Good Night, Insomnia

By July 20, 2016July 26th, 2016Article

In May of this year, the American College of Physicians (ACP), the “second largest physician group in the United States,” released a remarkable set of clinical guidelines for treating insomnia. The authors of the guidelines recommended psychological treatments, specifically CBT-I (cognitive-behavioral therapy for insomnia), not pharmacotherapy, as “the initial treatment for chronic insomnia disorder.” The authors go further, concluding “CBT-I provides better overall value than pharmacologic treatment.”

These conclusions and strategies will be familiar to those of us who practice health psychology. However, I hope the release of these guidelines serves as an invitation for many more psychologists to take an active interest in treating insomnia. The need for such interest is great: A third of the adult population reports insomnia symptoms. About 6% meet diagnostic criteria for a formal insomnia diagnosis. Insomnia co-occurs with other mental health and physical health conditions (1) and can greatly exacerbate the struggles of our clients.

Here is the good news: Even a casual review of the strategies used to treat insomnia will reveal that most of the relevant skill set is within reach of any psychologist in clinical practice. The remaining specialty knowledge and skills can be readily acquired. Below, I will briefly describe some of the knowledge and skills.

Sleep Hygiene. Sleep hygiene strategies focus on assessing (2, 3) clients’ current sleep environments and patterns and making modest changes, such as changing substance use, activity level and exercise, light level, and, of course, use of electronic devices. These will include many common sense strategies that many people simply ignore or that they (often wrongly) believe are unrelated to their sleep struggles.

Stimulus Control. Stimulus control strategies target unhelpful patterns of behavior around sleeplessness. In “behavior speak,” the goals are to: Strengthen cues of bed and bedroom for sleep and to weaken cues of bed and bedroom for arousal. Stimulus control strategies begin to disassociate the bed and bedroom from wakeful struggle (i.e., lying in bed awake), primarily by providing rules for when to be in bed and when and where to go when awake at night.

One key to effective sleep hygiene and stimulus control is to make these active treatments rather than marginalize them as information to be spoken or (worse) simply handed to the client. Like any health behavior change, the focus should be on thorough assessment, education, identifying functional obstacles, problem-solving, and ensuring adequate follow-through. Do not simply give a handout and expect behavior change!

Sleep Restriction. The third major component of CBT-I is sleep restriction. This somewhat counter-intuitive strategy is to restrict individuals’ time in bed so it approximates the average number of hours of actual sleeping they are getting. This improves their sleep efficiency, precludes or undermines many unhelpful sleep habits, and quickly increases their “sleep drive” (felt need for sleep) in subsequent nights. The sleepers’ time in bed is gradually increased as their sleep efficiency improves. Sleep restriction sounds daunting, but it works. For clients who are intimidated by sleep restriction, gentler forms of “sleep compression” are also promising (for specific protocols and review, see Perlis, Aloia, and Kuhn, 2011; 4).

Most effective behavioral treatments for insomnia also target individuals’ unhelpful reactions (pervasive worry, catastrophic thoughts, intense emotions such as anxiety, and physiological arousal) around sleeplessness. In fact, much of the session-to-session work in treating insomnia focuses on reducing or eliminating effortful struggle to sleep to permit more natural sleep to recur. Paradoxical approaches and new forms of CBT such as acceptance and commitment therapy (ACT) show promise as helpful complements or alternatives to the behavioral strategies reviewed above.

Where to start? You may read this recent review of behavioral treatments for insomnia or review this page on the APA Division 12 site.