By Sharon Brock, MEd, MS

Not getting enough restorative sleep is a rampant health concern across the US. It’s estimated that 50 to 70 million Americans suffer from sleep disorders, and 1 in 3 adults do not get the recommended 7 to 8 hours of sleep regularly.

Many of us have tried sleep hygiene techniques, such as keeping our bedroom dark, cool, and quiet and having a one-hour-before-bed evening routine, but still have trouble sleeping soundly on a consistent basis.

Stanford sleep specialist Fiona Barwick, PhD, DBSM shares that sleep hygiene is only one piece of the puzzle.  “If you have good sleep and maintain good sleep hygiene, then you’ll continue to get good sleep,” says Dr. Barwick, Stanford Clinical Associate Professor, Psychiatry and Behavioral Sciences – Sleep Medicine. “But if you have poor sleep, all the sleep hygiene in the world will not help because it’s not targeting what we typically see in patients with insomnia, which is anxious thinking and not building enough sleep drive.”

What Causes Insomnia?

Insomnia is defined as difficulty falling asleep, staying asleep, or waking up too early (greater than 30 minutes before the alarm) three times per week for at least three months. Many factors can cause insomnia, such as stressors related to one’s job, finances, health, family and friends, new onset health conditions, or feeling unsafe in one’s environment.

Dr. Barwick says her patients with insomnia often spend hours lying awake, ruminating about relationships and events in their lives, or simply worrying about how their inability to sleep will impact their performance the next day (especially true for perfectionists). To address these factors, Dr. Barwick teaches classes on cognitive behavioral therapy for insomnia (CBT-I) at Stanford University.

“It’s a vicious cycle. The anxiety we feel about not sleeping can prevent us from falling and staying asleep,” says Dr. Barwick. “With CBT-I, we address not only the physical requirements of sleep but also how we think and feel about sleep. CBT-I helps to shift our mindset about sleep.”

 

This table shows the difference between sleep hygiene and CBT-I:

How to Cure Insomnia with CBT-I Training

CBT-I employs a classical conditioning technique of having patients get out of bed when not sleeping so that they associate their bed with sleep and nothing else. Just as Pavlovian dogs salivated when they heard a bell, Dr. Barwick says we can teach our brains to see our bed as a cue to feeling sleepy and falling asleep rather than a place where we lie awake feeling anxious.

Along with bed re-association, another technique for improving sleep is sleep consolidation, or shortening the time spent in bed. At the outset of treatment, students of the CBT-I course are instructed to reduce the amount of time they spend in bed (their “sleep opportunity”) and get out of bed promptly when the alarm goes off (no hitting snooze!), regardless of how they slept. As wakefulness at night decreases and sleep quality improves, time in bed, or sleep opportunity, is gradually extended.

This disciplined approach of spending a shorter amount of time in bed for two to three weeks increases sleep drive and thus sleepiness, or the desire to sleep. By the end of treatment, patients are falling asleep more easily, waking up less at night, and returning to sleep more easily. They have also ensured that their bed is re-associated with sleep, rather than lying awake worrying, thus breaking the pattern of insomnia.

Along with bed re-association, CBT-I also offers cognitive strategies to calm anxious thoughts about sleep, relaxation techniques to reduce tension in the body, as well as emotional relaxation practices like mindfulness.

How Do I Fix My Sleep Problems?

Ironically, anxiety about sleep is often the cause of our sleep problems, making stress management an important part of restorative sleep. Dr. Barwick says that “our mindset about sleep is critical. We are worrying about a system that is not broken.” Instead of anxiety about sleep, Dr. Barwick encourages us to learn about the biological systems involved in sleep and optimize them with our behaviors.

The three biological systems that need to be in working order for sleep to occur are:

• Circadian rhythm
• Sleep drive
• Stress management

“The way sleep works is, when your sleep drive is high, you understand your own circadian sleep-wake timing, and you allow yourself to relax, you should fall asleep and return to sleep easily,” says Dr. Barwick. “These biological systems of sleep are not broken; they are intact, but our worry about sleep can override their ability to function properly.”

For practical tips on how to optimize these three systems, read our blog, “Don’t Hit Snooze! And Other Practical Tips for Optimal Sleep.” 

What to Do When Lying Awake in the Night

If you’re lying awake in bed during the night, the first step is not to check the time. This can lead to anxious thoughts about how your lack of sleep will affect you the next day. It’s best not to look at the clock and trust that you’ll wake up and get out of bed with your alarm.

Secondly, take deep breaths and engage in mindfulness practices, such as feeling the softness of your pillow and appreciating the comfort of your mattress. Listening to gentle music or a guided meditation can also help relax the mind and body.

If these relaxation practices do not lull you back to sleep and you’ve been wide awake for over 30 minutes, Dr. Barwick suggests getting out of bed and doing a relaxing activity in another room until you feel sleepy again.

“It’s best to keep your bed for sleep, so if you can’t fall back asleep, be awake outside your bed in an enjoyable and relaxing way, such as reading a book in the living room,” says Dr. Barwick. “While reading, you build sleep drive and calm anxiety, so you’re more likely to fall asleep when you go back to bed.”

Another thing to remember is that your middle-of-the-night thinking comes from your emotional brain. During sleep, the rational part of your brain is offline, leaving your emotions to run unchecked. This can lead to bizarre dreams and even nightmares that could wake you up, especially if you’re going through stressful circumstances.

To address this, Dr. Barwick recommends reducing stress throughout the day, not just right before bed.

“People with anxiety are more reactive to stress and need to address sleep as a 24-hour endeavor,” says Dr. Barwick. “They need to put more effort into managing their stress response with exercise, deep breaths, and mindfulness throughout the day–not just before bed.”

Dr. Barwick explains that when we first go to sleep, our sleep drive is high enough to counter our stress level. But if we wake up 3-4 hours later, when sleep drive has diminished, it is harder to fall back asleep, especially if our emotional brain begins to ruminate from stress built up throughout the day. And since the rational part of the brain is offline, these negative thoughts can take over our consciousness.

Therefore, Dr. Barwick recommends journaling before bed to reframe life challenges and process difficult emotions. This way, if you wake up at night, you’ll be able to fall back asleep easily.

Along with journaling before bed, Dr. Barwick has a second recommendation for those experiencing anger that often leads to the rehearsal of mental arguments during the night.

“If you have resentment, I recommend you do loving-kindness meditation before bed. You can offer loving-kindness toward those whom your ego believes has ‘wronged’ you,” says Dr. Barwick. “This meditation can shift your emotional mindset from anger to ease, which will help you fall asleep.”