Cognitive Behavioral Therapy for Insomnia

Written by Martin Reed, MEd, CHES®, CCSH. Reviewed by Kenan Wilhoit, MD✓ Evidence-based contentThis article has been reviewed for accuracy by Kenan Wilhoit, MD. Dr. Wilhoit earned his MD at Quillen College of Medicine in Johnson City, Tennessee..

What is cognitive behavioral therapy for insomnia?

Short-term insomnia tends to be triggered by a one-off event or series of events. Sleep problems during times of stress or change are completely normal. However, when the stressful event has passed — or we have adapted to the life change that occurred — sleep problems can stick around.

Insomnia can be hard to shake off even after its initial cause is no longer an issue. That’s because we are now paying far more attention to our sleep and this can lead to the creation of incorrect, inappropriate, and unrealistic thoughts about sleep and inappropriate behaviors that harm sleep.

These ongoing thoughts and behaviors are the root cause of most cases of chronic insomnia.

Cognitive behavioral therapy for insomnia (CBT-I) is a collection of techniques designed to address these thoughts and behaviors. Cognitive is just a fancy word for thoughts. Behavioral is the fancy word for behaviors.

Common thoughts about sleep that can make sleep more difficult include:

• Thinking you need 8 hours of sleep
• Thinking that insomnia is ruining your ability to enjoy life
• Thinking that insomnia is caused by a chemical imbalance
• Thinking that you cannot function after a night of bad sleep
• Thinking that insomnia will have serious health consequences
• Thinking that a night of bad sleep will disrupt your entire week
• Thinking you need to nap if you don’t get enough sleep at night
• Thinking that if you spend more time in bed you will get more sleep
• Thinking that you are going to lose (or have already lost) control over your ability to sleep
• Thinking that the problems you encountered during the day were caused by your insomnia
• Thinking that you need to cancel appointments or social engagements after a night of insomnia

If you recognize any of the above thoughts, it is very likely that you will find CBT-I helpful.

Common behaviors that can make sleep more difficult include:

• Trying to force sleep
• Taking daytime naps
• Worrying about sleep
• Spending too much time in bed
• Clock-watching during the night
• Conserving energy during the day
• Not having a consistent sleep schedule
• Sleeping in a place other than the bed/bedroom
• Using the bed for activities other than sleep (or sex)

If you recognize any of the above behaviors, it is very likely that you will find CBT-I helpful.

CBT-I is usually delivered through weekly or bi-weekly sessions over a period of between 4 and 8 weeks.

CBT-I works by addressing the thoughts and behaviors that are the root cause of most cases of insomnia. The techniques used include:

Sleep education

Sleep education is included in a course of CBT-I to help you address incorrect thoughts about sleep and better understand how your behaviors affect sleep.

Having a better understanding of sleep can reduce sleep-related worries and anxiety, and therefore improve the likelihood of sleep.

Cognitive restructuring

This is a fancy way of saying ‘changing the way you think’. Cognitive restructuring will address (and help correct) certain ways of thinking that are unrealistic and inaccurate. We often have inaccurate assumptions about things. Cognitive restructuring helps correct these inaccuracies by proving that the opinions we have (even when we are absolutely sure about them and can easily justify them) may not be accurate.

Sleep restriction

When clients enroll in the Insomnia Coach course, I usually find that they are spending far more time in bed awake than asleep. Sleep restriction reduces the amount of time spent in bed to more closely match the amount of time spent asleep. The phrase ‘sleep restriction’ isn’t the greatest because it suggests that sleep is being reduced. When sleep restriction is done correctly it rarely leads to less sleep.

Stimulus control

This is another scientific phrase that could be changed to be more easily understood! I prefer to use the term ‘sleep reconditioning’ because the aim of stimulus control is to make the bed a trigger for sleep. For many people with insomnia, the bed has become a place of wakefulness and all of the difficult emotions associated with insomnia. The result? Whenever you get in bed (or think about the bed) you don’t see the bed as a place for sleep. Stimulus control corrects this by retraining the mind to see the bed as a place for sleep. This is done by using the bed for nothing other than sleep (or sex) and by getting out of bed when you can’t sleep.

Relaxation techniques

A common complaint among those with insomnia is being unable to sleep because of an active or racing mind. A lot of people who find it hard to sleep say that they can’t shut down their minds at night. Relaxation can help to calm the mind and make sleep more likely. A course of CBT-I usually includes at least one type of relaxation technique for the client to practice. Relaxation techniques for sleep include:

• Body scan
• Deep breathing
• Guided imagery
• Progressive muscle relaxation

It’s worth bearing in mind that the goal of relaxation is relaxation — not sleep! However, as you become more relaxed, sleep becomes more likely. It’s also important to note that relaxation is a skill. Relaxation rarely works when first tried. It takes a lot of practice.

Sleep hygiene

As you have probably realized, cognitive behavioral therapy for insomnia is a lot more than just sleep hygiene! A lot of people think that CBT-I is the same thing as sleep hygiene. It isn’t. Sleep hygiene is unlikely to improve your sleep if you are living with chronic insomnia. For this reason, sleep hygiene is usually included in a course of CBT-I but it is not the focus (in my online course for insomnia, I don’t even cover sleep hygiene).

Relapse prevention

Finally, a good course of CBT-I should teach you what to do if your insomnia returns. This will help prevent any future sleep issues from developing into insomnia.

Put simply, better sleep without the side-effects of sleeping pills.

Clinical studies have confirmed that CBT-I should be the first-line treatment for adults with chronic insomnia. That’s because sleeping pills for insomnia are only recommended for short-term use and come with potentially serious side-effects.

CBT-I, on the other hand, does not come with such side-effects, it produces significant improvements in sleep, and the benefits continue over time — they don’t stop when treatment ends.

Before trying CBT-I, you should know that your sleep may get worse in the first few weeks. That’s because it takes time to learn and adapt to the techniques you will learn as you progress.

Secondly, it’s important to bear in mind that CBT-I requires a lot of commitment and dedication. It’s far easier to take a sleeping pill than commit to the techniques you will learn and put into practice during a course of CBT-I.

If you are committed, CBT-I can improve your sleep.

CBT-I has been proven to improve sleep even if you are currently taking sleeping pills. It has also been proven to improve sleep even if you are living with other health conditions such as chronic pain or depression. It has also been proven to improve sleep regardless of your age and regardless of your gender.

CBT-I can improve sleep over the long-term.

CBT-I does not come with the side-effects associated with sleeping pills.

CBT-I helps create better conditions for sleep by tackling the thoughts and behaviors that can perpetuate sleep disruption.

The Insomnia Coach course uses cognitive and behavioral coaching techniques and it goes a big step further by focusing on newer acceptance and commitment coaching techniques that will help you move away from struggling with insomnia and toward living the kind of life you want to live.

If you enroll as a client, you will move away from struggling and get your life back from insomnia.

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