Insomnia symptoms affect approximately one third of all adults.1 Cognitive Behavioral Therapy for Insomnia (CBT-I) is recognized as the first choice intervention for chronic sleep problems. While sleep medications can be effective during periods of high stress or grief, CBT-I addresses the underlying causes of insomnia.10
CBT-I treatment typically follows a structured format. Clients can expect to attend four to ten weekly sessions lasting 30 to 60 minutes with a trained therapist, and can expect long-lasting results.6 CBT-I is typically covered by insurance. Private pay, per session, fees can range from free at a community or university-based counseling center, to over $200 for a seasoned clinician in private practice.
What Is Cognitive Behavioral Therapy?
Cognitive Behavior Therapy (CBT) is a short-term, goal oriented therapy. It is based on the premise that our thoughts drive out emotions and, in turn, our emotions influence our behaviors.
CBT counselors help clients to identify, challenge and change destructive or disturbing thinking patterns. More realistic thinking patterns can help people to better regulate their moods, and consequently make behavior choices that are based on reason instead of driven by negative emotions, such as anxiety, anger, or loneliness.
How Can CBT Help With Insomnia?
CBT-I is based on the 3-P model of Insomnia that suggests insomnia is caused by the interaction of Predisposing, Precipitating and Perpetuating factors. Our predisposing factors (genetic differences, tendency to ruminate/worry, etc.) make us more or less likely to develop a sleep disturbance. When our unique set of vulnerabilities is faced with a precipitating factor (a life stressor), the combination is sometimes enough to trigger insomnia symptoms.5
Perpetuating Factors, behaviors that a person engages in to compensate for or cope with their sleeplessness, (such as napping or reading in bed), can make the problem worse.5 Chronic Insomnia is often the product of poor sleep habits, (e.g. spending too much awake time in bed, napping, watching the clock), and anxious thoughts (“I need to get to sleep”).
CBT-I teaches clients to identify, challenge and change the thoughts that are keeping them awake. Patients are also coached in developing sleep-conducive habits, and educated on avoiding behaviors that perpetuate insomnia.11
Common CBT Techniques & Tools for Insomnia
CBT-I intervenes on three different levels: cognitive, behavioral and educational. Clinicians work with clients to restructure dysfunctional beliefs, attitudes and expectations about sleep. The behavioral component of CBT-I involves working on stimulus control and sleep restriction therapy. The educational piece focuses on teaching sleep hygiene and providing facts about sleep.8
Common CBT-I techniques/tools for insomnia include:
A Sleep Diary
This is a log where you track your sleep patterns. Initially this serves as a baseline, and over time, a measure of progress. The time you went to bed, how long it took to fall asleep, the quality of your sleep, how refreshed you felt upon awakening, etc. all tend to be part of the sleep diary.15
Stimulus Control
Lying awake in bed night after night can result in your bed and bedroom becoming a cue or trigger for wakefulness, frustration and anxiety. Stimulus Control aims to strengthen the association between your bed and bedroom with sleeping.15
Sleep Hygiene
The client is taught which behaviors and what type of environment tend to promote sleep. Examples include setting a consistent wake time, resisting the urge to nap, incorporating some aerobic exercise into your day, limiting caffeine, and making sure your bedroom is dark and at a comfortable temperature.2
Sleep Restriction Therapy
This technique is used to standardize the sleep/wake cycle. It limits the amount of time a client is allowed to spend in bed. This causes partial sleep deprivation and increases the probability that the client will be more tired the next night. Once sleep has improved, time in bed is gradually increased. Note this is not suggested when drowsiness would pose safety problems.10
Cognitive Therapy
Cognitive therapy for insomnia tends to focus on teaching clients to identify and dispute dysfunctional thoughts and attitudes about sleep. It can also help control or eliminate negative thoughts and worries that keep people awake.
Relaxation Training
Relaxation strategies are meant to reduce body tension and arousal at bedtime. Progressive Muscle Relaxation, guided meditations and/or simply focusing on taking slow, deep breaths are all common methods of relaxation.
Paradoxical Intention
This is when the client is instructed to actively avoid falling asleep. This is meant to reduce performance anxiety and paradoxically help the client to relax and fall asleep.10
Types of Insomnia
Some common descriptors of ways insomnia is conceptualized are listed below:
Acute Insomnia
This is usually a brief episode of insomnia typically caused by a life event such as a death, stressful change in a person’s job, or travel. Often acute insomnia resolves without any treatment.4
Chronic Insomnia
Chronic Insomnia is usually defined as a person having trouble falling or staying asleep at least three nights per week for three months or longer. Some people with chronic insomnia have a long-standing history of sleep issues.4
Comorbid Insomnia
This is Insomnia that occurs with another condition. Comorbidity between Insomnia and Anxiety or Depression is high.3 Other medical conditions can either cause insomnia or make a person uncomfortable at night (like arthritis or back pain).4 Insomnia can continue even after the co-occuring disorder is treated. The standard care recommendation is to treat both disorders simultaneously.3
Onset Insomnia
Difficulty falling asleep at the beginning of the night.4
Maintenance Insomnia
The inability to stay asleep. People with maintenance insomnia wake up during the night and have difficulty returning to sleep.4
Examples of Cognitive Behavioral Therapy for Insomnia
While CBT-I clinicians all use techniques from the same tool box, treatment plans vary based on a client’s presentation and response to treatment. An initial assessment to gather client history, rule out other possible sleep disorders, and screen for comorbid conditions is the usual first step.
Typically, clients are requested to begin maintaining a specific sleep diary to track progress. CBT-I treatments are usually four to ten weeks in duration. Treatment for comorbid conditions can last longer.
Example of CBT for Chronic Insomnia
Judy, 23, lives in the city with a roommate who can be noisy. She’s worried that her lack of sleep is impacting her ability to focus at work/school.
Judy Is Reporting:
- Periodic bouts of insomnia
- Family history of insomnia
- No depression and mild anxiety
- No other sleep disorders present
Judy’s Sleep Behaviors:
- Goes into bed at 10:00
- Falls asleep between 11:30P.M.-12:00 AM
- Wakes up at 6:00
- On weekends she goes to bed much later and sleeps until 9:00 AM
Sleep Environment:
- Roommate tends to be loud (chats on phone, watches TV)
- Walls are thin
- Sleeps alone in a comfortable bed
- Room is semi-lit by the streetlamp outside
Life Habits:
- Finishes work around 6:30
- Goes for a run or to the gym at approximately 7:00 P.M.
- Eats dinner at 8:00 P.M.
- Hangs out with her roommate, watches TV, computer/social media until bedtime
Therapist’s Plan for Judy’s Chronic Insomnia
This client’s plan would emphasize educating Judy on sleep hygiene and the 3-P model, (predisposing, precipitating and perpetuating factors). Behavioral suggestions to promote sleep would include:
- Staying out of the bedroom until drowsy and ready to sleep
- Using nighttime filters on her computer and phone screens
- Investing in blackout shades for the bedroom
- Exercising in the morning or at lunch and eating dinner earlier
- Setting a consistent wake-up time (even on the weekends)
Cognitive therapy would be used to address Judy’s anxiety over her insomnia. She is essentially giving herself a problem about her problem. One goal would be to teach Judy techniques to challenge and dispute her thought, “It would be terrible if I were tired at work.” A more effective replacement thought might be, “Many days I’ve been tired, and while that’s not optimal, I’ve still performed.”
Assertiveness training (a CBT technique) is also indicated. A specific goal for Judy might be to have her self-advocate and request that, at night, her roommate wear headphones or simply be more quiet.
Example of CBT for Sleep Maintenance Insomnia
Tim is a 39-year-old who lives with his spouse and young child. He is frustrated because he keeps waking up in the middle of the night unable to go back to sleep. He’s annoyed that he hasn’t been able to fix the issue on his own.
Tim Is Reporting:
- No family history of insomnia
- Personal history of sleep maintenance issues
- No depression or anxiety
- No other sleep disorders
Sleep Behaviors:
- Goes into bed at 10:00 to read
- Turns out light at 10:30 and falls asleep within a few minutes
- Typically wakes up twice per night for periods of 20-60 min
- Sometimes tosses and turns until he falls back to sleep
- Sometimes gets up and watches movies
- Wakes at 7:00 AM
- On weekends he tries to catch up on sleep by napping in the afternoons
Sleep Environment:
- Quiet
- Dark
Life Habits:
- Finishes work around 5:00
- Spends time with the family
- Eats dinner at 6:30
- Watches TV from 7:00-10:00 (occasionally dozes off)
- Goes to bed and reads for 30 min
Therapist’s Plan for Tim’s Sleep Maintenance Insomnia
For Tim, Sleep Restriction Therapy and Stimulus Control (reconditioning him to view his bed as only a place to sleep) are key. He is spending too much time in bed not sleeping.
A sleep schedule in which Tim is initially sleep deprived and then, once allowed to sleep, returns to bed and falls asleep quickly, is warranted. Sleeping time would slowly be increased until an optimal balance is reached.
Tim also spends too much time out of bed sleeping. Naps could be throwing off his sleep cycle and should not be an option. To lessen the probability of his napping Tim might be instructed to sit up vs.lying down while watching evening TV. Late night movies, which Tim might struggle to stay awake for, could be exchanged for less engaging, shorter TV shows and/or activities.
Example of CBT for Insomnia Co-Occurring With Anxiety
Cathy is 42, divorced, and living alone. Cathy struggles with anxiety that keeps her awake at night. She spends hours in bed thinking through every past encounter, she’s fearful about what others think of her, and she engages in “what if…” thinking frequently.
Cathy Is Reporting:
- No family history of insomnia
- Personal history of onset insomnia
- Mild depression, high anxiety
- Family history of anxiety
- No other sleep disorders present
Sleep Behaviors:
- Goes into bed at 10:00 P.M.
- Immediately re-plays the days events
- Worries about upcoming events and potential problems
- Falls asleep in 1-2 hours
- Sleeps soundly
- Wakes at 6:00 AM
Sleep Environment:
- Quiet
- Dark
Life Habits:
- Finishes work around 4:00
- Works out
- Eats dinner at 5:30
- Chats with family and friends
- Reads and then goes to bed
Therapist’s plan for Cathy’s Anxiety-Related Insomnia
For Cathy, CBT could be used to address anxiety, depression and sleep issues. As in the other scenarios, stimulus control to recondition Cathy to view her bed as only a place to sleep is needed. A first step might be to have Cathy process her worries well before bedtime and outside of her bedroom.
Time Boxing for Anxiety
Time boxing the amount of time spent processing anxious thoughts and teaching Cathy concrete skills to identify, challenge her “what if…” thinking could be part of Cathy’s treatment plan. Her tendencies to re-play scenarios and indulge her anxious thoughts might best be reframed as habits that take some time to break.
Worrying anytime outside of the boxed off time would be firmly discouraged. However, old habits die hard. So, when anxious thoughts float in Cathy would be instructed to remind herself that it’s not time to address this thought. Instead, she should get up and participate in an engaging distraction. Any unprocessed worries could be written on a sticky note to be addressed later.
Relaxation techniques to help promote sleep and reduce anxiety would be taught. Learning how to fact check emotions and not engaging in avoidance behaviors would also be goals. Learn more about CBT techniques for anxiety here.
Is CBT Effective for Insomnia?
A 2015 meta analysis found that “CBT for Insomnia improved global outcomes and nearly all sleep parameters in the general adult population, older adults and adults with pain.” No adverse effects were noted and no other psychological intervention matched its effectiveness.7
Robinson, Smith, Segal & Segal report that, “A recent Harvard medical school study found Cognitive Behavioral Therapy for Insomnia more effective than prescription sleep medication.” The benefits of the CBT-I intervention was reported to last at least one year post treatment.17
Geiger-Brown, et al, conducted a meta analysis of the effect of CBT-I on insomnia comorbid with medical and psychiatric disorders. Based on weighted mean differences they found CBT-I yielded a 20 minute reduction in sleep onset latency and a 17 minute improvement in total sleep time. These benefits were still in effect 18 months post treatment.12
How to Find a CBT Specialist for Insomnia
Many therapists are well trained in CBT techniques. However, therapists with the certification in Behavioral Sleep Medicine are best suited to carry out CBT-I training. They have knowledge in both the science of sleep and the science of behavior change.
CBT-I practitioners can be found through the American Board of Sleep Medicine and the Society of Behavioral Sleep Medicine.9
Online directories, especially those that allow you to search clinicians by specialties, your company’s employee assistance program, and college universities with sleep centers, are all viable ways of finding a CBT-I referral.
Cost Of CBT
If your insurance covers psychotherapy or behavioral medicine, it should cover CBT. Selecting a therapist who is “in network” (contracted) with your insurance company might limit your cost to a per session co-pay, (typically $20.00-$50.00).
Private pay (non-insurance) clients can expect to spend somewhere between $100-$200 per session with variables such as the clinician’s type of degree, experience, practice setting and geographic location all factoring into the fee.16 Therapists in more expensive cities, like New York or Los Angeles, may charge substantially more ($200+).16
Do you have outpatient mental health benefits, but your chosen clinician does not participate with your insurance plan? You might still have some recourse. Some plans, after the client has paid a specified amount of out of pocket costs, (a deductible), will pay a percentage of the rest.
Many university and community counseling centers, as well as some private practitioners, offer a sliding scale rate. They will adjust their fee based on their client’s income. If you do have insurance, call your plan prior to starting therapy (their number is typically on the back of your insurance card). Provide the name of the therapist you are considering seeing. They will tell you if the clinician is currently in-network, and if not, what percentage of the fee you are responsible for paying.
At-Home CBT Exercises for Insomnia
Many CBT-I interventions can easily be implemented at home.
Step 1
Establish a baseline of your sleep habits and keep a record of your progress. Sometimes it’s hard to see small successes. Keeping a record will show you if you are on track to reach your sleeping goals.
There are plenty of smart technology options (phone apps, smart watches, bedside monitors) that can collect and organize your sleep data. Some will produce light that stimulates melatonin production, and use gentle vibrations to help you sleep and wake.(F13)If you’d rather stick to pen and paper, you could instead download the National Sleep Foundation’s Diary.
Step 2
Set yourself up for success by cultivating sleep promoting habits. Here are a few to try out:
- Limit your bed to sleep and sex.
- Set a standard wake up time (regardless of sleep time).
- Only go to bed when you are very sleepy.
- Set your morning alarm and don’t look at your clock/phone until it rings.
- If you are awake in bed for more than about 10 minutes, get up and move to a different room. Do not return to bed until you are so drowsy you are about to fall asleep.
- Keep your bedroom dark.
- Do some aerobics and/or strength training exercises earlier in the day.
- Avoid “trying” to sleep. Try slow breathing, or reading a book to relax.
- Do not try to catch up on sleep; no naps!
Step 3
Grab hold of your thoughts. Nighttime is primetime for ruminating about past events and possible future problems. With the distractions of the day gone, anxious thoughts flood in. Switch up your routine by designating a different time of day, (15 min. max), to process worries.
If you are worried about forgetting something for the next day keep a pad near your bed. Write down your reminder and then reassure yourself that you don’t need to think about it anymore, you have a written reminder.
