How to Prevent Relapse During Your Insomnia Treatment
This article will conclude our in-depth look at the methods used during cognitive behavioural therapy for insomnia (CBT-i). We’ll focus on what happens towards the end of CBT-i sessions: relapse prevention. We’ll cover what relapses are; what relapse prevention is, and how you can ensure the results from CBT-i are long term.
What is CBT-i?
First, let’s quickly summarize what CBT-i is. CBT-i is a psychological therapy, meaning it’s a talking therapy. CBT-i is structured over a number of sessions, using a range of methods to help you tackle insomnia. The therapy focuses on the connection between your thoughts and your actions. The core goal of CBT-i is to help you change negative thought patterns and behaviours, which can cause and worsen your insomnia. You’ll learn the skills to replace these negative patterns with positive, helpful thoughts and behaviours to improve your sleep.
CBT-i is the primary recommended therapy to treat insomnia and is backed by science, meaning there is lots of evidence to prove it’s successful. By giving you the skills to recognise negative patterns and change them for yourself, CBT-i produces long term results. Relapse prevention is the pivotal final stage of CBT-i: it helps you to move forward feeling confident that you can continue getting the sleep you need.
Three stages of long term insomnia management
The management of insomnia can be divided into three stages, as explained by Dr David Cunnington in this article. We’ll look at each stage to better understand how insomnia can be managed in the long term.
During the initial phase, it’s likely that you will have recognised that your insomnia is causing problems in your life and that you need help. You might start researching how to get help and begin to seek treatment. There are various ways you can seek CBT-i treatment:
- Through your doctor
You might choose to go to your doctor and talk about the sleep problems you’re having. They may be able to refer you to CBT-i therapy if it’s available in your local area. This might involve being on a waiting list.
You could choose to seek therapy privately. If you do so, you must do your research and ensure you choose a therapist who is appropriately qualified, registered, and experienced in CBT-i. Private therapy can be a costly option but allows you to get therapy without waiting.
You could access CBT-i online through an online insomnia treatment programme. This involves online sessions which you access using a laptop, tablet, or smartphone. This can be a more affordable option and allows you to get the therapy you need immediately.
It’s important to note that you should pick what’s right for you when you’re choosing how to access therapy. Each option has pros and cons. It’s about what fits in with your preferences; what’s available in your area, and what suits your budget. In the initial phase you will have accessed therapy and be beginning your therapy sessions.
In the consolidation phase, you will have completed your CBT-i sessions. Your insomnia symptoms are likely to be under control as a result of the therapy. You might be feeling fairly confident that you can manage your symptoms. You will likely have a new bedtime routine and be sleeping on a regular schedule. You may feel less anxious about bedtime and sleep loss and instead may actually have developed a positive relationship with sleep.
During this phase, which includes the few months after your CBT-i sessions, it’s vital you don’t go back to old, negative sleep habits as this can undo the work you did during your therapy sessions. This article explains: “Return of symptoms, or relapse, is common in this phase, and important to get on top of quickly, as the fear of returning to how things were is still fairly real.” Throughout this article, when we talk about relapse, we’re simply referring to your insomnia symptoms returning. Since relapse is most likely during the consolidation phase, you must work hard to keep up with the methods you learnt during therapy so that you can maintain the progress you’ve made.
The maintenance phase is many months after your therapy sessions have ended. During this phase, you’re likely to be feeling in control of your sleep patterns and feel that insomnia is behind you. You will probably feel quite confident in the skills you learnt during therapy and feel happy with the results. You’ll likely be sleeping peacefully most of the time. You might even be able to vary your sleep routine sometimes to fit in with your life, while still maintaining restful sleep.
However, it’s important to remember that during this stage relapses can still occur. Life is constantly changing, and we can’t predict what’s going to happen. Stressful events can occur or unexpected changes can happen which can lead to a short-term return of your insomnia. During this time, it’s essential you already have a plan prepared to help you to deal with any relapses and get back on track quickly. This plan should be part of your relapse prevention.
What is relapse prevention?
As we’ve mentioned, relapse prevention is the final stage of CBT-i. Just as it sounds, relapse prevention helps you to prevent relapses back into insomnia. During this stage, you will review what you’ve learnt during the previous therapy sessions to ensure those lessons are solidified in your mind.
Your provider will ensure you have the skills to recognise triggers for stress and anxiety in your life, which we know can then trigger insomnia. You’ll recap how to be self-aware and notice signs that you are reverting to old, negative habits which could lead to insomnia. Using several methods, you’ll also know how to cope with insomnia relapses if they occur. The aim is to lessen the chances of a relapse occurring, as well as ensuring that you are prepared to cope with any relapses that do occur quickly and effectively.
Are relapses inevitable?
A return of insomnia symptoms is very probable and is completely natural. We know that times of stress can cause insomnia, and it’s impossible to avoid all stress in your life. Therefore, during times of stress, it’s likely that your insomnia symptoms might return in the short-term. Sometimes even when stress isn’t present, you might have the odd period of disturbed sleep. These relapses are very common and happen to the vast majority of people, even after CBT-i treatment.
This article on the topic clearly states: “The nature of insomnia is that symptoms can return. Sometimes this occurs during periods of stress when poorer sleep is to be expected, and other times somewhat unexpectedly. Research and experience shows that this is just part of what happens with insomnia, even if people are generally managing their symptoms well.”
Why are relapses upsetting?
Many people find relapses back into insomnia very upsetting. This is a natural emotion because it can feel like the treatment has failed, or that you have failed in managing your insomnia. It’s common to feel very negative when relapses happen, feeling that you haven’t made any progress or that ‘you’re back to square one’. You might feel very anxious and worried about it. You may fear that your insomnia will come back full force and that you won’t be able to get things under control. You might get very frustrated.
These feelings about an insomnia relapse are all completely valid and natural. However, this is when it’s imperative to remember that a relapse doesn’t mean you have failed! It doesn’t mean the treatment didn’t work, and it doesn’t mean your insomnia is going to take over again. To emphasise this, it’s vital to understand the difference between chronic and acute insomnia. Chronic insomnia is ongoing, typically lasting three months or more. With chronic insomnia, you’re experiencing insomnia symptoms regularly. This is when people tend to reach out for help and engage in CBT-i. The CBT-i sessions you complete will help you to overcome chronic insomnia.
On the other hand, acute insomnia only lasts for a short time. This article explains that acute insomnia typically lasts: “for a few days or weeks and occurs in the setting of a clear trigger such as stress, busyness or illness”. Relapses are similar to acute insomnia: they only last a short time (when you know how to deal with them) and tend to be in reaction to a trigger in your life. CBT-i treats chronic insomnia, but this doesn’t completely prevent short term insomnia symptoms returning. The good news is, CBT-i gives you the tools you need to deal with these relapses effectively so that you can get things back on track and prevent your insomnia from becoming chronic. This is the purpose of relapse prevention.
Reviewing what you’ve learnt
During the first stage of relapse prevention, you’ll go over the methods used during your previous therapy sessions to recap what you learnt. You learn a lot during your therapy sessions, and they will likely be over several weeks. It can be hard to remember all of this new information. Going over what you’ve learnt at the end of your sessions helps keep the information fresh in your mind and reminds you of the important points you need to remember going forward. Let’s take a look at what will be covered during the review stage.
Sleep education and sleep hygiene
You will go over the most important points you learnt during the sleep education stage of your therapy. This might include reviewing sleep cycles; how important sleep is; the effects of sleep deprivation; and the mechanisms in your body which control your sleep. You’ll also be reminded of how important sleep hygiene is, meaning positive habits which increase your likelihood of sleep. It’s crucial that you maintain good sleep hygiene moving forward, so this will be emphasised.
Stimulus control therapy
A stimulus refers to anything, either internal (within your body or mind) or external (within your environment) which creates a response. Stimulus control therapy is a method which works to build a positive association in your mind between your bedroom and sleep. During your CBT-i sessions, you will have been asked to control the stimuli in your bedroom environment to create this association. You’ll go over the importance of maintaining this association, along with the actions you need to take to stay on track with this goal. You’ll also recap how to use stimulus control therapy in the future if you find that you aren’t sleeping well.
The sleep restriction method limits the amount of time you spend in bed for a short time in order to regulate your sleep cycle. Previously in your CBT-i sessions, you will have been instructed to restrict your sleep. You will then have increased the number of hours you spent in bed gradually until you achieved the right amount of restful sleep each night. During the relapse prevention stage, you will no longer be engaging in sleep restriction because you should be sleeping peacefully throughout the night. However, you will recap what you learnt during this time along with covering how to use sleep restriction in the future if you need it.
This method aims to tackle anxiety and worry about sleep loss. The term paradoxical intention means deliberately doing something which seems contradictory or the opposite to what you’re trying to achieve. With this method, you are asked to deliberately try to stay awake rather than trying to fall asleep. The idea is to reduce anxiety around lying in bed awake at night by having you face that fear. When you stop trying to fall asleep, it tends to happen naturally. During the relapse prevention stage, you won’t be engaging in paradoxical intention any more, but you will recap what you learn during this method. You’ll go over how to use the method again to tackle insomnia if you have a relapse.
Cognitive restructuring helps you to identify negative thought patterns which could be contributing to your insomnia. You’ll learn to recognise negative thoughts which are not based in fact: these are called cognitive distortions. You’ll then be taught the skills to replace these negative thoughts with positive, helpful alternatives. Automatic negative thoughts are natural sometimes, even when you have completed insomnia treatment. Cognitive restructuring techniques can be used daily to help you tackle any negative thoughts which crop up. During relapse prevention, you will go over cognitive restructuring techniques to ensure you feel confident using them going forward.
Relaxation techniques involve using mindfulness and other techniques to help you achieve a state of relaxation. This can be extremely useful in tackling stress and anxiety, which contributes to insomnia. During CBT-i, you’ll be taught how to use a range of relaxation techniques to help improve your sleep. These are techniques which should be used regularly, even after your therapy sessions have ended. At the relapse prevention stage, you will be reminded of how to use these techniques and be given guidance on how regularly you should practise them.
Learning how to prevent relapses
As well as reviewing what you’ve covered during your previous sessions, during relapse prevention you will go through a number of techniques you can use to help you lessen the chances of a relapse occurring. Let’s take a look at what these techniques involve.
Utilizing the skills you’ve learnt
As well as reviewing the skills you’ve learnt, you will be guided on how regularly you should use them to maintain your progress. Some techniques will require regular use to prevent relapses. For example, it’s vital to maintain good sleep hygiene as much as possible (ideally every day) to prevent insomnia. This can include things like getting up and going to bed at roughly the same time each morning and night; keeping your bedroom a comfortable, calming place; having a wind-down routine before bed; watching what you eat and drink close to bedtime; exercising regularly, and so on.
It’s also really vital to keep up with the techniques you learnt during stimulus control therapy. Your bedroom should be kept for sleep, relaxation, and sex only at all times going forward. This will ensure you maintain your mind’s association between the bedroom and sleep which you built during stimulus control therapy.
Relaxation techniques should ideally be used regularly to help keep your anxiety controlled and to promote more restful sleep. How often you use them can vary depending on your preferences; what fits in with your lifestyle, and what your provider recommends. You might use relaxation techniques every night in bed, or you might practice mediation during the day twice a week, for example.
Cognitive restructuring should be used only when it’s needed. Some people may find that they don’t often have negative thoughts about their sleep after therapy, so don’t need to utilize their cognitive restructuring skills. Meanwhile, others may need to use those skills now and then if they find negative thoughts creeping in. This prevents things from escalating and causing the symptoms of insomnia to return. Other techniques, such as sleep restriction and paradoxical intention, only need to be used if you do have a relapse, which we will discuss later in this article.
As well as reviewing this information and being instructed on when to use these skills, you might do some ‘refresher’ exercises to give you a clearer view on how you will use them in the future. These exercises could involve a range of things. You might be asked questions about how you would use each technique and need to write down or voice the steps you would take. You might be given worksheets to plan when and how you will utilize specific CBT-i skills. You may even be given worksheets to take away with you which you can use as reminders in the future if you need them.
Looking for ‘signs’
During your previous CBT-i sessions, you should have built an increased self-awareness. This will be important going forward. In your relapse prevention sessions, you will focus on identifying signs that your insomnia is returning or that you are slipping back into old habits which could lead to a relapse.
Some signs might be individual to you, while others may be more common. Common signs might include feeling anxiety or stress start to build. However, how this anxiety manifests can be different for everyone. You might start to feel short-tempered; you might notice you are feeling your muscles tense; you may feel a bit nervous; you might feel your palms are sweaty, or you might feel your heart is starting to race. These are the signs you’re beginning to experience anxiety or stress, which we know can lead to insomnia.
Other common signs that you are slipping back into negative coping strategies might include taking long naps during the day; drinking a lot of caffeine; going to bed late; not maintaining a regular sleep schedule; not prioritizing your sleep, and so on. The idea of learning to identify these signs is to help you to be aware of the very first indications that a relapse is possible. You can then use your CBT-i skills to stop it in its tracks before the relapse occurs.
Anticipating potential problems
Another important factor in preventing an insomnia relapse is to anticipate potential problems. It’s important to consider potential problems which may occur in the future that could increase stress or which could cause you to revert to poor sleep hygiene. This helps you to be aware of risk factors and put the relapse plan (which we will discuss later on in this article) into action. This article explains: “RPT (relapse prevention therapy) aims to limit or prevent relapses by helping the therapy participant to anticipate circumstances that are likely to provoke a relapse. You can develop strategies to cope with these high-risk situations in advance.”
You may be given worksheets to help you identify future potential problems which you want to be aware of and plan for. This will be individual to you and your life. What might make someone else stressed might not affect you. Likewise, if something seemingly ‘small’ might cause you stress, be sure to list it. Everyone’s experience is valid, and it’s important you prepare for your own life realistically.
For example, you might want to plan for big changes if these make you particularly anxious. You might want to focus on stress at work, or a potential house move if you feel that’s in your future. You may want to ensure you mention dealing with arguments within a relationship. You might want to include smaller events which you feel cause you a lot of anxiety, such as being stuck in traffic; being in a room with lots of people; or working hard to try to reach your life goals.
On the other hand, you might want to prepare for events which could lead to you slipping back into poor sleep hygiene. These might include being out socially at night a lot which could affect your sleep schedule. It might be long work days which cause you to feel overtired and lead to you taking naps or drinking a lot of caffeine. Just as with the stress factors we discussed, this will be personal to you and your lifestyle.
Learning how to cope with relapses
As well as learning how to lessen the chances of relapses occurring, a vital part of relapse prevention is learning how to cope with relapses when they occur. This helps you to tackle your insomnia, ensuring it’s short term and that you get back on track quickly. Let’s take a look at some of the strategies which might be used to help you do this.
Using a sleep diary
Just as you might have used a sleep diary in your earlier sessions of CBT-i, during relapse prevention, you may be taught to use a sleep diary if a relapse occurs. You might be given sleep diary templates or worksheets to take away with you to use in the future if you need them. Sleep diaries are detailed records of your sleep patterns. As explained in this article, they include factors such as, “your bedtime routine, approximate sleep onset times, awakenings at night, awakening in the morning, naps during the day and other factors that influence your sleep.”
Using a sleep diary if a relapse occurs helps you to get a clearer view of what has changed in your sleeping patterns. This will enable you to pinpoint behaviours or triggers which are causing your relapse. The more information you have, the better equipped you are to deal with the problem.
Having a relapse plan
It’s vital to have a plan detailing the steps you will take to cope with a relapse when one occurs. As explained here: “It’s helpful to have a plan to manage relapse when it occurs, and important to implement it early to settle symptoms, as when insomnia symptoms recur it can result in a return of anxiety about sleep which is one of the factors that worsens insomnia symptoms.”
Part of this plan will be going through the list you made of potential problems you might encounter. With the help of your provider, you’ll plan how to deal with each problem if they occur to prevent your insomnia from becoming chronic. You can keep the list you’ve made along with the solutions you’ve come up with so that you have clear guidance if you need it in the future.
Another part of your relapse plan is to have a ‘sleep action plan’. This details the steps you should take to use your CBT-i skills if insomnia occurs. You may be given a worksheet to fill out to note these steps so that you have them to hand to follow when you need them. Depending on your provider and your own choices as to what you feel will work best for you, your sleep action plan might include:
- Ensuring you are using good sleep hygiene and correcting any poor sleep hygiene practices
- Planning the relaxing activities you will do if you are awake during the night
- Tackling negative thoughts with cognitive restructuring techniques
- Using relaxation techniques to help you fall asleep at night, as well as to help you get back to sleep if you wake up during the night
- Using stimulus control: this will entail making sure you are keeping your bedroom for sleep, relaxation, and sex only
- Using sleep restriction: you may plan out a schedule of when you should go to bed and wake up according to restricted hours. You will also be given a plan to increase those hours as you begin to sleep restfully.
- Using paradoxical intention: you might plan out which paradoxical techniques you’ll use to ‘try’ to stay awake
Looking at relapse as an opportunity for learning
Finally, your provider might emphasise that relapses are likely and that they are not a sign of failure. It’s important to understand that relapses are likely, but as we mentioned earlier, they don’t mean your CBT-i has been ineffective. You might be encouraged to view relapses as an opportunity to learn. Relapses allow you to utilize your CBT-i skills, allowing you to gain more experience in tackling insomnia on your own. This is a chance to build confidence and learn that you are in control because you have the skills to tackle any bumps in the road in the future.
This article aptly concludes for us by stating relapse prevention: “seeks to prevent this misinterpretation (that relapses are a sign of failure) by representing relapses as prolapses. In other words, relapses are reinterpreted as opportunities for learning and improving coping skills. This perspective serves to keep relapses as time-limited and harmless as possible.”
Dr David Cunnington, (2015), “Why does insomnia relapse? What can be done?” Sleep Hub
Mental Help.net, (2020), “Relapse Prevention Therapy”.
Kris Pierce, (2015), “Have a plan to manage insomnia”. Sleep Hub.