What Is Cognitive Behavioral Therapy for Insomnia (CBT-I)?
By Eleanor McGlinchey, PhD
While sleep has received greater attention as an important pillar of physical health, alongside nutrition and exercise - most people underestimate how much sleep is connected to our mental health.
Many research studies and clinical trials have confirmed that poor sleep is not just a symptom of mood disorders like depression and anxiety, but is often the cause and/or maintaining factor of other mental health conditions. However, we also see that when sleep improves, other aspects of mental health also improve such as emotion regulation abilities and concentration.
However, sleep can also be elusive for many people and simply having a doctor tell you to get more sleep is not as easy as it sounds for some people. For many, even the thought “I need to sleep more” can induce anxiety and dread as bedtime approaches.
What is insomnia?
It’s estimated that up to 30% of people struggle with insomnia. Some people believe that suffering from insomnia is only when you have trouble falling asleep, but this is only partially true. A diagnosis of insomnia is defined as difficulty falling asleep, staying asleep and/or waking too early in the morning and not being able to fall back to sleep that is coupled with daytime complaints of fatigue or other distress from poor sleep. This is the core definition of insomnia, although some doctors have also added that the awakenings must occur at least 3 days per week for at least 30 minutes or more and must have been taking place for at least one month.
Definition of chronic insomnia
Chronic insomnia is further defined as having occurred for at least 4 - 6 months. Cognitive Behavior Therapy for Insomnia (CBT-I) is a talk therapy designed to help people who are struggling to fall asleep or stay asleep, whether it’s been for a short period of time or years.
How does CBT-I differ from CBT?
Traditional Cognitive Behavioral Therapy, or CBT is a talk therapy that focuses on changing unhelpful thinking patterns or behaviors that unintentionally create or exacerbate emotional distress.
CBT-I utilizes these same core principles with an exclusive focus on sleep and the way insomnia starts to affect our mood. You might wonder, wait, isn’t sleep something my body is supposed to do naturally on its own? What exactly do thinking patterns have to do with sleep?
Great question, and one we’ll address in a later section. A key way that CBT-I and CBT are similar is that they are talk therapy approaches. Many people who have struggled with insomnia for a while and have turned to melatonin, CBD, or other sleep medications (e.g., Ambien, Unisom) are surprised to learn that CBT-I therapists focus only on cognitive and behavioral interventions to improve sleep, with great success.
What is CBT-I?
CBT-I is a short-term talk therapy that a sleep psychologist or trained mental health professional can provide in-person or even online. In fact, there are some benefits to virtual CBT-I as your therapist can get a glimpse of your bedroom and a better understanding of your sleep environment at night.
There are a few core elements in CBT for Insomnia, such as sleep tracking, learning about how sleep works and what negatively impacts good sleep, and active behavioral interventions to adjust your sleep habits. These will be tailored to the specific sleep difficulties that you’re experiencing.
Sleep assessment and sleep tracking
CBT-I always starts with an assessment of your current sleep habits and include asking you to track your sleep through a daily sleep diary. These days there are many apps that can help make this less tedious. While it might feel cumbersome to track your sleep, especially if you’ve struggled with the same pattern of insomnia every night (e.g., I get into bed at 11pm, spend an hour lying awake before eventually falling asleep, but then waking again only 5 hours later), it’s an important part of CBT-I.
Tracking your sleep through a sleep diary may help you notice details helpful for your sleep psychologist to learn about so they can tailor the sessions to your specific needs. Regular sleep tracking also gives you a method of tracking improvements and actively problem solving with your therapist.
Learning about how sleep works
After assessing your sleep, a CBT-I therapist will provide psychoeducation about sleep. This includes teaching you about the two main processes controlling sleep – process S and process C, described in more detail here – and reviewing other sleep hygiene practices that might be related to your current sleep difficulty. For example, you may already be avoiding caffeine during the afternoon and evening, but unintentionally creating the habit of napping. How does someone unintentionally nap? For example, let’s say it’s common for you to doze off on the couch for about 5-10 minutes while watching TV at night. A CBT-I therapist will likely advise you to cut out that “nap” before bed.
CBT-I is short-term
In many ways, CBT-I is structured very similarly to any other talk therapy experience that starts with your therapist getting to know you in initial sessions and then later ones are spent collaboratively working towards your sleep goals. After the intake session(s) where your CBT-I therapist assesses your sleep and any co-occurring health problems, most sessions will be between 30-45 minutes and focused exclusively on improving your sleep. While it depends on the nature of each person’s insomnia, CBT-I usually lasts between 4-8 session. Its highly focused and solution-oriented approach means that most people experience progress in a rapid amount of time.
How effective is CBT-I?
Research shows that CBT-I is the most effective nonpharmacological treatment for insomnia (where the underlying reason is not due to another medical cause). It is recommended as the first line treatment for insomnia and many clinical studies have shown it to be 90% effective at reducing insomnia symptoms.
In contrast to using medications to help you sleep, which can have unhelpful side effects, CBT-I focuses on helping people work with their body’s natural sleep mechanisms with successful long-term gains. If your therapist suspects another sleep disorder such as sleep apnea or narcolepsy, your therapist may advise you to have a sleep study conducted in a hospital or medical center sleep lab before you engage in CBT-I.
What causes insomnia?
The 3P model of insomnia has driven research and intervention work for many years. The P’s stand for predisposing factors, precipitating factors and perpetuating factors. All of these factors may work together to make it difficult for someone to sleep.
Predisposing factors are those that we all have at any given time to some degree (e.g., our genetic predisposition toward restlessness at night). Precipitating factors are those events or other triggers that initially lead to some acute experience of insomnia (e.g., a change in hormones due to perimenopause, a stressful period of work). Finally, perpetuating factors are the response that someone takes that might be keeping the insomnia going (e.g., dozing on the couch after work, thinking about sleep excessively). CBT-I is designed to reduce the strength of perpetuating factors of insomnia.
How does CBT-I work?
Stimulus control
The core behavior change elements of CBT-I are stimulus control and sleep restriction or compression. Both of these interventions work to increase sleep pressure (the need for sleep) and begin to reverse the association of wakefulness at night with sleeping at night. The instructions for stimulus control are probably ones you’ve heard of before - but may not have thought about in terms of sleep pressure.
Stimulus control includes to getting into bed only when sleepy (not tired but sleepy), avoiding activities in bed other than sleep and sex, and if you find yourself awake in bed and not sleeping, getting out of bed and going to a dimly lit area until you feel sleepy again. Repeat as many times as necessary to break the association between wakefulness in bed. Napping should be avoided as well to increase the pressure to fall asleep when the time comes for bedtime.
Sleep restriction and sleep efficiency
Sleep restriction might be implemented alongside stimulus control or separately but will rely heavily on the sleep diary data collected prior to its implementation. It involves reducing the time spent in bed to the amount of time actually sleeping. For example, if you regularly get into bed at 9pm but don’t fall asleep until 11pm, wake again for an hour at 2am and then finally wake for the day at 6am, you’re in bed for 9 hours per night but only sleeping for 6 of those hours. Sleep restriction will prescribe a 6 hour sleep window where you continue to keep the 6am wake up time but only get into bed at 12am.
This window is usually prescribed for at least a week until you’re able to achieve at least 85% sleep efficiency – meaning you can sleep through those 6 hours for at least 85% of the time. Gradually the sleep window will be expanded as the person achieves better and better sleep efficiency.
Changing unhelpful beliefs about sleep
Although the above elements of CBT-I were described as behavior interventions, they are in fact also cognitive interventions. In CBT terms, they are known as behavioral experiments that actually serve to help change thoughts or beliefs about sleep as well. Many people with insomnia have strongly held beliefs about sleep based on a lot of frustrating nights of insomnia, which seem to corroborate their beliefs as completely true.
Behavioral experiments can actually also help people adapt their beliefs about sleep by disproving assumptions they make about their ability to sleep or the anxious thoughts they have if they don’t fall asleep (e.g., tomorrow will be a wash). I have written before about other sleep-related thoughts that can be addressed through CBT-I.
A common example of a sleep-specific thought that changes through behavioral intervention is someone with the thought, “I’ll never be able to sleep through the night without waking.” A treatment plan for someone with this automatic thought might be to try sleep restriction and reduce their sleep window to 5 hours (or another shorter window than someone is used to sleeping). The reduction in this sleep window will allow someone to experience a night with less time for sleep interruptions and prove to themselves that they can sleep through the night after all. Just as strongly held beliefs may have emerged from sleepless nights, experiencing change in how you sleep can create new and more helpful thoughts or cognitions about sleep.
Get help for insomnia with sleep therapy in NYC
Thankfully, CBT-I is a highly effective treatment for most people who want to change their sleep habits by targeting the underlying behavioral and psychological factors that influence sleep. There are many great resources that have been developed to help the general public sleep better, but these can often be frustrating for someone who is experiencing insomnia for which sleep hygiene tips are not going to change the overall sleep experience. Insomnia can be isolating for many people who feel utterly alone in their struggle overnight when no one else is there to comfort them. You don’t have to struggle through this alone!
A CBT-I therapist can help to put your sleep on a different path that gives you more rest and a different perspective on your sleep health. It is also effective for people who are taking sleep medications and either want to taper off of them or reduce their use. Whatever the difficulty, our sleep disorder psychologists in NYC are here to help. If you think you may be suffering from insomnia, we encourage you to reach out for support and book a free consultation.
About the Author: Dr. McGlinchey has extensive training and experience delivering CBT-I and treating a wide range of sleep disorders successfully. She has been doing research on sleep across the lifespan for over 20 years and enjoys continuously learning more about sleep and how to help others sleep.