Staff Perspective: Understanding Symptom Specific Effects of Cognitive Therapy and Behavior Therapy for Insomnia

Staff Perspective: Understanding Symptom Specific Effects of Cognitive Therapy and Behavior Therapy for Insomnia

According to a recent Department of Defense Congressional Report to the Armed Services Committees (2021), “sleep may be the most important biological factor that determines service member health and combat readiness” (p. 1). Insomnia, a chronic inability to sleep (e.g., fall asleep, stay asleep, or experience early morning awakenings), is one of the most commonly diagnosed sleep disorders for both service members and veterans and associated with poorer physical and mental health outcomes (Kelly et al., 2019). The VA/DoD Clinical Practice Guideline (CPG) for the Management of Chronic Insomnia and Obstructive Sleep Apnea strongly recommends the use of Cognitive Behavioral Therapy for Insomnia (CBT-I) for the treatment of chronic insomnia based on the extensive amount of literature supporting its overall effectiveness (2019).

CBT-I involves both behavioral and cognitive interventions to target factors perpetuating insomnia symptoms. The basis for these interventions stem from different theoretical backgrounds and independently (i.e., Brief Behavioral Therapy and Cognitive Therapy for Insomnia) have been found to be similarly effective for the overall treatment of chronic insomnia. However, newer research by Blanken et al. (2021) examines how these different intervention approaches may have symptom specific changes over the course of therapy. This blog will briefly review the theory behind behavioral and cognitive approaches to the treatment of insomnia, interventions utilized by each approach, and the findings from research about symptom specific changes over the course of therapy associated with these commonly used interventions.


Spielman et al. (1987) developed a behavioral conceptualization of insomnia referred to as the 3-P model (i.e., predisposing, precipitating, and perpetuating factors). From this behavioral perspective, sleep is subject to the same conditioning principles as other wakeful behaviors and therefore can be modified. The two interventions that form the basis of BBT-I are stimulus control and sleep restriction. Stimulus control is based on the idea that the bed, bedroom, and bedtime activities have lost its signal or stimulus value as a cue for promoting sleep (e.g., conditioned arousal from tossing and turning in bed, increased levels of frustration or anxiety leading to hyperarousal, and sleeplessness) for individuals struggling with insomnia.

Common instructions for stimulus control include:

  1. Go to bed when you feel sleepy.
  2. If you are not able to fall asleep within 10 minutes get out of bed. Repeat as often as needed until you reach your wakeup time.
  3. Do not use the bed for anything except sleep or sex.
  4. No naps.

Another behavioral intervention is sleep restriction. Sleep restriction is based on the idea that wakefulness is the result of sleep opportunity (i.e., time in bed) exceeding a person’s sleep ability. People who struggle with insomnia often extend time in bed in hope that these efforts will result in getting more sleep. However, this is often a counterproductive strategy. Sleep restriction helps to match a person’s sleep ability with their sleep opportunity.

The following steps are taken when using sleep restriction with patients:

  1. Determine a person’s average total sleep time. This is typically done by subjective evaluations using a sleep diary.
  2. Determine when a person has to wake up and keep that time constant throughout the week regardless of the amount of sleep a person gets.
  3. Based on the person’s established waketime and average total sleep time (a measure of sleep ability), determine a corresponding bedtime. For example, if a person had to wake up by 6am and averaged 5 hours of sleep per night, the new bedtime would be 1am.
  4. We do not restrict a person’s sleep past 4 hours, and BBTI sets the limit at 5 hours.


Harvey (2002) proposed a cognitive model for insomnia that focuses on how excessive negatively toned cognitive activity leads to increased self-monitoring, threat detection, engagement in counterproductive safety behaviors (e.g., bad coping behaviors), and unhelpful beliefs about sleep that perpetuate insomnia.

The goal of this treatment approach is to:

  1. Reduce selective attention and monitoring for sleep-related threat cues
  2. Correct distorted perception of sleep and daytime deficits
  3. Correct inaccurate or unhelpful beliefs about sleep
  4. Eliminate the use of counterproductive safety behaviors

Cognitive interventions are focused on helping patients develop realistic thoughts about their sleep and to help with cognitive arousal that frequently interferes with a person’s ability to fall asleep or stay asleep.

These cognitive interventions can include:

  1. Providing psychoeducation about sleep (e.g., conceptualization of insomnia, how sleep is regulated)
  2. Teach and practice cognitive restructuring through ABC worksheets
  3. Teach and practice the use of scheduled worry time or use constructive worry techniques
  4. Provide education about patterns of problematic thinking, differences between reassuring versus alarmed based thinking
  5. Use of journaling to process emotional content


Blanken et al. (2021) conducted a randomized control trial (RCT) on the use of online cognitive therapy (CT) and behavioral therapy (BT) treatment for insomnia for a community sample of 219 adults. Using network analysis, the authors examined symptom-specific treatment effects of CT and BT over a 10-week online treatment regimen using the Insomnia Severity Index (ISI) and sleep efficiency (i.e., total sleep time divided by time in bed) calculated from sleep dairies. Data from sleep diaries were collected daily, and ISI scores collected bi-weekly. At the end of treatment, there was no significant differences between CT and BT on ISI scores. A summary of the specific symptom results across the 10-week course of treatment is highlighted below:

Behavioral Treatment:
Week 4 – Reported higher sleep efficiency and less problems maintaining sleep compared to the CT group
Week 6 – Reported higher sleep efficiency than CT group
Week 8 – Reported higher sleep efficiency than CT group
Week 10 – Reported Higher sleep efficiency and less dissatisfaction with sleep than CT Group

Cognitive Treatment:
Week 8 – Reported less interference with daily activities due to poor sleep than the BT group
Week 10 – Reported less interference with daily activities due to poor sleep, fewer problems initiating sleep, less early morning awakenings, and fewer worries about sleep compared to the BT group.

These results from Blanken et al. (2021) help us to get a better understanding how specific aspects of common treatment approaches to insomnia can have differential effects of specific insomnia symptoms. Understanding these differences can help clinicians when making decisions about what approach or interventions to use with patients who present struggling with chronic insomnia.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland, TX.


Department of Defense (2021). Study on the effects of sleep deprivation on the
readiness of members of the Armed Forces
Kelly, M. R., Robbins, R., & Martin, J. L. (2019). Delivering cognitive behavioral
therapy for insomnia in military personnel and veterans. Sleep Medicine Clinics, 14(2), 199-208.
Department of Veterans Affairs & Department of Defense (2019). VA/DoD clinical
practice guideline for the management of chronic insomnia and obstructive sleep apnea
Blanken, T. F., Jansson-Frojmark, M., Sunnhed, R., Lancee, J. (2021). Symptom-
specific effects of cognitive therapy and behavior therapy for insomnia: A network intervention analysis. Journal of Consulting and Clinical Psychology. Advance online publication.
Spielman, A. J., Caruso, L. S., Glovinsky, P. B. (1987). A behavioral perspective on
insomnia treatment. Psychiatric Clinics of North America, 10(4), 541-553.
Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and
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