What helps you get a good night's sleep?
We all want to sleep well, but what do you do when sleep doesn’t come easily, and you feel tired through the day? Recently I’ve been posting some quick videos about sleep hygiene as part of our clinic’s Facebook-based 14 Day Healthy Challenge. Each clip has summarized one or two basic tips for getting a better sleep at night. While the information I provide in these brief lessons may sound very simple and straightforward, putting the suggestions into practice can be much more of a challenge than people might expect. Yet the benefits are indisputable. Recent research has been heating up in the field of sleep, and a lot of it has been focused on what has been dubbed CBTi, which is the short form for Cognitive Behavioral Therapy for Insomnia. Put simply, CBTi has become the “gold-standard” treatment for insomnia, showing strong and lasting positive clinical effects.
What is CBTi?
Cognitive Behavioral Therapy for Insomnia is more or less an expanded version of the handful of tips I have been providing to our Healthy Challenge participants. It is made up of a dozen or so interventions that include education about the nature of sleep and good sleep habits, behavioral changes like sleep restriction, and cognitive exercises that challenge unhealthy beliefs and attitudes about sleep. To be effective, CBTi needs to be practiced over a period of several weeks, with the lessons introduced one at a time to give the participant time to practice and get used to any change in their sleep habits. When done properly, it has been shown that CBTi can significantly reduce the time it takes people to fall asleep, cut down on disturbances through the night, and help curb early morning wakening. Overall, it improves sleep efficiency, meaning that more of the time you spend in bed is spent sleeping, instead of doing other things like worrying about not sleeping. (1)
Why not just take a pill?
Despite its proven effectiveness, CBTi is still rarely used in most medical clinics. Instead, the standard practice for treatment insomnia is to prescribe medications called benzodiazepines – or related drugs – mainly because this takes very little time in the office in comparison to the repeated sessions that are required for CBTi. In fact, medication is so popular that close to two thirds of people who talk to their doctor about sleep problems will leave with a prescription. People like drugs because in the short run they appear to work really well. Unfortunately, they have a lot of side effects, not the least of which is drowsiness through the day. They also foster dependence, meaning that most users will find that they experience rebound insomnia when they try to stop using them, so will continue taking them indefinitely. However, despite their initial benefits, within several weeks sleep patterns will gradually return to the same habits that existed before the medication was started. Most people won’t be aware that this has happened, and will continue to overestimate how well they are sleeping on medication, but the fact of the matter is that in addition to their side effects the drugs don’t work well over the long run. (2)
What are the core lessons of CBTi?
To get the most benefit from CBTi, you should approach the lessons in a stepwise fashion. Each step is relatively simple, but requires practice. For example, sleep restriction, where you are required to use an alarm time to wake and move your wake time to a regular early hour takes a bit of patience and perseverance to work effectively. Here are some of the core take-aways of most CBTi programs:
1. Use an alarm time to get up in the morning. This is the single most effective thing a person can do to sleep better. While it often has the unpleasant side effect of making you sleepy at the start of things, with practice you will soon adjust to the new schedule and your sleep will become far more efficient.
2. Only go to bed when you are tired. Going to bed early does not usualy gain you any additional sleep. Instead, it provides you more time in bed to lie awake. Most normal adults only sleep for 5-7 hours each night. That’s all you’ll get, no matter how much time you spend in bed.
3. Don’t check the time. When you look at the clock this requires actions that actually serve to wake you up further. Also, when you give in to the urge to time-check you are actually reinforcing the behavior. In other words, you are teaching your brain to feel anxious about the time and check as frequently as possible. This will not help your sleep in the long run!
3. Avoid drinking caffeinated beverages (eg. coffee, tea, coke) after 4 pm. In addition to keeping you awake, caffeine is a diuretic, resulting in frequent trips to the bathroom. Similarly, using nicotine (smoking) should be avoided at bedtime, as nicotine is a stimulant that tends to keep us alert and awake. The fact that you enjoy your coffee and don’t get any jitters from it during the day doesn’t matter. Nor does it matter whether you can get to sleep quickly despite your stimulant intake. The negative effects of stimulants often don’t show up until later in the night, when your body goes into withdrawal.
4. Having a light snack before bedtime can help. Complex carbohydrate foods (eg. milk products) can help you to sleep. Avoid foods heavy on protein (eg. meats); fats (eg. chips, nuts); and sugar (most sweets). In other words, the old adage of having a cup of warm milk before bed really can help.
5. Exercise during the day helps to improve sleep, but strenuous exercise before bedtime interferes with a sound sleep. This is something my clients often get confused about. Because they are tired from lack of sleep, they assume that exercise will only make them more tired. Why would you do that? In fact, keeping in good shape is essential to good mental health, and activity during the day helps us maintain a healthy day night schedule and makes it easier to fall asleep and stay asleep at night.
6. Limit daytime naps to half an hour and keep them to the early afternoon. Any additional time you spend sleeping during the day will reduce the time that you will sleep at night. This means that a longer nap will rob you of an hour or two of sleep at night, regardless of how long you “sleep in”.
7. Get caught up on things. Avoid blaming sleep difficulties alone for problems with mood, productivity, energy levels and motivation. Keep in mind that there are many other reasons for these problems that you can probably do something about. For example, getting caught up on projects, doing less procrastinating, and keeping ahead of your projects will do more for your sleep than medication.
8. Do not fret about sleep problems. Thinking the worst becomes a self-fulfilling prophecy. Lack of sleep is not life threatening! It is more helpful to work on relaxing in bed rather than worrying about your sleep or some other problem. Relaxation is a skill that requires a bit of practice, but with time and perhaps with the help of some calming sounds or music you can learn to fall back into a sound sleep.
9. Use the bed only for sleep, sex, or when you are recovering from serious illness. Using the bed for other purposes, however enjoyable or relaxing they may be, only teaches your brain that the bed is for wakeful activities too. This will actually make you more likely to have problems getting to sleep and remaining asleep.
10. Limit your screen time immediately before bed, and never watch television or use your computer while in your bed. The light emitted by modern screens is super bright and tricks your brain into thinking it is daytime. This can actually confuse your internal body clock, throwing off your sleep schedule.
What else can you do?
We keep repeating the Healthy Challenge in our clinic because most of us lead busy lives in which it is easy to lose touch with lifestyle habits that promote good physical and mental health. If you want to sleep better at night, it will help to work on the many changes that go with CBTi. However, you will never sleep soundly if you do not also address the problems that exist in your daytime activities. Eating healthy foods, getting regular exercise, and engaging in other activities that challenge you each and every day are examples of some things that all of us could use some encouragement, support, and practice to maintain. If you are working on changing even a few of these things, keep it up!
You may also need to look more closely at other problems in your life. Whether you decide to try some self help approaches, or embark on some counseling, this will require your focus and energy over a longer period of time. We built the Myndplan app to help with this. Using our MultiAx, consumers can explore their own personality to identify strengths and weaknesses. They can also share this information with a health provider. Using this approach, it is easier to map out specific goals that are more likely to get to the root of the issues that may be holding a person back in life. Over the course of the coming year, we’ll be adding features that allow users to monitor their progress and keep track of their strategies for change. This is important for changing things like your sleep habits, because they often involve behavior change that requires practice over time.
The key to improving your sleep is understanding that with a sound plan, proven strategies, and some support and encouragement, real change is possible. Practice may not make things perfect, but it can definitely make for a better night’s rest!
Morin, C.M., Bootzin, R.R., Buysse, D.J., Edinger, J.D., Espie, C.A., & Lichstein, K.L. (2006). Psychological and behavioral treatment of insomnia: update of the recent evidence. Sleep. 29, 1398-414.
Holbrook, A.M., Crowther, R., Lotter, A., Cheng, C., & King, D. (2000). Meta-analysis of benzodiazepine use in the treatment of insomnia. Can Med Assoc J. 162, 225-33.
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