Cognitive Behavioural Therapy for Insomnia (CBT-i)

Let’s uncover what’s keeping you awake at night, and work to recalibrate your thoughts and behaviour to naturally restore you to better sleep

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What is CBT-i?

Cognitive Behavioural Therapy for Insomnia (CBT-i) is a specialised version of Cognitive Behavioural Therapy (CBT) that combines psychotherapy with established science about sleep. It engages your mind, body and sleep drive to create healthier thoughts and behaviours that bring on sleep naturally.

CBT-i is backed by research and recommended by clinical practice guidelines worldwide as the first-line treatment for insomnia.1-3 Medications should only be considered for short-term use and at the lowest possible dose when CBT-i alone is unsuccessful.

CBT-i combines 6 components –sleep diary, hygiene, control, sleep drive, relax, and thoughts. These components are selected and personalised to the individual, and delivered by an experienced and qualified mental health practitioner specifically trained in CBT-i, such as a sleep psychologist.

6 key components of CBT-i

Your sleep psychologist will design your treatment plan using the components that
may most benefit you.

Sleep dairy
Hygiene
Control
Sleep drive
Relax
Thoughts

Sleep diary

The sleep diary is an essential tool for CBT-i. It is used to determine how best to address your insomnia and improve your sleep. Sleep details to record include:

  • Time to fall asleep
  • Night-time awakening
  • Day-time naps

Your sleep psychologist will encourage you to record your sleep each morning, and use it to track your sleep patterns and improvements over time.

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Hygiene

Sleep hygiene involves increasing practices that encourage and support sleep, and decreasing or eliminating those that discourage sleep, for example:

  • Keep a regular exercise and sleep schedule
  • Avoid stimulating activities and food before bed
  • Create a calm and comfortable place to sleep

Your sleep psychologist will work with you to establish a day-and night-time routine that works for you.

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Control

Stimulus control works to break the connection between being in bed and feeling frustrated. After getting into bed to sleep, it’s best to get out if:

  • It feels like 20 mins has passed
  • Your mind is racing
  • Starting to feel frustrated or anxious

Depending on your mind’s response to lying awake in bed, your sleep psychologist will identify strategies that could help you relax so you can go back to bed when you start feeling sleepy again.

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Sleep drive

A temporary restriction of sleep time works to build your sleep drive –the longer you’re awake, the more your need for sleep increases. This allows you to eventually fall asleep faster and stay asleep more soundly through the night. Sleep restriction can be hard at first, but is one of the most effective components of CBT-i. It may involve:

  • Going to bed only at the prescribed bedtime
  • Avoiding naps in the day
  • Setting an alarm at the prescribed wake time

Your sleep psychologist will tailor the approach so that it works for your needs and routine.

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Relax

Relaxation training involves learning techniques that can help you cope with periods of stress. These are simple techniques that can be practised for a few minutes as needed in or out of bed:

  • Mindful breathing
  • Visual imagery
  • Progressive muscle relaxation

Your sleep psychologist will explain how and when you can incorporate them into your routine to reduce stress and anxiety, and help you transition into and back to sleep.

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Thoughts

The cognitive part of CBT-i involves changing thoughts that can make it very difficult to sleep, particularly feelings of guilt and anxiety about not sleeping. It may involve:

  • Scheduling a time to face your worries
  • Identifying triggers of negative thoughts
  • Challenging and reframing negative thoughts

Your sleep psychologist will help you examine unhelpful thoughts you may have about sleep. Through sessions and homework, you’ll learn to question these thoughts as they arise, and reframe them more positively.

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CBT-i program schedule

This is an example of a CBT-i program with 4 – 6 weekly sessions. Your sleep psychologist will personalise the components and schedule to your needs which may differ from the example shown.
 
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Why haven’t I heard of CBT-i before?

Although CBT-i is an effective treatment for insomnia, people with insomnia are not often referred to this treatment as demand for CBT-i specialists far exceeds supply. A recent survey identified just 752 CBT-i specialists worldwide, of which 88% are based in the United States.4

Finding a trained CBT-i specialist can thus be hard, and long wait times to see one may result in the preference for “quick fixes” such as sleep medications.

How long does CBT-i take to work?

Improvements in sleep quality and duration may be seen within 2 to 3 weeks of starting CBT-i, and sleep usually keeps improving as the program continues.5 During the CBT-i program, it will be important for you to keep a positive mindset and follow through on the recommended approach.

CBT-i is not a “quick fix” because changing behaviours and thoughts takes time and commitment. However, if the learned strategies continue to be used, improvements in sleep can be long-lasting, more so that sleep medications.6

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How is CBT-i different at Rivi?

At Rivi, we understand that women’s sleep challenges are complex and nuanced, requiring a deeply personalised approach. Factors that affect women’s sleep may include hormonal fluctuations (e.g. menstrual cycle, pregnancy, post-partum, and menopause), medical issues (e.g. depression, anxiety, headaches), and unique family dynamics (e.g. breastfeeding, co-sleeping, care giving responsibilities).

Our CBT-i approach is holistic — we look at the whole woman, the whole story, the full picture, and deliver a personalised therapy experience that starts with the causes and considers your individual context, contributory circumstances, and co-existing conditions. Ultimately working with you towards, and through to, your desired outcomes.

We also understand that you may be time-poor and already exhausted from the adverse effects from prolonged poor sleep. That’s why we’ve made CBT-i available online for your convenience, so you can have access to the therapy from wherever you are.

We’re here to guide and support you every step of the way towards better sleep. We’ve got you, and you’ve got this.

Who is CBT-i for?

CBT-i is suitable for most people with long periods of insomnia. It is effective for people of all ages including those with co-existing conditions and medications such as:

  • Sleeping tablets: Taking or not taking7
  • Women’s health: Pregnancy,8 menopause9
  • Sleep health: Sleep apnea10
  • Mental health: Anxiety,11 depression12
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Citations

1

Source: Qaseem A, Kansagara D, Forciea MA, et al. Clinical Guidelines Committee of the American College of Physicians. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016 Jul 19;165(2):125-33.

2

Source: Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017 Dec;26(6):675-700.

3

Source: Ree M, Junge M, Cunnington D. Australasian Sleep Association position statement regarding the use of psychological/behavioraltreatments in the management of insomnia in adults. Sleep Med. 2017 Aug;36 Suppl 1:S43-S47.

4

Source: Koffel E, Bramoweth AD, Ulmer CS. Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review. J Gen Intern Med. 2018 Jun;33(6):955-962.

5

Source: Morin CM, Beaulieu-Bonneau S, Ivers H, Vallières A, Guay B, Savard J, Mérette C. Speed and trajectory of changes of insomnia symptoms during acute treatment with cognitive-behavioral therapy, singly and combined with medication. Sleep Med. 2014 Jun;15(6):701-7.

6

Source: Mitchell MD, Gehrman P, Perlis M, Umscheid CA. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract. 2012 May 25;13:40.

7

Source: van StratenA, van der Zweerde T, Kleiboer A, Cuijpers P, Morin CM, Lancee J. Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis. Sleep Med Rev. 2018 Apr;38:3-16.

8

Source:  Zheng X, Zhu Z, Chen J, He J, Zhu Y, Zhang L, Qu F. Efficacy of cognitive behavioural therapy for insomnia or sleep disturbance in pregnant women: A systematic review ad meta-analysis. J Sleep Res. 2022 Dec 18:e13808.

9

Source: Drake CL, Kalmbach DA, Arnedt JT, Cheng P, Tonnu CV, Cuamatzi-Castelan A, Fellman-Couture C. Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Sleep. 2019 Feb 1;42(2):zsy217.

10

Source: Sweetman A, Lack L, Lambert S, GradisarM, Harris J. Does comorbid obstructive sleep apnea impair the effectiveness of cognitive and behavioral therapy for insomnia? Sleep Med. 2017 Nov;39:38-46.

11

Source: Jansson-Fröjmark M, Jacobson K. Cognitive behavioural therapy for insomnia for patients with co-morbid generalized anxiety disorder: an open trial on clinical outcomes and putative mechanisms. Behav Cogn Psychother. 2021 Sep;49(5):540-555.

12

Source: Manber R, Buysse DJ, Edinger J, Krystal A, Luther JF, Wisniewski SR, Trockel M, Kraemer HC, Thase ME. Efficacy of Cognitive-Behavioral Therapy for Insomnia Combined With Antidepressant Pharmacotherapy in Patients With Comorbid Depression and Insomnia: A Randomized Controlled Trial. J Clin Psychiatry. 2016 Oct;77(10):e1316-e1323.