What Is the Best Way to Fix Broken Sleep?

The answer might surprise you—and your doctor.

If you’re one of countless people who suffers from insomnia, you know how frustrating it can be. As your bed partner dozes, you toss about fitfully, trying everything you can think of to bring on sleep. Whether it happens at the beginning, middle, or end of the night, people will try almost anything to get relief.

There’s no shortage of tricks for falling asleep. Tell anyone you’re struggling with sleep and chances are they’ll recommend something that worked for them or their neighbor. Maybe it’ll work for you, or more likely it will join the pile of tricks you tried without much success.

What’s actually been shown to work in research trials? According to the latest guidelines from the American Academy of Sleep Medicine, effective options include:

  • Relaxation Training. When you’ve had terrible sleep night after night, pretty soon you’ll probably start feeling anxious about going to bed. As a result your bed becomes a place of tension and frustration—not a recipe for good sleep. Even if you’re falling asleep on the couch watching TV, as soon as your head hits the pillow you may suddenly feel wide awake. Relaxation training teaches effective ways of letting go of physical and mental tension, reducing bedtime anxiety and helping you fall asleep more quickly.
  • Stimulus Control Therapy. A powerful way to train the body to fall asleep more quickly is to form a strong link between bed and sleep. Stimulus control means using the bed only for sleeping—no TV, phone calls, reading, work, eating, etc. (Sex is the one exception.) It also includes getting out of bed if you’re not falling asleep quickly, to minimize the association between “bed” and “awake.” With practice the mind learns that Bed=Sleep, so we fall asleep quickly once we lie down.
  • Sleep Restriction. People seek insomnia treatment because they want to sleep more, so they tend to recoil when they hear “sleep restriction.” To be accurate, what’s being restricted is the amount of time in bed. It’s a highly effective and somewhat counterintuitive approach: Your time in bed is matched to the average amount of time you sleep each night (based on your sleep records). For example, if you’re spending 9 hours in bed every night and only sleeping 6 hours, your prescribed time in bed would be 6 hours per night (or sometimes up to 6.5). After a few nights a person generally starts falling asleep quickly and sleeping soundly, and additional time in bed can be added in small increments. This approach melds well with stimulus control therapy since it strengthens the link between bed and sleep.

Cognitive behavioral therapy for insomnia (CBT-I) combines these approaches into a highly effective treatment package (though it’s effective even without relaxation training). Many studies have shown that CBT-I can help most people with insomnia to sleep much better. (Some medications can help about as much as CBT-I in the short-term, but long-term outcomes tend to be better with CBT-I.)

In light of what’s been shown to work, what do healthcare providers recommend for their patients with insomnia?

According to a study in The Behavior Therapist, 88% of health practitioners (including nurses, physicians, psychologists, and others) recommended improved sleep hygiene as a stand-alone treatment for insomnia. Sleep hygiene includes things like limiting caffeine intake; avoiding excessive fluid intake in the evening; and making your bedroom cool, dark, and quiet.

Only about 30% of practitioners recommended stimulus control, and around 25% recommended sleep restriction. These numbers were consistent with what practitioners believed about the effectiveness of these treatments.

The study’s authors lamented that treatment providers most often recommended sleep hygiene — even though there’s little evidence for its effectiveness as a standalone treatment. (It is often included as a part of CBT-I).

Clearly there’s work to be done in bringing the most effective insomnia treatment to the millions who need it. A few weeks of the right approach can relieve chronic insomnia much more effectively than can sleep hygiene alone. And good sleep helps with pretty much everything

A list of tips for good sleep can be found here, with more information on my website: Resources for Sleep and Insomnia.

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