From taking a hot bath before bed to listening to a bedtime story, the internet is awash with sleep ‘hacks’ designed to help those struggling with their sleep to rest easier. But what these remedies often fail to address are the root causes of the sleep problems they’re designed to help in the first place.
That’s where CBTi – or Cognitive Behavioural Therapy for Insomnia – comes in. The evidence-based approach, which was recently named the “most effective” treatment for insomnia by a team of researchers in Australia, works by helping those struggling with their insomnia to identify the thoughts, feelings and behaviours that are contributing to their symptoms, and make changes to address them.
But how exactly does CBTi work to identify and address those behaviours?
To find out more about the approach, we asked Stephanie Romiszewski, consultant physiologist and director of the Sleepyhead Clinic in Exeter, to answer our questions. Here’s what she had to say.
How does CBTi work to treat insomnia?
According to Romiszewski, there are three key aspects of CBTi: re-education, which helps to address any unhelpful beliefs or ideas you may have about sleep and replacing them with scientific and factual information; behavioural changes, which will help to boost your sleep drive and physically make it easier to sleep; and making cognitive changes (such as learning relaxation techniques), which will make sleep easier and will also stop you from slipping back into anxiety-driven habits the next time you can’t sleep.
All three of these aspects work together to help those with insomnia to improve their sleep quality and make long-lasting, positive changes to their sleep behaviours.
Below, Romiszewski unpicks the three core aspects in further detail.
“Because we’re not very educated in sleep as a society, when we can’t sleep, our beliefs and understanding about what we need to do to fix our sleep are typically based on things that aren’t facts or science,” Romiszewski explains.
“For example, say you don’t sleep well, you might think ‘OK, I’m going to spend more time in bed because that’s going to increase my chances of sleeping more or sleeping better’. Unfortunately, the opposite is true – but because of your belief, and because you might be getting told this by other people around you, you’ll start a pattern of behaviour that actually leads to chronic sleep problems.
“So, in CBTi, the first thing we have to do is undo those beliefs by re-educating you and helping you to understand the facts, and then try to replace those beliefs with helpful ones that will actually lead to the right behaviours which will help you to sleep more.”
“After we’ve tackled your belief system, what we need to do is look at the science of sleep,” Romiszewski says. “The science of sleep tells us that depriving yourself of bed time – your ‘sleep opportunity’ – actually improves your quality of sleep.
“So, while people think they should spend more time in bed if they’re struggling to sleep – lying in, going to bed early, napping during the day or even trying to steal time from your day for rest by cancelling activities or avoiding doing things – that’s actually going to lead to a problem with sleeping, because it makes it hard for your body to understand the difference between sleep and awareness.
“So, instead of trying to get people to spend more time in bed, we do the exact opposite – something called sleep restriction or sleep scheduling therapy. Essentially, it involves stripping you away from you bed time. It’s a very mathematical process and we do it over several weeks during which we slowly, incrementally add more time to your sleep opportunity once we see sleep quality increase, to restore your sleep drive.”
“After we’ve gone through those first two stages, we need to work on the cognitive side of the problem, such as helping people to understand how to reduce their anxiety, relax and process their day better,” Romiszewski explains.
“This aspect is more proactive – it helps you to avoid sleep problems in the future. And while it’s true that some sleep behaviours can help you do this – such as waking up at the same time every day to help your circadian rhythm – we also need to think about the psychological side, too. And that’s when we start looking at your winding down process and giving you techniques to reduce your anxiety and calm yourself down, etc.
“We want to make sure that if you do have a bad night – which, by the way, is entirely normal – that you’re going to feel like you’ve got coping mechanisms.”