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When I discuss cognitive behavioral therapy for insomnia (CBTi) with patients, naturally their first question is “What is that?” My first response and the most important thing I can tell them is that CBTi has been deemed as a first-line treatment by the American College of Physicians due to clinical trials consistently showing it to be an effective treatment for insomnia. So what is it?
Typically the CBTi treatment starts with the patient meeting with a provider who is specifically trained in CBTi (usually a licensed psychologist). An initial intake is performed with the patient to understand what the specific insomnia problem is, as it could be difficulty getting to sleep, difficulty staying asleep, and/or waking too early and unable to get back to sleep, and understanding how the patient is impacted by the sleep disruption (i.e., is work or school performance affected, are personal relationships suffering, etc). During the intake session, the patient will receive a paper sleep log or be asked to track their sleep using similar means, which could include an electronic app on their mobile device, to bring to the next session. The information from the intake session along with the sleep log data are designed to tailor the specific recommendations discussed below.
Sleep restriction
The first recommended component is sleep restriction, also termed sleep consolidation, because this process consolidates sleep rather than restricts sleep. Sleep restriction involves assessing how much time the individual is spending in bed versus how much of that time they are sleeping. This is an estimate based on the data from the completed sleep log. The weekly average is assessed from the sleep log, because there can be daily variation. Sleep restriction is a process of limiting time spent in bed closer to the average time slept. For example, if an individual is in bed an average of 8 hours, but they are only sleeping 6 hours on average, then sleep restriction involves shortening that time spent in bed closer to the 6 hours. This works to metaphorically prime the sleep pump to get more consolidated sleep, and then part of the process is expanding the sleep window to find the individual’s optimal window of time in bed. So, for the individual who was in bed for 8 hours and then shortened down to 6 hours for a week or two, they may eventually start to expand the window based on how the sleep log numbers look and how they feel during the day. It is a systematic process that takes patience and time. Usually the time in bed window is opened back up slowly over time (week by week), so that the individual does not lose the benefits they have gained. This is a process that needs guidance, as there are exceptions to implementation to take into consideration, such as someone with bipolar disorder or seizure disorder, or someone who is excessively sleepy during the day. It is worth noting that when sleep restriction is used in the clinical setting, rarely if ever is someone restricted to under 5 hours of time spent in bed, even if they are reporting on their sleep log that they are getting less than 5 hours of sleep per day on average. The above information provides a high-level explanation of the process, keeping in mind that there are individualized factors that go into the actual implementation.
Stimulus control guidelines
There is another implementation which is part of the behavioral aspect of CBTi called stimulus control. The spirit of this recommendation is to reassociate the bed with sleep rather than it being paired with tossing and turning, frustration about not sleeping, and sleeplessness. The stimulus control recommendations include: (1) going to bed only when sleepy, (2) using the bed for sleep and sexual activity only, (3) leaving the bed if unable to fall asleep or if awake for a period of time in the middle of the night or early morning, (4) getting back into bed when sleepy, and (5) keeping a fixed wake time. These are all intended to help the bed to become a reassociated or strong cue (stimulus) for sleep.
Cognitive therapy
The "C" in CBTi refers to cognitive therapy, which helps to reframe or challenge thoughts and beliefs that may be maintaining the insomnia. A vicious cycle can include an active mind, worrying, and faulty attributions around sleep that increase the level of distress, which leads to continued sleep disturbance. Decreasing sleep-related anxiety can be accomplished by challenging any dysfunctional thoughts associated with sleep. Thoughts are malleable and can be reshaped into more adaptive and realistic alternatives to help decrease the emotional distress around sleep.
Sleep hygiene
It is important to keep in mind that sleep hygiene recommendations are rarely effective for treating chronic insomnia. They are good to assess in the intake session to ensure they are not contributing factors in the overall picture. Sleep hygiene recommendations include ensuring decreased light in the bedroom when going to sleep, making sure the bedroom is at a comfortable temperature, avoiding heavy meals, exercise, alcohol, and nicotine close to bedtime, limiting caffeine in the afternoon, and avoiding naps.
Relaxation techniques
Additionally, relaxation techniques are beneficial in creating a sense of relaxation and helping the individual to be in a more restful state. There is evidence to support that relaxation techniques are helpful with getting to sleep. These practices need to be incorporated during the day at a time when the individual is not stressed in order to effectively learn how to use them and become proficient. The caveat to learning these techniques is not to use them to “get to sleep,” as trying to sleep activates a fight or flight response and can backfire and become frustrating. Different relaxation techniques include progressive muscle relaxation, tensing and relaxing different muscle groups, deep breathing, and visualization of a relaxing scene or experience. Biofeedback is another technique to learn in modifying physiology as it involves looking at muscle tension, heart rate, respiratory rate, and skin temperature and modifying it in real time to see what changes lead to the best relaxing outcome.
CBTi is a combination of behavioral changes, cognitive changes, and relaxation techniques to set the sleep system up for success in promoting good sleep. CBTi can be done working with a trained provider in person or by tele-health (practitioners are able to see patients via tele-health in states where they are licensed), through self-application, online CBTi formats, or self-application through bibliotherapy (using a book format).
References
Spielman AJ YC, Glovinsky PB. (2011). Sleep Restriction Therapy. In Behavioral Treatments for Sleep Disorders. Oxford, UK: Elsevier.
Bootzin RR, editor.(1972). Stimulus control treatment for insomnia. 80th Annual American Psychological Association.
Bootzin RR ED, Wood JM. (1991). Stimulus control instructions. In: P H, editor. Case studies in Insomnia. New York: Plenum; p.19-28.
Morin CM EC. (2004). nsomnia: A clinical guide to assessment and treatment. New York: Springer.
Lichstein KL, Riedel BW, Wilson NM, Lester KW, Aguillard RN. (2001). Relaxation and sleep compression for late-life insomnia: a placebo-controlled trial. J Consult Clin Psychol; 69(2):227-39.
