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5 Key Components of Insomnia Treatment

Behavioral strategies to improve your sleep.

Key points

  • CBT-I has emerged as a treatment of choice for managing the sleep/wake complaints of insomnia sufferers.
  • Following assessment by a sleep expert, CBT-I clients typically go through a four- to six-session, standardized protocol.
  • CBT-I includes stimulus control, which is designed to remove the negative association between bed and undesirable outcomes such as wakefulness.

If you or anyone you know has had trouble sleeping in the last few years, you’re not alone. Societal, environmental, and work stressors are at an all-time high. It's no wonder sleep problems are running rampant.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, insomnia is characterized by dissatisfaction with sleep quantity and quality, despite adequate opportunity to sleep. Problems are encountered in initiating sleep, maintaining sleep, and/or awakening during sleep that cause clinically significant distress in social or work roles. These problems occur at least three nights per week for at least three consecutive months.

Prevalence rates for insomnia include an estimated 15 percent of the U.S. adult population. Despite this high rate, insomnia is still very much unrecognized, underdiagnosed, and untreated as a health problem. Yet there is mounting evidence that adults who regularly report getting less than six hours of sleep or requiring more than eight hours of sleep each night have increased levels of metabolic inflammation, which can lead to such diseases as diabetes, obesity, heart disease, and some cancers. If you have insomnia, know there are effective treatments available.

ljubaphoto/iStock photo
Source: ljubaphoto/iStock photo

Current data support the usefulness of cognitive behavioral therapy for insomnia (CBT-I), stimulus control, and relaxation training like biofeedback. Both biofeedback and CBT-I are recommended by the American Academy of Sleep Medicine, the National Institutes of Health, and the American Psychological Association for sleep disorders.

CBT-I actually incorporates elements of stimulus control and relaxation training into its approach. It has emerged as a "treatment of choice" for managing the sleep/wake complaints of insomnia sufferers. The National Institutes of Health lists CBT-I as a first-line treatment for insomnia, as effective as medication but likely even more durable over time. This therapy has been found to be efficacious (successful) across ages, gender identities, and cultural backgrounds.

Following assessment by a sleep expert (usually a health psychologist), CBT-I clients typically go through a four- to six-session, standardized protocol covering the five major components (described below): stimulus control, sleep restriction, methods to reduce arousal in bed, cognitive therapy techniques, and sleep hygiene. Many of these five major components are also addressed with biofeedback therapy for sleep problems. If you’ve ever wondered what exactly goes into behavioral therapy for sleep or are curious about what to expect, read on.

  1. Stimulus control is designed to extinguish the negative association between the bed and undesirable outcomes such as wakefulness, frustration, and worry. These negative states are frequently conditioned in response to efforts to sleep after prolonged periods of time in bed awake. The objectives of stimulus control therapy are for the client to form a positive and clear association between the bed and sleep and to establish a stable sleep-wake schedule. What this looks like in practice is only using the bed for actual sleep and sex, nothing else.
  2. Sleep restriction involves limiting the time in bed based on information taken from a sleep log maintained by the client. Without this sleep log, little can be done to actually change sleep patterns, so it’s critical to use it throughout the course of treatment. This approach is intended to improve sleep continuity by restricting the amount of time spent in bed while awake. As sleep drive increases (critical for good sleep) and the window of opportunity for sleep remains restricted, sleep becomes more consolidated. As sleep continuity improves, time in bed is gradually increased to provide sufficient sleep time for the client to feel rested during the day. This approach supports stimulus control goals by minimizing time spent in bed awake, helping to restore the association between bed and sleeping.
  3. Methods to reduce arousal in bed involve teaching a client to use various relaxation techniques such as progressive muscle relaxation, guided imagery, biofeedback, or slow abdominal breathing to lower somatic and cognitive arousal states which interfere with sleep. Relaxation training can be useful for clients displaying elevated levels of arousal. In fact, biofeedback, or the act of using physiological feedback to increase one’s self-awareness and moderate behavior, is also an empirically supported treatment for insomnia independent of CBT, though both combined appear to have the most benefit
  4. Cognitive therapy addresses the idea that cognitive (i.e., thought) distortions can contribute to and sustain unhealthy emotions and behaviors. This identifies and changes sleep-incompatible thoughts, attitudes, and beliefs in order to reduce negative sleep-associated emotions while also promoting sleep-compatible behaviors. Examples of these thoughts include “I can make up my sleep on the weekend” and “My life will be ruined if I can’t sleep.” This form of therapy typically involves homework assignments in which clients are asked to pay close attention to sleep-related thoughts and feelings and record them.
  5. Sleep hygiene involves teaching patients about healthy lifestyle practices that improve sleep. Common factors that can affect sleep include, for example, keeping a regular schedule, maintaining a healthy diet, getting regular daytime exercise, having a quiet sleep environment, avoiding all napping, and avoiding caffeine, other stimulants, nicotine, alcohol, excessive fluids, or stimulating activities before bedtime.

A typical CBT-I session-by-session schedule

Intake Session: Introduction, assessment, orientation, start sleep diary (including hygiene log)

Session 1: Sleep efficiency: Reclaiming the bed for sleep (review sleep diary, educate about sleep drive & circadian rhythm, start stimulus control & sleep restriction)

Session 2: Review, adjust sleep time, sleep hygiene behaviors

Session 3: Review, adjust sleep time, relaxation training

Session 4: Review, adjust sleep time, cognitive therapy I

Session 5: Review, adjust sleep time, cognitive therapy II

Session 6: Review, adjust sleep time, insomnia relapse prevention: action plan for addressing insomnia in the future

Don't be surprised if your provider asks you to complete some questionnaires like the Pittsburg Sleep Quality Index, as this will help inform a treatment plan to improve your sleep and track progress over time. There are also several mobile apps that can help facilitate some of the research-backed strategies mentioned above, and a sleep psychologist won't hesitate to encourage you to use technology to support your learning about how to improve your sleep (rather than stare into the abyss of the internet before closing your eyelids, a prime example of poor sleep hygiene practices we've all been guilty of).

For example, Woebot, a free CBT "robot," can guide you to spot your thinking traps as it relates to your sleep and learn to reframe them with more helpful thinking styles that may facilitate less worry around bedtime. Headspace or Calm both have their own version of sleep stories to help you unwind as part of a good sleep hygiene routine and reduce arousal before bedtime. Wearables as simple as your Apple watch can even help with taking a mindful minute to practice paced diaphragmatic breathing to reduce arousal.

Of note, changing your sleep requires doing something different between sessions (the strategies above), so consider asking your provider about behavioral strategies for sleep if you haven't already done these five steps.

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