On Cognitive Behavior Therapy and Mindfulness for Insomnia

Can’t sleep well? You’re not alone. It’s thought that about one-third of Americans don’t get enough sleep with 10% estimated to have chronic insomnia.

Many people are looking for alternatives to sleep medications and their plethora of side effects. The good news is that more and more research supports the efficacy of behavioral and cognitive approaches for insomnia, so much so that just recently the American College of Physicians recommended cognitive behavior therapy as a first-line treatment for those with chronic insomnia.

Why so many people struggle with insomnia?

There are multiple reasons, including:

1. Sleep can be affected by medical conditions such as Parkinson’s, hyperthyroidism, congestive heart failure, chronic obstructive pulmonary disease, sleep apnea and others. Moreover, sleep disturbances may accompany conditions that are pain related (i.e., arthritis and cancer)
2. Numerous prescribed medications—including steroids—may cause insomnia while others—such as fluoxetine—may alter sleep architecture (the cyclical pattern and organization of sleep) .
3. Sleep is affected by psychosocial factors. Stress or distress about life events (including those related to our personal, work, or family life) can disrupt sleep. Even though sleep usually returns to normal once the acute stressful situation is resolved, sleep disturbances may become chronic due to maladaptive habits or dysfunctional beliefs about sleep.
4. Sleep disturbance is also found in psychiatric conditions (i.e., depression, anxiety, bipolar disorder).
5. Lifestyle factors relating to diet, exercise, alcohol, nicotine, or caffeine consumption may also disrupt or interrupt sleep.
6. Environmental factors such as noise, room temperature, and light can also impact sleep. 

It is imperative to determine which factors affect an individual’s sleep, and based on that assessment, a treatment plan and therapeutic modalities are determined.

Insomnia Treatments

Cognitive behavior therapy for insomnia (CBT-I).

Cognitive Behavior therapy is a psychotherapeutic method designed to change a person’s beliefs, maladaptive thoughts, and expectations related to the realm of life that is being focused upon. In the context of insomnia, cognitive therapy seeks to modify expectations, causes, and consequences of insomnia.

Many insomniacs have dysfunctional cognitions about the causes of insomnia and its consequences. They believe that the effect of insomnia may be more devastating to their health, than it actually is. In addition, studies show that they actually sleep a lot more than they think they sleep.

They often adopt catastrophic thinking and make incorrect assumptions based on faulty misperceptions. These maladaptive thoughts, in turn, trigger heightened physiological arousal, which prevents sleep. This triggers the cycle of insomnia.

CBT therapy serves as a means to deconstruct the patient’s negative thoughts and beliefs about their condition, which in turn helps to decrease the anxiety and arousal associated with insomnia and eventually facilitates sleep.

Are there some people for whom CBT-I works better than others?

If people are not ready to work and put the effort into therapy, then changes cannot occur.

Cognitive therapy does not work for individuals who expect immediate changes. So, the answer is “Yes”, if someone relies too much on medication and expects the magic bullet to cure them, then cognitive therapy will not work.

It takes time to change maladaptive thinking patterns that are ingrained in the individual. It is like learning to ride a bicycle—it requires time and practice in the beginning to become proficient; but with time, new habitual patterns set in and the process becomes easier.

Mindfulness-based CBT approach. What’s this like?

Dr. Couvadelli has developed a 12-week program that incorporates teaching about normal sleep processes, sleep hygiene, progressive muscle relaxation, cognitive behavior therapy, and mindfulness. The purpose of this program is to address insomnia-related difficulties in a comprehensive manner.

One main component of the program is mindfulness.

Mindfulness is a practice that grew out of the Eastern contemplative traditions. The benefit of mindfulness is relaxation and insight. Regular use of this practice will change automatic and often stress-related “reactions” to life events and turn them into thoughtful, measured “responses.”

The practice of mindfulness involves the regulation of one’s attention on a moment-to-moment basis, although it is more than simply an attentional technique. Both the clinical literature on mindfulness and the Eastern traditions from which it is drawn all emphasize the importance of “nonjudgmental observation of whatever arises.” That is, one is instructed to pay attention and be present without labeling whatever arises in one’s awareness as “good” or “bad”—be it a strong emotion, troubling thought, or physical symptom.

Insomnia patients tend to be hypervigilant and are often very anxious, complaining about overthinking, having worrying thoughts and associated feelings when they try to sleep. Thoughts can become so automatic that one may not even recognize how often they have them and how they motivate one’s behavior.

Mindfulness training is used to help insomnia patients become more attentive to distractions and unwanted thoughts before an emotional cascade is triggered. In addition, it provides the patients with an anchor (breath, word, and/or sound) to use when they want to shift their attention from the distracting thoughts. Practice allows patients to more easily detect thought and behavioral patterns, and modify them accordingly.

Eventually, individuals who practice are better able to disengage from automatic thinking and become more relaxed, and therefore sleep better.