CGPR: Could you provide an overview of the core principles of Brief Behavioral Treatment for Insomnia (BBTI)?
Dr. Buysse: BBTI is a distillation of some core principles included in cognitive behavioral therapy for insomnia (CBT-I). Unlike CBT-I, which includes both cognitive and behavioral strategies, BBTI focuses on the behavioral components. It offers a shorter, more targeted intervention (Gunn HE et al, Sleep Med Clin 2019;14(2):235–243). Treatment begins with basic education about insomnia and physiologic regulation of sleep, helping patients understand the underlying mechanisms. It then emphasizes four recommendations to improve sleep: 1) reduce time in bed to align more closely with actual sleep ability, which helps strengthen the association between bed and sleep; 2) only go to bed when feeling genuinely sleepy; 3) establish a regular wake-up time; 4) if you experience prolonged wakefulness during the night, get out of bed and engage in a calming activity under low light until you feel sleepy, then return to bed. 

CGPR: How do you incorporate these in the session? 
Dr. Buysse: Most of the work is accomplished during the first session. Before this session, we gather a detailed history of the patient’s sleep problems, including the course of the problem over time, precipitating factors, exacerbating factors, or helpful factors. With this understanding, we know the person’s basic sleep patterns and challenges. The first BBTI session provides education about how we view insomnia. It emphasizes two key principles of sleep regulation: 1) the role of sleep drive, which builds the longer we are awake, and 2) the impact of our circadian rhythm—a 24-hour cycle influencing sleepiness and alertness. The session then focuses on analyzing the patient’s current sleep habits, including their bedtime, wake time, and patterns throughout the night. Finally, the session introduces the four key principles of BBTI and concludes with a personalized set of behavioral recommendations for sleep. Other people have further distilled the techniques to become a one-visit intervention. One-shot CBT-I has been used in a couple of studies (Ellis JG et al, Sleep 2015;38(6):971–978). I mostly do whatever I can in one session. 

CGPR: How does BBTI compare to CBT-I for older adults?
Dr. Buysse: One study showed slightly greater improvements in insomnia symptoms with CBT-I and sleep diary measures than BBTI, though differences were minor (Bramoweth AD et al, Behav Ther 2020;51(4):535–547). A small meta-analysis of BBTI in older adults reaffirmed its effectiveness in reducing insomnia symptoms, improving sleep quality, and achieving insomnia remission, as measured by sleep diaries and activity monitors. It did not directly compare CBT-I and BBTI (Chen YC et al, Age Ageing 2023;52(1):afac333).

CGPR: Do you ever use BBTI with an app? 
Dr. Buysse: In-person BBTI can be a great way to reinforce what patients are learning in an app. With BBTI, you can add a personal touch, explain recommendations in more depth, and tailor the approach to the patient’s needs—something apps can’t fully do. Apps that track a patient’s sleep can be useful adjuncts to BBTI, although some patients report worsening sleep anxiety when using them.

CGPR: Do you modify BBTI for older adults given their age-related sleep changes? 
Dr. Buysse: Older adults often experience changes in sleep quality, especially during life transitions like retirement. Many assume that retirement reduces sleep-related pressures, allowing for more rest. However, some find their sleep quality deteriorates after retiring. This highlights the importance of maintaining regular sleep schedules and staying active during the day to build sleep pressure and improve sleep at night. The biological clock thrives on regularity and schedules, and removing the schedule can negatively impact sleep. Additionally, common medical symptoms like nocturia can disrupt sleep in older adults. While it is often assumed that nocturia causes insomnia, research suggests addressing sleep quality itself can improve nocturia (Tyagi S et al, J Urol 2017;197(3 Pt 1):753–758). The first uninterrupted sleep period plays a key role in overall sleep quality. When older adults spend excessive time in bed, their sleep becomes fragmented, and the time before waking to urinate shortens. Using BBTI principles, compressing the total sleep time can increase the duration of the first uninterrupted sleep period, which may help reduce the severity of nocturia.

CGPR: What strategies do you recommend for overcoming resistance to behavioral change? 
Dr. Buysse: BBTI is largely a behavioral treatment, but I also use techniques like motivational interviewing to address resistance to change. I explore what patients fear might happen if they try something new, what they value about their current sleep patterns, and what they think might improve if they make changes. I also educate them about sleep using thought experiments tied to their personal experiences. I might ask if they’ve ever pulled an all-nighter. Most have, and when I ask what happened the next night, they usually recall falling asleep instantly and sleeping deeply. I reference this when recommending they reduce their time in bed, a suggestion that often worries those with insomnia. To explain sleep drive, I use contrasting scenarios. I ask, “What would happen if you stayed awake until 2 am and woke at 6 am every day? You’d likely fall asleep quickly, right?” Then I ask, “What if you went to bed at 6 pm and stayed in bed until noon? Would you sleep the whole time?” Most recognize neither extreme works, but it helps them see the importance of finding the right balance of time spent in bed. 

CGPR: What challenges do you see that are unique to using BBTI in older adults?
Dr. Buysse: The medical challenges faced by older adults often differ from those of younger adults. Common issues include pain, limited mobility, and difficulty adhering to behavioral recommendations, like spending less time in bed. This often means spending more time awake and out of bed—a challenge when they struggle to find engaging ways to occupy their time. Younger patients may embrace this as “the gift of time,” but for older adults, it can feel like a burden and lead to boredom or loneliness. Many older adults go to bed because they’ve run out of things to do or lack energy.

CGPR: How can patients effectively shift their mindset around sleep?
Dr. Buysse: Sleep can’t be forced—it’s an involuntary behavior governed by the brain and body. The harder you try to make yourself sleep, the less likely you are to be able to sleep. This can create a frustrating cycle, especially for those dealing with insomnia. A helpful strategy is to shift the focus from trying to sleep to trying to stay awake. Specifically, this applies when you’re lying in bed, unable to drift off. Instead of anxiously forcing sleep, focus on calmly staying awake—without distractions like screens or getting up. When you stop “trying so hard,” your brain and body can relax, allowing your natural sleep mechanisms to take over. I often explain to patients that our role isn’t to force sleep but to create the right environment for it, both mentally and physically. Once we’ve done that, we need to trust the brain and body to do their job. 

CGPR: Have you adapted BBTI for older adults with cognitive impairment? There must be challenges with sleep restriction.
Dr. Buysse: “Sleep restriction” can sound intimidating, but it means restricting time in bed, not deliberately shortening sleep duration. The goal is to consolidate sleep, resulting in deeper, more restorative rest. For example, most people would prefer six hours of continuous sleep over eight hours of fitful sleep with frequent awakenings. That said, sleep restriction only works when aligned with an individual’s natural sleep drive. I recently saw a patient whose caregivers set her bedtime at 9 pm, not because she was sleepy, but because their schedule required it. While this was part of a regular routine, it led to excessive time in bed and poor sleep consolidation. It disrupted her natural sleep cycle and worsened her sleep quality. This highlights a key point, which is that sleep restriction must be purposeful and patient-centered. Arbitrary bedtimes imposed for logistical reasons, like staffing shortages in residential care or nursing homes, can backfire. A mismatch between bedtimes and a person’s biological sleep needs often leads to more wakefulness, fragmented sleep, and unnecessary reliance on sleep medications.

CGPR: Do you adjust sleep medications before starting BBTI?
Dr. Buysse: Some patients express interest in tapering off medications, while others do not. Behavioral treatments can work in either situation. One common issue I encounter is patients taking insomnia medications too early, often due to the misconception that these medications will “knock them out.” It’s important to clarify that sleeping pills are not like general anesthesia—they help with sleep but don’t induce it directly. Many believe they need to take their medication early to feel sleepy, but sleep medications work best once the body is naturally sleepy. I often compare this to pushing a swing. If you try to push the swing while it’s coming toward you, it resists and disrupts the motion. But if you wait until it reaches its peak and starts moving away, a well-timed push helps it swing higher and more smoothly. Waiting until you’re naturally sleepy is like letting the swing start moving away, and the medication acts as the push to enhance the sleep process. In most cases, taking sleep medications closer to when you’re feeling sleepy leads to better results. 

CGPR: How do you train specialists to deliver BBTI? 
Dr. Buysse: My approach is straightforward. I meet with therapists, explain the rationale and key concepts of BBTI, and guide them through a patient workbook that serves as the outline for the treatment. The workbook that therapists use provides examples and structured guidance for presenting and applying the material. We do a two-way exchange: I not only demonstrate how to explain the concepts but also ask therapists to articulate how they would present the material themselves. People can email me or request access to the workbook online—I’m happy to allow people to use it and the BBTI techniques for noncommercial use. Visit www.tinyurl.com/455zw7kn for instructions on how to request information.

CGPR: What do you recommend for patients who want to learn about sleep and sleep drive? 
Dr. Buysse: I recommend two books. The Insomnia Answer talks about processes that regulate sleep and why it makes sense to reduce time in bed rather than extend time in bed (Glovinsky P and Spielman A. The Insomnia Answer: A Personalized Program for Identifying and Overcoming the Three Types of Insomnia. New York, NY: Penguin Group; 2006). There’s another book (with accompanying workbook) for people experiencing racing thoughts called Quiet Your Mind and Get to Sleep (Carney CE and Manber R. Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those With Depression, Anxiety, or Chronic Pain. Oakland, CA: New Harbinger Publications; 2009).

CGPR: Thank you for your time, Dr. Buysse.