Cognitive Behavioral Therapy for Insomnia (CBT-I)

If you are like many people reading this article, you see “Cognitive Behavioral Therapy for Insomnia” and think, what is that? Cognitive Behavioral Therapy for Insomnia, often called CBT-I, is an approved method for treating insomnia without the use of sleeping pills. Sound impossible? It isn’t. Sounds like hard work? It can be. CBT is aimed at changing sleep habits and scheduling factors, as well as misconceptions about sleep and insomnia, that perpetuate sleep difficulties.

In fact, the recent National Institute of Health state-of-the science meeting on insomnia concluded that CBT-I is a safe and effective means of managing chronic insomnia and its effects. At this point you may be thinking, “That is great, but I still don’t know what CBT-I is.” Cognitive behavioral therapy for insomnia includes regular, often weekly, visits to a clinician, who will give you a series of sleep assessments, ask you to complete a sleep diary and work with you in sessions to help you change the way you sleep.

For Christine, a swim and safety instructor for the U.S. Navy, a simple cat nap while recovering from knee surgery turned into a full bout of insomnia. She explained, “I had to take medication for the excruciating pain and it would make me sleepy. My doctor told me to stay on bed rest but I found it difficult to lie around all day without drifting to sleep. However, day time napping was making a big impact on my ability to fall and stay asleep at night. When the pain in my knee finally went away and I headed back to work, I found that I was hooked on napping.”

Christine went back to work and curtailed her mid-day napping but found that as soon as she got home she felt like dozing. She started going to bed earlier and earlier. For a person who gets up at 4:00am to go to work, this seemed like a good idea – except she was rarely sleeping soundly through the night and wound up feeling exhausted all day.

Sleep aids seemed to be the way to go at first for Christine. She tried a variety of prescription medications but found that none of them worked for her until her doctor gave her a prescription for Ambien®. Once she started taking Ambien things picked up — she no longer felt sluggish at work and she was sleeping through the night. She explained, “Even though I was finally sleeping, I had a nagging feeling that I couldn’t continue taking medicine for the rest of my life. But it was my insurance company that made the final decision when they stopped covering my prescription.” Ambien is indicated for the short-term treatment of insomnia, but once the short-term problem turned long-term, Christine was in the market for a non-pharmacological treatment.

Her pulmonologist suggested that she make an appointment with Dr. Donn Posner, PhD, MA and Clinical Assistant Professor in the Department of Psychiatry and Human Behavior at Brown Medical School and Director of Behavioral Sleep Medicine for the Sleep Disorders Center of Lifespan Hospitals in Rhode Island. Hesitant at first, especially because she didn’t think she needed to see a therapist for a sleep problem, Christine’s desire to try anything that might work won over.

Dr. Posner started his training as a behavioral psychologist — originally working in developmental disabilities, and started specializing in treatment of adult anxiety disorders. He explained, “I was working in the Midwest when a local sleep lab put out a notice to the psychiatry community that they had a large population of insomniacs in need of treatment. The lab offered to refer patients to any doctor who was interested. Yet, no one answered the call. A psychiatrist at the medical school where I was working asked if I had any interest, and so I explored the literature and found it to be up my alley. I started seeing patients and found that the treatment worked. That was 16 years ago.”

Christine found that CBT-I wasn’t a fast and easy cure. In fact, in the first six weeks of treatment she got less sleep then before. After keeping a sleep diary, Dr. Posner explained that Christine needed to stop taking naps and going to bed so early. This is called Sleep Restriction Therapy, and it is one of the primary components of CBT-I. Christine was used to going to bed early but Dr. Posner told her not to go to sleep until midnight. Without the mid-day naps and early bedtimes, she had a hard time staying up so late. She explained, “It was the hardest six weeks of my life.” Dr. Michael Perlis, Associate Professor of Psychiatry and Psychology at the University of Rochester agreed, “It is true that during this phase of therapy you may feel worse than usual during the day. After a few days of being very sleepy at bedtime, you should find it easy to fall asleep, and that is our goal.”

Over time, if Christine reported a good week of sleep in her diary, Dr. Posner would slowly allow her to go to bed earlier and earlier. Christine explained, “I could have lied to him about my sleep improvements if I wanted – but I knew it wouldn’t make me better.”

Another aspect of CBT-I is called Stimulus Control Instructions. Stimulus Control Instructions are created by looking at the patient’s sleep habits and pinpointing different actions that may be prohibiting sleep. Dr. Posner instructed Christine not to spend time in her bedroom when she wasn’t sleeping, leave the bedroom when she wasn’t able to sleep and not to return until she was ready to sleep.

CBT-I includes Sleep Hygiene Education, a customized list of things you should and should not do, in order to sleep. It often includes sleeping in a cool, dark room and avoiding caffeine, alcohol and tobacco before bedtime. Dr. Perlis explained, “Sleep hygiene education is most helpful when tailored to an analysis of the patient’s sleep/wake behaviors. The tailoring process allows the clinician to:

1. Demonstrate the extent to which they comprehend the patient’s individual circumstances (by knowing which items do and do not apply)

2. Critically review the rules, which in many instances need to be customized for the patient.”

When a clinician looks at your assessments and diaries, he or she will find the elements of your lifestyle that may prohibit you from falling or staying asleep. One common problem that affected Christine is clock watching. Many people who have a sleepless night here or there can relate to the obsession with staring at the clock and watching the sleepless hours go by. For someone with insomnia, watching the clock can become a routine. Dr. Posner told Christine to stop using clocks, so she covered her bedroom clock and only used it for the alarm. Dr. Perlis often tells his patient’s to put their alarm clocks under their bed. He explained, “If the alarm is set, there’s no need to know in the middle of the night what time it is. That and, more importantly, clock watching can only lead to worry and frustration and if nothing else worry and frustration are ‘wind to the flame’ of insomnia.”

Avoiding naps was the most challenging item on Christine’s list. Dr. Posner also informed Christine that she needed to stop working close to bed time because she was revving herself up instead of winding down. She stopped bringing work home and started reading, painting and focusing on relaxing. Spending a lot of time in your bedroom working, watching TV, surfing the internet and other stimulating activities can rev you up and condition you to stay awake. You can inadvertently train yourself to associate your bedroom with wakefulness.

Relapse Prevention is an important element of cognitive behavioral therapy. The patient needs to learn how to maintain what they’ve learned and prepare for the possibility of a future flare up. Dr. Perlis explained, “The patient needs to be reminded that lots of things may trigger a bout of insomnia and the main things one can do to protect against a new onset episode of chronic insomnia are:

1. Don’t compensate for sleep loss

2. Start stimulus control procedures immediately

3. Re-engage sleep restriction should the insomnia persist beyond a few days.”

Christine found that after the first six weeks of CBT-I she started to sleep better and better. Even though she was able to stop seeing Dr. Posner on a regular basis, she is careful to keep her CBT-I regimen intact. She explained, “I know there is always a chance that this could happen again. I can drop into my bad habits. If I have a bad night, I know to get out of bed. If I have a series of bad nights, I know to restrict my time in bed. I also know I can always call or visit Dr. Posner.”

Dr. Perlis emphasizes that when treatment is reinitiated, patients tend to have a quick recovery. “In the final analysis, the take home message is, ‘don’t let the small burning embers of transient insomnia accelerate into a blaze’.”

Christine concluded, “I went with an open mind, but I didn’t expect it to work as well as it did. Now I can go to bed and sleep on my own, which many people take for granted – but for me it is the biggest gift of all.