Acceptance and Commitment Therapy for Insomnia (ACT-i)
Sleep is vital to keep our mind and body healthy and to keep us functioning optimally. Our sleep moves in cycles throughout the night, with each stage of the cycle serving vital functions. When our sleep is interrupted, it causes a range of both night time and day time symptoms, including poor cognitive functioning, reduced physical functioning, and increased risk of other health issues, among many other consequences.
Insomnia is the most common sleep disorder which causes problems with falling asleep (known as onset insomnia) or staying asleep (known as maintenance insomnia). An individual can struggle with both onset and maintenance insomnia. Insomnia can affect people in the short term, for a few weeks at a time, or it can be chronic, meaning lasting over three months.
When insomnia is ongoing it can significantly affect daily functioning and quality of life. Thankfully, there are a range of effective, scientifically proven treatments which can help you to tackle insomnia and get the sleep you need.
What is ACT-i?
ACT is a newer therapy which combines psychotherapy and cognitive behavioural therapy (CBT) methods to address difficult emotions and their associated behaviours. You might also hear it referred to as a ‘third wave therapy’. This simply means that it’s more newly developed and researched, and that it takes into account, “concepts such as mindfulness, acceptance, and cognitive diffusion to alter people’s performance and relationship to events.”
Instead of working to change thought patterns, as with other forms of CBT, ACT works to help you accept your thoughts and emotions, while understanding that they don’t need to lead to actions or have such significance attached to them. This article explains aptly that during ACT patients: “learn to stop avoiding, denying, and struggling with their inner emotions and, instead, accept that these deeper feelings are appropriate responses to certain situations that should not prevent them from moving forward in their lives.”
ACT can be used to treat a range of mental and physical conditions, including insomnia. ACT for insomnia (known as ACT-i) focuses on dealing with the stress, anxiety, and other emotions which often come along with not being to sleep. We’ve all been there: when you’re lying awake in bed at night, you start to worry about the fact that you’re not going to get enough sleep and how that will affect you. It’s common to start feeling very negative (such as thinking you are never going to get to sleep), and to feel stress levels rise. Unfortunately, the more stressed we get, the less likely we are to sleep. As we struggle to fight these feelings and to get to sleep, it becomes a vicious cycle of becoming increasingly awake and agitated.
ACT-i works to help you accept these negative feelings and worries when you are awake, rather than desperately trying to change them or fight them. Dr Guy Meadows explains: “Such acceptance paradoxically acts to lessen the brains level of nocturnal arousal, thus encouraging a state of rest and sleepiness, rather than struggle and wakefulness.” Essentially once we stop trying to fight our emotions and just let them pass us by, stress decreases and we become more relaxed. This gradually encourages sleep and tackles insomnia.
As well as helping you to accept your emotions, ACT-i also works by helping you to commit to strategies and practical changes which are going to increase your likelihood of sleep. These actions, “avert unhelpful patterns of experiential avoidance and promote the ideal safe environment from which good quality sleep can emerge.” When acceptance of emotions and commitment to change is combined, they can equip you with the skills you need to continue getting a restful sleep in the long term.
Now that we understand what ACT-i is, we can take a look in more detail at the methods used to achieve these end goals. Each step is equally as important and is pivotal to tackling insomnia.
As we’ve mentioned, when we can’t sleep stress levels tend to rise, which only perpetuates insomnia. The acceptance stage teaches you to accept the thoughts and emotions you might experience around not being able to sleep without judgement. As you stop trying to change your emotions and instead let them flow, you become less worried by them and simply accept what is happening in the present. This actively reduces stress and with practice, becomes a positive habit that allows you to fall asleep.
A lot of the acceptance stage of ACT-i integrates mindfulness techniques. Mindfulness itself focuses on non-judgmental acceptance of the present and staying grounded to promote relaxation. It’s easy to see how these two concepts overlap and can work together. Through mindfulness you can learn to mindfully notice your senses and your emotions and take them for what they are. In fact, practicing regular mindfulness has been proven to help improve quality of sleep.
This detailed article on the topic explains that using these mindfulness techniques: “can help insomniacs to stand back and observe their level of wakefulness or unwanted thoughts and emotional reactions without becoming overly entangled or judging them, a quality that is inherent in the normal act of falling to sleep.”
The defusion stage follows on from acceptance, continuing to work on the concept that you don’t need to attach such significance to your thoughts and feelings. Rather than ‘fusing’ these emotions and thoughts (which simply means connecting them) with a lot of meaning, and seeing them as something you need to get rid of or solve before you fall asleep, you are thought to defuse or detach them from that meaning. Essentially you will learn that these thoughts don’t have the power to stop you sleeping, unless you give them that power.
Defusion exercises are carried out to achieve this understanding, such as exercises which help you to learn to identify, describe, and name the negative thoughts you’re having in relation to not being able to sleep. Exercises are also used to help you identify emotions and physical sensations. This includes: “‘Physicalizing’ exercises such as objectively locating and describing them (the emotions or physical feelings) and imagining them as objects and giving them a physical shape and colour.”
Valued sleep actions
We then move on to the commitment stage of ACT-i: committed actions and behaviours which are going to actively help you to sleep more restfully. It’s well known that poor sleep habits, such as napping during the day, drinking lots of caffeine to stay awake, and watching TV late at night in bed for example, can cause and worsen insomnia. A lot of psychological treatments for insomnia focus on changing these poor sleep habits and replacing them with positive helpful behaviours which are going to help you sleep.
ACT-i focuses on encouraging valued sleep actions, meaning positive behaviours which will help you to sleep just as mentioned. However, in comparison to other methods (such as CBT-i), where the methods for doing this are quite strict, ACT-i is more flexible. ACT-i aims to help patients make changes that are going to fit in with their individual lifestyle and work for them, rather than taking a strict blanket approach.
These valued sleep actions might include things like relaxation techniques, focusing on making positive calming associations with the bedroom, and focusing on resting rather than sleep. If you can’t sleep, understanding that your body and mind is still getting rest when you’re lying calming in bed can take the pressure off and allow you to relax.
In contrast to CBT-i where you can only use the bedroom for sleep and sex for example, ACT-i allows any relaxing activities within the bedroom. Another example is CBT-i encouraging you to get out of bed if you can’t sleep after around 20 minutes, and come back when you’re feeling tired. Instead, ACT-i focuses on lying in bed and experiencing any discomfort, but still resting: this will in time result in sleep.
The aim of this more flexible approach is to create sustainable, ongoing, positive change for the patient. Dr Guy Meadows explains that the goal is: “a healthy and flexible approach to sleep, any negative associations and therefore arousal levels would be reduced, creating a platform from which natural sleep could emerge effortlessly.”
Sleep restrictions refers to restricting the amount of time you will spend in bed to help to reset your body clock. By reducing the amount of time you’re allowed to spend in bed at night, it’s thought that it will encourage you to be able to sleep for the whole time you’re in bed. This typically starts with the amount of time you are usually able to sleep. So if you’re usually in bed for 8 hours but only sleep for 4 hours, you’ll only be allowed to be in bed for 4 hours.
Your tiredness will increase at first, of course, but with consistency, you will begin to sleep through the full 4 hours you’re in bed. Once this is achieved, the time will be extended gradually until you’re getting the full amount of sleep you need. This technique is very common in CBT-i. While it’s a valued technique is ACT-i, the therapy takes into account patient anxiety.
In ACT-i, it’s understood that reducing the amount of time spent in bed might perpetuate anxiety and stress around not being able to sleep. This might mean that patients are less likely to consistently stick to the rules. Therefore, if during ACT-i the patient’s anxiety is too high, sleep restriction is not used at first. Instead the therapy focuses on reducing that anxiety and working on the acceptance stages, before considering sleep restriction later on.
Which is better: CBT-i or ACT-i?
We’ve mentioned some of the differences between CBT-i and ACT-i, and the fact that ACT-i is a newer therapy whereas CBT-i is the first line of treatment for insomnia. It’s natural that you might be wondering which type of therapy is best. Fundamentally, each therapy is proven to be effective in treating insomnia. They are both fantastic tools for helping people to get the sleep they need.
The differences between the two therapies may mean that one suits you, your personality, and your lifestyle better: it’s more about what works for you as an individual rather than which therapy is better than the other. In fact, rather than the therapies being in competition, some insomnia treatment will utilize techniques from both CBT-i and ACT-i to bring the optimum results for patients.
Where to access ACT-i
Through your doctor
Since ACT-i is a newer therapy, you may be more likely to be offered CBT-i as a first line of treatment, depending where you seek treatment. However, if you feel that ACT-i is more suited to you and your lifestyle, or if you’ve tried CBT-i and it hasn’t worked for you, you could ask your doctor about ACT-i. Bear in mind that, depending on where you live and what is available, you may need to advocate for yourself to get access to the therapy you need.
If you resources allow, you could seek ACT-i face to face privately. If you do so, ensure that you do your research and check your therapist’s qualifications. Take your time to pick someone who is right for you, who is appropriately qualified and registered as a therapist, and who has experience in treating insomnia. It’s important to note that seeking private therapy can be very costly, so ensure you take your budget into account.
Finally you could choose to access ACT-i through an online insomnia treatment programme or an app. This tends to be more cost effective than seeking therapy privately, and still gives you the benefits of being able to access the treatment you want, when you want it. Online treatment enables you to have more control over your own treatment. You can carry out sessions when and where it suits you, fitting in with your lifestyle and preferences.
Nader Salari, Habibolah Khazaie, Amin Hosseinian-Far, et al, (2020), “The effect of acceptance and commitment therapy on insomnia and sleep quality: A systematic review”. BMC Neurology volume 20, Article number: 300 (2020
Psychology Today, (2020), “Acceptance and Commitment Therapy”.
Dr Guy Meadows PhD., (2020), “Acceptance and Commitment Therapy for Insomnia (ACT-I) by Dr Guy Meadows”. Association for Contextual Behavioral Science.