An Introduction to Cognitive Behavioral Therapy for Insomnia (CBT-I)

Cognitive Behavioral Therapy for Insomnia has proven as an effective first-line treatment for insomnia. The skills one picks up with CBT-I are not only effective with present sleep disorders but they can be used in the future should insomnia ever return. 

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a treatment technique that improves the quality and effectiveness of sleep by identifying and modifying unproductive thoughts and behaviors around sleep. And it’s recommended as the first-line treatment for insomnia by the American College of Physicians

Our Full Sleep solution for insomnia was developed in partnership with medical experts and modeled after proven CBT-I methodology. This article will explain CBT-I techniques and why it works for insomnia. 

But first, let’s examine insomnia and how it’s treated. 

Understanding chronic insomnia

Culturally, insomnia has become a kind of catch-all phrase for any sleep difficulty. But it’s more than a period of not sleeping well. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) defines chronic insomnia as a sleep disorder associated with one or more of the following symptoms:

  1. Difficulty getting to sleep: One of the biggest challenges for people with insomnia is an inability to quiet their minds when it’s time to get to sleep. Instead, they often lay there worrying about things that happened today or will happen tomorrow. On top of that, they tend to struggle with anxiety around whether they can get to sleep and the consequences of not being able to sleep. This thought cycle only makes sleep more elusive. 
  2. Difficulty staying asleep: There’s nothing unique about cycling in and out of sleep; we all do it. For example, people with completely normal sleep patterns might get up to go to the bathroom or struggle with middle-of-the-night acid reflux. But after they wake up, they go back to sleep fairly quickly. People with Insomnia, on the other hand, may lie there for hours, unable to get back to sleep. 
  3. Waking too early without the ability to get back to sleep: Terminal insomnia describes a condition of waking way too early. Someone struggling with insomnia may fall asleep quite easily at night but then wake up way before their alarm goes off, completely unable to get back to sleep. 

If you’re interested in understanding insomnia better, check out the article “Understanding Insomnia: Its Causes and Treatments.

How is insomnia treated? 

Most people, at one time or another, have trouble sleeping—and it’s not necessarily insomnia. Unfortunately, this means that they tend to try multiple home remedies before they ever see their doctor and have insomnia diagnosed and treated. 

Home treatments

When sleeping becomes difficult, people start looking for immediate relief. They’re typically not thinking about whether they should talk to their physician. They just want a good night’s sleep, hoping that will turn things around. 

Maybe that means a glass of wine at night, or a CBD or cannabis product. Sleep struggles could send them to their local pharmacy to pick up some melatonin or over-the-counter sleep aid. 

Generally, these options can be helpful for a night or two. But over time, the body builds up a tolerance to the sedative effects. The longer you rely on them, the less effective they become, which means you either need to take more of them or pursue other options. 

Sleep hygiene 

Sleep hygiene emphasizes creating a bedroom environment and daily habits that promote better sleep. This includes things like:

  • Creating a sleep schedule
  • Following a consistent bedtime routine
  • Planning wind-down time in your evening 

Good sleep hygiene is essential. In fact, it’s a critical part of CBT-I. But for people with a legitimate sleep disorder like chronic insomnia, sleep hygiene alone probably won’t make much difference. For instance, on its own, sleep hygiene can’t necessarily help with things like sleep onset latency (the duration of time between turning out the light to falling asleep) or terminal insomnia (waking up earlier than necessary). 

Sleep hygiene is a helpful place to start if you have sleepless nights. If you find that some minor adjustments to your schedule and habits have a significant impact, then problem solved. 

Professional treatments   

When sleep issues drag on, it’s time to talk to a physician. Especially if you’re experiencing things like:

  • Trouble falling asleep
  • Difficulties staying asleep throughout the night
  • Waking earlier than necessary
  • Feeling sluggish after waking up in the morning
  • Excessive sleepiness throughout the day

In an effort to treat chronic sleep problems, your doctor will be able to recommend behavioral therapy like CBT-I. Your doctor may also give you a prescription for sleep medications to help restore your normal sleep patterns. 

Sleep medication is typically considered second-line treatment. While medication can help someone get to sleep, that’s only a symptom of more chronic forms of insomnia. People need treatments that can impact the issues causing and exacerbating sleeplessness. Since sleep medication only works while you’re taking it, it’s not really getting to the core issues that affect your sleep.

CBT-I, on the other hand, addresses the root causes of sleep struggles. 

For a deeper look at insomnia, check out “Understanding Insomnia: Its Causes and Treatments.” 

What is CBT-I, and how does it work? 

Cognitive Behavioral Therapy for Insomnia has proven as an effective first-line treatment for insomnia. CBT-I is a relatively brief 4- to 6-session treatment program aimed at helping people who struggle with getting to sleep, staying asleep, waking too early, and being unable to get back to sleep. The skills one picks up with CBT-I are not only effective with present sleep disorders but they can be used in the future should insomnia ever return. 

CBT-I is a legitimate specialized treatment. If your doctor recommended CBT-I, you would be referred to a psychologist, psychiatrist, or another professional with specialized training. You wouldn’t be walking away with generic sleep advice and a handful of pamphlets. 

It’s important to recognize that even though CBT-I is a therapeutic behavioral solution, it does not delegitimize insomnia or suggest that it’s “all in your head.” On the contrary, it recognizes that our sleep habits, perceptions, and thought patterns validly impact our body’s ability to sleep effectively. 

Areas addressed by CBT-I

Throughout treatment, CBT-I covers specific areas that help people understand sleep better and align themselves with sleep more successfully. Here are some of the areas it covers:

Understanding sleep 

For something that everyone does, it’s amazing how little actual understanding of sleep people have. CBT-I helps fill in some of those knowledge gaps by teaching people the stages of sleep, how our sleep cycles work, and the differences between qualitative and quantitative sleep. For example, you might be getting a lot of sleep but not experiencing the full range of the sleep cycle. So the goal is to help us understand that more unproductive sleep isn’t better than less sleep that is actually restful. 

Sleep hygiene

As we previously addressed, sleep hygiene seeks to transform some areas where our habits and environment might be impacting our ability to get to sleep and stay asleep. While these changes might not single-handedly fix insomnia, they’re still essential to creating a lifestyle that is conducive to effective sleep. 

Stimulus control 

A critical element of CBT-I is training our bodies to get sleepy when we get into bed. This is so important because many of us create habits where we associate bed with many other activities besides sleep. On top of that, after struggling with insomnia for a while, the bedroom becomes a place associated with a lot of worry and a constant emotional battle with sleep. 

CBT-I helps reassociate bedtime and the bedroom with sleep. This means going to bed when we’re ready to go to sleep and getting up if we’ve been lying there awake for longer than 20 minutes. The goal is to cut out as much time awake in bed as possible. 

Sleep restriction  

This sounds a little overwhelming, and it might be one of the most counterintuitive elements of CBT-I. In the Full Sleep program, we call this “sleep efficiency training.”  For someone struggling with a sleep disorder, sleep becomes an all-encompassing focus with the goal to get as much of it as possible. This means multiple naps and often too much time lying in bed throughout the day. 

Sleep restriction is about restricting the amount of time one spends asleep. Generally, this means calculating the average amount of sleep you’re getting divided by the amount of time you spend in bed to get your sleep efficiency. So let’s say that over the week, you’re getting 5.7 hours of sleep a night, but you’re spending 10.4 hours in bed:

5.7 hours of sleep/10.4 hours in bed = That’s a sleep efficiency rating of 55%. Ideal sleep efficiency is about 80% or higher.

So if you’re getting about 6 hours of sleep a night and have to get up at about 6 am, a CBT-I therapist would adjust your bedtime for a period to cut out the excessive time in bed and ensure that you’re maximizing your sleepiness. This means for a period of time, your bedtime would be midnight. An important part of this process is keeping a sleep log to track your sleep efficiency. 

People can sometimes feel alarmed when they’re told that their adjusted bedtime is so late. But it’s critical to remember that you’re not really getting less sleep than normal. On the contrary, the goal is to condense the sleep time into fewer periods, allowing your body to go through the entire sleep cycle, and it helps associate your bed with sleepiness instead of anxiety. And even though this is the part of the CBT-I program that many people struggle with initially, it’s often the element they recognize as being the most productive and helpful. 

Meditation and relaxation techniques

As we’ve alluded to multiple times, for people struggling with insomnia, bed isn’t a place of relaxation; it’s a place of turmoil and anxiety. Meditation and relaxation techniques aren’t just about getting your body ready for sleep; they also help take control of your thoughts. And it’s not just something you climb into bed and do once, and it’s done. Especially at first, these intrusive thoughts need to be managed by focusing on techniques. 

And the more you practice the techniques you pick up from CBT-I, the easier it becomes to use them to center yourself, relax, and get to sleep. 

Breakdown of a typical CBT-I program

CBT-I programs are brief, typically lasting 4-6 sessions. A professional with specialized training and knowledge will guide you through the program. 

While the program includes all of the elements listed above, it can vary from provider to provider. Usually, it begins with an intake period where your personal health history is gathered. Then there is a lot of education around the topics of sleep and insomnia. Next, you’ll learn various relaxation techniques, along with how to track your sleep with a sleep log. Your therapist will give you a sleep schedule to try each week, based on the information you provide on your sleep log and other measures you fill out periodically. Finally, you’ll learn other behavioral (like what to do when you’re waiting for your bedtime or wake up in the middle of the night) and cognitive strategies (how to address worries and challenge your negative thinking). Finally, there’s a summary session, where you also discuss relapse prevention. This is a great option if you like the traditional therapy structure of meeting about once a week with a provider. It’s especially recommended to seek CBT-I if you have certain comorbid conditions where working with a specialized licensed therapist would be beneficial, for example, if you have other conditions that could be impacting your sleep (sleep apnea, bipolar disorder, dementia, etc.).

For further study of cognitive behavioral therapy for insomnia

The effectiveness of CBT-I is backed up by many studies and much research. That’s why many organizations and guidelines, including the American Academy of Sleep Medicine and the American College of Physicians, recommend it. 

If you’re interested in learning more about CBT-I’s efficacy, these studies are available:

The Full Sleep program and CBT-I techniques 

The Full Sleep program combines the power of advanced home technology with CBT-I principles and sleep coaching. The aim is to help you understand what obstacles are keeping you from sleep and equip you to get more restorative sleep. 

The REST device 

A critical part of the Full Sleep program is REST (Radar-Enabled Sensing Technology), a small bedside device that uses radar to collect accurate sleep data. This device is able to capture more accurate data than wearable technology or your phone. 

REST pairs with the Full Sleep app to offer real-time insights and feedback based on your progress. It also offers updates and guidance throughout the process. 

Been lying in bed struggling to sleep for longer than 20 minutes? REST gently encourages you to get up and move around until you’re ready to lie back down. This kind of encouragement and support can make a big difference in the wee hours when you feel like you’re struggling with insomnia on your own. 

Sleep program lessons 

In keeping with CBT-I principles, Full Sleep offers lessons that inform you about sleep, help you identify and change problematic thoughts and behaviors negatively impacting your sleep, and equip you with the tools you need for effective rest. 

Sleep schedules 

Our sleep efficiency training gives you a customized schedule to help you increase the quality of your sleep by raising your sleep efficiency rating, cutting out the ineffective time you spend lying in bed wishing you could nod off. 

Sleep coaching 

Everyone using the Full Sleep solution receives one-on-one guidance from a personal Sleep Coach. So you can be confident that your unique struggles with insomnia are receiving the individualized care necessary to overcome them. 

If you’re interested in learning more about Full Sleep, please read the testimonials posted on our testimonials page

Wondering if Full Sleep a good fit for you?

Take our qualifying survey to find out. Click here or to apply. Learn more about the program on our website.

You might also enjoy: