We all heard that good sleep is the foundation of a healthy and fulfilling life, yet many find themselves caught in a cycle of restless nights and tired days. About 1 in 3 adults will experience some insomnia symptoms, or in other words, not sleeping as well as you should. The lack of sleep can manifest itself in many ways, from not being able to remember things during the day, to mood disruptions and even some physical symptoms. There is rarely one certain cause for insomnia, usually it is a mix of neurobiological, hormonal, and psychological factors that are at play. Psychotherapy, with its holistic and individualized approach, can offer a pathway to understanding and then hopefully resolving these issues, helping individuals reclaim the restorative sleep they need. Unlike other interventions that might focus solely on medications or generalized sleep hygiene tips, psychotherapy delves into the root causes of sleep disturbances. This is both the good and the bad news. The good news is that by addressing both the conscious and subconscious barriers to sleep, psychotherapy offers a more sustainable and reliable path to restful nights. The bad news is that there is no immediate fix to sleep problems, and it requires some dedication and perseverance to create change.
Psychotherapy can address the biological contributors to sleep issues, such as stress-induced hyperarousal and hormonal imbalances, while simultaneously tackling the psychological challenges, including possible unresolved trauma, anxiety, and maladaptive thought patterns. On a behavioral level, therapy can help instill healthier habits and routines that align with the body’s natural rhythms, breaking cycles of sleeplessness and fostering restorative sleep.
The Neurobiological and Hormonal Roots of Insomnia
As trivial as it might sound to us, sleep is not something that just happens when we are tired enough. The state of sleep is carefully orchestrated by the intricate systems in the brain and body. Neurotransmitters like gamma-aminobutyric acid (GABA), serotonin, and dopamine act as conductors, regulating the sleep-wake cycle, while our hypothalamus helps us align the circadian rhythms with the natural world. But even if we are being lulled to sleep by the wondrous inner workings of our body, the stress, trauma, and lifestyle disruptions can throw these systems into disarray.
When people are experiencing stress (be it a real or a perceived trigger), the hypothalamic-pituitary-adrenal (HPA) axis produces a response. This axis is a link, a communication channel between different organs in the body that ensures a steady response to regulate the stress. Usually, to address a perceived stressor or a threat, the body releases cortisol —a hormone that, while essential for survival, can interfere with sleep when chronically elevated (España & Scammell, 2011). For the record, the same hormone is normally being released in the morning to help us wake up, stay alert and go about our day. That’s to say that it is not cortisol’s fault per se, but the timing of its accumulation that can seriously disrupt the sleep pattern. This heightened arousal perpetuates insomnia, creating a cycle of sleepless nights and anxious days. Similarly, conditions like ADHD and trauma-related disorders can disrupt neurotransmitter balances, further complicating the landscape of healthy sleep (Galovski et al., 2015).
In general, any hormonal shift can impact sleep. For women, it complicates the situation even more, with these shifts occurring monthly, or during menopause and pregnancy. The changes in estrogen and progesterone levels, that are tightly intertwined with women physiology, can affect sleep in many ways (Dorsey et al., 2021). However, these biological realities are not necessarily a cause for concern. The more we understand about the elements at play, the better we can correct and adjust our approach when dealing with sleep issues.
The Psychological Web of Insomnia
Beyond biology, our thoughts and emotions weave in yet another layer of complexity. Stress, unresolved trauma, depression, and cognitive distortions often create a mental environment that hinders sleep. The racing thoughts of stress-induced hyperarousal can make the bed feel like a battlefield, with healthy sleep being an unattainable goal. In some instances, unresolved trauma can add yet another layer to the complexity of bad sleep. For individuals haunted by nightmares, sleep becomes a perilous journey. In these instances, it’s the HPA axis that remains overactive, keeping the body on high alert long after the immediate danger has passed (The Neuroscience of Sleep, 2009). Same response is noticed in people with anxiety disorders, where they are unable to have restful sleep because they remain on high alert 24/7.
The social media tends to exacerbate these symptoms tenfold by adding even more challenges. The blue light from screens suppresses melatonin production, while the constant influx of information and social comparison heightens stress and delays sleep onset (Poe et al., 2010). All that can result in difficulties in transitioning to sleep, delayed circadian rhythms, and emotional dysregulation.
Psychotherapy: A Path to Restorative Sleep
So how can therapy get you to sleep full 8h? Psychotherapy can act as a guide, helping individuals navigate the tangled roots of their sleep struggles and then address the issues. It also can offer tools for a sustainable, long-term change.
Rewriting the Stress Story
Stress may be one of the most common culprits of sleeplessness, but it doesn’t have to control the narrative. Psychotherapy offers evidence-based techniques, such as mindfulness-based stress reduction (MBSR) and relaxation training, to lower cortisol levels and quiet the mind. Cognitive-behavioral therapy for insomnia (CBT-I) goes a step further, challenging negative thought patterns and teaching healthy sleep hygiene practices (Morin et al., 2006).
CBT-I is particularly effective because it addresses both the cognitive and behavioral aspects of insomnia. Studies have shown that CBT-I has a success rate of approximately 70-80% in improving sleep quality and reducing symptoms of chronic insomnia (Schramm et al., 2015). For instance, research indicates that individuals undergoing CBT-I experience significant reductions in the time it takes to fall asleep, the frequency of night awakenings, and overall sleep anxiety. By restructuring negative thought patterns about sleep and introducing different behavioral strategies, such as stimulus control and sleep restriction, CBT-I not only alleviates insomnia but also fosters long-term improvements in sleep health. Techniques such as stimulus control therapy help individuals associate the bed only with sleep, while sleep restriction therapy recalibrates the body’s natural sleep drive by limiting time spent in bed awake. These methods can improve sleep quality and also empower individuals to break the cycle of sleeplessness and anxiety by equipping them with tools to use whenever needed.
Addressing the Symptoms of Depression
Sleep disturbances are common in individuals with depression, often manifesting as insomnia, characterized by difficulty falling or staying asleep (Schønning et al., 2022). Depression can also alter the hormonal function of the body, which might cause sleep distortion. A study focusing on individuals with major depressive disorder found that initial insomnia was the most frequently reported sleep issue. Interestingly, the severity of insomnia symptoms did not significantly correlate with the level of depressive symptoms at the study’s outset.
Therapeutic interventions, such as mindfulness-based cognitive therapy, have been found helpful in alleviating sleep disturbances associated with depression (Schramm et al., 2015). Psychotherapy can help reduce the sleep disturbances by addressing the underlying psychological factors which, in turn, can lead to improvements in sleep quality.
Healing Trauma, Restoring Peace
Trauma can cast a long shadow over sleep, even years after it happened. For many, the bed can become a reminder of vulnerability, a place where nightmares or hypervigilance take hold. Trauma-focused psychotherapies, such as eye movement desensitization and reprocessing (EMDR) and prolonged exposure therapy, can help individuals process distressing memories, reducing their impact on sleep. EMDR, for instance, allows individuals to reprocess traumatic memories in a safe and controlled environment, diminishing their emotional intensity and frequency of intrusion during sleep. Similarly, prolonged exposure therapy helps individuals confront and desensitize themselves to traumatic triggers, breaking the cycle of hypervigilance that disrupts sleep. These approaches not only reduce the frequency of nightmares but also improve overall sleep quality by addressing the root psychological arousal that perpetuates insomnia. By integrating these therapies, clients often report feeling more at ease both during the day and when attempting to rest, fostering a sense of safety that is essential for restorative sleep. These therapies work by targeting the underlying emotional arousal that perpetuates sleep disturbances.
Mindfulness-based interventions also play a critical role in calming the nervous system. Practices like body scans and mindful breathing foster a sense of safety, allowing individuals to relax and transition more easily into sleep. This proved beneficial for those with PTSD, as it addresses the hyperarousal and emotional dysregulation often associated with the condition (Bottari et al., 2023).
Changing Behaviors, Transforming Sleep
Behavioral interventions are often the first choice of therapeutic approach for sleep. Clients can learn to identify and replace unhelpful habits with sleep-promoting routines. For example, setting consistent wake and sleep times, avoiding caffeine in the evening, and creating a calming pre-sleep ritual can significantly improve sleep quality. In our day and age, going off social media and avoiding scrolling the feeds before bed proved to be essential for sleep improvement.
For individuals with ADHD, for example, therapy often emphasizes the importance of structured routines. Techniques such as time management training and relaxation exercises help manage impulsivity and create a predictable environment conducive to sleep.
By addressing the individual underlying causes for sleep distortion, therapy ensures that bedtime becomes a peaceful transition rather than a nightly struggle.
Navigating the Digital Landscape
The glow of a phone screen has become the modern-day antagonist of sleep. Psychotherapy can help clients set healthy boundaries with technology, replacing late-night scrolling with restorative activities. Behavioral strategies, such as establishing screen-free zones or implementing a wind-down routine, counteract overstimulation. Addressing deeper issues, like fear of missing out (FOMO) or low self-esteem, can ensure a lasting change.
Embracing Circadian Rhythms
Our bodies are wired to follow the rhythms of nature, but modern life often pulls us out of sync. Therapy introduces tools like light therapy and consistent sleep schedules to realign these rhythms. Psychoeducation helps clients understand how simple changes, like morning sunlight exposure or regular meal times, can profoundly impact sleep. For those working night shifts, the process can work differently. In therapy, a client can establishing healthy ways to re-route the system and adjust to the new schedule without sacrificing their sleep.
Honoring Hormonal Changes
For those navigating hormonal shifts, psychotherapy can offer insight and tools to manage the challenges. Women facing sleep challenges due to menopause or pregnancy, for instance, can benefit from mindfulness practices and relaxation techniques designed for their specific needs. Therapy also provides a safe space to discuss medical options and lifestyle adjustments, empowering clients to make informed choices that can truly make a change.
The Therapeutic Alliance: A Path to Restful Sleep
Fixing one’s sleep is not a one-day task. Whereas medical options can offer some relief, without understanding and addressing the underlying issues, the lasting change is that much harder to achieve. Therapy can offer a deeper insight into what might be causing insomnia. Both the right medical practitioner and a therapist need to understand the interplay of biological, psychological, and behavioral factors that keep us awake. In therapy, the client will have the space of trust and collaboration that allows for change to happen. Psychotherapy can also offer a refuge from the isolation and frustration that often accompany insomnia.
The therapeutic alliance plays a crucial role in providing a supportive environment where clients can explore their challenges, recognize small but (always) significant progress, and build the resilience necessary for improving their sleep (Lorenzo-Luaces & DeRubeis, 2018). For example, clients struggling with insomnia often describe how a strong rapport with their therapist enables them to feel heard and validated, reducing the sense of isolation that exacerbates their condition. When appropriate a therapist can offer the words of encouragement, or celebrate the small victories like adhering to a consistent sleep schedule or successfully implementing relaxation techniques. These positive interactions can instill confidence and reinforce the belief that change is possible, creating a virtuous cycle of improvement. Anecdotally, one client reported that simply knowing their therapist understood their struggles and believed in their ability to achieve better sleep was a transformative aspect of their healing. Through therapy, individuals are able to address underlying issues such as stress, unresolved trauma, and maladaptive behaviors. In psychotherapy, the clients can learn a number of effective strategies to overcome sleep disturbances, fostering a healthier balance in their overall well-being. If you’d like to explore this topic more, or if you have any questions about this, please feel free to reach out to me.
