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Scandinavian Journal of Behaviour
Therapy
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Empirically Supported Treatments
for Insomnia
Neville J. King , Amanda Dudley , Glenn Melvin , Julie
Pallant & David Morawetz
Published online: 05 Nov 2010.
To cite this article: Neville J. King , Amanda Dudley , Glenn Melvin , Julie Pallant & David
Morawetz (2001) Empirically Supported Treatments for Insomnia, Scandinavian Journal of
Behaviour Therapy, 30:1, 23-32
To link to this article: http://dx.doi.org/10.1080/02845710118493
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Empirically Supported Treatments for Insomnia
Neville J. King
1
, Amanda Dudley
1
, Glenn Melvin
1
, Julie Pallant
1
and
David Morawetz
2
1
Monash University;
2
Faculty of Education, Institute of Human Development and
Counselling, Clayton, Victoria, Australia
Insomnia is a distressing and prevalent health problem in the general adult population.
Given both the side-effects and questionable efficacy of pharmacological treatments,
there is an urgent need for effective psychological interventions. Cognitive-behavioural
intervention strategies are often used in clinical management, but what is the empirical
support for these interventions? This review describes and evaluates the main cognitive-
behavioural interventions used in the treatment of insomnia: sleep hygiene information,
relaxation-based techniques, stimulus control instructions, sleep restriction therapy and
cognitive therapy. For many insomnia sufferers, it appears that the cognitive-behavioural
treatment approach represents a credible and effective alternative to drugs. Key words:
cognitive-behavioural treatments; empirical support; insomnia.
Correspondence address: Neville King, Faculty of Education, Institute of Human Development
and Counselling, Clayton, Vic 3168 Australia
O
ver the past few decades, several studies have indicated that the length and quality of sleep is
related to general health and longevity (Lilie & Rosenberg, 1990). Considering that humans
spend at least one-third of their lives asleep, sleep is universal and a fundamental human need
(Rechtschaffen, Bergman, Everson, Kushida & Gilliland, 1989). As a biological imperative,
sleeps absence may result in physical, cognitive and emotional consequences that greatly affect
an individuals level of functioning (Van Brunt, Riedel & Lichstein, 1996). In general, insomnia
sufferers display higher psychological distress, greater impairment of daytime functioning, are
involved in more fatigue-related accidents, take more sick leave and utilize healthcare resources
more often than do good sleepers (Morin & Wooten, 1996). Furthermore, persistent insomnia is
also associated with increased risks of major depression and prolonged use of hypnotic
medications, which have serious side-effects (Morin & Wooten, 1996).
Insomnia, referring to sleep difficulty, is a disorder characterized by difficulty initiating sleep
(sleep-onset insomnia) or difficulty remaining asleep (sleep-maintenance insomnia) (American
Psychiatric Association, 1994). The latter can be further subdivided into frequent or lengthy
nocturnal awakenings, or early morning awakenings with an inability to return to sleep (terminal
insomnia) (Bootzin & Rider, 1997; Van Brunt et al., 1996). Sufferers may experience only one or
a combination of these insomnia complaints. Insomnia can be described as a complaint of poor
quality, insufficient, or non-restorative sleep (Buysse & Reynolds, 1990). The actual degree of
disturbance is highly variable in pattern, that is, insomnia may occur in brief episodes of several
days, longer episodes of several weeks, or chronic episodes of months, years or decades (Bootzin
& Rider, 1997).
DSM-1V specifies a number of diagnostic criteria for primary insomnia (APA, 1994). The
sleeping difficulty must exist for at least 1 month and the sleep disturbance must cause clinically
significant distress or impairment in social, occupational or other important areas of functioning.
Furthermore, the sleep disturbance should not occur exclusively during the course of another
SCANDINAVIAN JOURNAL OF BEHAVIOUR THERAPY VOL 30, NO 1, PAGES 2332, 2001
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mental or sleep disorder and is not due to the direct physiological effects of a substance or a
general medical condition (APA, 1994).
Of the various sleep disorders, insomnia is the most prevalent, occurring occasionally in about
35% of the population and chronically in about 15% of adults (Buysse & Reynolds, 1990). Survey
data consistently demonstrate that more women than men report insomnia and that the incidence
increases with age (Lichstein & Riedel, 1994; APA, 1994). Young adults are more likely to
complain of difficulty falling asleep, whereas older adults are more likely to experience difficulty
maintaining sleep and early morning awakenings (Lichstein & Riedel, 1994). Insomnia typically
begins in young adulthood or middle age (APA, 1994), although it should be noted that some
research findings suggest that unhelpful sleep patterns are actually established in early childhood
(Ramchandani et al., 2000; Zuckerman, Stevenson, & Bailey, 1987). Clearly insomnia is a
significant and widespread health problem.
Risk factors
The major risk factors responsible for the onset of insomnia are now outlined briefly:
psychological factors, psychopathology, poor sleep hygiene and aging. It is likely that these
determinants interact in complex ways (Lichstein & Riedel, 1994; Morin, 1993).
Psychological factors
Stressful events, such as examinations and relationship difficulties, frequently cause sleep
disturbance (Vgontzas & Kales, 1999). In addition, a conditioning or learning component is
usually evident whereby the sufferer has come to associate going to bed with insomnia rather than
with sleep. The bedroom, the bed itself and rituals associated with going to bed may become
conditioned stimuli that continue to elicit alertness and ensuing insomnia long after the original
stressor is removed (Lichstein & Riedel, 1994). The anxiety surrounding an impending poor
nights sleep tends to produce physiological and cognitive arousal that is not conducive to sleep
(Van Brunt et al., 1996). This preoccupation at bedtime contributes to a negative cycle in which
the more the individual attempts to fall asleep, the more frustrated and distressed the individual
becomes and the less he or she is able to sleep (APA, 1994).
Cognitions unrelated to sleep concerns can also play a formative role in the development of
insomnia. Intrusive cognitions can include brainstorming, planning future activities or tasks,
brooding over the days events and any other arousing thoughts (Van Brunt et al., 1996). Research
findings show that intrusive thoughts are frequent causes of sleep disruption and affect sleep onset
(Espie, Brooks & Lindsay, 1989; Gross & Borkovec, 1982).
Psychopathology
Insomnia is often associated with some degree of psychopathology. On clinical examination,
people with severe insomnia are frequently diagnosed with co-morbid psychiatric disorders, such
as dysthymia or anxiety disorders. However, the causal relationship between insomnia and
psychopathology is not clear at this stage of research (Levin, Bertelson & Lacks, 1984; Vgontzas
& Kales, 1990).
Poor sleep hygiene
Poor sleep hygiene refers to daily activities and conditions that are incongruent with the
maintenance of high-quality sleep and daytime alertness (Bootzin & Rider, 1997; Lichstein &
Riedel, 1994). Examples of poor sleep hygiene include daytime naps, extended amounts of time
spent in bed, irregular sleep-wake schedules, inactivity, routine use of products which interfere
with sleep, such as caffeine, exercising or engaging in exciting or emotionally upsetting activities
24 King, Dudley, Melvin, Pallant and Morawetz SCAND J BEHAV THER
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close to bedtime, and a poor sleep environment, such as an uncomfortable bed or a bedroom that is
too bright, stuffy, hot, cold, or noisy (Bootzin & Perlis, 1992).
Aging
In older adults, insomnia is estimated to be 3050% more prevalent on average than in younger
groups, and the elderly consume sleep medication at about 4 times the rate of middle-aged persons
(Lichstein & Riedel, 1994). Normal aging is associated with deterioration in sleep and sleep is
variable across individuals within any age range (Van Brunt et al., 1996). Thus, it is unclear
whether insomnia is more common in the elderly or if this group simply exhibits an increased rate
of dissatisfaction with sleep that is normal for their age.
Cognitive-behavioural treatments
There are 5 main cognitive-behavioural strategies for insomnia intervention (Bootzin & Rider,
1997): sleep hygiene information, relaxation-based techniques, stimulus control instructions,
sleep restriction and cognitive therapy. As will become evident, these treatment strategies are
based on different assumptions about the causes of insomnia. However, the treatments are not
always mutually exclusive in terms of their programmatic aspects and theoretical premises. Each
of these treatments is now described and evaluated in terms of its empirical support.
Sleep hygiene information
Providing basic information about sleep and general sleep hygiene is usually a fundamental or
core component in the treatment of insomnia (Bootzin & Perlis, 1992; Pallesen, Nordhus & Kvale,
1998). The list below (Lilie & Rosenberg, 1990) presents a summary of good sleep hygiene
recommendations, which aim to promote environmental conditions and behaviour conducive to
healthy sleep.
Sleep as much as needed to feel refreshed and healthy during the following day, but not more.
Maintain a regular sleep schedule.
Exercise regularly and not close to bedtime.
Minimize use of caffeine, cigarettes, stimulants and other medications, particularly in the
evening.
Recognize that alcohol may cause fragmentation of sleep.
People who feel angry and frustrated because they cannot sleep should not try harder and
harder to fall asleep but should turn on the light and do something different.
Hunger may disturb sleep, so a light snack may help.
Few controlled investigations have tested sleep hygiene as a unitary intervention, but clinician
impressions and some findings suggest that the provision of such information is associated with
modest treatment gains (e.g. Morin, 1993). Interestingly, more recent research findings do not
support assumptions about sleep hygiene problems in people with insomnia. For example, Harvey
(2000) found no evidence that people with insomnia have poorer sleep hygiene than others and
questions the inclusion of sleep hygiene in multi-component treatment packages for insomnia.
Further research is clearly required on this aspect of the management of insomnia.
Relaxation-based techniques
Of all the cognitive-behavioural intervention strategies used in the treatment of insomnia,
relaxation-based techniques are the most frequently employed. There are a variety of relaxation
procedures, including progressive muscle relaxation, biofeedback, autogenic training, meditation
and guided imagery (Lundh, 1998). The rationale behind these interventions is to counteract
VOL 30, NO 1, 2001 Empirically supported treatments for insomnia 25
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physiological and psychological arousal that is assumed to delay sleep-onset and interfere with
sleep-maintenance (Pallesen et al., 1998). The differences between the methods are that some
focus primarily on the somatic level with an aim to achieve a decreased level of muscular tension,
whereas others focus primarily on the cognitive level, with the purpose of reducing tension-
inducing thoughts.
Progressive muscle relaxation. Progressive muscle relaxation (PMR) involves sequential
muscle tension-release exercises whilst teaching the client to differentiate between the changing
sensations of tension and relaxation (Lundh, 1998).
A number of controlled studies show that PMR is an effective treatment for adult insomnia. For
example, Lick and Heffler (1977) compared PMR, PMR plus taped relaxation, placebo control
and no-treatment control (n = 40). All subjects were required to complete daily records of their
sleep patterns. Physiological recordings of electrodermal activity, cardiac responses, skin
conductance and respiration were also obtained. The major finding from the investigation was the
superiority of the 2 relaxation training procedures over both placebo and no-treatment control
groups. Somewhat surprisingly, there was no significant difference between the 2 relaxation
groups. In other words, the provision of taped instructions for home use did not improve the
effectiveness of therapist live instruction in PMR. Importantly, the researchers found no
relationship between physiological data and treatment outcome, suggesting that relaxation
training techniques do not mediate improvement via a reduction in physiological arousal.
Biofeedback training. Biofeedback is a system of recording, amplifying and feeding back
information to the client about physiological responses. Several different types of biofeedback
training have been used in the treatment of insomnia, namely, electromyography (EMG), theta
electroencephalography (EEG) and sensorimotor rhythm (SMR) biofeedback (Bootzin & Rider,
1997). EMG biofeedback training has received the most attention from researchers. For example,
in a controlled trial reported by Freedman and Papsdorf (1976), 18 insomniacs were randomly
assigned to 1 of 3 groups: frontal EMG biofeedback, progressive muscle relaxation (PMR) or the
Williams exercises (control group). Results showed that for sleep-onset, biofeedback and PMR
groups improved significantly more than the control group. However, there were no significant
differences between the 2 treatment groups. Similarly, biofeedback and PMR groups
demonstrated significant decreases in heart rate, frontal, masseter and forearm extensor EMG,
while changes in control group were minimal. However, 2-month follow-up data yielded no
significant differences between the 3 groups on typical sleep onset time. Although most of the
treatment subjects reported they were helped by their relaxation procedure, few continued to
practise their relaxation skills a possible explanation as to why the 2 treatment groups were not
superior to the control group at follow-up.
Meditation and autogenic training. In contrast to PMR, which aims to reduces muscular
tension, meditation and autogenic training employ mental relaxation or attention focusing to
produce relaxation (Spielman, Caruso & Glovinsky, 1987). Meditation requires focusing attention
on respiration and silently repeating a mantra of in and out simultaneously with inhaling and
exhaling (Lundh, 1998). Similarly, autogenic training requires clients to rehearse simple, standard
phrases relating to sensations of heaviness and warmth in the limbs (e.g., my left arm feels heavy
and warm) (Spielman et al., 1987). Standard exercises of respiratory regulation are also taught.
Controlled studies have examined the effectiveness of meditation and autogenic training
(Nicassio & Bootzin, 1974; Woolfolk, Carr-Kaffashan & McNulty, 1976). In the Woolfolk et al.
study (n = 24) meditation and PMR were found to be superior to waiting list controls with
improvements being maintained at a 6-month follow-up. The treatments did not differ in
effectiveness. In the Nicassio and Bootzin investigation, 30 adult subjects were randomized to
autogenic training, PMR, self-relaxation control or no treatment control. As indicated by global
measures of improvement and reductions in sleep onset latency, autogenic training and PMRwere
equally effective as treatments and superior to both control groups. At a 6-month follow-up,
26 King, Dudley, Melvin, Pallant and Morawetz SCAND J BEHAV THER
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treatment gains had been maintained in time to fall asleep, but not in self-reported global
improvement. Although the findings of the studies are encouraging, the relatively small samples
pose a methodological limitation.
Guided imagery. Guided imagery aims to combat intrusive cognitions that affect sleep by
requiring the insomnia sufferer to focus attention on an image, such as a pleasant nature scene or
neutral object. The individual is required to concentrate on the image and visualize its special
characteristics, particular sensations, colour and associated movements (Lichstein & Riedel,
1994).
In a study by Woolfolk and McNulty (1983), 44 adult insomnia sufferers were randomly
assigned within severity blocks to 1 of the following 5 conditions: imagery training, imagery
training with muscle tension-release, somatic focusing, PMR or waiting list control. Results
substantiate the effectiveness of various forms of relaxation training in the treatment of sleep-
onset insomnia. All 4 treatment groups showed significant reductions in onset latency superior to
those in the control group. Subjects in treatment groups using visual focusing (imagery training
and imagery training with tension-release) decreased their number of awakenings significantly
more than subjects in treatment groups using somatic focusing (somatic focusing and PMR). At a
6-month follow-up, subjects using visual focusing reported significantly shorter sleep onset
latencies than those in somatic focusing groups. This suggests that whilst all techniques were
effective, visual focusing techniques, particularly imagery training, may be superior to somatic
techniques in the treatment of insomnia.
Stimulus control instructions
Stimulus control instructions are designed to assist the client with insomnia to establish a
consistent sleep-wake rhythm, strengthen the bedroom environment as a cue for sleep and weaken
the association with activities that might interfere with sleep (Bootzin & Perlis, 1992). The
underlying rationale is that the client has formed bad sleep habits, resulting in a conditioned
association between bedroom stimuli and arousal (Gabbard, 1995). The list below (Lichstein &
Riede, 1994) presents a summary of stimulus control instructions.
Go to bed only when you are sleepy.
If you are not asleep within about 10 minutes of going to bed, get out of bed. When you return
to bed the same rule applies; that if you are not sleeping within 10 minutes, get out of bed.
Set your alarm and get up at the same time every morning.
Do not nap.
Do not use the bed for anything except sleep (sexual activity permitted).
Much research has investigated the effectiveness of stimulus control instructions. For example,
in a controlled study reported by Morin and Azrin (1988) elderly insomnia subjects were
randomly assigned within severity blocks to either stimulus control, imagery training or a wait-list
condition (n = 27). To assess sleep difficulties, sleep-activated clocks were used, as well as sleep
diaries and ratings from both patients and significant others. Both treatment methods, stimulus
control and imagery training, produced significant improvement on the main outcome measure of
duration of awakenings. However, stimulus control yielded higher improvement rates than either
imagery training or the control condition. Sleep improvements were maintained by the 2 treatment
methods at 3- and 12-month follow-ups. Importantly, improvements on subjective measures were
corroborated by collateral ratings obtained from significant others and the electromechanical
timers.
Sleep restriction therapy
Poor sleepers often increase their time in bed in a misguided effort to provide more opportunity
for sleep, a strategy which is more likely to result in fragmented and poor quality sleep (Morin &
VOL 30, NO 1, 2001 Empirically supported treatments for insomnia 27
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Wooten, 1996). Sleep restriction therapy is based on the recognition that many insomnia sufferers
spend excessive time in bed attempting to sleep and therefore have poor sleep efficiency
perpetuating the insomnia (Pallesen et al., 1998). It prescribes an individualized sleep-wake
schedule that limits the persons amount of time in bed to his/her estimated number of hours of
sleep normally obtained (Bootzin & Perlis, 1992). As a result, at the beginning of treatment partial
sleep deprivation is induced and daytime sleepiness may be experienced, but as sleep becomes
more consolidated, the sleep-wake schedule is altered by increasing the amount of time in bed
(Bootzin & Rider, 1997).
Controlled studies have examined the effectiveness of sleep restriction therapy. For example,
Bliwise, Friedman, Nekich and Yesavage (1995) compared sleep restriction therapy and
relaxation training in the treatment of elderly insomnia sufferers (n = 32). Daily telephone calls
generated data on sleep times and sleep onset latency. Both treatments were associated with
significant improvements on the measures. At a 3-month follow-up, however, sleep restriction
therapy showed greater improvements in these older subjects. A possible explanation for the
superiority of sleep restriction therapy is that elderly clients may be more suited to this approach
than to muscular relaxation.
Cognitive therapy
There are a number of cognitive symptoms contributing to insomnia, such as worry, anxiety,
cognitive intrusions and dysfunctional beliefs about sleep and its consequences (Spielman et al.,
1987). In fact, some findings suggest that cognitive rather than physiological arousal retards sleep
onset (Gross & Borkovec, 1982; Lichstein & Rosenthal, 1980). The rationale behind these
cognitive strategies is to distract or alter maladaptive cognitions. The treatments are distinguished
by the specific ways in which this is achieved. Among the cognitive interventions are paradoxical
intention, thought stopping, articulatory suppression and cognitive restructuring.
Paradoxical intention. Many insomniacs exacerbate their sleep difficulties by worrying about
whether they will be able to fall asleep, thus perpetuating their insomnia (Bootzin & Perlis, 1992).
To reduce such anticipatory anxiety associated with trying to fall asleep, paradoxical treatment
involves instructing the insomnia sufferer to get into bed and stay awake as long as possible rather
than trying to fall asleep (Lilie & Rosenberg, 1990). Because this intention presumably reduces
the anxiety associated with trying to fall asleep, patients should become more relaxed and fall
asleep faster than they would otherwise. Of course, it might be argued that paradoxical intention
should not be described as a cognitive therapy, since the technique is not based on cognitive
theory. Nor does this particular strategy involve anything like the testing of beliefs as is typical of
cognitive therapy.
In a controlled investigation reported by Ascher and Turner (1979), 25 adult subjects with
severe insomnia were randomly assigned to paradoxical intention treatment, placebo treatment or
no treatment. Subjects completed self-ratings of sleep behaviour using a daily sleep questionnaire.
To assess the reliability of these self-reports, a spouse or room-mate was also asked to monitor
sleep behaviour. Results showed paradoxical intention to be helpful, relative to the 2 control
conditions. More specifically, index treatment subjects reported a significant reduction in sleep
onset latency and fewer awakenings with difficulty returning to sleep. Furthermore, there was a
moderate correlation between spouse/room-mate estimates and self-ratings on latency of sleep-
onset.
Cognitive restructuring. Clients with insomnia often subscribe to several irrational beliefs
about sleep, which in turn affect sleep efficacy (Bootzin & Rider, 1997). As opposed to simply
blocking intrusive thoughts, like thought stopping or articulatory suppression, cognitive
restructuring aims to address dysfunctional beliefs and attitudes, replacing them with more
appropriate ones (Lundh, 1998). This is achieved by providing the client with accurate
28 King, Dudley, Melvin, Pallant and Morawetz SCAND J BEHAV THER
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information and having them identify and rehearse alternative belief statements (Bootzin & Rider,
1997).
In a study reported by Sanavio (1988), 24 adult insomnia sufferers were initially assessed for
pre-sleep cognitive activation using a self-report inventory. Participants were then divided into
high and low pre-sleep arousal according to inventory scores and randomly assigned to either
biofeedback or a cognitive modification treatment (cognitive restructuring, paradoxical intention
and thought stopping). Both treatment conditions significantly reduced sleep-onset latency and
extended total sleep time. The degree of improvement was similar, irrespective of whether
subjects were treated by biofeedback or cognitive therapy methods and whether they complained
of high or low pre-sleep intrusions on pre-therapy measurements. Treatment gains were
maintained at 3- and 12-month follow-up assessments.
Most effective treatments
Morin, Culbert and Schwartz (1994) conducted a meta-analysis to examine the efficacy of
psychological treatments for insomnia and to ascertain the most effective intervention. A total of
59 treatment outcome studies, involving 2102 patients, were selected for review on the basis of the
following criteria: (a) the primary target problem was sleep onset, maintenance, or mixed
insomnia; (b) the treatment was non-pharmacological; (c) the study used a control group design;
and (d) the outcome measures included sleep onset latency, time awake after sleep onset, number
of nighttime awakening, or total sleep time. Treatments were classified into 6 categories: (1)
stimulus control; (2) sleep restriction; (3) relaxation therapy-somatic; (4) relaxation therapy-
cognitive; (5) paradoxical intention; and (6) sleep hygiene. Relaxation therapies were divided into
somatic (including techniques such as PMR, autogenic training and biofeedback) and cognitive
(including techniques such as imagery training, meditation and thought stopping).
Psychological interventions, averaging 5.0 hours of therapy time, produced reliable changes in
2 of the 4 sleep measures examined. The average effect sizes (i.e. Z scores) were 0.88 for sleep
latency and 0.65 for time awake after sleep onset. These results indicate for sleep onset latency,
treated patients were better off than 81% of the untreated patients, whereas for time awake after
sleep onset, treated patients were more improved than 74% of the control subjects. The effects
sizes for number of awakenings and total sleep time were more modest, but still reliably greater
than zero. The clinical gains achieved by the end of treatment were well maintained at the follow-
ups, which averaged 6-months in duration. These results are especially encouraging in view of the
chronic nature of insomnia.
Comparison of the treatment procedures indicated that stimulus control was the most effective
single therapy for either sleep-onset or maintenance insomnia. Sleep restriction therapy produced
even greater benefits, but this particular intervention was limited in the number of clinical trials.
Of the various relaxation-based methods, procedures aimed at reducing cognitive arousal (racing
mind, intrusive thoughts) were slightly superior to those targeting physiological arousal (muscle
tension). Comparison of biofeedback procedures showed no differences between methods
providing accurate feedback of EMG or EEG activity and placebo conditions giving bogus
feedback. These particular results suggest perception of control, rather than actual control is
important in overcoming chronic insomnia. Finally, multi-component interventions were found to
produce results comparable, but not always superior, to the most effective single-therapy
components (i.e. stimulus control and sleep restriction). In attempting to explain these findings for
multi-component interventions, Morin et al. (1994) emphasize that earlier studies often combined
various procedures in a hit or miss fashion and without an appropriate rationale.
More recently, a taskforce of experts appointed by the American Academy of Sleep Medicine
reviewed 48 clinical trials and 2 meta-analyses. They found that between 70% and 80% of
VOL 30, NO 1, 2001 Empirically supported treatments for insomnia 29
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patients treated with non-pharmacological interventions benefit from treatment. They also found
that the improvements in key sleep parameters produced by these therapies for chronic insomnia
sufferers are reliable and durable. (Morin et. al., 1999).
Comprehensive integrated multi-component CBT interventions
Whereas previous multi-component interventions often combined various procedures in a hit or
miss fashion and without an apparent rationale, there does exist one treatment program that
contains a carefully designed comprehensive integrated multi-component CBT intervention: the
Australian 46-week self-help program Sleep Better Without Drugs (Morawetz, 1994). This
program consists of a book and 3 audio-cassettes. It first helps patients to diagnose their sleep
problem and then presents more than 50 strategies that insomnia sufferers can use to improve their
sleep. These strategies include sleep restriction, sleep scheduling and stimulus control techniques
(the nine rules for better sleep), identifying and using the bodys ultradian rhythm (learning to
catch the wave of sleepiness), cognitive therapy (20 ways to reduce thinking and worrying in
bed), physical and mental relaxation, methods to eliminate sleeping medication, a sleep diary,
much information about sleep and sleep hygiene, advice for shift workers and 30 important sleep
hints.
Three outcome studies have examined the effectiveness of this program. The first (Morawetz,
1994) found a success rate of 80%. The second, an independent US study (Iler, 1997), found a
success rate of 83%. In the third and most recent study (Morawetz, 2000), particularly stringent
criteria were used to define treatment success. To be considered a success, the insomnia sufferer
had to be taking 2 hours less to fall asleep, sleep 2 hours longer, wake up 8 times less per night, or
eliminate all sleeping medication without any deterioration in sleep. On these very strict criteria,
the success rate averaged 87%. Thus, all 3 studies indicate that a carefully designed,
comprehensive integrated multi-component CBT treatment can produce even higher success
rates than most single-treatment options. This is true despite the fact that the multi-component
treatment reviewed here is in a self-help format, whereas the single-intervention treatments
surveyed above were almost all therapist-led.
Conclusion
It is clear that insomnia is prevalent, persistent and troublesome in the adult population,
profoundly affecting the mood, efficiency and relationships. Furthermore, it is a complex problem
with many different causes. Overall, the large majority of controlled treatment studies have
demonstrated that cognitive-behavioural treatment methods are effective in alleviating insomnia.
When effectiveness is examined across treatment modalities, stimulus control instructions and
sleep restriction therapy tends to produce better outcomes for both sleep-onset and sleep-
maintenance insomnia. Hit or miss multi-component treatments are not always superior to
effective single-therapies, but a carefully designed, comprehensive, integrated multi-component
Australian self-help CBT treatment has consistently produced success rates of 8087%. A
pleasing finding is the maintenance of treatment improvements that occurred in most studies. On
the other hand, methodological limitations are apparent in many of the treatment evaluations. For
example, outcome measures are sometimes restricted to self-reports, which can be questioned in
terms of their reliability and validity. Small sample sizes were also evident in some of the trials.
Many other issues require further investigation. For example, a few studies have attempted to
identify predictors of treatment outcome, but a more comprehensive examination of client and
situational variables is required. Similarly, more work needs to be undertaken on important
clinical issues, such as non-compliance with treatment recommendations and the potential value
of booster sessions.
30 King, Dudley, Melvin, Pallant and Morawetz SCAND J BEHAV THER
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