Dr. Donn Posner is one of the most active educators in CBT-I. He's founder and president of Sleepwell Consultants, adjunct clinical associate professor in Psychiatry and Behavioral Sciences at Stanford, and spent twenty-five years before that as director of behavioral sleep medicine at the Sleep Disorders Center of Lifespan Hospitals.

In this first of two episodes, Dr. Posner argues that chronic insomnia is a disorder in its own right — not just a symptom of something else — driven by perpetuating factors that become the targets of treatment. He covers:

• How insomnia disorder is defined, and what a proper CBT-I assessment looks like

• The sleep diary as the clinician's version of an X-ray

• The two core behavioral components — sleep restriction (more accurately, time-in-bed restriction) and stimulus control — and the mechanisms each one targets: homeostatic sleep drive and conditioned arousal

• Why sleep can't be willed — it's never under a patient's voluntary control

• How far the protocol can flex for individual patients

• The evidence base showing CBT-I works even alongside depression, anxiety, PTSD, or chronic pain — and that those conditions don't need to be treated first

Learning Objectives

After completing this educational activity, participants should be able to:

1. Describe how chronic insomnia disorder develops out of acute insomnia, and explain why the perpetuating factors that maintain it — rather than the original precipitant — are the targets of CBT-I.
2.  Identify the DSM-5 criteria for insomnia disorder, including the daytime-symptom, frequency, and duration thresholds, and explain the role of the sleep diary in assessment and treatment planning.
3.  Summarize the two core behavioral components of CBT-I — sleep restriction (time-in-bed restriction) and stimulus control — and describe the sleep-regulatory mechanisms each one targets, including homeostatic sleep drive and conditioned arousal.
4. Apply the evidence that CBT-I improves insomnia in the presence of comorbid psychiatric and medical conditions to decisions about treatment sequencing, recognizing that the comorbid condition need not be treated first.

Abigail Rasol: Hi, everyone. Welcome back to the Carlat Psychotherapy podcast, where we review different psychotherapeutic approaches to better expose you to the wide range of evidence-based modalities available. I'm joined today by Dr. Donn Posner to discuss cognitive behavioral therapy for insomnia, CBT-I.

Dr. Posner is a leading expert in CBT-I. He's the founder and president of Sleep Well Consultants and currently serves as an adjunct clinical associate professor in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine.

Prior to Stanford, he spent twenty-five years as director of behavioral sleep medicine for the Sleep Disorders Center of Lifespan Hospitals, where he trained and supervised clinicians specializing in sleep and anxiety disorders. Dr. Posner has played a major role in advancing CBT-I education through workshops, mentorship, and consultation, both nationally and internationally.

He's also the co-author of "Cognitive Behavioral Therapy for Insomnia: A Session-by-Session Guide," one of the most widely used clinical training guides for CBT-I worldwide.

So welcome, Dr. Posner. Thank you so much for joining us today.

Donn Posner, PhD., CBSM, DBSM: Thank you very much. Good to be here.

CBT-I: An Elevator Pitch

Abigail Rasol: CBT-I is probably new to a lot of the folks that are tuning in today.

If you could give us an elevator pitch for CBT-I, what is it? Why does it work? How does it work?

Donn Posner, PhD., CBSM, DBSM: I would say that cognitive behavioral therapy for insomnia is a little bit different than all the other cognitive behavioral therapies, because in order to practice it well, one needs to have a grounding in sleep medicine, which is something that as clinicians in graduate school we often do not get.

We understand now, after about forty years of research, that much of what we’ve been taught in graduate school about insomnia is not true: The idea that insomnia is a symptom of something else, whether it's a physical problem or a psychiatric problem, and once we treat the initial problem, the insomnia will go away.

That turns out to be so untrue that it just has been demonstrated over and over again. When you treat other disorders, often the one nagging symptom is insomnia.

I think everything that we have learned as clinicians about insomnia is true for acute insomnia. Anything can knock us off of track for a couple of nights or even a couple of weeks. That's acute insomnia, and it is likely true, that if that stressor remits or you adapt to it, the insomnia's going to go away.

What we're talking about here is chronic insomnia.

Chronic insomnia evolves out of the acute insomnia because people begin to do things to try to help themselves sleep. It's as if we're shifting our focus from the problem du jour, whatever that might be, to the sleep itself. It's like, "Oh my goodness, in addition to everything else, I'm not sleeping."

And then we start to put our hands on what essentially should be an automatic autopilot function of the body, which is sleep. We start to inadvertently do things that we're not aware of that mess that up. In behavioral sleep medicine, we call this perpetuating factors.

They perpetuate the insomnia long after the initial precipitant goes away. And what CBT-I does is it targets all of these different perpetuating factors to get them back in line so that you can sleep well again.

Defining Insomnia

Abigail Rasol: How exactly does the CBT-I community define insomnia? Is it anybody that is not sleeping perfectly? Is it subjective? Is it objective?

Donn Posner, PhD., CBSM, DBSM: It's definitely subjective. It has different elements to it, but there is a category in everybody's DSM-5 that is insomnia disorder.

And we define insomnia as either difficulty getting to sleep, staying asleep, or waking too early, that results in one or more daytime symptoms. You have to have something. It's a low bar. You have to at least be tired. But anything from tiredness to sleepiness to irritability to mood changes to physical symptoms to problems with focus and concentration and so forth.

The problem has to be occurring three or more days a week, and the chronicity of it is that it has to be occurring for more than three months.

What I will tell you is that when most of us in the field start seeing someone with insomnia disorder, it's often the case that they've had their insomnia for months and years and decades, and not just a few weeks.

Abigail Rasol: And that's probably in large part because so few people, including clinicians, know about CBT-I, and what's being thrown at these patients much more often than not is medications.

Donn Posner, PhD., CBSM, DBSM: Correct.

Assessing a Patient’s Fit for CBT-I

Abigail Rasol: So when a patient presents to you with insomnia, what are the questions that you ask to determine whether CBT-I is the right approach for them?

Donn Posner, PhD., CBSM, DBSM: In essence, we're looking for those perpetuating factors. We're looking for what is happening, what they're doing. We'll get a very big picture.

When I do an initial evaluation, I'll spend at least an hour, if not an hour and a half. A lot of it is focused on sleep and sleep medicine, and we are checking in on the other comorbidities. What does your depression level look like? What does your anxiety level look like in general? What other comorbidities do you have?

A lot of the time is spent on sleep in ways that nobody in a general practice in psychotherapy would be doing. I'm spending time just looking at what exactly is the nature of the insomnia, how does the person estimate that they are falling asleep? Are there other sleep disorders that are involved that we need to check for that could be contributing to the problem? What is it that the person does when they can't sleep, and what kinds of activities are they engaging in? What are they thinking about when they're laying in bed and they can't sleep?

All of this goes to finding points of intervention for later on. We're looking for those perpetuating factors.

Abigail Rasol: Is that assessment usually done in one session? Can it be drawn out over multiple?

Donn Posner, PhD., CBSM, DBSM: I think it varies from clinician to clinician, and it depends on how you're practicing. I'm often sending things to people ahead of time so that they are already filling out a lot of information that I can populate into an intake, and so I have a lot of information that I'm just checking on rather than asking about for the first time.

And then I'm using the opportunity to begin the process of education. A little crash course on sleep medicine to understand what it is that goes into normal sleep and how that goes awry. And it's also a way of suggesting to the patient that these things are fixable, and therefore there's hope even though it's been years and nothing else seems to have worked.

I'm often then taking the time at the end – if the patient decides they want to sign up for the therapy – to go over a sleep diary, because we cannot do this work without somebody filling out a subjective sleep diary, and that's our most important source of outcome variable.

Chronic Insomnia: A Type of Phobia

Abigail Rasol: You touched on some of the points that go into the treatment, I'd like to go in that direction. The psychoeducation, the sleep diary. It sounds like there is a lot of structure to the treatment. Could you speak about the trajectory of the treatment? You go from assessment to psychoeducation to the sleep diary, what else comes in along that path?

Donn Posner, PhD., CBSM, DBSM: Once we get a good sleep diary back from the patient, we've got data that we can then work with, and that informs the prescription. That's the way I think about it, that we're then making a prescription of the major techniques within CBT-I.

The first of those, and the core of those, is sleep restriction – which is terribly named and inappropriate – and stimulus control.

So those are the main core behavioral techniques, and that's where most patients are going to start. They're going to get them going on that and then bring them back in after a week or so, and you can already see tremendous benefits within a week if the patient has been adherent.

If not, what you're starting to engage in is problem-solving and cognitive work to look at what it is that's getting in the way of the patient carrying out these techniques. I think of chronic insomnia disorder as essentially a phobia and anxiety disorder – it is a fear of sleeplessness, a fear of what sleeplessness will do to me the next day or to my life. And what it requires is exposure.

An Introduction to the Therapy

Abigail Rasol: That's such an interesting way to conceptualize it. It makes a lot of sense, but that's not a perspective that you hear very often.

So what do some of those sessions look like?

It sounds like a lot of the work is being done outside of session with the client applying the instructions or the techniques to their night-to-night life in terms of their sleep. What's happening in the actual session?

Donn Posner, PhD., CBSM, DBSM: Like any CBT, what you're giving is homework, but the homework becomes everything.

When we're doing our courses and trying to teach clinicians how to do this work we often say, "One of the things you're going to do is a diary," and that's brought up at the beginning of treatment and is reviewed at every session right at the beginning of the session.

If it's not done, we're going to spend the session on why it wasn't done and how we can get it done. I spend a lot of time in that first session going over how to fill the diary card out, because if you just hand one to somebody and say, "Here, do your best," often that will create more anxiety, and patients will come in with blank diaries, or, a lot of question marks or blank boxes, which are not numbers or things that you can average.

What I tell my patients is, "Until we get this right, we can't proceed, because this is my X-ray. I can't really see what's going on and measure over time what's going on without being able to assess properly. And if you had a broken leg, you wouldn't want me to try to fix that leg without getting the X-ray first.”

The Diary Card

Abigail Rasol: It sounds like the diary card is a really fundamental part of the treatment. What does a diary card look like? What goes on it? What data are you extrapolating that you need to work with?

Donn Posner, PhD., CBSM, DBSM: There is now something called the consensus diary, and it pretty much captures what you need to capture for insomnia. For example, when are you getting into bed? When are you putting your head down on the pillow? It also looks at intention. When did you really start intending to sleep?

And then it's asking the questions that define insomnia. How long did it take you to fall asleep? How many times did you wake up? And of those times that you woke up and eventually got back to sleep, how long did that amount to? Did you wake up in the morning earlier than you wanted to, and if so, by how much? What time did you wake up? What time did you get out of bed?

The diary will also ask you to rate the quality of your sleep and how you felt about it. It also has a second page that looks at what you did during the day. Did you take any naps? How much caffeine did you consume? How much alcohol? What medications are you taking? Any other comments you would have.

So we're capturing that sort of data. But the most important data is what we call sleep continuity data. Trouble falling asleep, trouble staying asleep, waking up too early, how much sleep one gets.

Abigail Rasol: And then essentially, if I'm understanding correctly, you're using the information in the sleep diary to guide the suggestions that you give to the patient in terms of how they should modify their sleep in the following week?

Donn Posner, PhD., CBSM, DBSM: That's correct. So this is an evidence-based therapy and a very data-driven therapy.

Sleep Restriction: A Terrible Name

Abigail Rasol: So what are some of the suggestions that you would be giving? You spoke about sleep restriction, which you also said is a terrible name for what it is. What is it, and why is that description inaccurate?

Donn Posner, PhD., CBSM, DBSM: It isn't really sleep restriction. The more appropriate name, which also sounds terrible, but is at least more accurate, is that it is a time-in-bed restriction.

In people who have insomnia, you’ll always see a mismatch between how much time they're spending in bed and how much sleep they're actually getting. They just keep trying to glue themselves to the mattress and hope every night that the time will fill in and they'll start sleeping, and they never do.

So one of the things that we're doing is matching the amount of time they're spending in bed to the actual sleep that they're getting.

If you're getting six hours of sleep instead of the eight hours that you're in bed, that's a two-hour discrepancy. What a clinician might do is say, "We're now going to ask you to just be in bed for the six hours." For the first several nights it's very possible the person will sleep less than six hours due to the factors I just mentioned, but if they're honest to it and really adherent, it's going to have to fill in, and eventually, and it can happen within the course of a week, those six hours are being filled in mostly so that you're getting the vast majority of those six hours that you're in bed.

And it's a conditioning process, you're teaching yourself to sleep more solidly. You're teaching yourself to get those six hours, not in broken chunks over the course of the night, but in one piece. In having knitted that together you are training yourself to sleep solidly.

That process then can lead to us being able to slowly expand that sleep opportunity back to more normal levels eventually so that you're not left at six hours, and we can often bring people back to whatever is normal for them, which is different from every individual to individual.

Abigail Rasol: How does that process eventually allow you to extend the amount of time a person is asleep?

Perpetuating Factors

Donn Posner, PhD., CBSM, DBSM: If you're adherent, by the end of the week, you're going to be getting the same amount of sleep you've been getting for the last 10 years.

Which is not enough for you and is still going to leave you feeling tired, but then we're eventually going to extend that. But that is going to happen over a longer period of time because the other perpetuating factors take a little bit longer.

The perpetuating factor that sleep restriction goes after is something called sleep drive.

We all have something called sleep drive, and that is often one of the things that gets messed up when people transition from acute to chronic insomnia. They start doing things like extending their time in bed or napping during the day or falling asleep earlier, and by doing that they are spending sleep drive in the wrong place and at the wrong times, and they're weakening their sleep drive for the night. So sleep restriction is the way of getting on top of that.

The Role of Sleep Drive

Abigail Rasol: What exactly is sleep drive here? Is it the need to sleep?

Donn Posner, PhD., CBSM, DBSM: So we have two main mechanisms for sleep. Three, if you count the cognitive and anxiety pieces of this. But the two main pieces of what we call sleep regulation are sleep drive and circadian rhythm, and sleep drive is a homeostatic drive.

Every moment that you are awake, you are building something called sleep drive. One of the reasons that you're building sleep drive is that there's a buildup of a byproduct in our brain called adenosine. And as adenosine builds, it makes us sleepy. So what you want is a healthy dose of adenosine at night, and anything that you're doing to decrease that amount of adenosine during the day and over time is going to make your sleep less robust.

When we restrict your time in bed, that means you're awake for more hours during the day, and being awake for more hours builds more adenosine. I like to call adenosine the sleep god's natural sleeping pill.

It also starts to give you a hint to what we're doing in this therapy, which is we are not manipulating sleep. Sleep is not under anybody's control. Sleep is like heart rate and digestion and perspiration. Many of my patients say to me, "I've lost control of my sleep," and I say to them, "You never had it, and you never will."

What we can control in this therapy is being awake, and we know that the more hours that you're awake, the more adenosine and sleep drive you’re building.

Abigail Rasol: Other than sleep restriction, what are some of the other interventions that you are utilizing with patients in terms of restructuring their sleep?

Stimulus Control: Your Bed is for Sleeping

Donn Posner, PhD., CBSM, DBSM: The other main component is stimulus control. The idea is that one of the reasons that people may not be sleeping is that they are now in the chronic version of insomnia and associating their bed with other activities, whether that is watching TV or reading or doing work or eating in bed.

But this is also that they're spending a lot of time in bed awake thinking, worrying, engaged in too much fight against the sleeplessness, and all of that is being associated with your bed in a way that is conditioned, not unlike Pavlov's dogs, such that the bed itself or the bedtime routine becomes a conditioned stimulus for wakefulness.

Many patients will say, "I'm so sleepy on the sofa, it's hard to keep my eyes open, and then when I go to the bedroom, I'm wide awake." There's a great example of that conditioned arousal or that conditioned insomnia. So stimulus control is a therapy that says if you are not sleeping, don't do anything else in bed but sleep and sex.

And if you're not sleeping, get out of bed, and sooner rather than later. If I am awake, I'm not in bed. And if I get into bed, I'm asleep fast, and I would say within 10 to 15 minutes, or I'm not in bed.

In that way, we are eventually extinguishing the maladaptive condition response and building a new one, and getting into bed becomes a conditioned stimulus for sleep and sleepiness.

Abigail Rasol: So when you're saying nothing in bed other than sleep and sex, how strictly are we taking that? Are we saying not even reading for 10 minutes in bed until your eyes start to close?

Donn Posner, PhD., CBSM, DBSM: In therapy, yes. Right in the beginning, yes. I think the more seasoned you become in this therapy, you can make clinical judgments about that, but if you're new to this process, play it by the book, and by the book is right now, no reading. The trigger for you getting to sleep should be your pillow.

Customizing the Treatment

Abigail Rasol: That brings me to another question of mine that I had in terms of how customizable the whole treatment is, both for the client and for the therapist.

In terms of playing it by the book and what the standardized way to structure this intervention is. Would you say that for everything that you're doing, from the sleep diary to the sleep restriction to the stimulus control, there are clearly outlined ways to do it that you can apply to everybody, and then the clinician can deviate from those if they're experienced enough?

Or is everything to some degree a bit customizable?

Donn Posner, PhD., CBSM, DBSM: I would say that you said it pretty well. Again, when somebody's starting out, they should pretty much play it by the book. But very quickly, we know as clinicians, people bring and throw at us curveballs that we need to play with.

And what I say is, there's all kinds of discussions in the field about modifications to CBT-I for certain populations. How must we modify this for pain, or how much must we modify this for people with post-traumatic stress disorder, or the elderly, or that kind of thing.

And in my experience, we have data in all of these areas that there are many studies that show that regular, straight-on, unmodified CBT-I works just fine.

That said, as clinicians I think we're always modifying and tailoring an evidence-based treatment to individual patients.

So am I tinkering on every individual patient? I am. Would I say as a population, "Oh, we must do this ahead of time and make that assumption for this population?" No.

Abigail Rasol: Would that apply to individuals with sleep disorders as well? Do you see those as two different categories? For example, treating someone with narcolepsy versus treating somebody with a psychiatric diagnosis, or does everybody fall under the same category and benefit from the same strategies?

Donn Posner, PhD., CBSM, DBSM: Just about the same strategies. There's some things that we can do with a person with narcolepsy, but we're going to have to be doing that as part of a team with regard to medications that are typically used for narcolepsy.

But people who are certified in behavioral sleep medicine are not just doing CBT-I. We're also helping people with CPAP adherence. We're helping people with circadian rhythm disorders, which is really a different kind of sleep disorder than insomnia. We're helping people with parasomnias, like sleepwalking and night terrors, nightmares, those sorts of things.

CBT-I Can Improve Comorbidities

Donn Posner, PhD., CBSM, DBSM: In CBT-I, it has been thought for ages that, yeah, CBT-I is great for primary insomnia, but if the person has depression or if the person has anxiety, if their person has post-traumatic stress, or if they have pain, or they're recovered from cancer, or they have a neurological problem, then I'm not going to be able to get much traction on the insomnia unless you get that other problem under control.

And the data tells us the exact opposite story. It shows us that in the context of depression, anxiety, post-traumatic stress disorder, pain, and a whole host of other comorbid disorders, if you do CBT-I, insomnia will improve.

But wait, there's more. What we've found in the last ten to fifteen years is that not only does the insomnia improve, but the other comorbid or primary disorder also improves.

So we've turned the field on its head. And when we're training this, what I try to say to all the new people is, "Please do not think of CBT-I as a nice tack-on therapy for some of my patients who have some lingering problems with their sleep."

It can be that, but it can also be the first-line treatment you use for a number of different disorders to at least get them started.

With post-traumatic stress disorder, do we cure post-traumatic stress disorder with better sleep? No. But we get people farther down the line, and there's a trend toward fewer nightmares just doing the CBT-I without specific nightmare work. And people's anxiety gets a little bit better, and they're then more open to the treatment for PTSD.

CBT-I as a Gateway Treatment for PTSD

Abigail Rasol: How exactly does that work?

Donn Posner, PhD., CBSM, DBSM: In the VA (Veterans Affairs), people started calling CBT-I a “gateway therapy,” because lots of veterans would say, "I don't want to have my head shrunk, and I'm not interested in going to psychotherapy." But when they were asked if they wanted to work on their sleep, they said, "Yeah, sure, I'd be happy to work with a sleep expert."

And they did so, and the therapy is a lot like boot camp, it was very structured, and they got on board with that, and then their sleep got so much better that a lot of veterans said, "Gee, is this what therapy is really like? Because maybe I want to do that prolonged exposure for my post-traumatic stress disorder."

It would probably surprise almost everyone who is going to be listening to this that one could consider doing CBT-I as the first treatment that they engage in with their patients.

My feeling is that, medicine in general and, certainly psychiatry and psychology, missed the boat all these years ago by not including sleep medicine and this therapy as part of our training, and failing to give us a real understanding of what really chronic insomnia is and how much damage it does and why it's important to get on top of it and get on top of it faster and sooner rather than later.

And trying to correct that is essentially what my mission has been all of these years.

Abigail Rasol: I think you're absolutely right. We really have missed something fundamental, and it's done a huge disservice to a lot of our patients and to the field as a whole. Chronic insomnia is probably one of the most common comorbidities of anybody struggling with any psychiatric illness, and understanding it as this separate entity that requires its own approach and treatment and not just as one of the symptoms of the “primary diagnosis” makes a lot more sense conceptually, and is also clearly more effective.

We’ll pick up our conversation next week with some guidance for clinicians interested in training in CBT-I, as well as some more concrete examples of how the treatment functions in practice.

References

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Edinger, J. D., & Carney, C. E. (2008). Overcoming insomnia: A cognitive-behavioral therapy approach: Workbook and therapist guide. Oxford University Press.

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Manber, R., Edinger, J. D., Gress, J. L., San Pedro-Salcedo, M. G., Kuo, T. F., & Kalista, T. (2008). Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep, 31(4), 489–495. https://doi.org/10.1093/sleep/31.4.489

Manber, R., Buysse, D. J., Edinger, J., Krystal, A., Luther, J. F., Wisniewski, S. R., Trockel, M., Kraemer, H. C., & Thase, M. E. (2016). Efficacy of cognitive-behavioral therapy for insomnia combined with antidepressant pharmacotherapy in patients with comorbid depression and insomnia: A randomized controlled trial. The Journal of Clinical Psychiatry, 77(10), e1316–e1323. https://doi.org/10.4088/JCP.15m10244

Morin, C. M., & Espie, C. A. (2003). Insomnia: A clinical guide to assessment and treatment. Springer. https://doi.org/10.1007/b105845

Nowakowski, S., Garland, S. N., Grandner, M. A., & Cuddihy, L. J. (Eds.). (2022). Adapting cognitive behavioral therapy for insomnia. Academic Press. https://doi.org/10.1016/C2019-0-03656-4

Perlis, M. L., Smith, M. T., Benson-Jungquist, C., & Posner, D. A. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. Springer. https://doi.org/10.1007/0-387-29180-6

Stanford Health Care. (n.d.). Cognitive behavioral therapy for insomnia.

U.S. Department of Veterans Affairs. (n.d.). Insomnia. Veterans Health Library.

Walker, J., Muench, A., Perlis, M. L., & Vargas, I. (2022). Cognitive behavioral therapy for insomnia (CBT-I): A primer. Clinical Psychology and Special Education, 11(2), 123–137. https://doi.org/10.17759/cpse.2022110208

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.50) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity. This activity is available for CME credit for a defined period based on the date of publication, in accordance with accreditation requirements. The post-test must be completed prior to the expiration date; after that time, CME credit will no longer be available.