CBT-I: The First-Line Treatment for Chronic Insomnia with Dr. Donn Posner (Part 2 of 2)

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 — does not 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