By: Christina Pierpaoli Parker, PhD
For people who struggle with initiating and maintaining sleep—oftentimes for decades—insomnia assumes centrality in their lives, even their identity.
A well-recognized clinical phenomenon in the world of behavioral sleep medicine, insomnia identity describes the conviction that one has insomnia, independent of actual sleep patterns.
So, clinically, like a mentor of mine once remarked, when the patient stops thinking and talking about their sleep — or identifying as an insomniac– you know you’ve done some good, solid work.
Considered the gold standard treatment for chronic insomnia, CBT-I claims high clinical effectiveness and efficacy, with many patients experiencing durable symptom remission. It uses talk therapy—usually over 4-8 visits—to examine unhelpful thoughts, emotions, and behaviors maintaining insomnia and comprises 5 core treatment components: 1) sleep education, 2) relaxation training, 3) stimulus control, 4) time in bed compression/restriction and 5) cognitive therapy.
But for patients who have experienced longstanding symptoms and then don’t after treatment, remission can, admittedly, feel disorienting—even anxiety-provoking. Some of my own have analogized it to feeling naked, or like leaving the house without their phone.
How to manage this tragicomedy of anxiety secondary to insomnia in remission? A few practical thoughts:
1. Reflect and validate the feelings. Feeling felt, feeling understood, feeling seen – sometimes these serve as the best interventions for tricky feelings. What does this mean practically? Reflecting, not repairing. That could sound like some version of this:
“You’re used to having trouble sleeping and you don’t anymore. It feels disorienting and probably anxiety-provoking. That makes sense.”
Beyond demonstrating active listening, reflection—a pillar of motivational interviewing—gifts patients the opportunity to hear and edit their own words while disarming their reflex to convince themselves (and you!) of their experience. Simply hearing “that makes sense” offers a balm to the nervous system and preempts upregulating symptoms. Don’t believe me? Try remembering how your body and brain after someone offered those words in response to your suffering, pain, or strife. The phrase is like the Swiss Army knife of mental health.
2. Get paradoxical. Try not thinking about a white polar bear. Seriously, don’t. Stop!
(You’re probably thinking about a white polar bear.)
Our funny little exercise demonstrates how thought suppression usually increases the frequency of undesired thoughts or behaviors.
Similarly, the common preoccupation with avoiding recurring symptoms among people in remission from insomnia can increase the odds of recurrence. Paradoxically, when we allow patients to experience rebound symptoms—and work collaboratively to decatastrophize them— we can reduce the likelihood and severity of a recurrence. This application of paradoxical intention (PI) encourages patients to radically own, acknowledge, and permit the possibility of their symptoms returning, thereby reducing, or eliminating the performance anxiety associated with avoiding them.
Through exposure, PI minimizes sleep performance anxiety, diverts attention from sleep effort, and promotes expectation management– freeing patients of both having to manage insomnia AND the (potential) disappointment of re-experiencing symptoms. Paradoxical intention may look and sound like this:
- “Let yourself experience symptoms. Try staying awake for as long as possible.” (though, of course, the goal isn’t to keep yourself symptomatic)
- Lie comfortably in your bed with the lights off, but keep your eyes open (an exposure exercise, this helps teach patients the non-catastrophic implications of staying awake).
- “Let go of the expectation of full remission.”
- “Adopt a mindset of not expecting anything.”
The more patients try to do one thing (allow symptoms), the more the opposite may happen (maintained remission).
3. Use psychoeducation. Cognitive therapy assumes thoughts (i.e. how we process information), feelings, and behaviors have synergistic and reciprocal relationships. In other words: how we think influences what we feel and do; what we do can influence how we feel and think, too.
Conflating insomnia symptoms with a relapse illustrates a common, cognitive fallacy people in recovery can commit. And as a form of catastrophizing, this confusion can perpetuate insomnia via psychophysiological arousal–the disorder’s signature. Because telling yourself you’re experiencing a relapse (vs. having symptoms) sounds much, much scarier and feels more activating.
An elegant and effective intervention uses psychoeducation to differentiate symptoms from relapse. This typically sounds like: “You can have symptoms without experiencing a relapse.”
…and then clearly defining the terms: “You can experience symptoms— or features of a disorder—without having a relapse, which describes a full-blown return of the clinical syndrome prior to undergoing treatment. Symptoms don’t mean relapse.”
Empowering patients to understand and label the difference interrupts inflammatory cognitive processes implicated in maintaining insomnia.
4. Reframe. But as any good cognitive therapist knows, teaching patients to consider and sit with the worst-case scenario has its own unique therapeutic benefits. Reframing a relapse as an opportunity to refine and sharpen newly acquired CBT-I skills leverages the benefits of both cognitive and exposure-based techniques. My recommended script sounds like some version of this:
“Experiencing relapse does not undo the skills you’ve learned, if anything, it sharpens them. Even if you do experience a relapse, you now have the skills and support to navigate it. And it’s never going to be harder than the first time. You may experience symptoms again and that’s frustrating but manageable.”
Collaborating with patients to help them translate these scripts into their own coping statements, preferably through writing, usually enhances the therapeutic potency of these interventions.
For those who have experienced longstanding symptoms of insomnia, remission can have associations with secondary anxiety. Anticipating these feelings with your patients as well as creating a thorough discharge and relapse prevention plan using reflection, validation, paradoxical intention, psychoeducation, and reframing can help to manage and prevent symptoms of both.
Of course, should your sleep issues cause significant distress and impairment, consult with your healthcare provider or a behavioral sleep medicine specialist. Hope and effective treatments exist.