Back To Sleep:
Cognitive Behavioral Therapy For Insomnia

What’s Normal Sleep Anyway?

Well, it depends on you.

Each of us has different needs based on our age, our health, our lifestyles, and other factors.

What defines healthy sleep varies from person to person. But for most, “normal” means getting 7-9 hours of consistent, uninterrupted sleep every night.

Sleeplessness or finding yourself waking up often throughout the night are both markers of insomnia.

Chances are you’re not getting the kind of rest you need if you’ve noticed any of the following about yourself:

• You feel groggy most days
• You’re a frequent yawner
• Your mood is prickly
• Your concentration levels are low
• You’re forgetful
• You struggle to take in new information
• Your appetite is insatiable
• You’re clumsy
• Your motivation levels are low
• You rely on caffeine or carbs to keep your energy levels up

All of these are signs that you’re not getting the rest you need.

Even if you’ve only been experiencing any of these for a few weeks or months, they can still be signs that insomnia is causing harm to your physical health, mental health, and productivity levels.

But it turns out that there’s nothing abnormal about experiencing sleep problems. In fact, one in seven adults reports experiencing insomnia at any given point.

Insomnia Triggers

So what leads to poor sleep? Unfortunately, there’s no one easy answer.

There’s a laundry list of reasons, and figuring out why you can’t sleep is a key component of finding a way to get you back on track.

To help you identify what’s keeping you up at night, you can start by asking yourself:

• Are you under a lot of stress right now?
• Have there been any changes to your lifestyle or schedule?
• Are you keeping consistent times for going to bed at night and waking up in the morning?
• Are you interacting with your phone in bed or screens too close to bedtime?
• Are you eating and drinking too much within an hour of going to bed?
• Have there been any changes to your health recently?

Ultimately, you may need to work with your doctor to find out why you can’t sleep, but starting off by asking yourself questions like these can help point you in the right direction.

For Nora, she knew the light from the TV probably wasn’t doing her any favors when it came time to get better rest. But mindless television was the only thing she could think of to shut down her mind that didn’t require effort at the end of a long day.

She had struggled to get to bed before. But it was usually only something that happened every once in a while. For the most part, she actually was a great sleeper.

Lately, however, her once short-term sleep deprivation was becoming more and more frequent. She had started a new job, but it was a job she had fought for. It was one that she was excited about. She looked forward to walking into her office each day and actually enjoyed the projects she was working on. It was the first time she actually felt like she was doing a job she wanted to be doing.

It couldn’t the thing keeping her up at night, could it?

How To Treat Insomnia

Insomnia is a lot of things- it’s annoying and it’s distressing. But beyond that, lack of sleep can be detrimental.

It can leave you at risk for:

• Poor mood
• Increased anxiety
• Increased impulsivity
• Poor memory
• Less creativity
• Weakened immunity
• Weight gain
• Reduced sex drive

So what do you do when you’re spending more time counting sheep than getting shuteye?

If you’ve tried for better rest to no avail, it may be time to reach out for help. And the good news is that there are proven insomnia treatment options available to help you get better rest.

Most doctors will recommend that you start by assessing your sleep hygiene, a set of personalized routines and habits to help you get the best rest possible. Sleep hygiene practices are highly personalized and vary person-to-person.

Some may benefit from using over-the-counter sleep aids for help. Common sleep supplements include melatonin, valerian, Unisom sleep tablets, and antihistamines.

Even though these are all available without a prescription, you should still speak to a doctor before you start using them to make sure you’re taking them safely and properly.

If over-the-counter options don’t work, you do have the option to speak with your doctor about a prescription sleep aid. There are several different types of prescription medications available for this purpose, and you’ll need to work closely with a doctor to determine if any are the right fit for you.

Last but not least, CBT-i, or Cognitive Behavioral Therapy for insomnia, is another common option. CBT-i can be done alone or in combination with some of the other treatment options listed above.

What’s CBT-i?

Cognitive Behavioral Therapy is a form of talk therapy, and CBT for insomnia is specifically geared at helping you get better rest on a regular basis.

According to Psychologist and Sleep Specialist Dr. Alex Dimitriu:

“Cognitive Behavioral Therapy, in itself, deals with how we perceive things (cognition) and how we respond (behaviors). For insomnia, we work to modify beliefs and feelings around falling asleep, staying asleep, and overall sleep quality. The behavioral component looks at the things people do before they go to bed, as they try to fall asleep, return to sleep, and after waking.”

The idea is to bring your attention to the thoughts, behaviors, and habits that keep you up at night and replace them with a new set of habits that will get you not only the amount of rest you’re looking for but the quality of rest as well.

The goal of CBT-i can be broken down into four major parts:

1. Alter any thoughts and behaviors that are preventing you from getting rest
2. Understand which habits keep you up and learn new behaviors that reduce insomnia
3. Minimize conditioned arousal, or the things that cause you to lay awake at night
4. Reducing sleep-related worry that contributes to a constant cycle

CBT-i is designed to tackle your insomnia triggers from every angle, including:

• Situations
• Thoughts
• Emotions
• Physical Feelings
• Behaviors

How Does CBT-i Work?

You’ll work one-on-one with a specialist in regular sessions to achieve these goals. Most meet on a weekly basis; however, much of the work will be done on your own outside of your appointments.

This work might include practicing a new routine, minimizing old habits, journaling, trialing sleep medication, and learning stress-reducing exercises.

In your sessions, your doctor will encourage you to explore your sleep-related thoughts and behaviors and start to help you identify which are keeping you from getting shuteye.

In between sessions, you’ll practice new behaviors as assigned by your therapist and keep track of how they make you feel, what’s working, and what’s not making enough of a difference.

You’ll follow this pattern week over week for a few months until you start to rediscover a good night’s rest.

The number of sessions needed varies person-to-person, but most undergo between 4-10 sessions.

According to Dr. Alex:

“CBT has been researched and used for quite some time now to improve insomnia in people. It is more focused than traditional psychotherapy, and often a shorter course of treatment, targeted at more specific symptoms.”

Regardless of the number of sessions you need, you’ll finish by working with your specialist on putting together a plan that not only helps you get better rest now but down the road as well.

Insomnia is a fairly regular occurrence so it’s likely you’ll experience it again at some point in your life. The goal of CBT-i is to prepare you to know how to tackle it head-on before it becomes a destructive problem the next time you find yourself lying awake.

Nora was surprised when her doctor recommended Cognitive Behavioral Therapy for sleep. After all, she’d never needed therapy before. It was a totally new experience, and she didn’t know what to expect.

In her first appointment, her doctor began by asking her questions about her nightly routine, what she did when she couldn’t sleep, and the structures of her days. She wasn’t surprised at all when her doctor called out her late-night TV watching- she knew she’d get dinged for that.

And she knew it was a habit she had to break. She was hopeful that her doctor could help her do that.

But she was surprised when her doctor brought up her job and suggested it might be the point of stress.

Nora never thought of her job as her insomnia trigger. She loved her work- why would it be keeping her up?

But her doctor pointed out how Nora was consistently mentioning how hard she felt she had to work, that she was at a stage where she thought she needed to prove herself.

Her constant state of overachieving was an unconscious source of stress she hadn’t truly given credence to. She hadn’t recognized the magnitude of what it had begun to do to her overall wellness, including her sleep.

Her doctor suggested putting together a plan for tackling this anxiety source over time to see if she noticed a difference in her rest.

CBT-i Techniques

Depending on your situation and your personal needs, your doctor can pull from a whole list of CBT-i techniques.

Here are some of the most commonly used.

Sleep Hygiene

This is a CBT-i technique you’re more than likely familiar with. Sleep hygiene involves changing your lifestyle habits and routines that affect rest.

And it’s something everyone- from those who only struggle to fall asleep every once in a while to those experiencing extreme insomnia - can benefit from.

In fact, Dr. Alex notes that many of the tips included in sleep hygiene can help make big strides in preventing insomnia:

“Regular bed and wake times, and creating an ‘8-hour opportunity for sleep’ makes a huge difference for most people. Putting down screens before bed is also very helpful, one that’s often undervalued by many people who are struggling with insomnia.”

Sleep hygiene practices often include:

• Establishing consistent bed and wake times, even on weekends
• Creating a regular bedtime routine to signal the body it’s time to sleep and a regular wake routine to alert the body it’s time to get up
• Limiting the activities done in bed to sleep and sex
• Restricting the amount of time spent in bed
• Foregoing daytime naps, particularly late in the day
• Limiting screen time too close to bed
• Averting heavy meals and exercise within a few hours of sleep
• Avoiding stimulants like caffeine, nicotine, and alcohol too close to bed

The habits that work best are personal to each person and you’ll need to experiment to find what works best for you. Dr. Alex recommends keeping a journal so you can keep track of your progress as you try different habits and understand what’s best for you.

Stimulus Control

One of the most maddening parts of insomnia is the conditioning that happens when you’ve struggled to get rest for so long.

For instance, your head hitting the pillow should send a signal to your brain that it’s time to sleep. But instead, it might signal it’s time to overthink.

Negative associations between sleep and habits build up the longer you struggle.

This is where stimulus control comes in.

It minimizes the negative associations that have developed and replaces them with something more positive. For instance, only getting in your bed when you’re sleepy.

Read that again: sleepy. Not tired. If you get in bed and you can’t doze off, don’t just lie there. Get up until you’re sleepy and sure you can fall asleep.

Over time, you’ll retrain your brain to understand that getting in your bed is the place you fall asleep.

Sleep Restriction

Sleep restriction is just what it sounds like- restricting the amount of time you spend in bed.

It sounds counterintuitive- after all, if you’re tired, shouldn’t you spend more time in bed?

Not necessarily.

In fact, spending too much time in bed can lead to more insomnia, not less. The later in the day you spend in your bed, the more trouble you’re likely to have to try to fall asleep at night.

The idea behind sleep restriction is to improve your sleep efficiency, the amount of time you spend in your bed asleep divided by the amount of total time you spend in your bed.

Sleep restriction encourages your sleep drive. Because you only give yourself a finite time in bed to get rest, your body is more likely and more motivated to sleep more deeply.

Your doctor will encourage you to use sleep restriction in alignment with your body’s biological clock, or your body’s desired time to fall asleep and wake up. Your circadian rhythm can be influenced by sending your body signals when it’s time to rest and when it’s time to wake up.

Relaxation Training

Anxiety or increased stress levels are among the most common causes of insomnia. So relaxation training, or finding a way to minimize stress levels before sleep, is one of the most effective techniques for tackling insomnia.

This means sending signals to your brain that, though your mind and body might be experiencing many of the hallmarks of anxiety, like racing heart and racing mind, there is no real danger.

Relaxation techniques will include:

• Softening your muscles
• Calming your mind
• Refocusing your mind

Relaxation techniques are like a muscle- they’re something that needs to be practiced and built up over time. For the most success, you need to practice both during the day and right before bed.

Nora started by working with her doctor to create a sleep hygiene checklist:

• She set a daily bedtime for 10:30 pm
• She wouldn’t watch TV an hour before her set bedtime
• She created a daily bed routine that included a hot shower, meditation, and reading time
• If she did find herself still awake after trying to sleep for 10 minutes, she would leave her bed and read a book in another room, only returning to bed when she thought she could doze off. She would not turn on the TV.
• She would wake up at a set time every day- no longer would she lay around in bed, even on weekend mornings. If she wanted to relax a little more in the mornings, she would read her book on her couch or watch a little light TV.

Nora’s doctor also started working on relaxation techniques for her. Nora’s stress came up when she thought she needed to push herself even harder.

Her doctor first challenged her to recognize these moments when they happened and write them down. She would then go through a quick breathing exercise to clear her mind and refocus.

Then, Nora would come up with a plan and ask herself how hard she really needed to push herself and come up with a realistic plan of action.

CBT-i And Medication

CBT for sleep is one of the most effective methods for overcoming insomnia. It’s a relatively short-term treatment option and is highly personalized to fit the needs and habits of an individual.

Additionally, it gives those who participate in it the skills they need to tackle future problems long after they’ve finished treatment.

However, Dr. Alex notes that CBT-i alone might not be enough for everyone:

“The only drawback is that for some people, there may be a biological basis contributing to their insomnia. In these cases, seeing a doctor for additional options is often also helpful. Not everything is psychological.”

In these cases, your doctor may suggest adding a medication in combination with CBT-i to your treatment.

There are quite a few sleep medications available, and some are alarmed when they hear “sleeping pill”. While some prescriptions are strong, there are options available that aren’t narcotics or addictive.

You’ll need to work closely with your doctor to determine if medication is right for you.

Always follow instructions for medication from your doctor. Never change the medication or dosage without first speaking with your doctor to minimize side effects and avoid any negative withdrawal symptoms.

How Do You Know If You Need Help?

Like we mentioned at the start, there’s nothing abnormal about insomnia. In fact, everyone experiences sleep disturbances at one point or another.

So, how do you know if it’s time to see a specialist?

If insomnia is having a negative impact on your physical health, your mental wellbeing, your daily performance, and your general safety, you should seek help from a doctor.

Ultimately, you’ll need to speak with a doctor to find out if any sleep treatment, including CBT-i, is right for you.

However, some parts of CBT-i, like sleep hygiene, can be helpful to anyone who’s looking for a better night’s rest.

According to Dr. Alex:

“Everyone could benefit from CBT for insomnia because the truth is we could all learn to be better sleepers. Typically, people with trouble falling or staying asleep will benefit from CBT for insomnia, sometimes with the temporary use of medication. But the overall goal is to restore healthy, natural sleep - which, like working out, is best done with the supervision and guidance of a trained professional.”

How To Find Help

You can start by reaching out to your primary care doctor and asking for a referral to someone who specializes in sleep disorders. If you have insurance, you might also be able to get in touch with a representative to find a doctor.

If you don’t have insurance, you can use online search tools to find a sleep doctor in your area like More Than Tired and AASM.

Additionally, you can try reaching out to sleep labs in your city.

How To Get Ready For Your First CBT-i Session

After you’ve made your first CBT-i appointment, there are a few steps you can take to make sure you’re as prepared as possible on the day of your first session.

Dr. Alex recommends:

“Start by reading about CBT for insomnia online. Consider starting a sleep journal and starting to improve some behaviors before the first appointment. At a minimum, trying to keep a regular bed and wake time may be helpful.”

Then, start jotting down some points that you know will come up in your first appointment, like:

• Make note of everything you can remember about your insomnia. When did it start? How does it affect you?
• Make note of any medications you’re on and any other treatments you’ve undergone- for insomnia or otherwise.
• Try improving your behavior before your first appointment.
• Solidify your goals for CBT-i.

Clarifying your thoughts, understanding your goals, and getting ahead on easy changes to poor behaviors around sleep will help kickstart your progress and get you back to the kind of sleep you desire even faster.