Now, when people do seek treatment, they usually receive a medication, and medications are great. If you have a stressful meeting with your boss tomorrow, pop a pill; you’re going to sleep tonight. But oftentimes, people don’t want to have to rely on anything, especially over the long term, in order to get a good night of sleep. I have good news, and that is that healthy sleep is largely shaped by the things that we do: by our choices, by our behaviors. So in this way, the best sleep medicine is our behavior, behavioral medicine.
Cognitive behavioral therapy for insomnia, which is a really long name for a treatment, let’s just call it CBTI, has a substantial evidenced-base for the treatment of insomnia. And we know that not only does it work for most people, there are several different patient populations that can derive benefit: cancer survivors, people with PTSD, chronic pain, fibromyalgia, major depression.
Here, there is consensus: CBTI should be the first line of treatment when it comes to insomnia. And why is that? Why would something like therapy cure something that feels like a very physiological need? Well, in order to understand why CBTI works, you need to know a little bit about why acute insomnia becomes chronic, and has a lot to do with our behaviors.
The seemingly benign decisions we make in order to try to fix insomnia, actually perpetuate it. I blame our instincts. Let me give you an example. If you sustain an injury, you automatically apply pressure to any sort of bleeding wound. In this case, your instincts are helpful. But let’s say you’re going on a hike, and it’s a beautiful Colorado day, and you run into a bear. Every cell in your body mobilizes to react to your instinct to turn around and run. Your instincts are wrong. The bear will chase you, the bear will outrun you, the bear will catch you, and then — Well, it turns out that what your instincts should have told you to do is to make yourself look bigger, to stand tall, to puff out your chest, and talk to it on a loud voice, and in the very unlikely scenario where the bear actually attacks you, what you’re supposed to do is pick up a stick and fight back.
So this is the same thing that happens with sleep loss: we compensate for sleep loss because it tends to make sense to us. So what do we do? We doze off on the couch, we go to bed early, we sleep in late, we have an irregular sleep schedule, we become really preoccupied with whether or not we’ll be able to sleep, whether we’ve lost the ability to sleep, and this leads to a lot of hyper arousal, which is where CBTI comes in.
So there are several different components of CBTI that are tailored to each individual person, but in brief, what happens with sleep restriction is it takes someone’s existing sleep debt and grows it a little bit in order to consolidate sleep, so that people fall asleep faster, and they’re less likely to wake up. Stimulus control likes to strengthen the relationship between bed being a place for sleep, rather than other engaging activities, such as checking your email, plotting revenge, worrying, stress, or whatever else it might be.
Cognitive therapy helps people identify strategies that might be able to help them distance themselves from a mind that doesn’t seem to be able to turn off. How do they stuck up? How do medications and cognitive behavioral therapy compare with one another? Well, the evidence is in, and the results are clear. In the short run, CBTI and medications are equivalent, but in the long run, CBTI is the clear winner.
The problem with behavioral therapies is not a lack of evidence that they work; it is a lack of awareness that they exist. You could probably rattle off the names of several different sleep medications, but how many commercials have you seen for CBTI? If you have insomnia, take heart. The odds are squarely in your favor. Your sleep can get better. You can wake up rejuvenated, with mental clarity, who knows, maybe even enough energy to stand up to a bear.
But here, I think that what I’ll do is I will heed the advice of a great mind, who says that it’s more important to know what sort of person has a disease than to know what sort of a disease a person has. So, I know sleep science, but I don’t know you. We just met. I don’t know you or the relevant medical history that would have helped me design a treatment to help you cure your insomnia, but I can leave you with this: eat healthy, exercise, take care of your body, and do all that you can do to cap it all off with a night of great sleep.