Cognitive Behavioural Therapy for Insomnia (CBT-I)

Insomnia is, unfortunately, an all too common sleep disorder that makes it difficult to fall asleep, stay asleep or causes problems with waking too early. People can also have difficulty getting back to sleep once they wake up. Insomnia can contribute to low energy levels, decreased productivity at work and more melancholic moods. All in all, insomnia can have a significant impact on people’s quality of life.

Everyone needs different amounts of sleep, ranging from 7 to 9 hours, depending on the person. Some people are naturally inclined to get less sleep than that – so-called ‘short sleepers’ – and that is not a problem if they have no daytime functioning problems. But when someone is getting less sleep than they need to function well on a consistent basis, insomnia could be the culprit.

Cognitive behavioural therapy for insomnia has emerged as a promising treatment for chronic insomnia ⁽¹⁾ and is part of many nation’s gold standard treatment approaches for chronic insomnia. Cognitive behavioural therapy, also known as CBT-I is an effective treatment for chronic sleep problems and is the recommended first choice of treatment. ⁽²⁾ Cognitive behavioural therapy is a structured program, with modifications available to the individual. It works by helping identify and replace thoughts and behaviours that cause or worsen sleeping trouble. CBT-I is designed to help you overcome the underlying causes of your sleep problems, which can persist even if someone is taking sleeping pills.  Read on to find out more about CBT for insomnia and how it works.

How does CBT for insomnia work?

Cognitive behavioural therapy for insomnia focuses on recognising and changing the thoughts and behaviours that perpetuate insomnia. This type of therapy helps people learn to manage the thoughts that create ‘hyperarousal’, which is the key problem for people with insomnia.

Depending on the needs of the client, a sleep therapist will recommend different CBT-I techniques. Many therapists will also use mindfulness and acceptance, and commitment therapy approaches in addition to the behavioural parts of CBT-I, which includes cognitive therapy, time in bed restriction and stimulus control. ⁽³⁾

• Time in bed restriction – lying in bed while you are awake can lead to poor sleep because your body and mind will start to associate bed with being awake. Cognitive behavioural therapy coaches you to reduce the time you spend in bed to eliminate this. In the beginning, this causes partial sleep deprivation and makes you more tired the next night, helping you fall asleep faster. The focus of this approach is to gradually increase your time in bed, once your sleep has become higher quality and ‘consolidated’.

• Stimulus control therapy helps by improving the sleep/bed relationship and retraining the mind and body to sleep only when in bed. This can include getting out of bed when one is not sleeping, and going back to bed when sleepy enough to fall back to sleep.

• Paradoxical intention is a strategy that helps people let go of ‘trying to sleep’, which, paradoxically, makes sleep much harder. Worrying that you cannot fall asleep can keep you awake.

• Relaxation training can help you calm your mind and body. There are as many relaxation approaches as there are preferences, including imagery, visualisation, meditation and others.

• Sleep hygiene is insufficient on its own to help with insomnia but is an essential adjunct to the CBT-I approach. It helps with lifestyle habit change that can influence sleep, such as caffeine late in the day, excessive alcohol use, not getting sufficient exercise and helping wind down at night before bedtime.

Does CBT for insomnia really work?

There is a solid evidence base for CBT-I that spans 30 years. Previous studies have shown that CBT-I helps improve quality of sleep, time to fall asleep, and the number of nighttime awakenings. For example, according to one meta-analysis on the treatment effectiveness of cognitive behavioural therapy, non-pharmacological interventions showed robust improvement in sleep patterns and sleep quality of patients, including nighttime breaks in sleep in people with chronic insomnia⁽²⁾. CBT-I also improves the quality of sleep in older adults⁽³⁾.

Sleep medications can be effective for short term sleep, but they do not fix insomnia as they can’t address the underlying issues that cause it. Cognitive behavioural therapy for insomnia is a good treatment choice for patients with long-term sleep problems because it addresses those issues, particularly hyperarousal. This makes CBT-I a good choice, particularly those who are worried about dependence on sleeping medications or if they have side effects as a result of taking them. CBT-I has been shown to be more effective and longer-lasting in its effects than medication alone.⁽⁴⁾ This is because CBT-I teaches a person sleep management skills they can use their entire life.

Some parts of CBT-I are not safe for everyone, so always seek the assessment and screening of a qualified provider. Don’t make changes to your healthcare without consulting your physician.