Insomnia is more than just occasional trouble falling asleep or staying asleep. In fact, most people experience sleep disturbance at some point in their lives. If you have chronic trouble (meaning more nights than not) falling or staying asleep, don’t feel refreshed in the morning, and especially if lack of sleep begins to impact your personal or professional life, it might be time to seek medical help.
In the first installment of this series on insomnia, we talked about sleep hygiene, the first step in treating insomnia without medication. Insomnia has many possible causes, including sleep apnea, restless leg syndrome, thyroid issues, or other underlying medical conditions. Most people who struggle with sleep, however, don’t have an underlying medical problem, and for them, sleep hygiene alone will often restore their ability to achieve a sound, restful sleep each night. But when good sleep hygiene isn’t enough to solve your insomnia, working with a therapist who specializes in cognitive behavioral therapy for insomnia (CBT-I) may be helpful.
What Is Cognitive Behavioral Therapy for Insomnia?
CBT-I is a method of addressing both the behaviors that prevent you from sleeping effectively as well as the thoughts that can interfere with sleep. The behavioral aspect of CBT-I focuses on stimulus control and sleep restriction.
How Does Stimulus Control Work?
CBT-I goes beyond basic sleep hygiene principles–such as reducing caffeine intake and creating a “wind-down” period before bedtime–to delve deeper into stimulus control. The goal is to strengthen the bed as a cue for sleep and weaken it as a cue for wakefulness. These are the fundamental principles of stimulus control:
- Establish a regular wake-up time. Despite what you may have been told about establishing a regular bedtime being key to avoiding insomnia, it’s more effective to set a regular wake-up time. Maintain your rising time even on weekends. This will help you get plenty of morning light, which helps regulate your body’s natural sleep/wake cycle.
- Go to bed only when sleepy. It’s essential to distinguish between fatigue and sleepiness. Fatigue is a low state of physical and mental energy, but it isn’t a reason in itself to try to sleep. Sleepiness is a struggle to stay awake, such as dozing off while watching television or during a train ride.
- Eventually establish a regular bedtime. Once you’re sleeping soundly through the night, you’ll have a good idea of what your “natural” bedtime should be. Stick to your bedtime unless you’re truly not sleepy.
- Don’t lie awake in bed. If you’re unable to fall asleep, or if you wake up in the middle of the night and can’t immediately get back to sleep, get out of bed and do something quiet and relaxing, such as reading. Return to bed only when you feel sleepy again.
- Avoid napping during the day. For people without insomnia, an afternoon nap isn’t necessarily a bad thing. But for folks with sleeplessness issues, a nap can further disrupt the body’s sleep/wake cycle. For the purposes of CBT-I, don’t sleep during the day.
The Core of CBT-I: Sleep Restriction
Sleep restriction as a treatment for insomnia might seem counterintuitive. However, this therapy is very effective for putting sleeplessness to rest (so to speak). Studies indicate that 75 to 80 percent of people see significant improvement within four weeks of starting sleep restriction with a CBT-I therapist. Because it’s difficult to properly maintain a sleep restriction schedule while working through the issues causing your insomnia, it’s important to practice sleep restriction only with a trained CBT-I therapist or health care provider who can help you navigate potential challenges.
Here’s how sleep restriction works:
1. Your therapist will ask you to calculate how much sleep you get on an average night. In a bedside journal, record how much time you spend sleeping per night. After a week, calculate the average number of sleep hours you got each night. That’s your starting point.
2. Let’s say you calculated an average of 6 hours of sleep per night in that first week. For the next week, if your alarm is set for 8:00 a.m., get into bed 6 hours before that time. In this example, you’d go to bed at 2:00 a.m. After a few days of doing this, you should notice a decrease in your middle-of-the-night wakefulness. If you don’t, talk to your therapist.
3. After one week of sleep restriction, your therapist will advise you to add 30 minutes to your sleep time (assuming your nighttime wakefulness remains minimal). In this example, you’d now go to bed at 1:30 a.m.
4. After one week of going to bed at 1:30 a.m., add another 30 minutes to your sleep time. Continue adding 30-minute increments to your sleep time each week until you’re getting about eight hours of restful sleep per night.
5. If you begin to experience significant wakefulness in the middle of the night, your therapist will likely advise you to return to more sleep restriction to get back on track.
Don’t be discouraged if you feel tired in the first few weeks of sleep restriction. This is very common. In resetting your body’s sleep clock, you’ll slowly begin to experience more restful sleep.
Don’t Forget the Basics of Good Sleep Hygiene
CBT-I works best if you’ve already established great sleep hygiene. It’s important to reduce arousal and activation, as well as avoid ingesting certain substances. Here’s a brief recap:
- Maintain a bedtime ritual that involves an hour of wind-down time to relax and induce sleepiness.
- Avoid exercising within four hours of bedtime.
- Avoid exposure to bright light (especially TV or computer screens) within an hour of bedtime.
- Create a comfortable, pleasant, quiet sleep environment in your bedroom.
- Avoid clock-watching, which can cause anxiety.
- Make the cognitive switch from “trying hard to sleep” to “allowing sleep to happen.”
- Avoid caffeinated food and beverages after noon.
- Avoid taking medications that contain caffeine when it’s near bedtime.
- Don’t eat a meal close to bedtime, and don’t snack in the middle of the night.
- Ease up on alcohol. Alcohol may make falling asleep easier, but it increases tossing and turning in the second half of the night.
- Don’t smoke. Smoking and nicotine withdrawal (from quitting smoking) can both interfere with sleep. Your best bet is to quit smoking before starting CBT-I.
Unhelpful Thinking Can Prevent Sleep
Where does therapy fit into the equation? Beyond behaviors, your thoughts about sleep can often prevent you from achieving restful sleep. A therapist trained in CBT-I can help you identify harmful thoughts and teach you how to challenge and change them. For continued sleep worries, your therapist might recommend a “worry journal” to write down everything that’s bothering you, or prescribe a designated time to worry. The goal with both tactics is to think about all of these issues before you go to bed. If nightmares or anxiety interrupt your sleep, there might be more appropriate therapies for you.
CBT-I Isn’t a Do-It-Yourself Project
Depending on your specific needs, CBT-I may involve more than sleep restriction and stimulus control, such as light therapy in conjunction with other techniques. When looking for a CBT-I therapist, be sure to find out how and where the provider received his or her training. Being trained in cognitive behavioral therapy alone doesn’t qualify a person to administer CBT-I, which requires additional education specifically in insomnia.
The length of CBT-I depends on the issues underlying your insomnia. It typically consists of four to eight 50-minute sessions with a clinical psychologist who understands the specifics of sleep issues. Because sleep restriction is particularly challenging, select a provider who will work closely with you to help you achieve your sleep goals.
The One Medical blog is published by One Medical, an innovative primary care practice with offices in Boston, Chicago, Los Angeles, New York, Phoenix, Portland, the San Francisco Bay Area, Seattle, and Washington, DC.
Any general advice posted on our blog, website, or app is for informational purposes only and is not intended to replace or substitute for any medical or other advice. The One Medical Group entities and 1Life Healthcare, Inc. make no representations or warranties and expressly disclaim any and all liability concerning any treatment, action by, or effect on any person following the general information offered or provided within or through the blog, website, or app. If you have specific concerns or a situation arises in which you require medical advice, you should consult with an appropriately trained and qualified medical services provider.