Cognitive Behavioral Therapy or CBT for short is the gold standard for treating insomnia which means it has been proven to work in numerous clinical trials. The American Academy for Sleep Medicine, the American College of Physicians, and European Sleep Research Society all recommend CBT for insomnia as a first-line treatment.
What is CBT?
CBT is a form of therapy which was initially developed as a treatment for depression. The Cognitive in CBT means all the mental activity that we have. Examples are thoughts, beliefs, memories, images or values. The behavioral part is all the things we do on a daily basis. Can be things you do with others or things you do alone.
CBT saw it's beginning when the American psychiatrist Aaron T. Beck (and others) noticed a pattern of thinking that was common for many clients with depression. Not impressed with the result they were getting with traditional therapies at the time, they wanted to address these issues with a more straightforward and direct approach.
Humans have a great capacity for thinking, but that requires time and energy. Most of the time we take "mental shortcuts" and react to events that happen automatically without thinking much about it. A core principle in CBT is that psychological issues are often caused by engaging in unhelpful thinking (or cognitions) about our self, the world around us, or about other people. We often inaccurately interpret and process information because of our own experience and cognitive biases cloud our judgment.
If you ask a person why they are feeling stressed they will most likely give you an account of a situation that happened. "I'm stressed because I haven't been getting enough sleep lately." We seldom reflect on what exactly makes us anxious, sad or angry. Is it the situation or is it the thoughts we have about that situation. Why is it that two people can experience the same situation but have very different thoughts about it?
CBT proposes that it’s not the situation that makes us feel something, but the negative thoughts about that situation.
Changing what you do is often the most potent way of changing how you feel and think about something. The behavioral part in CBT is about testing new behavior and what happens when you get new experiences.
Many different approaches
CBT has now been used by thousands of therapists and millions of patients from all over the world since the 1960s. Since then different CBT approaches have been developed for a wide range of disorders, and outcome research has repeatedly demonstrated their effectiveness. One of these approaches is CBT for insomnia which this guide is about.
How CBT helps you sleep
CBT helps with unhelpful thinking and behavior, but how it is used to treat insomnia isn’t obvious. To illustrate how insomnia is caused by cognitions and how CBT can help you change these cognitions, we use two fictional people which represents two differences ways of experiencing sleep. Meet George who has insomnia and Susan who doesn’t.
George has had insomnia for a long time. Over the years he’s had many sleepless nights where he tosses and turns and waits for sleep. George's insomnia has been getting worse lately and he frequently wakes up in the middle of the night, and can't get back to sleep. For the last couple of months, he hasn’t been getting more than 4 or 5 hours of sleep each night.
Susan has always been a good sleeper. She always falls asleep within fifteen minutes of going to bed and wakes up feeling refreshed. Susan doesn’t really think much about sleep, it’s just something that happens when she goes to bed.
Why does George have insomnia and not Susan??
A not so obvious thing that separates George from Susan, is that George and Susan have very different beliefs about sleep. They experience precisely the same situation each night; they both go to bed and try to sleep. But their thoughts and feelings about this situation are very different.
George worries that it's going to be another night of sleeplessness and being dead tired at work the following day. The minute his head hits the pillow he's more awake than he was before. His minds start racing, starts feeling both anxious and frustrated. He's exhausted, but can't seem to fall asleep. After a while of unsuccessfully trying hard to sleep , he gets out his phone and listens to a podcast to distract himself. He finally falls asleep a few hours before he has to wake up for work.
Susan goes to bed and doesn't think much about it at all. She is sound asleep within fifteen minutes and without any effort whatsoever.
Thoughts, behavior, and feelings
George’s sleep problems started when the company he was working for experienced financial trouble and had to downsize. He worried a lot about losing his job and not being able to afford rent. George found that he became occupied with thoughts of worry most of the day and especially when he should have been sleeping. He tried as most will do when facing problems in life, to problem-solve his way out. After a while, George noticed that his sleep was getting worse. It frequently took a long time to fall asleep, and he often woke up multiple times at night.
Fortunately, George didn’t lose his job, the company is now doing fine, and he doesn’t worry or feel stressed about it anymore. But George is still struggling with sleep.
Georges story is typical when it comes to insomnia. It's common that some initial stressful life event that is the thing that sets it off, but the problems persist when things get better. An interesting thing about people that have insomnia is that the event that causes insomnia in the first place varies, but when insomnia has been established, people begin to behave and think the same way.
CBT does not concern itself what initially caused George’s insomnia, but the thoughts, feelings, and behaviors that maintain it. In George’s case, we can clearly see a pattern of him worrying about sleep and associating the bed with anxiety, hopelessness and the failure to get sleep.
To make people stop believing something the most convincing form of learning is experiencing the opposite. Who can argue with personal experience? To reduce George’s worry about not sleeping, he will need to experience what it's like to not worry and just get to sleep again. He needs to experience what it's like to look forward to going to bed and not dread it as he has for some many years. He needs to become more like Susan and not think about it.
To achieve this CBT for insomnia uses Sleep Restriction Therapy combined with Stimulus Control.
When most people that struggles with sleep hear about sleep restriction the first time, they immediately think that this is the worst idea ever. Why do you restrict your sleep when you want more of it?
Temporarily sleep restriction is the most powerful tool that CBT for insomnia has to offer. It’s about minimizing the time you are spending trying to sleep and forcing yourself into a new pattern. The name is a bit misleading as it could just as well have been called bed restriction. When doing sleep restriction, you determine the time you can try to sleep, and the time you should stop trying to sleep. We call this time your sleep window.
Your initial sleep window duration is the same as the amount of time you have slept on average the week before. If you have slept on average for 6 hours and 15 minutes in week one, week two will start with a sleep window of 6 hours and 15 minutes.
If you sleep or not in your window is not important, at least in the beginning. The only important thing is that you do not try to sleep outside of your sleep window. By restricting your sleep you will strengthen the forces that make you sleep, so they are stronger than the forces that keep you awake.
It's important to note that sleep restriction lasts for a short time (about six weeks). It also gets a little easier as you progress. Your sleep window will increase when you stop spending so much time trying to sleep.
Behavioral changes that lead to new experiences are amongst the most powerful methods for bringing about change in cognitions about sleep. Sleep restriction will make a person that suffers from insomnia get to sleep faster and stay asleep all night. Sleep restriction aims to get you to experience how it’s like to sleep without worrying about it. You gain confidence in your body's abilities to control sleep on its own without you having to think about it all.
Humans are receptive to something called conditioning, which is a form of learning by associating one thing to another. An example of being conditioned is when you hear a particular song, and the song makes you happy because you associate the song with a good time.
When people are having regular problems falling asleep and or staying asleep, we begin to associate the bed and trying to sleep with certain feelings. You get frustrated, angry, sad and anxious about not sleeping, you toss and turn, and despite being tired you can't get to sleep.
The bed and bedroom can become a stimulus that you associate with negative feelings. Many sufferers from insomnia report that they have a much easier time falling asleep for example on their couch or in a chair than in their bed.
CBT for insomnia uses stimulus control to break the negative association between trying to sleep and negative feelings. You do stimulus control by following a set of guidelines about when you should be trying to sleep and when you should get out of bed. Sleepedy employs stimulus control as a set of instructions to follow at the same time as doing sleep restriction.
It’s not about good sleep hygiene
“Drink tea, take a shower, have a bedtime routine, get to bed at the same time each night”. Chances are high that you might have gotten sleep hygiene advice is you have complained about problems sleeping to your doctor.
Sleep hygiene alone is never enough for the treatment of chronic insomnia. A common misconception about CBT for insomnia is that it’s only advice on sleep, going to bed and waking up at the same time. CBT for insomnia involves several behavioral interventions, but the goal here is to give you experience on how it’s like to just sleep without really thinking too much about it. Sleep hygiene which is about small things that promote sleep is often included in CBT for insomnia but is by no means the most important part.
Additional tools used in CBT for insomnia
Sleep restriction coupled with guidelines for stimulus control is by far the most important aspect of CBT for insomnia. There are also other techniques that may also play a part.
Strategies of reducing worry and overthinking
The evidence for CBT as treatment for insomnia
The American Academy for Sleep Medicine, the American College of Physicians and the European Sleep Research Society has published guidelines on how to treat insomnia. They have all looked at the tremendous amount of research and all recommend that CBT for insomnia should be the first-line treatment (Morgenthaler et al.; Qaseem et al.; Riemann et al.).
CBT delivered using a media-rich web application with automated support and a community forum is effective in improving the sleep and associated daytime functioning of adults with insomnia disorder (Espie et al.).
Espie, Colin A., et al. “A Randomized, Placebo-Controlled Trial of Online Cognitive Behavioral Therapy for Chronic Insomnia Disorder Delivered via an Automated Media-Rich Web Application.” Sleep, vol. 35, no. 6, June 2012, pp. 769–81.
Morgenthaler, Timothy, et al. “Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report.” Sleep, vol. 29, no. 11, Nov. 2006, pp. 1415–19.
Qaseem, Amir, et al. “Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians.” Annals of Internal Medicine, vol. 165, no. 2, July 2016, pp. 125–33.
Riemann, Dieter, et al. “European Guideline for the Diagnosis and Treatment of Insomnia.” Journal of Sleep Research, vol. 26, no. 6, Dec. 2017, pp. 675–700.