Do pain and insomnia have you tossing and turning all night, wondering when the sandman is going to release you into sweet slumber? If so, relief can come in the form of cognitive behavioral therapy, or CBT. It’s not a quick fix – it can take as many as 8 or 10 weekly sessions with a therapist trained in CBT for insomnia, called CBT-I for short. But it can provide a real, long-term solution.
Maybe you’ve heard of CBT before and thought it sounded, well, a bit odd. “There’s nothing weird about it,” says Michael Breus, PhD, clinical sleep specialist and author of The Sleep Doctor’s Diet Plan (2012, Rodale Books). “There’s no hocus pocus here. There’s no magic.”
CBT for insomnia aims to change how you think about sleep and about your pain. And it aims to change sleep habits that are contributing to your insomnia, such as when you go to bed and wake up and how long you let yourself toss and turn in bed. The therapy is customized for you. “This isn’t something you can do on your own,” says Breus.
Behavioral sleep medicine specialist Ryan Wetzler, PsyD, agrees, noting that trying laundry lists of so-called “sleep hygiene” tips won’t work. “People haphazardly do this aspect or that aspect. But you have to do it all. And there’s a systematic process you have to go through to reset the systems that regulate sleep.”
That process, says Wetzler, includes understanding your circadian rhythm (and resetting it if necessary through sunlight and physical activity) and unlearning what experts call “conditioned wakefulness” – that annoying phenomenon in which, no matter how sleepy you feel when you go to bed, you’re wide awake when your head hits the pillow.
Here are some approaches the therapist may teach you.
- Stop trying to fall asleep. “Trying” generates performance anxiety. Instead, lie in bed as if you don’t care if you ever fall asleep. Or try not to fall asleep. And voilà – sleep will come because you’re not chasing it.
- Don’t dwell on your pain. People who “catastrophize” their pain or insomnia don’t sleep as well as people who think less negatively about it or think about it less, period. An example of catastrophic thinking, says Breus, is: “I know that my pain is going to prevent me from getting 8 hours of sleep, and that means that I’m going to have a terrible day tomorrow.”
- Forget the “20 minute rule.” You may have heard that you should get out of bed if you can’t fall sleep within 20 minutes. Wetzler disagrees. “If you tell someone this, they’re not going to be able to resist looking at the clock.” Instead, says Wetzler, get up “the moment you think, ‘Crud I’m not going to fall asleep,’ or you notice yourself getting frustrated, irritated or anxious. Then sit that thought or emotion on the couch. Give your body a time-out for behaving badly in the wrong place. By repeating that, eventually the mind and body should give in.”
- Break the bedtime rule, too. People are often told to go to bed and get up at the same times each day – not always a good idea. “It’s not when you go to bed that matters, it’s when you get up that matters from a circadian standpoint,” says Wetzler. A better rule: Don’t go to bed until you’re truly sleepy.
CBT is effective for insomnia, and it’s surprisingly effective for pain. In a study published in 2009 in the Journal of Sleep Medicine, CBT reduced pain among a group of people with osteoarthritis by 20 percent on a pain rating scale. It also cut the time it took to fall asleep and the time spent awake in bed almost in half.
The key to success with CBT, says lead study author Michael V. Vitiello, PhD, professor of psychiatry and behavioral sciences at University of Washington, is this: “You’ve got to stick with it and you’ve got to follow the rules. It’s just like diets. Everybody knows how to diet, but it’s how you continue to diet in order to lose weight that counts.” The therapist is “someone to help you stick to the rules, to help you when you’re stuck and figure out alternate ways of doing things.”
To find a therapist trained in CBT for insomnia – and there aren’t many – call an accredited sleep center in your area, or ask your doctor for a referral. Breus recommends the American Board of Sleep Medicine’s website and the therapist finder tool on the Psychology Today website. Also try the Society of Behavioral Sleep Medicine website.