I’m not sleeping well lately. I don’t really know what the problem is — it may just be a general anxiety that I feel about our world, or it could be caused by the cold I caught around Christmas time. In any case, I seem to wake up in the middle of the night and have trouble falling asleep again.
Sleep is critically important for our well-being. Sleeping poorly can impact our immune systems, cause memory loss issues, and may even lead to increased likelihood of dementia. As if I need to tell you, it also makes you feel lousy.
There are a number of different ways that people can have trouble sleeping. Most people are concerned about having difficulty getting to sleep, difficulty staying asleep, frequent waking, or difficulty getting back to sleep after waking. There are also some other issues that could have more organic causes, like sleep apnea, restless leg syndrome, or narcolepsy. All three of these should be discussed with a physician.
I always think it’s funny, or ironic, when I have this problem, because one of the things I’m pretty good at is treating people who have insomnia. I use a technique called CBT-I (Cognitive Behavior Therapy for Insomnia), and it works really well.
CBT-I consists of three basic parts: sleep hygiene, psychological factors, and sleep restriction.
Sleep Hygiene
Sleep hygiene includes all the tips and tricks that help people to have good restful sleep. These are often the pointers that you can find in a magazine article, or that you may hear from your family doctor. Following these guidelines can help you to sleep better, and if you decide not to follow them, that may be the root of your problem. But everyone is different. Some of these factors may not have any effect on you at all. Or you may follow them all, and find that you are still not sleeping.
Here are some things to consider:
Don’t stay in bed. If you aren’t sleeping, and you find yourself tossing and turning or just recognizing that you are awake and thinking too much, get out of bed. Try not to stay in bed awake for more than 25 minutes. Staying in bed while awake teaches your brain that bed is a place where it is common to be awake, which is exactly what you don’t want. Limit your time in bed to sleeping and sex. Other activities — even reading, which many people do in bed — can be sending your brain the wrong message. If you find that you are still in bed awake after 25 minutes, get out of bed and do something relaxing. Read a book, do some stretching, or color a mandala. Once you feel tired, go back to bed and try to sleep again.
Limit your intake of caffeine. Caffeine inhibits good sleep, and it stays in your body for up to six hours after ingesting it. That means that you should not drink caffeinated beverages (I’m looking at you, coffee addict) after about 2pm.
Get up at the same time every day. Our bodies follow a circadian rhythm, and waking up at different times on different days can throw that rhythm off. Pick a time that work for you, and then don’t change it — even on weekends.
Turn off your screens an hour before bedtime. The blue light that is emitted by phones, TVs, and computer screens tells your body that it is time to be awake.
Exercise. Making your body tired gives you additional sleep pressure — that feeling that you need to sleep. Exercising each day ensures that you will always feel like sleeping at night.
Don’t drink liquids for three hours before bed. Reducing our trips to the bathroom helps us to achieve more unbroken sleep.
Psychological Factors
Stress and anxiety are the most commonly cited reasons why people say “I just can’t turn my brain off at night.” Thinking about our worries is common, but ruminating about them is not. In order to get past these worries, a therapist may be helpful to encourage processing unwanted thoughts and feelings so that they take up less mental space.
There is also a mental exercise that can help. Taking five minutes to do a “worry dump” — writing your concerns down before bed — can remove the concern that these issues need to be resolved immediately. If you make a list of problems, they will be there in the morning, and they can be handled then. Another very helpful tool is mindfulness meditation. Learning to meditate can assist in recognizing concerns and then letting them go, without them taking your sleep away.
Sleep Restriction
The third element in CBT-I is called sleep restriction. It is often the most difficult aspect of the treatment, at least for a short while. The idea is that broken sleep — waking up frequently, waking up and not getting back to sleep, or even not getting to sleep at all — can all be fixed by increasing sleep pressure — making you really, really tired. The process is a little complicated, but basically the patient keeps a sleep diary for a few days, which is then examined by the therapist. After it is determined that they have only been sleeping a total of, say, four hours a night in total (when you take out all the gaps of just lying there awake), then a new schedule is developed. If the desired wake up time is 6am, then the patient is told not to go to bed or take any naps until 2am. Then they are to get up at the regular time. After a few nights of unbroken sleep, the bedtime is gradually pushed back until the patient is sleeping well for up to 8 hours.
The first few weeks of this process can be painful. Some patients only are allowed three hours of sleep a night at first, and they end up feeling like a zombie for much of the day. But after a few weeks of unbroken sleep, they are back on a regular schedule, and they are often very grateful for the change.
Sleep is magic. One moment you are lying down, tired, and the next you are awake with the realization that time has passed, and somehow your energy has returned. I’m doing my own version of CBT-I, and I am more tired already. Hopefully I’ll be … zzzzz.
