Cognitive behavioural therapy for insomnia (CBT-I) is an efficacious treatment for primary insomnia, resulting in enduring and long-term sleep benefits. It is considered to be an effective treatment for insomnia that is co-morbid with substance abuse, medical and/or psychiatric conditions. Because of the overlap between insomnia, physical health, and psychological health, improving the sleeping quality through CBT-I in these individuals also often results in subsequent improvements in the co-morbid conditions.
CBT-I for individuals with insomnia and depression
Depression is a psychiatric condition that improves through CBT-I. However, the effect sizes of CBT-I are often smaller than those reported through CBT for other mental health disorders (Harvey & Tang, 2003). Furthermore, only 50% of the participants in one of the more successful CBT-I studies for co-morbid insomnia and depression remitted from insomnia (Manber et al., 2008). If insomnia does not remit, then depression is likely to relapse (Perlis et al., 1997), persist or worsen in severity over time (Staner, 2010). It is therefore essential to optimise the four CBT-I components for this population.
Component One of CBT-I: Psychoeducation
The psychoeducation component of CBT-I consists of general sleep education and sleep hygiene recommendations. This should be introduced in CBT-I before the administration of any behavioural prescriptions or the undertaking of any cognitive restructuring and is typically presented to the client and discussed during the first session. Essential components of general sleep education include information around why people sleep, the stages of sleep, and differences in sleep requirements (Kripke et al., 2002). It also contains what ‘normal’ sleep looks like, what happens to sleep with age and sleep inertia (Jewett et al., 1999). The two process theory of sleep regulation that incorporates circadian rhythms and homeostatic pressure (Borbély, 2000), and a model of insomnia and how it progresses over time (Ebben & Spielman, 2009) are helpful models to include. Sleep hygiene recommendations are also introduced to highlight the factors that may be exacerbating an individual’s insomnia severity and contributing to their poor subjective sleep (Perlis & Youngstedt, 2000).
Although the psychoeducation component of CBT-I is not an empirically supported individual intervention for insomnia (Morin, Culbert, et al., 1994), it is still a crucial component of the multimodal treatment and serves several purposes. Psychoeducation not only provides essential information that can help individuals sleep better, but also gently challenges some of the unhelpful thoughts, beliefs and attitudes that participants may have about sleep with real evidence from scientific research. Elevated dysfunctional beliefs and attitudes about sleep, as measured by the DBAS-16 scale, are significantly correlated with high insomnia, depression, and anxiety severity, but not with sleeping measures (Morin, Vallieres, & Ivers, 2007). Thus, psychoeducation can reduce insomnia and depression severity through lowering the intensity of participant’s firmly held beliefs about sleep, even if it does not directly improve sleep.
Psychoeducation can also be important for developing therapeutic alliance (Krupnick et al., 1996), as discussing essential factors of sleep allows CBT-I treatment to begin in a non-threatening manner. Many of the individual interventions are directive, with little room for discussion, but psychoeducation provides for the development of rapport with the participant through discussion of their sleep difficulties and beliefs as the information is being presented. A strong therapeutic alliance can then increase adherence to later behavioural instructions, result in more openness to cognitive restructuring, and improve overall outcomes for the participant (Trockel, Karlin, Taylor & Manber, 2013). Thus, beginning broadly with psychoeducation is likely to result in a better understanding of how to improve sleep, a reduction in unhelpful beliefs about sleep, and a better therapeutic alliance that can increase the clinical outcome for the other interventions in CBT-I.
1A. Sleep hygiene recommendations
Sleep hygiene recommendations were developed to educate individuals with insomnia about the possible factors that promote and inhibit optimal sleep (Hauri, 1977). By following these recommendations, it was proposed that one’s sleeping practices would no longer be perpetuating their insomnia (Mastin, Bryson, & Corwyn, 2006). However, there is no standard prescription for what optimal sleep hygiene consists of, and no weighting of what factors are most important. Even the developer of sleep hygiene has changed his recommendations over time (Hauri, 1993).
Stepanski and Wyatt (2003) reviewed seven studies that attempted to define sleep hygiene and found 19 different rules. Worse still, there was only one rule that was agreed upon unanimously, and that was to not consume caffeine before going to bed. Six of the studies recommended daily exercise, but not too close to bedtime. Six studies also recommended avoiding alcohol in the evening. Beyond these three items, most of the sleep hygiene rules were only supported by two or three studies (Stepanski & Wyatt, 2003). The lack of a standard definition of sleep hygiene means that it is tough to determine its efficacy, and may explain why it is not a supported intervention for treating insomnia (Morin et al., 2006).
Improving sleep hygiene knowledge has little impact on improving sleep quality, however improving sleep practices in line with sleep hygiene recommendations does (Brown, Buboltz, & Soper, 2002). This means that informing clients about sleep hygiene may not result in behavioural change, but when this does take place, it can have a substantial effect on their sleep and health (Brown et al., 2002).
The aim for sleep hygiene in CBT-I is, therefore, to determine which aspects are most likely perpetuating insomnia and depression in each client, and customise the treatment to the individual. By doing this, clients only have to focus on the issues that are of most concern to them and not waste their time worrying about recommendations that are already followed reasonably well (Hauri, 1993). Administering a questionnaire such as the Sleep Hygiene Index (Mastin et al., 2006) at baseline would also help the therapist target appropriate sleep hygiene factors for each participant during the psychoeducation phase of treatment.
Component Two of CBT-I: Sleep Scheduling
Both stimulus control and sleep restriction therapies can be combined under the term sleep scheduling. Taken together, sleep scheduling aims to eliminate the behaviours in insomnia that commonly disrupt sleep. By breaking conditioned responses, increasing homeostatic pressure for sleep and re-entraining the natural circadian rhythms, sleep scheduling results in both higher sleep quality and sleep efficiency (SE) over time, which increases the perception of a restorative night’s sleep (Ebben & Spielman, 2009; Vitiello, 2007). Sleep scheduling is usually administered after the psychoeducation component and before any formal cognitive therapy in CBT-I treatment.
2A. Stimulus control
Stimulus control therapy was initially conceived in the early 1970s as a direct application of instrumental conditioning principles to break the conditioned response of the bed, bedroom and bedtime in patients with insomnia (Bootzin, 1972). Any stimulus is thought to be able to produce several reactions in people, depending on their conditioning history with the stimulus. Individuals with insomnia are so used to being awake and frustrated in bed that over time the bed becomes conditioned with being aroused, annoyed and alert rather than with feeling tired and sleeping (Ebben & Spielman, 2009).
The stimulus control instructions aim to limit the time in bed awake so that the bed becomes reconditioned with the feeling of sleepiness and the behaviour of well-consolidated sleep. These include only going to bed when tired, waking up at the same time every day, just using the bed/bedroom for sleep and sex, avoiding naps during the day, and getting up if unable to fall asleep within 20 minutes of retiring to bed, (Lieberman & Neubauer, 2007).
Stimulus control is thought to help individuals with insomnia and depression in some ways. Firstly, by removing all other conditioned responses except for sleep, the bed soon becomes reassociated with falling asleep quickly. This reduces the time spent in bed ruminating, and over time positive associations can develop, where the individual becomes tired and sleepy whenever they retire to bed (Ebben & Spielman, 2009). Secondly, waking up at the same time each day allows for entrainment of the circadian rhythms, which then promotes sleepiness for the participant at a similar time each night. By not changing the waking time, regardless of when the individual goes to sleep or how many times they get out of bed during the night, this also mildly deprives them of sleep, and combining this with no naps during the day strengthens the homeostatic drive for sleep. This then allows the participant to fall asleep quicker when they finally do go to bed at night (Ebben & Spielman, 2009). All of these factors combine to improve sleep self-efficacy, sleep efficiency and sleep quality, which helps participants’ feel less concerned, more refreshed and more in control of their sleep.
Stimulus control as a stand-alone therapy is a supported behavioural treatment for chronic insomnia, according to the AASM (Morin et al., 2006). It has reliable and robust effect sizes in the available research in the field (Lacks, Bertelson, Gans, & Kunkel, 1983; Riedel et al., 1998; Turner & Ascher, 1979). The main difficulty with stimulus control is adherence to the instructions (Riedel & Lichstein, 2001). The guidelines appear somewhat counter-intuitive, and individuals with insomnia and depression have many preconceived notions as to what the cause of their insomnia is that does not involve instrumental conditioning (Bootzin, 1972). It is therefore essential to explain the rationale in substantial detail for participants to actually get out of bed after 20 minutes and to wake up at the same time each day. If the guidelines are not followed, their bed will not become reconditioned with sleep, their circadian rhythms will not be re-entrained, and their sleep will be unlikely to improve (Harvey, 2002). It is therefore vital to introduce cognitive techniques after stimulus control in CBT-I, so that any dysfunctional beliefs or safety behaviours that may limit willingness to adhere to stimulus control instructions are explored, understood and overcome.
2B. Sleep restriction
Sleep restriction, or bed restriction as it is sometimes known, was initially conceived in the mid-1980’s to take advantage of the positive benefits of sleep deprivation on various sleep measures (Spielman et al., 1987). It is a useful technique for the treatment of insomnia (Morin et al., 2006) that involves limiting the time in bed to an individual’s average subjective daily amount of sleep (Spielman et al., 1987). By only spending enough time in bed for sleep, sleep restriction temporarily induces sleep deprivation, which increases the homeostatic drive for sleep, decreases sleep fragmentation and consequently improves SE (Vitiello, 2007). However, it is important to prescribe the sleep at a constant time that is in line with an individual’s circadian rhythms and lifestyle (Ebben & Spielman, 2009).
Sleep restriction is similar to relaxation in reducing sleep onset latency (SOL) and wake after sleep onset (WASO) across CBT-I treatment, and more effective in maintaining these improvements by follow-up 3-months later (Friedman et al., 1991). After 12 months follow-up in another study, WASO had gotten worse since post-treatment with relaxation but continued to improve with sleep restriction (Lichstein et al., 2001). Therefore, one benefit for sleep restriction appears to be its enduring long-term insomnia improvements, which is essential in reducing the risk of depressive relapse (Perlis et al., 1997).
The downside of sleep restriction is that it temporarily increases daytime somnolence and reduces vigilance in the initial phases of treatment (Kyle et al., 2014) so adherence to this treatment may be difficult to obtain from individuals who are already concerned about daytime consequences of insomnia (Riedel & Lichstein, 2001). If there is excessive daytime sleepiness, caution should also be given regarding driving or operating machinery, and some time off work may be required. However, this increase in sleepiness prevents individuals with insomnia and depression from lying in bed ruminating or worrying, and it has been shown to significantly improve sleep initiation and increase overall sleep quality (Lieberman & Neubauer, 2007).
At 12 months follow-up, both stimulus control and sleep restriction adherence were the most significant predictors of ongoing improvements in SOL and WASO (Harvey, 2002). Consequently, as long as the long-term benefits of sleep scheduling are made salient and adherence issues are addressed in therapy, both stimulus control and sleep restriction can produce dramatic and robust improvements in insomnia symptoms.
Component Three of CBT-I: Relaxation
Relaxation reduces excessive physical tension and calms pre-sleep cognitive activity, fostering a more positive outlook and reducing overall concerns about sleep disturbances (Harsora & Kessmann, 2009). Relaxation techniques are therefore carried out across the entire CBT- I intervention with the objective of reducing physiological and cognitive arousal so that an individual can transition to sleep quicker and have a deeper, more restorative sleep (Edinger & Means, 2005).
Relaxation techniques sometimes included in CBT-I include:
- imagery training (Morin & Azrin, 1987),
- meditation (Woolfolk et al., 1976),
- thought-stopping (Levey et al., 1991)
- biofeedback training (Freedman & Papsdorf, 1976),
- diaphragmatic breathing (Smith & Neubauer, 2003),
- autogenic training (Simeit et al., 2004) and
- progressive muscle relaxation (Bernstein et al., 2000).
3A. Progressive Muscle Relaxation
Progressive Muscle Relaxation (PMR) is the most commonly used relaxation technique in CBT-I and is efficacious as a stand-alone treatment for insomnia (Morin et al., 2006). PMR involves tensing and releasing different groups of muscles throughout the body to reduce physiological arousal. It may have some additional cognitive benefits through focusing on and paying attention to particular areas of the body, but it is not as cognitively based as autogenic training, imagery training, thought stopping, or meditation.
In comparison to autogenic training and biofeedback training, PMR was not significantly different (Freedman & Papsdorf, 1976; Simeit et al., 2004). However, cognitive relaxation techniques were found to be more effective for reducing SOL (Morin, Culbert, et al., 1994). Consequently, cognitive relaxation techniques should be incorporated into CBT-I protocols more frequently.
Rather than administering only one relaxation technique in CBT-I for insomnia and depression, it may be more beneficial to briefly introduce several methods (both cognitive and somatic focused) and let the individual determine which techniques are the most effective in reducing their arousal levels and allowing them to feel relaxed both during the day and at night. Mindfulness meditation has been increasing in popularity immensely lately and has also been proving to be helpful in reducing arousal in more recent studies by Ong, Shapiro and Manber (2008).
In one study that treated individuals with insomnia with relaxation techniques, SE was found to increase from 67.0% to 78.8% over 6 weeks of treatment (Lichstein et al., 1999). Both anxiety and depression scores were also reduced after the 6 weeks of relaxation (Lichstein et al., 1999). Relaxation has been found to be the most effective when initially practised during the daytime so that the participant can practice reducing their arousal levels rather than using the techniques to help them fall asleep (Harsora & Kessmann, 2009). Once arousal levels are efficiently being reduced, relaxation treatments can reduce SOL more than sleep hygiene education or the combination of stimulus control plus sleep restriction (Waters et al., 2003). Although CBT-I is typically superior to relaxation alone (Edinger et al., 2001a), the additional benefits of relaxation on depression (Jorm et al., 2008), stress (Kaspereen, 2012) and anxiety (Manzoni, Pagnini, Castelnuovo, & Molinari, 2008) warrant it being added to a CBT-I intervention for co-morbid insomnia and depression.
Component Four of CBT-I: Cognitive Therapy
The term cognition refers to all mental activities, which are experienced in the form of verbal thoughts or images. Many cognitive processes have been found to be critical in differentiating individuals with insomnia from ‘normal sleepers’, including attention, perception, memory, beliefs, attributions and expectations (Harvey et al., 2005). These differences contributed to higher anxiety levels and increased cognitive arousal in individuals with chronic insomnia (Harvey & Tang, 2003).
To help break the cycle of insomnia, emotional distress and further sleep disturbances, specific cognitive techniques need to be implemented alongside the behavioural interventions in CBT-I. Cognitive techniques are formally introduced in CBT-I after both the psychoeducation and sleep scheduling components have been administered. Cognitive techniques for insomnia include cognitive restructuring (Edinger & Carney, 2008; Morin, 1993), cognitive control (Morin & Espie, 2003), constructive worry (Edinger & Carney, 2008), distraction (Ree, Harvey, Blake, Tang, & Shawe-Taylor, 2005), paradoxical intention (Broomfield & Espie, 2003), and mindfulness and acceptance of thoughts (Ong, Shapiro, & Manber, 2008).
4A. A cognitive model of Insomnia
Through research on the cognitive processes involved in insomnia, Harvey and colleagues developed a cognitive model that identified the five main aspects that were likely to be perpetuating insomnia (Harvey, Sharpley, Ree, Stinson, & Clark, 2007). The model proposed that individuals with insomnia typically:
- Spend excessive time ruminating about why they have not slept well in the past, and worrying about not sleeping well in the future.
- Misperceive their sleep to be worse than it is, overestimating initiation and maintenance of sleep problems and underestimating total sleep achieved, which exacerbates their anxiety and arousal over time.
- Pay more attention to both external and internal threats to sleep in bed at night and to functional impairments and tiredness during the day.
- Have many unhelpful and unrealistic beliefs about sleep, including hours of sleep needed, consequences of poor sleep, causes of their insomnia, and what they should do about it, and
- Maintain these attentional biases and unhelpful beliefs about sleep through safety behaviours, such as not going to work after a miserable night’s sleep, napping during the day, and spending extra time in bed in an attempt to catch up on ‘lost sleep’.
Harvey and colleagues (2007) then developed a cognitive therapy for insomnia, which consisted of Socratic questioning and carefully planned behavioural experiments, to address all aspects of their cognitive model. They found significant improvements in SOL (over 50%), WASO (37%) and total sleep time (TST – 11%) by post-treatment, with findings maintained by follow-up 1 year later and all 19 participants no longer meeting diagnostic criteria for chronic insomnia (Harvey et al., 2007). Significant improvements were also found in work and social adjustment, unhelpful beliefs, worry, depression severity and anxiety severity (Harvey et al., 2007).
Although these findings were promising, there was no control group in the study of cognitive therapy, and the duration of treatment varied between 6 and 22 weeks. As the optimal dose of CBT-I is 4 sessions across 8 weeks (Edinger et al., 2007), it may be possible to target all five factors from the cognitive model (Harvey et al., 2007) and achieve similar gains, but in a shorter period of time than what is found through purely cognitive interventions for insomnia. This is supported by a recent study by Roane and colleagues (2012), who found that the behavioural and cognitive interventions of CBT-I both produced significant reductions in unhelpful beliefs and attitudes about sleep, but created these cognitive changes in different areas.
4B. Constructive worry
To target worry and rumination in co-morbid insomnia and depression, both the constructive worry (Edinger & Carney, 2008) and the cognitive control (Morin & Espie, 2003) techniques could be efficiently used in CBT-I. The constructive worry technique instructs individuals with insomnia to spend time earlier in the evening problem solving any issues that they believe may keep them awake or cognitively aroused in bed at night (Edinger & Carney, 2008). Cognitive control also instructs individuals to spend 20 minutes reflecting on the day that has been a few hours before going to bed and to write a to-do list about what needs to be done the next day (Morin & Espie, 2003). By targeting these concerns earlier in the evening, less information needs to be processed in bed, and this can subsequently result in less cognitive arousal and frustration. If anything new comes up that they have not thought about, they can also quickly write this down on a notepad next to their bed and then continue to relax and allow sleep to come (Morin & Espie, 2003). These cognitive techniques are likely to be effective alongside sleep scheduling instructions in CBT- I by reconditioning the bed with sleepiness and sleep instead of worry, rumination and a racing mind.
Out of all the cognitive processes, individuals with insomnia have a propensity to use thought control strategies more frequently than normal sleepers (Ree et al., 2005). The strategies of aggressive suppression and worry appear to be particularly unhelpful, with their use predicting increased sleep impairment, anxiety and depression (Ree et al., 2005). Conversely, cognitive distraction is used more frequently by normal sleepers and predicts better sleep quality (Harvey & Payne, 2002). Thus, cognitive distraction techniques are likely to be helpful in allowing individuals to reduce their cognitive arousal levels and should be encouraged in CBT-I interventions for comorbid insomnia and depression.
4C. Imagery training
One particularly beneficial distraction technique is imagery training. Although it is often considered to be a relaxation exercise, imagery aims to distract the individual from obtrusive and pre-occupying sleep-related thoughts by using visualisation techniques. Thinking in the form of images has been found to resolve worry more efficiently than thinking in the form of words (Nelson & Harvey, 2002). Imagery can therefore also be considered as a cognitive technique in CBT-I.
Imagery involves visualising an interesting and engaging situation that is also pleasant and relaxing immediately before sleep (Harvey & Payne, 2002). Rosen and colleagues (2000) compared imagery to PMR and sleep hygiene education across 4 weeks of treatment, and found significant improvement in SE and WASO in both the imagery and PMR groups by post-treatment. Furthermore, the imagery group exhibited 16 minutes less WASO than the PMR group and had increased self-efficacy and depression severity by the 6-month follow up (Rosen, Lewin, Goldberg, & Woolfolk, 2000). Imagery should, therefore, be incorporated into a CBT-I intervention for comorbid insomnia and depression as both relaxation and a cognitive distraction technique.
4D. Highlighting sleep-state misperception
Another critical area that may need to be challenged cognitively is sleep-state misperception. To challenge sleep state-misperception, an individual’s objective sleep data, which is usually provided by a wrist activity monitor (Hauri & Wisbey, 1992), needs to be compared with their subjective sleep data from their sleep diaries. If a significant discrepancy is found between objective and subjective sleep, it often indicates that individuals perceive themselves to be awake during the light stages of sleep (stages 1 and 2) (Harvey et al., 2007).
Providing information that highlights the inconsistencies between objective and subjective sleep and giving information that sleep becomes lighter as the night goes on will often reduce anxiety about an individual’s quality of sleep, and result in better subjective sleep and increased the perception of a more restorative night’s sleep. Stimulus control is also a useful behavioural intervention for sleep state misperception, as it is not possible for the participant undergoing CBT-I to get up out of bed after 20 minutes of being awake if they are actually sleeping (Lieberman & Neubauer, 2007). Cognitive restructuring (Morin, 1993) can then be administered to look at the validity and utility of thoughts around being awake when they might actually be asleep.
4E. Cognitive restructuring
Cognitive restructuring is introduced after sleep scheduling in CBT-I to address and challenge any unhelpful beliefs and attitudes about sleep that may be perpetuating insomnia. To determine how strongly held participant’s beliefs are in CBT-I interventions, the DBAS-16 is often administered (Morin et al., 2007). The DBAS-16 highlights four main areas of unhelpful beliefs about sleep, including excessive worry about not sleeping, catastrophising the consequences of insomnia, having unrealistic expectations for sleep, and overestimating the effects of sleep medications (Morin et al., 2007).
Cognitive restructuring aims to elicit, identify, discuss, appraise, and correct any unhelpful thought processes that may be maintaining catastrophic beliefs about sleep and insomnia through Socratic questioning (Harvey et al., 2007). These questions focus on the accuracy of beliefs about sleep that an individual has, the evidence to support these beliefs, whether there are any alternative explanations for these beliefs, whether they underestimate their ability to cope with any problems they have, what they fear will happen if these beliefs are correct, and what they can do to address the issue (Morin, 1993). A reduction in these scores predicts better outcomes for individuals after CBT-I treatment (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001b).
4F. Mindfulness or acceptance-based techniques
Individuals with insomnia also exhibit an attentional bias for sleep-related threat during both the day and night. One way to target this is through the introduction of mindfulness or acceptance-based techniques (Dalrymple, Fiorentino, Politi, & Posner, 2010; Lundh, 2005; Ong & Sholtes, 2010). These techniques involve a non-judgmental, present-focused awareness, which means being aware of any thoughts, feelings or sensations that arise without changing them in any way. It also involves bringing back attention to whatever is occurring in the present moment and getting in touch with the breath or any of the five senses rather than getting caught up in the past or future (Dalrymple et al., 2010; Lundh, 2005; Ong & Sholtes, 2010).
Mindfulness and acceptance-based therapies theorise that it is not the content of thoughts that are troublesome to individuals, but rather the judgments or evaluations that are made about these thoughts. By remaining in the present and practising ‘defusion’ and acceptance techniques (Harris, 2007), the impact that these perceived sleep threats have should diminish over time. This could result in lowered arousal, more restorative sleep, and fewer impairments in daytime functioning (Dalrymple et al., 2010; Lundh, 2005; Ong & Sholtes, 2010).
Several studies have found modest improvements in sleep through mindfulness, as an individual intervention for sleep (Britton, Shapiro, Penn, & Bootzin, 2003; Heidenreich, Tuin, Pflug, Michal, & Michalak, 2006). However, recent findings have been more promising (Gross et al., 2011), especially when mindfulness is combined with other sleep interventions (Ong et al., 2008; Ong, Shapiro, & Manber, 2009). Although increases in mindfulness skill were not significant across all participants by post-treatment (Ong et al., 2008), participants with reduced pre-sleep arousal and sleep effort were found to be less likely to have had an insomnia relapse by follow-up one-year later (Ong et al., 2009).
Another study also found that mindfulness improved self-regulation of sleep by allowing it to occur naturally rather than forcing it, which subsequently predicted greater well-being (Howell, Digdon, & Buro, 2010). Adding mindfulness to CBT-I can therefore not only reduce insomnia severity but also improve daytime functioning. Mindfulness-based cognitive therapy is thought to be an effective treatment for relapse prevention in MDD (Ma & Teasdale, 2004). Because of the long-term improvements found for both conditions, mindfulness should be incorporated in some capacity in CBT-I interventions for co-morbid insomnia and MDD.
4G. Safety behaviours
The last cognitive aspect of insomnia that needs to be addressed in CBT-I is safety behaviours, which are habitual sleep-related behaviours or routines that people develop because they think that it helps with their insomnia (Harvey et al., 2007). Safety behaviours may lead to reduced adherence to behavioural interventions in CBT-I and need to be addressed through behavioural experiments for homework, to ensure optimal outcomes for co-morbid insomnia and depression.
Paradoxical intention is one such intervention that can be implemented as a behavioural experiment to reduce pre-sleep arousal and sleep effort, which can subsequently reduce the likelihood of insomnia relapse following the conclusion of CBT-I treatment (Ong et al., 2009). By instructing an individual that has continued to put considerable effort into sleeping that they should try to remain awake in bed for as long as possible, they are likely to obtain a more restorative night’s sleep (Broomfield & Espie, 2003). It is then possible to explain that it is their effort and performance anxiety that often leads to increased pre-sleep arousal and poorer quality of sleep throughout the night (Broomfield & Espie, 2003). Once the individual understands this, durable cognitive change is likely to occur, and more significant benefits can be obtained from the CBT-I intervention.
Due to the varied cognitive perpetuating factors for each individual with insomnia and depression, it is unlikely that a standard cognitive technique will be sufficient to help all individuals undergoing CBT-I. Conversely, if all cognitive strategies are provided, many of these will be unnecessary, and result in an excessively lengthy cognitive component of CBT-I (Harvey et al., 2007). As a result, the cognitive factors that appear to be perpetuating insomnia severity for each individual should be thoroughly assessed initially and then monitored throughout the CBT-I, with a particular focus on any adherence issues. By tailoring the cognitive treatment to the individual characteristics of each case of insomnia, it is then possible for optimal outcomes to be achieved.
How Can CBT-I Be Optimised Further?
For optimal outcomes to be achieved through CBT-I treatment, it must be flexible enough to be tailored to the patient and their primary presenting concerns. The most prominent risk of administering manualised CBT-I is if it is being implemented in a directive rather than a collaborative manner between the therapist and the patient (Cahill et al., 2008).
Treatment goals need to be negotiated with the patient rather than assumed, and any structure that is implemented should be provided in an autonomy-supported rather than a controlling way (Ryan & Deci, 2008; Zuroff et al., 2007). To achieve this, the patient needs to feel validated and understood with their concerns (Ryan & Deci, 2008), be provided with meaningful rationales for any suggested interventions or homework exercises (Deci, Eghrari, Patrick, & Leone, 1994), and have minimal pressure by the therapist to change in a particular direction (Miller & Rollnick, 2002).
It is also essential to view the patient with unconditional positive regard (Assor, Roth, & Deci, 2004) and provide them consistent support irrespective of their treatment decisions (Moller, Deci, & Ryan, 2006). Self-determination theory suggests that these factors help to ensure that an individuals’ psychological needs for competence, relatedness and autonomy are met (Ryan & Deci, 2008). If CBT-I therapists can meet these needs while educating patients about the effective interventions that are likely to help their insomnia and other presenting concerns, optimal improvements can be achieved.
If a patient undergoing CBT-I has an external locus of control, they are likely to attribute their difficulties to factors outside of their influence, and may, therefore, struggle to find an autonomous motivation to improve their situation. In these cases, motivational interviewing strategies (Miller & Rollnick, 2002) could be implemented either before or during the CBT-I intervention to enhance support, motivation and therapeutic alliance. This can subsequently improve adherence to treatment recommendations and result in higher overall treatment outcomes (Trockel et al., 2013; Zuroff et al., 2007).
A motivational interviewing intervention before CBT for anxiety has been shown to reduce resistance to CBT interventions (Westra, 2011), improve compliance with homework, and produce more significant overall reductions in worry in comparison to a CBT only intervention (Westra, Arkowitz, & Dozois, 2009). Encouraging family members or partners to help motivate and support the individual undergoing CBT-I can also improve adherence rates to the CBT-I interventions (Ellis, Deary, & Troxel, 2014), and could be utilised more if motivational ambivalence is present. The most optimal CBT-I treatment may, therefore, be one that supports the patients’ needs for autonomy while also motivating them to adhere to empirically supported interventions.
Although CBT-I consistently reduces psychological symptoms and distress, other daytime improvements through CBT-I have been less consistent (Morin et al., 2006). Acceptance and commitment therapy (ACT), and especially the values clarification and committed action components of ACT, can help patients endure more emotional discomfort and overcome barriers to change in the pursuit of their value-driven goals (Harris, 2009). A case-study of ACT principles following CBT-I (Dalrymple et al., 2010) indicates the potential for an amalgamation of ACT with CBT-I whenever presenting concerns consist of a lack of purpose or meaning. Mindfulness has already been shown as a helpful addition to CBT-I for certain individuals (Ong et al., 2008), and ACT teaches four mindfulness skills and concepts as core components of its treatment (Harris, 2009). Positive Psychology principles (Seligman, Rashid, & Parks, 2006) have been included alongside CBT to improve positive emotion, engagement and overall well-being in individuals with depression (Karwoski, Garratt, & Ilardi, 2006), but has yet to be attempted alongside CBT-I.
By incorporating more evidence-based interventions with CBT-I when necessary, and personalising the treatment approach to the characteristics of the client, optimal outcomes can be achieved in a higher proportion of individuals with depression seeking treatment for insomnia.
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Dr Damon Ashworth