Insomnia, my enemy

Sleep is one of life’s ultimate paradoxes. For those who have never had sleep problems, sleep is quite literally a dream. It arrives effortlessly, recharges the body, and replenishes the mind. After eight hours of sweet slumber, the mind can go from weary and haggard to refreshed and ready to dominate a new day. And to all you sleeping sweetly at night, those with insomnia say, “Screw you.”

Because for people who have experienced sleep problems, sleep can become a true nightmare. The more they try to fall asleep, the more elusive it becomes. Sleepless humans will try to quell their insomnia with endless products, apps, sleeping pills, “intelligent” mattresses, and “sleep hygiene techniques” like drinking Sleepy Time tea before bed and keeping the bedroom cool, dark, and quiet. Or as Arianna Huffington recommends in her new book, The Sleep Revolution, put on some really fancy lingerie. The global market for sleeping pills alone is projected to reach 76.7 billion dollars by 2019. But just like a paper finger trap, the more we try to resist and escape, the more ensnared we become.

Why? Well it turns out our brains have evolved in this very clever way. If we register a problem, there’s a part of our brain that makes sure we stay awake to fix it. As we toss and turn at night, perhaps a thought pops up like, “Crap! If I don’t fall asleep I’m going to bomb my presentation tomorrow morning. I hope I fall asleep soon,” or “Arianna Huffington now tells me that I need eight hours of sleep to be the best version of myself—I must get that but I can’t! Help, I’m ruined!”

How does this translate to the limbic system of our brain, the part of our brain that registers danger and triggers us into fight or flight mode? The Limbic Brain says, “Houston, we have a problem. There’s something bad out there—maybe it’s a snake or a tiger, we’re not quite sure. But to stay safe, please stay AWAKE and on red alert! And Frontal Lobe, please stay awake too—we need your excellent problem solving skills to fix this problem!” So there we are, our brains working tirelessly to keep us awake so we can solve this insomnia problem. It’d be funny if it weren’t so darn cruel.

What’s more, these very efforts to control the problem typically end up perpetuating the problem in the long run. Our attempts to manage the sleep deprivation by fixating on finding ways to sleep better, using sleeping pills to which we may eventually develop a tolerance, withdrawing from certain activities to try to conserve energy, trying to catch up on sleep after a bad night, staying in bed tossing and turning instead of getting out of bed: all of these problem solving strategies are known to potentially maintain insomnia long term.

Indeed, in my years of treating insomnia in downtown San Francisco, I’ve noticed a pattern among a subset of my patients. They are often high-achieving, badass problem solvers with an obsessive, self-critical bent. Throw in hypervigilance, a stressful work or home environment, a history of trauma, or a family history of anxiety and insomnia and you’ve got yourself a particularly barnacle-like form of sleep disruption. So when I tell my patients that what they first need to do is stop the problem solving and learn how to embrace the insomnia I am met with a resounding, “Screw you, Dr. Sze.” Screw you, because 1. Problem solving is my way of life; and 2. I don’t think you quite get how miserable this F*ing insomnia problem is.

This is fair criticism. But after recently surviving a year of sleepless torture (my second child was an abnormally sleepless baby, waking up with a jolting cry every 45 to 120 minutes for the first 14 months of her life), I can finally say I do kind of get how F*ing miserable it is. I did all the things you might expect of a sleep-deprived mom with an infant—sleep training, nap scheduling, buying fancy products to help my kid sleep—but in the end she was one of those rare babies where nothing actually worked (talk about humbling for me as a behavioral sleep specialist). But after I finally surrendered and accepted that no amount of problem solving would help my daughter sleep differently, I learned that figuring out a way to create more space for the sleeplessness was the only way through. Dropping the tug-of-war rope to accept things as they were dramatically reduced the suffering in and of itself. And coffee. Coffee helped too.

But I digress. To recap: Step 1: Embrace the insomnia. Stop making insomnia the enemy; learn in your own way to befriend it. Let your fight or flight system off duty for a moment. Do not get yanked into the media frenzy alerting the public that eight hours of sleep is the key to salvation. Practice a wee bit of acceptance and self-compassion, which are both known to activate the parasympathetic nervous system, the rest and repair system of our bodies. Please repeat this statement to yourself three times: “Insomnia is not my fault, it is not for lack of trying, it is not a deficiency of character.” Step 1 is to accept the elements that are out of your control and give yourself a break. Step 1 is to surrender.

You might think, “Is what I’m hearing is that there’s nothing I can do for my insufferable sleep problem?” No. What I’m saying is to be skeptical of the lion’s share of what the sleep industry is offering as solutions to your problem. Mattress technology, herbal supplements, white noise machines, wearable sleep trackers: none of these things have a solid evidence base for the treatment of chronic insomnia.

In fact, out of the ever-growing mountain of insomnia solutions, only two are strongly backed by research: (1) sleep medications and (2) cognitive behavioral therapy for insomnia (CBTi). Of these two approaches, research tends to demonstrate CBTi as more effective than meds (for example, see this study showing CBTi beating out Ambien for the treatment of sleep-onset insomnia). Additionally, given that the FDA has approved sleep medications only for short-term use (usually between 4-5 weeks), CBTi is also seen as a safer, side-effect free approach to managing insomnia compared to medication. For these reasons, the National Institutes of Health (NIH), American College of Physicians (ACP), and American Academy of Sleep Medicine recommend CBTi as the first line, gold standard treatment for addressing insomnia. Yet amazingly, very few people have even heard of the approach.

OK, after you’ve considered the evidence, and only after then, is it wise to move on to the next step.

Step 2: We begin a type of insomnia bootcamp, if you will, in which I get my patients on board with the most potent components of CBTi: sleep restriction (limit time in bed) and stimulus control (strengthen the bed as a conditioned cue for sleep and weaken the bed as a conditioned cue for wakefulness). To be more concrete, in the first few weeks of insomnia bootcamp, we limit your time in bed, establishing a consistent sleep schedule typically by delaying your bedtime and having you set an alarm for the same time in the morning every day. No sleeping in or canceling obligations after bad night days, no catching up on the weekend, no getting into bed early or pressing snooze in the morning even though you are dead tired, and no lying in bed awake at night for long stretches of time. If you’re awake, you get out of bed.

The science tells us that these techniques help regulate your circadian rhythm, recondition your body to associate the bed with sleep instead of wakefulness, and in the long run produce more efficient, consolidated, and restorative sleep. Perhaps not as exciting as wearable trackers and expensive lingerie, but unlike the bulk of sleep industry paraphernalia, CBTi has a tremendous evidence base pointing to its effectiveness.

The other result, in my opinion, is that you become a badass when it comes to sleep. In struggling with insomnia, and then willingly bringing on sleep-restricted nights, you go to places darker than most are willing to go and you come out alive on the other side. Instead of fixating on “Get more sleep” as the only route to more energy and sanity, an accepting insomniac looks to other sources of renewal—a brisk walk as the sun rises, a perfect morning cup of joe, a gratitude practice, a great piece of fiction, a phone call with a friend, a favorite pastime that had previously gone neglected. Moreover, in order to overcome the challenges of insomnia bootcamp, you have to learn tools to tolerate the demons. You have to learn how to make space for the negative thoughts, the thoughts that say, “This is too hard. I’m gonna lose it. I’m failing at this. What if I go crazy or make a terrible mistake because I’m so sleep deprived. What if this turns into a vicious spiral and sucks me into a pit I can never get out of.” These thoughts come up, and with the support of your therapist you learn tools for mindfully observing them, calling out the distortions, letting them bubble up and pass, practicing self-compassion, and not letting them run your life.

At the end of insomnia bootcamp, which tends to last about 6-10 weeks, most people (about 75-80 percent), even those with the most barnacle-like forms of insomnia, evidence significant, sustained improvement in their chronic sleep problems. Not just because they’re sleeping better, but because they are more tolerant of the inevitable bad nights that will at some point come their way. Instead of panicking at a bad night’s sleep and running to the store to stock up on melatonin and Sleepy Time tea, they have built the confidence that they can ride this out without driving the brain into its highly activating problem-solving fixation mode. They have looked into the eye of the tiger, refused to run, come out alive, and what’s more, built lasting trust in their minds and their bodies.

Insomnia, old friend, you ain’t got nothing on these folks.