CBT-I Components

Below are many of the major components and strategies of CBT for Insomnia.  

Component #1: Biweekly session scheduling

CBT-I often consists of 4-8 sessions typically scheduled every other week. It is a good idea to have at least 2 appointments scheduled at any given time.

Component #2: Maintain a sleep diary

Maintain a sleep diary and bring it to our sessions or send it to me electronically. 

• Download a sleep diary and instructions

• Send a photo of a completed sleep diary to me electronically

Component #3: Avoid substances that disrupt sleep 

Limit caffeine and alcohol, especially in the hours before bed.

Component #4: Maintain optimal bedroom conditions

Cool, dark, quiet, and comfortable.

Component #5: Relaxation strategies and techniques

Establish a wind-down period before bed that is non-stimulating and relaxing. Learn specific relaxation techniques and practice them before getting into bed (e.g., diaphragmatic breathing; progressive muscle relaxation; gentle stretching; relaxing mental imagery). Consider learning and practicing mindfulness meditation skills. For more information about these techniques, see:

• Relaxation skills

• Mindfulness skills

Component #7: Appropriate behavior in the bedroom 

Only get into bed if you are actually sleepy. 

Don’t engage in non-sleep related activities while in bed (e.g., reading, using electronic devices, listening to audio recordings, watching TV) (however, sexual activity can be an exception). 

Make a commitment to not engage in thoughts characterized by rumination, worry, or planning while in the bedroom. Avoid “clockwatching." 

It is ok to use relaxation techniques while in bed as long as they require minimal effort and you can achieve a relaxed state within a reasonable amount of time (e.g., within 15 minutes). Using relaxation techniques for longer periods or trying too hard to relax may be counterproductive.

Component #8: Take a time out from trying to sleep  

If you have not fallen asleep after about 20 minutes, or if you are getting anxious or frustrated while trying to fall asleep, or if you having a hard time not engaging in thoughts characterized by rumination, worry, or planning, you may be better off taking a “time out” from trying to sleep and simply wait for sleepiness to return. There are two possible methods. The first one has the most research to support its effectiveness. 

Method 1: The recommended method is to get out of bed, go elsewhere (e.g., the living room), and engage in a non-stimulating activity until you feel sleepy (which may take 30-60 minutes or more), and then return to bed. Try to avoid falling asleep anywhere other than your bed. Also, use blue light blocking glasses during the time out of bed. 

Method 2: If your really don’t want to get out of bed, it is important to be able to remain calm and relaxed and to refrain from engaging in thoughts characterized by rumination, worry, or planning. If you have a hard time doing this, I recommend either dedicating more time to learning and practicing relaxation and mindfulness meditation or to use Method #1 (getting out of bed).

Rationales for these strategies: 

• To avoid engaging in working too hard to try to sleep.

• To avoid conditioning your brain from associating your bed and bedroom with negative experiences involving frustration and anxiety. This can result in a conditioned automatic stress response that interferes with falling asleep. 

Cautionary notes: Getting out of bed during the night may increase the chance of falls. A dim flashlight is recommended. If you use a night light, use an amber-colored one.

Component #9: Maintain an appropriate sleep schedule

Maintain a regular rise time seven days a week. 

Either avoid napping, or limit napping to <20 minutes per day. 

Avoid “dozing” in the hours before getting in bed. 

Only get into bed if you are actually sleepy.

Component #10: The sleep consolidation protocol

Consider using this highly effective protocol to improve your sleep efficiency and total sleep time over the course of several weeks.

Step 1: Maintain a sleep diary every week.

Step 2: For the previous week, calculate the following weekly averages: 

• Average sleep opportunity per night (ASO); Average sleep time per night (AST); and Average sleep efficiency (AST divided by ASO). See instructions here.

• For example: ASO = 8 hours; AST = 6 hours; ASE = 75%

Step 3: For the next 7 days: 

• Maintain a regular rise time and reduce your prescribed sleep opportunity (SO) to your AST from the previous week + 15 minutes. 

• For example, if your rise time is 7am and your planned sleep opportunity is 6.25 hours, your prescribed bedtime would be 12:45am.

Step 4: Maintain a sleep diary and at the end of the week, calculate your ASO, AST, and ASE.

Step 5: 

• If your sleep efficiency is >85%, move your planned bedtime 15 minutes earlier for the next 7 days (e.g., if it was 12:45am the previous week, it would become 12:30am for this week). 

• If your sleep efficiency is 80-84%, maintain the same rise time and prescribed bedtime for one more week. If your sleep efficiency is <79%, return to steps 2 and 3. 

• Continue this process over the course of several weeks until you are satisfied with your sleep.

Component #11: Self-assessment

On an ongoing basis, assess the degree to which you are employing the above recommended strategies. Also note any challenges you are having with the strategies.