A Six-Week Cure for Insomnia?

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By Judi Ketteler

It's 3:00 a.m., and your mind is bubbling over with thoughts: I need to get to sleep. Why can't I just fall asleep? I'll screw up that presentation at work if I'm too tired. What if I get sick from all of this lack of sleep?

We've probably all had that internal insomnia-induced dialogue at one time or another. But for people with chronic insomnia, it's commonplace -- and they often reach for a prescription sleep aid. Sleeping pills now represent a $4.5 billion market, but they're not long-term solutions, says Gregg Jacobs, Ph.D., an insomnia specialist at UMass Memorial Medical Center and author of "Say Good Night to Insomnia: The 6-Week Program." Jacobs's newly updated book promises to provide the most effective way to get a full night's sleep -- by getting people to change their thoughts about sleep and developing new sleep patterns through cognitive behavioral therapy (CBT). Learn more about the science behind this claim and what other sleep experts have to say below.

Jacobs's book is full of tips and techniques for getting rid of insomnia. Here are six techniques he recommends.

1. Stop trying to achieve the perfect eight.
"The recommendation that we all need eight hours of sleep is a myth," Jacobs says. A major study of more than one million adults conducted in 2002 by Daniel Kripke, M.D., at the University of California-San Diego found that sleeping seven hours a night was associated with lower death rates than sleeping eight hours or more. Keep in mind that these are long-term epidemiological studies -- it doesn't mean that crashing for 10 hours one night suddenly puts you into a high death-risk category. A 2004 study from Japan that monitored the sleep habits of more than 1,000 participants, ages 40 to 79, over a nine-year-period found that those who slept an average of nine hours a night had a higher risk of death than people who slept five; people who slept 10 hours had a higher risk than people who slept four.

It's important for people with insomnia to understand that their insomnia is not going to kill them or make them sick. Part of what fuels the cycle of insomnia is the worry about lack of sleep. Taking the fear factor out is the first step. Also, it's important to not attribute lack of sleep to everything that might be going wrong in your life. "People need to understand that sleep is not the primary cause of all of their problems," cautions Donna Arand, Ph.D., clinical director of the Kettering Sleep Disorders Center.

2. Change your attitude.
A big chunk of Jacobs's program teaches people how to swap out negative sleep thoughts (NSTs) with positive sleep thoughts (PSTs). NSTs are unconstructive, often exaggerated thoughts. Examples of NSTs include: "I'm dreading bedtime," "I can't sleep without a sleeping pill" or "I'm going to lose my job eventually if I can't sleep." NSTs are knee-jerk reactions. Sometimes you don't even know you're having them -- and that they're having a disastrous effect on your sleep. You need to learn to recognize them and then actively replace them with PSTs, like, "I need less sleep than I thought," "I always fall back to sleep sooner or later" or "My sleep is getting better and better." Sound hokey? Just try it: The little mantras we repeat in our brains have a much bigger impact than we think. Jacobs gives the example of one patient who practiced subbing PSTs for NSTs for one week. After the week was up, she told Jacobs that it was the best week of sleep she'd had in years. After four weeks, she was sleeping close to seven hours a night and learned to think about sleep without panicking.

3. Stop giving yourself jet lag.
If you use the weekends to make up for sleep you lost during the week, you're just fueling the cycle of insomnia. By Sunday night, you haven't been awake long enough (called "prior wakefulness") to be able to fall asleep at your normal time. You've basically induced jet lag. The best thing to do is to establish a regular rising time -- and stick to it, no matter what time you fall asleep. If you have the opportunity to nap during the day, even for just 10 minutes, Jacobs suggests you do it -- just limit it to 45 minutes and don't take it later than 4 p.m., or within six hours of bedtime.

4. Don't go to bed too early.
Going to bed early in an attempt to "catch up" if you're not really tired will most likely leave you lying awake and growing more frustrated. If you can't fall asleep, or you wake up, get out of bed after 20 minutes, says Norah Vincent, Ph.D., associate professor at the University of Manitoba's department of clinical health psychology. "Have a place you go, and do something dull," she says. Only go back to bed when you're sleepy.

5. Your bed isn't the enemy.
You want to turn your bed into a cue for sleep -- not wakefulness. When Vincent conducted a study on online-based CBT training, sleep restriction -- or not spending too much time in bed -- was key. Try to avoid doing anything else in bed (except sex), like watching TV, checking e-mail on your laptop or talking on the phone, advise both Vincent and Jacobs.

6. Find your relaxation response.
Just as your body has a stress response (to fight or flee), it also has a relaxation response (RR). CBT programs like Jacobs's and Vincent's teach you how to channel your body's natural ability to calm down through relaxing the muscles, deep breathing (belly breathing, which is how we breathe when we sleep), imagery -- such as a favorite vacation spot, floating on a cloud, the beach, a mountain or any other place that feels peaceful to you -- and simply repeating mantras, words like "relax" or "peace." Practicing the RR throughout the day (10 to 20 minutes of practice a day is ideal) will help you become a pro when it's time to relax at night. Start by relaxing your muscles, and then move to noticing your breathing patterns and using a mantra or trying visual imagery.

Growing Support

Overall, 90 percent of the people Jacobs and his colleagues have worked with over the course of 20 years have been able to eliminate sleeping pills through CBT, which includes the tips described above -- essential components of the "6-Week Program."

Since the book's release in 1999, results from three major sleep studies have come out, providing further support for Jacobs's claims. Unlike many sleep researchers, Jacobs is not funded by, or a paid speaker for, drug companies. One was a 2004 study, funded by the National Institutes of Health and published in the Archives of Internal Medicine, conducted by Jacobs and his Harvard colleagues, which compared CBT to Ambien (the most widely prescribed sleeping pill) in 63 adults with insomnia. CBT was more effective than Ambien both in the short-term (four weeks) and the long-term (one year), and any benefit Ambien had disappeared once the drug group stopped taking it. The two other major studies (both published in the Journal of the American Medical Association) that compared sleeping pills to CBT also point to CBT being the more effective remedy.

Jacobs isn't alone in his support for CBT. "If insomnia resurfaces, a person who has learned CBT has all the tools to help themselves," says Arand, of the Kettering Sleep Disorders Center. The easiest and quickest option for primary care physicians is to prescribe sleeping pills (especially since most aren't trained in sleep medicine), Arand says. Now that research is showing these techniques work, she's seeing the professional community begin to embrace CBT. The New England Journal of Medicine, National Institutes of Health and the American Psychological Association now recommend CBT for treating insomnia, Jacobs says. Unlike sleeping pills, CBT has no side effects (like dependency or a hangover effect), and anyone can learn these techniques if they take the time to follow the program. Unlearning bad sleep behaviors and getting yourself to think differently about sleep takes some time. "The vast majority of people show maximum improvement in about six weeks," Jacobs says.

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