Cognitive Behavioural Therapy for Insomnia (CBT-I) is considered the frontline, gold standard treatment for chronic insomnia.
However, people are generally less familiar with CBT-I compared to other available treatment options, such as sleep medication. Therefore, it can be helpful to understand more about what CBT-I is and how it works.
In this post, I discuss everything you need to know about CBT-I to hopefully make a more informed decision regarding treatment.
Acute vs Chronic Insomnia
CBT-I treats chronic sleep disturbances that are maintained by sleep anxiety and disruptions to natural sleep systems. Therefore, it’s important to distinguish between acute (short-term) and chronic (long-term) types of insomnia.
Acute insomnia is typically a response to stress. When we are preparing for an exam, planning a wedding, or transitioning into a new role at work, it makes sense (and evolutionarily advantageous) that we are stressed and sleep becomes worse for wear. Acute insomnia is not a concern and will usually pass once the stressor is over (e.g., you are finished your exams).
Unlike short-term sleep problems, chronic insomnia lasts well after the stressor is over; sleep problems begin to take on form of its own. Typically, chronic insomnia is defined by a period of sleep disturbances that last at least 3 months, occurring 3 times a week. That being said, many people with chronic insomnia have sleep problems lasting years.
- Short-term (lasts a few weeks to a month)
- Results from stressors in life
- Goes away once the stressor is over
- Lasts at least 3 months and occurs at least 3 times a week
- Caused by sleep-specific issues rather than on-going stressors
- Generally requires treatment to alleviate
What does CBT-I look like?
CBT-I includes multiple components of evidence-based therapies for insomnia. They are designed to treat the causes of insomnia.
Sleep restriction therapy
Sleep restriction therapy is a way to limit the amount of time a person spends in bed awake to put pressure on our sleep systems.
People with insomnia often spend an excessive amount of time in bed because they feel fatigued and desire more sleep. This counterproductively leads to a significant amount of time spent awake (e.g., sleeping 6 hours but spending 10 hours in bed). An analogy to this problem is like wearing a size 10 shoe when you have size 6 feet – it feels uncomfortable.
Therefore, sleep restriction therapy brings down the amount of time we spend in bed to be closer to how much sleep we are producing. The idea is that the more time spent outside of bed will increase pressure for sleep, allowing for more deeper, consolidated sleep to occur (reduced nighttime awakenings).
In insomnia, the bed becomes associated (like Pavlov’s dog) with wakefulness. This is because people with insomnia spend so much time tossing and turning, ruminating, and worrying in bed. Over time, our brain begins to make a connection with the bed and being awake.
Stimulus control is a strategy meant to restore the association that bed equals sleep, rather than the bed being a place of fear and uncertainty. This is typically done by using the bed only for sleep and getting out of bed if sleep is not coming (doing some pleasant, such as reading a book, in the meantime).
People with insomnia have unhelpful beliefs about sleep that increase the feelings of pressure of needing to sleep. And as we know, the more we try to sleep the further away sleep gets.
Unhelpful beliefs include: “I need 8 hours of sleep or I won’t be able to function”, “I can’t handle being awake in the middle of the night”, and “I’ll never be able to fall asleep”.
Therefore, cognitive therapy, which tackles and tests these beliefs, help to reduce anxiety and set more heathy expectations of sleep and functioning. For example, testing the question “is it really true that you are unable to function without sufficient sleep?”. In this case, the person can probably come up with examples in the past where they have been able to perform relatively well despite a poor night’s sleep.
Relaxation and Mindfulness practices
Exercises like regular relaxation and mindfulness practices can also be helpful as part of the CBT-I package to reduce general arousal levels and our reaction to scary thoughts or feelings. These practices can facilitate better sleep.
Sleep hygiene include best practices to optimize the environment and behaviours for sleep, such as not drinking coffee in the evening and setting up a nighttime routine. Although these practices can be helpful to support sleep health, sleep hygiene not a standalone effective therapy for insomnia.
Effectiveness of CBT-I
CBT-I is a very effective therapy for insomnia symptoms. CBT-I works in a number of different populations suffering from comorbid conditions, meaning that most people can benefit from CBT-I. Clinical trials at our research laboratory finds that approximately 4 out of 5 people go from being above the insomnia threshold to becoming a good sleeper within four sessions.
Besides sleep, CBT-I also interestingly improves other outcomes, such as mood (Lau et al., 2022), anxiety (Zhang et al., 2015), and chronic pain (Finan et al., 2014). All in all, CBT-I is very effective when recommendations are followed.
CBT-I vs Sleep Medication
CBT-I and medication (e.g., the ‘Z-drugs’) are both evidence-based treatments of chronic insomnia. There are pros and cons of using either treatment.
Medication is effective and simple to use. There is also evidence that medication is equally as effective as CBT-I. However, medication tends to treat insomnia symptoms but does not address the causes of insomnia. Therefore, sleep problems tend to come back if medication is continued. Moreover, some medications cause side effects and generally is not preferred by patients nor providers.
On the other hand, CBT-I has greater durability and its effects last well after treatment is completed. This is because CBT-I restores one’s own confidence in sleeping well and addresses the underlying causes of insomnia.
The drawback of CBT-I is that it requires persistence and effort to see desired benefits. Following the recommendations can be tough and may not be consistent with everybody’s needs and values. For example, some people prefer not having to follow a standard schedule or a specific time in bed, which would pose a barrier to CBT-I.
Strategies to get the most out of CBT-I
Below are a few approaches that you can take to most effectively benefit from CBT-I:
1. Be willing to try out the recommendations! Some of the recommendations of CBT-I feel counterintuitive – such as getting out of bed when sleep is not coming. “But what if I never fall back asleep?”. Anxious thoughts might keep you from fully engaging. However, being curious and experimental in your approach will take you far to break out of the sleep anxiety and get your sleep back on track.
2. Sleep data from a sleep diary can be helpful. If you are working with a therapist, then completing a sleep diary can be helpful to get a sense of your general sleep patterns. Sleep diaries are self-report daily dairies that ask questions such as “when you got into bed” and “how long it took you to fall asleep” to get a picture of your sleep. The therapist can then provide individualized recommendations to support your sleep needs.
3. Reflect on your sleep goals and beliefs. Some sleep goals can be tricky because they don’t reflect reality. For example, many people come in with the goal of sleeping 8 hours but the number of hours we produce is actually completely unique to our own body. Other people might think that better sleep will mean that they have lots of energy throughout the day. However, fatigue is multifaceted and there can be a number of factors that could be contributing to feelings of tiredness (such as lack of activity or caffeine rebound). If you’re interested, here is an article on six strong goals for sleep.