“When you haven’t slept for 2-3 days, it is very unsettling to go to bed. I was worried about sleeping. I wasn’t really living. I was just exhausted. I was getting paranoid. I was desperate to sleep, but I just couldn’t.”
“Challenge, uncertain, discontinuous”: that is sleep for Janet in her own words. “Every night is a different experience. I don’t know what to expect. So, it is a feeling of insecurity,” she added.
Asking about her sleep the night before our discussion, she hurriedly brought her sleep log. She read her notes:
“9th February: went to bed at noon, woke up at 4:20 a.m.”
“10th February: I don’t know how much I slept. Tossed and turned all night.”
[Turning pages]
“4th January: lousy sleep. Tossed and turned.”
“13th January: 4 hours sleep.”
“14th January: tossed and turned. Didn’t sleep well. My husband was in the hospital, and I took half a buddy [sleeping pill]. The next night, I took another buddy because I had to sleep.”
Sleep is a central element of Janet’s life. “Not sleeping has been a part of my life. I can sleep well for six weeks, and then sleeplessness comes back.”
For her, hitting the pillow meant having a continuous dialogue with herself and a negotiation with sleep. “I wanted to go to bed, but I didn’t want to go to bed, because I was unable to sleep anymore. When you haven’t slept for 2-3 days, it is very unsettling to go to bed. I was worried about sleeping. I wasn’t really living. I was just exhausted. I was getting paranoid. I was desperate to sleep, but I just couldn’t.”
IT WAS TIME
The year 1999 is etched in Janet’s memory. The year when a good night’s sleep became a memory for her. She clearly remembers, “JFK Jr. and his wife were in a tragic airplane accident. I remember that the news was running every night because I watched it. I wasn’t sleeping.”
Janet and her husband were new to Montreal, having just migrated from Calgary and didn’t know anybody in Montreal. She taught full-time in Calgary but wasn’t qualified to teach in Quebec. She had two young kids and couldn’t step out, as her husband worked all day, and she had to stay with them. At the same time, her close friend had passed away, and her brother was having serious personal problems. “That was a lot,” she said.
“I spent a month not sleeping. It was horrible. I would go to bed exhausted and as soon as I put my head on the pillow, I was awake. I would start thinking that this is the way I am. I am just a person who cannot sleep. But I was never that person until 1999.”
Janet was 55 at that time. Sleep was never a problem before that, and thus it felt like a temporary slip in routine. But one incident made her realize that it was time to give this some serious attention.
One day, I had to run an errand. I just had a terrible fog, and I cannot believe that I ended up driving the wrong way on a very busy street. That’s it! I knew I needed to do something about this. I knew sleep deprivation could cause accidents. I became aware that I could be the cause of hurting someone. I wasn’t sleeping on the wheels, but I wasn’t paying attention.
It was time.
SLEEPING PILLS, THE BUDDIES
Despite recognizing the problem, she didn’t seek a doctor’s help. “I realized from friends who saw the doctor that they were always given a prescription for sleeping pills rather than real treatment. I didn’t want that.”
All Janet needed was to regain confidence in her ability to sleep and not depend on sleeping pills. “I had to break the cycle of not sleeping.”
Janet trusted her friend, who had insomnia and was taking Ativan. She started taking half of the 1 mg tablets of Ativan – it worked! She took them only for a week and stopped for a while.
“I have never been without Ativan since then. I have been on and off. I call them my buddies.” The ‘buddies’ that gave her confidence in her ability to sleep – the ‘buddies’ she kept next to her bed, knowing she could rely on them in dire need, not out of habit.
She tries hard not to rely on them. “I let 3-4 sleepless nights pass, and then I take one.” It would lower her anxiety about not sleeping. She shared, “I would go three months without Ativan and fall back in the cycle of not sleeping again for whatever reason.” Sometimes, for no reason.
Due to her fear of the uncertainty of falling asleep, occasionally she takes Ativan as a preventative measure when something important follows the next day and she cannot afford to have brain fog.
“My insomnia never went away. It always comes back. Ativan was a temporary fix.” Janet shared that she feels “guilty” and “feels like a cheater” to indulge with her buddies. “I don’t like it because I want to sleep by myself, not through a pill. I don’t want to be controlled by a drug.”
REGAINING CONFIDENCE WITH CBTi
Many have heard of CBT, cognitive behavioral therapy, a form of psychotherapy. But CBTi – CBT for insomnia – is less commonly known, despite being recommended as a first-line therapy for insomnia. It has been shown to be effective in managing insomnia amongst diverse populations, including shift workers, adolescents and adults with or without comorbidities. Compared to sleeping pills, CBTi is more effective, safer, has lasting benefits, and importantly, tackles the root cause of insomnia (to get more CBTi information curated by experts, visit: https://mysleepwell.ca/cbti/).
Like many, Janet was unaware of CBTi. “I don’t know how long CBTi has been around, but I never heard doctors talk about it. They never suggest getting enrolled in a program that offers CBTi. I believe people just want to have a quick short-term solution and thus get sleeping pills.”
Janet learned about a CBTi study at Concordia University during the pandemic. She was a perfect candidate, and she got enrolled in the study.
“The program was very easy. I did it once a week for four weeks. It involved a bunch of sleep hygiene techniques, including recording your sleep.” A practice that, evidently, she still followed. “They gave us a thought chart and strategies to break the circle of thoughts. One strategy was to count backwards to stop the train of thought.”
CBTi helped Janet to “NOT feel powerless” and to know that she could stop the spiral of negative thoughts and regain her confidence in sleeping on her own, without her buddies. “I felt I could deal with insomnia. It also helped me to know that legitimate resources are within reach,” she added.
The biggest game-changer for Janet was when a myth she believed was debunked. She was told that eight hours of sleep wasn’t necessary for everyone – that each person has unique sleep needs.
I think that misconception harmed me. It made me anxious and upset when I wasn’t getting that much sleep.
For her CBTi had psychological benefits too. “I felt better psychologically as I was addressing insomnia. I was trying. I felt like maybe tonight was a bad night, tomorrow will be better. I stuck well with the routine I was told to follow as a part of the program.”
Five years after the pandemic, Janet is still applying most of her learnings from CBTi. “CBTi really helped me decrease my sleep anxiety. [Additionally,] I don’t miss physical activity, no matter what. They stressed in the program that sleeping in the middle of the day if you haven’t slept the night before is the worst thing you could do. Just get through your day and sleep at night.”
A NEED FOR CHANGE
CBTi affirmed to Janet that she could deal with her insomnia. Given the positive impact of CBTi on her life, she highlighted the problem of accessibility of CBTi.
“It would be of help if doctors could tell people, ‘You can beat this. You don’t need to rely on medications. Get enrolled in a CBTi program.’ But doctors do not know about this.” This points towards the dearth of sleep education amongst family doctors and the translation of evidence-based treatments to the clinic. This is one barrier to accessing effective treatment for insomnia. “I think it would have been great for me if I had access to this in 1999.”
In Janet’s view, another barrier to accessing CBTi could be its expense. “If you are referred to a therapist for CBTi, maybe you don’t want to pay. But if they were told that you could access it online, it would help many people.” Indeed, CBTi and other safer drug treatments for insomnia are not covered by the RAMQ, Quebec’s public health insurance, which limits equitable access to insomnia treatments.
She added, “I believe that people are busy, and CBTi might look like work. But once you put in some work, it is easy to follow. It’s the best thing you could do for yourself if you have insomnia.”
Thus, efforts to enhance clinicians’ and pharmacists’ sleep education and training, to raise public awareness, to improve access to evidence-based insomnia treatments, and to implement actionable insomnia management strategies are needed (more on the benefits of CBTi and the issues of treatment access on The Current, CBC).
Janet, now 70, still experiences the highs of restful sleep and the lows of sleepless nights. But over the past 20 years, she has gained better control, confidence, and authority over her sleep. “I like to help myself. The CBTi program affirmed my ability to sleep by providing strategies I can use on sleepless nights – when no one else is awake.”
