For years, Cognitive Behavioral Therapy (CBT) has been the gold standard for treating insomnia. CBT techniques for insomnia have been proven to work in numerous clinical trials and are more effective than medication.
The American Academy for Sleep Medicine, the American College of Physicians, and the European Sleep Research Society all recommend CBT for insomnia (CBT-I) as first-line treatment.
What is CBT?
CBT is a form of therapy that was initially developed as a treatment for depression. The Cognitive in CBT refers to mental activity, such as thoughts, beliefs, memories, images or values. The behavioral part includes all the things we do on a daily basis. This 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 very impressed with the result of traditional therapies, they wanted to address these issues with a more straightforward and direct approach. And so Cognitive Behavioral Therapy was born.
A core principle in CBT is that our emotional reactions and behaviors are influenced by how we think about ourselves, others, and the world around us. 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 without giving them much thought. These shortcuts, or cognitive biases, often lead us to interpret and process information inaccurately.
If you ask two people to give a presentation on something they are both knowledgeable about, you might get two different reactions. One is hesitant and suggests someone else. The other immediately and enthusiastically agrees. It's the exact same situation. So why do they react so differently?
CBT explains that this difference in emotional reactions and behaviors comes from different ways of thinking about the situation. One thinks he might start to shake and others will notice. The other one thinks that this is a good opportunity to share his knowledge.
The common-sense model
The cognitive model
CBT proposes that it’s not the situation that makes us feel something, but the thoughts about that situation.
Changing what you do is often the most powerful way of changing how you think and feel about something. The behavioral part in CBT is about testing new behaviors and learning what happens when you gain new experiences.
If you always avoid giving presentations, you will never experience a successful one. Your negative thoughts about yourself in that situation will never change. A common unhelpful belief that people have when speaking to a crowd is that they will get anxious, start to shake, and the audience will see that as a sign of weakness.
To target the cognition that shaking is a sign of weakness, CBT uses something called a behavioral experiment. In these kinds of experiments, the goal is to get real experiences about what happens if you shake and if it's true that other people will react negatively to this. A typical behavioral experiment might be to videotape yourself talking in front of a crowd. When viewing the video afterward, try to notice the level of shaking and what reaction the group had to this. Most likely, you will see that your shaking was barely noticeable, and those who were listening didn't react at all.
The CBT triangle (putting it all together)
Therapy involves changing how you feel about something. Whether it is to achieve a goal or to stop being anxious or sad — it's all about changing emotions. Now, this is hard to do directly. We have little control over our emotions; they will pop up whether you like it or not. CBT aims to change how you feel about something through our thoughts (cognitions) and behaviors.
We can draw CBT's approach as a triangle because each element is linked together. The way you think affects your behavior, the way you feel affects the way you think, the way you feel affects your behavior, etc.
To make change happen, we either change how we think about something or the way we react to something or better yet — both at the same time.
CBT is evolving
CBT has 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 problems, and research has repeatedly shown its effectiveness. It’s common to talk about CBT as a specific kind of therapy, but in reality there are many models of cognitive behavioral therapies.
One of these models 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 sleep, let’s use two fictional people who represent two different 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, spent tossing and turning and waiting 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?
What may not be obvious but separates George from Susan, is that they have very different beliefs about sleep. They experience precisely the same situation each night; they both go to bed and try to sleep. Their thoughts and feelings in this situation, are very different.
George worries that it's going to be another night of sleeplessness and that he will be dead tired at work the following day. He thinks about how a lack of sleep might damage his body and wonders if he will ever sleep well again. The minute his head hits the pillow, he's wide awake. His mind races and he starts feeling anxious and upset. He's exhausted but can't seem to fall asleep. After spending quite a bit of time unsuccessfully trying to sleep, he pulls out his phone and listens to a podcast to distract himself. He finally falls asleep a few hours before he has to get up for work.
Susan goes to bed and doesn't think much about it at all. She is fast asleep fifteen minutes after she turns off the lights.
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 about losing his job and not being able to afford rent. George found that he became preoccupied with thoughts of worry most of the day and even more as nighttime approached and it was time to sleep. He tried, as most do when facing problems in life, to think his way out of it. 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 every night.
Fortunately, George didn’t lose his job. The company is now doing fine, and he doesn’t worry about it anymore, but he’s still struggling with sleep.
George’s story is typical when it comes to insomnia. It's common that some initial stressful life event sets it off, but the problems persist even when the stressor has resolved. It is notable 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 much with what initially caused George's insomnia. Instead, it focuses on the thoughts, feelings, and behaviors that maintain it. In George's case, we can see a pattern of him worrying a lot about sleep and the consequences of not getting enough. After a while, he starts to associate the bed with feelings of frustration and anxiety.
When George's thoughts constantly revolve around sleep and the consequences of him not getting enough, his mind will interpret this as a threat. The brain's threat detection system doesn't make the distinction between thinking about a threat or actually experiencing one. It does what it’s supposed to do and tells the body to get prepared for the threat.
When the brain signals the body to get ready, the body reacts immediately. It goes into a state of arousal where the main goal is to be prepared to handle anything. Arousal is, in many ways, a state that is the opposite of sleeping. Your heart beats a little faster, your breathing starts to increase in frequency. Pupils dilate, and you are more vigilant. Because the brain believes you are in danger, you go into a mild form of fight-or-flight mode where your senses are heightened, and muscles are ready to spring into action.
The most convincing and compelling way of learning that a previously held belief is false is experiencing the opposite. George has the view that he has to put in a lot of effort to get to sleep. A goal of CBT for insomnia is going to sleep without thinking or worrying too much about it. We want George to be more like Susan and experience falling asleep without effort, and as a result, learn that he can fall asleep easily without thinking too much about it. To help people get this valuable experience, CBT for insomnia uses something called sleep restriction.
When people who struggle with sleep hear about sleep restriction the first time, they immediately think it's counterintuitive. Why should you restrict your sleep when you want more of it?
To answer this question, we need to learn about sleep drive. Sleep drive is the force that makes you sleepy when you have been awake for a long time. To measure how strong your sleep drive is, the body uses a hormone called adenosine. The moment you wake up in the morning, the body starts producing adenosine. When the brain detects high enough levels, it starts shutting off wake-promoting areas in the brain, and you get sleepy. The longer you stay awake, the more adenosine the body produces, and your sleep drive increases.
The name sleep restriction is a bit misleading, and it could just as well have been called time-in-bed restriction or sleep consolidation. Sleep restriction is, in essence, spending less time in bed to increase the sleep drive. When starting with sleep restriction, you determine how much sleep you have been getting in total for the last week. If you have been getting an average of about 7 hours of sleep each night, you get an initial 7 hour window of time to sleep. This means that if you have to get up at 8 am each morning, you shouldn't try to sleep before 1 am. The 7 hours between 1 am and 8 am is called your sleep window. Whether you sleep or not in your window is not important, at least in the beginning. What is important is that you do not sleep outside of your sleep window.
It's important to note that sleep restriction isn't meant as something you should do for the rest of your life. It also gets a little easier as you progress. Your sleep window will increase when you stop spending so much time trying to sleep.
As previously mentioned, behavioral changes that lead to new experiences are amongst the most powerful methods for bringing about change in cognitions. By restricting your time in bed and building your sleep drive, you will strengthen the forces that make you sleep, so they are stronger than the forces that keep you awake. Sleep restriction aims to get you to experience what it's like to sleep without worrying about it. You gain confidence in your body's ability to go to sleep on its own without you having to think about it all.
Many people who suffer from insomnia report that they have a much easier time falling asleep on their couch, for example, than in their bed. This can be explained with something called classical conditioning, which we are all receptive to.
Conditioning 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 we have regular problems falling asleep and or staying asleep, we begin to associate the bed and trying to sleep with negative emotions. We get frustrated, angry, sad and anxious about not sleeping. We toss and turn, and despite being tired, we can't get to sleep. The bed and bedroom can become a stimulus that we associate with negative feelings.
CBT for insomnia uses stimulus control to break the negative association between trying to sleep and negative feelings. A common way to employ stimulus control is by having a set of guidelines or rules for sleep.
Some examples of rules for stimulus control:
- The bed should only be used for sleeping (and sex).
- Don't stay in bed outside of your sleep window.
- Don't go to bed until you are sleepy.
- If you can't sleep, get out of bed for a while and try again later.
It’s not about sleep hygiene
"Avoid caffeine, take a shower, have a bedtime routine, get to bed at the same time each night." Sounds familiar? Chances are high that you have heard advice like this before if you've been having trouble sleeping.
A common misconception about CBT for insomnia is that it's advice about sleep that you have heard before. Sleep hygiene recommendations like the above ones aren't necessarily harmful on their own and can be beneficial in some situations. There is, however, little evidence that sleep hygiene alone helps people with insomnia.
A problem with sleep hygiene advice is that it gives you the impression that sleep is something you can control if you try harder. If this were the case, insomnia probably wouldn’t exist.
CBT for insomnia involves making behavioral changes too, but with a very different intent. Here the interventions are designed to help you experience sleep without any effort.
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 play a part.
We have a tendency to take shortcuts in our thinking. Taking shortcuts and thinking fast is mostly a good thing. If we had to think things through and make an effort to be conscious of every thought, in every situation, we wouldn't have much time for anything else.
However, there are times when thinking fast, and jumping to conclusions can become unhelpful. Thoughts are influenced by how we feel and the things we have experienced in the past. We are susceptible to something called cognitive biases – which is just another word for the different shortcuts we tend to take. There are a lot of different cognitive biases, but they all make our thoughts stray further from reality and distort how we see the world. A classic example is confirmation bias – the tendency to filter information and only notice what confirms what we already believe to be true.
To help us slow down and put ourselves in a position to actually do something about these biases and skewed thinking, we can use something called cognitive restructuring. This technique involves identifying thoughts in a situation, what emotions follow these thoughts, and how strong these emotions are. By writing them down as sentences, we force our minds to slow down enough to catch our biased way of thinking.
Strategies for responding to worry
We have already learned that worrying about sleep is a factor that sustains insomnia. But for many with insomnia, worry isn't just limited to sleep, and a general approach for handling worry might be beneficial.
Like sleep, worry can't really be controlled. You can't stop thoughts from popping up in your head. But you can change how you react to them.
Changing how you respond to thoughts can be a strange concept, but you already react to some thoughts differently than others. You have thousands of thoughts every day. Some you don't pay much attention to, and some you dwell on. We all tend to think some thoughts are more important than others and require attention. But they are all essentially the same thing – just thoughts.
Usually, we don't notice ourselves responding to worry, and most of the time, this just happens automatically. To pause and start making active choices when it comes to individual thoughts, we need to train our ability to take a birds-eye perspective on our thoughts. Typically mindfulness is used for this, but also specific attention training exercises where you, for example, train on switching your attention with sounds.
The idea is that you need to become aware of worry to do something about it. There are several ways you can respond to worry - the most straightforward way to start is by postponing worry. This works by noticing thoughts of worry during the day and writing them down. Instead of engaging with these thoughts right away, you practice delaying the response to a planned "worry time."
In your worry time, you go through your list of worries during the day and decide how you want to respond. If the worry is something you can do something about, you use the time to make a plan. If it's the kind of worry that you can't do something about (most of them are). Well, then you don't do anything about it. You just let them be there without engaging with them.