Mindfulness for Insomnia
Some people in Western cultures have preconceived notions of mindfulness as being linked to a specific religion or practice. The practice of mindfulness comes from the Eastern concept of smriti, a Sanskrit word meaning awareness, or in a more nuanced translation, to come back to awareness. As a meditation practice, mindfulness is generally viewed as Buddhist in its origins. In fact, mindfulness is considered to be the heart of Buddhist meditation. However, experts such as Dr. Jon Kabat-Zinn and others who write on mindfulness, continue to reiterate that there is nothing exclusively Buddhist about practising mindfulness. It is a universal approach that can be practiced alongside other philosophies, religious traditions, or even in a secular sense. Although mindfulness is most often associated with Buddhism, being present and mindful is an important concept in many other spiritual traditions, including Christianity, Islam, Hinduism, Taoism, and Judaism. Over the past several years, some have used the term “secular mindfulness” as a way to denote the use of mindfulness practices in nonreligious contexts.
Mindfulness has existed for more than 2,500 years and involves paying attention on purpose, in the present moment, and non-judgmentally. It can be characterised by attitudinal foundations or principles that include non-judging, patience, seeing things as if for the first time, trust, non-striving, acceptance, letting go, and compassion. There is now substantial research demonstrating the health benefits of mindfulness meditation across a number of chronic conditions including coping with the symptoms of cancer, preventing the relapse of depression, and reducing the symptoms of anxiety.
Mindfulness meditation v relaxation techniques
Mindfulness meditation practices and relaxation techniques/practices are mind–body techniques that have similarities and differences. Having said this, these techniques are often used or discussed interchangeably. The result is that the differences between them become obscured. The National Center for Complementary and Integrative Health (NCCIH) in the United States puts meditation practices in a separate category from relaxation practices but notes that there is in fact some overlap.
There are several similarities between mindfulness and relaxation practices. For example, both types of practices can elicit the relaxation response to counteract the stress response. Although mindfulness practices can elicit the relaxation response and the reduction of chronic stress is one rationale for applying mindfulness practices in clinical settings, the intention of mindfulness and relaxation practices differ. Psychological theories suggest that mindfulness training may also improve psychological outcomes through mechanisms that do not depend on the relaxation response.
In clinical settings, the goal of mindfulness practices is to build awareness and acceptance skills in order to tolerate discomfort, gain distance from unhelpful thoughts, and ultimately make adaptive behavioral choices to reduce suffering and pursue valued goals, even while uncomfortable emotions or physical sensations may be present. On the other hand, the goal of relaxation practices is to elicit the relaxation response to directly reduce physiological and psychological stress, decrease physical tension, and increase a sense of calm in order to promote positive health behaviors and outcomes.
Mindfulness for insomnia
The first book published in modern times (in 2012), on addressing sleep disturbances with mindfulness meditation practices is titled ‘Buddha’s Book of Sleep’ and written by Dr. Joseph Emet. Emet trained in mindfulness meditation with Zen Master Thich Nhat Hanh. According to Emet:
“Sleep is not a new skill that we have to learn. We only have to be aware of how we prevent ourselves from sleeping and stop whatever we are doing that gets in the way. That is why mindfulness practice, which is based on awareness, is a good remedy for sleep problems.”
Two more recent, and more scientifically oriented books, were published in 2017 and 2019. The 2017 book, is titled ‘Mindfulness-Based Therapy for Insomnia’ by Dr. Jason Ong. The 2019 book is titled ‘Mindfulness for insomnia’ by Catherine Orzech and Dr. William Moorcroft. Ong and his colleagues developed what’s called Mindfulness-Based Therapy for Insomnia (MBTI). The programme is tailored specifically to insomnia. It integrates behavioural techniques for insomnia in addition to mindfulness meditation techniques. The mindfulness aspect is very practical in that it helps individuals to learn to recognise and manage uncomfortable thoughts and feelings including those associated with poor sleep.
MBTI is designed to treat the full range of nocturnal and daytime insomnia symptoms. It included the empirically supported behavioural treatments for insomnia (stimulus control, sleep restriction, sleep hygiene). The mindfulness aspect of MBTI is believed to complement these conventional behavioural sleep techniques and to replace the need for cognitive therapy. The mindfulness principles (see later) are cultivated through meditation practices and mindfulness exercises, based on the well known Mindfulness-Based Stress Reduction Program (MBSR) and the Mindfulness-Based Cognitive Therapy (MBCT) for depression programme. The goals of the MBTI programme are: (a) to reduce unwanted wakefulness at night and (b) manage negative emotional reactions to disturbed sleep.
Another recently developed programme is called GMATI (Guided Mindfulness with Acceptance Treatment for Insomnia). It was put together by Orzech and Moorcroft (2019). It uses mindfulness practices, self-compassion training, and acceptance techniques to help reduce the effort and anxiety about trying to make sleep happen. The programme focuses on improving the quality of an individual’s wakefulness so that they can sleep better at night. The logic underlying this is that the harder you try to fix the problem of insomnia, the more you become stuck in a vicious cycle.
Whilst CBT-I directly addresses factors that interfere with sleep, GMATI, like MBTI are indirect approaches. As you practise guided meditations during daytime waking hours, you free yourself from the idea that it will directly improve your sleep. This is very important, because if you meditate with a firm goal of achieving better sleep, it can undermine its effectiveness. Rather, the meditations during the daytime should be viewed as allowing their effects to gradually carry over to indirectly improve your sleep at night.
Mindfulness principles related to sleep
The mindfulness principles related to sleep are practised during formal meditations. They help guide the individual to recognize his or her attachment to rigid beliefs and expectations about sleep and daytime functioning, and then develop a flexible approach to the process of sleep. The principles are as follows:
Acceptance is an active process that involves seeing reality as it actually is i.e. without denying or renouncing any facet of it. It means being able to acknowledge how things actually are, rather than resisting them or pushing them away. The rationale is that adopting an accepting stance, reduces sleep-related arousal and distress. Being able to recognize and accept your current state is an important initial step in choosing how to respond. Many people who have trouble sleeping avoid getting out of bed and going to another room until they feel sleepy, and then return to bed. However, spending long periods of time awake in bed can condition you to being awake in bed. If you are awake, it’s better to accept that you are not sleepy, and get up and do something you enjoy or find satisfying, but nothing that’s too mentally stimulating.
Being attached to sleep or what you perceive to be ideal sleep, usually leads to worry and anxiety about the consequences of sleeplessness. This is counterproductive and inconsistent with the natural process of letting go of the day to allow sleep to come to you. Being willing to let go of trying to fix or change our experience to make it better, requires us to let go of wanting to control this experience. Letting go of our efforts and striving to sleep, makes it more likely that sleep will result. Letting go of an expectation to have a high quality sleep; results in a reduction in the effort put into trying to go asleep. This releases tension and arousal. Also, letting go of rumination, and thoughts about the future or past, helps us to relax thereby facilitating sleep onset.
Having a beginner’s mind involves being aware that each night is a new night. We often have preconceived ideas about the way something will be, and we see things through our memory and experience filters. The principle of beginner’s mind can be applied to sleep by approaching each night free of expectations or emotions that are the result of the previous night or recent nights. A beginner’s mind enables us to let go of making predictions about the future e.g. predicting another very poor night’s sleep. It also enables us to have an open mind about the night’s sleep ahead and just observe how things unfold.
Non-judging refers to thinking, feeling, or responding without the influence of an internal critic. Non-judging is an attitude of “just noticing” thoughts, emotions, or whatever may surface as relevant. It is easy to automatically judge the state of being awake in bed as being negative and unpleasant, particularly if we didn’t sleep well for a few nights. However, negative energy associated with this, can interfere with the process of sleep. When we begin to notice our thoughts, we realise that we are judging ourselves, others, and our experience on an ongoing basis. It’s easy to get stuck on thinking that we should be sleeping for a particular number of hours. However, it’s more helpful to simply acknowledge where we are right now. Being more flexible about how we view and relate to sleep will help us relax, and this creates more conducive conditions for sleep to come about.
Trust involves believing that things will tend to work out in the end. An example would be trusting your natural sleep system and letting it work for you i.e. trust that your mind and body can self regulate and self correct for sleep loss. Develop trust in your sleep system based on knowing that: (a) short consolidated sleep usually feels more satisfying than longer fragmented sleep, and (b) sleep debt/drive can promote good sleep provided it’s not associated with increased effort to sleep. Trusting that your body knows how to sleep when provided with the right conditions is an important step in overcoming insomnia.
Non-striving involves letting go of an attachment to a particular goal e.g. letting go of the goal of trying to fall asleep. Falling asleep happens naturally. It is outside of our control. If we exert effort to try to force ourselves to fall asleep, it is counterproductive and we actually become more alert.
When participating in a programme to improve your sleep, be patient! You are probably working with sleep/wake patterns that you have built up over a long time, sometimes many years. It takes time to unlearn these and make changes for the better. It’s very unlikely that the quality and quantity of your sleep will become much better, very quickly. Be content for improvements in your sleep to take place in their own time. Being patient with the process will result in better sleep coming sooner, as compared to being impatient.
An excellent description of mindfulness principles and how they relate to sleep is provided by The Sleep Health Foundation. You may access this via the link below, under the heading ‘What are the nine Mindfulness principles and how are they related to sleep?’ This description includes two additional principles i.e. Gratitude and Generosity.
There is a growing evidence base for the effectiveness of mindfulness as a stand-alone treatment and in combination with behavioural techniques, for the treatment of insomnia. Several clinical trials have demonstrated that in individuals with sleep disturbances, mindfulness programs have a significant impact on reducing insomnia symptoms and improving sleep quality. Some examples are provided briefly below.
A study published in October 2016 investigated whether additional sessions of cognitive therapy (CT) or mindfulness‐based therapy (MBT) could enhance CBT’s effectiveness in 64 participants with primary insomnia. All participants were given 4 sessions of standard CBT-I. They were then allocated to further active treatment (4 sessions of CT or MBT) or a no further treatment control.
The additional treatments resulted in significant improvements beyond CBT-I on self‐report and objective measures of sleep. The mean scores on the primary outcome measure i.e. the Insomnia Severity Index, were 5.74 for CT and 6.69 for MBT. Both are within the good‐sleeper range.
A systematic review and meta-analysis was published in 2019. 18 trials with 1654 participants were included. The findings suggested that mindfulness meditation may be effective in treating some aspects of sleep disturbance. The results reported also recognized that over time, mindfulness interventions led to lasting improvements in both the quality and quantity of sleep without adverse effects.
A randomised control trial involving 54 adults with Insomnia found that mindfulness-based treatments led to significant sleep improvements such as reduced insomnia severity, reduced awake time at night, and reduced arousal levels before bed. Also, the improvements were durable across the 6 month follow-up period.
A meta-analysis was published in August 2020. This analysed the results of seven randomized controlled trials assessing the effects of Mindfulness-Based Stress Reduction (MBSR) on sleep quality, anxiety, and depression as outcome measures among insomnia patients comprising patients aged above 18 years were included in this meta-analysis. In total, data for 497 patients were analyzed. The meta-analysis concluded that MBSR significantly improved sleep quality and mental health.
A study published in 2014 had as its main goal, to investigate the relationship of mindfulness (in the workplace) with sleep quality and the mediating role of psychological detachment from a day-level perspective.
The study concluded that mindfulness practised during work was related to subsequent better sleep quality, and this relationship was mediated by psychological detachment from work in the evening.
Chronic pain and insomnia are highly co-morbid, and CBT is a recommended treatment for both. However, CBT protocols that treat these conditions together show improvements in sleep but not pain. A study published in May 2020 was used as a pilot for a 6 session group protocol for an integrated CBT/Mindfulness programme for chronic pain and insomnia. This programme showed significant improvements in post-treatment sleep and pain measures.
A study published in May 2020 reported on preliminary data from an ongoing randomised controlled trial investigating the effect of mindfulness-based treatment for insomnia in ‘elderly’ (aged over 50) adults. The preliminary data showed that MBTI may be a promising intervention for ‘elderly’ individuals with sleep difficulties.
Being caught in a vicious cycle of poor sleep
People who experience insomnia, often view it as a problem to be fixed. Being caught in a vicious cycle of poor sleep is how many of these individuals describe their insomnia. Feeling this way triggers concern, which in turn causes more poor sleep, which results in even more concern, and so on. Such a scenario can generate a range of negative emotions, for example, frustration, irritation, and anger. Each of these each feed on the others, creating increased tension, anxiety, and discomfort in the body as well as resulting in an agitated mind. How we respond to being awake, when we want to be asleep, is within our control. We can respond in the way described above, with all the negativity and suffering it brings, or we can choose a different approach. We can acknowledge that we are awake and let go of striving to fall asleep or having catastrophic thoughts about it. Struggling with unwanted thoughts, emotions, and physical sensations associated with insomnia increase physiological arousal levels, which perpetuates the vicious cycle and sleeplessness.
A mindfulness approach to treating insomnia teaches people to be more accepting of what they experience when having problems sleeping, rather than directly making efforts to fall asleep. Being willing and able to accept the experience of poor sleep can result in fewer struggles, less arousal, and paradoxically, greater levels of quality sleep. The key to this approach is the emphasis on changing your relationship with insomnia by using mindfulness meditation.
The mindfulness approach to treating insomnia suggests dropping the focus on the goal of getting to sleep. It offers an alternative ‘goal’. Rather than trying to get to where we want to be i.e. asleep, we re-focus our attention on where we actually are. Also, we should stop trying to fight the situation (being awake), and instead accept it without judgement. This strategy for dealing with insomnia recognises that that frustration/anger/irritation/anxiety associated with not sleeping, are at the core of keeping the problem going. Finding a way to let go of these emotions can resolve a large part of the problem of insomnia. Mindfulness clears the way for the natural process of sleep to unfold, less hampered by tension and hyperarousal.
How mindfulness helps with insomnia
Ong, Ulmer, and Manber have proposed a conceptual framework for the cognitive mechanisms of insomnia. This framework emphasises that mindfulness/awareness and acceptance are essential components in treating insomnia. They propose that insomnia is caused by increased arousal, in which two levels of sleep-related cognitive arousal are present in the context of insomnia. They named these ‘primary arousal’ and ‘secondary or metacognitive arousal’. Put simply, metacognition means thinking about one’s thinking.
Primary arousal consists of cognitive (mental) activity, such as thoughts that directly impair sleep. Secondary or metacognitive arousal is related to the awareness and interpretation of primary arousal, which includes how positively/negatively one evaluates thoughts and beliefs about sleep. Mindfulness interventions specifically target the secondary arousal to increase awareness of the mental and physical states when experiencing insomnia symptoms and then to shift mental processes to an adaptive stance (acceptance) in response to these symptoms. The scientific literature indicates that awareness and acceptance may be the underlying mechanisms of mindfulness in improving sleep quality and reducing psychological distress associated with insomnia.