Is CBT-I Right for You?

Source: Theodoris Katis, 1088652-unsplash

In a recent comment to my earlier post, a person suffering from chronic insomnia relates a negative experience with CBT-I and dismay at being repeatedly referred for CBT-I by different health care providers. It is certainly true that CBT-I may not befit every patient. In my practice, I encounter a wide range of reactions, from “this makes no sense at all” to “this is the best thing I’ve done for myself,” with the majority falling somewhere in the middle. This situation is not unique for insomnia. Using the commenter’s analogy, some cancer patients may decline the recommended treatment out of concern with side effects and instead turn to alternatives that presently may have little empirical support. Working in the field of sleep disorders, I occasionally meet patients with severe sleep apnea who opt out of the gold-standard, albeit somewhat cumbersome, CPAP therapy and elect to try treatments that may be only partially effective. What constitutes a "gold-standard" recommendation is informed by statistical analyses of large groups of people, while it is the prerogative of each individual to choose from available options. And when it comes to insomnia, a variety of options and opinions can be identified from a brief internet search.

Let us consider, however, a couple of things that may need to go into the decision-making process regarding CBT-I as a potential therapeutic option for you, assuming you are looking for one. I’d like to start with a brief historical example unrelated to sleep. A brilliant poet and thinker, Goethe, disagreed with Newton’s color theory. He performed a light-through-prism experiment designed by Newton, but inadvertently varied some of the conditions and obtained a different result lending support to Goethe’s own theory of colors. Now physicists know that Newton was correct, but visual artists continue to study and make use of Goethe’s theory. This example underscores two relevant points: first, the exactness of methodology is a cornerstone of the scientific approach, and second, intention and context count for a great deal in a person’s decision making.

To start with the latter, the intention and the context are typically different between the CBT-I therapist and the client at the onset of therapy. Usually, the client’s intention is to go home after the session and get a good night’s sleep, in the context of expecting another dreadful day tomorrow if sleep–again–does not come. The therapist’s intention, on the other hand, is to establish a pattern which over time will help ensure that the average amount and continuity of sleep fall within normal limits, usually in the context of the client’s long-lasting struggle. Thus, to impart on the client the long-term vision of CBT-I is an important task of the therapist if the client is to consider CBT-I as a viable option.

The exactness of methodology, although seemingly self-explanatory, is not so easy to reach in CBT-I practice. If you ever tried to cook a dish following a friend’s recipe in earnest, you know just what I mean. The cooking process has to be slightly adjusted to achieve the same result, because of the different oven, etc. Similarly, behavioral recommendations need to be fine-tuned based on the client’s specific circumstances. For example, the stimulus control therapy (2011), a component of CBT-I, requires the client to get up and go to another room if sleep does not occur quickly. However, in a place like NYC, many people live in studio apartments with no additional rooms to go to. This does not mean they cannot utilize CBT-I, but rather that the specific methodology has to be adjusted to fit each client's individual circumstances. This issue appears obvious once explicitly stated, but many similar tacit assumptions work their way into the wording of recommendations and may result in misapplied methods, at least initially. Identifying and rectifying such sources of miscommunication is a task that may prove frustrating, contributing to the premature decision to quit.

As a last remark, sometimes another, unrecognized or uncontrolled condition may impact sleep, undermining CBT-I efforts. For instance, a circadian rhythm dysfunction, such as delayed sleep phase syndrome, often presents as insomnia, because of the inability to sleep at the desired or prescribed time. Standard CBT-I techniques, although still helpful to a degree, do not address the circadian pattern, and additional methods have to be used.

This is a brief and by no means exhaustive list of obstacles on the path of successful CBT-I. Notwithstanding, this therapy remains the best evidence-based approach presently available (2016). The next empirically supported therapy is a short-term use of a hypnotic medication. Currently, no medication is recommended as a long-term solution for insomnia, which fact bears weight on the prescribing physician’s licensure integrity. Proposed benefits of numerous other approaches may be supported by some studies (e.g., 2017a), but refuted by others (e.g., 2017b). While a provider makes recommendations considering available evidence, the decision as to what type of therapy to pursue ultimately lies with the client.