Sleep hygiene

Sleep hygiene is typically the list of rules that people find to improve insomnia when they’re doing an internet search. The recommendations can vary, but often include things like:

• Don’t drink caffeine in the afternoon and evening

• Don’t drink alcohol too close to bedtime

• Avoid exercise too close to bedtime

• Make sure your bedroom is dark, cool, and quiet when trying to sleep

• Have a consistent bedtime and wake time

• Have a wind down routine that you do nightly before bed

Many people who have seen these recommendations get concerned that CBT-I won’t work for them because they’ve tried implementing these changes and haven’t seen improvement in their insomnia.

It’s important to know that improving sleep hygiene by itself typically won’t get rid of chronic insomnia disorder. It may improve sleep for your friend who doesn’t have chronic insomnia, but for people with chronic insomnia, CBT-I is almost always needed.

It is still good to pay attention to sleep hygiene though, which is why we discuss it in treatment. I like to think of improving sleep hygiene as laying a good foundation for the rest of the treatment to work. In other words, if you don’t improve sleep hygiene (e.g., you’re drinking large amounts of caffeine in the evening), using sleep restriction or stimulus control will not work very well.

Sleep restriction and sleep compression

Sleep restriction and sleep compression are systematic ways of reducing time in bed to improve your body’s biological processes that help you to sleep. Sleep restriction typically yields quicker results compared with sleep compression, because you are reducing time in bed much more drastically. In my experience, many people tend to prefer sleep compression though, because it’s gentler and more gradual. Once sleep begins to improve with these treatments, time in bed is typically gradually increased again. It’s important to note though that you would never restrict time in bed too much. There are also some medical and psychiatric contraindications to engaging in sleep restriction and compression, so be sure to practice these techniques alongside a medical professional who is trained to deliver CBT-I. 

Stimulus control

Stimulus control is another component of CBT-I that many people have heard of. The goal of stimulus control is to help your brain and body re-learn that your bed is a place for sleepiness and relaxation only - not for wakefulness, not for other activity, and not for worrying. Stimulus control recommends you do things like only use your bed for sleep, only go to bed when sleepy, and get up out of bed after a prescribed period of time awake in bed.

Cognitive therapy

We view the world from our thoughts, and our thoughts are really like hypotheses about what’s going on. Sometimes our thoughts are spot on and quite accurate, other times, only partially accurate. Cognitive therapy is a way to examine your thoughts, and if they are particularly distressing or unhelpful, helps to reframe them in a way that can decrease distress. As part of CBT-I, cognitive therapy is used to explore thoughts about sleep like “If I don’t sleep, my work day tomorrow will be a disaster.”

Relaxation Exercises

Relaxation exercises can be helpful for people experiencing anxiety or tension around bedtime, and is also particularly helpful for those trying to stop taking sleep aids. Relaxation exercises done within CBT-I may include things like deep breathing, visual imagery, or progressive muscle relaxation. 

So what does insomnia treatment actually look like?

Some people deliver CBT-I as a ‘package’ where they always deliver, for example, 6 sessions of treatment where they first introduce sleep hygiene, then sleep restriction, then cognitive therapy. I believe that treatment should always be tailored to you and how you respond to it. Some people need just a few sessions, mostly focused on changing behaviors. For people with anxiety and depression, receiving more sessions, including the cognitive component as well as changing behaviors has been shown to be particularly effective.

Sleep diaries are kept throughout treatment to help tailor treatment to your needs, and to also identify which parts of treatment are working best for you. By the end of treatment, you will have essentially built a toolbox of techniques that you know will be helpful for improving your sleep.This means you are not only improving your sleep in the short term with CBT-I, but you’re also developing tools to help maintain good sleep in the long-run.