The promise of falling asleep faster, reducing the time you’re awake during the night, and getting more sleep overall would appeal to anyone who suffers from insomnia.
And if you can achieve this without taking sleeping pills, it’s an even more tantalizing idea.
Numerous research studies have shown that a non-drug treatment, called Cognitive Behavioral Therapy for Insomnia (CBT-I), can be as effective, and in many cases better, than taking sleeping pills.
Both the US National Institutes of Health and the American College of Physicians now recommend that a CBT-I approach should be tried before resorting to the regular use of sleeping pills.
This advice isn’t surprising, as CBT-I has been found to improve sleep in 75%-80% of people with insomnia. Furthermore, 90% of those completing a course find that they can stop taking sleeping pills.
CBT-I works by helping you to understand some of the possible causes of insomnia, and then supporting you to develop individual self-help approaches.
What’s more, although you can attend a clinic for the therapy if you wish, there are now also an increasing number of online courses. These can conveniently completed at home, and in your own time.
In this article I’ll look at the background to CBT-I and what the evidence says about its effectiveness. I’ll then review some of the prominent online CBT-I options, in case you’re interested in trying them for yourself.
What is Cognitive Behavioral Therapy For Insomnia?
CBT-I aims to present all this information about sleep and how to sleep better in a structured and guided way, tailored to your individual needs and development.
The overall objective is to change the way you think about sleep and how you can tackle problems such as stress and worry. These are often the root cause of many people’s insomnia.
The best CBT-I programs will lead you through the various stages with exercises and tests as you go along. Based on your results and feedback, for example from a sleep log, the programs then provide guidance on what you should do next or focus on more.
The gold standard is to undertake the program with a professional sleep therapist. However, that option isn’t realistic for everyone for reasons such as cost, time and availability of qualified therapists. Hence the growth in self-directed, online courses.
What does CBT-I cover?
There are different approaches to CBT-I, but most of the programs cover a common set of subjects, for example:
- Basic information about the importance of sleep and an initial personal insomnia assessment.
- A technique called ‘Stimulus Control” which aims to show how your bed and indeed bedroom should be a mental cue for going to sleep and not staying awake. It covers aspects such as:
- Getting up at the same time.
- Going to bed only when sleepy.
- Not staying in bed if you can’t sleep.
- Avoiding excessive napping during the daytime.
- How to restructure your sleep time; perhaps initially using a sleep restriction approach to build up to a more effective and satisfactory sleep pattern and length.
- How to manage issues such as worry and stress that can interfere with your sleep. This includes changing your mindset from trying hard to get to sleep to allowing sleep to happen naturally.
- Positive sleep habits, such as:
- Using the hour before bedtime to relax and wind down from the day’s activities.
- Making sure your sleep environment is calm, safe and relaxing.
- Avoiding food, drink and activities which may adversely affect your sleep.
- Relaxation and mindfulness techniques.
A personalized approach
The clever part of the CBT-I approach is identifying which of the various factors are most relevant for your particular situation.
The program should then offer you focused advice on where to concentrate your efforts to achieve the best results for you personally.
Most of the online programs last about 5-6 weeks, with some offering ongoing support after you’ve finished the main program.
Time commitment varies, but could be about 1 hour per week to complete the actual online part. However, it could take considerably longer to develop and test the suggested approaches yourself.
Evidence that CBT-I is effective
In 2012, the National Institute of Health reported the outcome from a group of sleep experts who had reviewed a large number of past studies of CBT-I compared to using medications. Their overall conclusion was:
CBT-I is effective for treating insomnia when compared with medications, and its effects may be more durable than medications. Primary care providers should consider CBT-I as a first-line treatment option for insomnia.
In 2016, the American College of Physicians produced a clinical practice guide for the management of chronic insomnia.
They again based their recommendations on a large scale review of research into the effectiveness of CBT-I. They made a similar recommendation that CBT-I should be the initial treatment for all adults with chronic insomnia.
Headline benefits of CBT-I
There are many consistent findings in the various studies of the effectiveness of CBT-I. Headline findings include:
- Between 40% and 50% less time to fall asleep when you go to bed.
- Up to 60% less time spent awake at night.
- An extra hour of sleep every night.
- Subjective assessments that the quality of sleep has improved markedly.
- CBT-I improves sleep in 75%-80% of people with insomnia and 90% found they could stop taking sleeping pills.
- Feeling much better during the daytime – not only less tired, but also less stressed.
Personally, those kind of figures seem very appealing – almost too good to be true! But the evidence base is strong, so if you suffer from insomnia, you might be interested in seeing if you can achieve this level of improvement to your sleep too.
Types of CBT-I programs
There are three basic types of program available. I’ll briefly cover those before looking at specific online programs.
Sleep therapist consultations
With this approach you’ll have regular face to face consultations with a sleep therapist. They will guide you through a CBT-I program and offer advice as you go along. This is the gold standard, but inevitably more expensive and there’s a severe shortage of qualified therapists.
If you suffer from chronic insomnia, it’s worth asking your doctor about this. The treatment may be available on your health insurance, or on the NHS in the UK.
The cost is normally calculated per session and varies enormously according to where you live and the reputation of the therapist. Examples are $450 for a six week session, but in some cases you may be charged $100 per session.
Group therapy sessions
In group therapy, a small group of people will meet with a sleep therapist at regular intervals (often weekly) and undertake the CBT-I program together. This reduces the cost, as well as providing opportunities for sharing ideas with other participants.
The availability of such group sessions will also depend on where you live, and in many areas are almost impossible to find. If your doctor can’t recommend one, you could try contacting a local sleep clinic. If it’s covered by your health insurance, it could be free.
Online programs are where the most development has been over the last few years. It’s partly driven by the cost, and also the lack of professionals trained in the face to face therapy.
Research results on the effectiveness of online treatments compared to face to face treatments vary. Some say they are equally effective, but a recent 2016 report suggested that online CBT-I wasn’t quite as effective.
Regardless, online and face to face were still both more effective than no treatment at all. The team in that 2016 study also concluded that:
our results also suggest that online treatment may offer a potentially cost-effective alternative to and complement face to face treatment.
Costs can vary between $50 to $300 depending on the length of the program and amount of online interaction with a therapist.
Review of online CBT-I programs
There are various different online CBT-I programs which can be accessed and followed from your own home.
I’ve limited my review to those where a recognized sleep and insomnia expert is involved in the development and running of the programs.
I’ve also mainly included those which you undertake yourself, without the direct support of a therapist or doctor. If you consult a doctor or therapist they may well recommend a different CBT-I program which they’re more familiar with.
Please note that none of the links to the program websites are affiliate marketing ones. And the prices listed were current as of November 2016.
- It took 43% less time to fall asleep.
- They spent 55% less time awake at night.
- They had 6.4 hours more sleep each week
One of the key people involved is Dr. Charles Morin, who is a Professor of Psychology at the Laval University in Quebec, Canada. He’s a well recognized expert in insomnia, with numerous research articles published.
You can either undertake the program through a sleep clinic with a therapist, or directly yourself. This video provides an overview of the program.
The Shuti program includes:
Access to research-proven SHUTi program, including 6 interactive lessons delivered over a 6-week period.
Online Daily Sleep Diaries.
Personalized Sleep Window recommendations each week.
Unique engaging interactions ensure knowledge transfer, foster skills practice and test strategy application.
Sleep Improvement progress reports.
Option to integrate with Fitbit™ Activity and Sleep Tracker.
Printable reference materials to share with friends and family.
Cost: $135 for an individual use for 16 weeks.
Sleepio is another well-researched online program with numerous trials and testimonials. It’s supported by the well-known expert on sleep and insomnia, Professor Colin Espie, at the University of Oxford in England.
You can watch a video on U-Tube where Professor Espie explains how Sleepio works.
One of their studies based on 164 people found that:
the Sleepio course helped around 75% of people with persistent sleep problems to improve their sleep to healthy levels, compared with the placebo and no treatment conditions which had relatively little impact.
an average reduction in time taken to fall asleep of 50% and in time spent awake during the night of 60% within the Sleepio group. We also found that people using Sleepio rated their quality of sleep as having more than doubled (a 115% increase) and their energy and daytime wellbeing levels increased by 58% during the daytime. Importantly, these improvements with Sleepio were found to be lasting because effects were maintained at our two month follow up point.
The Sleepio program covers all the CBT-I topics above. In addition, you get access to a library of information and all your past exercises.
You can also take part in a weekly ‘live group seminar’ with a sleep expert allowing you to share experiences and concerns with other participants, which could be helpful.
The online program uses an animation of the professor, which some people might find more user friendly.
They have numerous testimonials on their site. All report positive outcomes, with some mentioning that some parts are difficult, but worth sticking with. Others value the community approach so you can hear how others have dealt with sleep problems.
Cost: $300 for a full year’s access. Whilst this looks more expensive than other options, the longer access could be advantageous if you think it’ll take you longer to complete, or you might relapse into insomnia again.
This program is approved in the UK by the NHS, so UK residents might be able to access it for free.
If you’re willing to take part in an evaluation trial it’s also free. But half of those who sign up for the trial will only get an alternative, and probably less effective, on-line sleep education program.
There’s an option to switch to the full program after 6 months, but that’s quite a long time to wait if the basic non CBT-I program isn’t helping.
Conquering Insomnia Program
The Conquering Insomnia Program was developed by Dr. Gregg D. Jacobs, a sleep and insomnia specialist and assistant professor of Psychiatry at the University of Massachusetts Medical School.
The online version is based on a CBT-I program developed and used with patients in the university.
The program appears to rely more on the general research into the effectiveness of CBT-I, rather than actual trials with this specific online version. That said, Dr Jacobs’ extensive research into CBT-I was used to develop the online version.
The program covers 5 weeks as detailed below:
The website has lots of testimonials, with many saying that the program helped them to sleep better without needing sleeping pills.
This program appears to be much more standalone than the others, without a facility to interact with other participants. So part of your decision process will be to think about how important this aspect is to you personally.
Cost: The basic program costs $39.95; or $44.95 for a combination with added mindfulness exercises; and $49.95 for a version with a question and answer option. If you’re interested in this program it’s probably worth at least getting the combination version.
This free App isn’t designed to be a self-directed on-line CBT-I. Instead, it’s designed as an extra support if you’re seeing a therapist.
However, I decided to include it here as it’s free and still offers lots of useful tips which might help you.
It was developed by the US Veterans Association National Center for Post Traumatic Stress Disorder, Stanford School of Medicine and the Department of Defense’s National Center for Telehealth & Technology.
It’s currently the subject of studies into its effectiveness. And although it doesn’t have the same directed approach as the online options above, it does have lots of information about sleep and tools and exercises for improving your sleep. You can also use it to keep a sleep diary.
If you think you could benefit from one of these programs, it might be worth discussing with your doctor first. This is especially important if you’re currently taking any prescription drugs to help you sleep.
A doctor will also probably want to check that your sleep problems aren’t due to a different sleep disorder. It’s also probably worth seeking professional advice if your insomnia is the direct result of another illness or medical treatment.
That’s not to say CBT-I can’t help if you have another condition. You just need to be more cautious about the probability of success and any actions you might take.
It’s also important to realize that CBT-I isn’t an instant cure. It takes effort to follow the program and then keep using any techniques long after you’ve finished the actual therapy.
Cognitive Behavioral Therapy is increasingly being recommended as the first treatment option for insomnia. The Gold Standard is to complete the program with a dedicated sleep therapist.
This option might not be realistic for everyone for reasons of cost, time commitment or availability of therapists. In which case, an online program is definitely worth considering.
With no side-effects, it certainly seems to be worth trying such an approach before resorting to long-term use of sleeping pills.
Have you tried an online CBT-I program, or do you think it’s something you’d be interested in trying? Feel free to share your thoughts in the comments below.