Let Me Sleep On It: CBT for Insomnia

The February, 2016 edition of Consumer Reports recommends CBT as an alternative to medication for chronic insomnia (see https://www.consumerreports.org/cro/magazine/2012/08/how-did-you-sleep-last-night/index.htm for some of what they say about insomnia). CBT for insomnia (CBT-I) combines “standard” CBT with cognitive and behavioral interventions specifically focused on insomnia. There is a substantial body of research supporting the effectiveness of CBT-I and CBT-I has some significant advantages over medication for chronic insomnia (see https://www.consumerreports.org/drugs/the-problem-with-sleeping-pills).

As with other problems, we’d start with a good evaluation (including attention to medical issues that might interfere with sleep, the client’s evening routine including “screen-time,” and caffeine, alcohol, and drug use), establish a collaborative relationship, and negotiate mutually acceptable goals for therapy. We’d then focus on specific problem situations (i.e. times when the client has difficulty falling asleep or getting back to sleep) one at a time and developing an understanding of the situation, what led up to it, the thoughts and feelings the client experienced before having difficulty falling asleep, and the thoughts and feelings they experienced once they realized that they weren’t falling asleep. This should provide enough information for us to be able to develop an individualized conceptualization and treatment plan.

A number of interventions can be helpful with insomnia such as relaxation training, consistent bedtimes and wake-up times, regular exercise, quitting smoking, cutting back on caffeine and alcohol, keeping the bedroom quiet and dark, and not watching TV or using computers in bed.

Commonly used Cognitive Interventions include: (1) Restructuring catastrophic thoughts and beliefs about the consequences of lack of sleep, (2) Addressing sleep-related or sleep-interfering worry using the interventions we recommend for Generalized Anxiety Disorder, (3) Shifting attention away from fears of not sleeping to neutral or relaxing topics, and (4) Correcting misperceptions of sleep time. (People, especially insomniacs, overestimate the time spent awake and underestimate time spent sleeping).

Commonly used Behavioral Interventions – often referred to as “sleep hygiene” and “sleep restriction” – include: (1) Go to bed only at night and only when sleepy, (2) Use the bed only for sleep and sex, (3) If you are unable to fall asleep or return to sleep within 15 – 20 minutes, get up, go to another room, do something calm and relaxing, and return to bed only when sleepy, (4) Get up at the same time each morning regardless of how much you have slept, and (5) If sleep time is less than 85% of the time spent in bed, the time in bed is reduced (with a minimum of 5 hours in bed). If sleep time is greater than 85% of time spent in bed, time spent in bed is increased gradually until the desired amount of sleep time is reached.

For a case example of CBT-I that emphasizes behavioral interventions see https://sleepfoundation.org/sleep-news/cognitive-behavioral-therapy-insomnia. Note: until recently CBT-I tended to emphasize behavioral interventions. More recently there has been more emphasis on the importance of addressing worry and dysfunctional thoughts and beliefs.

For a recent comparison of behavioral interventions, cognitive interventions, and a combined approach as treatments for insomnia see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4185428/ (Note: The authors of this study have one thing wrong. Beck’s Cognitive Therapy includes behavioral interventions as an integral component. When they say “Cognitive Therapy” what they actually mean is “cognitive interventions.” Beck’s Cognitive Therapy actually is what they refer to as “CBT.”)