Unlocking the Power of CBT-I to Improve Sleep

For several years, I've been deeply invested in the world of sleep. I have conducted independent research and delivered a lecture on the topic to the local police department. In addition, I have done numerous trainings on sleep hygiene for patients in the psychiatric unit. I am constantly seeking the most effective strategies for optimizing sleep quality to share with my clients. This journey culminated in my participation in an intensive CBT-I (Cognitive Behavioral Therapy for Insomnia) training early last year, an experience that profoundly impacted my understanding of sleep and its management. I'm eager to share the key insights and practical tips I gained from this transformative training.

What is CBT-I?

CBT-I is a structured, evidence-based approach to overcoming insomnia. It focuses on identifying and modifying the thoughts, feelings, and behaviors that contribute to sleep difficulties. Unlike traditional sleep medications, which primarily address the symptoms, CBT-I tackles the root causes of insomnia, leading to more sustainable and long-term improvements in sleep quality.  A quick side note on sleep medications is that most of them are classified as “sedative hypnotics,” and it is important to understand that sedation is not the same thing as sleep.

Top Tips from the CBT-I Training:

1. Stimulus Control: This technique involves creating a consistent sleep-wake schedule and associating your bed solely with sleep.

   
   

   • Rule 1: Go to bed only when you are feeling sleepy.

   • Rule 2: If you are unable to fall asleep within 20 minutes, get out of bed and engage in a relaxing activity, ideally in another dimly lit room.  Some examples of activities would be things that are not too stimulating, such as folding laundry or washing some dishes. Definitely no electronics!

   • Rule 3: Repeat Rule 2 as needed throughout the night.

   • Rule 4: Get up at the same time each morning, regardless of how much sleep you got.  The research here shows that it is important to have a similar bedtime and wake up time, but between the two, the wake up time seems to be a bit more important.

     
     

2. Sleep Restriction: This involves gradually reducing the amount of time spent in bed to match your actual sleep time. This increases sleep pressure, making you feel more tired and improving sleep efficiency.  Napping is generally not a good idea for people struggling with nighttime sleep.  However, if you must take a nap, try to limit it to 30 minutes or less.

   
   

3. Relaxation Techniques: Incorporating relaxation techniques such as deep breathing, progressive muscle relaxation (PMR), a short warm or hot shower before bed, or mindfulness meditation can significantly reduce anxiety, relax muscles, and promote sleep onset.

   
   

4. Cognitive Restructuring: This involves identifying and challenging negative thoughts about sleep. These thoughts can include worries about not being able to fall asleep, the consequences of poor sleep, or catastrophic thinking (i.e, magnification of anxious and irrational thoughts).

   
   

5. Sleep Hygiene Optimization: While I've been advocating for good sleep hygiene for years, CBT-I reinforced the importance of these foundational practices. This includes:
   

   • Creating a relaxing bedtime routine: A warm bath, reading, or listening to calming music can signal to your body that it's time to wind down. These activities can help relax your mind and body, lower your heart rate, and prepare you for sleep. For example, a warm bath can increase your body temperature, which then drops as you cool down, mimicking the natural temperature drop that occurs during sleep.  This technique tends to work best if you plan to get in bed very quickly after getting out of the shower.

   • Optimizing your sleep environment: Ensure your bedroom is dark, quiet, and cool.  Most of us need a few degrees reduction in temperature to be able to fall asleep and stay asleep.  Aim for 65 to 68 degrees.

   • Avoiding caffeine, marijuana, and alcohol before bed: These substances can interfere with sleep quality, especially vital REM sleep.  A good rule-of-thumb is to limit your caffeinated beverages to the first half of your day and no alcohol at least 3 hours before bed.

   • Regular physical activity: Exercise can promote better sleep, but avoid intense workouts close to bedtime.

     
     

Takeaways

As a therapist working primarily with adolescents, I've found that many of these CBT-I techniques are particularly well-suited to this age group. Adolescents often struggle with irregular sleep schedules, excessive screen time, and anxiety-provoking thoughts, all of which can significantly impact their sleep. By incorporating CBT-I strategies into my practice, I've witnessed a remarkable improvement in sleep quality and overall well-being among my adolescent clients. However, it's important to remember that these techniques are not just for teenagers. Many of these principles are equally valuable for adults who are experiencing insomnia or simply looking to optimize their sleep.  I encourage anyone experiencing insomnia to explore CBT-I as a potential solution.

By: J. Joseph Fanska MA, LPC, LCPC, C-DBT, CYMHS