Insomnia is a condition characterized by problems such as difficulty falling asleep, difficulty staying asleep and (in most cases) unrestful sleep that fails to sufficiently refresh the body and mind. The American Psychiatric Association (APA) classifies insomnia as an independent mental health issue in a category known as sleep-wake disorders, and it also appears as a symptom or contributing factor in a number of other mental health problems. One well-regarded, but currently seldom used option for treating insomnia is a form of psychotherapy called cognitive behavioral therapy for insomnia, or CBT-I.
When viewed in a mental health context, insomnia is officially known as insomnia disorder. At one point, the criteria established by the American Psychiatric Association allowed doctors to diagnose this condition (then known as primary insomnia) only in people who did not have some other physical or medical condition that explained their sleeplessness. However, the APA criteria now allow doctors to officially diagnose all cases of insomnia, regardless of their underlying causes. Known potential causes of the disorder include use of a wide range of prescription and nonprescription medications, heavy caffeine use, alcohol use, nicotine use, commonplace or unusual stress, a poorly maintained sleep schedule, major changes in your daily schedule, arthritis, gastroesophageal reflux disease (GERD), hyperthyroidism, Alzheimer’s disease, and a learned habit of staying awake at night. Insomnia also functions as both a symptom and a contributing cause of mental health-related conditions such as depression and a range of anxiety disorders and substance use disorders.
Cognitive Behavioral Therapy for Insomnia
Cognitive behavioral therapy is the collective name for a diverse group of psychotherapeutic practices that seek to identify an individual’s harmful or dysfunctional behavioral patterns, teach the individual to recognize those patterns on his or her own, and then teach the individual to create new patterns that can replace the old ones and improve the quality of his or her daily life. CBT-I is a form of individualized cognitive behavioral therapy specifically designed to address the behavioral patterns that contribute to the presence of insomnia. It focuses on three behaviors in particular: the learned habit of growing more alert when going to bed; reliance on unhelpful or counterproductive techniques to deal with insomnia; and worrying about the consequences of regular sleeplessness. The three CBT-I techniques used to combat these behaviors are known as stimulus control, sleep restriction, and reduction of sleep-interfering arousal/activation. Stimulus control attempts to limit insomnia by increasing the strength of the mental cues that associate bedtime with sleep rather than wakefulness. During sleep restriction, patients initially reduce the amount of time that they spend in bed, then progressively increase this time as their sleeping patterns improve. Reduction of sleep-interfering arousal/activation relies on stress management and other techniques designed to lower sleep-related anxiety and let sleep occur as a natural rather than a forced event. Initial courses of CBT-I usually last anywhere from one month to six weeks, and involve a total of five or six hours of treatment. Monthly follow-ups are sometimes used to reinforce the main phase of the therapy.
In a report published in 2012 in the journal Psychiatric Times, a team of insomnia specialists reviewed the scientific findings regarding the effectiveness of cognitive behavioral therapy for insomnia. They concluded that 12 individual, high-quality studies support the effectiveness of CBT-I for a minimum of one year following initial treatment. Some of these studies directly compared the usefulness of CBT-I to the usefulness of prescription sleeping pills as a short-term insomnia remedy. The general conclusion was that CBT-I produces just as much benefit as medication, and carries the added bonus of avoiding some of the potentially serious side effects associated with sleep medication use.
Not all people respond quickly to the effects of cognitive behavioral therapy for insomnia, and in some cases, a six-week course of treatment only begins the process of addressing a patient’s insomnia symptoms. Despite the effectiveness of CBT-I, only roughly 1 percent of all patients with long-term insomnia receive this therapy as part of their treatment. The authors of the report in Psychiatric Times recommend the use of several approaches to increase CBT-I’s availability to a wider public. They include the establishment of certified Internet courses, use of group therapy sessions and the distribution of printed self-help materials.