What is Cognitive Behavioral Therapy for Insomnia?

Curated by Claudia Shannon / Research Scientist / ishonest

Do you spend endless nights staring at the ceiling in bed? Don’t worry, you’re far from alone.

About 30 percent of adults live with some type of insomnia, according to the American Academy of Sleep Medicine (AASM). Chronic insomnia — defined as sleeplessness that occurs at least three times per week for at least 3 months — affects about 10 percent of adults.

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Medication is available to treat chronic insomnia. But sleep experts say that a form of cognitive behavioral therapy (CBT) developed specifically to treat insomnia is both a more effective and safer option.

What is CBT-I for insomnia?

CBT is a form of talk therapy, or psychotherapy. In CBT, mental health professionals work with you to identify, address, and correct negative or inaccurate thinking and behaviors. They’ll help you come up with coping strategies so you can respond to problems more effectively.

CBT is often used to treat:

  • depression
  • anxiety disorders
  • substance use concerns
  • marital problems
  • eating disorders
  • severe mental illness

CBT-I is a form of CBT tailored specifically to address insomnia.

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CBT-I “focuses on the negative thoughts that people have about sleep, such as not being able to sleep or not being able to function optimally the next day due to insufficient sleep,” said Dr. Brian Wind, chief clinical officer of the addiction treatment program JourneyPure. “CBT replaces these with positive thoughts.”

The cognitive part of CBT-I involves exploring and assessing your thoughts, feelings, and behaviors around sleep. You’ll learn to reframe inaccurate or unhelpful thoughts about sleep.

The behavioral part of CBT-I focuses on address problematic habits to promote better sleep. This includes developing healthy sleep habits through:

  • relaxation training
  • stimulus control
  • sleep restriction

Cognitive behavioral therapy techniques for insomnia

CBT-I combines tried-and-true psychotherapy techniques with established science about sleep.

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“What makes it different than regular CBT is that we’re working with the body and sleep drive. There’s more physiology involved,” said Annie Miller, LCSW, a sleep therapist at DC Metro Sleep and Psychotherapy in Chevy Chase, Maryland.

According to the AASM, CBT-I methods include the following:

Cognitive restructuring

One of the first things therapists do to treat chronic insomnia is try to change patients’ thinking about sleep, particularly feelings of guilt and anxiety about not sleeping.

So, your sleep therapist may ask you to keep a diary for a couple of weeks to determine how to best address your insomnia.

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“People feel really upset if they’re awake. The more awake they are, the more stressed they get,” Miller said. “You have to change the way you think about sleep and sleeplessness.”

Miller noted that many people mistakenly believe that if they don’t get 8 hours of sleep per night, they’re falling short of what their body needs.

“People typically have the belief that if I don’t sleep, I will be a mess the next day or my health will suffer or my appearance will suffer,” said Miller. “That’s something we work on — what really happens if you don’t sleep. Once you accept that it’s OK if you don’t sleep, it’s very freeing.”

Stimulus control

People who experience insomnia tend to spend more time in bed being stressed about sleep, said Miller. Stimulus control works to improve sleep hygiene by limiting your time in bed.

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For example, you might be told to get out of bed if you find yourself lying awake for more than 20 minutes, sometimes even less.

“If you can’t sleep, get out of bed,” Miller said. “Get up and find a quiet activity.” This might be reading a book, working on an art project, or even watching TV.

“Something you can put down when you get sleepy so you can go back to bed,” Miller said.

Sleep restriction and compression

The longer we’re awake, the more our need for sleep increases. It’s known as your “sleep drive,” said Miller.

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Sleep drive can be increased by short-term restriction or compression of the amount of time you spend in bed. It’s “not sleep deprivation, but restoring the normal sleep schedule,” Miller explained.

For example, you might be directed to get up every morning at the same time and go to bed at the same time — or later — each night.

“If it’s later, that’s OK, because it ups your sleep drive and helps get your circadian sleep rhythm back,” said Miller. “The more you can accept a bad night’s sleep and know you’re building sleep drive, the easier it will be to get through it.”

How long does CBT take to work for insomnia?

CBT-I typically involves anywhere from 4 to 12 weekly 1-hour sessions with a qualified sleep therapist, according to the American College of Physicians (ACP).

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“It can be conducted either one-to-one or as a group therapy, or via video or telephone consultation,” said Samantha Miller, MD, a spokesperson for Drug Helpline. “There is also evidence that web-based modules and use of self-help books may be just as effective as CBT with a qualified practitioner. It does require commitment and is usually carried out over a period of time.”

Research has shown structured CBT-I counseling can be highly effective. A 2015 study of 41 people with chronic insomnia found that 61 percent of those who were treated with CBT-I by a therapist were in clinical remission from both insomnia and depression 3 months after treatment.

The ACP’s 2016 guidelines state that CBT-I should be the main treatment for chronic insomnia. Medications should only be considered for short-term use in people with chronic insomnia when CBT-I alone isn’t working.

“Cognitive behavioral therapy for insomnia is an effective treatment and can be initiated in a primary care setting,” said ACP President Wayne J. Riley, MD, in a statement. “Although we have insufficient evidence to directly compare CBT-I and drug treatment, CBT-I is likely to have fewer harms.”

Techniques to relax

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CBT-I therapists may also recommend a variety of relaxation techniques to enhance the effectiveness of therapy.

Annie Miller advises patients to establish a wind-down period to create a buffer between busy work, family time, and bedtime. Meditation, including progressive muscle relaxation as well as biofeedback and light yoga, can be helpful.

“The use of relaxation techniques such as mindfulness and meditation can also complement CBT as part of a treatment plan. This might involve listening to music or participating in guided meditation sessions,” added Samantha Miller.

Takeaway

Chronic insomnia is a common condition that can be treated effectively with CBT.

CBT-I is a specialized version of cognitive behavioral therapy that combines psychotherapy with techniques that physically prepare your mind and body for sleep.

Therapists teach patients to overcome negative feelings about sleeplessness. They also provide strategies to improve sleep hygiene and increase sleep drive, your body’s natural desire and need for sleep.

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