Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT)

CBT is an effective treatment for insomnia

The most effective long-term treatment for insomnia is a psychology-based treatment, cognitive behavioural therapy (CBT-I). Once people have had difficulties with sleep for 3 months or more (chronic insomnia), part of what contributes to ongoing problems is changed thinking and behaviour around sleep. CBT-I addresses both thinking and how people behave around sleep which helps to settle insomnia symptoms. It takes a while for CBT-I to work, and it also takes time and effort to put in to learn and practice the strategies that are part of CBT-I. But, unlike medications, which work quickly, CBT-I has long-lasting effects.

In their practice guidelines, The American College of Physicians recommends CBT-I as the first-line treatment for insomnia in adults.

What is cognitive behavioural therapy?

CBT-I is a treatment that generally takes between 3-8 sessions working with a psychologist experienced in treating sleep disorders and insomnia. Modern CBT-I consists of 5 core components (outlined below), rather than just a single technique. I’ll often see people who said they’ve “tried it all” and even worked with a psychologist on their sleep, but often they’ve only used or been exposed to one or two of these 5 components.

The 5 core components to cognitive behavioural therapy for insomnia are:

Stimulus control – basic principle is getting out of bed if you wake during the night and doing something else until you feel sleepy again
Sleep restriction – this involves matching the time you spend in bed more closely to how much sleep you are actually getting
Relaxation training – developing confidence in relaxation strategies that you can use if you wake at night and feel anxious, and can also use to manage stress and anxiety through the day are an important part of sleeping well
Cognitive therapy – involves challenging beliefs about sleep that people with insomnia tend to develop over time, like believing that unless sleep meets certain parameters they won’t be able to function the next day.
Sleep hygiene – consists of ensuring that body and mind are ready for sleep on getting in to bed and you have an appropriate sleeping environment without too much light or noise.

Is cognitive behavioural therapy for insomnia effective?

In 2015, I was part of a team led by Dr James Trauer who pulled together all the research on cognitive behavioural therapy for insomnia and analysed the results. The research showed that on average people went to sleep 19 minutes faster and stayed asleep 26 minutes longer after CBT-I. This is similar to the effects of sleeping tablets, but without the negative effects and the effects persisted long after treatment finished. In our research, the shortest treatment was 2 sessions and the longest 8 sessions.

This research was published in the Annals of Internal Medicine on June 9th 2015, and was covered by a number of media outlets who also wrote commentaries on the role of non-drug treatment such as CBTi in treating insomnia. Some of the media stories are at the following links:

Annals of Internal Medicine also put together a short video on cognitive behavioural therapy for insomnia and the findings of the research that you can find here.

Are there other treatments that can be added to CBT-I?

Current research in the area of CBTi is along the lines of how we can further improve CBTi to get even better results.

One of the techniques that can be added to CBTi is the use of mindfulness-based therapy. We have also completed research on a treatment that combined mindfulness with CBTi, showing it added to the effects of CBTi and hope to publish the research later this year. For more information on using mindfulness in sleep, watch this video.
Disruption of the body clock, or circadian rhythm, may play a role in insomnia symptoms for a number of people. If so, strategies to get the body clock back on track may help their sleep. At the moment we don’t have accurate ways of measuring the circadian rhythm, but tools are being developed that will allow this to be done in clinical practice. There is more information on managing the circadian rhythm in this video.
As CBT-I takes some time to work, I will sometimes use medication such as sleeping tablets in parallel with CBT-I. This can help people to get short-term improvement in their sleep whilst working on the long-term treatment with CBT-I. Medications that are used to treat insomnia are discussed in this post.

Where can I access CBT-I?

Currently there are limited numbers of health care providers with experience and training in CBT-I. This means CBT-I can be difficult to access, or there may not be treatment programs available in your area. As professionals working in this area, we are doing a lot of work training health care providers in CBT-I to improve access to this helpful treatment.

Australia

Melbourne Sleep Disorders Centre – individual CBT-I
Towards Better Sleep – Brisbane-based group CBT-I
Insomnia clinic at Woolcock Clinic – Sydney-based CBT-I program
Adelaide Institute of Sleep Health – Adelaide-based, mixed group and individual CBT-I sessions
Sleep Matters Perth – Individual and group-based CBT-I

United States

The Society of Behavioral Sleep Medicine has a provider directory where you can search for experienced CBT-I providers in your area.

Online

There is research going on looking at how CBT-I can be made more accessible using online programs or developing treatment programs that don’t need the expertise of psychologists or doctors who specialise in managing insomnia and sleep disorders. Two examples of online CBT-I programs with good research showing they are effective are:

This Way Up – Australian program (free)
Sleepio – UK-based online program developed with Prof Colin Espie

The US Department of Veteran’s Affairs have also developed an app, CBT-i coach, that is designed to be used in conjunction with working with a psychologist. This app allows people to work with psychologists that aren’t expert in CBT-I as the app provides a lot of the sleep-specific information.