Integrating ACT into CBT-I
As many people know, CBT-I is the gold standard treatment for insomnia. The behavioural components, specifically sleep restriction therapy and stimulus control, have the most evidence for effectiveness.
Where it gets more complicated is the cognitive piece. The traditional approach asks clients to identify and challenge unhelpful thoughts about sleep. For some people, that works well. For others, trying to talk themselves out of "what if I can't sleep again tonight" tends to backfire, and the unhelpful thoughts get more attention (try not to think of a pink elephant).
Acceptance and commitment therapy (ACT) does not ask you to dispute your thoughts or replace them with more balanced ones. It builds the capacity to notice a thought, let it be there, and choose how you respond anyway. For someone lying awake in the middle of the night, convinced they will never sleep properly again, that is a meaningful shift. The goal is to reduce the struggle with wakefulness and sleep.
In practice, this looks like cognitive defusion work, values-based reasons to stay consistent with a sleep schedule (why someone actually wants better sleep), and addressing the counterintuitive effects of sleep effort. The behavioural protocols from CBT-I stay intact however, what changes is how we relate to the difficult thoughts that come up through treatment.
Middle-of-the-night wake-ups are a good example of whether you should take a CBT approach or a more flexible ACT approach. Traditional stimulus control (CBT-I) is fairly rigid, and if you are awake for more than 20 minutes, you get out of bed. For a lot of clients, that protocol lands as another rule to potentially fail at, and another layer of anxiety on top of an already activated nervous system. With an ACT lens, the question becomes less about what you are doing. Are you staying in bed because it feels genuinely restful, or because you are hoping sleep comes back? Stimulus control can be applied more flexibly when a client has the psychological tools to accept and observe what is happening. I will often start with a CBT-based stimulus control protocol and check in with the client to see if we need to pivot to an ACT middle-of-the-night protocol, where they may stay in bed to allow rest rather than trying to force sleep (control and outcome-based thinking are the enemies of sleep).
Acceptance and behaviour change for insomnia (ABC-I) blends the behavioural structure of CBT-I, with cognitive flexibility and acceptance woven through. For many clients, it is what helps the hardest parts of treatment stick.
