Cognitive Behavioural Therapy for Insomnia

Insomnia, the most common sleeping disorder, makes it difficult to get to sleep or stay asleep. The leading insomnia treatment is called Cognitive Behavioural Therapy for Insomnia (CBTi) CBTi has over 100 ‘gold standard’ randomized controlled trials supporting its use in chronic insomnia. 

Sleeping pills help with sleep – CBTi helps people to conquer the real reasons for their sleeping issues. Pills help people get to sleep in the short term, but CBTI treats the underlying causes of persistent sleeplessness by addressing the thinking and behaviours that are causing it in the first place.

So what is CBTi?

CBTi is a collection of techniques that change the behaviours and thinking associated with insomnia. There are always two major components to the therapy – Stimulus Control and Time in Bed Restriction.

Stimulus Control

Stimulus control works to change our ‘association’ with the bed. When we lose sleep night after night but remain in bed while we are awake, we disrupt our natural psychological and physiological relationship with our bed. We come to associate our bed with being awake – and often to our thoughts, fears, and anxieties about losing sleep. Stimulus control is a set of strategies that help people re-associate their bed with sleeping. They go from ‘nowhere to sleep’ to ‘this is where I sleep’ they help reset that relationship.

Bed Restriction

Time in bed restriction is in part a kind of stimulus control. It requires waking at the same time of the day and ensuring that you are only in bed for the same amount of time that you are sleeping. Accurate diaries are important for me to plan your personal strategy for bed restriction. This strategy helps re-associate your bed with sleep by limiting the time you stay in bed – and it also helps reset your circadian rythm.

It sounds harsh to ‘restrict time in bed’ for people who aren’t sleeping, but look at it this way: the therapist is allowing you the same time you were sleeping already, just no more! It’s a hard part of the strategy, but it is really critical. You can go from very choppy sleep to short, but solid sleep. When you’re sleeping consistently for that time, and depending on your needs, we slowly increase the time.

Another key component to CBTi is learning to manage feelings and thoughts around sleep. This is done through cognitive therapy and relaxation training. Often this gets left out by those attempting CBTi on their own, or they read a strategy and only use it when it’s most challenging – when they can’t sleep. Relaxation training and challenging irrational thinking about sleep is a skill that needs practice so that it can be used effectively when it’s needed. 

Why CBT-I and not Pills?

Sleeping medications can be a successful short term treatment for sleep problems, but they aren’t treating insomnia. Many people can take sleeping pills and still have insomnia – which shows itself again when they come off the sleeping pills. The people who don’t continue to have insomnia are often people who developed ways of ‘not thinking about sleep’. They come to not worry about sleep and they didn’t become worried about stopping or develop ‘just in case’ measures for sleeping. This reduction of sleep effort is a key component of CBTi strategies. It is critical to recovering from insomnia even if you are on sleeping pills.

CBTi is not for everyone though. People with an increased risk of falling, risk of fragility fracture, need for total vigilance in their work, other sleep disorders (particularly sleep apnoea, parasomnias), people with unmanaged anxiety, phobias, or mood disorders, and people who are undergoing certain other therapies, such as exposure treatments for phobias and PTSD.  

Effectiveness of CBTI

Cognitive-Behavioral Treatment for Insomnia gives people longer and deeper sleep than people on Zopiclone. CBTi is also more effective long term. The evidence is robust, reliable and long term, including with a varied group of patient populations. These groups include people with chronic pain, fibromyalgia and other conditions. It is effective in over 80% of people for whom it is suited, making it the British Medical Association’s top recommendation for treatment of chronic insomnia.

The main reason people haven’t heard of CBTI is because there are not enough practitioners! I practice CBTi with my clients and would be happy to help you overcome your insomnia.