Luc P. Beaudoin, Ph.D. (Cognitive Science)
Adjunct Professor of Cognitive Science
Adjunct Professor of Education
Simon Fraser University
EDB 7505, 8888 University Drive
Burnaby, BC V5A 1S6 Canada
LPB@sfu.ca Skype: LPB2ha
Last Revised: 2015–06–10 (See revision history)
First published: 2015–06–04
A study published June 1, 2015, on the benefits of a “single-shot” of CBT-I (Ellis, Cushing, Germain, 2015 has received a lot of media attention and generated considerable discussion. Few of the commentators seem to have read the full article. Their response, (including a reddit thread with over 1,000 comments, and counting), seems to be to Northumbria University’s description of the study. It’s unfortunate that a research project should be judged without reading the actual article. That is the problem with closed access publications. SLEEP, the journal in which the study was published, has a 6-month embargo before it opens its articles to the public.
So, in this article I comment briefly on the discussion and the study itself.
Ellis and colleagues applied a single session of psychotherapy in the form of CBT-I (cognitive-behavioral therapy for insomnia) to 20 participants with acute insomnia — i.e., who had not (“yet”) developed chronic insomnia. The session lasted 60–70 minutes and was administered by Ellis himself. Both this group and a control group filled out an insomnia questionnaire and regularly filled out a sleep diary received. The control group received no other treatment. One month later, the CBT-I group had significantly lower levels of insomnia than the control group. Twelve of the former “remitted” whereas only three of the latter did.
Several people on reddit complained that the sample size was too small to prove anything. However, the authors statistically qualified their results (the short description gives a “t(38) 2.24, P < 0.05”). If their sampling and methodology was right, then they may be on to something. One study is just one study. But then so is every study in psychology. Scientific findings always require replication. The authors stated the need for replication in their conclusion.
That said, the title of the Northumbria University web page, “73% of insomniacs cured” is a bit bombastic. The target article summary used the phrase “remitted” not “cured”. It is questionable whether one can be “cured” of acute insomnia. The researchers assessed the participants three months after the treatment. That is the minimum period for clinical chronic insomnia in DSM-V (“The sleep difficulty occurs at least 3 nights per week, is present for at least 3 months, and despite adequate opportunity for sleep”). According to the target summary, the purpose of the study was to assess whether a single session of psychotherapy could prevent development of chronic insomnia. The authors indicate in their conclusion that their results suggest their intervention treated insomnia.
Even if we read the article as pointing only to prevention, the situation is likely to be a bit more complicated than the University’s website (PR) article suggests. For example, the final published experimental measurement was done one month after the intervention. It is quite possible that the control group’s remission rate would be higher at 4 months. The authors report a non-experimental observation 3 months after the intervention of the experimental group only. For ethical reasons, they gave the control group access to the same intervention as the experimental group, which prevents comparison. Also, we should expect insomnia treatment to be more complicated than that because even intensive CBT-I, while the treatment of choice, is not completely effective. Evidence for this is provided by the large number of researchers who continue to assess CBT-I, attempt to improve it, and to provide alternatives. I, for instance, have been working on an improvement to traditional imagery distraction called serial diverse imagining. (See the section on “Imagery distraction as an implementation intention” below).
Speaking of alternatives to CBT, just recently, in a different forum, I blogged about how mindfulness seems promising for insomnia. For instance, Black, O’Reilly, Olmstead, Breen, and Irwin (2015) found that mindfulness training was helpful for insomnia in older adults. In this context, several things are noteworthy about Black’s research. One such fact is that they specifically do not present their treatment as one that is directly targeted at insomnia:
We do not provide any instruction about sleep in our classes as the whole intent was not to make it a sleep intervention course. They learn the basics of mindfulness in the UCLA MARC course, see http://marc.ucla.edu (Black, 2015, personal communication)
This is consistent with mindfulness therapies which accept mental content and experience, including insomnia. CBT-I, in contrast, is “full on”, “in your face” targeted at reducing insomnia.
Another fact is how Black et al. cautiously expressed their conclusions:
Pending future replication of these findings, structured mindfulness meditation training appears to have at least some clinical usefulness to remediate moderate sleep problems and sleep-related day-time impairment in older adults.
Several other studies on mindfulness and acceptance are showing promising results for insomnia. See Ong, Ulmer & Manber (2011) for an explanation of the key concepts.
Some commenters are quite skeptical that such brief psychotherapy as Ellis and colleagues provided can have substantial benefits. To this there are several answers, such as that this is why we do empirical research: to see which of many conflicting intuitions is correct. (Clearly the authors feel a one-shot approach can help).
Now, brief forms of psychotherapy have been developed and studied for various types of problems for a long time. There is an established type of psychotherapy actually called brief therapy, for instance. See A Brief Guide to Brief Therapy by Brian Cade and Bill O’Hanlon (1993). However, the systematic “one shot” approach does not fit the “brief psychotherapy” mold. Cade & O’Hanlon, for instance, clearly emphasize in their introduction and throughout their book the importance of understanding the client’s concerns, in a way that is client-centred –not something one can do in an hour. CBT tends to focus more on the problem and brief therapy more directly on solutions. However, this one-shot CBT-I could presumably be plugged into the course of brief therapy. Further, the authors cite prior evidence in favour of brief psychotherapies for chronic insomnia.
What is relatively new about the study is that it’s about one shot CBT-I. And CBT-I does indeed appear to be the kind of treatment for which one can develop very concise versions. In fact, this is often done in practice.
Why bother researching short-form psychotherapy for insomnia? Well, coincidentally, today I just submitted an ethics application for my new cognitive treatment for insomnia (the cognitive shuffle, serial diverse imagining, or SDI) in which we wrote something that answers this question:
However, it is important to note that CBT-I is not easily accessible to the public because it is quite expensive and demanding (in time, finding an adequate therapist, finding an adequate strategy, etc.) Thus the interest in developing accessible and inexpensive alternatives.
In other words, like Ellis and colleagues, Julie Carrier, Jessica Massicotte-Marquez and I also justified researching the effectiveness of our treatment (SDI) because traditional CBT-I is so expensive. However, we do not claim our treatment (SDI) is a compressed form of CBT-I. SDI is a potential addition to the cognitive toolkit of therapist and client. It could be administered by itself to deal with insomnia; however, it ought not to replace sleep hygiene, problem solving, and other salubrious practices. CBT-I potentially deals with much more than just imagery distraction, including:
It is plausible that a one-shot treatment of CBT-I can deliver a lot of the above. However, one thing I would be quite surprised to see is if it can deliver significant cognitive restructuring. Cognitive restructuring can be quite tricky. So tricky in fact that some acceptance and commitment therapists are skeptical of it. They don’t press as hard to change beliefs and cognitions (though of course they do try to do some of that, it’s required in deep psychological change). They accept that the mind generates a lot of “garbage”. They use “cognitive defusing” not to make you stop thinking “those crazy thoughts” but to decrease their psychological potency.
Also, insomnia is often a symptom of some deeper problem that requires other psychological treatment. One might have an anxiety disorder or lack the wherewithal to leave an abusive relationship. Solve the source problem and the insomnia may also go away. A one-shot therapy session that focuses only on sleep considerations won’t cut it. More general cognitive therapy, meta-cognitive therapy, acceptance and commitment therapy (ACT) or other therapy may be required. An acceptance and commitment mindset, for instance, cannot be learned in a session. But the benefits are deep. Still, it is worth measuring just how effective one-shot therapy can be. Moreover, with software it should be possible to tailor short-form therapy to the individual. That is an approach taken by Ellis’ colleague, Colin A. Espie, in one of the latter’s commercial ventures (Espie et al, 2012).
Of course, it’s impossible to tell which component of the intervention applied by Ellis contributed most to its effects. A pamphlet was also given to the experimental group. Was it the pamphlet, a cognitive component, or a behavioral component?
Interestingly, prior research suggests that bibliotherapy for insomnia may be more effective than simple sleep hygiene (Bjorvatn, Fiske, & Pallesen, 2011). So it may be that the pamphlet played an important role. veluna on reddit pointed out that education alone doesn’t do the trick. There needs to be follow-up to ensure the application of what was learned. I agree that reading per se is not sufficient; nor is traditional therapy sufficiently efficient. As I argued in chapter 15 of Cognitive Productivity, key principles from educational psychology and expertise are as important for therapy as they are for bibliotherapy. In particular, I argued that therapist should try to boost their clients’ meta-effectiveness and combine treatments with productive practice (a form of deliberate practice and test-enhanced learning) that can be optimised with software.
Productive practice involves practicing answering questions (responding to challenges) over an extended period of time (applying principles of spacing, desirable difficulties, etc.). Participants could, for instance, be required to practice answering questions about the CBT-I materials. Using a productive practice system would come as close as one can reasonably get to ensuring that participants truly understand, can recall and apply the knowledge CBT-I aims to convey. Given the well documented problems of “transferring” and generalizing learning, and well-documented benefits of test-enhanced learning and deliberate practice, productive practice should be a standard prescription of psychotherapy.
Having said that, imagery distraction might have been the key component in the Ellis et al study because this technique is so easy to use. (See “Imagery distraction as an implementation intention” below.) In fact, one could argue that the Ellis et al paper is not the first one to demonstrate the effectiveness of succinct CBT-I, at least to the extent that some of its components (such as imagery distraction) have already been demonstrated to be effective alone, with only brief training.
Also, CBT is by definition cognitive and behavioral. Because the Ellis et al intervention did not separate the cognitive from the behavioral component in different treatment groups, we don’t know which (if any) was the active ingredient. So they could just as well have changed their title to “Cognitive OR Behavioral Therapy for Insomnia …” There is incidentally prior research on cognitive vs. behavioral treatment for chronic insomnia (Harvey et al, 2014). However, that type of research is very expensive.
Ellis et al argued in favour of face-to-face intervention. Therapy is after all supposed to be individualized (otherwise it’s just a course or lecture). The experimental group were not merely read a standard script, as is typical in a psychology experiment where control is of the essence. The therapy was delivered one-on-one by Dr. Ellis, who is a world-class expert in insomnia. One can reasonably expect that Dr. Ellis was able, at least in some small way, to use his expertise to tailor his treatment to the individual participant. While this is good for the participants, it does complicate the interpretation of the results from this study. A typical CBT therapist does not specialize in insomnia and might not as effective as Dr. Ellis. Typically, therapists must deal with a very wide range of cases, limiting their ability to specialize and develop expertise. Therefore, it is not evident that a normal therapist would be able to achieve the same results as this study (assuming therapy was indeed the cause of the difference). One would want to replicate the study with a more representative therapist—i.e., one that has received the typical amount of training on CBT-I that one can expect a typical CBT therapist to have received. (For a detailed discussion of expertise in knowledge-intense disciplines, see my book, Cognitive Productivity.)
Research on implementation intentions suggests it is helpful to learn very simple if-then rules to address key problems and meet their goals. E.g., “If I have difficulty falling asleep, I will do this.” or “If I want to sleep well tonight, I will do that”
We know from research in cognitive psychology of memory that if the “if” component has too many consequents (“then” parts), then the consequents (the targets) will be difficult to recall. More generally, the probability of recalling a target given a cue is inversely proportional to the number of targets the cue has been associated with. This is the “fan effect”, or cue overload. So, if there are too many things to do in response to a given challenge (such as wanting to have better sleep efficiency tonight), then you might not be able to remember much of what you need to do. Cognitive Productivity presents solutions to the cue overload problem, such as the reconstructible-discriminative cue mnemonic (“RDQ”). One trick is to specialize the antecedents of your rules (the “if” parts) and to develop habits.
A helpful habit is to use imagery distraction before bed. Traditional imagery distraction involves imagining a scene for an extended period of time. This is supposed to keep one’s mind from entertaining insomnolent processes. Insomnolent information processing is that which keeps one awake (e.g., ruminating) (Beaudoin, 2013; Beaudoin & Digdon, manuscript in progress). This is because traditional imagery distraction is somewhat counter-insomnolent (Woolfolk & McNulty, 1983; Morin & Azrin, 1987). In addition, according to conditioning principles, if one gets in the habit of using imagery distraction on a regular basis, even when one has no particular concerns, then this type of thinking will become associated with somnolence. It should make it even more potent on good nights. I mooted this idea in Beaudoin (2013). Gellis, Arigo & Elliott (2013) proposed something similar. But the general conditioning principle is quite old.
I assume that Ellis et al used traditional imagery distraction, which I refer to as Monotonous Imagery Distraction (MID) because users are given a small palette of things they could imagine and then asked to focus on one of those things for a long period of time. Harvey & Payne (2002) expected that people would get bored of MID which would decrease its effectiveness. It would be easy enough to test Harvey & Payne’s claim. (One could ask its users, for instance). However, their claim has not yet been directly tested. Moreover, Digdon & Koble (2011) failed to corroborate it. Nevertheless, I suspect that people who score low on tests of cognitive miserliness (Stanovich, 2009, 2010) or whose minds tend to race (and this is widely thought to be a contributor to insomnia), would tend to find it stultifying. Moreover, it is unreasonable to expect that imagining a candle or the like for several minutes can compete with the worries that tend to keep people awake, again, especially for people who are having trouble with their racing thoughts to begin with.
That’s partly why I developed serial diverse imagining (Beaudoin, 2013, 2014). SDI involves briefly generating new images and entertaining them for a short period of time (e.g., 8–12 s). If my theory is correct, SDI delivers more than just distraction. It is meant to be positively somnolent. I developed both a DIY method of SDI and the design of an app to facilitate SDI. (This apps are commercialized by CogSci Apps Corp.: somnoTest for scholarly research purposes, and mySleepButton® for end-users). Preliminary results (Digdon & Beaudoin, to appear) will be reported in July. (We are planning two other comparative studies this year. I am also currently co-authoring a detailed paper that characterizes SDI and other cognitive therapies in relation to my theory of sleep onset, insomnia and emotion (Beaudoin & Digdon).)
It would be interesting to compare the Ellis therapy protocol including MID with that protocol using SDI instead.
Conditioning and bad habits are thought to be major contributors to insomnia. Correcting bad habits before they turn into major problems is a reasonable course of action. Ellis et al are to be commended for researching efficient forms of therapy for acute insomnia before chronic insomnia develops. “Prevention is better than the cure”.
Beaudoin, L. P. (2013).The possibility of super-somnolent mentation: A new information-processing approach to sleep-onset acceleration and insomnia exemplified by serial diverse imagining. Meta-effectiveness Research Project, Faculty of Education, Simon Fraser University. Retrieved from http://summit.sfu.ca/item/12143
Beaudoin, L. P. (2014). A design-based approach to sleep-onset and insomnia: super-somnolent mentation, the cognitive shuffle and serial diverse imagining. Presented at the 2014 Cognitive Science Society Annual Conference’s workshop on “Computational Modeling of Cognition-Emotion Interactions: Relevance to Mechanisms of Affective Disorders and Therapeutic Action”, July 23, 2014, Québec, Canada.
Beaudoin, L. P. (2015) Cognitive Productivity: Using Knowledge to Become Profoundly Effective CogZest: BC. Retrieved from https://leanpub.com/cognitiveproductivity/ (First edition: 2013).
Beaudoin, L.P. & Digdon, N. (manuscript in preparation). Towards an affective information-processing theory of sleep-onset and insomnia. (If you’re an academic interested in reviewing and providing feedback on this paper, please contact firstname.lastname@example.org for a copy.)
Bjorvatn, B., Fiske, E., & Pallesen, S. (2011). A self-help book is better than sleep hygiene advice for insomnia: A randomized controlled comparative study. Scandinavian Journal of Psychology, 52(6), 580–585. http://doi.org/10.1111/j.1467–9450.2011.00902.x
Black, D. S., O’Reilly, G. A., Olmstead, R., Breen, E. C., & Irwin, M. R. (2015). Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances. JAMA Internal Medicine, 1–8. http://doi.org/10.1001/jamainternmed.2014.8081
Cade, B., & O’Hanlon, W. H. (1993). A Brief Guide to Brief Therapy. W. W. Norton.
Digdon, N. & Beaudoin, L. P. (2015: Accepted) A test of the somnolent mentation theory and the cognitive shuffle insomnia treatment. Poster to be presented at CogSci 2015 (The annual meeting of the Cognitive Science Society).
Digdon, N., & Koble, A. (2011). Effects of constructive worry, imagery distraction, and gratitude interventions on sleep quality: A pilot trial. Applied psychology: Health and well-being, 3(2), 193–206. http://doi.org/10.1111/j.1758–0854.2011.01049.x
Espie, C. A., Kyle, S. D., Williams, C., Ong, J. C., Douglas, N. J., Hames, P., & Brown, J. S. L. (2012). A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep, 35, 769–781. http://doi.org/10.5665/sleep.1872
Harvey, A. G. (2014). Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: A randomized controlled trial. Journal of Consulting and Clinical Psychology. http://doi.org/10.1037/a0036606.supp
Morin, C. M., & Azrin, N. H. (1987). Stimulus control and imagery training in treating sleep-maintenance insomnia. Journal of Consulting and Clinical Psychology, 55(2), 260–262.
Woolfolk, R. L., & McNulty, T. F. (1983). Relaxation treatment for insomnia: A component analysis. Journal of Consulting and Clinical Psychology, 51(4), 495–503.
Harvey, A. G., & Payne, S. (2002). The management of unwanted pre-sleep thoughts in insomnia: Distraction with imagery versus general distraction. Behaviour Research and Therapy, 40(3), 267–277.
Gellis, L. A., Arigo, D., & Elliott, J. C. (2013). Cognitive refocusing treatment for insomnia: A randomized controlled trial in university students. Behavior Therapy, 44(1), 100–110. http://doi.org/10.1016/j.beth.2012.07.004
Ong, J. C., Ulmer, C. S., & Manber, R. (2012). Improving sleep with mindfulness and acceptance: A metacognitive model of insomnia. Behaviour Research and Therapy, 50(11), 651–660. http://doi.org/10.1016/j.brat.2012.08.001
Ellis, J. G., Cushing, T., & Germain, A. (2015). Treating acute insomnia: A randomized controlled trial of a “single-shot” of cognitive behavioral therapy for insomnia, Sleep, 36(6), 971–978. http://www.journalsleep.org/ViewAbstract.aspx?pid=30045
Northumbria University (2015) 73% of insomniacs cured after 1-hour therapy session. Retrieved from https://www.northumbria.ac.uk/about-us/news-events/news/2015/06/73-of-insomniacs-cured-after–1-hour-therapy-session/
Stanovich, K. E. (2009). What intelligence tests miss: The psychology of rational thought. New Haven, CT: Yale University Press.
Stanovich, K. E. (2011). Rationality and the reflective mind. New York, NY: Oxford University Press.
2015–06–10 Updated with information from the source article, notably regarding periods of time.
2015–06–05. Corrected the Reddit comment count. I had accidentally referenced the submission’s score. Replaced some occurrences of the term “brief” to prevent confusion with standard brief therapy.
2015–06–04 (PDT). First draft.
The author, Dr. Beaudoin, is a co-founder of CogSci Apps Corp. and owner/manager of CogZest. CogSci Apps Corp. provides technical support and software to compare serial diverse imagining (SDI) with other cognitive treatments. mySleepButton® is an app for iPhone®, iPad®, iPod Touch® and Android that helps people use the serial diverse imagining treatment. (It will soon support other cognitive treatments).