Colleen Carney says the people who come to her sleep clinic have one thing in common: “They’re desperate.” Okay, two things: “And skeptical.”
“We see everyone, from 30-year-olds to 80-year-olds,” says Carney, an associate professor and director of the Sleep and Depression Laboratory at Ryerson University in Toronto. “By the time we see them, they’ve usually had a sleep problem for years and years. One study said the average time before people got help was a decade.”
It’s an incredibly common affliction: Over half of adult women regularly have trouble getting to sleep or staying asleep, according to information released by Statistics Canada last month. And when insomnia becomes chronic — when people have problems falling asleep, staying asleep, or waking up too early at least three nights a week for more than three months — it can be crippling. It leaves people more than just drowsy — they become irritable, unmotivated and preoccupied with sleep. There are physical effects, too: Insomnia raises your risk of high blood pressure, heart disease, diabetes and chronic pain. It’s even suspected to increase the risk of certain types of cancer.
The answer many insomniacs reach for is sleeping pills. But they’re habit-forming, have side effects and become less effective over time. Other people embrace the tenets of sleep hygiene, doing things like avoiding caffeine after lunch, banning screens from their bedrooms or exercising regularly. But it’s often not enough. “That’s the most well disseminated treatment, but it’s more for good sleepers who want to have good habits,” says Carney. “The people we see, they’ve given up caffeine, they don’t drink, they’ve tried all of this already.”
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A different solution has proven to help many people: Cognitive Behavioural Therapy for Insomnia (CBT-I) is an offshoot of standard CBT (a popular form of talk therapy that focuses on reframing negative thoughts and changing unhelpful behaviours) that focuses exclusively on sleep issues, retraining your body to sleep soundly. The treatment helps you change how you think about those 3 a.m. wake-ups, and trains your body by keeping a strict sleep schedule for about a month.
It’s so effective that it’s become the recommended first-line treatment in Canada, the U.S., and the U.K. for chronic insomnia. “It’s a very clear alternative to pills that’s more effective, and much safer,” says David Gardner, a professor of psychiatry and pharmacy at Dalhousie University. Here’s how it works:
How does insomnia become chronic?
It’s normal for people to have short-term sleep issues. Maybe you have trouble falling asleep for a few days before a big presentation, or for a few weeks after someone close to you dies. Chronic insomnia normally starts like that, and then becomes persistent in people who develop overly negative thoughts about their sleep or foster poor habits, like taking long naps. It’s counterintuitive, but “if you continuously react with anxiety or attempts to take control of your sleep, it’s going to result in chronic insomnia,” says Carney.
How CBT-I works
CBT-I starts with addressing negative thoughts around sleep. “Often it’s, Oh my God, I’m not asleep yet, I have to get up in only two hours, I’m not going to be able to function at work tomorrow, I’m going to get sick,” explains Judith Davidson, an associate professor of psychology at Queen’s University and the author of Sink Into Sleep. That amps up anxiety levels, making it harder to fall back asleep. Instead, people undergoing CBT-I are taught to think something like, I’m not going to feel great tomorrow, but I’ll get through it. “If you can make your thoughts boring, it really helps,” says Davidson. Relaxation therapy, which is also part of CBT-I, helps too. It teaches people how to calm their bodies — using techniques like contracting and then relaxing their muscles, from the top of their head down to their feet.
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The second aspect focuses on a person’s circadian rhythm — the 24-hour cycle that controls when you’re tired and when you feel awake. Insomniacs often go to sleep too early, then wake up in the middle of the night, or take long naps during the day and then have trouble sleeping. CBT-I asks them to follow a strict schedule instead, including waking up around the same time every day. “[That’s] like setting your clock,” says Carney. For the first month, that schedule also restricts their sleep to less than they’re used to, making them tired enough to avoid middle-of-the-night wakeups and helping them fall asleep quickly once they go to bed.
CBT-I also involves a little bit of homework — mainly filling in a sleep diary every day. Using that, the psychologist would set a bedtime — usually one later than normal — and a regular wakeup time. The therapy includes discussing good sleep habits (like getting out of bed after 20 minutes if you haven’t fallen asleep) and examining how well a person’s fears and beliefs around sleep match the truth. “It’s helpful to look at these thoughts in the light of day,” says Davidson.
What are the challenges?
People who complete a course of CBT-I, which takes 6–8 weeks, usually start falling asleep within 30–45 minutes of going to bed, sleep 30–60 minutes longer a night and spend less time in bed trying to sleep. And they’re often much happier, says Carney. So why don’t more people do this? One issue is that the program is hard to follow — people get very, very sleepy during the first few weeks, when their sleep is restricted. “I always liken it to eating: I could tell you what to eat so that you would be really healthy,” says Carney. “The question is: Would you follow it?”
Another problem is access. For a long time, it’s been a lot easier to get a prescription for sleeping pills — or take an over-the-counter drug — than it is to find someone qualified to offer CBT-I. In Canada, CBT-I isn’t regulated, but 90% of providers are psychologists with expertise in behavioural sleep medicine, says Davidson.
But access seems to be improving. Some family doctors with specialized training are now offering CBT-I as an alternative to sleeping pills, and new studies have found that online versions of the program are also effective, though they cost $100 and up. (Gardner has created a website that lists online CBT-I programs and reviews the evidence behind each, as well as books that help you DIY it.)
“Research has shown that these self-help programs work just as well as seeing a therapist,” says Gardner. “So we’re moving beyond this being an access issue. Now, it’s really about people being aware this is out there.”