Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills

Insomnia is a common problem characterized by trouble falling asleep, staying asleep or getting restful sleep. Cognitive behavioral therapy for insomnia is an effective insomnia treatment for chronic sleep problems.

Cognitive behavioral therapy for insomnia is a structured program that helps you identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Unlike sleeping pills, cognitive behavioral therapy for insomnia helps you overcome the underlying causes of your sleep problems.

How does cognitive behavioral therapy for insomnia work?

The cognitive side of cognitive behavioral therapy for insomnia teaches you to recognize and change beliefs that affect your ability to sleep. The behavioral part of cognitive behavioral therapy for insomnia helps you develop good sleep habits and avoid behaviors that keep you from sleeping well.

Cognitive behavioral therapy for insomnia contains one or more of the following elements:

• Sleep education. To make effective changes, it's important to understand the basics of sleep — for example, understanding sleep cycles and learning how beliefs, behaviors and outside factors can affect your sleep.
• Cognitive control and psychotherapy. This type of therapy helps you control or eliminate negative thoughts and worries that keep you awake. It may also involve eliminating false or worrisome beliefs about sleep, such as the idea that a single restless night will make you sick.
• Sleep restriction. Lying in bed when you're awake can become a habit that leads to poor sleep. Limiting the amount of time you spend in bed can make you sleepier when you do go to bed. That way you're more likely to fall asleep and stay asleep.
• Remaining passively awake. This involves avoiding any effort to fall asleep. Paradoxically, worrying that you can't sleep can actually keep you awake. Letting go of this worry can help you relax and make it easier to fall asleep.
• Stimulus control therapy. This method helps remove factors that condition the mind to resist sleep. For example, you might be coached to use the bed only for sleep and sex, and to leave the bedroom if you can't go to sleep within 15 minutes.
• Sleep hygiene. This method of therapy involves changing basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, drinking too much alcohol, or not getting regular exercise. You may be told to avoid napping and taught to maintain a consistent sleep schedule. It also includes tips that help you sleep better, such as ways to wind down an hour or two before bedtime.
• Relaxation training. This method helps you calm your mind and body. Approaches include meditation, hypnosis and muscle relaxation.
• Biofeedback. This method allows you to observe biological signs such as heart rate and muscle tension. Your sleep specialist may have you take a biofeedback device home to record your daily patterns. This information can help identify patterns that affect sleep.
• Sleep diary. To understand how to best treat your insomnia, your sleep therapist may have you keep a detailed sleep diary for one to two weeks. In the diary, you'll write down when you go to bed, when you get up, how much time you spend in bed unable to sleep, total sleep time and other details about your sleep patterns.

The most effective treatment approach may combine several of these methods.

Cognitive behavioral therapy vs. pills

Some newer sleeping medications have been approved for long-term use. But they may not be the best long-term insomnia treatment.

Sleep medications can be a very effective short-term treatment — for example, they can provide immediate relief during a period of high stress or grief.

Cognitive behavioral therapy for insomnia may be a good treatment choice if you have long-term sleep problems. You may want to try it if you're worried about becoming dependent on sleep medications, if medications aren't effective or if they cause bothersome side effects.

Unlike pills, cognitive behavioral therapy for insomnia addresses the underlying causes of insomnia rather than just relieving symptoms. But it takes time — and effort — to make it work. In some cases, a combination of sleep medication and cognitive behavioral therapy for insomnia may be the best approach.

Insomnia and other disorders

Insomnia is linked to a number of physical and mental health disorders and substance abuse. Ongoing lack of sleep increases your risk of illness and infection, high blood pressure, heart disease, diabetes and chronic pain. If you have a condition that's linked to insomnia, it needs to be addressed along with sleep problems.

Finding help

There are a limited number of certified Behavioral Sleep Medicine specialists, and you may not live near a practitioner. You may have to do some searching to find a trained practitioner and a treatment schedule and type that fit your needs. Here are two places to look:

• The American Academy of Sleep Medicine offers information about finding a Behavioral Sleep Medicine specialist on its website.
• The National Sleep Foundation website offers information about finding sleep centers. Many are associated with major hospitals.

The type of treatment — such as group vs. individual — and frequency of sessions can vary, depending on who you see. You may need as few as two sessions or as many as eight or more sessions, depending on your sleep expert, the program and your progress.

When calling to set up an appointment, ask the practitioner about his or her approach and what to expect. It's also a good idea to check ahead of time whether your health insurance will cover the type of treatment you need.

They can't replace meeting with a sleep specialist in person, but you may benefit from books, CDs or websites on cognitive behavioral therapy techniques and insomnia.

They can't provide the same services as sleep specialists, but licensed psychological counselors (psychotherapists) can offer cognitive behavioral therapy techniques to ease psychological concerns linked to sleep problems.

Who can benefit from cognitive behavioral therapy for insomnia?

Cognitive behavioral therapy for insomnia can benefit nearly anyone with sleep problems. The therapy can help older adults who have been taking sleep medications for years, people with physical problems such as chronic pain and those with primary insomnia, a condition that exists in its own right. What's more, the effects seem to last. There is no evidence that the therapy has negative side effects.

Cognitive behavioral therapy for insomnia requires steady practice, and some approaches may cause you to lose sleep at first. Stick with it, and you're likely to see lasting results.

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