Review of - Effective Insomnia Treatments: Investigation of Processes in Mindfulness and Cognitive Therapy

Overview

Our study this week looked at treating insomnia using two types of therapy; cognitive behavioral therapy (CBT) and mindfulness. These approaches were chosen because they have shown promising results in past insomnia studies and are clinically very effective in treating a range of conditions tied to thought, emotion, and behavior.

So, what is insomnia? People in this study were considered to have insomnia if:

1. They consistently had trouble falling or stay asleep
2. It happened 3 or more times per week
3. It causes sleepiness that made it much harder to function the next day

Insomnia is very common, with the American Psychiatric association estimating that 1 in 3 people have trouble with their sleep, and 1 in 10 people suffer from clinical insomnia. Some research suggests that improving these sleep problems can also help other conditions, like depression, which makes treating insomnia even more important.

What is Cognitive Behavioral Therapy, and how was it used here?

Cognitive Behavioral Therapy (CBT) is a type of psychotherapy that works by teaching people to change the way they think in response to problems. It is very goal-oriented, and helps people understand how their thoughts, images, beliefs, and attitude impact their behavior, and what to change to enable them to meet their goals. It’s very effective (as much or more than medication) for a range of conditions, and can be a huge asset in treating anxiety, depression, PTSD, eating disorders, and more.  Because it’s so effective at changing behavior, it’s also a tool in treating sleep problems, as this study hopes to show.

Part of CBT is identifying the thoughts and behaviors that contribute to a problem, and this study focuses on 5 main patterns of people with insomnia:  

1. Worrying about sleep and believing that not sleeping will make the next day worse (“I won’t cope tomorrow if I don’t sleep well”)
2. Focusing too much on the signs of bad sleep the next day
3. Overestimating how much bad sleep effects them during the day (e.g. believing that any mistakes are because of bad sleep)
4. Unhelpful thoughts and beliefs about sleep (e.g. “if I don’t get 8 hours of sleep, I won’t be able to work well”)
5. Engaging in bad sleep habits (spending too much time in bed, napping, ignoring social obligations, etc)

These beliefs and behaviors around sleep make each other worse and create a mindset that makes sleeping harder. The goal of CBT here is to teach people to recognize when they personally have these thought patterns and reshape their thoughts to avoid them.

What is Mindfulness Therapy?

Mindfulness-Based Cognitive Therapy or Mindfulness Therapy (MBCT), uses some parts of CBT, along with a mindfulness approach – being aware of one’s thoughts, but not reacting to them. For example, someone with insomnia might think “I’m going to be awake all night.” Rather than running through all of the consequences of staying awake, a mindful approach would acknowledge that the thought happened, then move on to a different subject without reacting to the concept of losing sleep. Mindfulness therapy can be very helpful for depression, stress, and related conditions. In this study, it was used on the negative thoughts about sleep, much like the CBT goals, but focused on letting go of the thoughts rather than addressing them.  

The big difference between CBT and mindfulness therapy here is that CBT works directly on changing negative thoughts, while mindfulness is more “thinking about thinking,” and works to move past the unhelpful thoughts without changing them.

How Large Was the Study?

Not huge, but not tiny. In total, 57 people completed the study and 3-month follow-up. Most participants were female (around 63%), with a standard age of about 50 years old. Participants were recruited from doctors, psychologists, local pharmacies, and advertisements in local papers, then screened in a phone interview.

What Was the Design?

For the procedure, everyone in the study was given four sessions of CBT for insomnia and a post-CBT assessment. They were then divided into two large groups with 2 subcategories*.

Groups A1 and A2 (29 people total) were immediately given more therapy; A1 was given mindfulness, and A2 was given cognitive therapy.

Groups B1 and B2 (28 people total) waited four weeks for more treatment, then B1 was given mindfulness, and B2 was given cognitive therapy. Then everybody was assessed again, with a final assessment given 3 months later.

What Were the Results?

Both CBT and mindfulness therapies helped with insomnia, and to more or less equal degrees. How much they helped was correlated with how well the participant was able to change their thought patterns around sleep, and the better their thoughts became, the better they slept.

Interestingly, even though both therapies worked, the higher participants scored on a cognitive therapy test, the better their sleep was, but better sleep did not mean better scores on the mindfulness assessment. Not surprisingly, people who did mindfulness therapy also got better at mindfulness, and more so than the groups that just did cognitive therapy. More surprisingly, the mindfulness group also improved in their cognitive thinking, even though their approach didn’t directly address how to modify unhelpful thoughts, beliefs, and behavior. So, it seems that mindfulness therapy helped because it also caused cognitive improvement, not because the actual mindfulness is tied to better sleep.

How Is This Useful to Me?

Part of the problem with insomnia is the self-reinforcing belief that you’re going to sleep badly, and your going to feel bad because your sleep was bad. Fixing this cycle is not only possible, but very doable with some simple, short term therapy. You can choose either cognitive intervention (changing the content of your thoughts) or mindfulness (changing your relationship with your thoughts) and have a good chance of seeing positive results. In both cases, the actual cause of the improvement is probably the change in content of your thinking, but either technique will get you there with about the same levels of success.

The best approach is to use a licensed therapist, but there are lots of no-cost resources and exercises online to promote CBT and mindfulness**, such as the self guided FreeCBTi.com and the Free Mindfulness Project. One of the nice things about both of these techniques is that they tend to have a much lower rate of side effects than pharmaceutical interventions, and you can always stop whenever you want. Try it and let us know how your sleeping has been!

*Group numbers (A1, A2, etc) given for clarity here, groups were titled “immediate mindfulness,” “immediate CT,” etc, in the actual study

**Resources not endorsed or recommended by the study. We received no compensation for, and have no relationship to the resources mentioned; we just think they’re good.

Full Study Info: Effective Insomnia Treatments: Investigation of Processes in Mindfulness and Cognitive Therapy; Christopher William Lee (a1), Melissa J. Ree (a2) and Mei Yin Wong (a3); Published online: 08 June 2018 in Behavior Change