What is Cognitive Behavioural Therapy for Insomnia (CBT-i)?

Insomnia is one of the most common types of sleep disorders, which is characterised by difficulty falling, sleep difficulties in the quality of sleep, waking up too early, and then difficulty falling back asleep. Insomnia is one of the most prevalent sleep disorders. It affects about 10 to 30% of the adult population. This disorder is more common in women, older adults, and individuals with some psychiatric or medical disorders such as anxiety, depression, or chronic pain.

Sleep is a very integral part of our life. People can often go longer without food than they can without sleep. Difficulties in falling asleep can have detrimental effects on our day-to-day functioning. This can impair our executive functioning, cause fatigue and irritability, hindrance in work due to difficulties in concentrating, and impair academics and even interpersonal relationships. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), Insomnia disorder is diagnosed when sleep disturbances occur at least three times per week for three months or longer.

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Cognitive behavioural therapy for insomnia (CBT-i) is a structured form of therapeutic intervention targeted towards individuals who have schizophrenia. This type of therapy focuses on modifying patients’ thoughts, patterns, and behaviours that may lead to sleep problems. Unlike medicines, which are a short-term solution to insomnia, (CBT-i) is a more long-term solution for insomnia as it targets the underlying causes of it.

Components of Cognitive Behavioural Therapy for Insomnia (CBT-i)

Components of cognitive behavioural therapy for insomnia (CBT-i) include several components that are focused on reforming thoughts patterns and behaviours that perpetuate insomnia. It identifies and reconstructs the unhelpful beliefs, assumptions and attitudes about sleep. Individuals with insomnia often develop dysfunctional thought patterns, such as catastrophizing the consequences of poor sleep and believing that they must get to a certain number of hours of sleep to function well. These thoughts can cause anxiety and thus further perpetuate insomnia.

The key techniques involved in reshaping these cognitive thought patterns are number one, cognitive restructuring, which involves challenging irrational beliefs. For example, a common saying is, “If I don’t get eight hours of sleep, I won’t be able to perform well at work.” Another way is through monitoring, by which the clients are encouraged to record and reflect on their thoughts around bedtime, and this can help us to identify the maladaptive patterns, which provide an opportunity for reconstructing the thought patterns.

Another component includes sleep restriction where the therapist would limit the amount of time spent in bed to the actual amount of time the person sleeps. The therapist calculates the person’s sleep efficiency, which is the ratio of time spent asleep to the time spent in bed. The individual is urged to limit their time in bed to correspond to their usual overall sleep duration. This creates mild sleep deprivation which increases the drive for sleep and eventually improves sleep efficiency.

Controlling certain stimuli, which are associated with bed and sleep can also improve the symptoms of insomnia. People with insomnia frequently participate in wakeful activities in bed, such as watching TV, eating, or worrying, which might weaken the bed-sleep relationship. Hence, clients are instructed only to use the bed for sleeping to condition their minds to associate the bed with sleep rather than weakness. If the person is not able to sleep within 20 minutes. They are often asked to engage in non-stimulating activities such as reading until they feel sleepy.

Read More: The Impact of Sleep Deprivation on Health and Well-being

Sleep hygiene also can improve the symptoms of insomnia. This refers to establishing healthy sleeping habits and creating an optimal sleep environment. For example, you can establish a sleep routine where you go to bed and wake up at the same time which helps to regulate the body’s internal clock. You can create a relaxing sleep environment by reducing any noise, light, and screen exposure, especially before bed. You can also cut down on caffeine or nicotine or heavy meals before bedtime.

Read More: ASMR: The Gentle Lullaby of Modern Sleep 

Furthermore, certain relaxation techniques such as progressive muscle relaxation, deep breathing, exercise, and mindfulness meditation can help to fall asleep and stay asleep. These techniques can also manage stress and anxiety which might exacerbate the symptoms of insomnia. (CBT-i) focuses on these components and provides a comprehensive and evidence-based approach to address insomnia’s cognitive, and behavioural dimensions.

Nature of Cognitive Behavioural Therapy for Insomnia (CBT-i)

CBT-i is a very flexible and adaptable therapeutic method. It is delivered in various forms depending on the needs and preferences of the client. It can be administered both in a group setting as well as an individual setting. An individual therapy CBT delivered one-on-one with a therapist who specialises in sleep disorders. It allows for individualised and unique treatment, which is tailored to address the unique cognitive and behavioural issues of that client. In a group setting, the therapist works with multiple clients simultaneously. These group sessions are usually conducted in sleep centres or community health organisations. Having group sessions allows the individual to share their experiences and receive peer support as well. Apart from that group sessions are quite cost-effective as compared to individual therapy.

CBT-i typically requires about 4 to 8 weekly sessions each lasting for about 30 to 60 minutes. In individual therapy, the numbers may vary based on the variety of insomnia and the client’s progress. Some clients achieve improvements in fewer sessions, while others may need additional time to address their complex cognitive issues.

Challenges and Barriers

CBT-i is a highly effective treatment for insomnia. However, certain challenges and barriers may arise during its implementation. One of the challenges in CBT is client motivation. Techniques such as sleep restriction and stimulus control require a great deal of discipline and consistency on the part of the client. These activities can often be very challenging to maintain, especially in the early stages when sleep deprivation is induced to improve sleep efficiency. Techniques such as sleep restriction can also lead to increased sleep throughout the day, which may discourage the patient, and they might be tempted to abandon the therapy altogether.

Unlike sleep medication, which often focuses on short-term relief, CBT-i can take several weeks to show any noticeable improvement. This can cause frustration and decrease motivation on the part of the client. All these factors can be reduced to therapy. Psycho-educating the client about how the therapy works, what they can expect from the therapy and setting realistic goals for one can help to address these barriers. Having a good therapeutic relationship where the therapist offers guidance and feedback can significantly motivate the client.

Conclusion

CBT-i is widely regarded as the most effective and long-term treatment for chronic insomnia. Unlike sleep medication that leads to dependence and only offers short-term relief, CBT-i addresses the underlying causes of insomnia by targeting the adaptive thoughts, beliefs and behaviours. CBT-i has been shown to offer long-term improvements in sleep quality, sleep efficiency, and sleep latency, even after the therapy has been terminated. CBT-i can reduce or eliminate the need for sleep medication as well. With its wide adaptability across different formats and populations, it can be empowering for individuals who look to combat insomnia and increase overall well-being.