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Insomnia, the most common sleeping disorder, makes it difficult to get to sleep or stay asleep. The most effective and long lasting treatment isn’t medication or melatonin (though people use them most frequently) – it is an approach called Cognitive Behavioural Therapy for Insomnia (CBTi) CBTi has over 100 ‘gold standard’ randomized controlled trials supporting its use in the treatment of chronic insomnia.

Numerous research studies have demonstrated the effectiveness of CBTI in improving sleep quality, reducing insomnia symptoms, and enhancing overall quality of life. It gives people longer and deeper sleep than people on Zopiclone. CBTi is also more effective long term compared to medication. Meta-analyses and systematic reviews have consistently found CBTI to be a highly effective treatment for insomnia, providing both significant improvement in people’s sleep – and long lasting improvements in that sleep. 

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 (and also nearly every other major medical and sleep association in the world!)

Benefits of CBTI

CBTI can lead to

  • Improved sleep quality and duration (better, longer sleep!)
  • Reduced reliance on sleep medications (helping you get off those sleep meds)
  • Enhanced daytime functioning and reduced daytime sleepiness (who doesn’t want to feel better in the day?)
  • Reduced sleep anxiety and worrying about sleep (which is sometimes worse than the sleep problem itself!)

Who Can Use CBTI Type Approaches?

CBTI might be suitable for you, even if :

  • You have chronic insomnia, even if related to physical and mental health conditions (some exceptions apply)
  • You have chronic pain, including fibromyalgia (best with a therapist, and not on a DIY basis)
  • You are experiencing work stress, relationship problems, grief and other life situations 
  • You are an older adults, as CBTI has been found to be particularly effective in this population

So what is Cognitive behavioural therapy for insomnia?

Sleep hygiene tips and tricks are great for people who are generally good sleepers and need to tidy up around the edges – these approaches do NOT work on their own once someone has insomnia.

CBTI is a structured, short-term psychological intervention thattreats the underlying causes of ongoing sleeplessness by addressing the ‘persisting’ drivers of the overall sleeping problem and the behaviours that we adopt that erode our sleep drive and get in the way of solid refreshing blocks of sleep. 

 

How Does CBTI Work?

CBTI addresses the root causes of insomnia through a combination of techniques, both behavioural and psychological.

Stimulus Control

Stimulus control therapy is an approach which aims to change our ‘association’ with the bed. Before we have insomnia, we just sleep in our bed and don’t really think about it. It is a place strongly associated with sleep in our mind and body.  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 can help you re-associate your bed with sleeping, taking you from ‘nowhere to sleep’ to ‘this is where I sleep’.  This may or may not involve doing things in bed or getting out of bed – depending on the person and their situation. I am not an advocate of a blanket rule on how to do this, as the usual ‘guidance’ online about this can create more problems for some people. 

 

Time in Bed Restriction

This strategy helps re-associate your bed with sleep by limiting the time you stay in bed – as well as helping to compress your sleep into a solid block, making your sleep deeper and more refreshing.  This also helps reset your circadian rythm.

Sometimes this is called ‘sleep restriction’ but I do not like this term because it does not actually restrict your sleep – it adjusts how much time you are in bed to just a bit more than you are already sleeping (subject to some limitations for low levels of sleep or certain populations of people).  It is not restricting sleep, but it is more about reducing time in bed that you were awake already.  When I ask a group of 50 people if they’d rather have 6 hours of solid, deep sleep or 8 hours of choppy broken sleep, they opt for the former – and this is exactly the starting goal!

It isn’t an approach everyone needs and is not appropriate for everyone. It also has many modifications and can be done in both ‘hard and fast’ and ‘slow and gentle’ ways. I prefer the latter because it helps set people up for success better, in my experience.  

Once a person is sleeping more soundly in that block of time, and the relationship between bed and sleep is a solid one, slow expansion of the time in bed happens next, until a person is sleeping enough to meet their own personal sleep need.

 

The mental side

A lot of people stop there – but the solution to long lasting recovery from insomnia is deeper.  Life will throw us curveballs with our sleep, and we need to eventually lose the fear of not sleeping – the sleep anxiety is often more problematic than the insomnia itself!

 

Cognitive Restructuring

Cognitive restructuring is a process which can help you identify and examine unhelpful beliefs around sleep which perpetuate the sleeping problem. You then learn to gently and compassionately replace them with more constructive and more accurate thoughts.

Addressing the psychological factors and thoughts that may contribute to insomnia, such as rumination, catastrophizing, and unrealistic expectations about sleep can have a profound impact on your quality of life – and your sleep.

 

Relaxation Techniques

Relaxation techniques are very popular and there are as many ways to relax as there are people.  Too often ‘relaxation tips and tricks’ are pulled out at bedtime, along with a healthy serving of sleep anxiety.  Have you ever decided to try a new technique thinking ‘wow this better work?’ That’s a recipe for not sleeping. These techniques can be practiced during the day or as part of a bedtime routine, but paying attention to the ‘intent’ and ‘pressure’ behind these activities is important. 

 Often this gets left out by those attempting CBTi on their own, or they read a list of ‘techniques’ and strategy and only use them when it’s most challenging – when they can’t sleep. This then becomes a ‘sleep effort’ and makes sleep even harder because of some ‘performance anxiety’ and pressure around ‘needing to make sleep happen’. This only makes sleep worse.

Relaxation training and challenging irrational thinking about sleep is a skill that needs practice and it can’t just happen in the middle of the night.

 

Mindfulness

Mindfulness helps us find equanimity with our situation in a way that brings us a bit more peace with it.  It helps us drop the ‘suffering’ part of a situation, and this can reduce that psychological arousal aspect of insomnia.  Imagine dropping the sleep anxiety.  That is totally possible. 

There are a wide variety of ways to practice mindfulness skills – some formal and some that fit neatly into your day, and the recommendation would depend on what is more likely to be successful for you.

Why CBT-I and not Pills?

Sleeping medications are supposed to be used short term for sleeplessness, 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. Maybe this is what brought you here.

The people who don’t continue to have insomnia are often people who developed ways of ‘not thinking about sleep’, either conciously or unconciously. 

The evidence shows that after stopping CBTI or sleeping pills, those who were doing CBTI are more likely to be sleeping well than those who were only on sleeping pills, specifically because the mental and behavioural skills they learn are longlasting.

Cognitive behavioural therapy for insomnia is not for everyone, though. Some people should only use these approaches under supervision for their own safey.

The main reason people haven’t heard of CBTI is because there are not enough practitioners! I practice a gentle form of CBTi (as opposed to a ‘strict’ and rigid one), blended with other evidence based approaches such as ACTI with my clients and would be happy to help you overcome your insomnia.

 

The information contained above is provided for information purposes only. The contents of this post are not intended to amount to advice and you should not rely on any of the contents of this post. Professional advice should be obtained before taking or refraining from taking any action as a result of the contents of this post. Tracy Hannigan disclaims all liability and responsibility arising from any reliance placed on any of the contents of this post.