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The Basics of Cognitive Behavioral Treatment for Insomnia

Of all of the treatments that are currently available for the treatment of insomnia, it has been widely accepted that Cognitive Behavioral Treatment for Insomnia – CBT-I – is not only the most effective, but also has the longest staying power. Cognitive Behavioral Treatment for Insomnia is a form of therapy that was developed at Stanford University for the specific purpose of improving the sleep of people whose insomnia is not based on a medical or physical disorder, but instead on habits and attitudes that they have developed and that need adjustment. By first defining the patient’s existing sleep patterns and habits and then identifying the ones that are working against them, the therapist is able to help the patient to make small steps to improve their sleep — not just for the short-term, but for the foreseeable future.


The first step of cognitive behavioral therapy for insomnia is always to identify exactly what is going on with the patient’s sleep patterns. If a patient has already undergone sleep lab testing the information provided may be of some help, but because CBT-I focuses on actual behavioral patterns in order to strengthen the impact of the bed as a cue for sleep, what is likely to be more valuable is to have the patient keep a journal of the times that they go to bed and wake up, as well as what they do during the day and particularly in the hours immediately before sleeping and after rising. An analysis of these inputs is often extremely enlightening for the therapist, who then targets three different components of the patient’s sleep behaviors.


CBT-I focuses first on improving sleep quality and then moves on to extending sleep quantity, and it does this in a way that may seem counterintuitive. The therapist begins by restricting the amount of time that the patient is able to spend in bed to the duration that they are actually sleeping. This is called sleep restriction, and it is intended to stop middle of the night awakenings. It effectively eliminates the time that the patient is spending tossing and turning and staring at the ceiling so that the patient’s mind and body learns that the bed is specifically for sleeping. So, if a patient usually goes to bed at ten and gets up at 7, but only spends six of the nine hours in bed asleep, the therapist will ask them to stay out of bed until midnight and awaken at six. Though this may be difficult, the end result is that the patient falls asleep quickly and stays asleep throughout the night. After about a week the quality of their sleep will have dramatically improved and the bed time and wake-up time can be gradually extended outwards, usually by periods of fifteen to thirty total minutes and never increased more than that in a week.


CBT-I also works on the various stimuli that can have a negative effect on the patient’s ability to fall asleep by providing the patient with guidelines that work to keeping away from cues that increase to alert the patient and to increase those that make the bed a signal that it is time to sleep. These guidelines include establishing a set time for waking up in the morning, no matter what time the patient gets to sleep each night. Though the goal is to help the patient to have a set bedtime as well, this is initially difficult with those suffering from chronic insomnia. Wake-up times are more easily controlled, and an effective way of resetting circadian rhythms. Patients are also advised never to go to bed unless they feel ready to fall asleep, and they are taught the difference between fatigue and sleepiness. They are taught to get out of bed if they are feeling alert and unable to sleep, and only to return to the bed when they feel sleep again, and to try not to nap during the day, even if they are feeling very tired. If the must nap, they are instructed that the nap should not exceed fifteen or twenty minutes.


The third focus of CBT-I is on the various individual nuances of the patient’s insomnia profile that require attention. These may include various thoughts that they experience while lying in bed or activities that they are engaging in that may be interfering with their ability to fall asleep. The goal is to shift away from a mindset of having to work to fall asleep and towards one where sleep simply happens naturally, the way that it does for those without insomnia.  Patients are often taught about a wide variety of relaxation techniques and stress management skills that not only evoke total body and mind ease, but also that shift the away from worrying, whether about sleep or anything else. They are trained to recognize their best bed time and use the hour beforehand for a number of activities specifically designed to create a separation between the rest of the day and bedtime. By engaging in these activities immediately before going to bed while tired, they will train the brain to recognize them as part of the natural process of falling asleep. Additionally, stimuli that may work against sleeping with ease, such as exercising within four hours of bedtime or using electronics within two hours of going to bed, are eliminated. Finally, environmental factors such as noise, light, a temperature that is either too cool or too warm, and a clock that is constantly presenting the time, are all eliminated so that there are no distractions and nothing to keep the doing anything but drifting off to sleep for the night.


CBT-I has been found to be effective for a wide variety of people suffering from insomnia and other sleep disorders. Those who are trying to adjust to CPAP therapy have found it useful, as well as those who suffer from nightmares or middle of the night awakenings.

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