I'm a Psychiatrist. There Are Common Myths About Sleep That Are Preventing You From Being Well Rested.

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7 days ago

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If you've struggled to fall asleep, you may have tried a slew of tips and tricks: blackout shades, leaving your phone in another room, avoiding screens before bed, and keeping your room at a cool temperature at night. Perhaps you've indulged in new sheets or a special mattress or a wearable sleep tracker, too.
Maybe these things have helped. Maybe they haven't. But there's another, more powerful approach to insomnia that's based on decades of research—and you might not even have heard of it. It works by changing our habits, questioning ideas that degrade our sleep, and bolstering our body's sleep drive. If its name is a bit of a mouthful, or its acronym a bit obscure, it makes up for it by sheer effectiveness, helping most people with insomnia slumber more contentedly.
This treatment, cognitive behavioral therapy for insomnia, or CBT-I, is recommended by experts as the first and best treatment for insomnia, over and above sleeping pills, in part because its benefits last longer, compared to medications. It helps people fall asleep faster, spend more of the night sleeping, and feel happier with their sleep. And most people, in any case, say they'd rather try behavior change for insomnia versus a drug (which is perhaps why all those wellness sleep-hygiene tips persist). As a psychiatrist who has done extra training in sleep medicine, I've seen CBT-I work.
About 10 percent of U.S. adults—or about 25 million people—suffer from insomnia, giving CBT-I vast potential. But there's a bottleneck: Traditionally, a clinical psychologist or therapist with extra training in CBT-I delivers the treatment over the course of multiple one-on-one sessions.Yet, there were just 659 behavioral sleep specialists throughout the entire U.S. as of 2016 (the most recent survey I know of). And fewer than 10 percent of clinical psychology training programs teach CBT-I. So there just aren't enough providers—not close to enough.
The good news is that the core strategies of CBT-I still work when delivered by a digital app, or even, to an extent, by self-help booklets. So anyone who puts these principles into practice is likely to get some relief—maybe even someone reading this article.
The 'cognitive' element—the C in CBT-I—seeks to dispel unrealistic ideas about sleep, pessimism about our power to improve our sleep, and the rush to blame sleep problems when we don't feel good. The theory is that certain beliefs—like the idea that we need eight hours, or that a bad night's sleep guarantees a lousy next day—worsen worries about sleep. These worries seem to activate our stress system and make it harder to fall asleep and stay asleep, triggering a vicious cycle of pessimism about sleep that makes sleep poorer. CBT-I tries to put a stop to this.
It really is a myth, by the way, that everyone needs their eight hours. The experts recommend seven, not eight, as the minimum number of hours for an adult. And it's also a myth that something is wrong if you don't sleep straight through the night. In clinic, I've found that some patients get relief just from learning that waking up once or twice during the night is part of normal, healthy sleep. A 2014 study that looked at the sleep diaries of 592 adults without sleep disorders found an average of 1.4 awakenings per night.
But it's not just how you think. It's also what you do. And while CBT-I does include sleep hygiene tips like avoiding caffeine and bright screens before bed, these maneuvers haven't been found to work well for insomnia, at least not on their own. CBT-I's main behavioral directives—the B in CBT-I—are probably less familiar: cutting back on time in bed, changing your habits for getting in and out of bed, and waking up at the same time each day (no matter when you fall asleep).
It may seem kind of ironic to ask someone trying to get more sleep to cut down on their time in bed. But restricting time in bed is one of the most powerful levers we have to make it easier to fall asleep and stay asleep. In traditional CBT-I, the person with insomnia brings a two-week sleep diary to one of those all-too-hard-to-find behavioral sleep specialists, who tallies up how much time that person is sleeping every 24 hours, on average. Then, the dissatisfied sleeper adjusts their time in bed to that number. If they were, for instance, spending nine hours in bed each night, but only sleeping for six and tossing and turning for three, they'd start going to bed later, getting up earlier, or both, thus trimming their time in bed down to six hours. The idea is to work with your body and what it's currently capable of, rather than clinging to the wish for longer sleep when it just isn't happening.
Cutting back on time in bed works partly through mild sleep deprivation, which makes you sleepier. And when you're sleepier, it stands to reason, you sleep more easily. (Just note that if you need to drive or operate heavy machinery, you should cut back on time in bed gradually, and track your daytime sleepiness. It's never safe to drive while sleepy.) As treatment progresses, if the once fitful sleeper finds they're sleeping longer and more easily, they extend their time in bed to match their newfound sleep ability. By doing this, you can actually train your body over time into getting more sleep, with small gains in average length of sleep at the end of a course of traditional CBT-I, and with sleep time continuing to increase, for some, even weeks or months after the end of active treatment.
If you find yourself balking at the idea of cutting back on your time in bed abruptly, there's a gentler way called sleep compression. This cuts back on time in bed more slowly, by 15 to 30 minutes each week, until sleep improves. With sleep compression, you can also stop, or reverse course and extend time in bed again, if you start to feel sleepier during the day. In one study, sleep compression and sleep restriction racked up similar gains in sleep satisfaction at 10 weeks.
So, you cut back on time in bed. But the hypothetical patient who was getting six hours of sleep still wouldn't force themself to stay in bed for six hours no matter what. This brings us to the next behavioral prong of CBT-I: changing your habits for getting in and out of bed. Since 1972, when the pioneering sleep psychologist Richard Bootzin first proposed these instructions in a case report, they have been thoroughly investigated in different variations. Two key instructions are: Don't go to bed until you feel sleepy (even if it's already your new, sleep-restricted bedtime), and don't stay in bed if you can't sleep. If you can't sleep, try a relaxing low-light activity like reading, or listening to music or a podcast in the living room—and then return to bed when you're ready. The classic thinking is that this breaks the association with bed as a place of frustration, and restores it as a cue for slumber. It's also possible that it simply encourages the kind of sleep that's most likely to succeed—that is, going to sleep when you're sleepy, rather than trying to sleep whenever you just really wish you could fall asleep. (If you can't or just don't want to get out of bed, by the way, a couple of older studies do suggest that doing the same kind of relaxing low-light activities in bed when you can't sleep might still help with insomnia, at least to some degree.)
No matter when you end up going to bed, or how often you wake up during the night, CBT-I also teaches patients to get up at (roughly) the same time each day. And there are two reasons why this matters. First, the later and the more often you sleep in, the more you tend to push back your body's internal biological clock—known as the circadian clock—which pushes your body's internal bedtime later too, making it harder to fall asleep when you want to. The second reason is that getting up later and keeping your bedtime the same shortens the length of your day, which means less time awake building up your drive to sleep, and less success at bedtime. If you woke up at noon, for instance, and then tried to go to bed at 6 p.m., you just wouldn't have built up enough sleep drive yet. And the same idea applies to more subtle shortening of the span of daytime wakefulness, like waking up late or napping.
CBT-I works well. But no single treatment works for everyone, and no treatment is free of hazard. In particular, those at high risk of falls should skip getting out of bed when they can't sleep. And again, please don't drive if you're experiencing daytime sleepiness.
Sometimes, too, insomnia is the harbinger of a different problem. So if your sleeplessness is unrelenting, you're waking up at night gasping for air (a symptom of sleep apnea), or if you have the strong urge to move your lower limbs at night (an ailment called restless legs syndrome), please look up a sleep specialist who can help get you a diagnosis and hopefully some relief. In the meantime, tell your friends about CBT-I. More people should know.