A Q&A with Dr. Amoha Bajaj of Princeton Psychotherapy Center

By Sarah Teo

As the daylight hours grow shorter this fall, many of us may try to improve our sleep, only to end up frustrated when traditional tips — such as keeping the room cool and dark or avoiding caffeine before bedtime — don’t make much of an impact. In addition, other factors can complicate things further, such as age, physical and mental health conditions, work circumstances, and more.

While pharmaceuticals sometimes provide a quick fix, another long-lasting, effective approach can be found in Cognitive Behavioral Therapy for Insomnia, or CBT-I. According to an article published in The Guardian last September, data supporting the effectiveness of CBT-I has been around for about 30 years, and clinical trials suggest that 70-80 percent of people with chronic insomnia who try the therapy end up with improved sleep. Furthermore, CBT-I is recommended as the first-line therapy for chronic insomnia by both the American College of Physicians and the U.S. Department of Veteran’s Affairs.

To explore how CBT-I can help provide consistent, quality sleep, I spoke with Dr. Amoha Bajaj of Princeton Psychotherapy Center.

Could you give us some general definitions of what both Cognitive Behavioral Therapy (CBT) and CBT-I are? How are they different from each other?

Cognitive behavioral therapy (CBT) is a short-term, structured, goal-driven and skill-based form of therapy. It focuses on the role of thoughts, emotions, and behaviors in psychological conditions. It is an effective form of treatment for depression and anxiety disorders (Cuijpers et al., 2016). Similar principles are also used to treat PTSD (Watkins et al., 2018) and substance use orders (McHugh et al., 2010). Generally, CBT is a form of treatment best for patients who are looking to change behaviors in some way. It is a collaborative treatment where the CBT therapist is an active participant in helping patients achieve change. Given the goal-driven nature of CBT, patients are often asked to practice skills in between sessions as homework assignments. This helps patients rehearse and practice the information discussed in weekly sessions.

CBT-I is Cognitive Behavioral Therapy for Insomnia. It is a form of treatment designed specifically to treat insomnia. It is a behavioral intervention (Espie, 2022) where patients are asked to change their behaviors to improve sleep quantity and quality and eliminate behaviors that limit sleep quantity and quality.

How did you become interested in CBT-I as a sleep therapy?

In my work as a clinical and health psychologist, I regularly work with patients who struggle with chronic medical conditions. These include (but are not limited to) cancer, chronic pain, and insomnia. I also primarily use CBT as a framework in treatment.

In my clinical practice, I noticed a few things when it came to sleep: 1) Many patients were desperate to get good sleep and felt that they had no option but to rely on sleep medication. 2) Many patients had used prescription sleep medications, over-the-counter sleep aids, or other substances and now felt desperate to sleep without any aids. 3) Patients held a wide range of beliefs about their ability to fall asleep and their ability to function after those nights of imperfect sleep. Given my training in CBT and the need for a non-medication intervention for sleep, I was drawn to CBT-I, the gold standard non-medication intervention. My approach to sleep health is rooted in a biological framework and the latest findings in sleep science, which is reflected in my clinical practice.
Also, when it comes to sleep, patients’ beliefs and behaviors lend themselves well to CBT in general, where we often challenge beliefs and modify behaviors to achieve a certain outcome.

How would you define short-term insomnia? Chronic insomnia?

Short-term insomnia is acute difficulty in falling or staying asleep or early-morning awakenings due to a recent stressor. This sleep difficulty can last from a few days to a few weeks and is typically present for less than three months. Short-term insomnia can become chronic insomnia once there are “perpetuating” factors that maintain the difficulty (Vargas et al., 2020) Some examples of perpetuating factors are excessive effort in trying to sleep, excessive time in bed, worrying about sleep, and poor daytime habits.

What are some more unique life circumstances that cause insomnia?

One classic example I can think of is post-traumatic stress disorder.

People respond differently to life circumstances. For example, some people may not experience any sleep difficulty after a job loss. Others might show changes in mood, sleep, and behavior in response to the same stressor. In general, examples of life circumstances that can contribute to sleep difficulty are major life changes related to work/school, family, or health, such as job loss, divorce, death of a loved one, or moving to a new location (Celyne et al., 2010). These would be considered unique life circumstances that can cause insomnia.

Can those with insomnia caused by mental health conditions be helped by CBT-I?

Yes. Sleep disruption is a common symptom of many mental health conditions, including post-traumatic stress disorder (PTSD) and major depression. Research shows that CBT-I can be effective to improve sleep even with a comorbid psychological diagnosis, such as PTSD (Hertenstein et al., 2022). In situations where the patient has sleep problems as well as a mental health diagnosis, it is important that the psychologist and patient collaborate closely to understand the bigger picture and the specific role of sleep in that bigger picture.

I’ve read about “sleep restriction” as part of CBT-I, which initially sounds counter-productive. Could you give us a sense of what that entails, and how it fits into the therapy program as a whole?

Sleep restriction, now referred to as time-in-bed (TIB) restriction, is one part of CBT-I. It entails restricting time in bed to a certain number of hours per night — over time, this trains the body to consolidate sleep. The hours of the sleep window (i.e. lights off to when you get out of bed in the morning) are determined by the patient and psychologist together, based on patient’s preference and age-normed sleep needs. The process limits time in bed so the body learns to meet its sleep needs during those designated hours, which tends to minimize nighttime awakenings. While it can take some time to normalize sleep in the beginning, eventually the window is extended or adjusted based on the patient’s response. Like everything in CBT-I, all interventions are collaborative.

Acceptance and Commitment Therapy (ACT) is also sometimes used to resolve sleep issues. What is it, and how can it work in conjunction with CBT-I?

ACT is a therapeutic approach that centers on one’s values and a willingness to see reality as it is. It includes a helpful set of skills to determine one’s attitude and approach towards making changes related to sleep. One of the central principles of ACT that can be helpful for sleep difficulty is the willingness to commit to making behavioral changes to prioritize sleep and life values and being willing to experience unwanted discomfort in the process of doing so (Salari et al., 2020).

However, the specific recommendations of ACT and CBT-I can be in contrast at times. For example, the two approaches differ in their recommendations about the function of the bed, when to stay in bed, and daytime napping. So, while aspects of ACT can be helpful, CBT-I is the standard recommendation non-medication intervention. ACT is currently being studied as potentially a second-in-line intervention or a supplemental approach to CBT-I (Paulos-Guarnieri et al., 2022).

“Insomnia and Sleep Hygiene” is listed as a presentation topic in your center’s workshop/class offerings. Have you given sleep-related workshops to area groups/organizations, and/or where would be some appropriate settings for such workshops?

We are currently designing a four-week educational group course on CBT-I that offers education on the basic principles of healthy sleep, age-normed sleep patterns, common interventions, and frequent challenges. Please stay tuned for more details at what’s upcoming at Princeton Psychotherapy Center.

Have you known anyone personally who has struggled with insomnia (a family member, friend, etc.)?

Anecdotally, and professionally, of course, I’ve heard lots of stories of sleep difficulties. Most commonly, sleep difficulty happens due to excessive worry or a major life change and is often temporary. There are three observations that come to mind when thinking of these stories: 1) The people who tend to see sleep changes as normal tend to be more resilient in coping with sleep disruptions vs. those who worry excessively about sleep, 2) Sleep needs change over the course of a lifetime, starting from infanthood to late life. It’s important to have realistic expectations about normal changes in sleep duration and patterns, and 3) Anecdotal experiences have certainly helped us understand and appreciate how sleep can impact mood and daytime functioning (and vice versa) so it’s an important target in maintaining psychological well-being.

What would you say to anyone skeptical of CBT-I as an effective therapy?

I’d encourage them to meet with a psychologist trained in CBT-I for an initial consultation and welcome them to discuss their questions and concerns freely. If they are reassured by the responses, then I’d encourage them to give it a try and to remember that it’s one of the most empirically supported non-medication treatments to improve sleep. And that it’s OK to feel nervous about making changes.

For those interested in local, face-to-face CBT-I, the Princeton Psychotherapy Center can be reached at info@princeton-therapy.com, or visit princeton-therapy.com.