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Medically Reviewed by Colleen Ehrnstom, Ph.D., ABPP
Cognitive Behavioral Therapy (CBT) is arguably the best way to address insomnia because it does not use medicines and can, if done right and the patient sticks with it, lead to long-lasting elimination of insomnia. The therapy does not work for everyone, and time with a specialist can be expensive and time-consuming, but for many who have tried it CBT has made a tremendous impact in providing lasting relief.
Proper CBT is structured and participants are given homework – things they have to work on before the next meeting with their therapists. Patients are usually encouraged to keep a sleep diary.
CBT is a training method for your mind. In day-to-day life, when things happen to you, your mind generates a response whether it be happiness, frustration, or anger. These responses can affect the ability to fall and stay asleep. Your mind has habits, regular patterns, and paths it wants to take. Your brain will take the usual path unless you know how to mitigate it. CBT teaches you how to do this and makes it easier to override this process. Small defects in sleep quality or duration can sometimes spiral to a long-term problem and CBT-I can help nip the problem in the bud.
CBT (CBT-I) addresses a person’s behavior through providing effective tools to address thoughts and behaviors that promote healthy sleep. Whether poor sleep beliefs develop organically or through incorrect information, detrimental ideas about sleep can promote and perpetuate insomnia. For instance, some people may believe that if they go to bed earlier, they have a better chance of getting more sleep. In actuality, however, the opposite is true as going to bed earlier often decreases the chance of falling to sleep. This is because the body’s circadian rhythm, or daily bio-rhythm, has a window of time that is optimal for sleep onset and trying to fall asleep outside of this window only creates frustration and anxiety further worsening insomnia. Another example is that many people may hold a belief that they need at least 8 hours of sleep to feel rested. While the majority of us need about 7-8 hours of sleep every night, the range is from 4 hours to 10 hours. If a person whose body requires only 5 hours of sleep continues to try and obtain 8 hours, he or she there can experience unnecessary stress and fragmented sleep associated with this perceived sleep loss.
Usually, patients attend several sessions (from 4 to 12) lasting about 30 minutes with a qualified sleep professional. Most commonly this is a psychologist with special interest in insomnia, but nurse practitioners, physicians, psychiatrists, and others that direct patient care can also provide CBT. In the process, misconceptions and misinformation about sleep in general are eliminated, and better sleep hygiene habits are developed.
Some long-term insomniacs have deep mistaken beliefs or emotions revolving around sleep. Therapists use conversation and coaching to correct these mental blocks. Therapists also attempt to set realistic expectations for how much sleep and the quality of sleep the patient should expect.
When a person goes through CBT-I, the practitioner first collects information about the patient’s sleep history and norms and educates him/her on factual aspects about sleep in general. Problems and bad habits are brought to light and corrected through discussion and examples. At each subsequent session, these areas are again discussed to reinforce adherence to the newly learned concepts.
Preferences will be reflective of a person’s symptoms, but CBT for insomnia may include behavioral tools such as:
As well as cognitive tools such as:
CBT-I works. Like other therapies, effectiveness varies from person to person but there are tools to optimize the model.
Studies have shown CBT can on average shorten sleep latency (the time it takes to fall asleep) by 30 to 45 minutes and increase total sleep time 30 to 60 minutes. A recent meta-study found CBT is “at least as effective for treating insomnia when compared with sleep medications, and its effects may be more durable than medications.” The evidence is not all that strong. Even though it is not a panacea, the combination of cognitive and behavioral tools can still help a lot of people. The study authors classified it as “low-to-medium quality” evidence, meaning CBT works as well or slightly better, on average, than medicines across all people who participated in the random trials considered.
Previous studies had shown CBT is better than other medical interventions for insomnia, as measured by changes in sleep-onset latency and the percentage of patients who could be classified as normal sleepers following treatment. An argument against CBT and in favor of pharmacology might be: CBT takes too long and for acute insomnia, the drug will be better. A meta-analysis published in the American Journal of Psychiatry found that “behavior therapy and pharmacotherapy produce similar short-term treatment outcomes” for insomnia. CBT-I can be done in conjunction with sleep meds in most cases. This can be helpful if you want to reduce or eliminate the use of medications.
CBT has also been found to be particularly effective in dealing with sleep disturbances associated with post-traumatic stress disorder.
The downside of CBT is the expense and time requirements the patient needs to spend with the therapist. The doctor and patient need to consider the trade-offs and insurance coverage. But the proven effectiveness of CBT and competitiveness with drug therapy are reasons to give it a shot. Online platforms and self-guided books have become a cost-effective option to learn and practice CBT.
Relaxation training includes meditation with instruction on abdominal breathing, repetitive focus (like a mantra), and paced respirations. Guided imagery and autogenic training have been used. Biofeedback and hypnosis can be employed if the practitioner is proficient in these techniques. Muscle relaxation techniques such as those employed by physical therapists can also be used.
If insomnia is a product of hyperarousal (rather than too little propensity to sleep), and this is certainly the case for some percentage of the population, then relaxation should help. People who demonstrate signs of stress or tension during the day should be good candidates for relaxation.
This is a bit of reverse psychology the insomniac can play on himself. The person lies in bed and practices good sleep hygiene but tries to remain awake. This can help the sleeper get around a mental block to drifting off to sleep.
Pain causes insomnia and sleeplessness can increase the subjective level of pain. Additionally, pain can make it challenging to get comfortable enough to get to the deeper stages (stages 3-4) of sleep. A recent study has found CBT is particularly effective in alleviating insomnia in those with chronic pain. The improvements in sleep duration persisted six months after therapy even when the pain continued.
Some CBT regimens incorporate sleeping pills, but only to get the patient started sleeping. Eventually, as the insomniac learns sleeping skills, he or she is weaned off the medicine. Psychologists who practice this type of therapy tend to focus not so much on insomnia as waking life. You might hear the term “stimulus control”; with respect to CBT this means telling patients to go to bed when sleepy, and getting out of bed when they are not sleeping.
There is some debate among CBT practitioners as to whether hypnotic medications should be used at all by their patients. A recent study showed that CBT helps patients whether or not they use sleep aid pills. This suggests that a good strategy for ending insomnia may be for the doctor to give the patient a sleeping pill along with the CBT and for the two to work together to taper medication levels over time. A mild sleep aid like melatonin or ramelteon sometimes is the best option.
It also depends on whether the patient has other conditions that may require medications. Scientific studies set up to compare CBT with medicine tend to exclude people with depression, apnea, and recent use of hypnotic medicines. There may be other factors that the doctor has to keep in mind when advising on an insomnia treatment.
Insomnia becomes more common with age as as our routines change, we have less external anchors for our wake and sleep cycles. In addition, some people have an in-born tendency to be “hyper-alert”, and have greater difficulty sleeping regardless of age. These people are more likely to develop insomnia. Even in some insomniacs who do require supplemental medication for sleep, CBT can provide the best template upon which these can be effective. CBT has been shown in controlled studies to be effective. Cognitive Behavioral Therapy also can identify concurrent problems with depression, anxiety, and other physical problems that may need separate attention through other measures. If other conditions do exist, these will need to be addressed concurrently. In this regard, CBT offers the most comprehensive approach to date for addressing insomnia long term by providing a foundation of knowledge and direction for behavior that enables the insomniac to maintain good quality sleep. Indeed, practitioners sometimes CBT to alleviate insomnia with the ulterior goal of treating depression.
A meta study (study of other studies) published in the journal Sleep found that behavioral techniques have been effective in alleviating insomnia in patients who do not use drugs, and in facilitating tapering off of drug use in long-term hypnotic users. Of course the studies considered were ones that had professionals applying CBT in controlled situations.
Researchers at the University of Pittsburgh and the Cleveland Clinic recently found good results from using a shorter form of CBT: brief behavioral therapy intervention (BBTI) for addressing insomnia in older people. This program consisted of only two in-person sessions and two phone sessions. They found the people who underwent this therapy had success in 67% of cases versus 25% in the control group. They also have found it be effective for younger people as well.
The National Center for Biotechnology Information has more on BBTI.
But, you might ask, if CBT is just a matter of learning the facts and adopting the correct practices, why do I have to pay a therapist for it? Why can’t I just read the facts in a book or on the internet and starting changing my behavior? You can, of course, and that’s partly why websites like Tuck exist – to get the word out about sleep myths and best practices. Many people need another person involved for coaching and to hold them accountable – which is why CBT services exist.
Behavioral therapy is used in many areas of life – think of Pavlov who conditioned dogs to expect food when they heard a bell. You can use it to make your life better.
A pilot program at the University of Virginia to test internet-based CBT found good results. Maybe in the future the Internet or other forms of delivery will be widely used to deliver CBT for insomnia An internet-based system called Sleepio has been introduced which uses CBT principles to coach people to get better sleep.
Check out the new developments in cognitive behavioral therapy as the first-line treatment of insomnia.