Updated: Oct 1, 2020
Cognitive behavioural therapy for insomnia (CBT-I) is the first-line recommended treatment for chronic insomnia and has been shown to be as effective as medication but with longer-lasting benefits.
A course of CBT-I typically consists of four appointments, occurring every 2 weeks.
The interventions used in CBT-I accomplish two goals:
Building adequate sleep potential (i.e. adequate sleep drive and properly timed circadian signals) at the right time
Addressing high activation that is interfering with sleep
In CBT-I, the first goal of building enough sleep potential is accomplished with sleep restriction therapy, an intervention in which an individually-tailored and consistent sleep schedule is followed for a few weeks.
Sleep restriction is used concurrently with stimulus control strategies to retrain the body and mind to associate bed with a deactivated state as well as traditional sleep hygiene strategies to optimize the sleep environment and reduce the impact of disruptive substances such as caffeine.
This combination of interventions is highly effective because, if the recommendations are followed correctly and consistently, very high sleep drive builds up within a few weeks. This sleep drive is high enough to overcome the very high activation that tends to occur in chronic insomnia.
Of note, these interventions can be very challenging. There is an expected temporary reduction in sleep and an increase in fatigue. Typically, this worsening is expected in the first 1-3 weeks before improvements are seen.
A common trap is to misinterpret this worsening of symptoms as a poor response to treatment. Other common challenges that limit improvement include not being consistent enough with the recommendations or stopping the recommendations before the point of improvement.
Please note: Sleep restriction therapy may not be appropriate if you have a concurrent untreated sleep disorder like sleep apnea or narcolepsy due to the increase in sleepiness. If you are concerned that you may have another sleep disorder other than insomnia, please consult with your physician.
Cognitive & relaxation strategies
CBT-I incorporates strategies used to deactivate. Relaxation strategies help with calming the body and mind whereas cognitive strategies target the overactive mind and sleep-disruptive thoughts & beliefs.
Is CBT-I a good option for me?
CBT-I is an excellent treatment but is not for necessarily for everyone.
CBT-I may be a good treatment option if you are very motivated to address insomnia and if you think you will be able to follow-through on recommendations such as being ready for sleep by a certain time, waking up at a prescribed time, discontinuing napping, as well as reducing your time awake in your bed.
You may first wish to devote some time building strategies that will allow you to benefit from CBT-I. For example, being able to wake-up by a prescribed time is essential to benefitting from sleep restriction therapy. You may wish to look at the Sleep Strategies articles for some tips (coming soon).
If you are not able to devote the time, attention, or effort to sleep for at least 2-4 weeks, a better option may be to try some general strategies found in these articles on preventing sleeplessness and addressing sleeplessness.
You can always revisit CBT-I in the future when you may be better able to benefit from it.
How do I obtain CBT-I?
There are many ways of obtaining CBT-I.
If you are interested an in-person or virtual course of CBT-I, look for a therapist who is trained specifically in CBT-I. While there is overlap the cognitive and relaxation strategies used in CBT for mood and anxiety symptoms, the behavioural strategies in CBT-I and the challenges encountered when treating insomnia are different. It is ideal to work with someone who has experience and expertise in insomnia.
If CBT-I with a therapist is not possible or not of interest to you, there are also online CBT-I programs and books. Please see the resources page for recommendations.