"How can chronic insomnia be treated with therapy?" "Doesn’t it require medical treatment?" These are questions that commonly come up when clients reach out to me looking for support with their chronic insomnia and the answer often surprises them.
Since insomnia is categorized as a sleep disorder and the doctor is normally the first professional that is made aware of the trouble, many imagine that the solution is also a medical one. This may be true in some cases. Where there is short-term insomnia your physician may determine that prescription medication (for a brief period) may be the solution. However, if you have struggled to free yourself from the grip of chronic insomnia for years, you have most likely already tried various prescription medications, in addition to countless sleep strategies, over the counter supplements, sleep products, or any suggestions from friends and family. But unfortunately, you may have found that nothing has really worked, or resolved your chronic insomnia permanently. This is because all these efforts and ‘solutions’ are not designed to address the underlaying reason(s) for the disruption in your sleep.
When insomnia becomes chronic (lasts longer than 3 months), it is usually because the sleep mechanism has been altered (either due to a triggering issue you may have initially experienced or sometimes out of nowhere). But why is it that when the trigger is resolved or is no longer at play, the insomnia still continues? The reason it becomes so sticky and hard to get rid of is because something (in the form of behaviours or thoughts) is maintaining this new altered sleep system and pattern. Without addressing these factors intentionally the insomnia continues to stick around and disrupt your sleep.
For chronic insomnia to be effectively treated, in addition to accurately diagnosing it and treating the contributing physical and psychological problems, there needs to be an identification and adjustment of the behaviours that maintain or worsen the chronic insomnia, as well as addressing and changing the thoughts that sustain sleeplessness. This is where CBT-I comes in and does the most effective job! Below I will discuss what CBT-I is, its effectiveness, who it is for, and how you can access it.
What is CBT-I?
Cognitive Behaviour Therapy for Insomnia (CBT-I) is a specialized form of Cognitive Behaviour Therapy (CBT). At its core, CBT is a skill-based approach to treatment that uncovers and challenges the negative thoughts and unhelpful behaviours we engage in and helps us replace them with healthier ones. It also places an emphasis on helping individuals learn to be their own therapists.
CBT-I takes this one step further and is tailored to address the unique challenges faced by those experiencing chronic insomnia and aims to treat this sleeping issue at its root. It is a multicomponent treatment that focuses on various factors affecting sleep, such as the thoughts relevant to sleep, behaviours surrounding sleep, environments and sleep habits, and stress levels. Depending on what fits the needs, the components target the specific patterns of thoughts and behaviour that is maintaining the insomnia. It aims to address sleep-related misconceptions and thoughts, adjust unhelpful sleep habits, and manage and lower sleep-disrupting stress. These components may include Education, Stimulus Control, Cognitive Restructuring, Sleep Restriction, Sleep habits, Relaxation Training & Stress Management.
As every person’s struggle with chronic insomnia is unique, every CBT-I treatment plan is individualized and based on a person’s specific medical, psychological, and social history, as well as their unique sleep/wake pattern. Information about the sleep profile is gathered through a sleep log, which provides an insight on potential areas of concern that is contributing to and/or maintaining the chronic insomnia. Once an accurate picture of the insomnia is established, components of CBT-I treatment are individualized to focus on the particular areas of concern in order to treat the issue at its root.
CBT-I is short-term and focused and does not require “deep therapy”, meaning it does not need to delve deep into issues from the past. It is typically done in weekly sessions with a trained CBT-I therapist and involves practicing the skills learned, as well as ongoing monitoring of the sleep pattern through sleep logs. CBT-I can also be implemented both as a stand-alone treatment for chronic insomnia or implemented with sleep medication and other treatments and psychotherapies that you may require or already be involved in.
Does CBT-I Work?
Yes, it does! Over 50 years of evidence-based clinical research has proved this. CBT-I has been demonstrated to be the most effective treatment option for chronic insomnia, even in comparison against other modes of treatment such as medication, sleep hygiene, and other psychotherapeutic modalities.
Due to this reason, the American College of Physicians and The American Academy of Sleep Medicine recommend CBT-I as the first line of care when treating chronic insomnia. It is considered the “gold standard” of treatment because:
It demonstrates 70-80% improvement (and is more effective than medication in most cases)
It addresses the root causes of insomnia rather than just relieving the symptoms.
It is short-term, and cost-effective in the long run when compared to the cumulative cost of medication over time
There are no side-effects or additional issues such as addiction.
The results are long lasting because it relies on teaching skills, which can be used anytime in the future if insomnia returns.
Who Is CBT-I For?
CBT-I is for those who have problems with falling asleep or staying asleep at least three nights per week for at least three months (for more information on insomnia read HERE). CBT-I may also be recommended for people with chronic insomnia that have not improved after trying other treatments on their own. Elements of CBT-I can also benefit anyone who is experiencing short-term insomnia (less than 3 months) and wants to prevent their acute insomnia from becoming chronic, as well as those who just want to improve the quality or length of their sleep.
CBT-I however, is not helpful in treating sleep issues due to other sleep disorders, such as circadian rhythm disorder, shift work, restless leg syndrome, nightmares, or obstructive sleep apnea. In such conditions a referral to a Sleep Doctor is warranted. Nevertheless, an individual may also be experiencing chronic insomnia at the same time as other sleep disorders. In such cases once the other sleep disorders are carefully assessed and addressed, CBT-I can be initiated.
Finding a CBT-I Therapist
You can receive CBT-I support either in a self-help format (through books or self-paced programs) or from a professional who has completed specific training in its application. Depending on your level of need and commitment, self-help material can be helpful in cases where there are general and straight forward issues around sleep and insomnia and you are the type that is able to self-motivate and stick to a standard plan. However, some may be experiencing sleep issues that are more complex and find that ‘self-help’ route is not meeting their needs. Others may find that they are too exhausted or lack the discipline to follow the program on their own. If you are one of these people, then working one-on-one with a CBT-I therapist may be a right decision.
Working with a CBT-I trained therapist provides the opportunity of comprehensively assessing your sleep and providing a profile of your insomnia, which can offer an in-depth and accurate understanding of the root cause of your insomnia. It also offers you a custom created treatment plan that is tailored uniquely to your sleep needs and issues and accounts for all your specific medical, mental, and situational circumstances. Working with a CBT-I therapist also provides you with ongoing one-on-one support from the first step to last, helping you through any hiccups you may experience and keeping you motivated until you reach your end goal of beating insomnia for good. Additionally, working with a licensed mental health therapist allows you the opportunity to address additional mental health or emotional issues (through an integrated treatment plan) that may also be contributing to your insomnia. This can further benefit the treatment outcome of your insomnia.
It is essential to note that sleep is a complex phenomenon with close relationship to other physical and mental health aspects. As a result, it is very important that the CBT-I practitioner that you work with is a regulated professional with the education, expertise, and the experience necessary in addressing sleep issues, as well as sufficient training and close familiarity with the nuances related to the application of CBT-I. Working with a professional who is bound by a regulating governing body can ensure competency and accountability. The services provided can also be tax-exempt and be covered under extended health and insurance plans.
Experiencing chronic insomnia for many years can be incredibly demoralizing and trying to find a cure can add to the frustration. It may feel like there are no options and you must accept your insomnia as part of your identity. However, the fact is that insomnia can indeed be successfully treated, as long as you are applying the right treatment. If you find yourself in a place where you have been suffering for a while and are exploring what options are out there or have questions about CBT-I that you can’t find the answers to, or if you are ready to take the next step, reach out to me with your questions and I will be happy to provide information about CBT-I and how it may benefit you.
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