Understanding Cognitive Behavioral Therapy for Insomnia and How it Can Help Your Sleep

What Is Cognitive Behavioral Therapy for Insomnia?

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a structured, evidence-based therapy designed to help people overcome insomnia. Unlike sleeping pills, it focuses on changing the habits, thoughts, and emotions that cause or worsen insomnia. It combines cognitive therapy, which addresses negative beliefs about sleep, with behavioral techniques that improve sleep quality. CBT-I is a brief therapy and typically involves 6-8 sessions. The goal is to teach skills that promote natural, healthy sleep patterns, helping you quickly self-correct if sleep gets messy in the future.

How Does CBT-I Work?

CBT-I targets the cycle of insomnia by addressing three key areas:

• Cognitive factors: Many people with insomnia develop worries or anxiety about sleep, such as "I won't be able to fall asleep" or "If I don’t sleep well, I won’t function tomorrow." These thoughts increase anxiety, making it harder to fall and stay asleep.

• Behavioral factors: Poor sleep habits, like irregular bedtimes, excessive time in bed, or napping during the day, can worsen insomnia.

• Physiological factors: Stress and hyperarousal can keep the body and mind alert when they should be winding down. For some, hormonal factors can be at play, and if this is the case, referrals to medical providers are needed.

  
  

CBT-I uses specific techniques to break this cycle:

• Sleep Restriction

  • This limits the time spent in bed to the actual amount of sleep a person is currently getting. For example, if someone sleeps only 6 hours but spends 8 hours in bed, they are encouraged to stay in bed for 6 hours initially. This increases sleep drive and improves sleep efficiency. Gradually, the time in bed is increased as sleep improves.

• Stimulus Control

  • Stimulus control helps re-associate the bed and bedroom with sleep rather than wakefulness or frustration. Key rules include:

    • Going to bed only when sleepy. We are talking about that involuntary eye-closing sleepy feeling at the beginning of treatment.

    • Using the bed only for sleep and intimacy. No phones, no television, no books, etc.

    • Getting out of bed if unable to sleep within 15-20 minutes.

    • Waking up at the same time every day, no matter what. Yes, this includes the weekend. And yes, I know this really sucks. Please remember this is a brief therapy, and some of these recommendations can loosen over time as sleep improves, but maintaining at least a semi-consistent sleep schedule is recommended for the long haul.

      
      

• Cognitive Therapy as Needed

  • This involves identifying and challenging unhelpful thoughts about sleep. This can reduce anxiety and pressure around sleep. The goal with challenging unhelpful thoughts is not to replace them with positive thinking that you don't believe. This isn't very helpful. The goal is to replace them with neutral or factual thoughts that you understand are true and actually believe. Trying to tell yourself you will feel totally fine and do awesome with only 2 hours of sleep is not likely to feel true and is honestly a waste of your time.

• Relaxation Techniques as Needed

  • Relaxation exercises such as deep breathing, progressive muscle relaxation, or other breathing exercises can help reduce physical and mental tension that interfere with falling asleep.

Benefits of CBT-I Compared to Medication

CBT-I offers several advantages over sleeping pills:

• Long-term effectiveness: CBT-I changes habits and thoughts, providing longer-lasting relief even after therapy ends. You will know what to do if you ever have an episode of insomnia again and can get your sleep back on track before it becomes a bigger problem.

• No side effects: Unlike medications, CBT-I does not cause dependency, tolerance, or daytime drowsiness.

• Improves overall sleep quality: It addresses some of the underlying causes of insomnia, leading to better sleep patterns.

• Can be combined with other treatments: CBT-I complements lifestyle changes and medical care. It can also be completed in conjunction with other mental health therapies, though it isn't recommended to do sleep restriction at the same time you are doing exposure-type therapies for PTSD.

  
  

Research On Cognitive Behavioral Therapy:

• Cognitive Behavioral Therapy has around 25 years of research supporting its efficacy (Anderson, 2017).

• Research has shown that around 70-80% of people who complete CBT-I experience significant improvement in sleep quality and duration, and 40-60% maintain this over time (Anderson, 2017).

Who Can Benefit from CBT-I?

CBT-I works well for adults and some adolescents with chronic insomnia, including those with:

• Difficulty falling asleep

• Frequent nighttime awakenings

• Early morning awakenings

• Sleep problems related to stress, anxiety, or depression

  
  

It is also effective for older adults and people with certain medical conditions who want to avoid or reduce medication use.

What to Expect During CBT-I Sessions

A typical course of CBT-I includes:

• Assessment: We will review sleep history, patterns, and factors contributing to insomnia.

• Sleep diary: Patients track their sleep times, quality, and habits for 1-2 weeks.

• Education: Learning about sleep cycles, factors affecting sleep, and how behaviors influence insomnia.

• Setting goals and Time in Bed Schedules: Defining realistic sleep goals and expectations.

• Implementing techniques: Applying sleep restriction, stimulus control, cognitive restructuring, and relaxation.

• Monitoring progress: Adjusting strategies based on sleep diary and feedback.

  
  

Patients are encouraged to practice skills daily and discuss challenges with their therapist.

Practical Tips to Support CBT-I

To boost the effectiveness of CBT-I, consider these tips:

• Keep a consistent sleep schedule, even on weekends.

• Create a relaxing buffer zone prior to bedtime, such as reading or listening to calm music an hour before you go to bed.

• Avoid caffeine, nicotine, and heavy meals close to bedtime.

• Limit screen time before sleep to reduce blue light exposure.

• Make your bedroom comfortable: cool, dark, and quiet.

• Use the bed only for sleep and intimacy to strengthen the sleep association.

• Be patient: improvements may take time.

  
  

These tips are from sleep hygiene recommendations. Please note, sleep hygiene is NECESSARY but not SUFFICIENT to change your sleep if you have clinically significant insomnia. Meaning you need to have good sleep hygiene in place, but if you have clinically significant insomnia, it is not likely to be enough to change your sleep. CBT-I would be helpful in these cases.

When to Seek Professional Help

If insomnia lasts longer than three months, affects daily functioning, or causes significant distress, professional help is recommended. If you experience symptoms like loud snoring, gasping for air during sleep, consistent morning headaches, or excessive daytime sleepiness, consult a Sleep Medicine doctor to rule out other sleep disorders.

We offer CBT-Insomnia as an individual therapy via telehealth at Momentum Psychological Health. Please contact us today if this therapy could be of benefit to you. Call us at 406-813-0961, fill out the get started form online, or send an email to info@momentumpsychologicalhealth.com.

References:

Anderson, K.N. (2017). Insomnia and cognitive behavioral therapy—how to assess your patient and why it should be a standard part of care. Journal of Thoracic Disease, 10(Suppl 1), 94-102.

Mitchell, M.D., Gehrman, P., Perlis, M, Umscheid, C.A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Family Practice, 13(40).