My struggles with insomnia began in my teens. I remember earnestly, pathetically, telling an old history teacher: “If I am yawning, it is not because I am bored, it is because I can barely sleep.”
“Have you tried a warm bath?” she offered, in what was to be my first instance of well-intentioned but ultimately completely useless advice. I stare at the ceiling until the early hours of the morning, my heart beating so fast it is as if I am being hunted for game. A warm bath is not going to cut it!
Sleep remained consistently elusive for the rest of my life. I tried magnesium, valerian tea, supplemental melatonin, the phonetics of these remedies often more soporific than the results. I blinked in the dark to relaxation podcasts; had an on again, off again relationship with the apps Headspace and Calm. For a while I watched ASMR (autonomous sensory meridian response) videos intended to induce brain tingles and relaxation, but there are only so many times you can view someone slowly brushing their hair before you start to feel gross.
I once heard someone describe sleep as an “old friend” who is “always there for them”. Sleep has been, for me, a decidedly more fickle friend, frequently just about the worst friend going: they will sometimes show up, but are mostly maddeningly unreachable and impossible to pin down. But I made a kind of peace with the ebbs and flows of my somnial life. Still, nothing prepared me for the insomnia I experienced on becoming a mother. I had a traumatic birth. After, I remember blinking in shock, in the early hours of a frigid January morning, my stomach muscles like wisps of chewing gum stretched to ribbons, my brand new baby boy sleeping beside me, unable to sleep despite having been awake for 48 hours.
I remember my own mother telling me I would never sleep the same after having a baby, and in those first months, it is fair to say she was right. I took over all the night-time wake-ups, of which there were many, because I was unable to sleep through them. Even when my baby was sleeping, and I was sleeping, it was still a strange half-sleep, in which I was hyperconscious of him being there, able to hear every sound he made as if they were being piped in beneath my dreams. I could no longer nap.
My son was a terrible sleeper, but around 10 months he had reached a point in which he would not sleep unless I was not just holding him, but holding him standing up or walking around (very unreasonable!). I would pace back and forth at the foot of my bed, listening to podcasts in one ear. Another episode. Another episode. Another. Sodding. Episode. If I so much as sat down, he would bolt wide awake, screaming. I was in a state of permanent fight or flight, of hyperarousal. We made the decision to sleep-train him, and after a brutal three nights, he started sleeping through. Instead of experiencing a renewed golden age of rest, as I’d expected, I found myself tossing and turning through the night. Sleep became gradually less accessible, until one day it disappeared.
My first fully sleepless night came a little before my son’s first birthday. I couldn’t explain it, but I knew in my bones it was connected to the trauma of my labour. I think now of a tweet: “Does the body ALWAYS have to keep the score???” This night underpinned my anxieties in the nights that followed: Perhaps I will not sleep at all? Perhaps I will never sleep again?! I wasn’t confident I should be allowed to participate in public life, playing in the park with my son, having lunch with a friend, dry-mouthed and sticky with sweat, acutely aware of the fundamental wrongness of my body and brain. My maternity leave was coming to an end, I was due back at work, but I felt more exhausted, less capable, than I’d ever felt.
As one does in moments of strife, I took to Reddit. On the insomnia board we all agreed the answer was not to obsess over sleep, yet there we all were, reading and discussing it frantically throughout the night. Medications were listed; tips were shared. But something that was consistently cited, reverentially so, was CBT-i, a form of cognitive behavioural therapy tailored for chronic insomnia that involves restructuring your relationship with sleep.
I had at this point spent a small fortune on hypnotherapy, a stranger whispering to me over the phone (it was during lockdown). She would tell me to imagine myself as a hot air balloon, a wave cresting in the ocean. Could I hear the faint ticking of a distant clock? I’d finish the sessions feeling relaxed to the point of liquefaction, but I still could not sleep. The only over-the-counter sleeping pills I dared take were starting to lose their effect, leaving me grouchy and more lethargic than if I hadn’t bothered with them at all. I was willing to go to extremes, which I was warned CBT-i was.
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Insomnia is on the up. A 2022 study from Nuffield Health’s Healthier Nation Index based on 8,000 people found 74% of UK adults reported a decline in quality sleep over that year alone, with one in 10 getting just two to four hours per night. Sleep deprivation worsens depression and anxiety, and impacts reasoning and alertness. I felt like a tapped tuning fork, vibrating with nerves. I had the sensation I had swallowed something enormous, and it was lodged in my body and throat. I would have parted with a considerable chunk of my savings to get one night’s unbroken sleep, to feel halfway normal for a single day. I was aware of being in a particularly vulnerable state, with many products promising expensive quick fixes (the biohacking company Eight Sleep is promoting an Elon Musk-endorsed mattress cover that responsively controls the temperature of your bed, promising an additional hour of sleep per night – yours for just £2,495) and so it was unsurprising to find that an insomnia treatment overview predicted the global market would reach $6.8bn in 2024.
I bought a CBT-i course from the Insomnia Clinic, one of the few specialist insomnia services in the UK (though more recently the NHS has introduced a similar digital treatment, Sleepio). “Course” was the right nomenclature for the package, as it felt like I was relearning something, practising a new skill. CBT-i offers a combination of interventions, including relaxation and distraction techniques, stimulus control and sleep hygiene, most of which are eminently sensible. You shouldn’t eat or drink caffeine, or doom-scroll through your phone, two to three hours before going to bed. You should lower the lights in the evening. Your bed should only be used for sleeping and sex, not for watching YouTube or staring at spreadsheets. The first week of the course involved keeping a sleep diary, then calculating how many hours I had slept on average a night, before beginning the main bulk (and hardest part) of the treatment: sleep consolidation (or sleep restriction). Once you have an average, you then permit yourself only that amount of time in bed. Not asleep. Just in bed.
There is a paradoxical intentionality to CBT-i, depriving yourself of sleep in order to access it. I was permitted five hours a night in bed, between 1 and 6am (a consistent routine is also part of the training). And even then, you shouldn’t go to bed unless you are actually sleepy. This part of the training required perhaps the most amount of discipline I have ever expended in my life. Before bed, I would do housework, watch entire series’ worth of gently calibrated television: nothing too engrossing, but captivating enough to keep me awake. Sometimes I’d just walk circles around the dining table. The theory is that you build “sleep pressure”, and the more experience you have sleeping in the bed, the more you strengthen your association with it and sleep. If I wasn’t asleep in 15 minutes, I had to get out of bed, walk around the dining table until I felt sleepy, then return to bed, where the same rule applied. If you spoke to me around this time, it is likely I seemed unhinged.
The first few nights were punishing. I was exhausted, entirely wrung out with sleep deprivation, returning to work and childcare, but even after keeping myself awake for hours, I would often find myself in bed, blinking at the ceiling, still unable to sleep. I’d drag myself out of bed, return downstairs, leaf through a book while slowly sipping water, until I felt adequately sleepy again. My morning alarm remained a horror. I’d get up, drink coffee in the backyard, shivering in the gloomy winter dawn. But I gradually saw improvements. My hypnic spasms – those involuntary muscle contractions as your body transitions from wakefulness to sleep, experienced more frequently by insomniacs – started to lessen. I had fewer false starts. The biggest improvement was the flattening of my sleep into larger chunks – fewer middle-of-the-night wakeups – which is why the treatment is called sleep consolidation.
Once I was consistently sleeping five hours, I was able to gradually extend the amount of time I was allowed in bed, by 15 minutes every few weeks or so. It took around six months before I was getting a nailed-on eight hours (though this is not a goal – in CBT-i you are encouraged to figure out how much sleep you realistically need, which may well be less). Alongside this more gruelling bulk of the treatment were more familiar cognitive and relaxation techniques. I learnt to allow my adrenaline to spike as I lay in bed, instead of fighting, conditioning my body to the idea there was nothing to be afraid of, nowhere to run. The key message delivered generally seemed to be: just calm down. Place less emphasis on sleep as part of the broader architecture of your wellbeing; there are many other reasons why you may feel bad.
A 2019 paper for the American Journal of Lifestyle Medicine named CBT-i as the “most effective non-pharmacological treatment for chronic insomnia”, with average reductions of 19 minutes in sleep latency (the time it takes a person to fall asleep) and a 10% improvement in sleep efficiency (time spent in bed actually asleep). Nice (the National Institute for Health and Care Excellence) recently began endorsing CBT-i as the first-line treatment for chronic insomnia, over pharmacological treatments, because of its relative longevity in managing insomnia.
I spoke to Prof Jason Ellis, director of the Northumbria Centre for Sleep Research, which specialises in CBT-i, to ask him about the efficacy of the treatment. He told me he found it better and more durable than other treatments, and something that works just as effectively for people with complex conditions, such as diabetes. “But if you want my honest opinion,” he added, “a lot of the interventions are designed by white middle-class men, who don’t take into account people who have three jobs, who don’t have another room, or bed, to go to.” Ellis told me about research he had been undertaking in prisons, where you cannot get out of bed. “We are coming up with counter controls, in which you might designate a sleeping side and a waking side of your bed.” I was fortunate, in that I had a living room to sit in and a Netflix subscription to watch Call My Agent! on, in those brutal hours before bed.
Ellis also spoke to me about another principle of CBT-i: that of figuring out how much sleep you realistically need, which might not be what he called the “eight-hour myth”. If you’re consistently waking up after six hours of sleep, it might be that is all your body requires, so why make yourself miserable by lying in bed fretting that you’re awake? Our understanding of the function of sleep is still so limited. A recent study, for example, found that a belief that the brain washes out toxins during sleep is perhaps not the case at all. The truisms we have come to accept about sleep, and the science surrounding it, are forever in flux.
I think sleep can become an obsessive preoccupation, and I don’t think headlines such as “Getting less than six hours of sleep may raise type 2 diabetes risk” are necessarily helpful to those already struggling to fall asleep. Insomnia aside, the Nuffield’s 2022 HNI study found that fewer people with household incomes of £15,000 or less got the recommended seven to eight hours of sleep per night than those on incomes over £75,000.
CBT-i fundamentally changed my relationship with sleep, prompting a recalibration of sleep from being a pleasure, an indulgence, to a necessity, like eating my vegetables. I was no longer permitted to linger in bed, to enjoy a lie-in (not that my son allowed for many of them). I now have a very functional relationship with sleep: I go to bed when I’m sleepy, and I get up at more or less the same time every day. I’ve learned to pay it less mind: I survived those nights in which I was pacing around the bedroom with my baby, those nights where I would despairingly watch the sun rise, still awake, still wired, and I will survive them again, if ever they come back around. I’ve had a few instances of relapse where I have had to revisit the treatment, resume my laps around the dining room table. But sleep has always returned within a few days, now in its more formal, business-like attire.
In those treacherous first days of chronic insomnia, I used to compulsively think of a line from Jean Rhys’s Wide Sargasso Sea: “Drown me in sleep. And soon.” Now I try not to think of anything at all: I just lie down and let it happen.
Lara Williams is the author of Treats, Supper Club and The Odyssey
