Cognitive Behavioural Therapy for Insomnia

CBT for insomnia (CBT-I for short) is an effective evidence-based treatment for chronic insomnia. There is ample research out there for how effective CBT-I is for insomnia. In our own clinical trials, we typically see nearly 80% of people become good sleepers by just 4 sessions. This is because CBT-I precisely targets the causes that maintain sleep problems.

As a provider of CBT-I, I am very partial to the treatment. The treatment works fast; is durable (gains during treatment are maintained for at least 3 years; Blom et al., 2016); is preferred by both patients and providers; and doesn’t have the same side effects as sleep medication.

Here’s a post on differences between CBT-I and sleep medication for those who are interested!

Values and Adherence to CBT-I

However, during my experiences, I also realized that CBT-I isn’t for everyone. Following the recommendations of CBT-I (also known as ‘adherence’) can sometimes be difficult. And unfortunately, adherence is directly to how much a person gets from the treatment.

In the case of CBT, how much you put into it is how much you get out of it.

The recommendations of CBT-I, such as getting out of bed when sleep is not coming and keeping to a regular bed/rise time, can certainly be anxiety-provoking. But perhaps more importantly, these recommendations may not feel right for some people because they are not consistent with how a person wants to live their lives.

Book on CBT

Let’s provide an example of how values might affect recommendations from a slightly different domain – in this case, nutrition.

Betty has been making big headway into her diet plan with a dietitian. She has lost 20 pounds over the past 6 months and is now comfortably within the normal range. She has a plan to lose a few more pounds before wrapping up her time with the dietitian.

After evaluating her current eating habits, Betty and the dietitian found that there was one area that could be improved. Betty often ate twice a week with her family. Her family believed that the best way to maintain familial relationships was through food – a large amount of it at that!

To reach her goals, the dietitian and Betty decided that she would try and reduce the amount of food she ate during these dinners. However, soon after making this plan, Betty found that her reluctance to eat as much as she normally would made her feel less immersed in family time. Despite her desire to lose a little more weight, she didn’t want her family meals to be a time where she had to worry about food. For Betty, the benefit just wasn’t worth the sacrifice.

Here you see a case where two values (losing weight vs eating how she normally did at family dinners) went head-to-head. And in this case, family dinner time was more important to Betty than losing a couple more pounds when she was already at a healthy weight.

When we engage in therapy for insomnia, similar battles can occur between the recommendations we know might help improve our sleep and our values in how we want to live our lives. Below, I discuss 5 values that may impact our ability to fully adhere to CBT-I recommendations.

Value #1: Not having a schedule each day

One of the main recommendations of CBT-I is to keep to a regular schedule in terms of bedtimes and getting up in the morning. This is important to make sure our internal clocks (i.e., our circadian rhythm) is set up well to strengthen our feelings of alertness and sleepiness.

However, this recommendation can step on certain people’s feet as they do not like the idea of going to bed or waking up at the same time every day. They love the idea of sleeping-in, going to bed later on the weekends, lying in bed after waking up to scroll through social media – so on and so forth. Although following CBT-I recommendation is not permanent (just until you feel confident in your ability to sleep again), giving up these values may be difficult for some patients.

Pressing the alarm clock
“Should I press the snooze button or get out of bed for the day?”

Value #2: Following a feeling

Following a feeling means that a person engages in a behaviour whenever they feel like it. If they feel like taking a walk, then they’ll take a walk. If they feel like doing some work, then they will do some work. In these cases, we are waiting for motivation to strike.

Although this strategy isn’t inherently bad, they can be problematic in cases of insomnia because what our brain tells us to do can affect our sleep. For example, people with insomnia will probably have a brain telling them to cancel plans, reduce activity, go to sleep early to catch up on sleep – all of these behaviours affect our drive to build-up deep sleep.

Therefore, a value in terms of following our feelings may be in conflict with CBT-I recommendations, which tells to engage in certain behaviours in spite of how we feel. Even if we feel like taking a nap, CBT-I would ask us to avoid it because it reduces our drive for sleep at night.

Value #3: Avoiding situation that make us nervous

In some ways, insomnia is kind of like an anxiety disorder because people with insomnia are often very scared of the idea of not getting enough sleep and what would happen if they didn’t.

Anxiety is maintained by avoidance. People with insomnia try their best to avoid situations that scare them, such as being awake in the middle of the night, getting of bed when they are trying to sleep, or giving up certain behaviours that they feel keep them safe (e.g., bedtime rituals).

The best way to defeat sleep anxiety is through exposure. As scary as it is, facing our fears is the only way to reduce our anxiety about something. And if we have a value towards avoiding situations that make us nervous, then it can be difficult to follow CBT-I recommendations.

Value #4: Current rituals and habits

There have been many times where a patient of mine has been reluctant to give up on engaging in certain activities before bed, such as reading in bed and doing prayers in bed.

Although these behaviours may seem harmless enough, there are generally two issues that I see that are associated with them.

First, people with insomnia may have a certain belief that “if I don’t read my book in bed, then I won’t be able to fall asleep”. The goal of CBT-I is to show that our body is capable of producing sleep without us having to actively get ourselves to sleep. Although reading a book in bed can be enjoyable and a non-issue in many cases, for people with insomnia this behaviour may be subtly maintaining their general anxiety about not being able to sleep.

The second problem is that engaging in wakeful behaviours in bed can contribute to an association between the bed and wakefulness. This phenomenon is called conditioned arousal and occurs when we are spending a lot of time in bed awake (which of course is the case in insomnia). The goal of CBT-I is to reduce the amount of time we spend in bed engaging in wakeful activities and restore the association between bed and sleep. Therefore, it is helpful to engage in these activities outside of the bed (e.g., on the couch or a desk) at least during treatment.

Woman reading in bed
Giving up reading in bed before trying to sleep can be difficult for some patients!

Value #5: Having a certain number of hours of sleep

People often come into treatment with a goal of getting 8 hours of sleep. And as much as I would love to satisfy this goal, some people simply are not 8-hour sleepers. They may need more, or they may need less. Unfortunately, we can’t change our sleep needs as much as we can’t change our height. And striving for 8 hours can actually lead to insomnia.

The recommendations of CBT-I increasing the quality of sleep, not the quantity. Therefore, if the number of hours is something that a person values greatly above all else, then CBT-I may not be the right step.

Fortunately, when I ask patients whether they would have 8 hours of somewhat crappy sleep or 6 hours of refreshing sleep, I have never heard someone want the former. They all prefer 6 hours of good quality sleep!

Concluding statement

I hope this post was helpful in understanding more about how values can impact treatment in CBT-I. It is important to mention that this doesn’t mean that you must avoid napping for the rest of your life or never read a book in bed to keep your gains. These recommendations are best done during treatment to get your sleep back on track. However, once you feel good about your sleep, it’s totally okay to go back to some of the routines you enjoy.

As I like to say, we sleep to live; we don’t live to sleep!

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Best wishes,