Things to consider
If you are not making as much progress as you hoped with CBT-I, below are some things to consider.
(1) Insure reasonable expectations for rate of progress
CBT-I requires at least a couple of months of diligent effort and a sufficient number of sessions with a therapist (often 6 to 8, or sometimes more).
(2) Assess fidelity to CBT-I methods (see checklist below)
CBT-I only works if enough of the strategies are out into consistent practice. The checklist below will help you assess the degree to which you have been implementing the strategies. If it is less than ideal, suggestions are offered for enhancing greater fidelity to CBT-I.
(3) Consider complicating situational factors (e.g., stress)
Situational factors may make it more difficult to implement CBT-I strategies or may be playing a role in your insomnia. These may need to be addressed in order to get a better result.
(4) Consider medical conditions (including other sleep disorders) or mental health conditions (e.g., anxiety, depression)
Medical and mental health conditions can make it more difficult to implement CBT-I or interfere with sleep. When insomnia persists despite an adequate trial of CBT-I, undiagnosed or undertreated conditions may be playing a role.
(5) Consider substance use (e.g., caffeine, alcohol)
Consider whether you regularly consume anything that could interfere with sleep.
(6) Consider whether you are taking any medications that affect sleep
Many prescription medications can contribute to insomnia and/or otherwise affect sleep (e.g., decrease deep sleep; suppress REM sleep). You can review the side effects of your medications by using these online checkers: drug side effect checker and drug interaction checker. More information can be found here.
(7) Consider use of medication for insomnia (in consultation with your physician)
While the American Academy of Sleep Medicine recommends CBT-I as the preferred treatment for chronic insomnia, they also endorse the appropriate use of medication as a temporary adjunct to CBT-I or when patients still have symptoms despite an adequate trial of CBT-I. More information about sleep medications can be found here.
CBT-I Fidelity Checklist
This checklist will help you assess the degree to which you have been implementing CBT-I strategies. If it is less than ideal, suggestions are offered for enhancing greater fidelity to CBT-I.
Part 1: Factors that influence physiological sleepiness
(1) How consistent is your sleep schedule, including your bedtime and your rise time?
If these times vary by more than 30 minutes, that could be affecting your results.
(2) Do you take naps longer than 20 minutes?
If so, that could be decreasing your drive for sleep.
(3) How much physical exercise do you get and how often?
If it is limited, try to get more.
(4) What is your sleep efficiency? If it is below 90%, consider using the “sleep consolidation protocol” to increase odds of reaching 90% or above.
This involves reducing your target sleep opportunity for this week to the previous week’s average sleep time (AST) plus 15 minutes. For example, if previous week’s AST was 6.5 hours (or 6 hours, 30 minutes), this week’s target sleep opportunity would be 6.75 hours (or 6 hours, 45 minutes).
(5) How much blue light exposure are you getting in the hours prior to bedtime or during the night?
Consider obtaining and using blue light blocking glasses during the last 1 to 2 hours before bed and at any time you are exposed to light during the night. This recommendation particularly applies to people who have a “night owl” tendency and are often not sufficiently sleepy at their target bedtime.
(6) How much bright light exposure are you getting in the morning?
If it is less than ideal, try to get more natural light or obtain and use a light therapy lamp. This is particularly important for “night owls” that want to be able to get up earlier in the day.
(7) This applies only to “night owls” who are trying to advance their circadian rhythm so they are sleepier at their target bedtime.
Consider taking timed low-dose melatonin (e.g., 300mcg 3-4 hours prior to bedtime).
(8) Consider taking a warm bath 90 minutes prior to bedtime.
This has been shown to lower the core body temperature and improve sleep.
Part 2: Factors that influence psychophysiological arousal
(1) Do you have a regular “wind down” period before bedtime?
If not, consider implementing this.
(2) To what extent are you using relaxation exercises during your wind down period (such as >5 minutes of diaphragmatic breathing, muscle relaxation, gentle stretching, use of relaxing imagery, meditation)?
If not, consider learning and practicing these methods during the day and during your wind down period.
(3) When you are in bed, how much difficulty do you have with letting go of thoughts about the past or future or about sleep itself (e.g., rumination or worry)?
If you’re having difficulty, I recommend learning mindfulness meditation techniques and practicing them regularly during the day. Also, set the intention to make your bedroom a “rumination and worry-free zone.”
(4) When you are having difficulty falling asleep, how much intentional effort are you engaging in to try to fall asleep (e.g., using relaxation and meditation techniques while in bed, tossing and turning and trying to get comfortable)?
There becomes a point at which these efforts are counterproductive.
(5) When you are having difficulty falling asleep, to what extent can you maintain a calm attitude (as opposed to being anxious about it)?
If you are anxious about not sleeping, try to cultivate an accepting attitude and focus on improving your experience of the present moment.
Part 3: Factors that affect your conditioned unconscious associations with your sleep environment
(1) Are you using your bed and bedroom for activities other than the act of falling asleep (within 20-30 minutes) or being asleep?
If so, consider moving all other activities to another location. Sexual intimacy is the exception to this.
(2) If you are awake in bed for more than 20 minutes, do you follow the “get out of bed protocol?”
This involves going to another room and engage in an activity until you feel sleepy, and then getting back into bed. If you aren’t using this protocol, consider employing it consistently.
Part 4: Factors that affect your sleep environment
(1) Is your bedroom cool, dark, and quiet?