Cognitive behaviour therapy for insomnia

Cognitive behaviour therapy for insomnia (CBT-I) is the widely accepted treatment of choice for insomnia, including insomnia that occurs in the context of a wide range of illnesses. It has a large evidence base showing it to be the most effective intervention for chronic insomnia. It consists of a package of measures that can be used according to individual circumstances. It must be stressed that some measures should not be recommended by therapists without specialist training and/or supervision. However, it is still helpful to understand the principles in order to avoid giving unhelpful advice.

CBT-I interventions work by strengthening the association between the bed and sleep and by reinforcing circadian rhythms and the homeostatic drive (the two main processes that regulate sleep). It is a matter for debate whether sleep hygiene measures are part of CBT-I, but most authorities would agree that they cannot be ignored. Some measures often listed as sleep hygiene advice are actually part of stimulus control therapy. Stimulus control therapy is an intuitive approach that can be adopted by occupational therapists.

Stimulus control therapy comprises a set of ‘rules’ that aim to create the behavioural and environmental cues that promote sleep – strengthening the association between the bed/bedroom and sleep:

  • Keep the bedroom only for sleep and sexual activity. This is a rule that needs modification for people living in one room or cramped accommodation. It means, for example, not watching television in bed.
  • Go to bed only when sleepy – and not when tired, or just because it is ‘bedtime’ or 8 hours before getting up time
  • Get up at the same time every day (7 days a week). Some flexibility may be needed here if the individual has to get up particularly early some days in a week. The important thing is not to sleep in late on non-working days. (If a little extra time is taken at weekends, it is better to be on the Saturday morning and keep to the schedule on Sunday)
  • Do not sleep in the daytime (although a sleepy driver should always ignore that rule and stop somewhere safe for a nap).
  • Do not remain in bed if awake for 15-minutes. The ‘15-minute rule’ suggests that if the individual is not asleep, or does not return to sleep on waking in a period of about 15 minutes (estimated without clock-watching), s/he should leave the bedroom and sit somewhere else, doing something interesting but unstimulating, until sleepy again. This should be repeated as necessary.

The 15-minute rule is difficult and must be adhered to for as long as it takes. However, it should never be recommended to anyone who is at risk of falls in the night and it may be unsuitable for people with any condition that affects mobility. Although the 15-minute rule is a cornerstone of stimulus control therapy, the acceptance and commitment therapy approach (see The Sleep Book by Guy Meadows, for example) argues that it is better to remain in bed and rest. There is certainly a case for that at the end of the night when it is possible that an individual is drifting in and out of light sleep.

It is probably best for occupational therapists not to recommend strict application of the 15-minute rule but (as with sleep restriction therapy, below) it reminds us that there could be times when it is unhelpful to remain in bed when wide awake.

Sleep restriction therapy (also known as sleep scheduling) works by increasing sleep efficiency (which is time asleep/time in bed expressed as a percentage). The only way that an individual can increase sleep efficiency is by reducing time in bed, with the likely result of restricting sleep. This is why it is a difficult strategy and not to be recommended lightly (and not at all to someone such as a professional driver or someone with a condition that is exacerbated by sleep deprivation, such as bipolar disorder or epilepsy). Once sleep efficiency is increased, time in bed can be increased gradually.

Sleep restriction therapy should not be recommended without appropriate training but the important message is that it is unhelpful to spend long periods of time in bed awake. However, therapists can still recommend improving sleep efficiency by going to bed a little later (when sleepy) and/or getting up a little later.

Paradoxical intent is another method for specialists which essentially asks the individual to give up trying to sleep. It is not recommended but reminds us that there may be times when it may not be worth trying to sleep. Indeed, it is never worth ‘trying’ to sleep because the act of trying increases arousal.

Relaxation is recommended as part of CBT-I. Most authorities favour progressive muscular relaxation.

For dealing with thoughts CBT-I recommends these strategies:

 Thought stopping involves repeating a meaningless word such as ‘the’ to oneself in order to distract oneself from other thoughts.

Rehearsal and planning. This involves setting aside time well before bedtime to go through all current events – things that have happened and things that need planning for – and to decide what needs to be done and to record a plan, so that in bed there is, in theory, no need for further consideration of the subject.

Imagery. Because we cannot think about nothing, it is necessary to have something to replace thoughts that make the mind busy. Imagery involves thinking through a prepared scenario in great detail. It should be interesting enough to

Cognitive therapy. When negative thoughts – particularly about poor sleep and any negative consequences – increase arousal sleep becomes less likely. It is therefore helpful to learn to challenge negative thoughts with more realistic alternatives.

Further information: a useful manual that can be recommended to patients/clients is Colin Espie’s Overcoming insomnia and sleep problems

Content on this page by Andrew Green and Louise Berger.