Published by the New York Times August 16, 2016
By Roni Caryn Rabin
We’ve all heard about the power of positive thinking. But will it help me sleep?
My problem isn’t falling asleep – it’s staying asleep. This particular form of torture has been dubbed “sleep-maintenance” insomnia. Call me a high-functioning sufferer: I’m usually O.K. once I’ve had my morning coffee. But I worry about the long-term health ramifications of losing sleep.
Now several medical organizations have endorsed a treatment known as cognitive behavioral therapy for insomnia or C.B.T.-I. In May the American College of Physicians advised its members that C.B.T.-I. was the first treatment they should offer patients with insomnia.
I wanted to try it, but there is a shortage of trained therapists with expertise in C.B.T.-I. I didn’t want to wait for an appointment; I just wanted to solve the problem.
So I decided to try an online sleep program. Convincing data that internet-based programs are effective is piling up,
and a recent review of clinical trials reported that insomniacs improved their sleep as much after online C.B.T.-I. programs as they did after face-to-face C.B.T.-I. counseling.
Internet programs are likely to be cheaper than most therapists, too. I downloaded a five-week course called Conquering Insomnia for $40. Another online C.B.T. program called SHUTi charges $135 for 16 weeks of access to a program, which includes a series of six sessions and follow-up for 10 weeks. Both programs provide individualized feedback on your weekly sleep logs.
The developers of these programs say they want them to be accessible to as many people as possible. One in 10 people suffer from insomnia.
“The number of clinicians nationally who know how to do C.B.T. for insomnia is a couple of thousand. We need 100,000,” said Dr. Gregg Jacobs, a sleep medicine specialist and assistant professor of psychiatry at the University of Massachusetts Medical School who developed the Conquering Insomnia program. “There are tens of millions of people out there who have insomnia.”
What I like about C.B.T.-I. is that it’s very no-nonsense. It’s focused on problem-solving. You won’t find any soul-searching about the deep psychological reasons you can’t sleep at night, just a lot of good information that will challenge some of your assumptions about sleep.
The program stresses good sleep habits, often referred to as sleep hygiene. Get up and out of bed at the same time every day. Don’t sleep in more than a half-hour on weekends, even if you are sleep-deprived (Sorry, I know that hurts). Varying your wake-up time throws off your body’s wake-and-sleep rhythms. Use the bed for sleeping and sex — and that’s it. Develop a bedtime routine.
But the key element of Cognitive Behavioral Therapy is cognitive restructuring, which challenges you to reframe negative ways of thinking that can become their own self-fulfilling prophecies. So if you’re lying awake thinking about what a basket case you’ll be tomorrow because you’re not asleep, well, that thought alone will keep you awake.
C.B.T. asks you to look at the situation differently, and replace the negative thought with a positive one.
“I’ll fall asleep eventually.”
“I can handle this if it only happens a few nights a week.”
“I usually function pretty well even when I don’t sleep.”
As part of my therapy, I started recording my sleep and wake times every morning in a sleep log. The first one I emailed in for feedback looked like Swiss cheese, with two-hour holes in my sleep pattern three or four nights a week. I awaited the response with trepidation.
The email I got back said I had broken a lot of the rules. My wake-up times were all over the place. I was spending too much time in bed and too little of it sleeping.
The program offered me a new sleep plan. For next week, I am to wake up at 7 a.m. every day since this seems to be my natural inclination, based on my sleep log. And I have a new bedtime: midnight. Not a moment before.
And even though my sleep is often interrupted, the C.B.T. process asks me to reframe this information. The reality, Dr. Jacobs told me, is that I am getting six total hours of sleep a night, and should use this as “a positive sleep thought.”
It’s too soon to know if my online therapy will have a meaningful effect on my sleep, but a recent meta-analysis of C.B.T.-I. suggests I have reason to be hopeful. The review found that C.B.T.-I. worked equally as well whether it was delivered in person or online. C.B.T.-I. users gained, on average, an additional 20 minutes of sleep a night and saw an improvement in mood after the treatment.
Other reviews have been less effusive, finding people fell asleep faster and slept better after online C.B.T., but still woke up in the middle of the night, and didn’t get more sleep overall.
Some health care providers are skeptical. They say online C.B.T.-I. is a cookie-cutter approach to a process that needs to be individualized. One concern is that some insomniacs may have another psychiatric disorder that needs to be addressed, like depression or anxiety, or an undiagnosed sleep disorder like sleep apnea, said Jennifer L. Martin, an associate professor at the David Geffen School of Medicine at the University of California, Los Angeles, who is board-certified in behavior sleep medicine and practices C.B.T.-I.
Still, Dr. Martin said, “For a subset of people who are highly educated and highly motivated, a book or online program is a great thing to try.”
Personally, I’m glad I got started with an online program. I have a pretty busy schedule, so it would be tricky squeezing in a weekly appointment with a therapist. Of course, if they had an opening at 4 in the morning, I could swing it.