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What is Cognitive Behavioural Therapy for Insomnia (CBT-I)?

Sleep is vital for our body and mind to function optimally during the day. Without regular restful sleep, we struggle to function, to keep up with our responsibilities, and find our mood can be markedly impacted. However, insomnia is a common sleep disorder which prevents many people from falling asleep or sleeping restfully throughout the night. If you struggle with insomnia, it’s vital it’s addressed so you can get the sleep you need.

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CBT-i basics

What is CBT-i?

CBT-i is a form of psychological therapy which helps to address the thinking patterns and behaviours which are contributing to insomnia. CBT-i teaches you to replace unhelpful thoughts and behaviours which feed into your insomnia, with positive, helpful thoughts and behaviours to help you get a restful sleep.

The American Academy of Sleep Medicine explains that CBT-i, “helps you change actions or thoughts that hurt your ability to sleep well. It helps you develop habits that promote a healthy pattern of sleep.”

Rather than just masking the problem, CBT-i helps you to get to the root causes of your insomnia and find healthy coping strategies. The strategies you learn through CBT-i can help you to tackle any future sleep problems, and enable you to continue getting the restful sleep you need.

What conditions can CBT-I treat?

CBT-i can, of course, treat insomnia, which is the most common sleep disorder. However, it can also be used to treat other sleep disorders. Additionally, it can be used to help people with physical conditions or mental illness to get a more restful sleep. It can help with all forms of insomnia, including onset insomnia (meaning trouble falling asleep at the beginning of the night) and maintenance insomnia (referring to trouble staying asleep throughout the night).

What are the benefits of CBT-I?

There are many proven benefits of CBT-i, including:

  • Helping you to get to sleep more quickly and effectively
  • Helping you to stay asleep restfully throughout the night
  • Allowing you to get the amount of sleep you need to function optimally
  • Giving you the tools you need to keep sleeping well in the future
  • Allowing you to feel more refreshed and restored during the day
  • Tackling anxiety around sleep
  • Promoting relaxation and stress reduction
  • Enabling you to introduce positive sleep habits
  • No side effects
  • Improving your mood
  • Allowing you to be more productive during the day
  • Many other benefits of having a restful sleep!

Is there proof it works?

There is a lot of proof that CBT-i works effectively in treating insomnia. Many studies have been done which have proven CBT-i is successful. The National Institutes of Health lists CBT-i as the primary treatment for insomnia. This article explains that evidence over the last 30 years has proven the effectiveness of CBT-i. They go on to state that: “The efficacy of CBTi to improve outcomes in primary and co-morbid insomnia has been repeatedly demonstrated, with improvements in both mental and physical health outcomes.”

In fact over 100 studies have proven that between 50% and 70% of patients gain long lasting results from a programme of CBT-i. All of this evidence and the proven benefits mean you can rest assured that CBT-i can help the majority of people to overcome insomnia.

CBT-i methods

Now that we know the basics of CBT-i, it’s time to look at how it actually works. There are a number of methods which are typically used as part of a CBT-i programme.

Sleep education

One of the first, and most important aspects of CBT-i, is sleep education. You’ll typically learn about the science behind sleep, why sleep is important, what happens when you don’t get the sleep you need, about sleep cycles, and more! This 2020 article on the topic explains that sleep education, “includes a review of the circadian rhythm and homeostatic sleep drive and how these normal functions impact sleep.”

This education gives you a solid basis to work from during the rest of your therapy. It also helps you to understand why it’s vital to be dedicated to the therapy programme, and how the programme will work.

Sleep hygiene education and training

As part of this education, you will also get sleep hygiene education. Sleep hygiene refers to positive habits which can help you sleep. You’ll learn all about the importance of good sleep hygiene and how it can make a significant difference to your sleep quality.

Through sleep hygiene training, you’ll learn to identify your own poor sleep habits that are interfering with your sleep and perpetuating insomnia. You’ll learn how to replace these habits with helpful sleep hygiene habits to actively tackle your insomnia. This article on the topic explains that, “This method of therapy is used to correct things you do on a regular basis that disturb your sleep. Sleep hygiene consists of basic habits and tips that help you develop a pattern of healthy sleep.”

Sleep hygiene includes changes such as:

  • A consistent sleep scheduleBy going to bed and getting up at roughly the same time each night and day, you help to regulate your body clock. Your mind will get used to going to sleep at that time of night, and with consistency you’ll begin to feel tired close to ‘bedtime’.
  • Making your bedroom comfortableIt’s important that your bedroom is used for sleep and relaxation only. It’s also vital that your bedroom is comfortable and conducive with sleep. This might include making sure your bed is comfortable; making sure your bedroom is not too hot or too cold; using dimmed lighting and blocking out external light; and so on.
  • Winding down before bedSetting aside 20 minutes to half an hour before bed each night to unwind and get your mind in a relaxed mindset for sleep can make a huge difference. This might include things like taking a bath, reading a book, or listening to calming music. It will also entail avoiding the use of electronics during your wind down time, like a smartphone or TV.
  • Reducing naps during the dayWhile short naps can be helpful, if you’re struggling with insomnia it can help to reduce or eliminate them so that you are more tired at night.
  • Watching what you eat and drinkYou’ll learn that it’s important not to go to bed hungry or too full, as this can make you uncomfortable. Eating a small, light snack before bed can be useful, and avoiding big heavy meals close to bedtime. It’s also important to avoid stimulants in the few hours before bed, such as nicotine, alcohol, and caffeine.
  • Exercise during the dayExercising can help your mind and body to be tired in a healthy way ready for bed. It can also help to regulate your mood and reduce stress. It’s also really helpful to get out in natural light during the day, to regulate your circadian rhythm (it relies on environmental cues such as sunlight to know when you should be asleep).

You might also learn what you should do if you wake up during the night to help you to get back to sleep more effectively. This might include not keeping a clock near the bed so you’re not checking the time; changing rooms if you can’t sleep for 20 minutes or more; practicing relaxation techniques; and so on.

Keeping a sleep diary

The next stage is often being asked to keep a sleep diary. You may be provided with a template or print out to follow and fill in each day. Alternatively you may simply be asked to keep note of specific things. You can also find sleep diary templates online.

A sleep diary will typically keep track of:

  • What time you went to bed and got up
  • How many hours of sleep you got
  • How many times you woke up during the night
  • Whether you felt refreshed in the morning
  • Which sleep hygiene habits you kept up with that day
  • How you felt emotionally when you went to bed

You’ll be asked to be consistent with your sleep diary and take a few moments to fill it out each day. This helps your therapist and you to identify patterns in your sleep, along with habits which may have contributed to your problems sleeping that day. The Sleep Council explains that, “The diary will help to pinpoint if you’re consistently waking at a similar time, what you’ve done that day, what you’ve eaten etc to see if there is any pattern.”

Once you’ve pinpointed specific thoughts, feelings, or behaviours which are contributing to your insomnia, it’s far easier to address them. Your therapy becomes much more effective when you can focus it on specific issues you’re having and change those patterns so you can get the restful sleep you need.

Stimulus control therapy

A stimulus refers to anything, either external or internal, which causes a response. Stimulus control therapy focuses on altering stimuli which are contributing to insomnia, and focusing on building a positive association between the bedroom and sleep.

This part of CBT-i is based on the idea that if you use your bedroom for things which stimulate you to be in an awake state, then your mind will make the association between the bedroom and being awake. Therefore, you will feel awake when you’re in your bedroom. This might include things like watching TV, doing work, or having stressful conversations in your bedroom.

Instead you’ll be taught to keep the bedroom for relaxation, sleep, and sex only. These will be strict rules you’ll be asked to implement and be consistent with. You’ll also be encouraged to only go to bed when you feel tired. If you are tossing and turning after 20 minutes, you’ll be asked to change rooms and do something relaxing, until you feel sleepy and ready to go back to bed. If you stay awake and restless in bed, it builds the association between bed and wakefulness. If you are only in bed when you feel tired, it strengthens the positive association we want between the bed and sleep.

With consistency and over time, you’ll begin to find that your mind automatically associates being in the bedroom with relaxation and sleep. Your mindset will shift when you move into the bedroom and you’ll begin to feel tired, ready for a restful sleep. The American Academy of Sleep Medicine states that: “this method helps you to fall asleep more quickly after you get into bed. You begin to have a positive response toward going to bed at night. Instead of being frustrating, it becomes relaxing and restful.”

Sleep restriction

With this method, you’ll be given strict limits as to how much time you can spend in bed. These limits will apply regardless of how long or how well you’ve slept. The first restriction you’ll be given will be the amount of hours you usually sleep restfully, even if this is only four or five hours. You’ll only be in bed for that amount of time, and will set an alarm to get you up after your time is up.

The aim of this part of the therapy is to reset your body clock. The sleep loss will at first make you feel more tired than you have been, but it’s vital to persist. After a while you will find that you’re sleeping more deeply, getting to sleep more quickly, and having a solid period of sleep.

Once you’re sleeping peacefully with that amount of time in bed, the restriction will be eased and you might be advised to add an hour. Once you’ve adjusted to that amount of time and are sleeping throughout, you’ll add another hour and so on. This continues until you reach the recommended amount of sleep for your age.

Paradoxical intention

Often when we lie in bed awake, we become stressed and anxiety builds: we might start worrying about the impact lack of sleep will have on us the next day, and begin to feel distressed. This anxiety actually makes it even harder to fall asleep. This method works to combat this.

The word paradoxical refers to something which is the opposite, or which seems contradictory to what you are trying to achieve. This method encourages you to lie in bed without doing anything to try to fall asleep. You might even be asked to try to stay awake in bed as long as possible.

The idea is to tackle the worry that comes with lying in bed awake and to normalize it in your mind. Once you’ve faced this fear, anxiety reduces and you’ll soon find that you are drifting off to sleep. You might also hear this referred to as remaining passively awake.

Cognitive restructuring

Cognitive restructuring focuses on helping you to identify negative thoughts and beliefs which might be keeping you up at night. As we mentioned, when we’re stressed at night and are having negative thoughts about sleeping, this actually contributes to the cycle of insomnia. With cognitive restructuring you’ll be taught to identify these negative thoughts and instead actively replace them with a more positive thought.

For example, if you have a negative thought like, “I should be able to get to sleep like everyone else,” you might learn to replace it with a more logical, positive thought like, “Everyone struggles to sleep sometimes, and with time I’ll be able to sleep well too”. As you begin to stop negative thoughts in their tracks, this will become a helpful habit and enable you to feel more positive in relation to sleep.

Cognitive restructuring can also involve other techniques such as setting aside ‘worry time’. This might be 10 to 15 minutes each day. During this time, usually in the early evening so it’s well before you head to bed, you can talk about or write down your worries. This gives you a set time and permission to get these worries out of your head. The idea is that the rest of the time you’ll be able to focus on relaxation. This helps to stop worries cropping up at bedtime.

Other cognitive restructuring techniques focus on distraction as a way to shift your mind away from negative thoughts. This might involve thinking about positive memories in bed to keep your mind busy. It may also entail listening to an audio book, sleep sounds, or some calming music as a way to occupy your mind while you drift off to sleep. Alternatively guided imagery might be advised. This uses audio of a calming voice guiding you through imaging a calming scene or a story to ease you into sleep.

Thought blocking

While cognitive restructuring focuses on changing negative thoughts or distracting from them, thought blocking methods focus on blocking negative thoughts from presenting themselves in the first place. This can be done in a number of ways, the first of which is articulatory suppression This method involves mouthing a short word repeatedly every three or four seconds. The word should be something short and without any emotional meaning, such as ‘the’ or ‘and’ for example.

This makes formulating any thoughts difficult, and so prevents negative thoughts. This article on thought blocking from Sleep Station explains that, “The underlying psychology is complex, but the theory is that mouthing a word requires a lot more mental power than just thinking it and the use of that mental power causes a blocking of the original intrusive thought.”

If needed, you could add to this process by imagining a shape while you mouth the word. This is often useful if you have intrusive thoughts at bedtime which involve imagery. You could also add a mental puzzle if you need to increase the challenge further, such as counting backwards in specific multiples, at the same time as mouthing your chosen word.

Imagery distraction is another way to do this, which is similar to guided imagery. You’ll focus on a memory or a scene and really engage in it vividly. The idea is that you’ll be so engaged in focusing on the details of this imagined scene, that your mind won’t be free to produce negative thoughts.

Combining CBT-i with other treatment methods

Mindfulness

Mindfulness techniques are commonly integrated into CBT-i to reduce stress and help you relax ready for sleep. Mindfulness focuses on being present in the moment, rather than worrying about the past or future. It has many benefits and is proven to help people with insomnia get to sleep more easily, as well as improving their sleep quality.

Mindfulness techniques used in CBT-i are guided, meaning you’ll be guided through the process by a therapist or a recorded audio. Types of mindfulness used in CBT-i include:

  • Guided meditationMeditation involves sitting or lying down in a comfortable position, with your eyes closed or relaxed. You’ll be guided into a deeply relaxed, meditative state. You’ll feel tension leaving your body and feel at peace. If your mind wanders, you’ll be encouraged to acknowledge your thoughts and let them drift past you. You’ll then be guided to bring your focus back to the present.
  • Guided visualizationYou may also hear this referred to as guided imagery. This involves being guided into a relaxed state and being asked to visualise a very calming scene. You’ll be asked to engage all of your senses to make the scene more vivid. You might even be guided through imagining falling into a deep sleep. As we mentioned earlier, guided visualization is often used as a distraction technique as part of the cognitive restructuring method of CBT-i.
  • Breathing exercisesBreathing exercises involve focusing on your breathing to keep you grounded in the present, and to promote relaxation. They can come in various forms. You may be asked to take a deep breath, hold it for a few moments, and then release it slowly. This deep breathing helps to slow your heart and respiratory rate, helping you to relax.
  • Progressive muscle relaxation (PMR)PMR involves being guided through tensing and then relaxing each individual muscle group throughout your body. As you do so, muscle tension leaves your body and you are able to reach a state of deep relaxation.

The aim of teaching these relaxation exercises through CBT-i, is to give you the tools you need to continue practicing mindfulness in the long term in your own time. These exercises can be done at any time of the day, and still improve sleep. Alternatively they can be done in bed at night to actually help you drift off to sleep.

Biofeedback

Biofeedback is another treatment which is often integrated into CBT-i. The treatment involves learning to be aware of your physiological processes, particularly those involved in stress. This awareness then allows you to learn how to control and calm these processes, to reduce stress and improve sleep.

This is done by using monitors to actively show you the changes in your physiological processes in reaction to stress. You’ll then see them change or slow down in reaction to you learning to calm them. Cleveland Clinic explains that, “Using a computer, special software, and sensors placed on the body, stress levels are recorded and the patient can learn to control normally involuntary processes such as heart rate, blood pressure, and muscle tension that increase under stress.”

When biofeedback methods are focused on tackling insomnia, you may also learn to become aware of and have influence over your brainwaves, as well as other processes. This is known as neurofeedback. It’s done through small sticky sensors on your scalp, connected to a computer. It’s completely pain free and non-invasive.This can be pivotal in helping you sleep restfully, as brainwaves slow as we reach deeper stages of sleep.

Hypnotherapy

Hypnotherapy is not commonly used during CBT-i as with our two relaxation methods, but it can sometimes be used so it’s important to mention it. Hypnotherapy involves sitting in a comfortable position with your eyes closed: you’ll be guided into a very deep state of relaxation, often known as a hypnotic state.

In this state you are more open to suggestion. This can be useful in changing thought patterns and behaviours which may be contributing to insomnia. This relaxed state can also be really useful in actually helping you to drift off to sleep and releasing stress. Don’t worry, unlike the hypnosis shown in shows and on TV, real hypnosis can not make you do anything you don’t want to do. You’re always in control and can wake up at any time you like. The relaxed state simply helps you to be more open to suggestion and change.

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Relapse prevention

Relapse prevention is the last, but vital stage, of CBT-i. This entails ensuring you can use the tools you’ve learnt through therapy in the long term, to prevent you slipping back into unhealthy sleep habits which could lead to insomnia. This stage of the therapy recaps what you’ve learnt and ensures you are prepared to move forward, feeling equipped to handle any bumps in the road.

You’ll be taught that if you have a few sleepless nights, instead of panicking or reverting back to unhelpful coping strategies, you use the techniques you’ve learnt. For example, you would check you’re sticking to good sleep hygiene habits. You would start utilizing relaxation techniques, using stimulus control, and sleep restriction if necessary. These skills will get you back on track and prevent your insomnia from continuing.

This article from the National Sleep Foundation explains that relapse prevention is vital and states that: “The patient needs to be reminded that lots of things may trigger a bout of insomnia and the main things one can do to protect against a new onset episode of chronic insomnia.”

Where to access CBT-i

Now that we know how useful CBT-i can be and how it works, we’ll take a look at how and where you can access this useful therapy.

Through your doctor

If you are struggling with insomnia, you could go to see your GP. They may be able to refer to a sleep clinic or to a therapist for CBT-i. This might involve being on a waiting list, or needing to advocate for yourself depending on where you live. Again depending on your location, some local health services may allow you to self-refer for therapy.

Privately

Another option would be access therapy privately. You can find a private sleep specialist through a search online to see what’s available in your area. This can be a costly option, but allows you to get therapy when you want it without having to wait. This gives you more control and can be a good option if your resources allow.

Online

Another option is using an online insomnia treatment programme, or an app. This is often more cost effective than private in person therapy, but still allows you to have that control. You can access therapy when you want it, and even in your own home. You can even use recorded relaxation sessions to help you fall asleep at night.

These choices give you the freedom to figure out which option will work best for your preferences, lifestyle, and budget. If you’re struggling with insomnia, ensure you do seek help: before you know it, you can be sleeping peacefully once again!

References

American Academy of Sleep Medicine, (2020), “Cognitive Behavioral Therapy”.

The Insomnia Clinic, (2020), “Cognitive Behavioral Therapy”.

National Heart, Blood, and Lungs Institute, (2020), “Insomnia”. National Institutes of Health.

Sleep Station, (2020), “Insomnia treatments – the evidence for CBTi”.

Brandon Peters, MD, (2020), “How Cognitive Behavioral Therapy for Insomnia (CBTI) Works”. Very Well Health.

Lawrence Robinson, Melinda Smith, M.A., Robert Segal, M.A., Jeanne Segal, Ph.D, (2019), “Therapy for Sleep Disorders”. Help Guide.

The Sleep Council, (2020), “Sleep Diary”.

Dr. Raminder Mulla, (2020), “Can’t sleep? Overthinking? How thought blocking can help.” Sleep Station.

The National Sleep Foundation, (2020), “How Meditation Can Treat Insomnia”.

Cleveland Clinic, (2020), “Biofeedback for Sleep Disorders.”

The National Sleep Foundation, (2020), “Cognitive Behavioral Therapy for Insomnia”.

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