Mental Health Matters: Sleep & CBT-I (CBT-Insomnia) – Amy Phariss, LCMHC

As a counselor, I begin nearly every session with a series of check-ins, and one of the most important is: How has your sleep been?

There is a reason I ask. Sleep is often connected to low mood, lack of motivation, increased stress, anxiety, depression, difficulty concentrating and just about every other reason a client comes to therapy. Sometimes poor sleep is a symptom of what is going on. Other times, after weeks or months of struggling, insomnia becomes a problem of its own.

In this month’s feature on brain health, neuropsychologist Jennifer Richards, PhD, mentions a treatment that many people have never heard of: cognitive behavioral therapy for insomnia, usually called CBT-I. For chronic insomnia, CBT-I is considered a first-line treatment and can be more effective over the long term than simply relying on sleep medication.

What Is CBT-I?

CBT-I is a specialized form of cognitive behavioral therapy designed specifically to treat insomnia. Despite its name, it isn’t simply about changing your thoughts, and it’s much more comprehensive than the familiar advice to avoid caffeine before bed or put away your phone.

Instead, CBT-I looks at the thoughts, behaviors and patterns that may be keeping insomnia going.

For many clients, sleep problems create a frustrating cycle. Imagine that you have several nights of poor sleep. Understandably, you begin worrying about whether you’ll sleep the next night. You go to bed earlier to give yourself more time. You stay in bed later in the morning. Maybe you nap because you’re exhausted. At night, you watch the clock and calculate how many hours you have left before morning. You begin to worry: will I be tired tomorrow? Is this going to be another restless night? I’m going to feel awful when I wake up. Ugh. This will never end.

See the cycle? Your brain begins looping. In no time, your heart rate increases, you’re hot, your bed is uncomfortable and your entire body is involved in this cycle of worry, fear and dread.

Before long, your bed—which your brain once associated with sleep—can become associated with being awake, frustrated and anxious.

CBT-I works to interrupt that cycle.

What Happens in CBT-I?

Treatment usually combines several strategies. A therapist may help you establish a consistent sleep and wake schedule and strengthen the association between your bed and sleeping. You may learn what to do when you’ve been lying awake rather than spending hours trying to force yourself to sleep or ruminate about what will happen if you don’t get to sleep sometime soon!

CBT-I also addresses the thoughts that often accompany insomnia: I have to get eight hours tonight. I’m never going to function tomorrow. Something is wrong with me because I can’t sleep. Learning to recognize and challenge these thoughts can reduce some of the anxiety that makes falling asleep even more difficult.

Another component may involve temporarily limiting the amount of time you spend in bed to more closely match the amount of time you are actually sleeping. This technique, sometimes called sleep restriction or sleep compression, helps consolidate sleep and gradually rebuild a healthier sleep pattern. Because individual medical conditions and circumstances matter, this part of CBT-I is best undertaken with appropriate professional guidance.

Relaxation skills and education about sleep are often included as well. For many clients, this can be frustrating. We’ve all heard the general sleep “rules” – get 8 hours, don’t drink coffee too late, go to bed at the same time. Clients tell me, “I know all of that. I don’t need to come to therapy to hear it again.”

The frustration is understandable. But counseling can help put all of these moving parts together, into a plan. And we can identify root causes for worry and anxiety that clients are often unaware of or haven’t linked to their sleep troubles. Putting all this together is the key to CBT-I.

Where Can I Find Help?

If you have persistent difficulty falling asleep, staying asleep or waking much earlier than you want, you can start by talking with your healthcare provider. Even for counselors, one of the first questions we ask ourselves and our clients is: can these symptoms be caused by a physical health issue? We have to first rule that out before we begin to treat the mental health issues.

Insomnia can have many causes, and conditions such as sleep apnea, chronic pain, medication side effects, depression, anxiety and other medical concerns may need to be evaluated. Many times, insomnia is the result of both physical and mental issues. Treating both increases progress.

If CBT-I is appropriate, look for a mental health professional or behavioral sleep specialist who has specific training in CBT-I. The Society of Behavioral Sleep Medicine maintains a directory of behavioral sleep medicine providers, and the American Academy of Sleep Medicine offers a searchable directory of accredited sleep centers. Your primary care provider or current therapist may also be able to help you locate a trained clinician.

There are evidence-based digital programs as well. CBT-i Coach, developed through the U.S. Department of Veterans Affairs in collaboration with Stanford University, offers education and tools based on CBT-I principles. It was designed to complement treatment rather than replace professional care.

Most importantly, chronic insomnia is not necessarily something we have to tolerate as we get older. Sleep affects how we think, feel and function. When I ask my clients, “How has your sleep been?” I’m not making small talk. The answer often tells us something important about what is happening everywhere else, and helping clients get better sleep helps all other areas of their lives.

Support for You and Your Loved One

Taking care of your mental health matters, especially when you’re caring for someone else. If caregiving responsibilities are leaving you feeling overwhelmed, exploring additional support can be a helpful next step.

CaregiverNC helps families connect with screened, qualified caregivers throughout North Carolina. Learn how our caregiver registry works or explore our Care Concierge program for personalized help coordinating care.

Need help finding care for yourself or a loved one? Contact CaregiverNC or call (910) 692-0683 to discuss your needs.