When Sleep Hygiene Isn’t Enough

Cognitive Behavioral Therapy for insomnia may be just what you need.

Posted Apr 16, 2019

Annie Spratt / Unsplash
Sleepless nights
Source: Annie Spratt / Unsplash

Put down the chamomile tea and look around. Has your bedroom become a sea of “sleep hygiene” products? Blackout shades, climate control, sunrise simulation, white noise machine—the list may go on and on. If so, you may be among the many searching for a good night’s sleep.  

Oftentimes we are given the message that if we are diligent about sleep hygiene, insomnia will melt away, leaving a blissful night’s sleep in its wake. But what if good habits aren’t enough? For sure, sleep hygiene is important, and for many people, it’s just the thing to get back on track. But for those who struggle with chronic insomnia, it may not be sufficient to break the cycle.

I don’t need to quote statistics to emphasize the impact of poor sleep or insomnia on a person’s quality of life. I see it all the time in my practice, I hear it from family and friends, and my own experience has been no different. Insomnia is not a facet of any particular disorder; it can exist independently or alongside anxiety, depression, or PTSD (among others). For the millions struggling with it, insomnia can seem intractable. Sleep becomes the enemy. You try to balance the reprieve offered by sleep aids with the potential side effects. Relief seems out of reach.  

What many don’t realize is that there are common behaviors, thoughts, and feelings that go along with chronic insomnia that can contribute heavily to the problem. How often do you “sleep in” on a weekend, or take a nap to try to catch up? Or maybe you stay in bed for nine hours with the hope of getting at least seven. And if you can’t fall asleep, do you lie there for hours, worried that if you get up you’ll start the cycle all over again? If these routines sound familiar, they may be at least part of the reason that your insomnia has stuck around.

But hold the self-blame for a second, because self-criticism can play a huge part in insomnia, too. When basic lifestyle adjustments don’t work, we can think there’s something wrong with us, or that we are not trying hard enough. Catastrophic thoughts creep in while we lay wide awake: “If I don’t get a good night’s rest tonight, tomorrow will be a nightmare.” We obsess about getting those eight hours of sleep, which suddenly seem essential to avoiding that terrible cold going around.

These are assumptions that, the majority of the time, are simply untrue. They can lead to an unhealthy and anxious attitude toward sleep, which in turn makes our insomnia worse. These so-called “cognitive” aspects of insomnia are often overlooked but can be among the hardest to cope with on those sleepless nights.

What you’ve probably noticed is that none of this has anything to do with sleep hygiene. So, the bad news is that chamomile tea won’t cut it. The good news is that there's another angle to try. Cognitive Behavioral Therapy for Insomnia, or CBTi, is the gold standard, evidence-based treatment for clinical insomnia. It is a short-term, standardized protocol that can successfully improve both the quality and quantity of sleep. When taught by a trained clinician, it is more effective long term than any other treatment for insomnia—including sleep aids.

CBTi puts common-sense techniques before elaborate bedroom set-ups, and uses the behavioral principles of classical conditioning—think Pavlov’s dogs—to help strengthen the link between our bed and a good night’s rest. CBTi also works to give the facts (not the fads) around sleep, challenging the myths that literally keep us up at night: the reality is if you get a bad night’s sleep, not only will you likely still function the next day, you may actually sleep better the following night. It highlights the habits with the most positive impact while challenging some popular mainstays. For example, exposure to bright light immediately upon waking helps regulate your circadian rhythm, but daytime sleeping, even the oft-touted “power nap,” is almost always a bad idea because it reduces your need for sleep later on.

CBTi moves away from the idea that clinical insomnia represents a deficiency in motivation or effort. It creates a sense of agency without blame: Our bodies have an inherent sleep drive, and we can take steps to reclaim it. It acknowledges that by itself, sleep hygiene may not be sufficient for the treatment of clinical insomnia. And that’s ok.

CBTi is not well known, but it’s out there, and it can help. Speak to your doctor or clinician to learn more about it and if it may be appropriate for you.

Sasha Berger, Ph.D. is a licensed clinical psychologist specializing in trauma, mood disorders and insomnia. At Octave, she runs a Cognitive Behavioral Therapy for Insomnia group to help address both chronic and acute sleep problems, and presents on this topic within primary care settings.

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