If You Tried Cognitive Behavioral Therapy for Insomnia and It Didn’t Work for You, It’s Likely You Didn’t Really Try It
COGNITIVE BEHAVIORAL THERAPY
FOR INSOMNIA
(CBT-I)
With my wife, Jan Maslow, I’ve created an 8-week online cohort course for people who are having trouble with sleep. We’ve called it, “From Restless Nights to Effortless Sleep.” The course integrates the three approaches that have been shown to be most effective for treating insomnia. Because the main obstacle to sleep is most often the life-long tendency to “try too hard,” underlying the entire course is an eye to cultivating a capacity for the experience of effortlessness.
The three components of our Effortless Sleep Course are:
· Cognitive Behavioral Therapy for Insomnia (CBT-I)
I’ve written about effortless mindfulness here and Yoga Nidra here.
* * * * * * * * * * *
Here’s a brief overview of Cognitive Behavioral Therapy for Insomnia:
Cognitive Behavioral Therapy for Insomnia (CBT-I for short) is based on Cognitive Behavioral Therapy (CBT for short).
So what is CBT?
The “C” in CBT refers to cognition — that is, the often distorted, dysfunctional thoughts and beliefs that affect every area of our lives — physical and psychological — of which we’re usually partially or totally unaware of.
If you’re not very familiar with mind-body medicine, you might well believe that whatever your physical problems are, they have nothing to do which what you think. But research shows that through examining the deeply hidden beliefs and assumptions underlying our stories about what’s happening, we can:
- Reduce or eliminate symptoms of asthma, migraines and other forms of pain
- Alter physiological hunger signals to make healthy eating much easier
- Reduce symptoms of Parkinson’s disease
- Reduce symptoms of depression and trauma
- Change the neural pathways associated with autism ADHD, and OCD
and so much more.
The “B” in CBT refers to behavior. CBT uses behavioral interventions that can radically help people with severe depression, trauma, OCD, physical pain of all kinds, and of course, insomnia.
CBT-I which is CBT tailored for treating insomnia, reduces, or at its best, totally cures insomnia through the use of both cognitive and behavioral methods that calm the mind and substantially change the physiology underlying our sleep-wake cycle, such that it becomes easy to fall asleep and get back to sleep.
I was initially certified in CBT-I through a program created by Dr. Gregg Jacobs. Dr. Jacobs developed the Behavioral Medicine Insomnia Program at Harvard Medical School’s Deaconess Hospital in Boston, in 1991. It was the first comprehensive program for insomnia that did not use drugs. Over the past 30 years, it has been taught to thousands of patients and healthcare practitioners. It was considered successful enough that he was awarded a four-year grant by the National Institutes of Health to study the effectiveness of his Insomnia Program compared to medications prescribed for sleep. (Spoiler alert: it was more successful).
I more recently received a second certification in CBT-I through a three-day course taught by leaders in the sleep medicine field, Drs. Colleen Carney and Meg Danforth. The course included extensive instruction on how patients with depression, anxiety, chronic pain and trauma can benefit from CBT-I .
As developed by Dr. Jacobs and others, CBT-I is based on a simple principle: rather than making an effort to sleep, we can learn how our brain and body function naturally to help us sleep and then learn how to cooperate with that natural functioning. When we’re in harmony with our natural functioning, sleep happens effortlessly.
Not only humans, but all mammals, as well as reptiles have natural sleep-wake cycles along with a number of other natural cycles. But we humans tend to live our lives with so little awareness of these cycles that it may be hard to believe that our bodies could actually be ready and eager to sleep or eat all on their own, without any mental gymnastics.
We can learn to tune into these circadian cycles (cycles that occur within a 24-hour period), not only to get high quality, restorative sleep with relatively little effort, but to more easily develop healthy work, eating, exercise and recreational habits as well.
In addition to our sleep-wake cycle, circadian rhythms regulate our digestion, immune, and other systems of the body. They affect our metabolism and weight through regulating blood sugar and cholesterol levels, and can even affect our mental-emotional state, particularly our levels of happiness and sadness (SAD, or “seasonal affective disorder,” is an example of this). There are also cycles of greater and lesser susceptibility to illness, and even times throughout the day that are more favorable for analytic or creative thinking!
Some of our body’s natural rhythms are independent of the environment, but for the most part, sleeping and waking are affected by sunlight. Light stimulates our hypothalamus (the “master clock” in our brain) to produce hormones such as cortisol and acetylcholine that increase alertness, and darkness stimulates it to produce melatonin, adenosine and other “sleep” hormones. These circadian rhythms harmonize our sleep-wake drive with the sun so that we generally stay alert throughout the day (except for a dip in energy which often occurs in mid-to-late afternoon) until the sun goes down when our sleep drive takes over.
In 1987, psychiatrist and sleep specialist Arthur Spielman developed a protocol to help people find a sleep schedule that would best align them with their natural sleep-wake cycles. (Dr. Spielman referred to this process as “sleep restriction,” the term which is commonly used in CBT-I. Since that term tends to evoke an uncomfortable feeling of control, the opposite of what we’re aiming for, I’ve chosen to refer to it as “sleep scheduling” instead.) Sleep researchers around the world have come to agree that if you could choose just one thing to do to improve your sleep, it would be to go through the steps of the process for determining your ideal sleep schedule.
Some people have tried CBT-I and claim it doesn’t work for them. For quite a few, the way they’d been taught sleep scheduling, along with other aspects of CBT-I, may have paradoxically ended up emphasizing a kind of strained effort, the exact kind of effort which has been shown to impede good sleep. For this reason, we’ve made the cultivation of effortlessness the thread that runs through every aspect of the course. One of the positive side of effects of going through the course is that the effortlessness you cultivate for the sake of sleep can, over time, begin to seep into all aspects of waking life as well.
In other articles, I explain how the following — effortless mindfulness, Yoga Nidra, music I’ve specially composed to facilitate deep sleep, and sleep hygiene, when used properly — help to balance out the tendency in CBT-I to intensify tense “efforting” rather than minimize it.