Cognitive Behavioral Therapy compared to sleeping pills

How good is Cognitive Behavioral Therapy compared to sleeping pills?

How effective is Cognitive Behavioral Therapy compared to sleeping pills?! A common question.

As far as I know, there’s just one way to combat sleep with plenty of pros but no cons in the form of side effects – Cognitive Behavioral Therapy for Insomnia (CBTI).

Some sources point to success in about ~80% of cases, which puts it at the top regarding how effectively it works to combat these questions. It’s the gold standard therapy for insomnia, and it’s recommended by the American College of Physicians and the American Academy of Sleep Medicine.

In defense of the pills, they have a quicker effect on improving sleep than CBT. A drug is instant. Learning and changing take time.

CBT seems to have a similar effect after “a few weeks” or “4-8 sessions”.

Pills give a longer duration of sleep, which sounds good initially, but with more insight, it doesn’t have to be. CBT tries to normalize and get good sleep. Pills aim for MORE sleep which isn’t something to cheer for if the sleep is worse.

CBT gives a better subjective quality of sleep, it takes less time to fall asleep, and people wake up more infrequently.

CBT gives a lifelong skill. When you’re done with the treatment, you keep your results and might even keep improving afterward, in contrast to pills, which lose their effect when you stop using them and might even give worse sleep when you quit than before you started.

The beautiful part of cognitive behavioral therapy is that it’ll fiddle, poke and affect everything that gives you your problems. It won’t just mask something and hide it. It’ll try to solve and remove problems. I want you to learn to take care of yourself, and by doing so, you’ll get skills for life to care for yourself until the end of your days instead of being dependent on externals. “Teach a man to fish…”. It’s a long-term solution instead of short-term comfort.

Do you want to learn and get better, or do you want to hide the troubles and be unconscious, which is far from the same thing?

From what I see and hear from people who’ve tried to get help with their sleep, the standard way of battling sleeping issues seems to be sleeping pills and nothing more.

That’s sad.

Or… Is it? If that’s what the (likely suffering) patient wants – to rely on external help – rather than learn themselves, that’s a lovely tool. It’s precisely what they asked for.

Use enough, and it’ll knock you out regardless of why you “can’t sleep”.

Some patients who get the more classic help get something to take at night to help them sleep – and it won’t work.  The prescription of sleeping pills increased by 60% in the USA between 2000 and 2005, and the entire west seems to do more or less the same. Did we notice a sudden health benefit from the pills, so we should devour as many as possible – or is there something else? Those who keep to drugs tend to increase the dose, which often doesn’t do the trick. It’s not just a question of dose. It’s a question of using the right solution for the problem. Sedatives might mitigate some of it but rarely remove the problem. Perhaps it hides part of a symptom entirely.

People prone to rely on drugs enough to use sleep aids commonly use more of those tools. Perhaps they also use

• Something to relax in the daytime.
• Caffeine or other stimulants to keep going during the day since trouble sleeping makes you so tired.
• Something slower to release or “with a longer half-life” to keep them sleeping at night because they wake up after a few hours.
• Something to manage their mood, like an anti-depressant.

So they’re on several pills and still don’t like their sleep.

Those who rely on pills to sleep don’t achieve something better than those who try to solve the problem.

If they get lovely, restful, and peaceful sleep from the tools… and then stop, then what?

Rebound sleeplessness is expected because of just that. You start using them and go for it for a while. You might even be more or less pleased with your sleep. But when you stop using them, you’ll fail even harder than when you started, and you’re back at it again.

If that sounds like a bad idea, the solution to care about life is for you. The hard part of that one is that it takes time, and energy, requires all sorts of effort, and you’ll have to do and keep doing when you’re “done”. Learning is a process, and changing is hard. To get great results here, you’ll have to learn theory about sleep and the connection between your environment, your body, thoughts, emotions, habits, and how you sleep. It’s a process, and it’ll take time. Behaviors, feelings, and thoughts generally don’t change overnight, which is why things are done relatively slowly, and the same change is kept for ~(7-)14 days before being evaluated.

You’ll have to create routines and show discipline and endurance. In some cases, even grit, since this isn’t always pleasant.  You might have tried parts of this before, but it’s unlikely that you’ve tried all of it, endured, and kept going over time – and still can’t sleep. When you meet a therapist for sleep CBT, it’s not rare to go at it for 10+ weeks since it’s about learning and relearning, which takes time. 

The tools in an approach like this could help people fall asleep more quickly, sleep deeper, and for a more decent amount of time. “A more decent” amount of time is highly relevant since that means it’s regardless of if you’re sleeping for too long or too short before starting the program.

Long-term studies say that people tend to feel calmer and more satisfied with their sleep when they’ve gone through a period of CBT to aid their sleep.

The reason why it works isn’t strange, usually. You solve the problem that keeps you from sleeping instead of keeping it and brute forcing sleep. If you can’t sleep, and the reason is related to the psychological, behavioral, emotional, or the most common physiological parts, this will likely do the trick. It’s about analysis, reflection, and learning how to handle life.

If there’s something pathological or something in the brain that doesn’t work as it should, this might fit worse. That doesn’t count what’s treatable with therapy and tending to life, such as anxiety, depression, and other causes of sleeplessness. “Pathology,” in this case, points to damage to the brain and its functions, like tumors, defects from birth, or something acquired from injuries. Or, for that matter, other abnormalities for other reasons; some sleep better from stimulants, for example. Some don’t produce melatonin and got to supplement it to regulate their circadian rhythm. They could benefit from CBT, but that’s a clear example of when the brain doesn’t quite work as intended.

If it doesn’t, it’s harder to predict the outcome of the intervention.

Cognitive behavioral therapy (CBT) generally revolves around changing something that doesn’t work in the desired way. It changes those things through action – by doing – to get a tangible change in your behaviors, leading to changes in other areas. It’s either to change the behaviors themselves or to change what they lead to. Behaviors are either done or not, which is binary. We’ll get to why they’re done or not; that is usually analyzed with a “behavior analysis”. Behaviors are also either functional, meaning they lead to what they’re meant to lead to or not. Remember that. Functional behaviors are great. We want to get rid of behaviors that are not functional. If they are functional or not depends on the situation. Different behaviors may lead to the same outcome. The same behavior might be functional at different times, so functionality is a relevant part to keep in mind in the analysis. The context is relevant!

You’re less likely to do something scary and more likely to do something that gives you joy or a pleasant feeling, such as using drugs. That might be obvious, but it’s crucial to underline. The reasoning there is key. We’ll dig deeper into that later. In short – emotions affect what we do quite a lot. Worth mentioning here might be that feelings are affected by external and internal factors, such as what we hear, see, or think. When I tend to people with CBT, we keep thoughts, emotions, behaviors, and physiology in mind. They are all critical. The environment might be relevant as well. To start by giving a tangible example of how all of this is relevant before we dig deeper into the “how”, let’s look at a tiny part of the start of an analysis of someone’s sleep troubles. When someone can’t sleep, we’ll need to know why, as with every other problem we’re trying to solve. So we do this to try to figure it out:

Before changing what we’re doing, it’s necessary to analyze enough of what we’re doing wrong, so we can change what we’re doing into something that leads to progress. Said behavior ought to take us to where we’d like to be. So initially, it’s essential to find the problem. That’s mainly done with diaries and questionnaires. “What happens when?” “How much?”, and so on. The result will be an analysis of the problem that is concrete enough to deduce what has to change, rather than “I can’t sleep” when tending to sleep or “I think and get anxious” when trying to do something about troublesome thoughts. An analysis like that should include the problem, when it occurs, how it started, and why it keeps bothering you.

The problem likely persists because of some behavior(s). Likely behaviors you control, so it’s possible to do something about them. It’s likely interesting to know why they’re there and their purpose, but as long as they change, that’s often what matters. The changing of behaviors should include you learning what consequences behaviors get. Doing A results in B, and doing X results in Z. If you’ve never reflected on it earlier but rather just… done things and “can’t sleep” or “get anxious”, that’s often a helpful lesson. That part is called “applied behavior analysis”; it helps us point out consequences from behaviors and include if they reinforce or punish. If you do something and get punished, you’ll be less likely to do it again. You’ll probably avoid it if possible. Something reinforced is pleasant. Taking a pill to get rid of anxiety and have a good night’s sleep is quite the reinforcement!

So, the analysis questions why we do what we do. Spontaneously we often do what we do because it’s pleasant. We either get something lovely or get rid of something we don’t want. What do your behaviors lead to? You might have done something satisfying – but what’s the consequence? Was it a short-term pleasure, and you’re suffering long-term?

I like good long-term results, not pleasant short-term ones – and that’ll permeate plenty of my teachings.

You’ll love that over time if you keep at it.

Reinforcement works like this.

First, there’s a starter with something to initiate the behavior, S –> Reaction or behavior, R –> Pleasant Consequence, C

The enjoyable part of C increases the likelihood, frequency, and magnitude of R. It’ll be done more often and MORE once it’s done.

Run –> Amused, people think you’re doing great, or you get a good feeling afterward (Reinforced!)

Running will be done more often.

Punishment

Starter, S –> Reaction/behavior, R –> NOT pleasant Consequence, C

R, Drive, scratch the car –> Get yelled at, C

Anxiety and bad feelings make the behavior less likely to get done again.

Documentation, plenty of writing, and making things concrete and possible to track are necessary to see progress, or lack thereof, to change and adapt, or just celebrate when things are going great. The documentation also aids in learning those patterns between consequences and the behaviors you’ve done to get them.

You can’t have the same confusion you started with once you’ve been going at it for a while, even though you’ve made progress. You’ll have to learn the connections between environment, behaviors, emotions, physiology, and thoughts. That’s why you’re doing this. This will help you soon – and it’ll help you for the rest of your life.

Learning to manage life to sleep is a skill.

You can practice managing your sleep to improve it for as long as needed.