Insomnia Treatment: It's Not Always "Common Sense"

I recently completed CBT for insomnia treatment with a patient. His sleep has improved dramatically over 5 sessions and he’s leaving treatment happy. Those “wins” are what make me so passionate about this work. As we wrapped up, he said “Everything you showed me was just common sense. I can’t believe I couldn’t figure this out myself.”

I’m happy that I was able to guide him through treatment well. But his comment made me chuckle. When people with insomnia hear what CBTI entails, they usually have the opposite reaction: That makes no sense!

Why does CBT for insomnia seem counterintuitive?

“You want me to get out of bed if I can’t sleep? How am I going to fall asleep if I’m not in bed?”

“Stop napping? But I can’t get through the day if I’m this tired!”

“Stop sleeping in on the weekends? That’s when I make up for all my sleep loss throughout the week!”

It makes sense to me that CBTI principles don’t always make sense to patients. In a lot of ways, I am asking patients to do the exact opposite of what they want to do. And sometimes it’s the exact opposite of something that used to work for them.

That conversation with my patient motivated me to see if I can explain the “common sense” behind CBTI to a wider audience.

Answering common questions

Why haven’t I figured it out already?

If CBTI techniques are based in common sense, why haven’t you figured out how to get better sleep already? In my experience, education about sleep (and overall health) is lacking. File it with other “common sense” topics we aren’t taught in school, like stress management and making a household budget. It’s only in the past few years that we have been talking about the importance of sleep as basic health. Even then, what we hear most about are medications and reducing blue light exposure. You probably were never taught about the behavioral ways to regulate sleep, even though scientists have known about it for decades.

How am I going to fall asleep if I’m not in bed?

Stimulus control is one of the main techniques in CBTI. Simply put, the bed is for sleep, and sleep is for the bed. Lying awake in bed is one of the worst things you can do if you have insomnia. But you might naturally wonder, “how am I supposed to sleep if I can’t stay in bed?” The simplest explanation is based on building associations.

Why do you expect to see and smell buckets of popcorn at the movie theater? Because you’ve seen and smelled them there every single time you’ve gone to the movies. It would seem weird if you went to a movie theater and there wasn’t popcorn.

We want to build the same association between your bedroom and sleep. If you are asleep almost all of the time that you are in bed, your brain will form a strong connection and learn “I sleep when I’m in bed.” If you spend half of your time in bed awake, that connection is much weaker.

Keep in mind that it takes several weeks to build strong associations. So the improvements won’t happen overnight (no pun intended). But the more consistent you are in getting out of bed when you’re not asleep, the stronger that connection will become.

I need to nap! I’m exhausted!

Another CBTI technique is to stop napping. Understandably, this is the opposite of what patients want to hear. “I’m exhausted! I can’t make it through the day without a nap!”

For this to make sense, you need to know about sleep drive or sleep “hunger.” Much like our appetite for food, we have an appetite for sleep. The longer you go without eating, the hungrier you are. If you have a small snack, you won’t be hungry for a little while. If you have a bigger snack, you’ll stay full for longer. The same is true for sleep. A short nap (10 minutes) reduces your sleep hunger a little. A longer nap (60 minutes) reduces your sleep hunger even more.

In order to sleep solidly through the night, your sleep drive needs to be high at night. Every time you nap or doze, you reduce the sleep hunger that you have available at bedtime.

What if it still doesn’t make sense for me?

You may get to the end of this article and find that CBTI still doesn’t make sense to you. That’s OK. One of your provider’s jobs is to explain the techniques in a way that makes sense to you. And that might require explaining the techniques in a few different ways until it clicks. But another part of your provider’s job is to work with your specific circumstances and goals. Give your provider a chance to develop a plan unique to your needs.

It’s an honor when patients trust me to develop a treatment plan that works for them. Though the road may be bumpy at times, watching them get healthier and happier is a huge reward. I hope that every reader finds a treatment that makes sense to them.