Cognitive Behavioural Therapy for Insomnia (CBT-I)

Sleep—it’s so important to have, yet sometimes so hard to get. Mental illness can make getting a good night’s sleep particularly difficult. Whether it’s depression, where you’re exhausted but can’t sleep, or mania, where you have too much energy to feel the need for sleep, insomnia is something that spans across diagnoses. A key non-medication strategy is cognitive behavioural therapy specifically targeting insomnia (CBT-I). It includes cognitive elements, but the emphasis is really on the behavioural aspects.

A good starting point is to keep a sleep log. While you may think you’re aware of your sleep patterns, chances are keeping a log will give a better understanding. There are several examples in the resources listed below.

Behavioural elements

Sleep hygiene

Sleep hygiene is a set of behaviours that promote better sleep at night. Most of us are familiar with many of these recommendations, including:

• avoid caffeine later in the day (there’s a caffeine content list here); alcohol and nicotine can also interfere with sleep
• avoid screen time close to bed, as the blue light tells your brain that it’s time to be awake
• don’t nap during the day
• get regular exercise, althoug not right before bedtime.

You can read about sleep hygiene here.

Boost sleep drive

The drive to sleep comes from an accumulation of tiredness during the day. Napping during the day cancels out some of this accumulated sleep drive, making it harder to get to sleep at night.

Increase sleep efficiency

Sleep efficiency is the ratio of time asleep divided by time in bed. For people dealing with insomnia, sleep efficiency is typically quite low; there’s a lot of time spent in bed while awake.

To increase sleep efficiency, you need to start by spending less time in bed. This can be difficult, as it usually means sleeping less at first. However, it will allow you to establish a better sleep pattern.

You should only go to sleep when you’re sleepy; trying for a consistent bedtime can mean spending more time in bed awake.

If you’re in bed awake for more than 15 minutes, you should be getting out of bed. Get up and do something that’s not very stimulating, and only go back to bed when you start to feel sleepy. Rather than clock-watching to monitor that 15 minutes, try using a meditation or nature sounds track that lasts about 15 minutes; if it finishes and you’re still awake, get up.

Wake up at a regular time

This is essential in CBT-I, even though it’s counterintuitive in some ways. The idea is to get up at the same time regardless of how long or how well you slept. Getting up at a set time should happen even if it means disrupting a sound sleep. Waking up at the same time every morning gets your sleep drive started at a consistent time each day.

Challenge thoughts related to sleep

Some common sleep-related myths are:

• I need 8 hours of sleep to survive
• If I don’t get a good night’s sleep, then … (something bad will happen)
• If I’m having trouble sleeping, I need to try harder
• If I have a bad night of sleep I should try to catch up on sleep later

You can try the Dysfunctional Beliefs and Attitudes about Sleep scale to see how many problematic sleep-related beliefs that you have.

Thought patterns like these increase the level of anxiety around sleep and can push you into behaviours that actually worsen sleep.

The behavioural changes related to spending less time in bed awake can also help to chance feelings of frustration and negative cognitions that can become associated with bed. You shouldn’t be doing anything in bed other than sleep or sex.

While trying to increase sleep efficiency may feel like the opposite of what you should do, insomnia treatment guidelines consistently recommend CBT-I as one of the most important and effective treatment measures. Have you ever tried any of these strategies?

Resources

• University of Washington: CBT for Insomnia Treatment Manual
• CBT-I Coach app
• Department of Veterans Affairs: Improve Your Sleep
• My Sleepwell: Sleep diary
• TherapistAid: Sleep diary