Paradoxical intention for sleep

What is paradoxical intention?

A way of taking the effort out of falling asleep by turning it round. You go to bed as usual and put the light out, and then, instead of trying to sleep, you lie there with your eyes open in the dark and let yourself stay awake — not by doing anything, simply by giving up on sleep for now.

In the clinical version, as the American Academy of Sleep Medicine’s task force describes it, the person is asked to stay awake as long as possible after getting into bed — deliberately doing the thing they fear, staying awake, so that the anxiety about performing and the conscious intention to sleep stop getting in the way (Edinger and colleagues, 2021).

The idea is older than sleep medicine. Viktor Frankl, the Viennese psychiatrist who founded logotherapy, described paradoxical intention as one of its techniques (Frankl, 1960), and by the late 1970s behaviour therapists were testing it in people with insomnia.

Why would trying to stay awake help you sleep?

Because sleep is one of the few things that effort makes worse. Colin Espie and colleagues trace how poor sleep takes hold along what they call the attention–intention–effort pathway: noticing sleep, then intending to sleep, then trying to make it happen. Their argument is that sleep is a relatively automatic process, and that focused attention and direct attempts to control it can inhibit it (Espie and colleagues, 2006).

Paradoxical intention takes away the intention. If you are not trying to sleep, there is no attempt for sleep to resist, and nothing to fail at. Why trying to sleep keeps you awake goes further into the theory.

One study tested exactly that mechanism. Broomfield and Espie (2003) recorded a week of sleep in 34 people who struggled to fall asleep, then randomly assigned them to 14 nights of paradoxical intention or none. Those practising it reported significantly less effort to sleep, and less anxiety about sleeping, than the controls. Measured by actigraphy — a movement sensor — the time they took to fall asleep was no different from the controls’; by their own estimates it tended to be shorter. The authors thought that gap more probably reflected how readily anxious sleepers overestimate the sleep they lose.

In other words, the clearest effect is on the trying itself — which, for many people who lie awake, is the problem.

Does paradoxical intention work?

Reasonably well, by the standards of a single technique, on evidence that is real but thin.

• An early trial. In 1979, Turner and Ascher compared paradoxical intention with progressive muscle relaxation and stimulus control in people with sleep difficulties. All three reduced sleep complaints more than a placebo or a waiting list, and none did better than the others (Turner and Ascher, 1979).
• The reviews. A 2006 review of 37 studies, done for the American Academy of Sleep Medicine, counted paradoxical intention among five psychological treatments that met the criteria for empirically supported treatment (Morin and colleagues, 2006). The academy’s practice parameters that year called it an effective therapy on its own, at their “Guideline” level, one step below the strongest (Morgenthaler and colleagues, 2006).
• The meta-analysis. The first systematic review and meta-analysis of the technique, in 2022, found 10 trials. Compared with no active treatment, paradoxical intention led to large improvements in key insomnia symptoms and large reductions in sleep-related performance anxiety; compared with other treatments, the improvements were smaller but still moderate on several central outcomes. The authors’ own caveat is that methodologically stronger studies are needed before firmer conclusions (Jansson-Fröjmark and colleagues, 2022).

What the 2021 guideline says

Less than you might expect. The American Academy of Sleep Medicine’s 2021 guideline makes recommendations on six behavioural and psychological treatments for chronic insomnia, and paradoxical intention is not one of them (Edinger and colleagues, 2021).

Its task force did review it. It found 5 randomised trials, only 2 of which reported time to fall asleep in a form it could analyse: in one, people fell asleep about 28 minutes sooner by their sleep diaries than with a placebo treatment; in the other, there was almost no difference. It rated the overall quality of the evidence very low, noted that most of the studies reported nothing but the time it took to fall asleep and that the trials were small and decades old, and said that for some patients the instruction to stay awake could raise anxiety about sleep.

Put together: decades of small trials, mostly favourable, a recent meta-analysis in its favour, and no recommendation from the 2021 guideline — which does recommend CBT-I, stimulus control, sleep restriction and relaxation.

How do you do paradoxical intention?

Gently, which is the whole skill.

1. Go to bed when you feel sleepy, at about your usual time, and turn out the light.
2. Lie in a comfortable position with your eyes open in the dark.
3. Give up trying to fall asleep. Tell yourself, mildly, that there is no need to sleep yet, and that you will stay awake a little longer.
4. Don’t do anything to stay awake. No phone, no reading, no getting up to keep busy, no propping your eyes open. You are not fighting sleep; you are just not chasing it.
5. Let thoughts come and go. If your eyes want to close, let them, and don’t make a note of it.
6. Leave the clock alone. How long you have been awake is not part of the exercise.

Two points keep it from turning into something else. It is not sleep deprivation: if sleep arrives, you let it. And it is not forcing yourself to stay up: the moment staying awake becomes an effort of its own, you have swapped one kind of trying for another. The point is giving up the effort to sleep, not fighting sleep.

Give it more than one night. The 2003 mechanism study ran for 14 nights, and the first few can feel strange. If lying there stops being restful and turns into a struggle, a different piece of advice takes over: get up, keep the light low, do something dull and come back when sleepy (what to do when you can’t sleep).

Who is paradoxical intention for?

People who try very hard to sleep. If your nights feel like a performance — willing sleep to come, monitoring how awake you feel, dreading another bad night — paradoxical intention is aimed squarely at you, because what it removes is that pressure. The 2022 meta-analysis found large reductions in sleep-related performance anxiety compared with no active treatment, and the 2003 study found it lowered the effort people put into sleeping.

It is a technique for getting to sleep. Most of its studies measured only the time people took to fall asleep (Edinger and colleagues, 2021), and the one study of how it works was in people who struggled to fall asleep. The same logic may help after waking in the night, but that is not what the trials tested.

If doing nothing is harder for you than doing something, a routine may suit you better — the military method relaxes the body step by step, and 4-7-8 breathing gives you a slow count — as long as it stays a way to spend the time, not another way of trying.

When does paradoxical intention backfire?

• When it becomes another performance. “I must stay awake so that I fall asleep” is still trying to sleep, with an extra step. If you catch yourself checking whether it is working, the check is the effort creeping back.
• When staying awake means doing things. Scrolling, reading or planning in bed to keep yourself awake is not paradoxical intention; it is simply being awake, and it teaches the bed the wrong lesson (the bed is a cue).
• When the instruction itself frightens you. The task force that reviewed it for the American Academy of Sleep Medicine thought it could raise anxiety about sleep in some people, and might appeal least to those who already find falling asleep hardest. In one study, combined with feedback on how accurately people judged their own sleep, it lengthened the time they reported taking to fall asleep (Edinger and colleagues, 2021). If the thought of lying there awake fills you with dread, start with something else.
• When sleep has been a problem for months. Then it is a reason to see a doctor, not to look for a better technique.

If what keeps you awake is less the trying than the thinking — the day replaying, tomorrow being planned — racing thoughts at night is the better place to start.

When should you see a doctor?

When trouble sleeping happens most nights, has lasted for months and is affecting your days. For chronic insomnia, cognitive behavioural therapy for insomnia (CBT-I) is the first treatment to try: the American College of Physicians recommends it as the initial treatment (Qaseem and colleagues, 2016), and the American Academy of Sleep Medicine recommends it strongly (Edinger and colleagues, 2021). How to fall asleep fast ranks every technique, this one included, by the evidence behind it; all of them are for an ordinary busy mind, not a substitute for care.