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Cognitive Behavioral Therapy May Help With Your Insomnia


Sleep expert Rachel Manber, PhD, has seen the pervasive miseries of insomnia. Frustrated and tired patients tell him they lie down all night in search of that comfortable and elusive place. Others forgo evening outings or vacations to avoid wasting their sleep schedules. Still others become anxious at bedtime, wondering whether to take sleeping pills or relax with a nightcap.

But trying so hard to fall asleep is counterproductive, says Manber, professor of psychiatry and behavioral science at Stanford University Medical Center and specialist in behavioral sleep medicine.

“When you talk to someone who sleeps well and ask them, ‘How do you sleep? How are you doing that?’ they will probably look at you with blank eyes. They do nothing. Sleep is an automatic process, ”she says.

“When you talk to someone who has trouble sleeping, they name a long list of things they do to try to sleep. And this very effort to sleep ends up creating arousal and interfering with sleep.

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Instead of trying to sleep, allow sleep to happen, says Manber.

For more than two decades, she has helped patients shake off their ineffective habits, quit sleeping pills, and fall asleep on their own. His method: cognitive behavioral therapy for insomnia (CBT), a non-drug treatment that can improve sleep by helping patients change their beliefs and behaviors.

More and more doctors have learned about CBTI since the American College of Physicians issued a guideline in 2016 calling it the first-line treatment for chronic insomnia in adults, preferred over sleeping pills.

It’s not that sleeping pills don’t work. They often do, but they can have side effects and drug interactions and are not intended for long-term use. Also, once patients stop taking them, insomnia may return, requiring further drug treatment.

In contrast, CBTI solves insomnia without drugs and equips patients “with skills that no one can take away from them so they can use them when insomnia returns,” Manber explains. “As you know, life comes and when we get stressed we tend to lose sleep.” By applying CBTI skills, people can prevent or recover from new episodes of chronic insomnia.

When patients undergo CBTI with a sleep specialist, insomnia typically improves with four to six sessions, Manber says. But many people can find relief with these measures at home.

Wake up at the same time every day

You can’t control when you fall asleep or you won’t experience insomnia. But you can control what time you wake up each day. “If you always wake up at the same time,” Manber says, “you are invigorating your internal body clock which controls sleep and wakefulness.”

She suggests choosing a regular wake-up time that matches your circadian rhythm. This regular wake-up time sends signals to your body, she says. “It creates a very robust biological clock. If you vary the wake-up time, the signal amplitude becomes flatter, the signal is weaker. It does not support your sleep.

“When your clock is robust, you naturally start to feel more or less sleepy at the same time each night. This is why I say you have to start in the morning.

Many sleep problems are caused by an irregular schedule, says Manber, so avoid the temptation to sleep, even on your days off.

Go to bed when you are sleepy, not when you are tired

People often confuse physical fatigue or mental fatigue with drowsiness, “but they’re separate experiences,” says Manber. “We define ‘sleepy’ as the likelihood that if you put your head on the pillow, you will fall asleep quickly.”

Another way to understand the distinction: “Fatigue is a function of energy; sleepy is a function of the need for sleep. “

The need for sleep accumulates during our waking hours, but people cannot experience it if they are still in a state of high arousal or high stimulation. “In other words, people can be tired, but wired. The feeling of “wired” prevents them from feeling drowsy and as a result, they cannot fall asleep.

As Manber suggests, “You’ll fall asleep faster if you fall asleep when you’re no longer connected and start feeling drowsy.”

When people with insomnia are lying in bed unable to sleep, they usually worry about another bad night and how severe they will feel the next day. It conditions their minds to view the bed as a place of wakefulness, stress, and anxiety.

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On the other hand, if people spend most of their time in bed sleeping, the mind will learn to associate it with restful sleep.

One caveat, however: people shouldn’t spend less than 5.5 hours in bed each night, even if they get less sleep than that.

Don’t spend too much time in bed

People with insomnia tend to spend a lot more time in bed than they can sleep, emphasizing quantity over quality. They will stay in bed for 8 hours, but will only sleep 6 hours in total.

And they tend to have short periods of poor-quality sleep, says Manber. “When people spend too much time in bed, many end up dozing here and there. So the brain sleeps a little. It is not very refreshing sleep, it is not good sleep. But if you add all the sleep crumbs, it adds up. “

To avoid poor sleep, try limiting the time in bed to consolidate your sleep into one block. If you only get an average of 6 hours of sleep per night, you would be spending 6 hours in bed each night to aim for deeper, higher-quality sleep. “If you got 6 hours of sleep, it would be a lot nicer to have them all in one piece,” says Manber.

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You might be tired at first, but once you’ve built up a solid period of sleep, you can extend your time in bed. But carefully shorten your sleep hours to avoid a dangerous level of sleepiness. “If you develop a significant level of drowsiness, step back and see a CBTI therapist,” Manber says. These specialists may also look for other causes of drowsiness, such as sleep apnea.

There’s another good reason to avoid spending too much time in bed: to allow enough time for the sleep drive to develop during your waking hours, says Manber.

“The sleep drive is something that builds up in our system. The longer we are awake, the stronger our desire for sleep, ”she says.

If you don’t build up enough pressure while sleeping, “when you fall asleep you actually get sleep deprived, which won’t stand a long period of sleep,” says Manber. “This is one of the main reasons we don’t want people spending too much time in bed: to make sure your sleepiness is strong.”

Stay in bed only when you sleep

People with chronic insomnia not only have trouble falling asleep, but staying asleep. For example, if they wake up at 3 a.m., they might not fall back to sleep for a few hours.

According to standard CBTI recommendations, if people cannot fall asleep within 20 minutes at the start of the night, they should get out of bed and do something calm, such as reading a book, and go back to bed when they are sleepy. .

Manber agrees. “You should stop trying.”

But it’s important to avoid any activity that creates a lot of physical or mental arousal, for example cleaning the house or reading a political book that upsets your emotions.

Still, she says, not everyone can get up in the middle of the night if they can’t get back to sleep, for example, those who are bedridden or stay in a hotel room with others. . “In this situation, you get to the heart of what is most important here, and the main thing is to stop trying to sleep.”

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Some research shows that for waking up in the middle of the night, “if you just lie in bed and stop trying to do something calming, that helps too,” says Manber.

Some patients prefer to stay in bed and get comfortable with an audiobook. “People choose to listen to books that they’ve heard before,” says Manber. If you are using an electronic device, be sure to block blue light, which can interfere with your body clock. Again, the trick is to find material that is not too stimulating. Instead, people should listen to things “that are nice but grab their attention and aren’t boring,” she says.

In doing so, “their attention is away from sleep. They no longer try to sleep, and sleep rises to the surface and takes them away.

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