CBT-I is a multi-component treatment that addresses cognitions and behaviours that interfere with sleep. Alan provides a structured CBT-I program that’s usually covered in a six session treatment protocol (normally one session per week over 6 consecutive weeks). The protocol is flexible/semi-structured in relation to the order of treatment components and the number of treatment sessions. Some clients will complete the treatment in less than six sessions and others will need more than six. An example of a semi-structured six session program is briefly outlined below.
This session is primarily an initial assessment which involves a comprehensive intake interview and the completion of questionnaires. Together, these provide an assessment of the sleep problem and information on the client’s medical and mental health history. This provides an indication of whether or not the client is a suitable candidate for CBT-I and identifies any contraindications. If time allows, some basic sleep education will be provided.
Sleep education is an important aspect of CBT-I because clients often hold incorrect beliefs that interfere with good sleep. Sleep education involves education about the biological and psychological processes that regulate sleep. Clients who gain some understanding of these processes will be better prepared to understand recommended changes to their habitual sleep-related behaviours and cognitions. They are also more likely to adhere to and benefit from treatment.
The sleep log (sometimes called a sleep diary) is also introduced. This log is the most important data collection tool used in CBT-I. It is used to help recognise patterns in an individual’s sleep and track the impact of treatment. It’s a simple log that’s based on a client’s recollection of their previous night’s sleep. Each morning’s log requires only a couple of minutes to complete. The information gathered using a sleep log is very useful for identifying the nature and degree of the sleep problem in order to develop an effective treatment plan. Based on the case conceptualisation one or two initial recommendations may be made.
In this session, the sleep log is reviewed. Stimulus Control Therapy (SCT) and Sleep Restriction Therapy (SRT) are explained and guidelines are provided. Poor sleepers frequently engage in behaviours that results in their bed being a cue/signal for wakefulness. This happens because the bed/bedroom has been repeatedly, negatively linked or paired, with nights of poor sleep accompanied by tossing and turning in bed, frustration, anxiety, worry, and even fear. Through repeated pairing of the bed with these states of hyper-arousal, the bed, and sometimes the bedroom, can become conditioned or learned cues for arousal and wakefulness, instead of sleep. This negative linking with the bed and the bedroom has been learned. This being the case, it can be unlearned and that is what stimulus control therapy aims to achieve.
During this session, potential obstacles to adherence to SCT and SRT guidelines are identified and an attempt is made to address these. If time permits, other treatment components are introduced and/or recommendations made.
In this session, the sleep log is again reviewed and the degree of adherence to guidelines and recommendations is reviewed. The important of adherence is discussed and empathised. Based on an analysis of data from the sleep log, the time in bed (TIB) recommendation is adjusted appropriately. The concept of cognitive arousal is explained and its connection with insomnia is explained. A variety of techniques to calm the mind and relax the body are introduced.
Sessions (4) – (5)
The usual content for these sessions is the following:
- Reviewing the sleep log and, if appropriate, adjusting the TIB (time in bed) recommendation.
- Establishing the degree of adherence and its association with progress, and addressing any identified obstacles to adherence.
- Introducing aspects of cognitive therapy as required. Cognitive therapy is employed to help clients understand how some of their thoughts and beliefs about sleep can contribute to their insomnia, and how to come up with alternative, more helpful, and often more accurate thoughts. This aspect of cognitive therapy is called cognitive restructuring. The modified thoughts and beliefs lead to reduced arousal and facilitate changes in behaviours to ones that are consistent with a strengthening the sleep drive and/or circadian clock. Cognitive therapy can help reduce sleep-related arousal and increase the likelihood of adherence to treatment recommendations. The provision of education includes the facts and common myths underlying beliefs about sleep. By providing such sleep education, used in conjunction with cognitive restructuring, the scientific facts provided will serve to alter inaccurate cognitions that were uncovered during the cognitive restructuring.
Note: During sessions (3) to (5) consideration will be given to whether or not it may be appropriate to include an adjunctive treatment component e.g. mindfulness and/or breathing re-education (for breathing self-regulation) as part of a client’s treatment program.
Again, as in previous sessions, the sleep log is reviewed and the TIB recommendation is adjusted, if appropriate. The degree of adherence to treatment recommendations is reviewed. Barriers to adherence are identified and addressed and the importance of adherence is reinforced.
Relapse prevention is a very important aspect of the final session. Treatment elements that the client found helpful are identified and form the cornerstone of the relapse prevention plan.
There may be times when a client experiences a setback e.g. a stressful life event can result in making it difficult to fall asleep. Fortunately, it’s possible to sustain the benefits experienced from the program, by being aware of the key recommendations implemented that served the client well and for them to continue to do (or resume) what worked for them.
- CBT-I is a collaborative process and the skills/techniques taught to clients, in the sessions, require practice. Homework assignments are therefore an important aspect of treatment.
- After each session, a client will receive a supportive phone call from Alan. They will also be e-mailed information relevant to the session, in the form of one or more of the following: explanatory notes, links to relevant articles, and/or links to relevant videos.