Do you like getting out of bed in the middle of the night if you can’t sleep? If you’re anything like The Sleep School’s clients, the answer is most definitely “No” and you’re probably fed up with being told to do so. We all know that lying in bed stressing about the fact that you can’t sleep is unhelpful; however, it’s our belief that telling people to get out of bed every 15 minutes (aka ‘the quarter-hour rule’) if you can’t sleep, is equally unhelpful.
Cognitive Behaviour Therapy for insomnia (CBT-I) is well established, but it is unworkable. Counterintuitive techniques such as stimulus control, sleep restriction and thought challenging are often cited as the reason why it doesn’t work for everyone and reports only moderate levels of effectiveness and poor long-term adherence.
If the aim of the quarter-hour rule is to limit the amount you lie in bed struggling, then surely the focus should be on teaching individuals to struggle less with the discomfort, rather than getting out of bed to avoid it. You wouldn’t tell an anxiety sufferer that the key to long-term happiness is to avoid all anxious situations; so why tell insomniacs to avoid the bed?
At The Sleep School, we are pioneering a new approach using Acceptance and Commitment Therapy for insomnia or ACT-I. This challenges the established dogma by teaching people to change their relationship with their insomnia by increasing their willingness to experience it. Given that it is often people’s nightly battle with insomnia that keeps them awake, learning an effective approach to gently staying in bed with their insomnia presents a powerful new way of overcoming it.
How Staying in Bed Helps . . .
Whilst I am not against getting up in the night because even normal sleepers do it every once in a while, for the reasons laid out below, I do not believe that forcing people out of bed if they can’t sleep is a long-term workable strategy for recovering from insomnia.
Given the choice, most of us would prefer to lie awake resting in a warm and cosy bed. Intuitively this makes sense because if you’re going to fall to sleep you don’t want to be downstairs doing the ironing or reading a boring book, as is commonly recommended.
You also get a lot of benefit from resting in bed, something which our clients report saves their valuable energy for living their lives, an action that paradoxically improves their sleep by lessening the mental resentment that ‘insomnia is ruining their life’.
Teaching people to be willing to be awake also cultivates a much healthier mental attitude towards sleep, especially when compared to the unhelpful pressure of knowing that if you’re NOT asleep within 15 minutes then you’ve got to get up!
The assumption that people automatically feel more relaxed once they get out of bed is also questionable. For many Sleep School clients leaving the bedroom is often associated with the end of sleep, fuelling classic insomnia woes such as “Why can everyone else sleep and I can’t”, and triggering feelings of failure, loneliness and despair, none of which help sleep.
For clients whose anxiety does dissipate on escaping the bedroom, they run the risk of ‘using’ this technique as an avoidance strategy, similar to using alcohol to mask feelings of anxiety and force oneself to sleep. Unsurprisingly, such clients report their unwanted thoughts and feelings waiting for them when they return to bed and thus feeling helpless as to how to deal with them, other than to simply escape again.
Even the theory that getting out of bed limits the opportunity for unhelpful sleep associations to be formed is questionable. I have seen many clients whereby the act of religiously getting up has resulted in a new association that the night-time is for getting up and being active, unhelpfully waking them up night after night to do just that.
It has also been argued that getting out of bed increases the body’s natural sleep drive, increasing the likelihood of sleep when getting back into bed. I disagree with this since sleep drive is dependent on being awake and will increase whether you’re in bed or not.
At The Sleep School, we believe that sleep need not be a struggle. We use mindfulness and acceptance-based approaches to help you ‘watch’ and ‘welcome’ everything that shows up in your mind and body moment by moment, whilst benefitting from the rest by staying in bed. You can’t control what shows up in the night, but you can always choose the most helpful response. Paradoxically, when you can give yourself permission to be awake, you remove the obstacles in the way of falling to sleep.