Cognitive Behavioral Therapy for Insomnia (CBT-I) is an evidence-based treatment that focuses on changing thoughts and behaviors that cause difficulties. CBT-I for sleep addresses the underlying issues contributing to insomnia. Here’s an overview of CBT for insomnia and the components typically involved.
Please feel free to contact me or set up a free consultation to discuss whether CBT-I for sleep difficulties might be helpful for you or a loved one. We can also discuss how other therapeutic techniques could be mixed in if you have other goals.
Key Components of CBT-I for Sleep
The following are the basic tenets of cognitive behavioral therapy for insomnia:
CBTI for Sleep Education
We will start by discussing slumber cycles and what constitutes good sleep hygiene. This includes learning about biological processes such as circadian rhythms and pressure. This education prepares you for setting goals. What outcome do you want from cognitive behavioral therapy for insomnia? We’ll break this up into measurable steps so you can track your progress and stay motivated to improve.
We’ll also discuss things more generally, including creating an environment conducive to slumber (e.g., dark, quiet, and cool bedroom), avoiding caffeine, alcohol, and heavy meals before bedtime, and establishing a routine.
Cognitive Therapy
Next, we will dive into the CBT portion of treatment. This revolves around identifying and challenging negative thoughts and beliefs. You’ll develop a more positive mindset about sleep capabilities and address anxiety related to insomnia. Along with the cognitive portion, you’ll also learn progressive muscle relaxation, deep breathing exercises, and meditation to reduce physical and mental tension.
Behavioral Therapy
The next step is working to associate the bed and bedroom with slumber rather than wakefulness and to reduce the daytime-related anxiety that stays with you when you go to bed. Homework may include going to bed only when sleepy, getting out of bed if unable to doze, and maintaining a consistent wake-up time. You’ll limit the time spent in bed to the actual time spent sleeping to build a sleep drive, gradually increasing time in bed as efficiency improves.
Effectiveness of CBT for Insomnia
Research has shown that CBT-I for sleep is highly effective for many individuals with chronic insomnia. It often significantly improves the quality and duration of sleep and overall daytime functioning. It can also reduce the need for medications.
Cognitive Behavioral Therapy for Insomnia Example
Cognitive Behavioral Therapy for Insomnia (CBT-I) is a structured, evidence-based program, and Casey, a 28-year-old medical student, pursued it because of this. This fictional example shows how a CBT-I for sleep program might be structured.
CBT-I for Sleep Assessment Phase
I start with a comprehensive interview to assess Casey’s history, current nighttime habits, and potential contributing factors to her insomnia. I ask questions about whether other family members have experienced the same issues and whether any other psychological challenges exist in her family. We cover all aspects of her life, including work, social, and hobbies, looking for possible sources of stress and contentment.
As part of the assessment, I asked Casey to track her sleep patterns for the next week with a very specific journal that covers quality, daytime sleepiness, and other related factors. She also uses an app that tracks the quality of her slumber and aspects that she may not be aware of.
CBT-I for Sleep Psychoeducation
In our next session, I educate Casey about practices that promote good rest, such as maintaining a regular schedule, creating a comfortable environment, and avoiding caffeine and electronics before bed. We go over the basics of circadian rhythm and the importance of rest. Then, we go over CBT-I and what it will entail, including the types of homework she will be asked to do. Cognitive behavioral therapy for insomnia is a perfect choice for Casey, given how smart, insightful, and organized she is.
CBT for Insomnia Behavioral Interventions
We learn from her journaling that Casey is having the most difficulty falling asleep, and then she wakes up once or twice and has trouble relaxing when this happens. We talk about some behavioral interventions that are typically used in CBT for insomnia, including:
- Stimulus Control: Strengthen the bed-rest connection by only using the bed for sleep, going to bed only when tired, and getting out of bed if unable to fall back after 20 minutes, even if it is late at night.
- Restriction: Limit the time spent in bed to match the amount of sleep one gets, gradually increasing it as efficiency improves. Specifically, she will change her bedtime to a little later and watch TV in another room until she feels tired.
- Relaxation Techniques: I teach Casey relaxation exercises like progressive muscle relaxation, deep breathing, or guided imagery to induce greater restfulness.
CBT for Insomnia Cognitive Interventions
In addition to the behavioral interventions, there are cognitive techniques that are used with CBT for insomnia, including
- Cognitive Restructuring: We work to identify and challenge Casey’s unhelpful thoughts and beliefs (e.g., “I must get 8 hours of sleep to function”) and replace them with more realistic and positive ones (e.g., “I can do fine with less sleep as long as it is restful.”)
- Paradoxical Intention: We reduce the pressure of bedtime by encouraging her to stay awake and avoid trying too hard to sleep. The homework after session two is to stay up a full hour later than usual and continue to journal to see what effects that produces.
CBT for Sleep Difficulties and Hygiene
Along with the specific CBT-I techniques above, Casey will more generally work to improve her nighttime routine, including:
- Maintaining a consistent sleep schedule (any changes we make, she’ll do for at least a week or two).
- Create a restful bedtime environment using apps to promote rest and relaxation.
- Limiting exposure to screens and bright lights before bed.
- Avoiding caffeine and heavy meals close to bedtime. She realizes, for example, that she should not have desserts containing chocolate after dinner.
- She incorporates regular physical activity into her day but not too close to bedtime.
CBT-I for Sleep Sessions
Here is how the example above is broken down into sessions.
Session 1: Initial Assessment and Sleep Education
- Objective: Gather information and educate.
- Activities:
- Review her sleep diary and questionnaires.
- Discuss her sleep history and current issues as far back as childhood.
- Explore her family history of insomnia, anxiety, and stress management concerns.
- Discuss other stressors now and in her recent history
- Educate her about sleep hygiene and the basics of rest
Session 2: Introduction to Behavioral Techniques
- Objective: Implement stimulus control and rest restriction.
- Activities:
- Introduce stimulus control instructions.
- Develop a sleep restriction schedule based on the diary.
- Teach relaxation, mindfulness techniques, and simple meditations.
Session 3: Cognitive Techniques
- Objective: Address unhelpful thoughts and beliefs about sleep.
- Activities:
- Introduce cognitive restructuring – how it works and what will be involved.
- Practice identifying and challenging unhelpful thoughts.
- Continue to monitor her sleep diary and adjust behavioral techniques as needed.
Session 4: Review and Adjust
- Objective: Evaluate progress and make necessary adjustments.
- Activities:
- Review her progress with her diary and questionnaires.
- Adjust the restriction schedule if necessary, but not more often than weekly.
- Reinforce cognitive and behavioral techniques, what is working, and what could work better.
- Introduce paradoxical intention if needed.
Session 5: Maintenance Strategies
- Objective: Plan for long-term maintenance of good sleep habits.
- Activities:
- Discuss strategies for preventing relapse based on the triggers she’s learned.
- Create a plan for maintaining sleep improvements.
- Schedule follow-up sessions if needed – she decides to continue to come in every two weeks until she feels that she has made all the gains she set out to make.
This structure provides a comprehensive approach to CBT-I for sleep, focusing on the behavioral and cognitive aspects of her diffciulties.
CBT-I for Sleep in My Practice
The following are the steps involved in CBT-I for sleep difficulties and what to expect with each:
- Assessment: This is the initial evaluation of your patterns, habits, and potential causes of insomnia. We’ll trace this back as far as you’ve had these challenges.
- Goal Setting: We will establish specific, measurable goals for improvement. This will help you see your progress and stay motivated throughout treatment.
- Intervention: Next, we will implement CBT-I techniques for insomnia. Usually, this means meeting weekly for 4-6 weeks before potentially moving to an every-other-week model. You will keep a diary between sessions to track progress and identify patterns.
- Adjustment: We will modify CBT for insomnia techniques based on your response to treatment.
- Maintenance: When you have seen satisfactory improvement, we’ll develop a long-term plan to sustain your improvements. This may include coming in for booster sessions as necessary.
Cognitive Behavioral Therapy for Insomnia Possibilities
I offer several possibilities for clients to receive CBTI for sleep:
- Individual Therapy: One-on-one sessions are the most frequent type of cognitive behavioral therapy for insomnia. These sessions are easy to deliver virtually, so I serve most states in the US.
- Couples Therapy: CBTI for sleep challenges can be delivered to couples if both people are experiencing insomnia or one person is experiencing issues and the other person wants to help.
- Family Therapy: Similar to couples therapy, CBT-I for sleep can work in family treatment to help one or more members while others provide support.
- Integrated Therapy: CBT for insomnia can be one part of a more comprehensive treatment plan. Many people who receive cognitive behavioral therapy for insomnia also want to address other challenges and barriers.
CBT-I for Sleep Referrals
I would happily set up a free consultation if you’re considering CBT-I for sleep problems. We can discuss whether cognitive behavioral therapy for insomnia suits your situation. If not, we can discuss whether another clinical technique may work, or I can refer you to outside providers with other specialties.
