If you frequently have insomnia, one of the best treatment options is cognitive behavioral therapy, which involves changing “maladaptive” thinking and behavior in order to promote better sleep. The effectiveness of cognitive behavioral therapy for insomnia, or CBT-I, was confirmed by two analyses last year. One, in JAMA Internal Medicine, combined data from 37 studies of people who had insomnia as well as psychiatric or medical conditions, such as chronic pain, cancer, and depression. The other, in the Annals of Internal Medicine, included 20 studies of people with uncomplicated insomnia. Both found CBT-I to be beneficial—more so than sleeping pills because the effect persists after treatment has been completed, with none of the adverse effects of the drugs.
In July 2016 the American College of Physicians endorsed CBT as the initial treatment for chronic insomnia. It stated that CBT-I can be employed by trained primary care or mental health professionals, and done via in-person sessions, telephone- or Internet-based programs, or self-help books.
CBT-I is a practical approach; you may need only four or five sessions. For insomnia, the primary goal is to recognize and change irrational thoughts and beliefs about sleep that elevate stress and anxiety and thus cause or exacerbate sleeplessness. For example, the therapy may help you understand how worrying about sleeplessness can keep you awake. You may be able to train yourself to think of something else—or at least to refrain from catastrophic thoughts (“If I don’t sleep, I will fail that test and then I won’t get the job”). CBT-I can help you see that even if you are not at your peak after a restless night, you’ll probably do okay anyway. Are you convinced that you can’t get along without sleeping pills? CBT-I can also guide you to behavioral strategies that can help you achieve unmedicated sleep.
Doing CBT for insomnia online
Your doctor may be able to refer you to someone trained in CBT-I. But there are a limited number of such specialists, and there may not be one near you. Another hurdle is the cost of therapy, though insurance may cover it. One promising option is online CBT-I, which may be used on its own or in conjunction with in-person therapy.
The online programs typically provide guidance on how to counter negative thoughts about sleep that increase anxiety or arousal, along with quizzes, behavioral assignments, relaxation training, advice about improving your sleep habits and environment, and a sleep diary. One assignment, for example, may be to try sleep restriction, a well-proven strategy that involves shortening your sleep time initially and gradually lengthening it. With some programs, therapists review the assignments and diary and give personalized feedback and support. Online social communities as well as email or text-message reminders and prompts may also be provided. The 6- to 20-week programs typically cost $100 to $150. Some less-expensive programs are available in CD format.
Accumulating research shows that these computer-based programs can be highly effective. For instance, in a Swedish study in Behavior Research and Therapy in 2015, people with insomnia benefited as much from eight weeks of therapist-guided online CBT-I as from group-based live CBT, and the improvements continued during the six-month follow-up. Other studies have found online CBT-I to be more effective than standard sleep advice delivered online or on paper.
One online program is SHUTi (Sleep Healthy Using the Internet), developed by researchers at the University of Virginia Health System. They have published several studies demonstrating its effectiveness in not only treating insomnia but also improving related psychological symptoms such as depression and anxiety. Another research-supported program is Somnio, created by a researcher from the University of Amsterdam.
You can get a feel for online therapy by trying CBT-I Coach, developed by the U.S. Department of Veterans Affairs and available as a free mobile app. It was designed to be an adjunct to in-person CBT but can be used on its own.
Bottom line: If you sleep poorly and self-help steps haven’t worked, consult a health care provider to make sure there’s no underlying cause such as sleep apnea, physical illness, or depression. If you have uncomplicated insomnia, consider CBT-I, either in person or online. Not everyone is suited to online therapy, however—for instance, some people may fail to follow through with the program without regular face-to-face support and coaching. But some may actually prefer it.
Also see Test Your Sleep Smarts.