According to a recent report published by the University of Pennsylvania School of Medicine, Roughly one in four Americans have acute insomnia each year. With so many Americans struggling to stay asleep, it’s no wonder that insomnia is considered a major public health problem among medical professionals. Many individuals turn to prescription drugs for the help they need to maintain a regular sleeping schedule. However, sleep medication can have unwanted side effects and can create problems instead of solving insomnia symptoms.

What if there were a drug-free option that insomniacs could use to get the relief they need?

Enter cognitive behavioral therapy (CBT). By using CBT techniques, people with insomnia can learn how to “train their brains” so they can get a restful night’s sleep without using medication. With just a little bit of help from a CBT professional, you can develop the tools you need to keep insomnia at bay.

What Is CBT-i?

Cognitive behavioral therapy for insomnia (CBT-i) is a form of short-term talk therapy used to treat patients’ insomnia symptoms. CBT-i aims to help change your thought patterns and habits to promote a good night’s sleep. It’s important to note that this therapeutic option is not a “cure” but instead gives you the tools to manage the symptoms and achieve better sleep.

According to research from the University of Massachusetts Amherst, CBT is an often underutilized tool for treating insomnia due to its time commitment and educational requirement from patients. However, when approached correctly, CBT-i can have a tremendous impact on improving the quality of sleep.

How Does CBT-i Work?

CBT-i is based on two psychological principles: cognition and behavior. The cognitive aspect of CBT-i educates insomniacs on recognizing and changing the thoughts and beliefs that keep them from entering a restful sleep cycle. Therapists help patients develop the tools they need to control and eliminate negative thought patterns and anxiety that keep insomniacs up at night.

The second component of CBT-i involves behavioral changes that help insomniacs develop better sleeping habits. This part is tailored to patients depending on their individual needs and how their brains learn to adopt new behaviors. Depending on your specific needs, your therapist may recommend one of the following commonly used techniques.

Stimulus Control Therapy

Through this method, your therapist will recommend that you remove stimuli that contribute to sleep resistance. Setting rigid bedtimes and wake times, leaving the room if you can’t fall asleep by a set time, and restricting bed use to sleep and sex are all recommendations your therapist may make using this method.

Sleep Restriction

One common occurrence in people with insomnia is the tendency to lay in bed while awake. Sleep restriction combats this bad sleeping habit by reducing the amount of time you spend in bed, purposely inducing slight sleep deprivation to encourage fatigue. Over time, your sleep will improve and the time you spend in bed increases.

Sleep Hygiene

This behavioral method helps change lifestyle habits that could be contributing to poor sleep, such as drinking too much caffeine, smoking too much or not getting enough exercise. It also encourages patients to carve out time to wind down, usually about an hour or two before bed.

Sleep Environment Improvement

As one might infer from the name, sleep environment improvement has to do with adjusting your sleep surroundings. Changes could include buying a more comfortable mattress, turning the TV off while you sleep or hiding your phone from view during the night.

Relaxation Training

With help from your CBT-i therapist, this method will train your mind and body to relax enough to sleep. This approach may involve meditation, imagery, muscle relaxation and other holistic therapies.

Remaining Passively Awake

This method involves what one might equate to “reverse psychology”: Instead of making adjustments to promote sleep, the patient will actively try to avoid falling asleep. The thought is that by inducing anxiety over having to stay awake, your body will respond by falling asleep faster.

Biofeedback

If your insomnia is particularly bad, your therapist may recommend observing your body’s biological signs, such as your heart rate or muscle tension. This may require seeing a sleep specialist who will provide you with a biofeedback device to track such measurements. With these daily records of your sleep patterns, you can use the information to identify problematic patterns that discourage restful sleep.

Is CBT-i Effective?

Based on a review article in Annals of Internal Medicine, research suggests that CBT-i can be incredibly effective. In the article, researchers combined data from 20 CBT-i trials that included more than 1,100 participants with chronic insomnia. According to the data set, the average person who received CBT-i treatment fell asleep 20 minutes faster and spent 30 fewer minutes awake during sleeping hours than those who did not receive therapy.

What may be even more surprising to learn is that CBT-i treatments are as good as (and sometimes better than) treatments involving prescription medications such as Ambien or Lunesta. The effects of CBT-i last six months longer on average after the therapy ends compared to those relying on sleep medications.

It’s important to note that treatment takes time to take effect. Traditionally, CBT-i requires patients to see a therapist weekly for 30 or 60-minute sessions over a 12 to 20-week period. For a quicker approach, patients may choose intensive CBT-i. This method concentrates the patient’s time commitment through traditional CBT-i into a month, week, weekend and, sometimes, even a single eight-hour session. Other therapists may still combine CBT-i with smaller doses of sleep medication for more severe chronic insomnia cases.

Does CBT-i Have Risks?

Because CBT-i does not rely on the use of medication to treat insomnia, it does not have any of the risks that are generally associated with it. However, patients undergoing therapy may be forced to step outside of their comfort zone, making significant life changes to improve their sleep behaviors.

Perhaps the most significant risk that CBT-i patients face is that the therapy may not work. According to research conducted by the Australasian Sleep Association, “CBT-i, whilst the most effective long-term treatment, does not work for everybody across all circumstances.” In more severe cases, additional therapies may be required, including the use of sleep medications. This could pose a risk for those with addictive personalities or are particularly sensitive to such medicines’ potential side effects, including increased drowsiness, nausea, or reduced mobility.

Who Provides CBT-i?

CBT-i sessions are provided by a licensed psychologist or psychiatrist, depending on whether or not the use of medication is required. If you’re going the drug-free route, you’ll likely engage a psychologist rather than a psychiatrist for therapy. In addition to your psychologist or psychiatrist, you may need to see a sleep specialist — someone who can observe you while sleeping using biofeedback monitors to measure your heart rate, waking hours, and other biological data points.

When selecting a therapist, it’s essential to choose someone who:

  • Is well-versed in cognitive behavioral therapy
  • Has experience treating insomnia
  • Makes you feel comfortable and listens to your needs

Seeing a licensed therapist can get expensive, so make sure you ask about rates ahead of time to avoid sticker shock (just one more thing to keep you up at night). The best way to reduce the rates associated with seeing a psychologist/psychiatrist is to choose a provider in your medical insurance provider’s network.

Final Thoughts

Insomnia can negatively impact many facets of your life, leaving you feeling groggy and disoriented at all hours of the day. By committing to a CBT-i treatment program, patients can get the long-lasting relief they need to combat the effects of insomnia. With the proper attention paid to changing negative thought patterns and making strategic changes to sleep behaviors, people living with insomnia can master the art of falling asleep in just a few weeks.

Frequently Asked Questions

How long does it take for CBT to work for insomnia?Most CBT-i treatment sessions involve 30 to 60-minute weekly sessions over a 12 to 20 weeks period. However, you can opt for intensive CBT-i, which condenses all the treatment to as little as a month, week, weekend or a single long-day session.
How does CBT work for insomnia?CBT for insomnia helps patients identify and make changes to negative thought patterns and poor sleeping behaviors. This is done through short-term talk therapy sessions targeted at assisting with sleep, along with making behavioral changes to patients’ everyday lives that will help them achieve better sleep over time.
What is the main side effect of cognitive behavioral therapy for insomnia?Because CBT-i does not use medication to treat insomnia, the only side effect for patients is a better night’s sleep. However, CBT-i alone does not always work for every person, and more severe cases may require medication use. These medications can have serious side effects, including drowsiness, nausea, decreased mobility, and addiction.

References

Christodoulou, Alexandra, “Using Cognitive Behavioral Therapy to Treat Insomnia in Adults” (2018). Doctor of Nursing Practice (DNP) Projects. 144.

Corliss, J. (2015, October 30). Cognitive behavioral therapy offers a drug-free method for managing insomnia. Retrieved February 12, 2021, from https://www.health.harvard.edu/blog/cognitive-behavioral-therapy-offers-a-drug-free-method-for-managing-insomnia-201506108071

Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills. (2016, September 28). Retrieved February 12, 2021, from https://www.mayoclinic.org/diseases-conditions/insomnia/in-depth/insomnia-treatment/art-20046677

Publishing, H. (n.d.). Boot camp for better sleep. Retrieved February 12, 2021, from https://www.health.harvard.edu/sleep/boot-camp-for-better-sleep

Ree, M., Junge, M., & Cunnington, D. (2017). Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults [PDF]. Wembley, Western Australia: El Sevier.

Soo Jeong Youn, P. (2018, October 23). Intensive cbt: How fast can i get better? Retrieved February 12, 2021, from https://www.health.harvard.edu/blog/intensive-cbt-how-fast-can-i-get-better-2018102315110

University of Pennsylvania School of Medicine. “One in four Americans develop insomnia each year: 75 percent of those with insomnia recover.” ScienceDaily. ScienceDaily, 5 June 2018. www.sciencedaily.com/releases/2018/06/180605154114.htm.

van Straten A, et al., Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis, Sleep Medicine Reviews (2017), http://dx.doi.org/10.1016/j.smrv.2017.02.001