Three ways to fix sleep issues when nothing else works

"You're not going to make me get out of bed when I can't sleep, are you?" asked my patient, a mother and researcher who had been suffering from insomnia for about a year. As a psychologist who treats insomnia, I have heard some version of this refrain many times.

She had tried some of the standard interventions — including this one to get out of bed. Unfortunately, it increased her anxiety and did not quell her racing thoughts at night. By the time she came to see me, she had begun using sleeping pills a few times per week.

The behavioral strategies typically prescribed for insomnia have a strong evidence base but are not a great fit for everyone. They can leave people frustrated, desperate, skeptical and anxious.

The problem is not necessarily with the techniques. Some people may need to implement them differently — perhaps in a more relaxed, less goal-oriented way, or in combination rather than as singular interventions.

Popular advice can also be misguided at times. For example, the admonition not to read in bed removes an important bridge to sleep for many people with insomnia — one they may have used successfully for years. The common behavioral approaches also may not target the overthinking at night that insomnia patients often struggle with.

While insomnia is related to anxiety, depression and other mental health challenges, it can also exacerbate and even cause psychiatric symptoms. Treating the insomnia, in many cases, need not depend on treating any underlying psychiatric condition, and can benefit not just sleep but also mental health.

There are several reasons we lie awake — from sleep apnea to iron deficiency to trauma to circadian issues to the dog's jumping on the bed. Many of these issues require help from a physician.

For others, I offer these cognitive and behavioral interventions that have helped my patients, including the researcher who was able to reduce her use of sleeping pills substantially:

Think of sleep as a bodily function. If you were about to sneeze and someone said, "Bless you," too soon, the urge may suddenly have dissipated. Or if you've ever had to suppress a sneeze in a hushed setting, you've probably been able to do it. But make yourself sneeze? Impossible.

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Sexual function is similar: Biological drive and action are important but not enough. You need to put your mind on the right things and take it off performance.

Sleep also is easily derailed by self-consciousness and is impervious to effort because it lends itself to performance anxiety. We pressure ourselves to sleep well because of real or perceived high stakes, and consequently we get in its way.

Once you understand that sleep is a bodily function, it is easier to let go of trying to control it. In the late evenings, many of my patients are tired but determined quality-control engineers who anxiously monitor their environments, behaviors and level of sleepiness. Their in-bed regimens are just as conscientious, and in the mornings, they check their sleep data on apps. It is work, not rest.

Contrast their approach with the comforting rituals we use to help children fall asleep. They feel enveloped in love and safe. Sleep naturally overtakes them when their bodies are ready.

Adults can reclaim this natural relationship to sleep and learn to get out of its way. Recognize that it is not your job but your body's job to sleep. Approach your sleep habits in a relaxed, flexible and curious manner.

Compress your sleep window. When we adopt an unrealistically lengthy period for sleep (falling asleep at 10 p.m. and waking at 8 a.m., for example), it can lead to interrupted sleep, light sleep and protracted wakeful periods.

Pizza dough provides a useful analogy. Roll it out onto too large a surface and it will be thin and holey. Roll it out over a small area and it will be nice and deep.

People are prone to longer sleep windows when they are on a more relaxed schedule, for instance when they are working from home or are retired. Or they may fall into a self-perpetuating pattern of rising late or falling asleep early to compensate for waking at night. Also, our capacity for sleep may diminish with stress, anxiety, late caffeine, lengthy naps, changes in health, medications and so on.

Try to remediate the factors that are stealing your sleep. But even if you can't, it is important to match your sleep duration to your actual rather than wished-for capacity for good sleep.

When you experiment with compressing your sleep window, try not to feel too anxious. This is not the often-prescribed, stricter and potentially more anxiety-provoking technique known as "sleep restriction," which initially constrains the time in bed to the average number of hours slept.

Try your new schedule for at least eight nights in a row, then fine-tune with further or less compression, and implement flexibly. For many people, roughly seven hours makes for a nice, thick pizza.

Take mental selfies. If you live with insomnia, you probably know how the mind can be at night. It steers us through our regrets, anxieties, problems and to-do lists. We would do better if we were to face our problems during the day, wind down at night and wait until drowsy to come to bed.

We also could use the selfie setting. Redirect your focus from the subject of your overthinking to the fact that you are overthinking. Exercise this self-awareness gently, nonjudgmentally and repeatedly — as often as you can catch yourself overthinking.

Then try directing your attention to a "soothing distractor" such as a peaceful book, audio book or lecture series (on a generous timer). A good soothing distractor can be better than the familiar techniques people tend to turn to at night, such as muscle relaxation and visualizations. These otherwise excellent approaches may not last long enough on a bad night or may be too goal-oriented or insufficiently distracting. You can still use them as needed once you are already feeling sleepy or for rapid calming.

If your chosen distractor keeps you awake, try something else. Make sure any light exposure is very dim and tilted toward the red end of the spectrum. You can start out in bed if you like.

The ideas offered here are not intended as a comprehensive guide to improved sleep. But I hope that they help you to feel optimistic and encouraged, and that they give you a fresh start.

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