Cognitive Behavioral Therapy, Insomnia, and Alcohol Use Disorder (AUD)

Man talking to small group

We recently published an article on the use of medication-assisted treatment (MAT) for alcohol use disorder (AUD). In that article, we talk about the widespread prevalence of alcohol use in our society. Consuming alcohol is a socially approved activity. It’s a common way for people to relax after work, and a fixture at weekend events, such as summertime cookouts or pool parties.

However, recent research suggests even moderate alcohol use can lead to significant health problems. To learn more about the new research on alcohol use, please navigate to the blog section of our website and read these articles:

National Alcohol Awareness Month: April 2023

Medication-Assisted Treatment for Alcohol Use Disorder (MAT for AUD)

Study Examines Novel Ways of Treating Alcohol Use Disorder

One thing you’ll learn from those articles is the scope of the harm caused by alcohol use and excess alcohol use in the U.S. Between 2015 and 2019, over 700,000 people died of alcohol-related causes: that’s far greater than the number of people who died from opioid overdose during the same five-year span.

That’s why it’s important for scientists and addiction researchers to find new ways to support people with alcohol use disorder (AUD) who want to quit drinking: the harms caused by alcohol on an individual, community, and national level are significant.

A primary challenge for people seeking to abstain from alcohol is relapse to alcohol use. People relapse for a variety of reasons, including:

  • Stress: Challenging life events can cause people to seek relief from alcohol
  • Environment: Cues that remind people of drinking can precipitate relapse
  • Emotions: Feelings triggered by stress and the environment can lead to patterns of behavior that lead to relapse

There’s another problem, common to many people early in recovery from AUD, that can exacerbate all of the potential causes of relapse we list above: insomnia. A study published in June 2023 addresses the problem of insomnia in a group of veterans early in recovery from AUD, and examines the use of cognitive behavioral therapy – insomnia (CBT-I) in reducing sleep problems that may precipitate relapse and/or contribute to the harm caused by ongoing alcohol use.

CBT-I for Insomnia During AUD Treatment

In the study “Effect of Cognitive Behavioral Therapy for Insomnia on Alcohol Treatment Outcomes Among US Veterans” researchers designed a random control trial with the following objective:

“To test the feasibility, acceptability, and preliminary efficacy of CBT-I among veterans early in their AUD treatment and to examine improvement in insomnia as a mechanism for improvement in alcohol use outcomes.”

The research team cites research indicating a large percentage of people in treatment for AUD report symptoms of insomnia, but a technique widely accepted as the first-line treatment for insomnia – CBT-I – is not frequently used in the early stages of AUD treatment of recovery from AUD.

CBT-I is a derivative of cognitive behavioral therapy (CBT) designed to treat symptoms of insomnia. Evidence shows CBT-I can reduce insomnia symptoms in 70-80 precent of patients. The goal of CBT is to help patients identify how their thoughts and feelings affect behavior. The of CBT-I is to help patients identify how their thoughts and feeling affect their sleep.

CBT-I therapists use a wide range of techniques during treatment session, including but not limited to:

  • Cognitive restructuring
  • Breathing exercises
  • Relaxation techniques
  • Mindfulness
  • Meditation

To determine whether CBT-I improves sleep in veterans with AUD early in AUD treatment, researchers recruited 67 patients with AUD and divided them into two groups. The experimental group participated in five weekly sessions of CBT-I, while the treatment-as-usual group participated in one single educational session about sleep hygiene. Researchers directed all participants to keep a sleep journal for the duration of the experimental period.

To examine outcomes, researchers used three metrics:

  1. The Insomnia Severity Index
  2. Short Inventory of Alcohol Problems
  3. Self-Reported Alcohol Intake

They collected data at the beginning of the experimental period, at the end of the experimental period (which they call post-treatment), and at 6-weeks follow up after the end of the experimental period.

Let’s see what they found.

CBT-I and Sleep Hygiene During Early AUD Treatment: The Results

We described the basic components of CBT-I above. Therapists use those techniques to help patients identify the thoughts and emotions that may cause insomnia, which in turn can increase risk of relapse. Patients in the treatment-as-usual group participated in one session on sleep hygiene. Sleep hygiene is a general term describing the latest ideas about improving sleep that everyone can use.

Sleep hygiene sessions – unlike CBT-I sessions – do not focus on thoughts or emotions, but rather, practical tips about getting better sleep. Common sleep hygiene tips include:

  • Consistent wake time: get up at the same time every morning.
  • Consistent bed time: go to bed in time to get at least 7-8 hours of sleep.
  • Create a relaxing evening routine.
  • Only use the bed for sleeping or sex.
  • Only go to bed when sleepy.
  • Keep the bedroom as cool and dark as possible.
  • Turn off electronic devices 30 minutes before bedtime.
  • No electronic device in bed.
  • Avoid large meals before bedtime.
  • Avoid alcohol and caffeine before bedtime.

We mention these foundational concepts of sleep hygiene for two reasons. First, they can help anyone learn how to improve their sleep. Second, they’re also part of what any CBT-I therapist would include as part of treatment with CBT-I. Therefore, a person engaging in CBT-I would learn all of those sleep hygiene tips, which a CBT-I therapist would augment with patient-specific techniques – in this case, related to AUD recovery – to support the general tips common to sleep hygiene.

Here are the results.

Sleep Hygiene or CBT-I for AUD-Related Insomnia

Metric 1: Insomnia Severity Index

Experimental group

  • Post-treatment: Showed significantly superior improvement in insomnia symptoms, compared to treatment-as-usual group
  • 6-week follow-up: Improvement persisted through follow-up

Treatment-as-usual group

  • Post-treatment: Showed significantly inferior improvement in insomnia symptoms, compared to experimental group
  • 6-week follow-up: Inferior improvements persisted through follow-up

Metric 2: Short Inventory of Alcohol Problems

Experimental group

  • Post-treatment: Showed significantly greater decreases in alcohol-related problems at post-treatment
  • 6-week follow-up: Decreases in harm persisted through follow-up

Treatment-as-usual group

  • Post-treatment: Showed significantly inferior decreases in alcohol problems, compared to experimental group
  • 6-week follow-up: Inferior decreases persisted through follow-up

Metric 2: Effect on Heavy Drinking

Experimental group

  • Post-treatment: No significant differences between groups
  • 6-week follow-up: n/a

Treatment-as-usual group

  • Post-treatment: No significant differences between groups
  • 6-week follow-up: n/a

We’ll discuss these results below.

AUD Treatment: How CBT-I Can Help Patients Seeking Support

In this study, researchers learned something new: CBT-I can improve sleep and problems related to alcohol in patients early in AUD treatment regardless of whether patients maintain abstinence. Ceasing alcohol intake and full abstinence are the ultimate goals of most people in treatment for AUD. However, in the big picture, reducing harm and problems related to alcohol is an important part of recovery, even for patients who relapse or do not achieve full abstinence.

We’ll repeat: abstinence from alcohol is the ultimate goal for a vast majority of people seeking support for AUD, but reducing alcohol-related harm and alcohol-related problems is a positive outcome that can help patients work toward long-term, sustainable abstinence. This aligns with the most recent studies on what it means to be in recovery. For decades, clinicians and people viewed recovery as binary, defined by abstinence: if you’re abstinent, you’re in recovery, if you’re not abstinent, you’re not in recovery.

Now, experts view recovery differently. Here’s the latest definition, as determined by a group of researchers and experts in the paper “Defining and operationalizing the phenomena of recovery: a working definition from the recovery science research collaborative”:

“Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.”

Experts now see recovery as a process that includes – but does not require – complete abstinence at all phases of the recovery journey. Recovery is a process that involves efforts to achieve abstinence with the overall goal of improving wellness and total health. For people with AUD, total health most often means total abstinence. We support patients seeking total abstinence every day. For others, total health may mean drastically reducing alcohol intake and eliminating the harms caused by alcohol, without the singular goal of total abstinence.

Overcoming Insomnia Helps AUD Recovery

For both groups of people, this new study shows that CBT-I is a valuable and effective tool in reducing insomnia and alcohol-related problems in people early in AUD treatment. Based on these results, we can conclude that when combined with lifestyle changes, community support, and counseling, CBT-I may be effective in helping people achieve abstinence, if that’s their goal. Overcoming insomnia can reduce stress, improve cognition, boost mood, and improve overall wellbeing. While CBT-I did not show superiority to sleep hygiene in reducing heavy drinking days for patients in the study we discuss above, it did help patients improve in areas that facilitate recovery. This is a promising finding, and gives us hope that in the future, clinicians can view CBT-I as an effective, valuable component in an integrated, holistic approach to AUD treatment and recovery.

The materials provided on the Pinnacle Blog are for information and educational purposes only. No behavioral health or any other professional services are provided through the Blog and the information obtained through the Blog is not a substitute for consultation with a qualified health professional. If you are in need of medical or behavioral health treatment, please contact a qualified health professional directly, and if you are in need of emergency help, please go to your nearest emergency room or dial 911.