Good news—there is no reason to suffer with insomnia, especially now that there is a nonpharmaceutical treatment that is proven to work. It’s called cognitive behavioral therapy for insomnia (CBTI). CBTI is a specialized from of cognitive behavioral therapy that emphasizes changing how our thoughts are structured (the cognitive element) and how we act (the behavioral element).
Many studies have shown that CBTI works in people who are healthy…in those who are sick…in the young, the middle-aged and the old. It works so well that the American College of Physicians now recommends that people with insomnia try CBTI before starting any medication. In head-to-head trials comparing CBTI to drugs, CBTI had a bigger effect on sleep and daytime functioning—and these effects lasted longer. (Drugs, after all, don’t have staying power.) And CBTI avoids the side effects of sleep medications.
But there is a big challenge. There simply aren’t enough specialists trained in delivering CBTI to go around. If you are lucky enough to find someone near you who can deliver this treatment, you may need to wait weeks or months for an appointment, and then you will need to plan on two or three months of in-person meetings with the therapist. It’s simply unrealistic to expect that the estimated 40 million Americans who experience insomnia in any given year all could be helped with this approach alone.
More good news: There are other options, beyond in-person CBTI with a therapist, that use similar techniques to help insomnia in ways that are quicker, cheaper, more accessible and more flexible. To understand these new approaches and which one might be right for you, let’s start with a little background about insomnia itself—and how CBTI works.
DO YOU REALLY HAVE INSOMNIA? A SELF-TEST
While CBTI can help anyone who occasionally has trouble falling sleep, if you have genuine insomnia, you owe it to yourself to get help for the sake of your health. That’s because insomnia not only makes you feel miserable—it can also increase your risk of developing diabetes, depression, obesity and cardiovascular disease. In my practice, I tell patients that they have insomnia if…
•It takes you longer than 30 minutes to fall asleep (at a time when you would normally sleep) or you wake up more than three times during the night and stay up for more than 30 minutes in total, and…
•This happens more than three times a week, more than three weeks a month, for at least three months.
HOW CBTI WORKS
Before I meet with anyone who has a sleep problem, I e-mail them a sleep diary and ask them to write down such things as when they went to bed, when they fell asleep, whether they woke up at night, how long they were up, etc.—and to bring the diary to our first session. Then I explain the principles of CBTI and individualize a sleep program based on the specific issues raised in the sleep diary.
The key first step is usually sleep restriction. Sounds crazy, right? But it’s one of the important behavioral changes that can be involved in CBTI. While restricting the amount of sleep you’re allowed may seem counterintuitive—especially for someone who is already not getting enough sleep—it works by increasing the drive to sleep. For example, by setting a late bedtime (say, 1 am) and an early wake-up time (7 am), with no napping and no weekend sleeping in, sleep becomes consolidated. With the sleep drive increased, you’re able to fall asleep more quickly and stay asleep, meaning fewer arousals or awakenings at night. The program may also contain rules about sleep hygiene, such as using the bed for only sleep and intimacy, no television watching or reading permitted.
Gradually, the sleep restriction is loosened a bit. Usually within 10 to 20 days, we can ease back on the bedtime so people can go to bed 15 minutes earlier. I add 15 minutes each week. By the third week, my patients are generally getting more sleep. That’s when I introduce the cognitive elements, using a questionnaire to uncover a particular patient’s cognitive “distortions” that are interfering with sleep. For example, catastrophizing—worrying about the very worst outcome for any problem—is a common cognitive distortion that leads to insomnia. It produces anxiety that interferes with sleep. The patient and I work together until the patient understands that his/her worst thoughts aren’t materializing. By reframing the thoughts, they become less anxiety-provoking.
This CBTI process takes four to eight weekly in-person therapy sessions—the first two sessions are about an hour, the rest are about 30 minutes. In those sessions, the patient gets help figuring out what sorts of changes will work for the person as an individual and how to overcome obstacles to those changes. If you can find a therapist and have the therapy covered by insurance or pay for it out of pocket, it’s a great approach.
But if you don’t have the time, money or access, here are other CBTI-oriented solutions that might work for you…with my personal take on who is more likely to benefit from each one:
- Brief behavioral treatment for insomnia (BBTI). Meet CBTI’s little brother. This abbreviated variation of the full CBTI program is also effective and may be all you need. It focuses on modifying behavior with less emphasis on the cognitive reframing elements. And it takes only four weeks with just two in-person sessions and two telephone sessions. While there are no head-to-head studies comparing full CBTI to BBTI, several studies do show that BBTI helps people improve sleep. I can vouch for this in my own practice—most of my patients don’t need to complete the entire CBTI program. For about 60% of my patients, by week three, sleep restriction has worked so well that they don’t need to continue coming to see me. We don’t need to start with the cognitive retraining. Any expert who is trained in cognitive behavioral therapy should be able to deliver BBTI. (See below for ways to find a therapist.) My take: BBTI works best for people who are really good at following rules, even a little obsessive about bedtimes and keeping the diary. The more strictly a person follows the instructions the better the results.
- Telephone therapy. CBTI therapy delivered not in person but over the telephone or with video-conferencing is a compromise between in-person therapy and self-help treatment. Phone-based cognitive therapy has been proven to work in treating anxiety, depression—and insomnia. In a study that compared the effects of eight weekly phone treatments to the effects of an informational pamphlet, phone therapy improved sleep and daytime functioning better. My take: Phone-based treatment is a great option for people who live in remote areas without easy access to a trained therapist but who still need some guidance and cheering on. (Note: Some practitioners will advertise that they do “telemedicine” and can perform this type of phone therapy easily.)
- Online programs for insomnia. The Internet is also a great vehicle for delivering CBTI. Two well-tested programs are Sleepio and Sleep Healthy Using the Internet (SHUTi). Both are tailored, interactive programs that guide users through CBTI over a six-week period—a similar pace to “in person” CBTI, but there’s no actual therapist you are working with directly (so you don’t need to find a trained therapist and schedule office visits). In a recent study, participants who used SHUTi had better sleep compared with people who received only educational materials—and in a follow-up one year later, the sleep benefits persisted. Sleepio has also shown positive results, with a statistically significant improvement in sleep quality in those using the online Sleepio program, compared with placebo. The cost of SHUTi is $135, and users have access to the site for 16 weeks. Sleepio is also delivered over six weeks but permits access to the site for a full year—it costs $300. My take: These evidence-based programs work well and are good options for people who don’t need a lot of personal coaching.
- A free app for insomnia. CBT-i Coach, designed for military veterans to be used alongside face-to-face CBTI-based therapy, is a free app that can be used on its own as well. CBT-i Coach allows users to create a sleep prescription, keep a sleep diary and set reminders. The app is available on iTunes for Apple devices and Google Play for Android devices. My take: It’s really meant to be a companion to CBT-I therapy, so I would not recommend using it by itself.
WHEN CONVENTIONAL CBTI IS BEST
The new generation of quicker, easier, faster, more interactive approaches for helping people with insomnia may work for many people who can’t afford the time or money to take a full course of CBTI. But if you have tried these alternative approaches and still aren’t sleeping well, don’t give up. A full program of face-to-face therapy might work much better for you.
Whether you are looking for CBTI, BBTI or phone therapy, below are links to some organizations that can help put you in touch with a qualified therapist. Sleep tight!
Resources to find a sleep therapist:
- Society of Behavioral Sleep Medicine
- Association for Behavioral and Cognitive Therapies
- National Association of Cognitive-Behavioral Therapists
- Academy of Cognitive Therapy