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Can't Sleep? Try These Evidence-Based, Drug-Free Techniques

Use Cognitive-Behavioral Therapy for Insomnia to put sleeplessness to rest.

Can't sleep? You're not alone.

Up to 30 percent of the population report sleep disruption, and roughly 10 percent of people present with significant impairment in daytime functioning due to sleeplessness (National Sleep Foundation, 2020). Sure, there are some who decide to stay up either by choice or necessity (I'm thinking of the overwhelmed single mom or procrastinating college student). For the purposes of this article, however, "sleeplessness" will refer to the experience of frustrated sleepers who give themselves ample opportunity for sleep, but cannot easily achieve it.

The Complexity of Insomnia

Insomnia itself is a complex condition. Most people experience short-term insomnia at some point in their lives due to common reactions to stressful life events (health problems, relationship difficulties, recovery from surgery, etc.) Mental health challenges, such as depression, anxiety, or psychological trauma, may also trigger the onset of insomnia. After the initial stressor or psychological problem is resolved, many people find themselves able to sleep well again. Fortunately, this type of "short-term" insomnia tends to last for several days or weeks at most.

For others, however, insomnia persists even after the initial triggers are resolved. This happens partly because of repeated negative reactions to the sleep loss, such as lying in bed tossing and turning, trying to "make up" for lost sleep by going to bed earlier, or by hyper-focusing on insomnia throughout the day. After several nights (or weeks) of sleeplessness, just the act of getting into bed may trigger conditioned responses of anxiety and dread. Sooner than later, nighttime itself breeds panic and fear, and a good night of sleep becomes rare and unpredictable.

Exploring Treatments

Numerous treatments have emerged in attempts to alleviate sleeplessness. These approaches range from more "natural" treatments (melatonin, herbs) to pharmacological interventions (sedative antidepressants, benzodiazepines). While sleeping pills may help some in the short term, they are not recommended for long-term use due to their side effects and potential risks (McCrae et al. 2006; Williams et al. 2013). Even then, medications themselves do not "fix" the underlying causes of insomnia, and not everyone responds well to this approach.

Fortunately, there is an evidence-based, drug-free treatment available called Cognitive-Behavioral Therapy for Insomnia, or CBT-I. While it's best to move through CBT-I with an experienced clinician, many of the techniques and practices of CBT-I can be applied on your own. The efficacy of CBT-I is documented throughout multiple studies, and it has been shown to provide better long-term management of insomnia compared to medications alone (Qaseem et al. 2016). This method is so effective that in 2016, the American College of Physicians recommended that all adult patients receive CBT-I as the first line of treatment for chronic insomnia.

The primary reason why CBT-I works so well is that it addresses and corrects underlying thoughts, feelings, and behaviors contributing to insomnia. Along with promoting healthy sleep hygiene, practitioners utilize psycho-education, cognitive restructuring, and behavioral techniques to promote long-lasting, sustainable change. The following techniques fall under the overarching umbrella of CBT-I and may help you finally put insomnia to bed.

Stop Fearing Sleeplessness

One of the perpetuating factors that contribute to insomnia is the fear of not sleeping. Restless sleepers often lie awake at night, ruminating over worst-case scenarios if sleep is not achieved by a certain time frame. They may worry about how their work performance might suffer or fret over potential health risks associated with sleep deprivation. In reality, as sleep expert Dr. Daniel Erichsen states in Why We Don't Sleep (2019), the degree to which sleep deprivation affects overall health and executive functioning is unclear and largely misunderstood.

It turns out, the average spectrum for healthy sleepers ranges roughly from 5.5 to 7 hours per night. This is well below the 8-hour "requirement" promoted throughout segments of the wellness community. In response, one may experience added pressure to obtain a certain number of hours of sleep each night. This unnecessary pressure doesn't help the true insomniac find rest.

If you can't meet or sustain a full 8 hours each night, rest assured that most people actually don't sleep this much. It turns out, a night of poor sleep may not be as bad as some make it out to be.

Spend Less Time in Bed

Sure, this may sound strange if you're trying to get more sleep. Contrary to popular opinion, however, spending less time in bed does not lead to less sleep, but helps improve the quality of your sleep and decreases the time you spend awake in bed. In addition, limiting your time in bed helps to build a stronger sleep drive, making it easier to fall asleep once your head hits the pillow. This practice helps retrain the brain to associate the bed with sleep rather than anxiety or dread. Additional guidelines involve only going to sleep when you are tired and getting out of bed any time you can't sleep or feel anxious.

To establish a regular sleep schedule, experts recommend calculating the total number of hours you are actually asleep each night and limiting your time in bed to closely align with this window of time. Dr. Jacobs, sleep expert and author of Say Goodnight to Insomnia (2009), recommends determining your maximum allowable time in bed by adding one hour to your average sleep time. For example, let's say you are only sleeping for 6 hours a night, but staying in bed for 8. To correct this, limit your total time in bed each night to 7 hours. This includes 6 hours of your average sleep time plus one extra hour. Next, establish a regular wake time and count back 7 hours to identify your scheduled bedtime. For example, if your wake time is set for 6 a.m., then your scheduled bedtime would be 11:00 p.m.

Experts recommend that you do not attempt to go to sleep prior to entering your sleep window, no matter how tired you may feel. In addition, experts recommend that you do not limit your time in bed to less than 5.5 hours, at a minimum. After you find yourself in a consistent habit of falling asleep rather quickly, then you can start gradually increasing your total time in bed. Usually this is done by moving your bedtime up by 15 minutes each week until you've reached your desired bedtime.

Elicit the Relaxation Response

Another important technique is learning how to elicit the relaxation response to calm the mind and body. The term "relaxation response" was initially coined by Herbert Benson, a pioneer of Mind-Body Medicine. Research suggests that heightened cognitive arousal tends to delay or disrupt sleep and well-practiced relaxation techniques can help address these barriers (Lichstein et al. 2011). There are many ways to elicit the "relaxation response," many of which involve a combination of breathing techniques, guided imagery, body focusing, and other mindfulness approaches.

To induce the relaxation response, start by developing a relaxed, non-judgmental attitude. Set an intention to avoid forcing, controlling, or judging any feelings or sensations that may arise. Begin taking a few slow, deep breaths, holding each breath for 5-7 seconds and exhaling for a count of 7-8.

As you breathe out, meditate on a gentle, calming word such as "relax," or "peace." Direct attention towards the body and engage in a sequential body scan, noting any areas of tension or discomfort. Focus on sensations of heaviness and warmth through your arms and legs. Repeat for as long as needed until you reach a desired state of relaxation while aiming for at least 15—20 minutes per day.

Try to Stay Awake (Paradoxical Intention)

This technique is believed to work based on the relationship between performance anxiety and sleep. If you struggle with insomnia, you may experience heightened anxiety when you try to induce sleep rather than allowing it to happen on its own. In this way, sleep becomes much harder to obtain the more it is sought out. Paradoxically, you may find it easier to fall asleep when you stop trying to sleep and instead focus on staying awake.

To practice this technique, lay in bed as you typically would, keeping your eyes open and fixed on a neutral object. When your eyes start to droop, gently open them, and remind yourself of your attempts to stay awake. Before you know it, it's morning, and you may find that sleep has overpowered you. You faced your fear of staying awake, and look what happened. You ended up winning in the end.

Remember, if you've made it through a day with little to no sleep the night before, you can and will make it through another. Sleeplessness itself is not the thing to be feared. And in fact, among other things in life, you may find that sleep tends to get easier the less you worry over, demand, or try to perfect.

©2020 Elizabeth Dixon, LISW-CP. All rights reserved.

References

Erichsen, D. (2019). Why We Don't Sleep. How the wellness industry unintentionally created an insomnia epidemic. [Kindle version]. Retrieved from: {[https://www.amazon.com/Why-Dont-Sleep-unintentionally-epidemic-ebook/dp…

Jacobs, G. (2009). Say Goodnight to Insomnia. New York, NY: Henry Hold and Company.

Lichstein, K., Taylor, D. J., McCrae, C., & Thomas, S. J. (2011). Behavioral Treatments for Sleep Disorders. Elsevier Inc. DOI:
45 10.1016/B978-0-12-381522-4.00004-3

McCrae, C., Nau, S., Taylor, D., Lichstein, K. (2006). Insomnia. In: Fisher JE, O’Donohue WT, eds. Practitioner’s Guide to Evidence-Based Psychotherapy. New York, NY: Springer; 324-334.

McCrae C., Lichstein K. (2001). Secondary insomnia: diagnostic challenges and intervention opportunities. Sleep Med Rev. 5(1), 47-61.

National Sleep Foundation. (2020). Insomnia. Retrieved from: https://www.sleepfoundation.org/sleep-disorders/insomnia

Qaseem, A., Kansagara, D., Forciea, M.A., Cooke, M., & Denberg, T. (2016). Management of Chronic Insomnia Disorder in adults: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med, 165(2), 125-133.

Williams, J., Roth, A., Vatthauer, K., & McCrae, C. S. (2013). Cognitive behavioral treatment of insomnia. Chest, 143(2), 554–565. https://doi.org/10.1378/chest.12-0731

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