As much as 15% of the population experiences chronic insomnia, and occasional insomnia affects up to 35% of people. Given the importance of sleep to overall health, well-being and cognitive function, this problem can pose real challenges to many.
Fortunately, the relatively new approach of cognitive behavioral therapy for insomnia, known as CBT-I, is proving itself extremely useful to help people fall and stay asleep. CBT-I takes an evidence-based approach to treating insomnia, providing a structured program to change thoughts and behaviors. Think of CBT-I as a form of sleep coaching that can help you deal with the root issues behind your insomnia. Take a look at how CBT-I works — whether conveyed in person, via a remote session or self-managed through an app.
How Does CBT-I Work?
As you can see from its name, CBT-I pairs cognitive therapy and behavioral therapy to put you back in control of your ability to sleep. The cognitive side of CBT-I focuses on the thought patterns (and worries) that keep you from sleeping. The behavioral side turns to your sleep habits, helping you to make healthy changes that encourage good sleep.
CBT-I is a relatively new therapy, first recommended by the American College of Physicians in 2016 as the gold standard for insomnia treatment. In fact, the ACP recommends CBT-I as its first-line choice for insomnia therapy, ahead of any use of medications. Numerous studies support its effectiveness, and many therapists and physicians prefer it to the treatment of insomnia with medication because CBT-I has essentially no side effects.
CBT-I is a multicomponent type of treatment, combining cognitive and behavioral therapy with an educational component that helps you understand the nature of sleep and its connection to your thoughts and feelings. Those thoughts and feelings are dealt with in the cognitive component of CBT-I, while the behavioral side of the therapy helps you learn healthy sleep habits.
When you undergo CBT-I, a trained health care provider hones in on the thoughts and feelings that hinder your sleep, including those worries that seem to crop up at 2 a.m. and refuse to go away. During anywhere from two to eight sessions, you’ll explore whether those thoughts and feelings are accurate and learn to reframe them in a way that lets you sleep.
CBT-I is remarkably effective, with as many as 80% of patients experiencing improvement. They fall asleep quicker, wake up fewer times during the night and get more sleep overall. These positive results tend to stay strong over time, with little relapse.
Elements of Sleep Coaching, or CBT-I
The major elements of CBT-I, which is sometimes also referred to as sleep coaching, include cognitive reframing of thoughts, stimulus control therapy, sleep restriction, relaxation and sleep hygiene education. Sleep therapists will recommend some or all of these elements depending on a client’s specific insomnia experience.
You try to sleep, but your mind won’t shut down. It keeps spinning and spinning, replaying the stupid thing you said yesterday, the big presentation you have to make tomorrow or the way it felt when you were rejected 10 years ago. The negative thoughts and worries start to cycle, repeating themselves. As a result, you worry about whether you’re going to be able to sleep — and those worries keep you awake.
Too many people are all too familiar with this negative cycle of insomnia. CBT-I attempts to break the cycle by addressing the dysfunctional thoughts themselves. With CBT-I, you identify the thoughts causing insomnia and then learn to evaluate their accuracy objectively with your therapist. Typically, learning these new cognitive behaviors involves keeping a sleep diary and doing homework assigned by the therapist. By challenging and changing dysfunctional thoughts, you can eliminate their power over your ability to sleep.
An additional feature of this cognitive side of CBT-I is learning to remain passively awake. Yes, you may be awake in the middle of the night, but if you learn to stop trying to fall asleep, paradoxically, you may find it easier to fall asleep.
Stimulus Control Therapy
The key to this element of CBT-I is redefining your bed as a place to be used only for sleep and sex. When you eat a midnight snack in bed, watch TV, scroll through your social media on your mobile device or even read, you’re actually training your body and mind not to sleep while in bed.
As part of this element of your therapy, you may also be told to leave your bed if you’re awake for more than 20 minutes, returning when you’re finally sleepy. You may also need to avoid napping and to learn to go to bed and set your alarm at consistent times. All these factors help your mind reframe its associations with your bed, defining it as a place for sleep.
Lying in bed without sleeping trains your body to lie in bed without sleeping. That’s the reason behind sleep restriction, which paradoxically asks you to try to get less sleep than you need as a way to get more sleep.
With sleep restriction, you turn to your sleep diary to see how much sleep you’re actually getting. Let’s say you’re sleeping for four and a half hours a night. Yes, you need eight hours, but that isn’t going to happen overnight. So instead of trying for that eight hours, you aim for five hours. That might mean staying awake till 1 a.m. or later. As your body gets used to five hours of sleep, you can expand that to five and a half — until you realize that you’re actually getting the sleep you need.
Sleep restriction is particularly effective with older adults, but it’s not recommended for those with bipolar disorder or seizure disorders.
Relaxation techniques can calm your body and your mind, allowing you to fall asleep. Relaxation techniques that are often used in CBTI-I include:
- Hypnosis. Guided or self-hypnosis can help you train your mind to relax.
- Breathing exercises. Deep, slow breathing is proven to slow your heart rate and reduce the anxious feelings that may be keeping you awake.
- Meditation also reduces anxiety and stress while increasing the relaxation needed for sleep.
- Progressive muscle relaxation. This technique focuses on relaxing specific muscle groups in a pattern.
Educating clients about sleep hygiene is an important component of CBT-I. The key to sleep hygiene is creating a comfortable environment for sleeping. This can involve removing the TV from your bedroom and keeping alarm clocks out of view (still within reach, of course). In addition, maintaining a bedroom that’s dark, cool and quiet can help to encourage sleep.
Sleep hygiene also includes behavior outside of sleep hours. Cutting off all caffeine before nighttime, getting enough exercise and limiting alcohol consumption are all choices that can improve sleep.
Because CBT-I is relatively new, there aren’t enough trained therapists to meet demand. Ask your physician or therapist if they have (or are willing to get) training in CBT-I or if they can recommend someone licensed to offer this therapy. CBT-I benefits almost everyone coping with insomnia, including those whose insomnia is caused by chronic pain or by mental health issues. With some practice, CBT-I can deliver long-lasting results and allow you to get a good night’s sleep.