Cognitive behavioural therapy for insomnia (CBT-I) is a research-supported treatment and is considered the first-line intervention for chronic sleep problems by the American Academy of Sleep Sciences.
In this post, I discuss how CBT-I works, whether it is effective in treating sleep and other problems, and how to get the most out of treatment.
How CBT-I Works
CBT-I works by tinkering with our sleep systems to make it work for us, rather than against us.
When we are struggling with insomnia, we naturally engage in behaviours that counterproductively affects our sleep. For example, we might stay in bed longer, cancel plans, take naps – these behaviours affect our sleep drive (what we need for deep sleep)and circadian rhythm (because we are going to bed and waking up at regular intervals), which is what we need to get the deep sleep that we need.
We might also stay in bed feeling frustrated, which can increase sleep anxiety and overtime lead to creating an association between the bed and wakefulness – known as conditioned arousal.
CBT-I therefore uses strategies to 1) increase sleep drive; 2) balance the circadian rhythm; and 3) reduce sleep anxiety.
What the research says about CBT-I
Overall, the research for CBT-I is very promising. Studies show that people with different medical and psychological comorbidities (e.g., depression) can benefit from CBT-I (Wu et al., 2015).
In our own clinical trials at the Sleep and Depression Laboratory at Toronto Metropolitan University, we see remission rates between 70 to 80%. That means, nearly 4 out of 5 people coming into treatment go from being a poor sleeper to a good sleeper within four sessions of CBT-I.
One particular advantage of CBT-I compared to sleep medication is long-term durability. Oftentimes, people who get off medication will notice that their sleep problem return; on the other hand, people who finish up CBT-I tend to stay a good sleeper years after treatment (Blom et al., 2016). This is because CBT-I targets the causes of insomnia.
Even more, research from our lab suggests that you don’t have to stay with the recommendations forever after treatment to retain its benefits (Lau et al., 2022). Therefore, you can have your cake and eat it too!
CBT-I helps more than sleep problems
Beyond improving sleep problems, such as difficulty falling asleep, staying asleep, waking up too early, CBT-I can also impact other important mental and physical health areas.
For example, there’s a lot of research that CBT-I improves symptoms of mood and anxiety (Ye et al., 2015). The improvements in sleep and energy can also impact physical issues, such as chronic pain and fatigue (Jungquist et al., 2010).
How to benefit more from CBT-I
Below are a few strategies to get the most out of your CBT-I experience.
1. Work with a therapist
Although there are self-help books and apps for CBT-I, such as Goodnight Mind by Dr. Colleen Carney, a therapist can be helpful in providing the most effective recommendations by analyzing your sleep diary. The sleep diary is a way of tracking your sleep to understand how to best tinker with your behaviours to support sleep health.
2. Try out the recommendations
The recommendations of CBT-I can sometimes be difficult to follow, such as only getting into bed when sleepy and getting out of bed when sleep is not coming. These recommendations sometimes increase our sleep anxiety, which tells us to stay in bed. However, giving the recommendations a real college try can be helpful to support efficacy and not fall into a vicious trap.
3. Use a sleep diary
As discussed above, a sleep diary gives us a sense of patterns in our sleep that can inform recommendations. Using a sleep diary (see here for an example: see here) can be helpful in understanding possible problems. For example, if you are generally producing 6 hours of sleep but spending 9 hours in bed, then that can be a reason why sleep feels light and non-restorative. Again, a CBT-I therapist can use this information to support their recommendations for therapy.