Sleep Glorious Sleep: Cognitive Behavioral Treatment for Insomnia
By Dina Scolan
Sleep is coveted, rejoiced, relished and enjoyed by us all. After all we spend a third of our life in bed, and while there, we prefer to be asleep, right? The unfortunate reality is that for some, sleep is elusive. Chased and sought after but poorly attained. Many people struggle to fall asleep and to stay asleep. If that happens for several nights in a row, it inevitably, causes anxiety and stress in and around bedtime, which in turn will only make it harder to fall asleep. It’s easy to see the downward spill.
Insomnia is a sleep disorder that is characterized by difficulty falling and/or staying asleep. People with insomnia can either have difficulty falling asleep (primary insomnia) or waking up often during the night and having trouble going back to sleep (secondary insomnia). Both cause equal amounts of distress and dread in those who struggle with them. If you’re super lucky, you will have a touch of both and can’t get to OR stay asleep.
A common cause of chronic insomnia is everyday life stressors. Concerns about work, school, health, finances or family can keep your mind active at night, making it difficult to sleep. Stressful life events or traumas — such as the death or illness of a loved one, divorce, or a job loss — also may lead to insomnia.
Most of us struggle with sleep from time to time; for example, when we are stressed, going through a particularly emotional event, or the night before a big day. This is called acute insomnia. Troubling though it may be, this kind of sleep strain is pretty normal and does not usually warrant treatment. Chronic insomnia, however, can take a toll mentally and physically and lead many to seek medical help. Insomnia is usually considered chronic if a person has trouble falling asleep or staying asleep at least three nights per week for three months or longer.
When people finally get tired of tossing and turning and head into the doctor’s office, they often find themselves prescribed a sleep aid. Some are over the counter like an antihistamine or melatonin, while others such as Ambien, Lunesta, Restoril, Trazadone, Xanax are physician prescribed. A few of these work better than others, and all have side effects. While these often provide the sweet relief of long awaited zzzz’s, they are not considered a long term option- as many build a tolerance or dependence, meaning that a person will require more and more of the drug to get the desired effect. In addition, when you stop taking the medication, most find that insomnia returns since the root of the problem was never really treated.
A worthy competitor if not a better option to a pharmaceutical intervention is a kind of psychotherapy called CBT-I (cognitive behavioral therapy for insomnia). It’s a kind of talk therapy that evaluates and identifies unhelpful thought and behavior patterns, particularly around sleep. The beauty of this intervention is that it is a long-term solution that places the power to fall asleep with you and not a pill, so the effects are far longer lasting. In addition, you carry the success with you long after treatment stops, because you changed all the factors that interfered with healthy sleep.
CBT-I has several components: Stimulus Control, Sleep Hygiene, Sleep Restriction, Cognitive Control and Relaxation Training.
Stimulus control involves removing the stress, anxiety and negative associations around the bed and bed time. If you went to the same restaurant night after night and each time had an increasingly negative experience, it would be reasonable that you would not want to return. You would likely have some pretty solid negative thoughts and feelings about that place based on your experiences there. Well, the same thing happens when your bed is a place of repeated, nightly frustrations and negative experiences. The Stimulus Control portion of CBT-I works to change the negative associations associated with one’s bed. It teaches you that a bed is for sleep or sex only and removes all other activities such as reading, watching tv, or scrolling through your phone and has you go to bed only when you’re actually sleepy. Removing your clock from your bedroom is also a good idea during this phase.
Sleep Hygiene- Good sleep habits are important in establishing quality sleep. CBT-I provides education on why it’s important to have good habits and routines around sleep— including consistent sleep and wake times, avoiding caffeine and alcohol, as well as exercising regularly and eliminating daytime naps.
Sleep Restriction- This part of CBT-I helps to reset one’s sleep clock and remove the negative experiences of tossing and turning all night. It starts by keeping a sleep log to learn how many hours of real sleep you are currently getting and then working backwards from your wake up time to set your bed time based on that number. For example, if you are usually getting 3 hours of sleep and need to be up at 6, then in the sleep restriction phase of treatment, your bedtime would be 3am. That bedtime is slowly moved back over the course of weeks. You may be fatigued at first, but it resets your clock. Plus, if you were only getting three hours anyway, all that was really eliminated was the tossing and turning.
Cognitive Control- Most people who have been struggling with insomnia have some stressful thoughts that increase emotional arousal and make sleep less attainable. These might include things like “I won’t be able to function if I don’t get a solid night sleep”, “Poor sleep has to be damaging to my health”. Your therapist will help identify and reframe these thoughts to that you are not working yourself up while also trying to wind down to sleep.
Relaxation Training – It can be helpful in falling asleep to learn to slow down your thoughts, focus on your breathing, and release muscle tension. Sometimes this phase uses breathing exercises, meditation, muscle relaxation or visualization to help reduce tension and prepare your body and mind for sleep.
You can expect the course of CBT-I to last several weeks, but that’s a small price to pay for a life-time of restorative sleep!
For further information or to talk to a therapist about insomnia or CBT-I, please contact us at 630-522-3124.