter 4 because we so often find it helpful to work on this early in treatment.
In this chapter we are going to focus on the two additional mental fitness skills we have found to be most relevant to sleep. They are mindfulness and cognitive defusion. Poor sleepers who practice these types of skills have been able to increase their ability to have restful and restorative sleep (Ong & Sholtes, 2010). Mindfulness and cognitive defusion skills can be practiced anywhere at any time. You can do them in a more formal setting with props such as pillows and guided recordings, or you can do them informally with nothing but your mind and your breath. This book contains guided recordings to assist you in practicing these skills.
Mindfulness is intentional focus on the here and now. It is when you are “full of mind.” It refers to any time you deliberately choose to pay attention to what is happening in this moment. Let’s try an example. Set a timer for thirty seconds. Ask yourself to use those thirty seconds to pay close attention to the sounds around you. This can be done with eyes open or closed and with your body in any comfortable position. Just try your best to intentionally focus on the sounds around you. Once the time has passed, ask yourself the following questions.
This is an example of mindfulness training. You engaged in a deliberate and focused exercise to be fully in this moment. In this exercise, you used one of your five senses to guide your focus. You identified the ways your focus shifted (or not). You also noticed what, if any, thoughts showed up. There is no need to assess how well you did this mindful exercise because there is really no correct way of practicing mindfulness. It just takes a willingness to pay attention to your attention. Studies have shown that a daily mindfulness practice (with a cumulative total of approximately thirty minutes) can influence our brains in as little as eight weeks (Hölzel et al., 2011).
Mindfulness is not about achieving a state of happiness or contentment or a blank mind. Oftentimes the information we receive when we pay attention to the present moment is unpleasant or painful. Mindfulness is about using your focus and your awareness to be as open as possible to what you are experiencing right here, right now. Mindfulness is about being present with whatever thoughts, feelings, and sensations you experience. Through mindfulness training you can improve your ability to notice whatever shows up, without necessarily having to act on it. This can help you stay on track with your goals. For example, mindfulness can be helpful when you notice your anxious thoughts about your sleep program. You can be mindful of these thoughts and proceed with the program anyway because it is consistent with your goal of improving your sleep.
When you hear the term “mindfulness” you may also think of meditation. There is a vast amount of information on the similarities and dissimilarities of these two concepts. For our purposes, we will use the term “mindfulness” to refer to the intentional practice of paying attention to this moment. We will use the term “meditation” to refer to a specific type of “formal” mindfulness practice. However, we don’t want you to worry too much about these labels. No matter what you call it, strengthening your ability to focus and pay attention, on purpose, is tremendously helpful with sleep. This is because you are teaching your mind to have contact with the present moment. This will allow you to quiet your mind if an active mind is keeping you awake. It also will allow you to notice anxiety- or arousal-provoking thoughts and respond to them with equanimity.
There are many opinions about how to practice mindfulness. Many mindfulness exercises use the breath as an anchor, but mindfulness does not always have to involve your breath. The most important guideline that we know of is this: just try something! Mindfulness is not a skill you can gain by reading about it or watching a video. You have to do it. Here are some helpful ideas on how to get started.
If you find this thirty-second practice useful, you might try practicing longer—five minutes, or better yet, ten. You can use the guided audio files that are available at the website for this book: http://www.newharbinger.com/33438.
Mindfulness is a practice. It is a skill that develops over time. Mindfulness training creates strength and flexibility. It is one way to improve mental fitness. Optimal practice involves daily commitment. Three minutes every day is more valuable than two hours once a week. Mindfulness can be that accessible.
Cognitive defusion, our second mental fitness tool, comes from acceptance and commitment therapy (ACT). It is derived from the understanding that we can get tangled up and lost in our thoughts. We can literally get “fused” with thoughts. We lose sight of ourselves. We also lose sight of other, often helpful, information. Think about the zoom lens on a camera. When you zoom in, the focus is on one small part of the picture. Your zoom lens screens out all the other information. Now imagine that your eye becomes fused with the lens itself. You are no longer a person looking through a lens. You are the lens. You have no separation between you as a person and you as that lens. That is fusion.
Please note that fusion is not “bad.” Fusion can be helpful in certain situations. When you are driving in traffic it is crucial to pay attention. You want all of your thoughts and awareness to zoom in on your driving. You want to ignore the distractions around you, such as the radio or your phone. In sleep-related situations, however, fusion is often unhelpful. When you are trying to fall asleep, it can be problematic to zoom in on the experience. The zoom lens amplifies your fears. When you get fused to your thoughts in these moments, you end up in the insomnia spiral.
Cognitive defusion is a skill that helps you to step back from the thoughts your mind is generating. In defusion, we are less interested in whether the statements are true, and more interested in how to shift to a wide-angle lens. This is about the relationship between you and your thoughts. When you “defuse” yourself from the content of your mind, you help yourself, and your mind, to be more objective and less reactive.
There are many ways to practice cognitive defusion. As with mindfulness, the key is to engage in experiential exercises. Thinking and reading about defusion is helpful, but will not directly improve your mental fitness. Here are some helpful ideas on how to get started.
What did you notice? You may have had a thought like, Oh there is that thought again, it’s like a broken record. Or you may have said to yourself, Here I am, standing over these thoughts and I wonder why I am doing this. No matter what you thought, it is likely that you got a sense of you as a person, separate from these thoughts. You are you, and those words on the piece of paper are your thoughts. You are not your thoughts. No matter what the content of your thoughts are, you are here in this moment noticing thoughts. You have these thoughts but they do not have you. That is cognitive defusion.
Now imagine that your thoughts are the content of this ticker line at the bottom of the screen. You are the person watching this information move across the screen. Sometimes it is new information. Frequently, it just repeats a story. When you notice that you are here and your thoughts are there (on the screen), you are practicing cognitive defusion.
Your mind: “I am never going to fall asleep.”
You: “Thanks, mind.”
Your mind: “This book won’t be able to help me.”
You: “Thanks, mind.”
Make sure your tone is one of compassion and kindness. Your response should be one of sincerity, not sarcasm. You may not like what your mind is telling you, but you can still thank it. Your mind is only doing what it is designed to do. Minds are designed to generate thoughts, feelings, urges, sensations, and memories at a staggering rate. Your mind also reminds you that you are only doing what you are designed to do. You are designed to notice all of this information. You are designed to let this information support, but not dominate you.
We are going to use George, whom we introduced in chapter 3, to illustrate these skills. George is a self-employed businessman and father of three children. His sleep problems started after the birth of his third child. His current difficulties include trouble falling asleep and waking too early in the morning (around 3 a.m.). He is fatigued during the day, concerned about his job productivity, and anxious about how to fix his sleep problems. George has an active and busy mind. His thoughts are repetitive and racing during the day and during the night.
As part of his sleep program, George starts practicing mindfulness exercises during the daytime. Each day he does at least one routine task mindfully, such as brushing his teeth, lathering on his shaving cream, or kissing his children good-bye. At the office he practices slowing down: after hanging up the phone he takes three mindful breaths before he places his next phone call; and he walks mindfully when going from his office to the conference room or bathroom.
After about a week of practicing being mindful in his daily life, George starts to set aside five or ten minutes for a “formal” mindfulness exercise. Sometimes he uses one of the guided recordings; other times he practices in silence. He usually does this in the evening, after the children have gone to bed. Sometimes the mindfulness exercise has a calming effect. Other times it makes him even more aware of painful emotions and sensations. George reminds himself that the goal is not to feel a certain way. The goal is to be open to all feelings.
George continues to have a busy mind at night. His daytime mindfulness practice helps: when he is lying in bed, he is better able to let go of his thoughts and focus instead on his breath. Sometimes. He decides to add cognitive defusion skills to further untangle himself from his thoughts. His go-to method is to picture his thoughts on the ticker at the bottom of a television screen, though he sometimes places his thoughts on pickets carried by people in a parade, or on leaves floating down a stream.
With a lot of practice and a big dose of willingness, George is better able to step back from his overactive mind and drop into the present moment. He can still enjoy a fast-paced mind when it serves him well during the day. But he can also take brief breaks during the day and feel less frenetic. And he is better able to disengage from his thoughts when he would rather be sleeping.
There are two common challenges with mindfulness and cognitive defusion. The first is using acceptance skills with a change agenda. An example of this is using mindfulness or cognitive defusion during the night specifically to help you fall asleep. The trap has been set; you are using your skills to change your situation. This is a trap because the goal of these skills is not to change your situation, but to increase your acceptance of the situation. Mental fitness skills work best when your intention is to accept whatever is happening as it is, without judgment and without expectation of it being different. In these moments, it is important to remind yourself that you are using mental fitness skills to accept that you are awake, when you would rather be asleep.
The second challenge is knowing when and where to practice mindfulness and cognitive defusion. Of course you will be most motivated to try these skills when you are struggling with falling asleep! This is akin to trying to improve your cardiovascular fitness in the midst of a race. Fitness skills need to be honed in advance. They require time and consistency to build your strength and stamina. It is recommended that you first practice mindfulness and cognitive defusion during the daytime hours (or when you are in your wake cycle). After you have established proficiency during your wake cycle, you then can utilize these skills during your sleep cycle.
“I do not have time.”
Use some of the mindfulness and defusion exercises with this statement. What happens when you step back from this thought? In the few moments it took to work with this thought, you engaged in the very skills you do not have time for! It is as simple and straightforward as that.
“It is too spiritual (or too religious, or too unscientific).”
Although mindfulness has a long tradition in Buddhism and Hinduism, it also can be practiced in a nonreligious, nonspiritual fashion. Over the past several decades, researchers such as Jon Kabat-Zinn and Jeffrey Brantley have applied mindfulness to the treatment of a number of ailments. Mindfulness has gained strong scientific support in our Western world. It is now widely recognized as a useful intervention for both medical and psychiatric issues. Cognitive defusion also is scientifically based. It was largely developed in the psychology laboratory of Steven Hayes. Consider checking out these researchers’ publications to learn more about the science of mindfulness and cognitive defusion.
“It is just a popular trend right now.”
Mindfulness and cognitive defusion are certainly popular right now. For good reason. The studies are consistently and significantly showing the benefits. Even when the trend moves on to something else, you can be sure the benefits will still be here.
“When I try it, I get really uncomfortable.” Or: “When I try it, I get really emotional.”
Yes, mental fitness can be hard to practice. These skills are, at times, uncomfortable. Remember the value of discomfort. Establish some personal guidelines for what is outside your comfort zone but not pushing you into your danger zone. When you are just outside your comfort zone, give yourself reassurance and praise. If you see yourself headed to your danger zone, take a break.
“It does not help me to fall asleep.”
These skills were not developed to help you fall asleep. They were designed to help you accept what is going on, at any given time. You happen to be caught in the spiral of insomnia. These skills will help you interrupt that spiral by allowing you to relate differently to your thoughts. By accepting instead of struggling, and by stepping back from your thoughts, you can decrease your physiological arousal. This will help your body be more primed for sleep, but it will not help you to control your sleep.
Also, these skills will help you to follow through with your program. When your mind serves up obstacles to doing stimulus control or sleep restriction fully, or to making uncomfortable behavioral changes, you can use mindfulness and defusion to deftly navigate these obstacles. You can thank your mind, and then continue to do what we know will help you sleep better in the long term.
“I do not like practicing mental fitness. Do I have to do it?”
No. You do not have to do anything you do not want to do. However, consider whether there is value in trying it anyway. You do not have to like it to find benefit.
Use worksheet 12.1 to record your practice of mindfulness and cognitive defusion. Spend some time considering what types of exercises you would like to use. Set up a time that you will practice these skills. Use reminders, such as Post-it notes or alarms on your phone, to support your plan. Check out the audio recordings that accompany this book (available at www.newharbinger.com/33438) to see if any of these will provide useful guidance.
Worksheet 12.1: Your Mindfulness and Cognitive Defusion Plan
Exercises I am interested in trying include:
My goal is to practice times a week, for at least minutes.
Preparations to make ahead of time (for example, download guided exercises, research local mindfulness groups):
Strategies for remembering to practice (for example, schedule time on calendar, set alert on phone):
|
Date |
Exercise |
Duration |
Notes |
You can expect a nonlinear learning curve with mindfulness and cognitive defusion: two steps forward, one step back. Some days you will find it easier to be mindful of the present moment and defused from your thoughts than on other days. You will notice more improvement if you practice on a daily basis. These skills require consistency and repetition. As your mental fitness increases, you will notice that you are less reactive to your busy mind. You will be able to quiet a busy mind while lying in bed. You will be able to choose a focus such as your breath and keep returning to this focus. Your capacity to hold this focus will increase. Your capacity to recognize when your focus has strayed, and to bring it back, will increase. Mindfulness training can help you become more aware of your thoughts, which is the first step in cognitive restructuring. With designated worry time, mindfulness training can help you more quickly notice when your mind is worrying. Then, when you decide to delay worry to your next DWT, you can use mindfulness to help you shift your attention to the present moment (or whatever you want to focus on). Similarly, you can use the skill of cognitive defusion to say to yourself, Oh, there’s worry. Thanks, mind, but I will worry later! These acceptance-based skills can optimize your ability to work on these change-based cognitive skills.
We have made the point that with mindfulness practice you are not trying to achieve any one particular outcome, such as a blank mind or calm state. Mindfulness is meant to be a “nonstriving” practice. How, then, can you determine whether or not it is “working”? Use effectiveness as your compass.
Although you may not feel relaxed each time you practice mindfulness, practicing regularly can certainly make you feel more centered or calm throughout the day. Are you noticing any decrease in the type of anxious arousal that may be feeding your insomnia spiral? Are you able to use what you have learned in your daytime mindfulness practice to quiet your mind when you are in bed?
Is your practice with cognitive defusion strategies helping you step back from your thoughts? For example, can you notice thoughts like I am so tired, I have to stay in bed longer, but then choose not to act on them? Are you taking less seriously all the catastrophic thoughts about your sleep that your mind serves up? If your mind is busy at bedtime or during a middle-of-the-night awakening (when cognitive restructuring may be too arousing), are you able to use defusion strategies to disengage?
Look back at the treatment plan you developed using worksheet 5.1. Are you already making use of all of the strategies you selected? Have you been doing your core behavioral treatment for at least six to eight weeks? If so, you are ready for part 4 of this book, which will help you evaluate your progress, change your plan if you need to, and maintain any gains you have made.
Otherwise, continue to work your program. You may want to linger here, focusing on the strategies you already are using. Or you may want to continue to add to your toolbox with the cognitive or behavioral strategies you are not yet using. Of course, continue to track your progress using your sleep log and your Sleep Log Summary worksheet.