I talk a lot about cognitive behavioral therapy for insomnia (CBT-I) in this podcast. This episode will explain exactly what CBT-I is and how it helps improve sleep. The audio from this episode was taken from a Facebook Live, originally recorded in May 2019. You can find the Insomnia Coach Facebook page at facebook.com/insomniacoach. You can also watch the video that accompanies this podcast on the Insomnia Coach YouTube channel – just go to youtube.com/insomniacoach and click on the Insomnia Coach Podcast playlist.
Click here for a full transcript of this episode.
I just want to talk a little bit about CBT-I, what it is, why it’s the best treatment, certainly the best long-term treatment for chronic insomnia, just because I think that we’re still really struggling with getting the awareness of CBT-I out there and what it is, what it means. I just want to say this right from the start, that CBT is not CBD. It’s not a marijuana product or cannabis product. CBT-I is a collection of skills. Anyway, with that out of the way, let’s get going.
CBT stands for cognitive behavioral therapy for insomnia. Now it’s not therapy in the traditional sense of the word. It probably gives you these ideas that you’re lying on a couch with your hand on head, eyes closed, just recounting all your fears and worries. It’s not really therapy in that traditional kind of stereotypical idea that we have around therapy.
What CBT-I is, is a collection of techniques or skills that you can implement that effectively retrain you to trust your sleep system again, and over time this reduces any sleep related worries. It also helps you identify and address and fix any behaviors that you might be implementing in an attempt to kind of compensate for bad sleep or lost sleep, that can actually perpetuate insomnia or make the problem worse. CBT-I also helps correct any unrealistic thoughts or incorrect thoughts that you might have about your sleep or unrealistic expectations that you have around sleep. The usually just end up putting extra pressure on you. You feel like, “Oh, I’ve really got to get these eight hours of sleep,” for example. And that in itself makes sleep more difficult.
With that being said, there are some core components of CBT-I. All practitioners generally follow a similar pattern in terms of how they implement or the actual components that they’re using, but they might just have slightly different philosophies as to the best way to encourage people to observe the techniques and the components. But generally speaking, it won’t vary that much from provider to provider, because they’re all evidence-based techniques.
With that being said, what I would like to do is just talk about how I approach CBT-I. Now, with my company, InsomniaCoach.com I offer a phone coaching package and also offer an online course. I’m going to talk about the online course, primarily, because it’s more structured. It helps me use that as an example for how we introduce each stage of CBT-I and what’s involved.
When I work with new clients, they generally like to start with sleep education, and that’s just because all of us, I’m not talking specifically about people with insomnia here, but virtually everyone has unrealistic expectations or beliefs about sleep. Most of us don’t really understand what sleep is or what normal sleep is. I like to start off with sleep education, just to kind of challenge any incorrect thoughts or assumptions about sleep, because these can really pile on the pressure if you believe that you should be sleeping in a certain way, or if you believe that some part of your sleep isn’t normal, when, in fact, it probably quite is normal. All these things build that sleep anxiety and make sleep more difficult. That’s why I always start off with a little bit of sleep education.
Then I like to introduce the sleep diary. It’s really difficult to get a good overview of your current sleep patterns without a sleep diary. Because, if I say to you now, “How much sleep do you think you get on a typical night?” It’s quite difficult to answer that question, because you’ll be thinking of the night that you had a really bad sleep and then the night that you maybe had a little bit better sleep. So, it’s hard for you to, off the top of your head, give me an answer to that, or give yourself an answer to that.
By keeping a sleep diary for at least a week, you can get a better overall picture of your sleep, because you can kind of like get an average of your sleep over the course of a week. You can see, then, it gives you a bit more of a clearer picture as to how long on average it’s taking you to fall asleep, how many times on average you’re waking during the night, how much sleep you’re getting on a typical night. The sleep diary is good for that, because it gives you a good overview of where you currently are with regards to your sleep.
But it’s also really helpful, because it helps us monitor progress, so as the weeks go by, as you’re working through a course of CBT-I, you can actually see the techniques are working. You might have had a bad night halfway through a CBT-I course, for example. If you aren’t keeping a sleep diary, you’re probably likely to dwell on that bad night. But if you are keeping a sleep diary, as you should be when you’re going through a course of CBT-I, you’d be able to look at your sleep diary and see the general overall trend is still positive, and that can be really helpful.
All right, so that’s the introduction to getting started with CBT-I. Now, practitioners will introduce the remaining components at different times, or they might slightly customize them according to your individual needs. But then you’re generally looking at sleep restriction, which is a terrible phrase, because it implies that we’re restricting sleep. We are not restricting sleep. What we’re doing is restricting time in bed.
A lot of people with chronic insomnia say they might average, let’s say, four hours of sleep at night, but they’re getting in bed at 10:00 at night and getting out of bed at 6:00 in the morning. They’re allotting eight hours for sleep, but they’re only getting four hours. That means that the other four hours are just spent awake in bed, tossing and turning, feeling anxious, worried, frustrated, and this doesn’t help us sleep.
Sleep restriction is about reducing this sleep window down to more closely match the amount of time you spend asleep. Now, the goal here is to consolidate sleep, so instead of spreading out tiny little snippets of sleep throughout a really long sleep period, you are going to be getting nice, strong, uninterrupted chunks of deeper, more restorative sleep.
The other benefit of this is it helps create and strengthen an association between the bed and sleep. A lot of people with chronic insomnia, especially if you’ve been suffering for insomnia for a really long time, you’ve kind of learned to associate the bed with being awake, being frustrated, being anxious, because you spend a lot of time in bed doing those things. With sleep restriction or bedtime restriction, you’re going to be spending almost all of your time in bed asleep instead of awake. Over time this retrains you to see the bed as a place for sleep, and over time this makes the bed a strong trigger for sleep. That’s sleep restriction or bedtime restriction.
The next technique that’s often used is called stimulus control. Another really terrible phrase. Terminology is very scientific, research-based. Stimulus control, basically, means, as I touched on before, we want to associate the bed with sleep and nothing else. Insomnia really is, when insomnia gets perpetuated, when it gets just keeps on going, it’s insomnia, insomnia, insomnia, and it gets worse and worse over time, it’s perpetuated. This is a symptom of a learned association between the bed and bad things. You go to bed and you’re expecting a bad night, you’re expecting to be awake. We want to break this learned association and get you back to the good old days where you thought about your bed, or you got into bed, and you felt great.
The only way to do this is to make sure that the only thing you do in bed is sleep. To get started, what we do is make sure that you see the bed as a place only for sleep. You’re not watching TV in bed. You’re not writing an essay in bed, if you’re doing homework, for example. You’re not checking emails in bed. You’re not doing any activity in bed apart from sleep. We do have the little side note that it’s okay for sexual activity to take place in bed, because that generally doesn’t have a negative effect on sleep. But generally speaking, the only thing you do in bed is sleep, and that’s really what stimulus control is about.
Now, the hardest thing about stimulus control is that it also means that if you’re in bed at night and you can’t fall asleep, or if you wake up and you can’t fall back to sleep, then you get out of bed and you wait until you feel sleepy again. Then you get back into bed and you repeat the process. If you can’t fall back to sleep, then again, you get out of bed. This is a really hard technique to follow, because it can kind of make you into this human yo-yo where you’re in and out of bed all night long. The reason this is difficult, I’m sure you’re thinking it right now, “How am I going to get to sleep if I’m in and out of bed all night?” Well, when you’re implementing stimulus control, it may well lead to less sleep in the short-term. But you have to remember, though, what we’re trying to do here is give you a long-term solution to your insomnia. To get all these long-term benefits, unfortunately, there is a bit of short-term pain. There is a little bit of difficulty getting started in order to reap those long-term benefits.
If you’re awake in bed after waking up during the night or you’re struggling to fall asleep, you can wait like 20, 30 minutes, just estimate this amount of time in your head. You don’t want to be clock-watching. Or, if you just feel really wide awake and anxious, and you just know that you’re not going to fall asleep, then that’s your cue to get out of bed. Go into the living room or another room, and just engage yourself in a relaxing, enjoyable activity. Something that’s a little bit more enjoyable than lying in bed, tossing and turning, being mad that you can’t sleep. Some good examples would be reading, listening to an audio book. Some people like to do crosswords or Sudoku puzzles or things like that. Then once you start to feel yourself get sleepy again, then that’s your cue to go back to bed. Not try to sleep, but just lie back down in bed and just see what happens. If you’re struggling again, it’s been like another 20, 30 minutes, or you’re feeling really anxious again, then you repeat the process. You get out of bed until you feel sleepy again.
Now it’s important to bear in mind that this technique is certainly not intended to improve your sleep on the night that you’re trying it out. This is like an investment in your long-term success. The first few nights, maybe even the first couple of weeks, could well lead to less sleep, because you’re going to be getting in and out of bed. But what this does is it kind of like builds up any loss of sleep, builds up sleep drive. As long as you stay committed, this propensity or desire to sleep will get stronger and stronger and stronger until you’re going to get to the point where, when you’re combining it with this bedtime restriction, as your bedtime approaches, as the start of your sleep window approaches, you’re going to be starting to get really sleepy the longer you commit to these techniques. This increases the chance of sleep, and it also will help consolidate your sleep, so it’s going to be less fragmented. It’s going to be a deeper sleep.
When you wake during the night, you’re going to start to recognize that the bed is a place for sleep, so you’ll be less concerned when you wake during the night. This will mean that over time you’ll actually need to get out of bed less often. These are probably the two main techniques of CBT-I. The sleep restriction, the bedtime restriction, following a sleep window that’s appropriate to your average nightly sleep duration, and stimulus control, which is about getting out of bed when you can’t sleep, using the bed only for sleep so that you can build this association between the bed and sleep.
Then, CBT-I will normally include some kind of relaxation component. In my online course, I put this just around about the halfway mark. Because, I see sleep restriction and stimulus control as the best techniques. They’re the best two, the most effective in a course of CBT-I. But relaxation definitely has its place, but it’s important to note that relaxation is not intended to make you sleep. The goal of relaxation is relaxation. That’s it. And relaxation is a skill. It takes a lot of time and a lot of practice before you actually get good at it.
When I introduce relaxation when I’m working with clients, I encourage just practicing relaxation during the day for two weeks before you even try it in the evening. This can be like a guided meditation or progressive muscle relaxation. There’s a number of different relaxation techniques out there. But it’s important to just see the goal of relaxation is relaxation, to practice for a couple of weeks during the day. Then what you can do is, once you feel like you’re starting to get proficient, you’re starting to get quite good at the relaxation techniques, they’re helping you relax, you can start introducing them in the evening, closer to your bedtime. I like to call that hour before bed is like the buffer zone where you just reserve that time for relaxing, enjoyable activities to help you unwind. This can be a good time to implement some of these relaxation techniques just to help you unwind and relax and kind of like put the day to bed before you get into bed.
Some people also find that relaxation can be helpful for when they first get into bed, or if you wake during the night, and you start to feel a tiny little bit of anxiety creeping up. Sometimes just doing some visual imagery or some progressive muscle relaxation can help relax you and calm you back down. A result might be you fall back to sleep. But just remember that your goal is relaxation, not sleep.
What else is included in a course of CBT-I? CBT-I often includes some sleep hygiene. The problem with sleep hygiene is there’s no evidence that it is an effective treatment for chronic insomnia. By itself, sleep hygiene won’t really do anything. When they do research studies, looking at good treatment options for chronic insomnia, they often give sleep hygiene to the control group, the no treatment group. Because, in the medical community, in the scientific community, the academic community, we know that sleep hygiene doesn’t work, so we offer sleep hygiene to the control group as like the no treatment group.
But with that being said, when used in combination with CBT-I, there may be some benefits, especially if your sleep can sometimes be disrupted by environmental cues, such as like if there’s a lot of light or sound coming into your bedroom, things like that. I go through sleep hygiene right towards the end of a course of CBT-I when I’m working with clients.
Then the very last thing that is usually covered is relapse prevention. By the time you get to the end of a course of CBT-I, you’ve got all these skills. You should be seeing some notable improvements in your sleep. But it’s important to bear in mind that you’re still going to have bad nights every now and then. Right? Because, everyone has a bad night every now and then. The best sleepers in the world have a bad night of sleep every now and then. You know, you get some bad news, or you have to move house, change job, or there’s a health scare, something like this. That’s going to be upsetting, and it’s going to add stress, and it’s going to disrupt sleep.
Relapse prevention is all about recognizing and expecting bad nights to occur in the future, but also reminding you of all the techniques that you found helpful during your course of CBT-I that you can fall back on should you need them in the future.
Now this is why CBT-I is so great, and it’s such a fantastic treatment, such a fantastic long-term solution for insomnia, is because it’s a collection of skills and techniques. Once you’ve learned them, they are with you for life. It’s not like an ongoing subscription. Yyou’re not having to pay money every month for the rest of your life like you are with supplements, or sleeping pills, or something like that, because you’ve learned these skills and they will be with you forever. Anytime that your sleep gets disrupted again in the future, you just empty that vault back in your mind and remember all the skills that you learned, and you can reintroduce these into your routine, and get your sleep back on track.
All right, we’re about the 20 minute mark now. I think I’m going to call it a day. If you’ve never given CBT-I a try, I really encourage you to look into it. Ask your doctor about it. Just Google it. Just become more aware of it. It’s really challenging when I’m in these insomnia support forums, or I’m just talking to people with insomnia, and they could have been suffering with insomnia for like 10, 20, 30 years and they tell me they’ve tried everything, but they’ve never heard of CBT-I. Through no fault of their own. We’re just doing a really bad job of getting this awareness out there. My real aim is just to give you that awareness, and I really hope you’ll take the next step and just do a little bit of research about it. If you have any questions, I’m more than happy to help out. You can email me. My email address is [email protected]
Thanks for listening to the insomnia coach podcast. If you’re ready to implement cognitive behavioral therapy for insomnia, CBT-I techniques, to improve your sleep, but think you might need some additional support and guidance, I would love to help. There are two ways we can work together.
First, you can get my online coaching course. This is the most popular option. My course combines a sleep education with unlimited support and guidance, and is guaranteed to improve your sleep. I will teach you and help you implement new CBT-I techniques over a period of eight weeks. This gives you time to build sleep confidence and notice results without feeling overwhelmed. You can get the course and start right now at InsomniaCoach.com/online.
I also offer a phone coaching package where we start with a one hour call. This can be voice only or video, your choice, and we come up with an initial two-week plan that will have you implementing CBT-I techniques that will lead to long-term improvements in your sleep. You get unlimited email-based support and guidance for two weeks after the call, along with a half-hour followup call at the end of the two weeks. You can book the phone coaching package at InsomniaCoach.com/phone.
I hope you enjoyed this episode of the Insomnia Coach podcast. I’m Martin Reed, and as always, I’d like to leave you with this important reminder. You can sleep.
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