CBT-I and Insomnia: Train Your Brain to Get Good Sleep
When we are consistently struggling with insomnia or other sleep-related problems, our minds can sometimes get involved and make our sleep issues much worse. It’s easy to get into harmful thought and behavior patterns that enforce poor sleep. Thankfully, CBT-I (or cognitive behavioral therapy for insomnia) is a powerful school of psychology that gives us the resources to break those harmful patterns and help us get to sleep.
As someone with Autism and ADHD, I have struggled throughout my life with sleep issues like insomnia. Autistic and ADHD people are at higher risk for having sleep-related problems such as insomnia, circadian rhythm disorders, the delayed onset of melatonin, restless leg syndrome, sleep apnea, and more. After learning about my neurodivergence, I came to understand how my sleep issues were related to my neurotype, and I was able to find resources to help me (and my neurodivergent clients) get better sleep. If you want to learn more, you can read my Autism, ADHD, Sleep Guide. In the article, I go into detail about the connections between neurodivergence and sleep issues as well as loads of tools you can use to get a better night’s sleep.
CBT-I was one of the most helpful resources I found. In this article, you are going to learn about CBT-I and how to apply some CBT-I practices to your life.
We are going to:
Review what CBT-I is
Confronting stressful sleep thoughts
Mental distraction techniques
and review additional CBT-I resources
Please note that this article is for educational purposes and is not intended to treat or diagnose a medical condition. If you are struggling with chronic insomnia or other long-term sleep issues, I recommend seeing a medical professional that can rule out, diagnose, and treat any medical condition that may be causing these sleep issues for you.
What is CBT-I?
CBT-I (or cognitive behavioral therapy for insomnia) is a type of therapy specifically curated to help those with sleep issues get consistently good rest at night. CBT-I helps to disrupt intrusive and stressful thoughts that keep us awake at night and help us to better associate bed with sleep. When we have difficulty falling asleep, our minds can quickly spiral and fixate on the worst possible outcomes of our poor sleep. Regardless of how rational these thoughts may be, they are always unhelpful and usually make falling asleep much more difficult. This is because the stressful thoughts activate the body’s fight-or-flight response, preventing relaxation from taking place.
Practices like CBT-I can be really helpful when this happens. CBT-I is designed to disrupt these thought patterns, which allows the body to turn down the stress response and turn up our nervous system’s rest and digest state (the state that allows us to fall asleep).
I don’t usually recommend cognitive behavioral therapy to my Autistic and ADHD clients. This is because, for neurodivergent people, cognitive behavioral therapy can feel disingenuous and like gaslighting. However, the exception to this is CBT-I. I have found a lot of success with CBT-I practices for myself and my clients.
CBT-I Practices
There are a variety of CBT-I practices available to use to fall asleep. The practices I’ve included here are the ones I’ve found to be most helpful for myself and my clients. These include sleep stimulus control, confronting stressful thoughts, mental distraction techniques, the 15-minute rule, and relaxation exercises.
Generally, it’s best not to overwhelm the body and mind by making too many changes at once. I recommend starting by experimenting with one practice at a time and seeing which works for you. If you try to include each of these practices all at the same time, this may stress the body out and make your insomnia worse. The goal here is to help the body and mind relax, so proceed gently!
Sleep Stimulus Control
It’s easy for us to create negative associations with bed and sleep. If you use your phone in bed, for instance, then we have created an association between the wakeful activity of phone-scrolling with bed, which can affect our ability to fall asleep. Sleep stimulus control helps to break those harmful associations and strengthen the beneficial ones. Here’s how it goes:
Avoid using your phone while you’re in bed. This is a wakeful activity and trains your brain to associate bed with wakefulness.
Avoid sleeping in other places besides your bed. If you nap, try to always nap in your bed. This will strengthen the association between sleep and bed.
Don’t watch the clock. If you’re having trouble falling asleep, watching the clock will make this worse. Try facing the clock away from your bed or flipping your phone screen side down.
Only use your bed for sleep and sex. Definitely avoid doing work in your bed, but even things like reading or knitting can weaken the bed and sleep association. Try to find different places to do those activities.
Only go to bed when you’re sleepy. Going to bed when you’re wired, hoping it will make you tired, probably won’t work and will only weaken the bed = sleep association. By going to bed only when we’re tired helps strengthen the bed = sleep association.
If you want to learn more, read my article on sleep stimulus and the sleep stimulus control protocol.
Confronting Stressful Sleep Thoughts
When we struggle with insomnia, we come to know stressful sleep thoughts very well. We can’t fall asleep, and our minds easily sleep into catastrophizing the situation: “I’m never going to fall asleep,” “tomorrow is going to be so hard,” “this is so bad for my health,” and so on. These thoughts, as rational as you may believe them, only worsen our restlessness. Luckily, there’s something we can do about them. One way to handle them is to confront them and change our perspective. Here’s how it can look:
When you notice stressful thoughts, identify them. You may consciously repeat them in your mind and notice how they make you feel.
Then, transform them. We want to acknowledge how difficult the situation is without making them into a catastrophe by restoring comfort. For instance, the thought “I will never fall asleep” can be transformed into “I’m not falling asleep right now, but I will eventually.” This shift reminds the mind that sleep is inevitable and allows the body to relax. The thought “tomorrow is going to be so hard” can be transformed into “tomorrow may be difficult, but I’ve gotten through sleepy days before, so I can do it again,” etc.
Notice how this new thought makes you feel. Does it help you to feel validated and calm?
The more we confront and transform these stressful thoughts, the less our minds will catastrophize the nights we get poor sleep and the more restless nights we’ll get.
Mental Distraction Techniques
Another way of disrupting these stressful thoughts is to distract ourselves from them. If transforming them doesn’t work for you, mental distraction might. Here are two ways of practicing mental distraction when we’re trying to fall asleep:
The CALM Visualization
This exercise is best for those who are good at and like visualizations. Here’s how it goes:
Imagine you are standing in front of a whiteboard with your favorite colored marker in your hand.
On the whiteboard, write the word CALM and the number 1, then circle it.
With your other hand, take an eraser and erase it.
Start over by writing the word CALM and the number 2, then circle it.
Repeat for as long as it takes to fall asleep.
A more sophisticated version of counting sheep, the CALM visualization is active enough to keep the mind involved but dull enough to allow you to fall asleep.
Cognitive Shuffling
If you have trouble with visualization, as many neurodivergent people do, then cognitive shuffling may be more useful to you. This exercise is particularly helpful for busy, neurodivergent minds! This exercise may also be useful if your stressful thoughts are rational but you no longer want to engage in them.
Pick any word of any length. For example, let’s say we use the word “garden.”
Start with the first letter of the word (in our case, “g”) and think of every word you can that begins with that letter (grape, garbage, grandmother, etc.).
When you can’t think of any more words that begin with that letter, move on to the next letter in that word (in our case, “a”) and repeat the process.
Continue until you fall asleep.
The purpose of cognitive shuffling is to scramble the mind’s thoughts so they no longer make logical sense and, therefore, lose their importance. Cognitive shuffling disrupts the evaluative parts of the brain that keep us awake and allows the brain to shut down and go to sleep.
The 15-Minute Rule
When we’re struggling with insomnia, sometimes the problem isn’t the thoughts themselves. Sometimes the problem is we just aren’t tired enough to fall asleep. If addressing our thoughts isn’t working, the 15-minute rule can help. This is how to do it:
When it comes evening time, wait until you feel sleepy before going to bed. If you have trouble with interoception, this may be difficult for you. I recommend starting with some interoception practices before trying out the 15-minute rule.
When you’re sleepy, go to bed. Get up from bed if you haven’t fallen asleep for roughly 15 minutes (estimate, don’t watch the clock!). This can be difficult, but it will help you in the long run!
Have a relaxing activity ready for you to do while you’re waiting to feel sleepy again. This activity can be reading, folding laundry, knitting, etc.
Once you feel sleepy again, start the process over. Go back to bed and, if you’re not asleep in about 15 minutes, get up again.
Please note that if this activity makes you feel anxious or if you get fixated on the clock, it’s best to just drop the activity altogether. In this case, I recommend trying relaxation and distraction techniques first.
If you want to learn more about sleep stimulus control and the 15-minute rule, check out this article.
Relaxation Techniques
There is an abundance of resources available online to help you relax and regulate the body. Here are some examples of relaxation practices that work well for me:
Breathing exercises. Some examples of breathing exercises that work well for my clients and me include the belly breath, the box breath, and progressive deep breathing.
Progressive muscle relaxation (PMR). This technique uses muscle tension and releases to activate the vagus nerve and induce a deep state of relaxation. Learn about it here.
Guided meditations. Both UCLA and Dartmouth have excellent resources and meditations you can use for both sleep and relaxation.
If you want to details on relaxation exercises that you can try yourself, check out my article on relaxation techniques.
CBT-I Apps
It can be helpful to have outside help with CBT-I exercises. Here are some apps I recommend checking out:
MySleepButton—Designed by cognitive scientists, this app uses cognitive shuffling techniques to distract the mind and initiate sleep.
Calm—This app has guided meditations, sleep stories, and other resources to help you fall asleep.
CBT-I Coach—This app uses CBT-I exercises to help you fall asleep.
Conclusion: CBT-I
Sometimes, if we are having difficulty falling asleep and staying asleep, we can get into negative thought patterns and create harmful associations with bed and sleep. These thought and behavior patterns will often make it even more difficult to fall asleep and create a self-perpetuating loop of insomnia. CBT-I is a powerful school of psychology that gives us the resources to break this cycle. CBT-I practices are designed to disrupt harmful thought patterns and create a strong association between bed, sleep, and rest. These practices can include sleep stimulus control, thought confrontation, mental distraction, and relaxation practices.
If you are a neurodivergent person who is struggling with your sleep, I recommend looking at my article on Autism, ADHD, and Sleep. In the article, you will find lots of interesting information about the connection between sleep and neurodivergence and an abundance of resources you may be able to include in your sleep toolbox to help you get consistently good (or decent) sleep.
I also have a detailed Neurogivergent Sleep Workbook. In the workbook, you’ll find information about Autism, ADHD, and sleep, a dozen workbook pages to help you better understand your own sleep patterns, guides to help you get on track with your sleep, and even more resources.
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