How does CBT-I work?
Part 2 of Our Science Series | CBT-I, or cognitive behavioral therapy for insomnia, is the gold standard for treating insomnia. Learn more about CBT-I and how it works.
«Previous: Understanding Insomnia
CBT-I, or cognitive behavioral therapy for insomnia, is the gold standard for treating insomnia. It is the most effective known treatment for insomnia and has been proven to work for as many as 70% to 80% of patients with primary insomnia in clinical trials. Improvements include less time to fall asleep, more time spent asleep, and waking up less during sleep. Unlike sleeping pills, the improvements from CBT-I are maintained over time. This is why both the American College of Physicians and the American Academy of Sleep Medicine recommends CBT-I as a first-line treatment for insomnia patients.
CBT-I is NOT about sleep hygiene
Before we dive into how CBT-I works, it is important to clarify that CBT-I is NOT about sleep hygiene. This is a popular misconception. While common advice such as “avoid caffeine after 4pm”, “limit alcohol in the evening to no more than 2 drinks before 7pm” or “minimize the use of blue-light emitting devices an hour before sleep” are helpful, there is little evidence that sleep hygiene alone is sufficient to treat insomnia.
For any insomnia treatment to be effective in the long-term, it needs to address the root causes behind sleeplessness (recall Spielman’s 3 P’s Model from Part 1). Traditionally, CBT-I is a multicomponent treatment that combines several approaches, including cognitive restructuring, stimulus control, and sleep restriction.
A core principle in CBT-I is that the way we sleep is influenced by our thoughts and feelings about sleep. People with insomnia often have dysfunctional thoughts about sleep that result in behaviors that are detrimental to good sleep.
Cognitive restructuring attempts to break this destructive feedback loop by identifying, challenging and reframing the thoughts and feelings that contribute to insomnia. For example, many insomniacs have distortive thoughts such as thinking “Oh my god, it’s been 15 minutes but I still haven’t fallen asleep. I’m never going to be able to fall asleep”. These thoughts, in addition to being logically wrong, also create a negative stress cycle where the longer you can’t fall asleep, the more you think these thoughts, the more stressed you become, and the more unlikely you are to fall asleep soon.
Cognitive restructuring equips patients with the tools and skills to challenge and alter their dysfunctional thoughts and feelings. This usually takes the form of structured exercises that require active participation from the patient.
Stimulus control is based on the psychology of conditioning. Classical conditioning was first studied by the Russian scientist Ivan Pavlov in 1897. Pavlov observed in a series of experiments with dogs that he can provoke a conditioned response (salivation) to a previously neutral stimulus (a bell ringing). Similarly, people with insomnia often associate wakefulness (conditioned response) to their bedroom (stimulus) due to habits such as reading, watching TV or using devices in bed.
Stimulus control aims to break these associations by reclaiming the bedroom as a sanctuary for restorative sleep. Some guidelines for stimulus control include:
- Use the bed only for sleep and sex
- Adhere to a consistent wake up time
- Get out of bed if unable to fall asleep within 20 minutes
- Have a plan-of-action for what to do if woken up in the middle of the night
You will also learn to recognize the difference between being tired and being sleepy, so you only go to bed when you’re sleepy (and not just tired).
Sleep restriction therapy is one of the most powerful tools in sleep psychology and has been extensively researched. People with insomnia often find it counterintuitive that you have to try to stay awake in order to get better sleep, but this is fundamental psychology at work. You’re so sleepy by the time you hit the pillow that you immediately fall into a deep, restorative sleep. In time, your mind starts forming a strong, permanent association between your bed and quickly falling into a restorative sleep. This association will benefit your sleep for the rest of your life.
The way sleep restriction works is by narrowing your sleep window at the beginning of treatment to increase sleep efficiency, or the ratio of time asleep to time-in-bed. Your sleep window is then gradually adjusted in each subsequent session so that you would be able to achieve your sleep goals eventually. There are techniques used by sleep clinics to calibrate your time-in-bed on a regular basis, using your past sleep data and combining it with results from a sleep questionnaire.
Increasingly, relaxation techniques such as breathing exercises, progressive muscle relaxation, guided imageries and meditation are also introduced to supplement CBT-I during treatment. Patients learn and practice techniques to regulate their heart-rate and breathing, relax specific muscle groups in the body, and observe their subconscious mind. Benefits include reduced stress and anxiety, and achieving a state of hyper-relaxation that is conducive to restorative sleep.
CBT-I with Stellar Sleep
Stellar Sleep’s digital CBT-I program is rooted in the same clinically-proven practices used during in-person CBT-I. We combine the traditional CBT-I program with content personalization and relaxation exercises, to create what is probably the most effective treatment for insomnia that is available, and we have the data to back this up. Moreover, our program makes it convenient for you to access treatment anytime and progress at your own pace, all from the comfort of your smartphone. In Part 3, which is also the final part in this deep dive series, we will tell you more about what you can expect from the Stellar Sleep program.