Relaxation techniques include progressive relaxation, imagery training, biofeedback, meditation, hypnosis and autogenic training, with little evidence to indicate superiority for any one approach. Patients are encouraged to practice relaxation techniques throughout the day and early evening. Even a few minutes two to four times a day is useful. A last-minute relaxation attempt minutes before sleep will not work miracles. Muscular tension and cognitive arousal (eg, a “chattering” mind) are incompatible with sleep. At the cognitive level, these techniques may act by distraction. Relaxation reduces physical and mental arousal but is less effective as a stand-alone treatment and is better used in combination with other treatment interventions.
Cognitive therapy involves enabling the patient to recognise how unhelpful and negative thinking about sleep increases physiological and psychological arousal levels. Setting aside 15–20 minutes in the early part of the evening to write down any worries, make plans for the following day and address any concerns that might arise during the night allows the day to be put to rest. It is helpful to challenge thoughts that arise at night with “I have already addressed this and now I can let go of it!”. “Time out” — some form of soothing activity before bed — can be useful in reducing arousal levels. Thought-stopping attempts or blocking techniques, such as repeating the word “the” every 3 seconds, occupy the short-term memory store (used in processing information), potentially allowing sleep to happen. Cognitive restructuring challenges unhelpful beliefs, such as “if I don’t get enough sleep tonight, tomorrow is going to be a disaster”, which maintain both wakefulness and helplessness. Another cognitive and behavioural technique is paradoxical intention. Clients are encouraged to put the effort into remaining wakeful rather than trying to fall asleep (decatastrophising), thereby strengthening the sleep drive and reducing performance effort.