Do you worry yourself awake frequently? Cognitive behavioral therapy can help.
If you have trouble getting to sleep and staying asleep, that’s insomnia. It happens to everyone from time to time. But it can also become a chronic problem. For some people, fretting about whether they will be able to sleep — and the emotional upset of not being able to when they try — can itself become the root cause of insomnia.
“This heightened state of arousal is what’s getting in the way,” says Stephen Amira, a psychologist at Harvard-affiliated Brigham and Women’s Hospital who treats insomnia. “The more aroused you are, the more difficulty you have with sleep.”
An approach called cognitive behavioral therapy for insomnia (CBTi) can help, and research shows it works as well as or better than sleep medications over the long term. CBTi helps you to change the negative and unproductive thinking patterns and habits that get in the way of a good night’s sleep. Think of it as boot camp for better sleep.
What is it?
CBT is a general behavioral counseling technique, but CBTi focuses specifically on what you think, feel, and do to undermine restful sleep. A typical treatment plan involves first ruling out medical causes and then meeting with a therapist weekly five to eight times.
Initially, you need to complete a sleep diary to record your sleep pattern. Then you return to the therapist’s office to work on some or all of the following areas, depending on your needs:
Sleep hygiene. As part of CBTi, you will learn some sleep-friendly habits that help establish a healthy sleep pattern. (See “Tips for good sleep.”)
Sleep restriction. The hallmark of insomnia is lying awake in bed. To address that, CBTi initially shortens your sleep period to strengthen your internal sleep drive. Gradually you increase it to your normal sleep duration.
Stimulus control. This is designed to break the association between being in bed and struggling to sleep. You go to bed when you feel sleepy; if you don’t fall asleep after 15 minutes, you get up and return when you are sleepy again. You also limit use of the bed for recovery from illness, sexual intimacy, and sleep — not snacking, reading, or TV watching.
Cognitive therapy. This means working with the therapist to identify and correct negative thoughts and feelings associated with sleeplessness. These include thoughts that you are abnormal and will never get good sleep again, or fears that you will lose your mind, your job, or your marriage from lack of sleep.
Relaxation. It helps to learn techniques, like rhythmic breathing or meditation, to relax and soothe yourself before bed. “Normal sleep is essentially the byproduct of being able to relax and let go,” Amira says.
Good sleep hygiene can improve the quality and quantity of your slumber. Here are some helpful tips:
– Maintain consistent bedtimes and wake times seven days a week, even after you have a “bad” night.
– Reserve the bed for three things: recovery from illness or injury, sexual intimacy, and sleep. Don’t use it as a place to watch TV or read.
– Avoid daytime naps. For most people, naps interfere with falling asleep at night.
– Don’t drink alcohol within a few hours of bedtime. It can cause nighttime awakenings.
– Avoid caffeine (coffee, tea, soda, chocolate) in the evening. It can cause shallow sleep or more frequent awakenings.
– Don’t go to bed on either an empty stomach or a full stomach.
– Make sure your bedroom is quiet, safe, and relaxing.
– Turn the clock face away from the bed to reduce anxiety about how much you are sleeping.
What to expect
CBTi is simply a set of behavioral changes to alter what is essentially a learned behavior. By reducing some of the fear and anxiety associated with sleep, you can eventually start to look forward to bedtime. When you go to bed, you want to have an “ahh” experience, rather than an anxious and stressful “oh no” reaction.
However, if you prefer to avoid the traditional counseling setting, you can also try a book, DVD, or online program for insomnia based on CBTi principles. “If someone can derive relief from one of these, I don’t have a problem with it,” Amira says. “It’s just that there are some people who need the personal attention that counseling offers.”
Although CBTi is considered a better long-term solution than sleeping pills, medication may still have a role. The most widely prescribed sleep drug is zolpidem (Ambien, Ambien CR, Edluar, and Zolpimist), along with eszopiclone (Lunesta), and zaleplon (Sonata).
Amira says “judicious use” means short-term, rather than every night for prolonged periods. For example, if you have a very important event coming up and need rest, you could use the pills for a few days. But otherwise, give CBTi a chance to work. “Ultimately, the behavioral approach empowers the individual to control insomnia, rather than rely on some external solution,” Amira says.
How to get it
Most health insurance plans cover CBTi, which falls under mental health coverage. There’s only one problem: not many therapists are trained in this specific type of counseling.
You can find lists of certified specialists throughout the country from the American Board of Sleep Medicine (www.behavioralsleep.org/FindSpecialist.aspx). The best-studied online sleep CBTi program is called Sleep Healthy Using the Internet, or SHUTi (www.shuti.me). — Harvard Men’s Health Watch