Episode 31: How to Treat Insomnia- Part 1: CBT-I

Shownotes:

According to the American Psychiatric Association, one third of all adults experience insomnia symptoms, It’s that prevalent. But when it comes to treatment for insomnia, what’s the best course of action? Around since the 1990s as a comprehensive, manualized treatment for insomnia, CBT for Insomnia has been the gold standard for addressing this issue. To learn more, we’ve invited Dr. Michael Grandner.

Transcript:

DR. SHELBY: How are you sleeping? Are you sleeping? I’m Dr. Shelby Harris, Director of Sleep Health at Sleepopolis, and this is Sleep Talking with Dr. Shelby, the show that dives deep into all things sleep so you can get the rest you deserve. Today, we’re learning about how to treat insomnia with Dr. Michael Grandner, but first, does rain sound like fried chicken?

KFC seems to think so. That’s why they’ve been working with Hatch, the company specializing in sleep sounds and devices, to record high temperature fryers in their Louisville test kitchen. The result? Kentucky Fried Chicken Rain is now available on Spotify and YouTube as a featured sleep sound.

Traditional sleep sounds range from white, brown, or pink noise to nature based recordings like ocean waves. But if the sounds of frying chicken are your first choice for falling asleep, as I often say, you do you. What’s your take on this, Michael? Could you fall asleep to the sound of KFC?

DR. MICHAEL GRANDNER: If you didn’t tell me what it was, I hear you. Like, it could sound like rain sounds. I actually, I grew up near the ocean, so like, I’m more of an ocean sounds than a rain sounds. 

DS: Yes. 

DMG: If it just makes you hungry, maybe that’s not the best choice, but if it sounds like white sprinkly sort of sound, you know, I, I totally get it. I hear it. 

DS: Now I kind of want to make fried chicken just to see what this, I’ve never paid attention to the noise.

If you like Sleep Talking with Dr. Shelby, take a second to follow or subscribe on YouTube, Spotify or Apple podcasts. It seems simple, but it helps us reach a lot more people to get them the rest they deserve.

Insomnia is a condition that makes it difficult to fall asleep or stay asleep, even in ideal conditions. According to the American Psychiatric Association, one third, yes, one third of all adults experience insomnia symptoms. It’s that prevalent. But when it comes to treatment for insomnia, what’s the best course of action?

Around since the 1990s as a comprehensive, manualized treatment for insomnia, CBT for Insomnia has been the gold standard for addressing this issue. To learn more, we’ve invited my colleague, Dr. Michael Grandner. 

In fact, there’s so much to discuss, we’ve broken our conversation into a special two part episode with part one covering CBT for insomnia and part two covering additional treatments for insomnia, including acceptance and commitment therapy and medication. So if you or someone you know suffers from insomnia or thinks they might suffer from insomnia, these episodes are for you. 

Among many other distinctions, Michael is the Director of the Sleep and Health Research Program at the University of Arizona and Director of the Behavioral Sleep Medicine Clinic at the Banner University Medical Center.

Michael, thank you so much for being here for our special two part episode and welcome to Sleep Talking with Dr. Shelby. 

DMG: Thank you very much. 

DS: I’m excited to do a bit of a deep dive into insomnia treatment, something that we both could probably spend days talking about. But let’s talk about our initial love for the gold standard treatment for insomnia.

So cognitive behavior therapy for insomnia, henceforth to be known as CBT-I, as I’m going to talk about it here. So, so tell us about CBT-I. How is it used to treat insomnia? 

DMG: So the way CBT-I works is by essentially retraining your brain to sleep. When, when people have trouble sleeping, often it’s not just because, you know, they suck at sleeping, like it’s a skill they never mastered. I mean, we were born able to sleep. It’s just, it’s like not being able to breathe because something is preventing your body from doing the thing it’s naturally able to do. And the difference between CBT-I and say, other sleep aids and approaches, rather than try and increase the level of sedation, as if that was the issue, what it does is it helps your body get out of its own way, to allow yourself to sleep using your natural ability to sleep, which helps make that sleep better quality, long term. As opposed to sort of a short term push, it’s more of a long term solution. 

And the way it does this is, usually the thing is when people have trouble sleeping, what do they do? They try and fix that problem often by spending extra time in bed, by struggling with sleep, by fighting with sleep, and the real enemy of sleep is effort. And so what they’re doing is they’re fighting for sleep and they’re adding energy into the system instead of pulling it out.

And what ends up happening is sleep becomes predictably stressful. And then as soon as sleep becomes predictably stressful, that predictable stress becomes the very activation that keeps you awake. And that’s how it becomes a self perpetuating cycle that takes on a life of its own. So whatever the original cause was is irrelevant at this point. The ball is rolling. It doesn’t matter whether the ball was pushed, or kicked, or shoved, or whatever. It’s rolling now. And now we have to stop it. It’s going on its own. And that’s what CBT-I does. It stops the ball from rolling on its own. 

DS: Yeah, I think you hit the nail on the head with a few of the things here and that I often will say to my patients, you’re trying to control something that can’t be controlled, right?

A lot of times, I mean, I work in the New York City area, so like control is a big thing that a lot of people do. And it’s the one thing that they feel like they’ve lost the ability to control something that they feel like they should control. So once you can kind of get out of your own way, like you were saying, I think that’s a huge, huge improvement for people.

Sometimes I say like, even before you start sleeping better, when you’re not trying to control it and you’re not thinking about it as much, then the sleep will probably come after that. So what about the different parts of CBT-I? So CBT-I is really a combination of different treatments. So can you tell people about that?

DMG: Yeah. CBT-I is kind of a toolbox. Where there’s a couple of core components to CBT-I, and then a bunch of extra ones. And the core things aren’t actually what people generally think of. Some of them are a little counterintuitive. The first, and, and my opinion, the most important, but people may argue with me on this, is a concept called stimulus control.

What stimulus control means, it’s, you’re controlling the stimulus value of the bed. What does that mean? Imagine a place you hate going, like, sometimes I’ll say the dentist chair, but I have a friend who’s a dentist who hates when I use that analogy. He says, well, I’m not that bad. It’s like, well, it’s not about you. It’s a cultural thing. 

So imagine a place you hate going. Like, you’re not even there yet. You know, so you’re, you’re not in the dentist, you’re in the dentist chair. You’re not, nothing’s happened. You’re already reacting. You’re in the waiting room. You’re already sort of amped up. You’re responding to an event that hasn’t even occurred yet.

The response is predating the stimulus at this point, because it’s so learned. You’re in the car driving there. You’re already kind of antsy. You’re delaying making the phone call to make the appointment months in advance, because you’re already responding to an event that hasn’t occurred. 

A positive example would be like going to the gym, like even if you’re tired and kind of hungry, you walk in there, you can get through the end of your workout once you start because being in that place creates a response just by being in there. When a very limited number of options exists once you are somewhere, and you repeat that and that becomes learned, just being there creates that response, whether it’s something negative or something positive. And it’s like walking into your favorite restaurant, you get hungry. 

So what you want to do is you want to make the bed be the place where you just look at a bed, you start getting sleepy. What ends up happening is actually the opposite, because what’s supposed to happen is you get into bed, you fall asleep, and then that becomes what’s predictably going to happen. But when something causes us to not be able to sleep. Especially when we start doing other stuff in bed, like if we’re watching TV or reading, I mean, a lot of people, their bed is also their office, it’s also their couch, it’s also, all these other things happen.

So, first of all, sleep itself isn’t the thing that’s predictably occurring when you’re there. Then, you get stressed and activated, then the thing that does become predictably tied to being in bed is thinking, worrying, tossing, turning, and fighting, and getting frustrated. So even if you were falling asleep on the couch, barely keep your eyes open, you get into bed, if you have a stimulus control issue, either the bed isn’t helping you fall asleep, or even worse, the bed could be waking you up, because that’s what you’re used to having happen there.

And a core part of CBT-I is breaking that cycle and rebuilding the bed as the place where sleep reliably occurs. So that when, even if you are a little stressed out, you get into bed, close your eyes, head on pillow, under blanket, your brain’s like, oh, I’m about to fall asleep. Then you do. So that’s, I think one core component.

DS: Can I add something to that? 

DMG: Yeah, of course. 

DS: If someone is wondering if they have a stimulus control issue with the bed, just ask yourself, what’s the first thing you think of when you think of your bed? 

DMG: Right. Oh, good one. 

DS: And most insomnia patients don’t say sleep. A lot of times they just say rest, frustration, something else. If sleep’s not top of mind, that tells you a lot. 

DMG: And that reminds me, stimulus control matters at the beginning of the night and the middle of the night. Maybe you fall asleep fine, but then you wake up in the middle of the night and can’t get back to sleep for whatever reason, and then you’re laying in bed fighting with your sleep for an hour.

Then, what your body gets used to happening is when you have an awakening, your brain’s like, oh, here we go again, and you start this process even if it wasn’t necessary, because it’s predicted. So yeah, exactly right. So the other core component of CBT-I is about leveraging your body’s natural rhythms to drive up your sleep drive and get over whatever barriers you have.

And usually we do this by manipulating schedules. So let’s say you’re not eating your vegetables because you want to, but you just can’t stomach it. There’s some barrier preventing you from doing it. You sit down, plate full of broccoli. You can’t eat it. How many pieces of broccoli can you eat? Well, I can eat, I can eat two, not 12.

Like, okay, great. Next time I’m going to put a plate of the two pieces of broccoli on for you. It’s like, yeah, but I don’t, I don’t like that. Like, well, we know you can eat two. Show me you can eat two, but what about all that I need? Forget that for now. You’re not getting it anyway. Let’s just get you comfortable eating those two.

Okay, comfortable eating two. Let’s try three. Comfortable eating three. Let’s try four until you’re able to build it back up. It’s more complicated than that, but essentially that’s sort of what we’re doing. Sometimes what we do is we squeeze out all of the wakefulness and concentrate your sleep as deep and reliable and strong as we can with what you can do.

Build that up and then expand it out. It’s sort of like, if you want to run distance, you know, you want to run a marathon, we don’t start with a half marathon. We don’t even start with a 5k, we start by hitting the gym. And just working on your leg muscles, make it so that you can get the sleep that you want by overcoming those barriers.

So, we’ll, we’ll manipulate your schedule to make sure you’re going to bed at a time where you’re most sleepy. You’re waking up at a time that will set you up for your best sleep the next day. And make the sleep you’re getting as concentrated and powerful as possible. And then use that as a place of strength to grow.

DS: And it’s not easy, though. I mean, sleep restriction is tough, but I personally find sleep restriction to be more powerful than the stimulus control. That’s an interesting little debate that we could have there. 

DMG: Yes. Notice I didn’t use the word sleep restriction. 

DS: I know. 

DMG: Because, so people in our world call it that. And, and it essentially, sometimes what you are doing is sleep restricting, but actually a lot of times it’s mostly just time in bed restriction where you’re distilling, distilling that sleep. So it is extremely powerful of a technique. 

DS: Yeah. 

DMG: However, it’s very difficult to get right, right away in a way that people are able to tolerate.

DS: Yeah. 

DMG: Because when you make drastic changes, the more extreme you make those changes, the faster you will see results and they will stick, but it often gets worse before it gets better. 

DS: Yeah. 

DMG: And sometimes that’s hard to talk people through, but I think if you explain what the point is that we’re doing here. So when we say, I’m going to reduce the amount of time you’re spending in bed, I still don’t call it sleep restriction only because that means something different to a sleep person. 

DS: I know. 

DMG: Everyone’s got a pet name for it, you know. 

DS: I know. 

DMG: It’s just one of those things of like, man, I wish, I wish we knew more marketing people back in the eighties when this was, was getting developed.

And that’s why you need a good therapist. That’s why you could automate the process. And for some people that’s good enough. But for a lot of people, that’s what you need a good therapist for is to understand these processes so they can optimize that process for you and help navigate you through it and, and stimulus control and schedule manipulation sort of work hand in hand because, you know, you can say, look, here’s your time in bed window that we’re going to use, but still, if you can’t sleep, you have to get up.

You can’t spend that time in bed and, and then they, they, they work very interactively with each other and honestly, you know, and, and I’m sure you’ve got the same experience in your clinic, people come in every week. I get at least somebody who says a new person who says, I am the worst sleeper ever. I am the hardest case you’ve ever had.

This has been going on forever. This is impossible. I like to tell them that, yes, I get those often enough. You’re not alone. And I’m not saying that to minimize your issue. I’m saying it to make you not feel really alone. Cause often you feel like you’re the only one with this problem. And not only that, typically six to eight sessions, usually after about, unless something is complicating the issue, like a medical issue or some other medication, comorbidity or something, anything that’s gonna stretch it out a little more, but like a typical insomnia case, I say, look, six to eight sessions. How long have you had this problem? 

DS: Yeah. 

DMG: I can’t promise you’re going to have perfect sleep. But you won’t need perfect sleep. You’re going to come in one day and you’re going to say, you know what? I’m good. I’m fine. Like I, this is not anything I’m stressing or worrying about anymore. 

DS: What I find really interesting, and then I just briefly want to talk about the cognitive part, but what I find fascinating, Michael, is that you Didn’t lead off with sleep hygiene, which is what so many people will say is part of CBT-I or like the main thing when they think about it. So can you talk about that a bit? 

DMG: Yeah, so, so here’s the deal. Talking to an insomnia person, what they will tell you is sleep hygiene is not a core component of CBT-I because it is neither necessary nor sufficient. You can completely ignore sleep hygiene and do CBT-I as effectively as if you didn’t ignore it for most people. And some people are surprised to learn that sleep hygiene is usually what we use as the placebo control.

DS: Yeah. 

DMG: Not because sleep hygiene is useless. Sleep hygiene is not a treatment for insomnia. Think of it this way. Brushing your teeth is hygiene. You know, everyone should brush their teeth, preferably more than once a day. It can fix lots of problems. Not brushing can cause lots of problems. It can prevent problems.

There is no way to brush your way out of braces. It’s just not possible because it’s, it’s not the problem it solves. Same thing. Another good analogy is hand washing. Everyone should wash their hands. And if you’re sick, you should wash your hands even more. And it’ll prevent reinfections, it can keep you from getting sick, but hand washing is not going to replace an antibiotic if you have an infection. Hand washing cannot treat the disorder. That’s the difference between hygiene and treatment. Hygiene sets you up for success. And it can prevent problems. It can fix small problems. But it’s not going to treat a condition once it reaches a certain threshold. Doesn’t mean it’s wrong or bad or useless or dumb. It just means it’s often not enough once you cross that threshold. 

The problem is, though, and I don’t know if you’ve had this experience, a lot of people will come into clinics and say, Yeah, yeah, I tried all the behavioral sleep stuff. 

I’m like, well, what did you do? It’s like, well, I did all the sleep hygiene.

I’m like, well, yeah, but that’s not, it’s like I tried all of dental medicine because I brushed my teeth. Like, no, there’s a whole other universe of stuff out there that you just didn’t know about. But good news. I can do all that with you. 

DS: We got extra stuff. 

DMG: Yeah. 

DS: And what about the cognitive component? 

DMG: The thing with the cognitive piece is that’s also a little bit of a controversy in the field where some people feel like, well, if the schedule manipulation and, and stimulus control, I mean, you know, if those components alone are necessary and sufficient, you know, often you may not even need to do some of the cognitive piece because you’ve sort of steamrolled over, over some of that anyway, and, and the, the behavioral stuff helps build reprogram the cognition, because if you’re worrying about not sleeping, but I’ve sort of reprogrammed your sleep where you can sleep, you’re not not worrying about it anymore.

But there is often a cognitive piece. And it’s different than cognitive therapy and depression, anxiety. It’s, it’s weird that, that even though both of these conditions, whether it’s depression, anxiety, or insomnia, you’re dealing with thoughts and feelings that you can help to reprogram and learn to recognize when they’re unhelpful, but it’s weird that they don’t seem to translate as well from one to the other.

With insomnia, people are worried about not sleeping, and they’re worried about their insomnia. And, you know, telling people to stop worrying doesn’t really help. So sometimes the cognitive approaches with insomnia are a little different than with depression, where it’s about helping to teach people how to think about and how to feel about their sleep in a slightly different way that’s a little more helpful.

Sometimes it’s about setting appropriate expectations. Or sometimes there’s a relaxation component where that’s the barrier. There’s mindfulness techniques in there, sometimes there’s thought challenging and reframing. 

There’s an interesting paradox with insomnia. And this is, this applies behaviorally as well as, as cognitively, where the main enemy of sleep is effort. And so the more you do, the more likely it’s going to cause issues. So you can do all of the things, but if you find yourself doing all of the things that might actually be contributing to the problem. So sometimes less is more. But yes, there is often a cognitive piece where we’re helping people not worry about their sleep as much.

And I don’t mean saying like, oh, don’t worry about it. You’ll be fine. Sometimes I have to say like, look, yes, sleep is important, but going a few nights without sleep isn’t going to kill you. And if you’re worried that you’re going to die, stop. And let me explain to you why. 

DS: Yeah, and that’s why I think all the optimization for lack of a better word that everyone’s talking about in this perfection with sleep, I think is leading to a lot of this anxiety about sleep for a lot of people because they’re just obsessing about, I have to do all these things in order, in order to guarantee a perfect night’s sleep. And that that’s just not realistic. 

DMG: Yeah. Sleep doesn’t need to be perfect to be perfectly fine. If it did, we would have died out a long time ago. I mean, it’s only been the past hundred years or so that we had decent mattresses, indoor lighting, and climate control. I mean, if sleep required all of these things in place for humans to be perfectly functional and accomplish great things, Our species wouldn’t have made it this far. Like actually sometimes more is less. 

DS: So why is CBT-I then considered the gold standard? Like why is it, you know, American Academy of Sleep Medicine, Primary Care Societies, why are they all recommending it as the first line treatment? 

DMG: So it’s interesting where there have been clinical studies of using this versus placebo for decades. And, and actually it’s also been compared with medications. And it works. It actually really, really works where if you take people’s insomnia and you measure it before and after you get dramatic improvements. Not only that, but it works often better than anything else. I mean, often we hear about, well, there’s the medication approach and then there’s this lighter approach that’s safer, more natural. If you want to avoid the side effects of the medications, maybe go down this route. 

But this is a weird situation where actually CBT-I outperforms medications. Where people don’t believe you, because they say, well, I take something and it knocks me out. It’s like, yeah, but it doesn’t work the way you think, and it wears off over time, and often it makes your daytime worse.

And often, when people come in with a sleep problem, it’s not because they have a sleep problem, it’s because they have a daytime problem. And, if you give them a sedative medication, the main side effect is increased drowsiness, increased fatigue, increased cognitive problems, increased safety problems. And so like, maybe you fix some of the nighttime issue, but then you made the daytime worse, and actually people over anticipate how much a sleep medication is actually going to fix their nighttime issue, and they’re very surprised that it doesn’t always work the way they think it does.

So, here you have, when you have head to head CBT-I versus the most powerful sleeping pills that have been prescribed in the last 30, 40 years, the published data shows, in head to head comparisons, in most situations, there’s no statistically significant difference at the end of, if you did once a week for eight weeks or eight weeks of medication, at the end of that eight week period, there’s actually no real difference except that the people who did CBT-I were falling asleep slightly faster than the people who took the medications. Everything else was essentially identical. That’s the published comparative meta analysis across pooling, across studies. So, it works. Really well. 

DS: And it works long term. 

DMG: Right. 

DS: You stop taking a medication, you don’t sleep. 

DMG: And then you don’t have the risks. And what CBT-I is doing, it’s re teaching your brain how to sleep. You only have to teach it once. And then, you know, maybe life happens, but now you have the skills. So we actually published some data recently. This work was led by Hannah Scott with Michael Perlis and others.

We were looking at CBT-I trials. And showing that people, even years after they were done, their sleep was better than even when they finished. As opposed to most people on medications where things can slide back. So, not, they don’t always slide back after medications, and sometimes people are on stuff long term with other risks, but you could be done with CBT-I, and still continue to get better because you learn how to do it yourself, which is empowering and helpful and powerful.

So then that gets to the question of, of why it’s the gold standard, what’s the gold standard? Because every academic or professional body that was tasked with evaluating the evidence, they always come up with the same answer. That’s CBT-I first, CBT-I first, CBT-I first. That’s not what people are doing. That’s not what people are getting, and it’s weird, where else in all of medicine, or psychology, any field, where do you have a condition like insomnia that’s this common, that is this reliably tied to outcomes that people care about? With a treatment that is this effective? That is this relatively easy to implement, that is this safe, that has so many positives to it, yet most people have never even heard of it? 

Doctors aren’t saying, oh, you have insomnia, you should be doing this first. 

DS: Yep. 

DMG: Why is that? I, I don’t know the answer to that question, but it’s, it’s really interesting. And I think the more people hear this, the more, and the more they go and say, look, why aren’t, why are you writing me a prescription for something, then you, then you have people writing prescriptions for things I’m not, I’m not going to get into it, but medications that are not only not indicated for insomnia, one of the most prescribed medications for insomnia doesn’t beat placebo in clinical trials, yet it’s used all the time. So why? 

Maybe it’s because of there’s not enough providers, but if someone needs to get into clinic, I can make room, if we can train more people. I think this is something people need to learn about because certainly their providers aren’t being taught it. 

DS: And that’s why I do a lot of the stuff I do, like this podcast and Instagram and all that sort of stuff is because People are still, to this day, surprised to hear about CBT-I, so- 

DMG: Right. Or they’re like, well, I heard like, well, if we can’t sleep, get outta bed. It’s like, well, 

DS: Yeah, well 

DMG: Maybe that is stimulus control In a nutshell, they’re like, yeah, but I got outta bed and I couldn’t fall right back asleep. Like, well, that wasn’t the point. Like, this is what you need a therapist for to walk you through the process.

That’s just, that was just part of the process and, and so we can, we can help people with this. 

DS: A hundred percent. Any interesting cases you can think of? 

DMG: Oh, lots. So this is the thing, I don’t know if this is the same in your clinic, but I very rarely get simple, straightforward cases because those people already talked to their doctor and, like, I get the people who already tried everything and it still didn’t work.

So, like, I’ll have people where we have to bend the rules and we have to know where we can bend them and how much before breaking them, but we have to help this fit into people’s lives. I mean, I’ve got, I don’t know, I could go in all kinds of directions. 

I mean, especially people who have in their mind that they’ve gotten so used to having this insomnia, their sleep gets better and they sort of don’t know what to do with themselves because now they’re like, but how can I be this person who- what do I do now with all this free time that I have?

DS: Exactly. It’s a beautiful thing to do a treatment that has such, I mean, it’s not perfect. It doesn’t work for everyone, but it works for many, many, many people. And it’s, It’s like the most effective psychotherapy that there really is, it’s just so many aren’t trained in. 

DMG: Yes, and it’s not rocket science, and actually it’s just people don’t know it’s available to them.

DS: Yeah, exactly. 

DMG: So, so they can, and I’m sure you’ve talked about this a bit, and you could put it in whatever notes you have, but like SBSM has a directory, there’s the CBT-I .directory website that people can go on to find people who have training and experience with this. Wherever you live, there’s probably someone who you can get access with.

And now with telehealth, you could do this via zoom or whatever. And so all you need is someone in your state or someone who’s licensed in your state. or in SciPact where they can go across state lines. You should be able to find somebody. 

DS: Michael, I feel like we’ve been getting into some really good stuff here, but believe it or not, we’re actually out of time. So, could you maybe stick around for a second episode, a part two, so we can dive into ACT and some alternative treatments for insomnia? 

DMG: Yes. It’s all good.

DS: Thanks for listening to Sleep Talking with Dr. Shelby, a Sleepopolis original podcast. Produced by Ready Freddy Media. 

Remember, if you’re tired of hitting snooze, hit subscribe or follow right now in YouTube, Apple Podcasts, Spotify, or wherever you’re listening. And for even more sleep tips, visit sleepopolis.com and my Instagram page, at @sleepdocshelby. Until next time, sleep well.