Today on the blog, Emily K. Fitton, LCSW, discusses the benefits of cognitive behavioral therapy for insomnia. She shares her own personal experiences with CBT-I and explores its clinical implications.

 

I’ve struggled with insomnia for most of my adult life. It would get worse during times of stress, but it became unbearable after a family crisis about two years ago.

I have what’s called sleep maintenance insomnia: waking in the middle of the night, sometimes for hours, and on bad nights not being able to fall back asleep at all. My daytime symptoms include feeling irritable, clumsy, and cloudy – profoundly unwell and exhausted. (Thankfully I have never nodded off during sessions with clients!)

I tried melatonin until a colleague told me that it’s only appropriate for sleep phase disorders, in which a person’s circadian body temperature rhythm drops either too late or too early at night. (The body temperature drop is what triggers the pressure for sleep). She recommended CBT-I, or cognitive behavioral therapy for insomnia. As most insomniacs do, I felt desperate and wanted to avoid prescription medications. I tried CBT-I, using the clinical training manual. After practicing the prescribed techniques, I now generally sleep well, and am able to regulate myself during the occasional nights of insomnia.

Insomnia occurs naturally in the wake of stressful life events. Chronic insomnia develops when people worry about the sleep loss itself, and then employ behaviors to compensate for it. These “common sense” behaviors, like sleeping later, paradoxically make the insomnia worse, driving more worry. In this way, the insomnia takes on a life of its own.

In a six-week CBT-I program, clients learn to replace these negative thoughts and behaviors with positive ones that aim to restore their ability to sleep well again. CBT-I also offers a protocol for clients to taper off of sleep medications. In fact, all leading medical associations now recommend CBT-I as the first-line treatment for insomnia before resorting to medications.

I appreciate this emphasis on mind-body harmony. We all have innate, biological sleep and wakefulness systems. CBT-I teaches clients to support their natural systems to create optimal conditions for sleep, which includes daytime as well as nighttime choices.

It was personally helpful to me to learn the science behind sleep and insomnia. I used evidence-based facts to create positive sleep thoughts (PSTs) that replaced the negative sleep thoughts (NSTs) that were keeping me up at night. As in my clinical practice, knowing how things work (or should work) helps me regulate anxiety and gives me direction and focus.

Using PSTs to change beliefs also helped one of my clients, John, a middle-aged man with sleep maintenance insomnia. Learning that we don’t need eight hours of sleep for optimal performance reduced his anxiety about not getting enough sleep. He stopped trying to force himself to sleep every night. He relaxed and focused on learning his own sleep needs, recording these needs in a sleep diary, and used the PSTs to coach himself through nighttime awakenings. This stopped the cascade of stress hormones that had previously escalated his overactive wakefulness system. He now regularly averages 6.5-7 hours of sleep each night.

Joe, a 38-year-old man, was convinced that he had delayed phase disorder (a.k.a., being a night owl) and worried that insomnia causes chronic health problems. CBT-I provides research findings that debunk a causal link between insomnia and heart disease and diabetes. Learning this encouraged Joe to try CBT-I’s behavioral techniques. The big step for him was a willingness to change lifelong habits by way of sleep scheduling. This meant he had to stick with regular bedtimes and wake times in order to reset his circadian rhythms. His success with sleep scheduling showed him that his insomnia wasn’t something his body was doing to him, and that he was in control of his lifestyle choices.

As a psychodynamic psychotherapist, I can clearly trace the threads of my clients’ histories in the anxiety that manifests in insomnia. However, CBT-I’s exclusive focus on sleep, its short treatment duration, structure, and prescriptive nature offers clients concrete relief from an experience that’s made them miserable for so long.

 

Emily K. Fitton, LCSW, is a psychotherapist in private practice in New York City. She is a graduate of the Manhattan Institute for Psychoanalysis’ Trauma Certificate Program, MITPP’s Adult Program, and Fordham University’s Graduate School for Social Service, and is a clinical supervisor at Maria Droste Counseling Services.