Over the years, I’ve tried every non-pharmaceutical trick in the book to overcome my insomnia: White noise. Room-darkening shades. No caffeine after noon. No screen time before bed. Meditation. Yoga. Journaling. Melatonin. CBD. And on and on, ad nauseum.
Sleep has always been elusive for me. At its worst, five years ago, I was getting by on just a few hours of shuteye each night. For months, I was running on fumes, and I needed help, which led me to an online insomnia treatment program that thankfully made a lasting impact on my sleep for the better.
Everyone experiences the occasional sleepless night, and that’s especially true during a period of increased uncertainty like a pandemic. But when a few restless nights turn into a pattern that hurts your quality of life, it’s time to seek help, says Dr. Jennifer Martin, professor of medicine at the David Geffen School of Medicine at UCLA and a member of the American Academy of Sleep Medicine board of directors.
“A bad night of sleep when you’re experiencing stress is a normal response,” says Martin. “Clinically, we think of insomnia as an actual sleep disorder if it happens at least three times a week and goes on for three months or longer.”
If you’ve been tossing and turning for weeks, months or years, here’s what experts suggest when it comes to finding help and starting treatment for insomnia.
Working with a sleep specialist
“Don’t ignore sleep problems,” says Terry Cralle, a registered nurse and sleep educator based in Washington, DC. “We sometimes characterize it as, ‘Oh, if you need sleep, you’re weak, or you’re not ambitious, or you just need to power through.’ None of that’s true. Sleep is a biological need. We need sleep like we need water.”
You can talk to your primary care provider about insomnia, but your general practitioner might not be well versed in the latest treatments.
“For a lot of regular doctors, [medication] is the only thing they know about,” Martin says. But these days, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia — not pills.
You can ask your PCP for a referral to a sleep specialist, or you can search for one through the Society for Behavioral Sleep Medicine or the American Academy of Sleep Medicine. Sleep specialists, who’ve all been trained to treat sleep disorders, can be physicians, psychologists or even dentists. Most medical doctors who treat sleep issues specialize in internal medicine, psychiatry, pediatrics or neurology, according to the AASM. Therapists and psychologists can also specialize in treating sleep disorders.
If you can’t meet with a specialist in person or you don’t have one in your area, many providers provide treatment for insomnia via telemedicine, and a recent study shows that telemedicine is as effective as in-person CBT-I.
“With the pandemic, telemedicine is now becoming the norm, so it would not be difficult at all to find a specialist,” says Bill Fish, managing editor of SleepFoundation.org and a certified sleep science coach.
Online program for insomnia
Self-guided, online CBT-I programs like Sleepio, SHUTi and CBT-I Coach are another avenue for people interested in a DIY approach. When my insomnia was at its worst, a Google search led me to Sleepio’s online program. It was a godsend. I followed the six-week regimen to a T, reading articles about sleep, watching weekly videos and following the guidelines laid out in the program, like getting out of bed when I couldn’t fall asleep and waking up at the same time each morning.
“There’s data that they actually work for a lot of folks,” Martin says of online programs, but she warns that they don’t offer the individualization of in-person or telemedicine therapy. An online program also requires a lot of self-discipline.
“Be really honest with yourself,” she says. “If you’re the kind of person who can do a program on your own, if you sign up for P90X or whatever and you actually do all the workouts and that’s your way of doing things, there are really good online programs.”
Breaking down CBT-I
CBT is a therapeutic approach that aims to change negative or unhelpful thinking patterns. CBT-I specifically is designed to help insomniacs understand their broken relationship with sleep and then rebuild it, replacing irrational sleep beliefs and habits with ones more conducive to a good night’s rest. That includes letting go of the notion of “trying” to sleep, which can create a vicious cycle: The harder you try to sleep, the harder it becomes to fall asleep.
“It’s kind of a rip-the-Bandaid-off approach,” Martin says. “We try to fix everything that might be making a person’s sleep worse.”
Whether you work with a specialist or go the self-guided route, you’ll begin CBT-I by keeping a sleep diary to track how much sleep you’re getting at night. Then, your program will include a combination of the following strategies:
If you spend hours every night tossing and turning in bed, it eventually creates an association between the bed and being awake, which feeds into the cycle of sleeplessness. During sleep restriction, you limit your time in bed to only the time you’re sleeping: Use your sleep diary to determine how much sleep you get per night, on average. Then you restrict your time in bed to that amount, plus about 15 minutes.
For me, this was the hardest part of CBT-I. During the first week of my program, I was only able to be in bed from 12:30 am to 6 am, based on the 5 or so hours of sleep I was averaging each night and the time I needed to be up for work. To limit my time in bed to that narrow window, I stayed up late when I was exhausted and got out of bed at the same time every day, even when I felt tired enough to sleep for a few more hours. The days were brutal, but at night, I started falling asleep not long after my head hit the pillow — a far cry from tossing and turning until 4 am.
“The sleep restriction is hard, and it works,” Martin says. “I usually tell people we shouldn’t do it during final exam week. Let’s pick a time to do that when you can get through it. The beginning is harder, and then it gets easier.”
And I can assure you, it does get easier. Each week that you maintain good sleep efficiency — meaning that at least 80 to 90 percent of time in bed is spent sleeping — you can add another 15 minutes to your sleep window. Over the course of several weeks, I worked up from my 5.5-hour sleep window to a full 8.5 hours.
If lying awake in bed creates an association between the bed and wakefulness, so will any other waking activity in bed (aside from sex).
“Don’t do anything else in the bed. Don’t argue with your partner, don’t pay bills, stay off the electronics. We’re just going to associate that with being awake and not being asleep,” Cralle says.
Stimulus control therapy includes eliminating all waking activities from your bedroom, along with avoiding daytime naps and maintaining a regular wake-up time (even on weekends and after nights of poor sleep).
Cognitive therapy techniques
Cognitive therapy challenges our false or misunderstood ideas about sleep. Learning how sleep works makes it less elusive, Martin says: “When you have facts and information it’s a little easier to change the way you approach sleep in general.”
For me, learning that most people underestimate how much sleep they’re getting was a turning point. Instead of panicking after a sleepless night, I felt reassured knowing I probably got more sleep than I remembered.
Many CBT-I programs also introduce relaxation techniques to “work on what’s going on in our mind when we get in bed at night,” Martin says. This could include writing down negative thoughts about sleep and then rewriting them as positive statements or listening to a relaxation meditation.
CBT-I programs emphasize good sleep hygiene, which includes all the things you should do (and avoid) to promote good sleep, like avoiding caffeine late in the day and cutting down on alcohol.
“The other thing is just really developing strategies for winding down at the end of the day, so your brain and body are relaxed when you get into bed,” Martin says. If you usually watch an action-packed TV show before bed, for example, you might try swapping it for a lighthearted novel.
“Some people feel that a glass of warm milk helps them sleep, when maybe it is the custom of the action that is actually telling your brain to relax,” Fish says. “If something works for you personally, stick with it. Consistency is key.”
Give it time
Shifting long-held beliefs and habits takes time. The average length of CBT-I treatment is four to eight weeks, Martin says, which is relatively quick compared to therapeutic programs for other conditions. While some parts of the approach (like sleep restriction) can be unpleasant, CBT-I works: Studies show it’s effective in the long run for keeping insomnia at bay.
What about sleeping pills?
For chronic insomnia, experts say sleeping pills aren’t a great option. In the long run, they can lead to dependency.
“One of the challenges when people start taking a sleeping pill is they work for a while, but then they work less well,” Martin says. “Getting off sleeping pills requires slow, methodical dose reduction supervised by a physician. So, do people get addicted to them? Not in the traditional sense that we think about drug addiction. But is it hard to stop taking them? Absolutely.”
As for melatonin, “it’s not really a sleep aid; it acts on your circadian timing system,” Martin says. Melatonin is better for dealing with jet lag or changing your sleep schedule than for treating insomnia.
When CBT-I fails, rule out other conditions
Studies show CBT-I has a success rate of around 70 to 80 percent. But if you complete a CBT-I program and still struggle with sleep, it could be a sign of another condition.
“There is a lot of overlap between insomnia and sleep apnea,” Martin says. Your doctor might order an overnight diagnostic test to rule out sleep apnea or other conditions.
Ultimately, whether you’re dealing with insomnia or overlapping conditions, it’s worth talking to your doctor to get to the root of your sleeplessness.
“Poor sleep is not inevitable,” Cralle says. “There are many ways to help your sleep, so always bring it up.”