Cognitive Behavioral Therapy for Insomnia (CBT-I): A Guide for First Responders in Alberta

Insomnia, a condition that makes it hard to fall asleep, stay asleep, or get restful sleep, can seriously affect your health and daily life. For First Responders, who often work irregular hours and deal with high-stress situations, the risk of insomnia is even higher. This guide explains Cognitive Behavioral Therapy for Insomnia (CBT-I), a proven, non-medication treatment, and how it can help First Responders in Alberta.

Understanding CBT-I’s Basics

Cognitive Behavioral Therapy for Insomnia isn’t just a set of sleep tips. it’s a structured therapy. It’s based on the idea that chronic insomnia is often caused by learned behaviors and thoughts about sleep. These behaviors and thoughts can create a cycle, where worrying about sleep leads to poor sleep, which in turn increases worry. CBT-I aims to break this cycle by changing both behaviors and thoughts. The history of Cognitive Behavioral Therapy for Insomnia is rooted in decades of research and development.

Behavioral Changes: Improving Sleep Habits

The behavioral part of CBT-I focuses on creating healthy sleep habits and making sure your bed is associated with sleep. Two key techniques are:

1. Stimulus Control Therapy: Your bedroom environment has a big impact on your sleep. This method strengthens the connection between your bed and sleep.

   • Stimulus Control Rules:
     • Go to bed only when you feel sleepy (not just tired). Sleepiness is the physical feeling of needing sleep.
     • Use the bed and bedroom only for sleep and intimacy. Avoid reading, watching TV, working, or using electronic devices in bed.
     • If you can’t fall asleep or go back to sleep within about 20 minutes, get out of bed and go to another room. Do something quiet and relaxing (avoid screens) until you feel sleepy. Repeat this as needed.
     • Wake up at the same time every day, even on weekends, no matter how much sleep you got. This helps regulate your body’s natural sleep-wake cycle.
     • Avoid naps. Naps can make it harder to fall asleep at night.

2. Sleep Restriction Therapy: It might seem like spending more time in bed would lead to more sleep. But for people with insomnia, it often leads to broken, unrestful sleep. Sleep restriction helps consolidate sleep by first limiting the time spent in bed to match the actual amount of sleep you get.

   • How Sleep Restriction Works:
     • Use a sleep diary to track your sleep for one to two weeks. This shows your baseline total sleep time.
     • The total time in bed is then limited to your average total sleep time. For example, if you average 5 hours of sleep, your initial time in bed might be 5 hours.
     • This creates mild sleep deprivation, increasing your drive to sleep. As your sleep efficiency (the ratio of time asleep to time in bed) improves, the time in bed is slowly increased in 15-30 minute steps.
     • The goal is to find the best balance between time in bed and sleep duration, leading to solid, restful sleep.
     • Sleep restriction can initially cause more daytime sleepiness. Avoid driving or operating heavy machinery if you feel very sleepy.

Cognitive Changes: Rethinking Sleep

The cognitive part of CBT-I focuses on identifying and changing unhelpful thoughts and beliefs about sleep. These thoughts often create anxiety, making it harder to sleep. CBT-I for First Responders addresses these thought patterns.

1. Cognitive Restructuring: This process involves identifying, challenging, and changing negative thoughts.

   • Identifying Negative Thoughts: Common negative thoughts in insomnia include:
     • “I’ll never sleep well again.”
     • “If I don’t sleep enough, I won’t be able to function tomorrow.”
     • “I need 8 hours of sleep to be healthy.”
     • “I’m a terrible sleeper.”
   • Challenging Negative Thoughts: Examine these thoughts for accuracy and helpfulness. Questions to challenge them include:
     • “Is this thought based on fact or fear?”
     • “What evidence supports this thought? What evidence contradicts it?”
     • “Is this thought helping or hurting me?”
     • “What would I tell a friend who thought this?”
   • Developing Balanced Thoughts: Replace negative, unhelpful thoughts with more balanced, realistic ones. For example, instead of thinking, “I’ll never sleep well again,” think, “I’m having trouble sleeping now, but I can learn ways to improve.”

2. Sleep Hygiene:

   • A consistent sleep schedule reinforces your body’s natural sleep-wake cycle. Go to bed and wake up around the same time every day, even on weekends.
   • A relaxing bedtime routine signals your body to wind down. This could include a warm bath, reading a book (not on a screen), listening to calming music, or practicing relaxation techniques.
   • Make your sleep environment dark, quiet, and cool. Use blackout curtains, earplugs, or a white noise machine. Your bedroom should be mainly for sleep.
   • Avoid caffeine (coffee, tea, energy drinks) and alcohol near bedtime. Caffeine is a stimulant, and alcohol, while initially making you sleepy, can disrupt sleep later.
   • Regular exercise can improve sleep, but avoid intense exercise close to bedtime. Aim for at least 30 minutes of moderate exercise most days.

3. Relaxation Techniques: Reducing tension is key for falling asleep.

   • Progressive Muscle Relaxation: Tense and relax different muscle groups to promote physical relaxation.
   • Deep Breathing Exercises: Slow, deep breathing can calm your nervous system.
   • Mindfulness Meditation: Focus on the present moment without judgment, reducing racing thoughts.

CBT-I for First Responders: Handling Specific Issues

While research specifically on CBT-I for First Responders is limited, the large amount of research on shift workers and people in high-stress jobs supports its benefits.

The Unique Problems Faced by First Responders

First Responders face a combination of factors that make them prone to insomnia:

1. Shift Work: First Responders often work irregular schedules, including nights, weekends, and holidays. This disrupts the body’s circadian rhythm, the internal clock that controls sleep and wakefulness.

2. Exposure to Trauma: First Responders regularly see emergencies and traumatic events. This can lead to hyperarousal, intrusive thoughts, and nightmares, which interfere with sleep. Understanding First Responder PTSD is a vital component of addressing these issues.

3. High-Stress Environments: The constant pressure, demanding workload, and responsibility for patient care create high stress. This can lead to anxiety and worry, making it hard to relax and sleep.

Research Showing CBT-I’s Effectiveness

Studies have shown CBT-I’s effectiveness in populations with similar challenges:

1. Firefighters: A study in the Journal of Consulting and Clinical Psychology found that CBT-I improved sleep quality and reduced depression and anxiety in firefighters (https://pubmed.ncbi.nlm.nih.gov/23398945/). Firefighters, like other First Responders, work irregular shifts and are exposed to trauma.

2. Nurses: A study in Applied Nursing Research showed that a brief CBT-I intervention improved sleep and reduced fatigue in nurses working rotating shifts (https://pubmed.ncbi.nlm.nih.gov/28213349/).

3. Shift Workers: A study in Behavioral Sleep Medicine explored a modified CBTI program for night shift workers. Results showed significant improvements in sleep quality and daytime functioning.

Changes for First Responders

CBT-I can be adjusted for First Responders:

1. Shorter Treatments: Some studies have used shorter CBT-I interventions (2-4 sessions) with good results.

2. Online Delivery: dCBT-I and telehealth offer convenient options for First Responders with irregular schedules.

3. Mindfulness: Mindfulness techniques can help First Responders manage stress. These can be included in CBT-I to address the hyperarousal and anxiety from trauma.

Getting CBT-I in Alberta

Knowing about coverage and availability of CBT-I in Alberta is important for First Responders seeking treatment.

Alberta Health Services (AHS)

In Alberta, mental health services are provided through AHS. CBT-I, when delivered by a registered psychologist or psychiatrist, is generally covered. However, access to publicly funded CBT-I can be limited, and wait times can be long.

Private Insurance and Extended Health Benefits

Many Canadians have extended health benefits through their employers. These often cover psychological services, including therapy with registered psychologists. Check your benefits package to see your coverage for CBT-I.

Statistics and Research

CBT-I’s effectiveness is supported by research. Here are some key findings:

• Meta-Analysis: A meta-analysis of 20 studies, published in Sleep, found that CBT-I significantly improved sleep quality, with an effect size of 0.75 (https://pubmed.ncbi.nlm.nih.gov/17241560/). This indicates a substantial improvement.

• Insomnia Severity Reduction: Another study found that CBT-I reduced insomnia severity by 50% in 70-80% of patients.

• Long-Term Benefits: Studies show that CBT-I’s benefits are often maintained over time.

Ongoing Research Areas

While CBT-I is well-established, research continues:

1. Comorbid Conditions: Some researchers think CBT-I may not be as effective for people with insomnia and other mental health conditions (e.g., depression, anxiety) or medical illnesses.

2. Treatment Duration: There’s debate about the best length and intensity of CBT-I.

3. Digital vs. Face-to-Face: There’s conflicting evidence on the effectiveness of dCBTI compared to traditional CBT-I.

4. Long-Term Maintenance: Research is ongoing to find ways to enhance long-term benefits.

Next Steps

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a powerful treatment that can greatly improve the sleep of First Responders in Alberta. By addressing behaviors and thoughts contributing to insomnia, CBT-I gives First Responders tools to regain control over their sleep, leading to better health and job performance. While access challenges exist, the long-term benefits make it a worthwhile investment. Investigating specialized programs in Alberta, along with using existing healthcare coverage, can lead to better sleep and a healthier First Responder workforce. To begin improving your sleep and find out more about how the program of CBT-I for police can benefit you, contact Responders First today. We are dedicated to supporting the well-being of First Responders and can help connect you with the resources you need.

Don Davis

15+ years of emergency response experience. Passionate about connecting our first responder communities with critical resources. Author of hundreds of articles and guides on First Responders mental health care. When not responding to emergencies, you can find me playing with my dogs, hiking, or enjoying a good book.