(Photo: Geon-soo Park/Sung-Il Kim/Corbis)
So you can’t sleep. An estimated 30 percent of Americans suffer from chronic insomnia, and the sensible, standard advice given to them is to practice sleep hygiene and simply try going to bed earlier. If (or when) this fails, there are of course dozens of sleep medications available over the counter or via prescription.
And yet the best treatment for chronic insomnia, according to the scientific literature, is one that most people haven’t tried, no doubt at least in part because it sounds insane: The secret to getting better sleep may be to purposefully get less of it, at least for a time.
It’s called sleep restriction therapy, and it’s a component of CBT-I — that is, cognitive behavioral therapy specifically for insomnia. The idea is to reduce the amount of time you spend trying to sleep to the actual number of hours you are capable of sleeping. Here’s how it works: You keep careful track of how much sleep you are really getting for several weeks — let’s say it’s about five and a half solid hours per night. Then you set a nonnegotiable wake-up time, usually the latest possible hour you can get up and still manage to get to work on time — say, 6:30 a.m. So, under the guidelines of sleep restriction therapy, you don’t allow yourself to go to bed until 1 a.m. If you’re successfully sleeping during that time, you gradually allow yourself to go to bed earlier, in about 15-minute increments, until you’re sleeping a sound seven to eight hours per night.
Of course, the last thing a person who can’t sleep wants to do is intentionally deprive himself of the very thing he’s after. And yet the bulk of the evidence shows that it works, at least as well as — or, according to some studies, better than — medication. Late this summer, for example, a review of 20 studies examining the efficacy of CBT-I was published in the Annals of Internal Medicine, finding that this approach to fighting insomnia was about equally as effective as medication. Other, earlier clinical trials have compared CBT-I to popular drugs such as Ambien and Restoril and have found that the therapy worked better than the medications in helping people overcome their insomnia.
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CBT-I is more than just sleep restriction — it focuses on changing an insomniac’s thoughts and behaviors regarding sleep, and much of it does include the typical sleep advice, like shutting off your electronic devices about an hour before sleep or going to bed and getting up at the same time every day. This is all fine and good, says Dr. Michael Perlis, director of the behavioral sleep medicine program at the University of Pennsylvania’s Perelman School of Medicine; it’s when he introduces the sleep restriction part of CBT-I that he tends to lose people. “The minute they find out what they’re supposed to do, that’s the end,” he said. “They’re done.” And this, Perlis and other sleep specialists Science of Us interviewed said, is no doubt a big part of the reason why the therapy is woefully underutilized, despite the raft of evidence backing it up. “People get very focused on total sleep time, on how much sleep they got,” Perlis said. “And they forget what actually pisses them off is not six hours of sleep — that’s not great. But waiting for sleep, being in bed at the middle of the night staring at the ceiling? That’s what you want to get rid of.”
But sleep restriction, to put it mildly, is hard. Really, really hard. For insomniacs, resisting the pull of sleep when it blessedly, finally makes itself known goes against their every instinct. Ben Johnson, a librarian in Seattle, tried it for about four weeks in September, after a nine-month bout of chronic insomnia. By nature and by profession Johnson is a meticulous researcher, so he thought he knew what he was in for, yet it was still much more difficult than he expected. “The first week was hard, but then by week two the cool new factor of the whole thing had worn off. You know, This grand experiment! This will help me out! By the second week I was just sort of like, Well, this is helping, because I’m sleeping more soundly, but at the same time I was also like, Screw this, this is terrible,” Johnson said. It was difficult enough to stay up at night; during the day, at work and at home as he tried to play with his young son, he felt like a zombie. “It was really hard to be a person,” he said. “It was really difficult to do anything [other] than, like, stare into space.” Still, he kept at it, until he stretched the five and a half hours he had been sleeping to seven.
As it turns out, the reason why sleep restriction — and CBT-I as a whole — works may be as simple as some old-fashioned classical conditioning, that staple of psych 101 classes, explained Perlis. You’re so exhausted by the time you hit the pillow that you immediately fall into a deep sleep, so, in time, your mind starts associating your bed with actual, restful sleep. The flip side of this explains why insomnia can be so hard to get over, too: Too many panicked, sleepless nights and you start associating the act of trying to sleep with failing to sleep.
Besides, you likely know from experience that the amount of time it takes to get something important done tends to shrink or expand to the amount of time you allow it. It’s why many new parents report their productivity at work increases after they have children; when they can no longer stay late at work to complete a project, suddenly they’re able to get it done during the workday. “When things absolutely have to get done, they have a curious way of getting done,” wrote Oliver Burkeman in a recent column at The Guardian regarding his own experience with sleep restriction, and it appears to be true. The same principle that applies to deadlines seems to apply to sleep, too.
By Melissa Dahl
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