Not Everyone - 7 Viewpoints from a Psychologist in Private Practice
Since 1999 I have been a psychologist providing CBTi to clients. Below are seven professional opinions about who benefits most from CBTi based upon both current research findings and the dynamics in play I have observed in a private practice setting.
1. CBTi is ideally suited for persons who have psychophysiological insomnia.
Insomnia is typically defined as:
- awake in bed for at least 30 min (trouble falling and/or staying asleep)
- at least 3 times per week
- the sleep difficulties cause problems with daytime function
Psychophysiological insomnia is characterized by:
- worries about sleep
- an irregular sleep schedule
- behavioral changes to cope
- sleeping in
- taking naps longer than 30 min
- going to bed earlier.
Many of the original studies of CBTi were completed with participants who fit these criteria for for extended periods. Consistent with the research, my observations have been that clients with chronic psychophysiological insomnia have had very good results with CBTi. They appeared to achieve meaningful and lasting gains from the treatments. If you meet the above criteria, CBTi is probably a great option for you to consider.
2. Notice that I did NOT mention above whether or not the insomnia was related to depression or anxiety? That’s because it’s also now well accepted that CBTi benefits persons with anxiety and depression who share at least some characteristics of the group above. In reality, most persons struggling with insomnia also have other challenges like anxiety, depression, substance use, and/or medical problems. Updates to the most recent classification systems of insomnia (DSM-V and ICSD-3) reflect this, partially in hopes of encouraging health care providers to address insomnia whether or not it is related to other health issues. Insomnia researchers have shown that CBTi is effective at reducing insomnia for persons also dealing with anxiety and depression. Similarly, researchers studying depression have also found that adding CBTi to standard treatments for depression results in better outcomes and reduced risk of relapse. These findings mirror my observations as a practitioner. It makes sense to address insomnia among clients with anxiety and depression. Spending time awake in bed is a breeding ground for worry and rumination, psychological processes known to maintain anxiety and depression respectively. Thus, I encourage all clients who are struggling with anxiety and depression to take a look at their sleep quality and consider whether CBTi may be part of the formula for their optimal health.
The first two assertions above are widely accepted by researchers and clinicians alike. However, the five ideas expressed below are more based upon my clinical observations in a private practice setting. They are better viewed as professional opinions rather than conventional wisdom. Nonetheless, experience has taught me that they are useful ideas for clients to consider.
3. CBTi benefits persons who are able to utilize the techniques. This may seem obvious, but the provider needs to understand the demands of clients’ lives, and adapt the approaches to fit. I’ll never forget the experience of teaching Stimulus Control Techniques (SCT) to a provider in Hong Kong who kept asking, “But where does the patient go when leaving the bed?” I reflexively responded that it didn’t really matter because where the patient went was not related to the underlying mechanism of the treatment. However, when I circled back and tried to understand his question further, he explained that it is not uncommon in Hong Kong for people to sleep next to each other in a shared space such as a single room apartment. I was humbled realizing that the particular technique was not viable, and grateful for the feedback. There are numerous examples of other challenges which make it difficult to utilize some of the CBTi techniques:
- persons required to travel across time zones for work
- parents of newborns
- fire fighters
- hospital patients
- those in elder care environments.
Also, it is important for prospective clients to be aware that some common procedures are contraindicated. For example, getting out of bed if awake for more than 20 min (or clearly awake) may be dangerous for persons who are at risk of harm from falling (e.g., persons with impaired balance). As such, I am a proponent of an individualized approach for each client rather than following a “one size fits all” pre-determined set of procedures.
4. CBTi benefits persons who are adequately assessed for and receiving appropriate co-treatments, if other health challenges are present. Over the years, many persons have self-referred to me for insomnia as the first step towards improving their health. For some of these, insomnia was a symptom of a health condition not yet identified. Included in a rather long list of conditions are thyroid dysfunction, obstructive sleep apnea, and even paraneoplastic syndrome. Fortunately, I was able to quickly refer them to other providers. Pursuing CBTi with a “let’s see if this helps first” approach for those clients would have likely delayed their access to more urgently needed care. I’ve also come to appreciate that when my clients have strongly suspected that their insomnia was a symptom of an unidentified or untreated problem, CBTi has not seemed to be much help. Sleep is sensitive bio-rhythm, and there are an infinite number of situations and conditions that can disrupt it. Therefore, I strongly recommend that persons seeking help for insomnia also obtain a current check up from their primary care provider so that they are feeling confident that any other medical issues have been assessed, re-assessed, and/or treated.
5. CBTi benefits persons who have adequate stability and support. This may also seem obvious, but if a client doesn’t show up to scheduled appointments because active substance use is interfering, CBTi is not likely to not work. Similarly, if a client is acutely suicidal, that issue needs to be attended to first, so that insomnia or other issues can be meaningfully addressed. That being said, I have successfully worked with clients who were concurrently being treated in Intensive Outpatient Programs (IOPs) for severe substance use problems. The key factor was that the clients had adequate support to maintain stability.
6. CBTi benefits persons who are satisfied with more efficient sleep and improved daytime function as indicators of treatment success. That means that CBTi helps people:
- fall asleep quicker and/or wake up less
- experience improved daytime mood and/or productivity.
Importantly, CBTi is not necessarily intended to increase the amount of time a person sleeps. So, if this is the client’s main objective, CBTi yields disappointing results. In this situation, if welcomed by client, I offer to share some information that may dispel sleep myths and consider related goals. However, when clients persist with wanting increased amount of sleep as their primary goal, then I tell them frankly that CBTi may not achieve that goal and respect their autonomy regarding their decision to move forward. Client resources (i.e., time and money) are precious commodities. When client and provider goals are misaligned (even slightly), my experience is that clients are not satisfied with outcomes.
7. CBTi may benefit persons who are motivated to try it. The interventions are based upon underlying principles related to our bodies’ healthy feedback loops: optimizing homeostatic pressure, circadian rhythm entrainment, maintaining healthy sleep routines, and striving for mental balance. Unless the strategies are contra-indicated for specific reasons (as mentioned above) CBTi is benign and likely to benefit most of us in terms of increasing or maintaining healthy, restorative sleep.
Almost every year I notice a report in the popular media showcasing CBTi as an alternative to medication treatments for insomnia. Although I am always glad to see the coverage and promotion of CBTi, I am also usually disappointed after reading the articles because readers are not adequately informed about who benefits from CBTi. So much so, that I’ve been motivated to write this article for persons considering the treatment. The reality is that CBTi is not helpful for all individuals suffering from insomnia. Like all evidence based treatments, the evidence supporting CBTi is based upon responses from study participants with specific characteristics. Additionally, transferring efficacious treatments from research settings into other clinical arenas can be fraught with challenges.
Authored by Jim Carter, Ph.D. licensed clinical psychologist at SBH. CBT for insomnia can include a variety of strategies including sleep scheduling, stimulus control, sleep hygiene, worry management, cognitive restructuring, etc. CBTi is a short-term intervention that typically occurs over 3-8 sessions.
Published Oct 2019