If you have ever been to see your doctor due to insomnia, you may have been recommended ‘cognitive behavioural therapy’. While it’s a very effective treatment, a problem frequently encountered is that no one knows what it actually is. The name itself gives little away. This article aims to shed some light on this effective but not widely understood practice.
Cognitive behavioural therapy is a type of talking treatment (sometimes called psychotherapy) where the link between your thoughts (or cognition) and actions (or behaviours) are explored. Using fancy medical terms to describe the therapy might be technically exact, but it doesn’t help anyone understand what it actually is and can even make the process seem intimidating.
The central premise is that the way we view a problem might not necessarily be fair or accurate. These unhelpful thought patterns influence our actions, and these actions can feed back into how we think. Cognitive behavioural therapy explores all this and tries to sharpen our thought processes. Hence, they’re a more fair reflection of what’s happening.
Cognitive behavioural therapy is used for various conditions. There’s a specific type for insomnia, which has been imaginatively named Cognitive Behavioural Therapy for Insomnia (or CBT-i).
To make it one step more complicated, CBT-i is not one specific thing. It’s a collection of talking therapies usually delivered together over a few weeks. Some therapies are based on changing how you think (cognitive therapies), and others are based on changing how you act (behavioural therapies). There are also educational components and relaxation techniques.
To understand how CBT-i works, it is worth recapping what insomnia is.
Insomnia is the difficulty in falling asleep, staying asleep or waking early. It causes poor daytime functioning, including poor concentration, mood disturbance and fatigue. It’s widespread, with around 10% of the adult population suffering from it at any time.
The factors that make insomnia stick around for months or years are called perpetuating factors. These often start with behaviours originally intended to help you deal with daytime tiredness, such as napping or drinking lots of caffeine. Gradually you become habitualised to poor sleep and lose the association of the bed meaning sleep. It is common to develop false beliefs about sleep, such as thinking your insomnia is genetic and has no cure. Or thinking you need to have eight hours’ sleep or you won’t be able to function the next day. Throughout all this, people with insomnia find their inability to sleep extremely frustrating and anxiety-provoking, making sleep even more challenging. So, other aspects of CBT-i focus on managing these frustrations.
One of the first jobs of CBT-i is to educate on sleep. Knowing the backdrop and context of sleep gives you a better idea of where the problem lies and what the different therapies aim to do.
Sleep hygiene is another cryptic term that describes the routines and practices that encourage good sleep, such as ensuring your bedroom is calm, dark and quiet. It’s not a treatment for insomnia by itself, but it provides an essential foundation of good practice for the rest of CBT-i to build on. Sleep hygiene is discussed in more detail here.
Cognitive therapy means looking at the thoughts around sleep. People with insomnia tend to have more underlying false beliefs about sleep than people without insomnia. They also have many negative sleep-related thoughts during the day and night that work together to perpetuate insomnia.
For example, a fixed belief that eight hours of sleep is needed to function is not true. Believing this might make you ‘try hard’ to sleep, which is a surefire way not to get to sleep. It may lead you to spend excessive time in bed to achieve it, weakening the association of the bed meaning sleep.
Anxieties and worrisome thoughts are common reasons to stay awake. Various techniques exist to manage these worries – such as writing a diary of what is on your mind and then symbolically closing the book on these worries in the knowledge that you will open the book again in the morning. You know there are things you need to think about, but you don’t need to think about them when you’re trying to sleep.
Another absolutely baffling term. One of the key problems with insomnia is the loss of association between the bed and sleep. This could be because the bed is used for activities other than sleep, such as watching TV or computer work. It can also relate to how getting into bed can stimulate frustration for a bad sleeper – because here is the battlefield of trying to get to sleep. And frustration – all those things, anger, stress, worry – are foolproof ways not to fall asleep.
Stimulus control therapy works to strengthen the link between the bed and sleep. It’s advised to only get into bed when you are very sleepy (too early, and you will lie awake, thus weakening the link with sleep). And most importantly, if you can’t get to sleep after around 15 minutes, you should get out of bed, find a relaxing, distracting activity, and wait for the urge to sleep to return naturally.
Not only the most counter-productive component of CBT-i, but sleep restriction is also one of the most effective. People with insomnia characteristically lie in bed for hours but spend only a fraction of it actually sleeping. This ratio is called ‘sleep efficiency’.
With sleep restriction, the general idea is to significantly reduce the amount of time spent in bed so that nearly all of this time is spent asleep. This usually means bedtime is very late – around 1am or 2am. The crucial aspect is that the wake-up time has to be set in stone. After a couple of days of playing by these quite harsh rules, the individual will be so tired when they get into bed (at around 1am or 2am) that they fall straight asleep and don’t wake up overnight – then get out of bed bang on time. As sleep efficiency improves, bedtime is gradually brought back in small steps until more overall sleep is achieved.
Relaxation therapy can come in many forms and aims to reduce the stress levels that can prevent you from falling asleep. This can involve breathing techniques, muscular relaxation therapy or mindfulness techniques.
The short answer to this is: very effective. There is a substantial and high-quality base of evidence behind CBT-i. Over 70% of people participating with CBT-i should see significant improvements in their sleep sustained for over a year. When compared to sleeping tablets, the gains are similar in acute insomnia, but over time CBT-i significantly outperforms sleeping tablets.
CBT-i is also effective when delivered in multiple formats – either as a 1:1 session with a therapist, a group session, or online. This is excellent news when faced with the challenge of delivering CBT-i to many people with insomnia.
If you have insomnia and would like to look into treatment with CBT-i, then get in touch at www.thebettersleepclinic.co.uk.