Why People Don't Try CBT-I: Barriers to Treatment

In a recent poll, only 8 percent of you responded that you have tried cognitive behavioral therapy for insomnia (CBT-I). This was surprising to us because we frequently write about its effectiveness. It got us wondering, "Why hasn't more of our community tried CBT-I?"

It turns out there are very real barriers that can make it hard to get CBT-I. In an earlier post, I discussed challenges facing medical providers. In this post, I will describe the obstacles that make it difficult for patients to fully commit to CBT-I. More importantly, I will offer suggestions to help you overcome those challenges.

Feel free to participate in the poll Carin mentioned, here:

Why is it so hard to get CBT-I?

Although so many of us struggle with insomnia, we don't receive good quality education about it. There is plenty written about how to treat it, but much of it is written by companies selling us a magic cure –- supplements, bed linens, alarm clocks, and prescription medications. We don't hear as much about behavioral treatment, even though it is recommended by multiple medical associations as the best treatment for insomnia disorder.^1,2

Much like our providers, we patients have been taught that insomnia is a symptom of something else. Maybe anxiety, maybe hypothyroidism, maybe menopause. We are told that insomnia will go away once the "real" problem is addressed. But that is often not the case.

Regardless of why or how it starts, insomnia disorder tends to take on a life of its own after a few months. As a condition, it has its own perpetuating factors that need to be dealt with.

Some people with insomnia have even received the message that their sleep problems are "trivial" and that they should be able to deal with them on their own. People with insomnia also may not seek treatment because they do not want medication. They may be under the impression that medications are the only good treatment for insomnia.¹

Many people have not received good information about insomnia treatment. And because our time with our providers is often so rushed (don't get me started on the overall state of healthcare!), we don't have time to discuss options and preferences.

CBT-I may sound difficult

If we do learn about CBT-I, it can sound unpleasant. It is a (mostly) behavioral treatment, which obviously includes behavior changes. Some of these changes can sound hard – avoiding naps, cutting down on caffeine, etc. Some of the changes can even sound bizarre, like "You can't sleep, so spend less time in bed." Insert confused emoji here!

Understandably, sometimes people's initial reaction is, "I can't do that!"

Even when we are willing to change our behaviors, real-life obstacles can get in the way. CBT-I usually involves at least 6 to 8 appointments lasting an hour each. Appointments are scheduled every week or 2 weeks. Things like work, school, and family obligations can make it difficult to fully engage. Between taking time off of work and finding transportation and child care, the time commitment for sessions can feel overwhelming. Also, homework is assigned at each appointment. You need to commit to treatment outside of appointments too.¹

Finally, patients may find it difficult to locate a CBT-I provider who accepts their insurance. There is a documented shortage of CBT-I providers. Waitlists and out-of-pocket costs add another layer of obstacles for many.¹

How to overcome barriers to CBT-I

Unfortunately, there are several hurdles to getting the most effective treatment for insomnia. Here are some tips to help you overcome them.

Don't minimize your insomnia

Although you may have received the message to "just deal with it" before, that is terrible advice. Getting good sleep is important for all areas of your health – physical, cognitive, emotional, and social. It's important enough to warrant its own treatment.

Educate yourself

Overcome knowledge barriers with trustworthy resources. In addition to the educational articles on this website, check out the American Academy of Sleep Medicine. They offer free articles on healthy sleep and insomnia, and tools to assess your sleep needs and locate treatment.

Balance your expectations

Yes, some aspects of CBT-I are challenging. But it is a short-term challenge. In my experience, most people get over the hump and start sleeping better within 2 to 3 weeks. And while changing behavior is hard at first, it almost always gets easier once a new routine is established.

I will tell you a secret: My patients tend to get better even when they only do three-fourths of what I advise. I don't like to say that out loud because I want patients to completely engage in the treatment. I know people will get better faster the closer they stick to the program. But I have been providing CBT-I for 15 years and can confidently say that patients get better even if treatment doesn't go perfectly.

Don't avoid CBT-I because you think it sounds too hard. Don't let perfection be the enemy of progress!

Consider telehealth and self-guided options

Between the provider shortage and the hustle of our lives, you might not be able to see a local CBT-I provider. But CBT-I has been provided successfully via telehealth for over 15 years. Expand your search to include providers who are practicing via telehealth. If that is not an option, consider one of the many self-guided options that use CBT-I principles. The best programs allow you to log on at your convenience but still provide personalized assessment and feedback to get you sleeping better.

Have you found it challenging to receive CBT-I? Please share your experiences and how you coped with them.