Dr. Donn Posner is a leading expert in Cognitive Behavioral Therapy for Insomnia (CBT-I), founder and president of Sleepwell Consultants, and an adjunct clinical associate professor in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. He is co-author of Cognitive Behavioral Therapy for Insomnia: A Session-by-Session Guide, and he has trained and consulted with clinicians nationally and internationally across nearly four decades of clinical practice.

In this second of two episodes, the conversation turns from what CBT-I is to how clinicians actually learn and deliver it. Dr. Posner reviews the available training pathways and what proficiency really requires, and explains why sleep hygiene — the advice most patients have already heard many times over — is not enough to treat chronic insomnia, even though it has a place later in the work. He identifies the high-yield principles any clinician can apply immediately, including a fixed morning wake time, early light exposure, and getting out of bed when not sleeping. He then examines sleep effort as a perpetuating factor and CBT-I as fundamentally a therapy of acceptance, describing how he prepares patients for a treatment that will make them feel worse before it makes them better, and how cognitive work addresses the fear and resistance that follow. He closes with what clinicians should expect from a course of treatment — typical length and spacing, responder and remitter outcomes, and the durability of gains — along with how he handles sleep medication and why guidelines place CBT-I ahead of hypnotics.

Learning Objectives

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

• Explain why sleep hygiene is ineffective as a monotherapy for chronic insomnia, and describe the more limited role it plays within a full course of CBT-I.
• Identify high-yield behavioral sleep medicine principles — including a fixed morning wake time, early light exposure, and getting out of bed when not sleeping — that clinicians can apply before completing formal CBT-I training.
• Describe sleep effort as a perpetuating factor, and summarize how the cognitive and acceptance-based components of CBT-I address the dysfunctional beliefs and resistance that arise during treatment.
• Summarize the expected course and outcomes of CBT-I (including typical session number and spacing, responder and remitter outcomes, and durability of gains) and explain why guidelines position CBT-I ahead of hypnotic medication.

Topics Covered in This Interview

• Pathways to training in CBT-I and behavioral sleep medicine
• Board certification in behavioral sleep medicine
• Why sleep hygiene alone does not treat chronic insomnia: the dental hygiene analogy
• Where sleep hygiene does belong within CBT-I
• Available CBT-I training programs and online options
• How clinicians become proficient: consultation, community, and case experience
• High-yield behavioral sleep principles any clinician can apply
• Sleep regularity, fixed wake times, and morning light exposure
• Why getting out of bed is the hardest intervention for patients to accept
• Sleep effort as a perpetuating factor
• What good sleepers do — and do not do — to fall asleep
• CBT-I as a therapy of acceptance
• Preparing patients for the work: “I'm going to make you worse before I make you better”
• The cognitive component: uncovering and debunking dysfunctional beliefs
• Common patterns of resistance, and exposure as the remedy
• Typical treatment length, session spacing, and pacing
• Responders versus remitters, and what the outcome data show
• Durability of gains and the role of sleep self-efficacy
• Managing and tapering sleep medication alongside CBT-I
• Why guidelines position CBT-I ahead of hypnotic medication

Abbreviated Transcript

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. Today I’m continuing my conversation with Dr. Donn Posner on Cognitive Behavioral Therapy for Insomnia, CBT-I. If you haven’t listened to part 1 of our conversation yet, I highly recommend doing so first. 

So Dr. Posner, picking up where we left off, what are the options for a clinician that wants to start working with CBT-I? How much additional training do they need to pursue before they take it on?

Training to Provide CBT-I 

Donn Posner, PhD., CBSM, DBSM: It’s a process. There is a society called the Society of Behavioral Sleep Medicine, and you can get a board certification in behavioral sleep medicine.

Nobody’s really asking for that right now though. At the moment, it’s mostly about getting better training. Sleep hygiene is a lovely set of do's and don'ts that we all know and most of our patients know by the time they get to us, because they're very attuned to these things. Get more exercise, drink less caffeine, drink less alcohol, don't bring devices to bed. And they've heard this over and over again, and we've already done the research, and the research says when you do sleep hygiene alone as a monotherapy, it simply does not work very well for chronic insomnia.

Abigail Rasol: So is it a component in CBT-I?

The Role of Sleep Hygiene 

Donn Posner, PhD., CBSM, DBSM: Yes. But only later in the therapy as a way to clean up things that aren't closer to perfect. 

The best way I can inform people about sleep hygiene is that sleep hygiene is like dental hygiene. What is dental hygiene? Dental hygiene is flossing and brushing. Are those things good? Yes, they are. Are the sleep hygiene rules generally good? Yes, they are. They can be, I think, overlearned and overblown in terms of us putting too much weight on them, and some of them don't have a lot of data behind them, but they make a lot of common sense. 

But chronic insomnia, not acute insomnia but chronic insomnia, is a cavity, and all the flossing and the brushing in the world will not fix the cavity.

So if you fix the cavity, is it good to teach a dental patient proper technique in flossing and brushing? Yes, and that's why sleep hygiene is included in CBT-I. But if you use it as the only therapy you're doing, you're not going to get very far.

So back to training. Just like anything else, there are a number of workshops out there.

CBT-I Training Programs for Clinicians

Program	Organization	Link
Training in Cognitive Behavioral Therapy for Insomnia (CBT-I)	University of Pennsylvania	https://www.med.upenn.edu/cbti/
Cognitive Behavioral Therapy for Insomnia (CBT-I) Training for Clinicians	PESI Inc	https://www.pesi.com/topics/cbt/cbt-i/?srsltid=AfmBOoouMbiSZDwSdLWAT60GyzESlx18gcxz6IeF9ZySUvH4stBCo1QF
Introductory Course in Cognitive Behavioral Therapy for Insomnia (CBT-I)	University of Arizona	https://uarizona.cloud-cme.com/course/courseoverview?EID=54988
CBTIweb	A provider-focused, web-based learning course in Cognitive Behavioral Therapy for Insomnia	https://cbtiweb.org/

So there are ways to get at least the basic training. Dissemination and implementation research will tell us that a workshop is usually not enough to become proficient at anything, but it's a start.

Abigail Rasol: How do you become proficient in CBT-I in particular? 

Donn Posner, PhD., CBSM, DBSM: You become proficient by getting consultation and working with people who know how to do this stuff. Not on a case-by-case basis, it’s not supervision necessarily. You don't have to start from scratch. But you're going to hit cases where you're not sure how to run things and trying to tap into the community and find people who would be willing to work with you to help you with cases is essential.

Abigail Rasol: To make that initial foray into the world of CBT-I, is one of these one-day or two-day workshops sufficient to give the clinician a little bit of ground to start working with?

Donn Posner, PhD., CBSM, DBSM: Yes, it's really that balance of now I've got these tools, how do I get good at this? And the answer is you can't get good at it unless you start doing it. 

Like any therapy that you've ever learned to do, there's going to be a day when you jump in and see your first patient. And you need to do that, and you start learning from that process as well.

With CBT-I, the problem is that in order to do this and to be able to think outside the box with every individual patient, you're going to need some grounding in sleep medicine. And that's the one thing that you don't have. We try in our workshops to give you some, so that by the end of our workshop, we're at least giving you enough of that as it relates to insomnia to be able to get rolling.

Applying CBT-I Principles

Abigail Rasol: Would you say that for the average clinician that does not have a grounding in behavioral sleep medicine and has not been through a course or one of your workshops, there are certain high-yield interventions or ideas from CBT-I that they can extrapolate into their work? 

Donn Posner, PhD., CBSM, DBSM: I think there are concepts from behavioral sleep medicine that anyone can use fairly quickly, and we're gaining a lot of traction with that. It’s really not even necessarily for people with insomnia, but I would say just about anybody with a mental health disorder. 

Here's rule number one. If nothing else, getting your patients to get up at the same time every morning and get out and get a little bit of sunshine is going to go a long way to helping them.

Normalize and stabilize their sleep regimen. Sleep regularity matters. Structuring somebody's sleep is going to go a long way to helping their mood, to stabilizing them in a lot of ways. It’s not going to fix everything, but it's a great start. 

Beyond that, you don't have to know a lot to at least make the suggestion to patients that it is never going to behoove them to lay in bed tossing and turning and struggling. So getting out of bed when you're not sleeping is a good thing. 

The problem is, I would say of the two techniques, the one that sounds the hardest when we're doing CBT-I is sleep restriction. It turns out that's not the hardest, and it's the one you're going to lay off the quickest. 

The hardest thing for people to do is to get out of bed. They are so programmed not to let go. 

The Importance of Getting Out of Bed

Abigail Rasol: Why is it so difficult for people not to get out of bed, and why is it so important? 

Donn Posner, PhD., CBSM, DBSM: Another perpetuating factor we haven't talked about yet is something we call sleep effort. And I have already mentioned to you that sleep itself is something that is what I refer to as autopilot.

When sleep drive and circadian rhythm are well-aligned and your body knows when to sleep, you're generally going to sleep better. And as long as those things don't get messed up and you're not too anxious going to bed, then you're going to sleep. 

It should be like that. And I always do this activity. Whenever I'm doing a course, and I've been doing this for 17 years, we're always teaching therapists. 

Of course, some therapists have sleep problems but many do not, and I'll always ask for a volunteer in the audience, say, "who's a good sleeper?" And somebody will raise their hand, and I'll say, "Last night, did you sleep well?" They'll say yes. And I'll say, "Okay. I don't need to intrude in your privacy. I don't care whether you read in bed or even eat a bowl of gravy in bed. Is it fair to say that at some point you put down everything, you turned off the TV, you turned off the lights, you put your head down on the pillow?" The person will always say yes. And I'll say, "At that point, what did you do to get to sleep?" And the answer is always the same: I don’t know. 

What I mean to say is that you will never hear a good sleeper say, “The first thing I have to do is empty my mind." And you'll never hear a good sleeper say, “The first thing I do is breathe in to a count of four, hold to a count of four, and breathe out to a count of four."

But what you hear patients with insomnia doing all the time is sleep effort. They are working at something they have no control over. Imagine working at sleep. Imagine you're now putting mental and physical effort into anything. Does that sound conducive to sleep to you? And yet it is the most insidious and hardest thing for patients to break. When you raise this point with them, they see it right away and they laugh, and they'll say, "Yes, of course," and, "I can't do that," and, "Yeah, that's me," and, "I have to stop that." But they can't see themselves doing it.

It's almost like an ACT concept, that it's very hard for brains to get around not fixing things. So this therapy is very much a therapy of acceptance. When we say get out of bed in the middle of the night, it's not just because we don't want you associating your mattress with being awake. A much bigger factor is not working at it anymore. The idea of let's get up and give up, and if I don't sleep tonight, that's fine because it's only going to build more sleep drive for tomorrow, and eventually I'm going to sleep.

I tell every patient who wants to engage with me in CBT-I, "I'm going to make you worse before I make you better. Are you in?" I won't leave you that way, and you'll be better eventually. But this is a working therapy and a no pain, no gain therapy. It's going to take work, and you need to have commitment.

The Role of Cognitive Work

Abigail Rasol: I would imagine, even with that warning up front and the patients that accept it wholeheartedly and with determination, there's still a lot of discouragement that can come out as they are actually going through the therapy. 

When a patient is coming to you and saying, "It's not working. I don't want to do this," or, “This is much harder than what I signed up for,” how are you handling that?

Donn Posner, PhD., CBSM, DBSM: The most important answer to that is probably the C in CBT-I. So now you're getting to the cognitive pieces, and as I said, this is a phobia.

What you're tapping into is, why wouldn't you go to bed later, or why wouldn't you get out of bed in the middle of the night? Often what you're going to uncover without having to scratch too deeply is fear. "If I do what you're telling me to do, Dr. Posner, I'm going to be awake the entire night. And if you do that, then what's going to happen? Then I won't be able to function the next day, or I'll develop some horrible disease, or..." And so you're doing cognitive work to start to debunk, what we call in the field, dysfunctional beliefs.

There, the work is not that dissimilar from any other cognitive work, except for knowing some of the details of sleep medicine that you can utilize in that process. 

Confronting Resistance

Abigail Rasol: In terms of that resistance that you might get, have you observed any common pattern in what types of patients tend to struggle most with the treatment, particularly in the earlier stages?

Donn Posner, PhD., CBSM, DBSM: There are different types of common resistances. The ones that I started to label already are, "I'm not going to be able to function the next day." Again we don't have the time to go through the cognitive work. The bottom line is that the patient needs to learn that there is a big difference between functioning and not functioning. But you can't learn that unless you test it, right? 

And so you have patients who either don't do things; for example, "I've stopped exercising because I'm afraid that if I exercise I'll make myself worse," and they can't learn that's not true.

In fact, exercise leaves them more alert and less fatigued – but they won’t believe it until they try it. It's an exposure exercise.

So you'll get resistance in those areas. The more anxious the patient is, the longer it's going to take.

Just like any other anxiety disorder, everybody's going to sit on a continuum of how anxious they are and how willing they are, and it takes more cognitive work and more problem-solving, and maybe breaking the steps down into smaller bits. 

Treatment Timeline

Abigail Rasol: Is there a specific length or range of time during which the treatment has been proven to be effective, or is that something that's very variable?

Donn Posner, PhD., CBSM, DBSM: We wrote one of the original manuals on how to do this step by step. That lays it out as an eight-session protocol. And that was a research protocol. I rarely do that many sessions. I would say my average is closer to six. 

Abigail Rasol: And that's presuming one session a week?

Donn Posner, PhD., CBSM, DBSM: No. Generally speaking, in my practice, the average length of stay is between five to eight visits, probably averaging closer to six, but spread out over about two to three months.

The initial sessions are often done weekly. But once somebody is starting to do better, and now we're just starting to gradually increase their time in bed and work on some other things like their anxieties, then they can stretch that out for a couple of weeks and play with some things. This allows them time to increase those total sleep times and those times in bed. 

Delayed Progress

Abigail Rasol: Say a patient is eight visits in and is clearly still struggling with symptoms of their insomnia. What is your understanding of why it's taking them longer than it should? Are there any patients for whom it ultimately does not work at all, or is it just a matter of breaking through the resistance?

Donn Posner, PhD., CBSM, DBSM: That's where consultation comes in. All of the data that we have in this field is reported in terms of responders and remitters. So you get people who do CBT-I, and they're better by 50 or 60 or 70%, but they're not perfect sleepers.

What the data tells us is that at least 50% of the variance of anybody's chronic insomnia is due to perpetuating factors, and if you fix those perpetuating factors, on average you're going to make the patient 50% better. 

Do we have patients who go through this and they're perfect at the end of treatment? Yes. So you have responders and remitters. What the data tells us is that the reason that CBT-I is the primary treatment for insomnia is that one year later, the relapse data are fantastic.

Most people have not lost their gains. It's the gift that keeps giving. There are papers now that show maintained gains at two years, three years, and there's one paper at 10 years. So if you keep practicing what you learned, you're going to stay better. So people get better on their own with time, just continuing to practice. It's like working a muscle.

One of the things that builds over time is something we call sleep self-efficacy. I don't think you build that in six weeks or eight weeks, but at the end of a year, if you keep getting on top of little bouts of acute insomnia and putting those embers out, and it doesn't turn into a brush fire, you become more and more confident in your skills, and therefore more and more willing to keep doing them. 

So people get better over time. But at the end of the day, if you ask me, I would say that I probably can count on my fingers and toes the number of patients who did exactly what I told them to do and didn't get one iota better in 37 years of practice. 

Abigail Rasol: I would assume that a lot of the patients coming in to see you have tried a lot because, like we've said, CBT-I is not so well known. So to have gotten to CBT-I, you must be quite desperate, so to say. 

Donn Posner, PhD., CBSM, DBSM: Desperate is a good word. Yes.

Tackling Sleep Medication

Abigail Rasol: So I would guess that a lot of the patients coming in to see you have been on some sort of sleep medication or are currently on sleep medication.

How do you decide what role the sleep medication plays? Are you suggesting they stop the medication before you start the CBT-I? Are you working with the two together and then tapering off? What does that look like?

Donn Posner, PhD., CBSM, DBSM: I'm a bit of an outlier. I definitely work with my patients to get them off the medication beforehand because it makes the therapy better and faster. And there's a whole rationale for that, and they have to be on board, and the physician has to be on board. 

I would say the vast majority of people in the field will help people to taper off the medication during the course of the therapy, and that's fine too. It’s almost always in collaboration with the treating physician. The goal is usually to get the person off medication because although medications are really good for insomnia, they were never intended for long-term use and they have their own long-term consequences. 

Almost all of the governing organizations around the world now say that the number one treatment for insomnia should be CBT-I, above and beyond and before hypnotic medication.

That is because the data is very clear. CBT-I is as effective as hypnotic medications in the short run and more effective over the long run, in the sense of when you discontinue treatment, CBT-I is the gift that keeps giving, and in fact, total sleep time increases over time. When you discontinue sleep medications, often the insomnia comes back.

The guidelines are that you should try CBT-I before you go on a hypnotic medication. But of course, nobody in the field knows this, and so everybody goes on medication. 

So there's absolutely protocols and ways to help people off the medication during the course of CBT-I, and it is a priority in the treatment. 

Abigail Rasol: We’re almost at the end of our time here, but I wanted to ask if there is anything that I missed that you think is important to mention about CBT-I, or any sentiment that you'd like to share with the audience as a takeaway from the conversation. 

Donn Posner, PhD., CBSM, DBSM: I think we hit the highlights. What I always tell people about a workshop or a talk is, "I'm happy to come talk, but I'm not going to teach people how to sleep in an hour. And I'm not going to teach therapists how to do CBT-I in an hour." 

So what we're going to talk about is what you and I talked about largely here. Nobody from this thing learned how to do CBT-I, not really. But what they learned is that it is a potent therapy, that it does more than what we think it will do, that it can work in all kinds of circumstances, and that you don't have to fix everything else first. And that it is, again, a very powerful therapy that I believe should be in the toolbox of every mental health clinician around the world.

Abigail Rasol: I definitely agree with you. Hopefully our conversation exposed a few more people to what CBT-I is and how much potential it really has. Thank you so much for joining us today. I think we had a great conversation.

Donn Posner, PhD., CBSM, DBSM: It was my pleasure. Thank you for having me.

Abigail Rasol: Thank you to our listeners for joining us, and we will link the resources that Dr. Posner mentioned in our description.

References

American College of Physicians. (2016). ACP recommends cognitive behavioral therapy as initial treatment for chronic insomnia.

Baglioni, C., Espie, C. A., & Riemann, D. (Eds.). (2022). Cognitive-behavioural therapy for insomnia (CBT-I) across the life span: Guidelines and clinical protocols for health professionals. Wiley. https://doi.org/10.1002/9781119891192

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

Holst, S. C., & Landolt, H.-P. (2015). Sleep homeostasis, metabolism, and adenosine. Current Sleep Medicine Reports, 1, 27–37. https://doi.org/10.1007/s40675-014-0007-3

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
 

Resources Mentioned

PESI. Cognitive Behavioral Therapy for Insomnia (CBT-I) Training for Clinicians. PESI offers CBT-I training courses, including online courses and seminars focused on evidence-based assessment and treatment of insomnia.
 PESI — CBT-I Training

University of Pennsylvania, Perelman School of Medicine. Training in Cognitive Behavioral Therapy for Insomnia (CBT-I). Penn's Behavioral Sleep Medicine Program offers basic and advanced CBT-I training and related educational resources.
 University of Pennsylvania — CBT-I Training

Sleep Consultancy Ltd. Cognitive Behavioral Therapy for Insomnia (CBT-I) Courses. Training and educational resources for clinicians interested in CBT-I, information on training at the University of Edinburgh.
 Sleep Consultancy Ltd. — CBT-I Courses

University of Pennsylvania, Perelman School of Medicine. Upcoming Seminars: Training in Cognitive Behavioral Therapy for Insomnia (CBT-I). Information about Penn's Basic and Advanced CBT-I seminars and training opportunities.
 Penn CBT-I Seminars

Sleep & Health Research Program. CBT-I Training. Information about training in cognitive behavioral therapy for insomnia at the University of Arizona.
 Sleep & Health Research Program — CBT-I Training

CBT-Iweb. CBT-Iweb. Online CBT-I training and educational resources for clinicians.
 CBT-Iweb

Society of Behavioral Sleep Medicine. Behavioral Sleep Medicine. Professional organization offering information, resources, and training opportunities related to behavioral sleep medicine and CBT-I.
 Society of Behavioral Sleep Medicine

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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.