1: Intro to Insomnia
Okay, you have sleep problems and you’d like to learn how to get better sleep, so you’re asking “what do I do now?” Well, I’m glad you asked! I’ve put together the following guide to walk you through this process, with the goal of focusing on what I’ve found to be the most important concepts, as well as on delivering it as simply and practically as I can. And, as I promised, this will be based completely on the evidence-based approach called Cognitive Behavioral Treatment for Insomnia. This isn’t necessarily a guide to CBT-I (though you can find my primer here or find other resources), but instead my own adaptation of it based on my experience delivering it.
Let’s begin: do I have insomnia?
I think this could be important, since the intervention has the word insomnia in it. =) Sure, even if you don’t meet all the criteria, you can still get a lot out of learning and applying these principles, but I do think it’s important to note that this intervention was designed for and validated to be highly effective in treating this specific condition. Fortunately, it’s not all that hard to find out if you have insomnia, and the bar is not that high. After all, up to 35% of Americans experience insomnia symptoms short-term or longer, and around 10% have chronic insomnia.1 That’s a lot of people.
Here is a pretty widely agreed-upon criteria: If you have difficulty falling asleep and/or staying asleep, and it causes daytime sleepiness or other issues, and you have these issues 3+ nights a week for 3+ months, you meet the criteria for insomnia disorder.2
There are some caveats of course. If your sleep is being disrupted primarily due to another factor (medical, psychological, environmental/situational) then the sleep problems take a back seat and the focus should be on treating that problem. Some examples are: breathing issues, excessive snoring, illness or other medical condition, depression, psychological trauma. These are things you need to speak to a medical provider about.
How does insomnia develop?
Insomnia can be thought about as the sleep problem you’re left with even though the thing that originally disrupted your sleep is now out of the picture. Many things can disrupt your sleep, like having a new baby, a stressful period in your life, a medical problem, being on a deployment, an injury… you get the picture. However, when the thing that triggered the sleep problem goes away but your sleep doesn’t get back to normal, it’s because your body has gotten stuck in a pattern of poor sleep. This precisely is chronic insomnia.
In case you’re interested, this is where the behavioral perspective becomes handy when you’re thinking about insomnia. The thing that triggered the short term insomnia has gone away, but the sleep problems have stuck around and taken on a life of its own. Chronic insomnia. It has become self-reinforcing. And the thing doing the reinforcing: your behaviors. Specifically, all the ways you consciously or unconsciously adapted to the sleep problems in order to cope with them. These things include but are not limited to: taking more naps, getting into bed early, sleeping in on weekends to make up for lost sleep, using sleep aids or alcohol to fall asleep, passing time in bed by reading or browsing social media until you get sleepy, etc. These aren’t things that are inherently bad, and of course it makes sense why someone would do these things to cope with the sleep problems, but they are now the things that are keeping the insomnia going. So here is the beauty of looking at the problem through a behavioral lens: we can use behavior to address the things that keep the insomnia going, and we can use behavior to re-train the body to get stuck in a pattern of good sleep.
As you might imagine, it makes sense why this approach would be more effective long-term than medication at treating insomnia – because it gets to the root of the chronic insomnia problem. It interrupts all of the ways the insomnia is being enabled and kept alive. And it uses behavior to re-train your sleep patterns so you get predictable, consolidated, and restorative sleep (that just means “better sleep” – sorry, I recognize that those adjectives sound like an infomercial, but I’m using them clinically and they have specific meanings).
So, are you ready for my list of top 10 tips for better sleep? Or 10 behavior changes that fix insomnia? Just kidding, I really don’t like that approach. For one, that’s been overdone… you can Google that yourself and get like 500 different articles. Second, most of the clients who come to see me have already tried some or many of those tips, with little success. That’s because there are a lot of tips that vary in quality (some that are not very helpful and some that are decidedly terrible) and because if you have had insomnia for a while, just trying out a few tips is unlikely to really fix all of the inertia that the sleep problems have developed.
The approach that I have found to be the most effective (based on sound CBT-I research) is to start with a bit of learning about the biological processes that regulate sleep, and then to focus on the most important behavioral changes that target these systems. In essence, I like to front-load the behavioral changes that are shown to be the most effective at addressing insomnia, while always tying everything back to the biology of why it works. In my opinion, this is the most efficient and effective way to go through the CBT-I intervention.
Now that you know, are you ready to learn about how sleep works?