Treating Your Insomnia

04-04-2025

People are often surprised that a psychologist can help with sleep. I had someone last month say, “I’ve visited nearly every other doctor, and a sleep psychologist was never mentioned.” Not only was this their last stop on the journey to finding remedies for their insomnia, but it was also the only treatment that improved their sleep. Insomnia affects about 33% of the U.S. population, that’s about one in three people. If you did your own research, you’d probably find similar stories in your own life. You might find people describing difficulty with sleep in various ways. So, what exactly is insomnia?

Insomnia is diagnosed when there’s difficulty falling asleep, staying asleep, or waking up too early, and these issues affect your daily functioning—such as impairing your ability to think clearly, plan, or engage in activities. At some point, perhaps all of us have experienced insomnia. It becomes a real issue when it lasts for weeks, months, or even years. Having insomnia for a couple of nights because you’re worried about something doesn’t mean you have a problem; in some ways, it means you’re human! We all lose sleep over stressors at some point. However, once the stressor resolves itself, our regular sleep cycles tend to return.

The first stop people make when they struggle with sleep is usually their general practitioner. This is often when the conversation about medications is introduced. For some, a short-term sleep medication can be a great option to get back on track. However, we now know that sleep medications are not a long-term solution. Many times, these medications fail, and the insomnia begins to creep back. This happens because the body develops a tolerance to the medication, and soon enough, you’ll need more of it to achieve the same effect. Additionally, several sleep medications have a risky potential for addiction. Not to mention that long-term use of some of these medications, such as Ambien and Lunesta, has been associated with a higher risk of developing dementia in older adults. Lastly, these medications often do not address the underlying causes of chronic insomnia.

The gold standard treatment for insomnia is no longer medications, for all the reasons stated above. The gold standard now is Cognitive Behavioral Therapy for Insomnia (CBT-I), a specialized form of therapy that focuses on breaking the cycle of poor sleep. CBT-I describes how poor sleep develops due to the relationship between your thoughts, emotions, and behaviors. In other words, the connection between your mind and body influences what you do or don’t do. This connection can apply to many issues, like anxiety and depression, but when it comes to insomnia, it might look like this: As the sun sets and nighttime approaches, you might think, “Oh no, am I going to be able to sleep tonight? What if I don’t sleep and then I’ll be too tired to work tomorrow? Ugh! Tonight will probably be no different, and I’ll be up all night again. I can’t possibly function like this.”

Because of the connection between your mind and body, it may not surprise you that when you think worry filled thoughts like these, your body reacts by activating the stress response system. This leads to feeling worried, concerned, agitated, frustrated, or just plain angry. One thing is for sure: you can’t feel sleepy and stressed at the same time. So now, your bodily reactions make it harder to relax into sleep. These reactions might influence your behaviors surrounding sleep, such as adjusting your bedtimes or wake-up times. You might think, “I better sleep in because I didn’t get to bed until much later,” or “maybe I should go to bed earlier because I have to get 8 hours of sleep” This might lead to spending more than eight hours in bed, which can paradoxically affect sleep.

Spending more time in bed than you can sleep can lead to more sleep fragmentation i.e., more waking up in the middle of the night. It can also make it harder to fall asleep, as forcing yourself to sleep simply doesn’t work. Those of you who are parents know this. You can’t make a child sleep who isn’t sleepy and we are no different. At times, it may lead to inconsistent wake-up times, which confuses your body’s natural clock. Sleep starts to feel unpredictable, and these behaviors further perpetuate the cycle of poor sleep. As a result, negative thoughts about sleep might start to emerge, like, “No matter what I do, I can’t sleep. Something must be really wrong with me.” And you can see how the cycle continues. This is what leads to a chronic problem, one that medications don’t address.

CBT-I is a short-term therapy, usually about 6-8 sessions, that aims to break this cycle of poor sleep. The cycle may look different for each person, so a health psychologist who understands behavioral sleep issues can identify what your treatment plan requires. Perhaps you have fewer worry thoughts but tend to adjust your wake-up times depending on how the night went. Or maybe this is a particularly stressful time in your life, and you need help calming your nervous system. Sleep is not a one-size-fits-all issue. I often compare sleep to appetite. Not everyone needs the same caloric intake or likes the same foods. Some people have food allergies or are lactose intolerant, so they need to be mindful of what they eat. The same is true for sleep. Not everyone requires 8 hours of sleep; some people are genuinely content with less, while others may always wake up in the middle of the night but can fall back asleep.

Like appetite, there are things we can control about sleep and things we can’t. For example, you can’t make yourself hungry just because it’s noon. You can influence hunger by being more active or going longer without food, but you can’t control when you feel hungry. Similarly, you can’t control exactly when you will feel sleepy. CBT-I helps us focus on what we can control like adjusting sleep routines, schedules, increasing activity, challenging beliefs about sleep, and engaging in relaxation practices. Research shows, with practice, these techniques make it easier to fall asleep, consolidate sleep, and even increase the total amount of sleep, if your body allows. However, CBT-I cannot control how or when you’ll feel sleepy or how your brain processes sleep. There are aspects of sleep that remain outside our control.

I like to remind folks that you are wired for sleep. Those systems are not “broken” they may be functioning different at this time for reasons known or unknown to you. I think of CBT-I as therapy that helps you regain trust in the systems inside of you that are responsible for sleep. I know that’s easier said than done, especially if you’ve been struggling with sleep for so long. That’s why tailoring a CBT-I plan to your individual needs is so important.