Sleep Better with Cognitive Behavioral Therapy for Insomnia

Do you lie awake night after night, struggling to catch the sleep that eludes you…then feel exhausted and miserable during the day? Don’t just suffer stoically—insomnia is serious! It increases the risk for high blood pressure, obesity, diabetes, anxiety and substance abuse. What’s more, although insomnia often is considered a sign of depression, new research reveals that the insomnia can come first and double a person’s risk of developing depression.

Sleeping pills may seem like a quick fix, but don’t be too hasty in taking that route. Though these drugs do help some people, they also can have bad side effects…and according to one study, long-term use is associated with increased risk for early death.

There’s a much better option that can get you the deep, blissful sleep you need. It’s completely safe and drug-free, and because it addresses the underlying causes of insomnia (unlike medication), its benefits persist even long after treatment ends. It’s called cognitive behavioral therapy for insomnia (CBT-I), and just a few sessions can go a long way to restore normal sleep patterns. CBT-I has been shown to relieve insomnia for a wide variety of people, including older adults and those who suffer from chronic pain, fibromyalgia, cardiovascular disease, mood disorders and other health problems. It can even help people who have been taking sleeping pills for years. Here’s what you should know about CBT-I…

IS THIS SLEEP SOLUTION RIGHT FOR YOU?

For insights, I turned to Donn Posner, PhD, a leading expert in CBT-I. He is a psychologist at Stanford University School of Medicine in California and coauthor of Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. Dr. Posner confirmed that chronic insomnia is a serious disorder that should be treated. However, he also noted that a few restless nights should not be considered insomnia (important to know so that you don’t feel overly stressed about an occasional bad night!).

True chronic insomnia means difficulty initiating or maintaining sleep, despite adequate opportunity to sleep, that occurs at least three times a week and lasts for at least three months, according to Dr. Posner. How long can it take you to fall asleep before it’s a problem? Most experts in the field consider 30 minutes of lying awake, either before first falling asleep or after having woken up in the middle of the night, as the cut-off. In addition, Dr. Posner said, “insomnia leads to some daytime consequences—for instance, fatigue, memory problems, difficulty concentrating, poor work performance or even anxiety about being unable to fall sleep. Insomnia is not just a nighttime disorder…it’s a 24-hour disorder.”

If you think that your sleep pattern fits the above description of insomnia, talk to your doctor—a medical problem could be interfering with your slumber, and you may find that sleep comes more easily once that underlying condition is addressed. If your insomnia persists, however, you should strongly consider trying CBT-I.

WHAT TO EXPECT DURING TREATMENT

The first step with CBT-I is for you to find a sleep specialist who offers it. To do this, ask your doctor for a referral to a qualified professional with expertise in CBT-I…or find a practitioner through the Society of Behavioral Sleep Medicine or contact the nearest certified sleep center and say that you’re interested in CBT-I.

Once you choose a sleep specialist, you can expect to undergo a thorough evaluation of all areas of functioning to determine all the factors that are contributing to your sleep problems, Dr. Posner said. Genetic makeup, internal rhythm, social life, home life and work life are all evaluated…and you are instructed to keep a sleep diary to help pinpoint problematic patterns. Your therapist also tries to determine whether an emotional issue or even another sleep disorder precipitated your insomnia. When the evaluation is complete, the therapist creates an individualized treatment plan, typically consisting of four to six weekly one-hour sessions.

Then the real work begins. As the name implies, CBT-I involves both behavioral and cognitive elements. Though therapy is tailored to each patient, a typical protocol includes the following…

Sleep restriction. This is meant to improve sleep quality by strengthening your body’s drive to sleep, since people with chronic insomnia often engage in behavior that weakens their sleep drive. You may be instructed to stop napping or to avoid dozing off in front of the TV, for example. Only as your “sleep efficiency” improves do you start going to bed earlier and staying in bed longer. The idea is for you to be very sleepy at bedtime…which makes it much easier to fall asleep.

Stimulus control helps break the cycle of tossing and turning, which conditions you to think of the bed as a place for alertness and frustration. You are cautioned against using your bed at any time of day for anything other than sleeping or sex.

The rationale: When a person habitually struggles to fall asleep, he “works” at what should be a natural process…and he becomes conditioned to associate the bed with anxiety, frustration and effort. In contrast, by getting out of bed whenever he cannot sleep, he gives up that struggle. If he applies this rule consistently, over time the bed becomes a trigger for sleep rather than for wakefulness, Dr. Posner explained. That association between bed and sleep is further reinforced when he avoids using the bed at all while awake. The only exception is sex. “If we asked people to give up the bed as a place for sex, they wouldn’t comply anyway. But more importantly, during sex you presumably are not trying to sleep, so it doesn’t present the same problem as, say, reading in bed with the intention of getting to sleep. It is really sleep effort above all that we try to eliminate,” he said.

Sleep hygiene. Typically patients are advised to avoid caffeine after noon…and to avoid exercise, alcohol, heavy meals and nicotine within two hours of bedtime. Your sleep therapist also reviews your bedroom environment to make sure it is dark and cool enough to be conducive to sleep. (Many people keep their bedrooms too warm for good sleep.)

Anxiety abatement. The therapist teaches you how to deal with the anxiety you may feel before heading to bed. You will practice counteracting “catastrophic” thinking with more rational thoughts so your anxiety lessens and sleep comes more easily. You also may be shown relaxation techniques to practice during the day and at bedtime. And you learn to avoid staring compulsively at the clock, which only makes you fret more as you calculate how much sleep you’re losing. If you need an alarm clock, you may be told to use one without illumination…or to place the clock under your bed where you can’t keep checking it.

Commitment is key: Too many people try one or two of the techniques for a few nights, and then if they don’t immediately start sleeping better, they get frustrated and give up. “There is nothing magic that will work tonight. It takes dedication and commitment to make CBT-I work because you have to rebuild your innate sleep drive and realign your body’s natural rhythms before you’ll be able to sleep well,” said Dr. Posner. Be forewarned—during treatment, sleep problems often get worse before they get better…but that’s a sign that the protocol is working. It can take a week or two to start seeing real progress. “Given that most people with chronic insomnia have had the problem for years, a couple weeks of work should be a good trade,” Dr. Posner added.

Covering the costs: The Affordable Care Act now requires insurance companies to cover behavioral health treatments, but benefits vary depending on the state you live in, your insurance plan and your sleep therapist’s professional degree. The price for a course of CBT-I treatment averages about $460 for up to six sessions. It’s also worth noting that you may end up saving money in the long run. A recent study showed that older adults with insomnia spent an average of $1,100 more on health care over a six-month period compared with those who did not have insomnia—and that, after completing as few as three sessions of CBT-I, participants’ total health-care costs dropped significantly.

So even if you have to pay out of pocket, you may want to consider CBT-I an investment in yourself. Chances are good that it will end up saving you anxiety, aggravation and money…promoting optimal health overall.