The occasional sleepless night, though unpleasant, isn’t typically a huge problem. But if you’ve had trouble falling asleep and staying asleep over weeks or months, or you have other sleep-related issues, you may want to look into sleep therapy.
What is sleep therapy?
Sleep therapy is usually administered by a sleep psychologist. It involves different types of treatment designed to help you overcome sleep problems. The most common first-line treatment for chronic insomnia is Cognitive Behavioral Therapy for Insomnia (CBTi or CBT-i).
“A sleep psychologist either treats or supports treatment for the full range of sleep disorders,” says Molly Atwood, Ph.D., assistant professor of psychiatry and behavioral sciences at Johns Hopkins University. “The most common sleep disorder that we encounter is insomnia disorder, whether it's something that's completely standalone, or something that's related to a mental health condition like anxiety or depression, or a physical condition like chronic pain.” Insomnia occurs in about 10% of the population, she adds.
Sleep psychologists also treat what are known as parasomnias, disruptive behaviors that take place while sleeping, such as sleepwalking. “We can also provide supportive therapy for the treatment of more medically-based sleep conditions — obstructive sleep apnea, for example,” Atwood says.
How does sleep therapy work?
CBTi is a structured program that helps identify thoughts or behaviors that cause sleep problems or make existing problems worse. The goal is to use the basics of cognitive behavioral therapy with a focus on insomnia-specific issues, replacing sleep-disrupting behaviors with sleep-promoting habits.
For example, “if someone has a poor night of sleep, they might start sleeping in later or napping during the day or trying to go to bed earlier, and that over time can weaken our drive for deep sleep and contribute to an acute insomnia becoming more chronic,” Atwood says. Or, if stress or an overactive mind are causing sleep disruption, a sleep psychologist might utilize a variation of CBTi that promotes mindfulness to help you break the thought patterns that are interrupting sleep.
Another form of CBTi is sleep restriction, in which the amount of time you spend in bed is cut back. This is for people who have difficulty falling asleep or who awaken in the middle of the night and have trouble getting back to sleep. Research suggests that spending too much time in bed can actually exacerbate insomnia. By cutting back on the time you’re in bed, sleep restriction can help boost the drive for sleep and encourage deeper sleep. After the initial restriction, the time in bed is gradually increased until you’re more efficient at falling and staying asleep.
Is CBTi effective?
In a word: yes. Along with its various approaches, another advantage of CBTi is its efficacy. “CBTi is one of the most effective treatments,” Atwood says. “So, 80% of people will see significant benefit. Maybe not full remission, but that's a pretty high number for a psychological treatment. And it's really short-term, too. I think some people have an idea of therapy as something you have to be involved in for years. But CBTi can treat insomnia in as little as four to six sessions.”
How can sleep therapy benefit other parasomnias?
When treating sleepwalking, sleep talking, nightmare disorder, or other sleep disorders and parasomnias, Atwood says she takes a different approach. “We can also provide supportive therapy for the treatment of more medically-based sleep conditions. So, for example, obstructive sleep apnea, which is best treated with something like a CPAP machine. A lot of patients will have difficulty acclimatizing to a CPAP, and we can help, especially if [there's] issues with claustrophobia, or anxiety while wearing it. And we can also help support medical interventions for conditions like narcolepsy or idiopathic hypersomnia, which are more issues with excessive daytime sleepiness.”
Sleep therapy over medicinal treatments
There’s no shortage of medicines available for sleep problems — and though they have a place, they may not be ideal for chronic insomnia, Atwood explains.
“For more acute insomnias, it can be helpful to do a short-term course of medication. If you're going through an acute stressor, it might be helpful to take [a prescription sedative] for a month just to get you through it until it passes and then get back on track,” she says. “But once you have had the sleep problem for a couple of months, and it's persisted past that acute stressor, medication is no longer going to be the most helpful option. What we find is that once you stop the medication, the patterns that have taken hold that really dysregulate the sleep systems in your brain persist, and then the insomnia comes back.”
Another issue with long-term medication dependency for sleep is that our bodies can develop tolerance to sleep medications, forcing us to increase the dose over time to maintain efficacy. With therapy, on the other hand, you treat the cause, learning habits and behaviors that help restore your natural sleep drive and maintain it for the long-term.
How to know if you need CBTI or sleep therapy
So, how do you know if you’re a good candidate for sleep therapy? If you’re having trouble sleeping because you’re going through a stressful life event, that may pass on its own. But if it persists, CBTI can be a good solution.
“Our sleep system is sensitive to what's going on in our life. So it's super normal if you are going through a stressful time to have sleep disrupted,” Atwood says. “It's a survival mechanism. If there was an emergency in the middle of the night, an acute stressor, you wouldn't want to sleep through that. We need our system to be sensitive to our fight or flight response so that we can make it through difficult times if needed.
“But if the problem is prolonged, it's not just an acute stressor that's going to go away, like chronic pain for example, or just a stressful life situation that people are having trouble getting out of, or if the stressor goes away and the insomnia problem persists several nights per week for a couple [of] months, that would be the time to reach out,” she adds. “Because usually certain patterns at that point take hold that make it hard for it to resolve on its own.”
How to find a sleep therapist
If you think you may be a good candidate for CBTI, you can ask your primary care physician to refer you to a sleep psychologist or search for practitioners that operate within your insurance network. You also can search within your state for a practitioner through the website of the American Academy of Sleep Medicine.
Alternatively, Atwood notes that there are digital therapeutics available, and research suggests they can be helpful in treating insomnia. These apps (such as Somryst and Sleepio) offer personalized information and coaching in CBT-i on your phone.
