How can CBT help with insomnia?

Difficulties with sleep can be a common and frustrating problem that many of us experience at some point in our lives. It can sometimes be a lonely experience - we may not feel understood by our friends and family, particularly if they are good sleepers! In the small hours of the morning, we may feel that we’re the only person in the world who is awake. This, however, is not something we just have to learn to accept, as it can be treatable.

Cognitive behavioural therapy for insomnia (CBT-I) is an effective treatment for sleep difficulties. Poor sleep can have a significant impact on functioning in a range of areas such as work, relationships, home life and leisure activities.

Daytime insomnia symptoms can include:

• poor concentration
• irritability
• fatigue
• memory problems
• disorientation.

Poor sleep has also been linked to depression and anxiety. 

“In the morning you beg to sleep more, in the afternoon you are
dying to sleep, and at night you refuse to sleep.”

- Anonymous 

What is insomnia?

Insomnia is defined as "difficulty in getting to sleep, difficulty maintaining sleep, early wakening, or non-restorative sleep which occurs despite adequate opportunity for sleep and results in impaired daytime function". 

Sleep disturbance in the absence of daytime impairment is not considered to be an insomnia disorder.

There is no standard definition of what constitutes 'normal' sleep — the amount of sleep needed to ensure good health varies from person to person and with ageing.

Insomnia can be categorised according to duration or likely duration:

• Short-term insomnia lasts less than 3 months.
• Long-term (or chronic) insomnia lasts for 3 months or longer.

Short-term insomnia is common and can occur in association with stressful events or changes in sleeping patterns such as illness, financial difficulties, the birth of a child or environmental disturbance.

Chronic insomnia can co-exist with other conditions (for example anxiety or depression). Unhelpful behaviours and thoughts are believed to be involved in the development of chronic insomnia.

It is recommended that other sleep disorders (such as obstructive sleep apnoea and parasomnias) are considered as part of the assessment of a person with suspected insomnia.

What are the treatment options for insomnia?

Within the NICE guidelines, CBT-I is recommended as the first-line treatment for insomnia. This is both short-term (if unlikely to resolve soon) and chronic, long-term insomnia, in adults of all ages. Unlike medication, benefits associated with CBT-I persist on completion of treatment.

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What is cognitive behavioural therapy?

In a nutshell, cognitive behavioural therapy, also known as CBT, is a talking therapy that helps you to understand how what you think affects the way you feel, and subsequently what you do (or don’t do).

Through CBT, you can learn how these components relate to one another and find ways to challenge and replace unhelpful thoughts and behaviours to improve the way you feel. CBT is commonly used to treat anxiety, depression, and other mental health problems.

How does CBT for insomnia (CBT-I) work?

Cognitive behavioural therapy for insomnia is a structured and practical evidenced-based treatment that helps you to identify and change thoughts and behaviours that cause or worsen sleep problems, and create habits that promote good sleep.

The first step with any CBT treatment is an assessment and exploring suitability for treatment. This involves the therapist and client developing a shared understanding of what the problem is and what is keeping it going.

The next step is setting and agreeing therapeutic goals. This helps the therapist to understand what the person coming to therapy wants to work on. To get the most out of treatment, the client will benefit from completing tasks in between sessions to initially monitor and then try out the ideas being talked about in sessions. This
will typically involve keeping a sleep diary for a while. A sleep diary can be helpful in identifying sleeping patterns and lifestyle factors that may exacerbate or maintain insomnia.

CBT for insomnia is very much tailored to work with each client’s unique needs. In some cases, it could be beneficial to engage with CBT to focus on managing an anxiety problem or depression. These can both have a negative impact on sleep and therefore, if this is the cause, it could be beneficial to work on this first. CBT-I combines several different approaches. Sessions may include cognitive, behavioural, and educational components.

Key components of CBT-I:

Sleep hygiene and psychoeducational interventions

Good sleep hygiene should initially be established. This aims to make people
more aware of behavioural and environmental factors that may be
harmful or beneficial to sleep and make changes. Education about
sleep is an important part of treatment.

Stimulus control and sleep restriction

These may sound like intimidating terms, but the aim here is to strengthen the connection between bed and sleep, and to reset your sleep pattern to increase
your sleep efficiency. Sleep efficiency is the percentage of time you spend sleeping in bed, which can simply be calculated by adding up the number of hours you sleep divided by the number of hours you spend in bed multiplied by 100.

Identify unhelpful behaviours which might be inadvertently maintaining
the sleep problem:

The goal is to associate our bed with only sleep. This means no reading, scrolling mindlessly on social media, playing or chatting on our phones, or doing work-related tasks. Sex is the only exception to this rule! Lying in bed when you are awake can become a habit that leads to poor sleep. Reducing the time spent in bed not sleeping is done by scheduling a new, consistent bedtime and a time to get up based on the time currently typically spent asleep. Once this schedule is
developed with your therapist, it then involves sticking to the same routine 7 days a week for the best results. Once your sleep has improved, your time in bed is gradually increased.

Another element of stimulus control involves getting out of bed if we can’t get to sleep within 15 minutes. If we lie there for hours we will associate our bed with sleeplessness. Instead, we should get up and go into another room – read, make a hot drink or a hot water bottle - a sedentary and boring activity that won’t make us feel really awake but will allow us to go back to bed when we start to feel sleepy again.

This is often the most challenging part of treatment however stimulus control and sleep restriction are important interventions and there is strong evidence suggesting they are the most effective part of any CBT treatment programme for insomnia.

Relaxation training

This involves reducing some of the physical symptoms which can lead to sleeping problems. Clients learn the skills to help calm their mind and body. Approaches may include meditation, imagery, progressive muscle relaxation, diaphragmatic breathing and many others.

Cognitive interventions

“Not all thoughts are facts!” This component of treatment will look at the skills to recognise and challenge unhelpful thoughts and beliefs about sleep and sleeplessness.

Insomnia is a vicious cycle:

• Situation - initial poor sleep due to stress, pain, or other reason. 
• Thoughts - "if I don't sleep now I won't function properly tomorrow"
• Feelings - you may be anxious, worried and experience muscle tension. 
• Behaviour - try to change habits which in fact lead to continued poor sleep eg: napping, and going to bed earlier. 

The cognitive aspect of treatment focuses on teaching clients to evaluate and test out any unhelpful thoughts and assumptions they have. A lot of worry about sleeplessness can be based on beliefs that are not accurate. Evaluating our thoughts is therefore an important process in CBT to help us identify if we have any unhelpful thoughts about insomnia that are making us feel worse. Sometimes we can respond to our thoughts as if they’re facts and this can inadvertently make us feel worse or add to our distress. For example: “I’m never going to get to sleep tonight” and “If I don’t get eight hours sleep tonight I’ll not be able to function at work tomorrow."

Some steps in becoming a detective of your own thoughts are:

• Notice the thought and write it down.
• Reflect on how this thought makes you feel, and write that down.
• Consider the thought critically - (would it stand up in a courtroom
  if it was on trial?) Do you have any evidence that confirms or
  disputes that thought?
• Write down a new and more accurate version of that thought.
• Consider how thinking the new thought makes you feel and write
  that down.

Relapse management

The final part of the treatment will involve pulling all the learning together and developing a plan to support the client to identify high-risk situations for a setback - identifying signs and symptoms that mean the problem should be addressed now and agreeing which strategies could be helpful to prevent a slip from becoming
a relapse.

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CBT for insomnia is an established treatment that has a good evidence
base. Treatment does require hard work and commitment. Your therapist
will work collaboratively with you every step of the way. The benefits however
can be long-lasting and can have a hugely positive impact on your life as
CBT-I is designed to help alleviate the suffering caused by sleep problems.

If you feel you would benefit from CBT for insomnia, reach out to me via my profile.