Countless adults in the United States suffer from insomnia, the maddening inability to sleep when given the opportunity. Thankfully there are short-term, non-drug treatments that dramatically improve the sleep of most people with insomnia. The American Academy of Sleep Medicine recommends cognitive-behavioral therapy for insomnia, or CBT-I, as a first-line treatment.
When friends and family members find out that I treat insomnia, they often ask what the treatment involves. They’re not looking for a 90-minute lecture on CBT-I, of course: They want to know its essence.
In the end, the way to sleep well in general is to let go of how I sleep tonight. To understand why this is so important, you need to consider what leads to insomnia. A typical path goes like this:
- Something identifiable disrupts your sleep. The dog was freaking out, the baby was teething, you took a steroid medication, you're worried about your job—whatever.
- Nobody likes to miss out on sleep, so you do the reasonable thing the next day and sleep in an hour or two later. Or maybe you take a nap in the afternoon. Whatever you do, you try to make up for some of the lost sleep, which feels nice...when it works.
- On the other hand, you're still not sleeping great at night, and now you start to stress out about your sleep—even if the original source of the problem has resolved. As bedtime approaches, you worry that you’ll lie awake for hours, or that you'll be up in the middle of the night, or will wake up hours before sunrise and won’t be able to fall back asleep. Your bed becomes a place of anxiety and stress, not relaxation and sleep. What if I’m awake all night? The understandable and predictable “Oh no!” doesn’t raise the odds of falling asleep easily and sleeping well.
The biggest factor that keeps insomnia going seems to be well-intentioned efforts to make up for the sleep you lost last night. A focus on how I’m sleeping tonight comes at the cost of how I’ll sleep in the long-term.
When our sleep is poor more nights than not, we’ll probably do things that we think will help us but that actually prolong our sleep problems:
- Go to bed earlier to try to get more sleep. When we go to bed too early, odds are we won’t be ready to fall asleep. Most likely we’ll just have more time to lie in bed awake, feeling anxious and stressed, and reinforcing bed as a place of anxiety and unrest.
- Sleep in after a poor night’s sleep. While it seems like a good idea, sleeping in is likely to interfere with good sleep the following night. As with going to bed earlier, a person won’t have built up the strong drive for sleep that helps us fall asleep quickly and sleep soundly.
- Stay in bed even if not falling asleep quickly. Most people reason, “if I’m in bed, at least I’ll fall asleep when I’m ready to.” They probably fear that they’ll miss their "sleep window” if they get out of bed. The result is hours and hours training ourselves to be awake and stressed out about sleep when we’re in bed—and not really getting more sleep.
- Take naps during the day. While a well-timed nap can be helpful in some cases, more often than not it just makes it harder to fall asleep at night. Naps are especially problematic when they’re long and later in the day.
- Use alcohol to fall asleep. While alcohol tends to bring on sleep, it’s a net loss—even though we may fall asleep faster, our sleep will be lighter and more broken up. There’s also the added problem of conditioning ourselves to need alcohol to fall asleep, which brings its own set of problems.
Taken together, these factors keep the insomnia going. The role of CBT-I is to change these behaviors:
- Choose a standard bedtime and wake-up time. These times are based on careful records of an individual's sleep, and aim to match the time spent in bed to the average amount of sleep a person is actually getting. When we go to bed and get up at about the same time each day, our bodies and brains learn to expect sleep at the appropriate time.
- Stick to the sleep schedule regardless of how you sleep each night. This instruction is crucial to interrupt counterproductive efforts to regain lost sleep. If you had a bad night’s sleep and still get up on time, you're actually increasing your chances of sleeping well the next night.
- Generally avoid naps during the day. Time spent awake is an investment in good sleep. Skipping the nap makes it more likely that you’ll be ready to sleep come nighttime.
- Get out of bed if you're not falling asleep quickly. As soon as you know sleep is not imminent or you start to worry that you're not falling asleep, get out of bed—and return only when sleep is likely. Over time we can relearn that “Bed = Sleep,” rather than “Bed = Place-to-Worry-About-Sleep.”
- Avoid “sleep aids” that hurt in the long run. External agents like alcohol knock us unconscious without providing high quality sleep. Part of the beauty of CBT-I is that it relies on your body’s own ability to generate sound, restorative sleep, without having to ingest any chemicals.
What all these instructions have in common is a long-view approach rather than a shortsighted focus on tonight’s sleep.
It’s important to point out that CBT-I is for people who have chronic insomnia. The average person who seeks out CBT-I has had insomnia for years. If you read this and think, “I take naps but I sleep great at night,” or, “I sleep in to make up for lost sleep and my sleep is generally good”—exactly. CBT-I is for people with frequent and persistent difficulty sleeping.
Countless nights’ sleep have been sacrificed to insomnia and the behaviors that maintain it. If you’re willing to risk having a few more bad nights’ sleep—for the right reasons—chances are that your sleep will be much better in pretty quick order.
The information in this post draws from a treatment manual by Michael Perlis and colleagues.