by Dr. Silberstein
Cognitive-behavioral therapy for insomnia, or CBT-I, is a brief, effective, and proven treatment of insomnia. It focuses solely on sleep difficulties and the steps to take now to solve them.
CBT-I offers a long-lasting alternative to sleep medications. Sleep meds seem like a great solution in the short-term – you take a pill and fall asleep. However, not everybody can or wants to use sleep meds due to their side effects, possibility of becoming dependent, and other reasons. The effects of CBT-I are long-lasting because the factors that maintain the insomnia are addressed, not just the symptoms. Recently (July 1, 2016), the American College of Physicians (ACP) has recommended cognitive-behavioral therapy for insomnia (CBT-I) as first-line therapy for chronic insomnia.
Like most therapies, CBT-I begins with a thorough evaluation. Your therapist would want to confirm the diagnosis before starting treatment. The assessment will not only cover the current nature of your sleep and sleep difficulties, but will also include other areas of your life, including psychological, biological, social, and occupational aspects. You may be asked about your job and work hours, stressors you might be facing, past or current emotional difficulties, who you live with, your medical history, etc.
After completing the evaluation, your therapist will create a treatment plan tailored specifically to you, based on your unique sleep difficulties, lifestyle, and work schedule. The treatment plan typically consists of several of the following components:
Matching your time in bed with the time you actually sleep.
Most individuals with insomnia spend a lot of time in bed, but sleep for only a portion of that time. With your unique sleep needs and sleep behaviors in mind, your therapist may instruct you to spend less time in bed. The goal is not to sleep fewer hours, but to decrease the time you are in bed yet fully awake.
Making sure you use your bed for its intended purpose, and only that purpose.
A lot of people with insomnia use their bed in creative ways. In addition to sleeping (when they can), they eat, read, watch TV, read work emails, play on their phones, and sometimes just hang out in their beds. This makes the bed associated with activities other than sleep. The goal of treatment is to eliminate associations that are not conducive to sleep while strengthening the association between one’s bed and sleep. Taking into consideration any health concerns and other variables, your therapist will instruct you to only use the bed for sleep (and sex, too).
Improving your sleep hygiene.
Sleep hygiene refers to various habits and practices that are needed to have a good night sleep. Your therapist will review your daytime and nighttime behaviors that are related to the wake-sleep cycle and make sure you maximize your chances of a good night sleep. Common guidelines include not consuming caffeine after a certain time, increasing daytime physical activity (but not right before bedtime), timing meals so they don’t interfere with your sleep, and making sure your bed and bedroom are as comfortable and sleep-conducive as possible.
It is important to keep in mind that CBT-I is a multi-component treatment. In addition to the components described above, other interventions are often utilized, including cognitive therapy. It is proven to work in the majority of chronic insomnia patients who adhere to the treatment plan.
Those who begin CBT-I should also know that it usually involves a commitment to 4-8 sessions (weekly or biweekly). And, while improvements can be seen fairly quickly (compared to having lived with insomnia for years), many patients find the initial 1-2 weeks of treatment challenging. The reason is that patients are instructed to avoid some compensatory habits they have adopted to cope with their insomnia, but have actually helped maintain their insomnia. For example, you may be asked to drink less coffee during the day, which – initially - could make you feel more sleepy at work (but also more sleepy at bedtime). Or, you may be instructed to postpone your bedtime, which might be extremely difficult if you have been up since early morning. Keep in mind that these strategies can feel very hard to implement in the short-term but lead to results in the long-term, if followed on a daily basis.
Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. Michael L. Perlis, Carla Jungquist, Michael T. Smith, Donn Posner, Springer (April 1, 2008).
Omrit Silberstein, PsyD, DBSM