Sleep Better

Lesson 10: Can't sleep? The CBT-I toolkit

Goal: understand cognitive behavioural therapy for insomnia (CBT-I), the recommended first treatment for long-term insomnia, and try its core techniques safely.

What insomnia is

Insomnia means trouble falling asleep, staying asleep or waking too early, despite having the chance to sleep, and it affects how you feel and function during the day. When it happens at least 3 nights a week for at least 3 months, it’s called chronic insomnia.

Insomnia often starts with a trigger (stress, illness, a new baby, a move) and then keeps going after the trigger has gone, because of habits and worries that build up around sleep: going to bed early to “catch up”, lying in bed awake, napping, and dreading bedtime. CBT-I targets exactly those.

Why CBT-I comes first

The American College of Physicians recommends that all adults with chronic insomnia be offered CBT-I as the first treatment, before sleeping pills. It improves sleep, its effects last after the program ends, and it doesn’t have the side effects or dependence risk of medication. The Sleep Foundation reports that around 70 to 80% of people with insomnia improve with it. It usually takes 4 to 8 weekly sessions.

CBT-I has several parts:

1. Education about sleep (Lessons 1 to 3).
2. Sleep hygiene: light, caffeine, alcohol and bedroom (Lessons 4 to 6).
3. Relaxation (Lesson 7).
4. Cognitive work: changing unhelpful beliefs such as “If I don’t get 8 hours I’ll be useless tomorrow.”
5. Stimulus control and sleep restriction: the two most powerful parts, described below.

Stimulus control: retrain the bed

The aim is to make bed a strong cue for sleep again.

1. Go to bed only when you’re sleepy (eyes heavy, nodding), not just tired or because it’s “bedtime”.
2. Use the bed only for sleep and sex. No phone, TV, work or worrying in bed.
3. If you can’t sleep within about 15 to 20 minutes, get up, go to another room and do something quiet and dull in dim light. Return to bed only when sleepy. Repeat as often as needed.
4. Get up at the same time every morning, no matter how badly you slept, including weekends.
5. No daytime naps while you’re doing this.

The first week is often hard. Stick with it; it’s usually the most effective single change.

Sleep restriction: less time in bed, better sleep

This sounds backwards, but it works. People with insomnia often spend 9 hours in bed to get 6 hours of broken sleep. Cutting time in bed to match actual sleep builds stronger sleep pressure, so sleep becomes deeper and more continuous. Then you gradually extend it.

1. Keep a sleep diary for 1 to 2 weeks (Lesson 14). Work out your average time asleep and your average time in bed.
2. Calculate sleep efficiency: time asleep ÷ time in bed × 100. For example, 6.5 hours asleep in 9 hours in bed is 72%.
3. Set a sleep window equal to your average sleep time, but never less than 6 hours when doing this on your own. Fix the wake time first, then count back. For 6.5 hours with a 6 am wake time, bed is 11:30 pm.
4. Stick to it for a week, with no napping.
5. Adjust weekly:
   • efficiency above 90%: go to bed 15 minutes earlier
   • 85 to 90%: keep the same window
   • below 85%: shorten the window by 15 minutes (but not below 6 hours)
6. Repeat until you feel rested during the day.

Be careful with sleep restriction. It makes you sleepier for the first week or two. Do not do it without medical supervision if you:

• drive for work, operate machinery or work in a safety-critical job
• have bipolar disorder, epilepsy or a seizure disorder
• have untreated sleep apnoea, a parasomnia such as sleepwalking, a major illness or recent surgery
• are pregnant

And don’t drive if you feel drowsy.

Getting CBT-I

You don’t have to do this alone, and guided programs work better for many people.

• Free online (Australia): THIS WAY UP Insomnia Program, a self-paced CBT-I course of four lessons designed to be completed over about two months. The Sleep Health Foundation also lists other evidence-based digital programs, including MindSpot and the free CBT-I Coach app.
• With a professional: your GP can refer you to a psychologist trained in CBT-I, and in Australia a mental health treatment plan can cover up to 10 Medicare-subsidised sessions a year. The Sleep Health Foundation lists trained psychologists and group programs.

Exercise 10

Calculate your sleep efficiency for last night (time asleep ÷ time in bed). If it’s under 85% most nights, start a sleep diary this week ready for the two-week reset in Lesson 14, and look at the THIS WAY UP program.

Sources

• healthdirect, Insomnia
• Qaseem et al. (2016), Management of chronic insomnia disorder in adults, American College of Physicians guideline, Annals of Internal Medicine
• Sleep Foundation, Cognitive behavioral therapy for insomnia and Sleep restriction therapy
• Sleep Health Foundation, Cognitive behavioural therapy for insomnia (CBT-I)
• THIS WAY UP, Insomnia Program

This course is general information, not medical advice. If you have ongoing sleep problems, loud snoring with pauses or gasping, or sleepiness that affects driving or work, see your doctor. In Australia, if you are struggling or feel unsafe, call Lifeline on 13 11 14.