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Does Cbti Really Work for Insomnia?

Around one-third of the adult population is estimated to have insomnia or sleep problems at any time. About 10% will meet diagnostic criteria for insomnia disorder. Over 3/4 of them will have insomnia up to a year later. Half will still be suffering at the three-year mark.  Obviously, effective treatment can improve the health and wellbeing of a vast number of people. 

And, because you are reading this – it may help improve your quality of life, too.

Cognitive behavioural therapy for insomnia (CBT-I) is a behavioural medicine approach to treating chronic insomnia.  CBTI is the number one recommended treatment for insomnia, according to all major medical and sleep associations around the world.

How Does CBT-I Work?

In a nutshell, CBTi is an approach that works with your sleep related thoughts, feelings and the behaviours those thoughts and feelings create.  

When you aren’t sleeping well, you can develop negative thoughts which generate fear and a ‘fix it’ attitude. The fear itself raises arousal levels in the brain, which itself makes it difficult to fall asleep or stay asleep.

The attempts to ‘fix’ the insomnia often involve approaches that have no evidence and don’t work much more than a few days. This generates more fear and desperation and creates a vicious circle on the psychological side of insomnia. This begins a cycle of anxiety about sleep.

You may also have changed your sleep behaviours as a result of those anxieties. These behaviours often worsen your sleep. Laying in bed hoping to ‘catch a few extra minutes’ erodes biological sleep drives and makes your sleeping issue worse.  Tossing and turning and being anxious in bed both create physical and mental negative or unhelpful associations and can impact your ability to relax, switch off your thinking and get good sleep in your bed.

CBT-I is a set of approaches used together to ‘reverse engineer’ the sleeping issues that have developed.  I often use parts of CBTI alongside mindfulness work in order to improve people’s sleep.

What is the evidence for CBT-I ?

Yes, cognitive behavioural therapy for insomnia works. That is why all of the medical and sleep associations recommend it over medication as a first option.

CBT-I has been studied for over 30 years, including with over 100 randomised clinical trials. This kind of trial is a ‘gold standard’ for comparing a treatment with no treatment or with another treatment.  CBT-I has been proven to improve people’s ability to fall asleep and stay asleep. It helps even those with extremely poor sleep and very long-term insomnia.

Over 80% of adults with insomnia experience improvement in their sleep when doing CBT-I. The effects of treatment are long-lasting because they get to the root of the things that keep insomnia going – those unhelpful thoughts, feelings and behaviours. 

Who does CBT-I help?

The treatment is suitable for many (but not all) adults.  Some medical and psychiatric conditions may mean a person can’t do all the parts of CBT-I.  However, improving sleep in those with some kinds of mental health difficulties can promote remission of symptoms, including depression and anxiety. 

Cognitive behavioural therapy for insomnia has also helped people with chronic pain improve their sleep. Despite still having a painful condition, their sleep duration and sleep quality improves, and as a secondary benefit – so can their pain. 

Medication and CBT-I?

CBT-I is also effective in reducing reliance on medication. CBTi can be done while people are on medication (though some situations are more tricky), or after they have come off medication.  It can also be delivered while a person is tapering off medication under supervision from their doctor.  Sometimes, mediation and CBTI are the best way to proceed, depending on the person.

In one study of people who had insomnia for an average sleeping medication of 19 years (so many with a lot more years than that!), over 85% were sleeping better and tapered off medication at 6 months. 

Many people find CBTi helpful in coming off medication because they receive support through any rebound insomnia they may experience, as well as reducing the feeling they ‘need’ it to sleep.  The effects last longer than medication because people are learning skills that last a lifetime that directly address the root causes of insomnia – rather than covering them up.

What usually doesn’t work is to do CBTi and take medication ‘occasionally’. We call this ‘contingent use’. This reinforces the idea that sleep comes from ‘outside’, whereas the aim of CBTi is to reconnect you to your natural sleep ability.  People who do CBTI and take medication sometimes but not to a plan are sabotaging their possibility of success.