What is Sleep Therapy?

One of my biggest challenges career-wise has been trying to explain to people what it is that I actually do. What goes on in a therapy room is hard for most people to understand until they’ve done it, but I think that sleep treatments, in particular, are especially hard to imagine. “But what do you actually talk about for all that time?” is a question that I get a lot. So, I wanted to spend some time talking about how sleep therapy works and who it might benefit. 

Because I think that specific examples are easier to understand, I figured that I would walk through a course of CBT-I (cognitive behavioral therapy for insomnia) with a real/fake example (real in that the problems are real ones I’ve seen repeatedly, but fake in the sense that the specific details have been changed to protect confidentiality).

Let’s call her Joy. Joy is 52 years old. Joy mentioned to her primary care provider recently that she’s been having trouble falling asleep most nights and that she’s been waking up a lot during the night. Luckily, her doctor knew that CBTI is the first-line treatment for insomnia (you can read more about that here) and she knew that I specialize in treating sleep problems, so she gave her my name. Side note: cheers to all the PCPs who know about and recommend sleep psychologists - it’s a sign not only that they are up-to-date on research, but also that they genuinely care about their patients. But I digress…

15-Minute Consultation Call

Joy scheduled a consultation call using this link. During that call, I asked her a couple of questions about her sleep, told her about how CBTI works, and she asked me a few questions about what to expect. I told her that she could expect to attend 4-8 sessions, 50 minutes each, and we made plans to meet virtually so that she could fit our sessions into her lunch break. 

First Session

For all mental health providers, that first session is usually called the “intake” session and it goes a little differently than all the others. During Joy’s intake we spent time going over paperwork like consent forms and confidentiality. We also chatted and generally got to know each other a little bit. I then launched into my long list of questions. These questions might sound tedious, but they are necessary to make sure that we have the right diagnosis and exclude other causes of Joy’s symptoms. As we were talking, I learned all about Joy’s daily routines, her family, her stress levels, and finally her history with insomnia and other psychological and health issues. We discussed things like medication and her goals for treatment. 

At the end of that session I asked Joy to start logging her sleep each morning. I taught her how to use a sleep diary app (the one I use is called NOCTEM COAST) and asked her to begin filling it out the next morning. We scheduled her next session for the following week because I like to see at least a week’s worth of diary entries before we begin CBTI. 

I also want to mention that it can sometimes be a little disappointing to complete that first session and have to wait another week to get started with treatment. I actually feel that disappointment too because I’m usually excited to get started. However, it is actually so important that I make sure that we are treating the right problem and that we’re not missing anything. For instance, if Joy answered questions in a way that made me think that another disorder like obstructive sleep apnea was going on, she probably would only get minimal benefits from CBTI and she would still be feeling terrible. I would much rather have the opportunity to get her the correct resources right away. 

Second Session

Joy and I met a week later for her first session, and we dove right in. This session is a busy one because I generally go over A LOT of information. For instance, I told Joy all about how insomnia typically develops for most people and then explored how it played out for her. We talked about risk factors for insomnia, what causes insomnia to begin in the first place, and then how and why it lingers. I then told her about how sleep works from a biological and psychological perspective. I explain all these things because we harness both biological and psychological principles to create a treatment plan. 

Joy is a self-described night owl. She prefers a late bedtime and a late wake up time and she struggles to get to sleep before midnight, so we set up a new schedule for her that takes that into account. I gave her some guidelines about what when to get into bed, when to get out of bed, and what to do if she can’t sleep. We planned for her to try this new plan, continue with her sleep diary, and we would meet again in a week. 

Third Session

Joy came to this session with mixed feelings. In all honesty, she was pretty tired. But she was super consistent with the plan and was starting to see the pay off. She was falling asleep much quicker (within 15 minutes!), and was only getting up once during the night to urinate and then going right back to sleep. She was waking in the morning feeling pretty tired, though. So we spent a good amount of time this session talking about ways to decrease fatigue and make the mornings less miserable. We made some tweaks to her sleep schedule and discussed a few other challenges she faced with sticking to the plan and made a plan for overcoming those barriers. 

Fourth Session

Joy came to this session with less fatigue and feeling more hopeful. She again was super consistent and the changes that we made to her schedule were really helpful for her. During this session we spent time talking about how the years of insomnia that she experienced and how menopause only worsened her sleep. She shared how stressful it was to be unable to sleep and how it impacted her relationships and her work. She talked about how every night was miserable and the dread she would feel going to bed every night. We explored the thinking patterns she had around insomnia and the consequences of a poor night’s sleep. She shared that this process had started to shift some of that thinking (for instance, she realized that she was potentially overestimating the danger of poor sleep and how thoughts like, “if I don’t sleep I’ll get really sick” were actually making it harder for her to sleep. We discussed how to start to shift those thinking patterns. 

Fifth Session

By the fifth session Joy was sleeping really well. She was feeling much less anxious about sleep during the day and evening and she was feeling more rested. We reviewed the progress that she had made thus far. We made a few more tweaks to her sleep schedule and we reviewed what was most helpful and what to do if she starts having trouble sleeping again. We decided that Joy would keep logging her sleep for now, but that she wouldn’t need to keep coming in weekly. We scheduled a session for about a month out so that we could check in and evaluate her progress. We also took some time to celebrate her hard work!

In Conclusion

So there you have it, that’s what a typical course of CBTI looks like! Of course, it doesn’t always play out exactly like this. Sometimes we have more hurdles to overcome, such as tapering off medications or addressing extra anxiety, but generally it goes a lot like this. I hope you found this useful and maybe it even helps to demystify therapy in general. If you are ready to get started, book your 15 minute consultation! I would love to work with you.