Changing minds: how CBT can break the sleepless cycle

Although many GPs still seem unaware that it can be used to treat insomnia, cognitive behavioural therapy has proved an effective non-drug intervention. What does it entail?

Cognitive behavioural therapy (CBT) is well established as a means of helping people to manage problems by changing how they think and act. It’s commonly used to treat anxiety and depression, but it can also be useful for several other conditions, including bulimia, alcoholism and insomnia.

The occasional night of poor sleep is nothing to worry about. But, if it keeps happening, finding an effective way to sleep well again can become an all-consuming task. Desperate to drift off, many of us avidly follow sleep hygiene advice (see “Clean and serene”, page 6) and try herbal remedies and over-the-counter drugs such as diphenhydramine, a sedating antihistamine designed only for short-term use. But these measures don’t always work.

I’ve experienced long-term insomnia since contracting Covid-19. Thoroughly exhausted after months of sleeplessness, I approached my GP for help. He promptly offered me an antidepressant that helps people to sleep. CBT was never mentioned. 

Perhaps my doctor didn’t feel that my condition was chronic (lasting more than three months) at the time. Or maybe he was one of several GPs who, according to behavioural psychologist Alison Gardiner, simply haven’t yet realised that CBT is the treatment recommended by the National Institute for Health and Care Excellence. 

Gardiner is the founder of Sleepstation, an NHS-approved online service that applies a set of techniques known as cognitive behavioural therapy for insomnia (CBTi). It’s used by about half of the GP practices in England. 

“We get 47% of our referrals from only 20 parts of the country,” Gardiner says. “When people know about the service, they use it. Some of the resistance to getting people into CBTi is down to the fact that sleep isn’t really dealt with as a mental health condition. When someone tells their GP that they’re depressed, say, the GP understands what to do and where to refer them. When someone presents with a sleep problem, the GP may not be aware that CBTi is a good approach. Patients are also unlikely to be aware of it.”

What is CBT for insomnia?

CBT is based on the concept that our thoughts, feelings and actions are all connected, and that negative thoughts and feelings can trap people in a vicious circle of behaviour. Dr Jason Ellis, professor of psychology and director of Northumbria University’s centre for sleep research, describes how it’s being applied to insomnia.

“CBTi is very focused on behavioural concepts,” he says. “It aims to identify, challenge and change any dysfunctional beliefs, attitudes or acts that contribute to insomnia. The rationale behind it is that, when you have insomnia, you try to compensate for it. All the effort you make to try to sleep, coupled with the additional time you’re spending awake in bed, leaves you feeling worried, frustrated and angry – and that’s how we believe that insomnia develops. CBTi aims to address those issues.”

One of the first stages of the treatment is to analyse a patient’s sleep hygiene to help identify any lifestyle or environmental factors that may be playing a role in their insomnia. 

“The interesting thing about this component is that people with insomnia generally have good sleep hygiene,” Ellis says. “But we still incorporate it, just in case.”

Teaching patients the facts about sleep is another initial component. Known as psychoeducation, this aims to dispel common myths – that everyone needs eight hours’ sleep a night to function properly, for instance – that may be contributing to someone’s insomnia.

How CBT for insomnia works

The CBTi programme will ask you to complete a sleep diary for a week or two. This involves noting down what time you went to bed and what time you tried to sleep, and estimating how long it took you to drop off (checking the clock is not advisable). You also keep track of whether you woke during the night and, if so, how long it took you to get back to sleep. Lastly, you note what times you woke up and got out of bed.

Several free apps offer a sleep diary function. These include Sleepful, a CBTi programme devised by the clinical sleep research team at Loughborough University. 

What’s powerful about this technique is that it works on the physical function of sleep and has a short feedback loop. People do see a difference quite quickly

From your diary entries, you’ll learn how long you were asleep as a proportion of the time you spent in bed, which gives a sleep efficiency score (the normal range is 85% to 90%). This leads to one of the core techniques of CBTi: sleep restriction therapy. This is suitable for most people with insomnia, but inappropriate for some patients, including those with a history of bipolar disorder, seizures and/or obstructive sleep apnoea.

“The name of this therapy is terrible, because it doesn’t restrict anyone’s sleep,” Gardiner says. “What it does do is fix a person’s sleep into a set time window. For instance, if you spend 10 hours in bed but sleep for only five hours, there’s no point spending all that time in bed. It works on something called sleep pressure, one of the neurological mechanisms that control sleep.”

Over the course of a day, everyone gradually builds up the need to sleep. After about 16 hours, the pressure to sleep will usually be strong enough to help us to drift off. Sleep restriction aims to keep someone with insomnia up a little longer so that their sleep pressure becomes even stronger. 

“When your sleep pressure is at a very high level, it won’t just help you to sleep initially; it will also enable you to get back to sleep quickly after brief periods awake,” Gardiner says. “What’s powerful about this technique is that it works on the physical function of sleep and has a short feedback loop. People do see a difference quite quickly.”

Improving sleep efficiency 

As part of the restriction process, your sleep efficiency score is reviewed regularly. Adhering to your sleep window can help to improve your score. 

“The first week will be associated with a very brief, mild form of sleep deprivation, as it takes a little while for your brain to reconnect and get back into the sleep default position,” Ellis explains. “Once the amount of time that someone can sleep for starts to increase, we give them an extra 15 minutes in bed for the following week. We gradually increase the time in bed in increments of 15 minutes as their sleep efficiency improves.”

A further element of CBTi is known as stimulus control therapy. This is designed to change how a person with insomnia views their bedroom, as it’s easy to start assigning feelings of dread to the space when you can’t sleep. One idea is to get out of bed if you can’t sleep before any frustration kicks in and do something meaningless for 30 minutes before trying again. Another component is the removal of behaviour such as going to bed early to watch TV or read a magazine. This helps to designate the bedroom as a space that’s solely for sleep.

The various anxieties that can build up around the consequences of insomnia are also dealt with as part of CBTi. For instance, people may worry that their condition could cost them their job. 

“We may have to deal with some catastrophic thinking,” Ellis says. “A person’s thoughts can become irrational when they can’t sleep.”