Cognitive Behavioral Therapy for Insomnia (CBT-I or CBTi) Guide


Every day and night, millions of Americans struggle with getting the necessary rest they need. For these people, sleep is a very rare commodity. As a result, there are more sleepy Americans during the day than there should normally be.

Sleep deprivation, no matter the cause is a serious problem, and one that should be corrected as quickly as possible.

Types Of Insomnia

Before we move forward to the available treatment options, it is important to distinguish between the various forms of insomnia.

Acute Insomnia

This is the mild or brief insomnia experienced by about 35 percent of all adults at any given time. These are usually occasional and can be caused by anxiety, worry, life event, nurturing a new born, poor health, work related stress, travel, bad news and even noise.

Most people will probably experience this at some point in their lives.  If this isn’t managed properly, individuals might experience a more severe form of insomnia that’s more prolonged, but typically lasts less than 3 months or 90 days.

These are caused by anything from work related pressures and emotional turmoil, to psychological or mental health problems (people experiencing episodes of mania may not be able to sleep for an extended period of time). This happens in about 20 percent of the population.

Chronic Insomnia

Those who are suffering from this condition, typically experience insomnia at least thrice a week for at least 90 days. This is the smaller percentage as you have just about one in ten adults experiencing this.

There are other forms such as comorbid insomnia which is often caused by a psychiatric condition or the side effects medications, onset insomnia where an individual finds it difficult to fall asleep and maintenance insomnia where the individual struggles with staying asleep.

All types of insomnia have their effects on both the individual’s personal lives, their productivity as well as the entire American economy. Studies have shown that people suffering from insomnia will often display symptoms such as fatigue, cognitive impairment, poor recall ability, sleeping on the job, depression, increased tendency for mistakes –can be dangerous when you’re working with power tools, heavy equipments, and even working on sensitive financial tasks, low energy, irritability or mood fluctuations and overall lower productivity.

Bottom line, insomnia can cost you big time, including your means of earning a living. This is why you need to treat it very quickly. While there are other treatment options like the use of sleep aids for various types of insomnia, we’ll be focusing on just one in this guide: Cognitive Behavioral Therapy for Insomnia, aka CBT-I.

In this guide, you’ll find out everything about this wonderful therapy and how CBT-I can help get rid of insomnia permanently. Here’s what you’ll learn in this guide:

  • What is Cognitive Behavioral Therapy for Insomnia and Why Is It Considered a Viable Treatment Option And Effective Sleep Therapy?
  • Components of CBT-I
  • The treatment process
  • How to get the most out of your treatment
  • Are the results from the treatment permanent?
  • Possible side effects

What is Cognitive Behavioral Therapy for Insomnia?

In the simplest of terms, it is simply the process of adopting and making use of attitude changes and adjusting your lifestyle as well as beliefs to help you get better sleep. Please understand that it’s not just limited to curbing a few sleep inhibiting habits such as caffeine consumption and powering down your devices so they don’t interfere with your sleep.

No, it goes far beyond that. The ultimate goal is to create a completely strong mental association between your bed and sleep. This way, way, when you hit the bed, your mind automatically starts shutting down so you can sleep.

The great news is that it has been widely hailed as an excellent, long term solution to many different types of insomnia. So, if you’re looking to improve your sleep quality and get adequate shuteye at night, this is a treatment option you want to try.

The success of CBT-I as a treatment for insomnia is based on the use and application of one or more of the components:

  • Comprehensive analysis of the patient’s sleep disorder
  • Stimulus control therapy
  • Sleep restriction
  • Sleep scheduling
  • Biofeedback
  • Motivation improvement
  • Relaxation therapy
  • Sleep hygiene education

These make up the basics or foundation of the CBT-I approach to tackling insomnia. The goal is that by the time the patient internalizes all these components, they will be able to sleep on demand.

CBT-I has become important in the face of other ineffectiveness treatment methods –particularly where chronic insomnia is concerned. For some people, their insomnia isn’t about difficulty in falling asleep, it’s waking up after barely getting enough REM sleep and then being unable to go back to sleep.

For those who don’t know, REM sleep means rapid eye movement sleep and is actually when your body gets to really rest during the night. Your body typically goes into this state after 2-3 hours of sleep.

So, if you miss these cycles, it would just feel as if you never really slept. There are also those who even though they go to bed before 10p.m., don’t actually fall asleep until 3a.m. If these people have to be up by 6a.m., you can see how difficult it would be for them to cope, as their bodies would not have been well rested. This is partly why all insomnia sufferers routinely feel that they have been deprived.

How To Determine Your Treatment

Let’s examine each of these components and their applications to see how they will fit into your treatment.

  1. Analysis of the Patient’s Sleep Habits

Understanding what causes the patient’s sleep disorder is often the key to getting the most effective treatment. Careful self-analysis and sleep stock taking will help you identify potential triggers, pitfalls, sleep inhibiting patterns and sleep termination. What are your sleeping habits? More importantly, what are your sleeping habits right before you go to bed and after?

Understanding this will help rule out other causes of insomnia such as obstructive sleep apnea. If for instance, it’s difficult to sleep because you’re always worried about work, family or the children, then you know that the best solution to this would be to find ways to eliminate all such worrying thoughts and develop new positive thoughts in order to sleep better.

Maybe your own unique situation involves being interrupted when you’re just drifting off to sleep by incoming calls, phone beeps and other distractions. Once you identify this, you can then mute your devices, and put them away in drawers where they won’t interrupt your sleep. Clearly identifying the triggers can help you and your CBT-I specialist create an effective sleep plan/strategy.

  1. Stimulus Control Therapy

Stimulus control therapy is aimed at helping you get rid of all forms of excitement, arousal, worry and anxiety that might prevent you from going to sleep when you should. Think of it as a way to eliminate anything that stimulates you.

This usually involves a set of techniques and strategies that will help you link the bedroom to sleep and rest as against wakefulness. Once you master this, your mind will automatically relax and become calm as soon as you step into the bedroom or sleeping quarters.

Done correctly, it will help you eliminate all counterproductive sleep rituals, thus ensuring that you fall asleep within minutes of hitting the bed. Individuals would often have to follow a few instructions to make this work over a period of time.

For instance, only go to bed when you feel sleepy. If you can’t sleep while in bed, get out of the bed and go do something else. Also, the bedroom should only be used for sleep and sex, nothing more. This means that all forms of reading and screens should be confined to other rooms.

If you must read, it should be something pleasurable and relaxing –avoid all stimulating reads. Setting a consistent sleep schedule also plays a role in stimulus control. With this, you’ll train your body on when to sleep and when to wake up.

This would often mean going to sleep and waking at specific time intervals –sleep at 10-10.30p.m., waking up at for example. You’ll also need to avoid naps, particularly those evening naps you’re tempted to indulge in after a hard day’s work.

  1. Sleep Scheduling and Sleep Restriction Therapy (SRT)

You’d think that for someone suffering from insomnia, what they need is more sleep, frequently as against sleep restrictions. This is why it is often called a counterintuitive approach to fixing your sleeplessness.

Yet, it has a success rate of 75-80 percent when used over the course of one month. Sleep restriction therapy often involves the use of less sleep, and then increasing the amount of sleep you get over time until your body gets used to the idea of you getting 7.5 to 8 hours of sleep every night.

To make this work though, you will need the help of a sleep therapist or a CBT-I specialist. The processes involved in sleep restriction are as follows:

For the first week, you’ll pick a time during which you need to wake up. You’ll need to keep to this time for a while.

Then, keep track of how much sleep you’re getting per night over the course of 1-2 weeks as against when you go to bed. The idea is to be able to accurately tell how much time you’re wasting in bed minus when you really fall asleep. For instance, many insomniacs go to bed at 10.30 and toss and turn until they finally fall asleep around 2.a.m. So, if you’re going to have to be awake at 6, it means you are actually getting only 4 hours of sleep as against 7.5 hours per night.

Once you have determined just how much sleep you’re getting and have set your waking time, you need to keep out of the bedroom until four hours before your waking time. This means that if you set your waking time for 6a.m., you’ll need to stay out of the bedroom until a few minutes to 2a.m. And when you do get in, go to bed and wake up at 6, no questions. Even if you feel tired and want more sleep, you need to be up at 6a.m.

When you wake up, open the drapes or turn on bright lights to wake your body up. This is important because you’ll most likely feel lethargic. The lights will help stimulate your wakefulness so you can be fully awake.

After one week of following this schedule, you’ll need to add 30 minutes more to your sleep schedule. That means going to bed at 1.30, instead of 2a.m. you’ll do this in 30 minute increments ever week until you achieve optimum sleep.

This process of retraining your body does work. The downside however, is that you’ll feel more tired, grumpy and even bleary eyed during the day courtesy of the sleep scheduling. But, since you’re probably going through all these as an insomniac, you might as well use it to your max benefit and train your body until your sleeping regimen is fully restored.

  1. Biofeedback

This usually involves observing biological signs that causes wakefulness and use that information to create an effective sleep schedule for you. These biological signs often include tension, increased pulse rate, high temperature and so on.

Your sleep specialist will equip you with a portable biofeedback machine that will monitor all these. For instance, if your biofeedback machine indicates prolonged increased pulse rate, this might mean that you’re having anxiety right before going to bed.

Identifying the cause can often help eliminate the issue. This way your sleep specialist will be able to determine what the possible cause of your insomnia could be and help you adopt and implement healthier sleeping habits.

  1. Motivation Improvement

Also referred to as sleep environment improvement, this method helps you determine how your environment might be affecting your sleep, and steps to take to make your environment more conducive.

For instance, TV lights and other device screens can adversely affect your sleep. So can noise from the street, neighbors or even in the house. The idea is to do everything to create a serene, peaceful, noiseless sleeping zone. The fewer distractions you have, the better you’ll sleep. It’s that simple.

  1. Relaxation Therapy and Training

When you have spent the whole day wired and in the “go” mindset, it can be somewhat difficult to just power down shortly after getting home at night. This is where relaxation therapy comes in. This insomnia combating technique does wonders for your sleeplessness.

It puts you in a frame of mind that is conducive to restfulness and sleep. And the extra benefits such as mental clarity, self control, increase productivity, inner peace and tranquility, prolonged good health and stress relief makes it such a worthwhile practice.

There are five major components of this:

Autogenic training

With this method, individuals are trained to combine their imagination in the quest for visual imagery with the awareness of their bodies to help them relax and wind down. The most common routine is for the person to imagine a tranquil, serene environment and feel their body’s different sensations physically. For instance, they may be instructed to feel their legs, warmth in their face, coolness of the floor, their heartbeat, or just listen to their breathing. The idea is to take the mind off all worries and “trick” the body into a state of serenity, where they can easily fall asleep.

Deep breathing techniques

These techniques are designed to teach you how to breathe so deeply that your nerves are calmed and you feel relaxed. A typical routine is for you to place your hands on your stomach and chest at the same time, breathe in deeply while focusing on the expansion of your belly and chest against your hands. You may also focus on your heartbeat while doing the breathing exercises.

Progressive muscle relaxation

This is useful in helping you identify and control your muscles. With this technique, you’ll need to slowly contract/tense certain muscle groups and relax them one after the other. Most routines will start from contracting your leg’s muscles and relaxing them, followed by the abdomen and chest muscles, then the arm, shoulder and neck muscles, and finally the facial muscles.

Meditation techniques

You’ve probably heard that meditation is ineffective or a waste of time. Well, most of those who say these things aren’t patient enough to understand that it’s not an instant process. It takes time, and mental discipline. The process of mastering meditation itself is meant to teach you discipline and self control as well as help you relax. Your CBTi specialist will help you determine whether to use mindfulness meditation or transcendental meditation. Mindfulness meditation involves the process of concentrating on sensations, thoughts, and presence happening Transcendental meditation involves the repetition of a mantra –one word or phrase- over and over in the bid to calm your thoughts and nerves. You’ll have to discuss this with them as each specialist has his/her own favorite method.

Guided imagery

With this technique, the individual would have to listen to an expert instructor, real or through an audio tape, help guide them into a state of relaxation. While akin to autogenic technique, the difference is that this focuses on helping you bring up imagery that will help provide insights into your current sleepless state and other important parts of your life.

All of these methods are effective and will be recommended to you depending on your particular needs and requirements.

  1. Sleep Hygiene Education

This component is predicated on the fact that certain lifestyles can influence your sleep capabilities. For some people’ their insomnia is largely tied to their various lifestyles. If you drink as much as four cups of coffee over the course of a 12 hour period, chances are that you would find it difficult to sleep at night.

So, this is aimed at helping the suffering individual understand how cutting caffeine, alcohol, and lack of exercise can affect their sleep schedules. As a rule, don’t drink caffeinated coffee after 4p.m. if you want to sleep.

Caffeine requires at least six hours to be completely broken down in the body. So, taking it after will most likely, guarantee your insomnia. You’ll also learn basic winding down techniques that will help prepare you for sleep.

The CBT-I Treatment Process

Understanding what to expect from your sessions and treatment process will help you be better prepared. The key to getting the best possible results is participation and openness.

Even though most insomnia patients come in with just that complaint, each individual’s situation is often different. Most cognitive behavioral therapists know this. As a result, your session can be just you and the therapist, or if they feel the need, with other individuals such as family or other patients.

During your first consultation, your therapist would want to know what your situation is, your concerns and problems. They’ll gather critical background information about your mental, psychological and physical state.

So, you should expect to be asked questions about past/present mental and psychological problems or issues that you might be facing in the quest to get more insight about your own situation.

Your first contact with your chosen therapist isn’t meant to just help them, it’s meant to help you too. This is when you feel the therapist out to determine if they’ll be the right person to help treat your condition. All therapists are capable, but with something this sensitive, you would want one that you are completely comfortable with.

You’ll want to find out what their approaches are, the therapy they’ll be proposing for you, what your treatment goals are, how long each session will be as well as the number of treatment sessions you’ll need to get results.

Please be aware that you may probably need to have a few treatment sessions with them for them to accurately devise a proper treatment plan for you. Ultimately, ensure that you are comfortable with them; this is key if you want to get great results from the treatment.

Your in-therapy and post therapy sessions will often involve some introspection, and personal research as your therapist will encourage you to talk about your feelings, emotional issues, mental health problems is any, thoughts, ideas, personal medical history, current health issues and even work related stress.

Remember that everything you talk to them about is confidential. If you don’t feel comfortable talking about them though, you can always tell them you don’t want to talk about it.

Your therapy sessions may be any from ten to twenty. These will depend on how much treatment and help you need.

So, you’ll need to keep them apprised of your peculiar issues or situation, how bad your insomnia is, how long you’ve been suffering from this and its current effects in your life, what you have been doing or are currently doing to get a solution, and if you’re getting any support from anywhere while trying to cure your sleeplessness.

Tips for Getting Great Results from CBT-I

As with all treatment options, you have a primarily active role to play in this. CBT-I is not a passive treatment protocol. You need to be involved and even more committed to your treatment process to get the most out of it. The following are best practices that you should adopt when you’re getting treatment:

Openness and Forthrightness is Key

We understand that you may be unwilling to talk about all your issues with someone you don’t know. So, we’ll recommend just sticking to the task on hand. Remember, they’re not your shrink and shouldn’t be your “dumping ground” for emotional issues. You should however be open to telling them what you think and expressing how you feel. If you’ve had bad experiences that might be interfering with your sleep, feel free to tell them.If you however, have some reservations about certain issues and feeling, and are unwilling to express them, by all means tell them you don’t want to talk about it. Your CBT-I therapist is there to help you get better, not grill you like you’re at a deposition.

Consider this a Partnership

It is important to note that this is a two-person activity; and an active one at that. You’ll both need to set goals and track those sleep goals. You’ll both need to work hand in hand to bring out the results you so ardently desire.

Adhere to the Treatment Regimen Religiously

There are times when you wouldn’t want to come in for your therapy session. Whenever you feel unmotivated, try and honor the commitment to show up. Many people routinely skip sessions because they feel results are slow in coming.

Unfortunately, many of them don’t have realistic expectations. So, when they are not able to magically sleep after the first session, they give up on the treatment. Don’t do this. As much as possible, come in, but understand that it’ll take a while to start seeing results.

Have Realistic Expectations

Speaking of expectations, having a realistic one can make all the difference in the world. Every individual’s case is unique, which means that some people will start seeing results as early as the second/third session, while others would have to wait until the 8th or 9th This is often dependent on the root cause of your insomnia, patient disposition and a whole lot of other factors. The point is, be patient.

Execute all Tasks In-Between Sessions

You will be given assignments and tasks to do while you’re at home. Please do them religiously. Success comes more from consistency and adherence to the plan, than from a lackadaisical approach to the treatment.

Please note: It is easy to give up on and decide that CBT-I doesn’t work after a few sessions. Don’t give up. However, if after the 10th session for instance, you don’t see any results, tell your sleep therapist immediately, so they can either recommend a better therapy or send you to another expert.

Can the Results From CBT-I Be Sustained?

A 1999 study about the long term effects of CBT-I and sleeping pills showed that compared to sleeping pills, CBT-I’s results were prolonged as the patients were still enjoying improved sleep quality two years after the study, compared to the patients who were placed on sleeping pills.

Another 2004 study aimed at helping sleeping pills addicts stop the habit, showed that CBT-I, when used in accordance with withdrawals medications helped the participants quit sleeping pills after just 10 weeks.

The great thing about cognitive behavioral therapy for insomnia is that it doesn’t just address the symptoms –this is what most sleep aids do. It addresses the root cause, which means that the possibility of sustaining those results are huge.

As a result, many patients often live the rest of their natural lives free of insomnia; unless those root causes are triggered again. And in the rare eventuality that they start experiencing another episode of sleeplessness, the good news is that the person can recover and cure themselves automatically following the same CBT-I processes they internalized during their first treatment sessions. So, think of it as a life tool that will always be useful to you, IF your insomnia crops up again.

Possible Caveats and CBT-I Side Effects?

To a large extent, there are little or no physical side effects from the therapy. However, patients might find the emotional exploration, psychological analysis and soul searching a little unnerving.

It’s also possible to have really intense sessions where there’s some crying, some anger or frustration. So, if the occasional emotional vulnerability and discomfort are major issues for you, then you should be aware of this.

Now that you know everything about CBT-I, we need you to understand that so far, it’s the best possible treatment for most forms of insomnia and that with the longest lasting result.

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