Have you tried all the sleeping pills, teas, and apps and still can’t seem to catch your zzz’s? If so you need to meet Dr. Sarah Silverman! Dr. Sarah is a holistic, Stanford-trained, behavioral sleep medicine specialist whose goal is to empower people to improve their own health and not be reliant on sleeping pills. She is an insomnia expert who believes everyone deserves to feel well rested. Every. Single. Day.
Continue reading learn more about Dr. Sarah and her holistic approach to treating insomnia taken from an Instagram live interview. For the full interview watch here.
Dr. Val: What is your approach to helping women who struggle with sleep?
Dr. Sarah: Of course, it’s going to be unique to each woman. We all have our differences and what makes us comfortable. I want to preface this by saying that the sleep advice that is available these days is kind of generic with good intentions, like helping folks sleep better and prioritize their sleep. But when it comes to having an actual sleep disorder like insomnia, you could be doing all of those things but that general sleep advice may not be enough to target the root cause of the problem. For that reason, I always recommend seeing a sleep specialist who can dive into those reasons why you may be struggling in the first place and come up with a tailored solution.
One of the approaches that I take is through cognitive behavioral therapy for insomnia (CBTi) lens. That’s a combination of cognitive strategies and behavioral strategies. So the cognitive strategies focus more on any negative thoughts or beliefs that may be interfering with sleep. The behavioral strategies focus on any habits or behaviors that may be perpetuating the problem.
With that, my approach is very much along the same lines as yours in terms of a holistic health model. I believe that mind and body and soul are much internally connected, so we really do need to target each of those since they are so connected.
Dr. Val: In terms of the people you work with, what does that look like? Do you go through a formal CBTi program? I know you mentioned that you individualized it. Sometimes I’ve seen people get better within two weeks and I know sometimes it can be several months. What does it look like on average for you? I’m sure there’s a lot of variations there.
Dr. Sarah: There’s definitely variation. It varies on an individual basis because everyone’s sleep is so unique. For the average length of time, it usually is pretty short term. I agree with you, because sometimes just explaining the process of sleep, and explaining the relationship between sleep and stress, and sleep and mood, really does help really quickly. On average, roughly, I would say six sessions give or take. Usually they’re spaced out, over the course of a few months. You figure there are a lot of changes that can be made in a relatively decent amount of time.
Of course, yes, I do follow a standard CBTi protocol; but I do like to customize that based on each individual’s concern or sleep issues.
Dr. Val: Have you felt like any of your patients have “failed” CBTi? Sometimes patients or clients who come see me have worked with other therapists or practitioners in the past or have already read the books I typically recommend. Sometimes I scratch my head like, “Did they really follow it?” What do you do for CBTi-resistant people or do you think there are people who wouldn’t benefit from CBTi?
Dr. Sarah:It’s a wonderful question. I would say I do come across some folks, where CBTi doesn’t provide the relief they are looking for. Usually with this, it could be a number of things. Some of the big ones I usually see are other sleep disorders like sleep apnea, for example, or there’s a lot of anxiety. They can have a lot of negative sleep thoughts that even through the course of the treatment, we weren’t really able to break down or they continue to affect how the person functions throughout the day. Sometimes in that case, it’s worth exploring the anxiety piece, whether that’s with an anxiety specialist or I’m also a big fan of neurofeedback.
So, it really does depend; but I’d say with women especially, it usually is untreated sleep apnea that often leads to not seeing as much improvement as we’d like. The data on CBTi tells us that 70-80% of people who complete a full course of the treatment do experience a really big remission of symptoms. There is a small percentage of folks who may not see as much improvement and for those folks it does get a little bit nuanced; but there is usually something there that is being suppressed.
Audience comment: Are people open to CBT?
Dr. Val: I have a follow up question to that as well. As a medical doctor, there are people who are concerned about seeing a specialist like a behavioral specialist. Sometimes I don’t even use the word “therapy” when I help patients with insomnia. Have you had any type of resistance in your community? Is there a lot of stigma around seeing a therapist or having therapy — or is it not so much of an issue anymore?
Dr. Sarah: I think there still is a stigma around seeing a therapist. Usually if I’m working with an integrated team, the way I tell them to explain what I do to their patients is: This is more of a workshop or a class that gives you the strategies that help you manage your sleep disruption. I think when people look at it that way, that it’s more a workshop, then it kind of takes the pressure off “having to be in therapy” so to speak.
I still get some resistance, of course, from people who have been struggling for years. There’s always a little bit of skepticism. I like to shock people because usually they do come around and they change their perspective.
Audience comment: I feel like a lot of people want a quick fix.
Dr. Sarah: One of my main goals — and I want it to be a goal of the patient I work with — is to eventually be able to come off of sleep medication. You’re absolutely right. A lot of folks will build up a tolerance for sleep medication and it loses its effect over time. So, they start to notice that even though they’re taking something, they’re still not sleeping well. On the one hand, I do see value in sleep medication on a short-term basis. For many people, when you’re in this state of having insomnia for so long, you’ll do anything to really improve your sleep. I think medication can be really helpful on a short term basis to get people through that time of high stress and time of crisis. After things settle a little bit or we stabilize sleep, we can have a conversation about okay, what would it look like to potentially work with your prescriber to do a slow taper off of this sleep aid. I usually work with the prescriber to come up with a plan that is realistic. I usually don’t even touch the topic of medication until the patient I’m working with feels more confident in their ability to sleep. I like to see folks build up that sleep confidence in their own natural ability.
Dr. Val: One of my favorite questions to ask experts is about middle of the night awakenings. What are your thoughts about them and what causes them? What do you do or what works best?
Dr. Sarah: It’s going to look a little bit different for everybody; but I would say, especially for the population you work with, it is very common to have middle of the night awakenings when you’re in perimenopause. It depends on the woman, it could occur during menopause or post-menopause. Perimenopause is often when most experience changes in their sleep. Some of the causes of those wakeups could be due to the changes in estrogen or progesterone. Also, we think about those sex hormones that change, but our cortisol, our stress hormone, can also change during that time as well. It can definitely be hormonal related.
It could also be a normal time to wake up because we all wake up once we complete a full sleep cycle. It could also be due to low blood sugar. Some folks will have a drop in their blood glucose and that might trigger a wake up. It can also be triggered by an untreated sleep disorder.
Another big one is due to anxiety. If it’s not addressed during the day, it can trigger a middle of the night awakening.
A last note from Dr. Sarah:
If you are struggling with your sleep, I encourage you to really talk with your doctor because there are really great treatments available. There are many different approaches to sleep struggles and you do not have to suffer. Definitely reach out because sometimes doctors don’t always ask about sleep. I want to tell folks to advocate for themselves, bring it up if it is becoming something that’s happening on a regular basis.
Dr. Sarah’s 3 tips for a better night’s sleep:
- Always try to wake up at the same time every morning
- Get more natural light exposure, especially in the morning
- Try not to look at the clock when you’re awake