What is CBTI?
Cognitive behavioral therapy (CBT) was created in the 1960's and includes methods for modifying thoughts and behaviors. It is used for a wide variety of issues, such as coping with a loss of a loved one, phobias, eating disorders, or anxiety.
Cognitive Behavioral Therapy for Insomnia (CBTI or CBT-I) is considered the gold standard for treating insomnia:
- A systematic review of several studies concluded that CBTI is effective when compared with medications, the effects may be more durable than medications, and that primary care providers should consider CBTI as a first option for treating insomnia.
- The Mayo Clinic has stated that CBTI is an effective treatment for chronic sleep problems and is usually recommended as the first treatment.
- The American College of Physicians strongly recommends that adult patients with insomnia receive CBTI as the initial treatment.
- The American Journal of Lifestyle Medicine says that it produces results that are equivalent to sleep medication, with no side effects, fewer chances of relapse, and a likelihood of sleep improving after the treatment has finished. It's a comprehensive program and is the gold standard for getting rid of insomnia.
The 5 Components of CBTI
CBTI has 5 components:
- Cognitive restructuring
- Stimulus control
- Sleep hygiene
- Relaxation training
- Sleep restriction
Cognitive restructuring involves changing the way you think about things in your life so that they no longer cause you stress. It's very common for insomniacs to develop sleep anxiety, where the thought of sleep creates anxiety that they won't be able to sleep that upcoming night, which then in turn prevents sleep.
One method for breaking the cycle of poor sleep causing sleep anxiety, and this anxiety causing poor sleep, is to counteract anxious thoughts with calmer thoughts. For example, after sleeping poorly, feeling tired and frustrated, you could say, "Even people who normally sleep well, occasionally sleep badly. Because I'm tired, I'll sleep better tonight."
Insomniacs often associate their bed with stress, because they spend many hours in bed frustrated that they're not sleeping. And it's common that insomniacs are sending emails from bed, reading social media, and doing other things that are causing stress and preventing sleep. The only activities to be done in bed are sleep and sex. And if you can't sleep, get out of bed to do something relaxing, and return to bed once you're tired.
What you do during the day can hurt your sleep. Here are the most important sleep hygiene guidelines:
- Go to bed and wake up at the same time every day (including weekends).
- Limit screen time an hour or two before bed.
- Get regular exercise, and ideally not within a few hours of going to bed.
- Use your bed only for sleep and sex.
- Expose yourself to sunlight in the morning and afternoon if possible.
- Don't eat too much at night, and limit your intake of caffeine, alcohol, and marijuana, especially in the later part of the day.
- Have a regular routine or sleep ritual before you go to bed, signaling your brain that it's time for bed. And make sure the time leading up to sleep isn't spent with stressful thoughts and feelings.
- Limit naps to no more than 25 minutes, and not later than 3 pm.
There are many techniques that can help ease you into a relaxed state so you can sleep quickly and deeply. It's recommended that you incorporate some of these techniques into your nightly pre-sleep routine:
- Take a warm bath or shower: Not only is this relaxing for most people, but when you get out of the water your temperature drops, which is a cue for your body to produce melatonin, the sleep hormone.
- Meditation: Using a seated technique that helps you relax will slow your thoughts, calm your emotions, and lower your blood pressure, putting you into a state that will make it easier for you to fall asleep and stay asleep. You can also use a moving meditation, such as yoga or tai chi, as long as the movements aren't raising your heart rate, which will prevent sleep.
- Deep breathing: Taking slow, deep breaths has many of the same benefits as meditation.
- Progressive Muscular Relaxation (PMR): Tensing and relaxing different muscle groups to relax the body and mind. PMR often includes a visualization component as well as a breathing technique.
- Reading fiction: There's anecdotal evidence that reading before bed helps induce sleep. There's not yet enough research to conclude that this practice is helpful, but it's possible that reading fiction helps you get into a state similar to a dreaming state, and this is a good reason why you shouldn't read non-fiction before bed. Reading non-fiction, such as a self-help book, may be over stimulating as you're excited about your goals. Although there are some non-fiction themes that may work for you. One sleep coach who herself suffers from insomnia reads archaeological books, which she finds mildly interesting, but not enough to be stimulating.
- Biofeedback: A process that has you control your breathing, heart rate, and other bodily processes in order to reduce stress. A biofeedback therapist connects electrical sensors to you to measure heart rate, breathing, muscular tension, sweat gland activity, brain waves (EEG), and body temperature. Then they teach you different methods to reduce your stress through breathing techniques, visualizations, and meditation. There are some biofeedback devices for your home, and are generally considered safe, or you may do biofeedback in a hospital, physical therapy clinic, or medical center.
Sleep Restriction or Sleep Consolidation
Sleep restriction was developed by Dr. Arthur Spielman, a neurologist and sleep specialist from New York who helped pioneer non-pharmacological treatment for insomnia. Some sleep experts consider sleep restriction a misnomer as this technique doesn't restrict sleep, it restricts the time in bed that isn't spent sleeping. As the time in bed not sleeping can cause anger, frustration, and sadness, this technique removes any stressful associations with sleep, making it easier to sleep. The technique conditions the sleeper to develop the habit of falling asleep quickly, staying asleep throughout the night (though there may be bathroom breaks that occur at the end of a sleep cycle when it's natural to be more awake), and waking up well-rested. For this reason some sleep experts prefer the term sleep consolidation, as it gets rid of the fragmentation of sleep patterns.
The longer we're awake, the more pressure there is for sleep, known as homeostatic sleep drive. While we sleep, the pressure decreases, and begins to build back up once we wake up. Other circumstances that may cause an increased sleep drive are mentally exhausting experiences (such as learning a new language, or intensely focusing on any task for an extended period) and physically demanding exercise (such as hot yoga), which may cause deeper or longer sleep on the days that we engage in demanding activities. This may be why older adults are more likely to struggle with sleep maintenance insomnia: their sleep pressure is decreased by frequent napping, and they are less likely to engage in mentally and physically demanding activities.
Sleep restriction is the process of causing the sleep drive to increase, which encourages you to sleep more deeply with fewer interruptions. The brain will adapt to several days of spending less time in bed by getting as much rest from the limited period allowed for sleep. Once the habit of sleeping more deeply has been established, you can start increasing the amount of time asleep in order to sleep between 7 and 9 hours per night.
The goal of this process is to increase sleep efficiency, which is the time you spend in bed divided by the number of hours slept. If you only sleep on average 4 hours, but you spend 8 hours in bed, your sleep efficiency is 50%. A good sleep efficiency percentage depends on who you ask, but 85% is generally considered good, and above 90% is ideal.
This technique also puts you in alignment with your circadian rhythm, which is the body's natural sleep and wake cycle.
Sufferers of sleep maintenance insomnia tend to not sleep deeply and don't benefit from all stages of sleep. Dr. Michael Breus refers to this type of sleepers as dolphins, as dolphins sleep with part of their brains awake and another part asleep. Humans with a dolphin chronotype tend to be highly intelligent, high-strung, wake up easily and often due to light and noise, and don't feel well-rested. According to the National Institute of Health's Center for Biotechnology Information, humans cycle through 2 stages of sleep: rapid eye movement (REM), and non-rapid eye movement (NREM). NREM has 3 stages (N1-N3). A typical night's sleep has 4 to 5 sleep cycles and the order is N1, N2, N3, N2, REM, with each stage lasting 90 to 110 minutes. The first REM period is short, and NREM is long, and throughout the night REM gets longer and NREM gets shorter.
The technique has several steps and requires modifications based on the sleeper's sleep patterns. For this reason it's best done under the guidance of a qualified sleep therapist or coach. The steps are as follows:
- Record your sleep: What time you went to bed, approximately how long it took you to fall asleep, how many times you woke up during the night, when you got out of bed, and how long you spent in bed awake. You can use a sleep diary, mobile sleep tracking app, or wearable device that tracks your sleep (but make sure that your device is accurate - there are several devices that don't track sleep well).
- Determine your average hours of sleep per night: Using the data from step 1, determine how much time you actually sleep, not time in bed.
- Set your sleep and wake time: As most people have to wake up in the morning for work or school, use that time as your wake time and minus the average hours of sleep per night from step 2 from your wake time. If you wake up at 6 am, and you only slept 6 hours, your bedtime is 12 am.
- Stick to this schedule for 2 weeks, as closely as possible.
- If sleep efficiency is above 85%, add 15 minutes per night once a week to your sleep: Once you're sleeping well, not interrupted by longer periods staying awake, you can move your sleep time 15 minutes earlier once per week. If your sleep time was 12 am, you can move it to 11:45 pm. If you can maintain healthy sleep for a week on this schedule, move your sleep time to 11:30 pm. Repeat this step until you're not feeling tired during the day, and you're still sleeping uninterrupted, and waking up refreshed. If sleep efficiency is below 80%, then the time in bed will be further restricted.
Can You Nap During the Sleep Restriction Process?
Your sleep therapist or coach will determine if this is a good idea. Some people have been able to take a nap of 25 minutes or less once a day before 3 pm and have still been successful with the sleep restriction process, though others advise against it. But keep in mind that napping is risky as you may be reducing your sleep drive. If you started the sleep restriction process, took a nap, and found that it's taking you longer than 15 minutes to fall asleep at night, you'll want to skip the nap.
Tips for Sleep Restriction
- Stick to a good sleep hygiene plan. Breaking the rules of sleep may prevent this process from working as well.
- Schedule your mornings to include sunlight and your days to include physically and mentally focused activities.
- Stanford Medicine recommends not using less than 5.5 hours for sleep time.
Can Doing Just One Component of CBTI Fix Insomnia?
According to the USU Center for Deployment Psychology, if someone has one source for their insomnia (such as a partner's snoring), you only have to address that problem. But most people with sleep problems, especially chronic insomnia, have multiple contributing factors. So for most insomniacs, it's best to do every component of CBTI.
According to Dan Ford, Certified CBT-I Clinician and Clinical Director at the Better Sleep Clinic, the most common perpetuating causes of insomnia are patients trying too hard to sleep resulting in extending their time in bed to try to get more sleep which reduces sleep pressure, and lying in bed awake trying to force their body to sleep, which triggers the stress system.
Dr. Paul DePompo, founder of the Cognitive Behavioral Therapy Institute of Southern California, explains that the most common issues with their patient's insomnia are bad sleep hygiene (e.g., too much time in bed and sleeping in too long), coupled with an anxious demand that they must sleep to be able to be healthy and perform the next day. The most helpful aspect is the focus on accepting if they do not get the sleep they desire. It is that demand for sleep that sets up a negative cycle fueling the insomnia.
Can CBTI Help for Patients With Other Disorders Such as Depression or Anxiety?
Yes, you can improve your sleep even if it's caused by another condition, which is called secondary insomnia. If your insomnia isn't caused by another condition, it's primary insomnia. According to the Sleep Research Project at the University of Memphis, treating secondary insomnia is often necessary, and it often improves the primary condition.
Is There Anyone Who Shouldn't Use CBTI?
Is CBTI Difficult?
Because most insomniacs need to make more than one change in order to improve their sleep, some find making a lot of changes overwhelming and hard to do consistently. Dr. Steve Orma, a psychologist who suffered from insomnia, put himself through CBTI and described the process as difficult. He had already used CBT to effectively treat his anxiety, and he's a licensed therapist, which made it easier for him to stick with the program. The average person who isn't a licensed therapist is much more likely to follow through with the guidance of an experienced professional, or a highly-rated sleep app.
The good news is that as living with insomnia is already difficult, so many insomniacs are already motivated. And the program doesn't require perfection to work. It may take some time to change, but most people notice improvements in the first 3 weeks.
Some insomniacs are reluctant to start because they have the impression that sleep restriction means that they will be sleeping even less during the program. For example, if you only sleep 6 hours per night, and your sleep restriction plan only allows you to sleep for 6.5 hours per night, and you know that you're supposed to get 7-9 hours, it sounds counterproductive. But the reality is that you're only sleeping 6 hours anyway, and the extra time you spend in bed is counterproductive as you're probably spending that time stressed, developing a negative association with your bed and sleep.
How Long Does it Take to See Results?
What to Do if CBTI Doesn't Work
We asked Dan Ford about the next steps if CBTI isn't working. He explains "It really depends on what we see as getting in the way of progress. We would revisit the original assessment and make sure medications and co-occurring diagnoses are revisited. Many SSRIs (Selective serotonin reuptake inhibitors such as Zoloft) and SNRIs (serotonin and norepinephrine reuptake inhibitors such as Symbalta) shorten sleep and increase wakefulness, so these may need to be addressed."
"If it's poorly managed anxiety, depression, or trauma, then EMDR (eye movement desensitization and reprocessing) might be suggested to address that. We'd see this as an alternative to the "cognitive" components of CBTI."
"Is there undiagnosed obstructive sleep apnea? Potentially send the client for a full sleep study to confirm no other factors are present, and future management with sleep medications may also be an option. There is a subset of male "objectively short sleepers" that are known not to respond as well to CBTI and so these individuals may need hypertension management and sleep medication."
Where You Can Get CBTI
You can follow a more traditional route and see a licensed psychologist or psychiatrist who is experienced in working with patients with insomnia. You can verify credentials for the American Board of Sleep Medicine via their listing site, and search for sleep centers at the American Academy of Sleep Medicine. This will probably be the most reliable, but most costly.
Another option is a certified sleep coach. There's a large range of cost and quality, so it's best to do a lot of research if you're considering this option.
The newest option, which is growing in popularity, is mobile sleep apps. The higher quality apps will help you track your sleep, educate you on sleep hygiene, make suggestions based on your feedback, and have a sleep coach that will answer questions as well as help guide you. These are cheaper than the above options. I used the Sleep Reset for three and a half months; you can read about my experience on my Sleep Reset review.
Dr. Po-Chang Hsu believes that CBTI apps have their, but can't replace a therapist: "CBTI apps can be a great auxiliary tool, helping people with insomnia self-regulate and adopt better sleep habits. However, I believe that an app cannot substitute for a therapist. Only a professional can pick the strategies that would work for each patient."
The last option is to study CTBI and guide yourself through the program. This is free but requires a lot of time to get educated and isn't recommended.
How to Find a CBTI Therapist
- Association for Contextual Behavioral Science (ACBS) for searches within and outside of the United States.
- Association for Behavioral and Cognitive Therapies (ABCT) for searches within the United States.