Standard CBT-I protocol for the treatment of insomnia disorder

The purpose of this chapter is to provide an overview of what you might expect to find in a CBT program for insomnia. That is, what would comprise the standard treatment protocol. I have taken the perspective that the published literature provides us with the greatest confidence in knowing what is effective, and so have included, as standard, those elements of CBT that have the strongest evidence base. That said, a feature of the insomnia trials literature is that CBT has typically been evaluated as a multicomponent therapy, so discrete elements have not necessarily been investigated as fully as one might wish, and the contribution of those elements to the overall treatment effect remains largely unknown. Consequently, where a given intervention has been a common component in trials demonstrating the effectiveness of CBT, I have taken the view that there are good grounds for thinking of that intervention as part of the standard protocol. In other words, it is at the very core of CBT for insomnia. Inevitably, I have had to make some choices and some judgements in proposing this standard protocol, and I recognise that others may take a different view. My intention is that the chapter is practical, in keeping with the purpose of this book, rather than heavily referenced to source materials, so I have relied mainly on clinical guidelines, practice parameters and systematic reviews when citing evidence. It is important to note, however, that clinical trials, of which there are many, are readily accessible through these overviews and I would recommend that you look at some of those to see just how varied CBT for insomnia can be, in content, content ordering, in treatment duration and in format of delivery. There are situations, however, where I have felt it helpful, and interesting perhaps, to provide more referencing1; for example, to the scientific and historical roots of CBT. I often feel that these are overlooked. It is very important to appreciate the strength, depth and longevity of our field, even if the terminology we use (and sometimes re-brand) appears as if it is novel! Our confidence that CBT works is also based on this provenance, and the diligent work of countless clinicians and researchers over many decades. Finally, this chapter is provided as a platform upon which other chapters may build. By presenting this standard protocol, focussed primarily in relation to adults with insomnia, applications of CBT to other populations, age groups and circumstances, protocol variations, and emerging approaches to therapeutics can compare, contrast and evolve through the course of the textbook. I have also tried to write as much as possible in plain language, and to share personal accounts of how I would deliver CBT, to make this chapter as clinically informative as possible. If you would like further insight into my approach to the actual delivery of CBT-I, I would refer you to two recent books, one for patients (Espie, 2021) and the other for clinicians (Espie, 2023).