CBT-I: What is it and How does it work?

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the most effective treatment for insomnia. We'll tell you what it is and how it works.

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The following is a guest post from the experts at House of Wise, a luxury brand of CBD wellness products that empower women to own their sexual, sleep, and overall health.

At House of Wise, we talk a lot about CBD, but we're also fans of CBT, which stands for Cognitive Behavioral Therapy. CBT is a type of evidence-based therapy that involves changing one's thought and behavioral patterns. According to the American Psychological Association, "In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications."

House of Wise's in-house sleep expert Dr. Kristen Casey specializes in Cognitive Behavioral Therapy for Insomnia, also known as CBT-I, which is a structured, evidence-based program. Dr. Casey fell in love with the study of sleep during her internship at the Veterans' Administration in Phoenix. She now owns a private practice, Evolve Psychological Services, which treats patients for insomnia using CBT.

CBT-I is recommended as the first line of treatment for chronic insomnia; however, CBT-I is not a blanket treatment for all sleep disorders, of which there are more than  70. During CBT-I treatment, a psychologist will help you identify what is causing your insomnia symptoms and work with you to develop better habits. As Dr. Casey puts it, "we focus on psychoeducation and creating realistic sleep goals, changing our thoughts and our behaviors about sleep."

What Is Insomnia?

The Mayo Clinic defines insomnia as "​​a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep." Insomnia can be short-term (or acute) and last for days or weeks, or the sleep disorder can be chronic, meaning it lasts for a month or more.

One important thing to note about insomnia is that it may be a patient's primary problem, but it could also be a symptom of another underlying issue. While insomnia is a diagnosis in and of itself, "sleep difficulties are embedded within a lot of other diagnoses, like depression or mood disorders," says Dr. Casey.

While most adults need seven or eight hours of sleep per night, that number isn't a hard and fast rule; just because you aren't getting eight hours doesn't mean you have insomnia. Dr. Casey says that during CBT-I treatment, one of her goals is to shift her clients' perception from "I need this many hours" to "I need consolidated, quality sleep."

During your first session with a CBT-I practitioner, says Dr. Casey, "we perform a mental health and sleep assessment to determine if your symptoms are best explained by chronic insomnia."

If your psychologist suspects that other sleep disorders or medical concerns are present (such as sleep apnea), they may refer you to a primary care or sleep medicine practitioner instead of or in addition to CBT-I. Research usually indicates that when sleep disturbance is part of another disorder (such as PTSD, chronic pain, or depression), CBT-I is still very effective.

What to Expect From CBT-I

CBT-I is a six- to eight-week treatment that consists of 30-to-60 minute sessions with a therapist, and it can easily be conducted via telehealth since it mostly involves collecting self-reported information and data from the patient.

"I often tell clients, 'I'm not going to be creepy and watch you sleep,'" Dr. Casey says. "Instead, I try to get as much baseline data as I can without being there.”

Dr. Casey gathers that data in the first session by asking questions such as:

  • What time do you go to sleep?
  • How many times do you wake up in the night?
  • What do those awakenings look like?
  • What time is your final awakening?
  • How long does it take you to fall asleep
  • What does your bedroom look like?
  • What is your bedtime routine?
  • Do you have a bed partner? What are their habits like?

From there, the doctor and patient will work together to establish some initial sleep goals and also start a sleep diary. Every morning, you’ll record what your previous night of sleep was like in your sleep diary.

You can't necessarily control when you fall asleep, but you can control when you wake up, so that's what Dr. Casey focuses on first. Once you and your doctor have established an ideal wake time, you work together to come up with a bedtime routine and other solutions. Over the course of the treatment, your doctor may suggest that you try out different sleep windows to see what works best for you. It's important to maintain a consistent wake time, even on weekends.

"From there, we come up with other ideas for the person's presenting issue," says Dr. Casey. "What is keeping them up at night? What's waking them up? What's getting in the way? A lot of times for people, it's a feeling of anxiety."

How Your Environment Contributes to Sleep

Whenever possible, your bed should only be used for sleep and sex. "If your mind associates the bed with stress, anxiety, or reliving memories, you're never going to get to sleep," says Dr. Casey.

Of course, all sorts of other things can interfere with your sleep, from using your phone right up until bedtime to have a room that's too hot or too bright. Some people might be taking medications that interfere with their sleep or drinking too much alcohol before bed. Dr. Casey considers all of these factors when treating someone using CBT-I.

In general, Cognitive Behavioral Therapy requires that you — the patient — understand and change your own behavioral patterns, and CBT-I is no exception. After each CBT-I treatment session, a doctor will give you suggestions for what to work on, try out, or practice in the coming week.

For instance, if your bed is being conditioned to other things outside of sleep and sex (e.g. working in bed), your doctor will urge you to stop using your laptop in bed and reserve the space only for sleep and sex. If your room is the wrong temperature (below 65 or over 75 degrees) or too bright (e.g. if you have overhead lights on), your doctor will encourage you to change those factors. If you are scrolling on your phone up until you close your eyes, your therapist might suggest that you establish a better bedtime routine, or "buffer time."

If your sleep issues stem from anxiety and stress, your therapist will help you learn and practice "anti-arousal" measures — that is, relaxation and self-soothing techniques that involve progressive muscle relaxation, diaphragmatic breathing, and guided imagery or visualization.

Nutrition and exercise both contribute to "sleep drive," which is your body's biological need to sleep. So exercising more could increase your sleep drive, while drinking caffeine late in the day can interfere with sleep drive. While Dr. Casey and other psychologists cannot recommend specific exercise or nutrition plans, they will gather data on these topics to determine what other health factors may be interfering with your sleep.

Technology share chart
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Digging Into Sleep Data

At the beginning of each CBT-I session, Dr. Casey checks in with patients about their general well-being — "how are you as a human?" — and then starts digging into the patient's self-reported sleep data.

Each week, your therapist will collect your sleep data and sleep scores and plot them on a graph so you can see what's working and what's not. Over the course of the six weeks, the goal is to help patients achieve a score of at least 85, meaning that you are sleeping at least 85 percent of the time you are in bed.

"A lot of times, therapy can feel elusive," says Dr. Casey. "CBT-I is very data-driven, and that's why I like it." The evidence-based approach has the effect of helping to demystify sleep.

At the end of a  CBT-I treatment, the goal is that you will have learned what is causing your sleep issues and you'll walk away with a new sleep plan (or further recommendations if your symptoms haven't improved).

"It's important to become knowledgeable about the biological, physiological, and psychological factors that impact the sleep process," says Dr. Casey. "We may hold beliefs about sleep and subsequently engage in behaviors that negatively impact our sleep cycles, which are totally within our control to change."