Cognitive Behavior Therapy for Insomnia
Cognitive Behavior Therapy for Insomnia (CBT-I) is a short, structured, evidence-based approach to treating sleep difficulty and insomnia. CBT-I focuses on the connection between our, thoughts, behaviors, and sleep. For example, while most of us engage in behaviors that we think will improve our sleep, such as going to bed early if we are having trouble sleeping, often these behaviors maintain or worsen insomnia over time. Also, it is natural to worry about not sleeping when we have trouble doing so, yet worry worsens sleep. We can’t worry and fall asleep at the same time!
CBT-I typically takes about 6 to 8 sessions although treatment length varies depending on the client’s needs. Appointments include cognitive, behavioral, and educational components. For instance, relaxation training, stimulus control, and sleep consolidation aim to enhance relaxation, implementation of helpful sleep behaviors, and quality sleep. Below is more information on the key components of CBT-I:
Stimulus control
When we spend long periods not sleeping, we create certain associations that make sleeping more difficult. For example, the bed itself may become a cue for being awake rather than asleep or you may engage in behaviors in bed, such as using your phone or watching TV, that hinder sleep. Stimulus control aims to change unhelpful associations so that your bed becomes a place for quality sleep. Standard stimulus control guidelines include:
- Using the bed for sleep and sexual activity only
- Getting out of bed when unable to sleep (after about 20 minutes)
- Setting an alarm and getting out of bed at the same time daily
- No napping unless you need to do so for your safety
Sleep consolidation (aka sleep restriction or sleep efficiency therapy)
People with insomnia spend too much time awake in bed. This leads to sleep becoming more and more inconsistent over time. For example, you may get into bed around 10 pm and get out of bed around 6 am, a total time in bed each night of 8 hours, yet, on average, only sleep 4 or 5 hours a night. One of the reasons this is problematic is the longer we are awake in bed, the more our brains associate the bed with being awake, making it more difficult to sleep.
The goal of sleep consolidation is to reestablish consistent sleep (falling asleep and staying asleep) and increase your sleep drive (The biological desire to sleep, which gets stronger the longer you are awake). Sleep consolidation involves matching your time in bed each night with the amount of time you are sleeping. For example, if you are currently sleeping about 5 hours per night, your time in bed window would initially be 5.5 hours a night. Once you are sleeping consistently throughout the night, your time in bed window is gradually expanded until you are getting an amount of sleep each night that leads you to feel rested and function well during the day.
Cognitive restructuring
It is natural to start worrying about sleep when you are not sleeping well. For example, you may get into bed at night and think, “What if I don’t sleep tonight? I am going to feel horrible tomorrow.” Or “There is no way I am going to sleep tonight. I haven’t slept well all week.” As I’m sure you have noticed, the more you worry about sleep, and the more pressure you put on sleep, the less likely you are to sleep. When you worry, you are alert and you can be alert and fall asleep. Also, worrying can lead to spending more time awake in bed which makes it more difficult to sleep.
Cognitive restructuring aims to identify, challenge, and change unhelpful thoughts about sleep that make it more challenging to sleep. By creating and focusing on more neutral and/or balanced thoughts about sleep, you can decrease worry and pressure on sleep and set yourself up to have a better chance at sleeping. For example, you may practice telling yourself, “I am going to take things one night at a time and practice behaviors that support my sleep.” Or “Not sleeping is unpleasant and it is not the end of the world. I can cope with this.”
Relaxation training
Relaxation exercises can reduce muscle tension and help ease an active mind making it easier to fall asleep. For instance, slow, deep breathing and/or progressive muscle relaxation (A technique that involves tensing and relaxing different muscle groups). It is helpful to practice relaxation exercises as part of a daily routine and during the day or evening and not just related to sleep (This helps them be more effective and takes a sense of pressure off of sleep). With that being said, it can be useful to practice a relaxation exercise for a few minutes upon getting into bed or upon waking during the middle of the night.
Psychoeducation and Homework
CBT-I includes a discussion of the rationale behind interventions and an understanding of sleep hygiene and helpful behaviors that support quality sleep. It also involves completing a sleep log in between appointments and implementing the behaviors and coping skills discussed throughout treatment. While it is challenging to change sleep behaviors, one of the main barriers to the effectiveness of CBT-I is clients not implementing the encouraged behaviors.
To learn more about CBT-I, please contact us here at CBT Denver!