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Acceptance and Commitment Therapy Shown Effective for Certain Patients With Insomnia


Acceptance and commitment therapy can significantly help patients with primary insomnia and secondary symptoms, especially anxiety associated with insomnia and those who have not responded to cognitive behavioral therapy for insomnia.

Acceptance and commitment therapy (ACT) had a significant effect on primary insomnia and secondary symptoms, particularly anxiety associated with insomnia, according to study findings in Nature and Science of Sleep.1

These findings imply that ACT could be an intervention for people who do not respond to cognitive behavioral therapy for insomnia (CBT-I) and have high anxiety about sleep problems. For some, CBT-I is helpful, especially if participants initially have worse sleep.2

This study was conducted because ACT is part of the third wave of CBT. The efficacy of ACT for insomnia compared with CBT-I in patients with chronic primary insomnia was the aim of this study. According to the study authors, it is the first study that compares the effects of ACT and CBT-I on insomnia and mood symptoms associated with sleep disturbance.

“ACT does not encourage patients to avoid thoughts, feelings, or physical sensations but allows patients to experience them as they are. The acceptance of insomnia reduces the severity of the patient’s symptoms and, paradoxically, can lead to a higher level of sleepiness,” explained the study authors.

Two people are talking to each other in a therapy session.

Two people are talking to each other in a therapy session.

Psychotherapy session: © loreanto- stock.adobe.com

First, patients with chronic primary insomnia were recruited from a university hospital between August 2020 and July 2021. Thirty patients were enrolled and randomly assigned to receive either ACT (n = 15) or CBT-I (n = 15). Then, respective interventions were performed over the course of 4 weeks consisting of 4 sessions of face-to-face therapy and 4 sessions of online therapy. Outcomes were measured using a sleep diary and a questionnaire.

After the intervention, the ACT and CBT-I groups possessed significantly improved sleep quality, insomnia severity, depression, beliefs about sleep, sleep onset latency (SOL), and sleep efficacy (SE) (P < .05). Nonetheless, anxiety was significantly reduced only in the ACT group, and not in the CBT-I group (P = .015).

In this study, CBT-I showed a greater effect size in decreasing dysfunctional beliefs about sleep (partial η2 = 0.450) compared with ACT (partial η2 = 0.249), while ACT showed a greater effect size in decreasing depression (partial η2 = 0.317) and anxiety (partial η2 = 0.223) compared with CBT-I (depression: partial η2 = 0.123; anxiety: partial η2 = 0.019, ns).

“The degree of anxiety reduction in the ACT group showed a large effect size (partial η2 = .223),” explained the authors.

The concluded that new treatments using mindfulness and acceptance-based approaches might be effective interventions for patients who do not respond to CBT-I, and especially for patients with anxiety that is related to marked nighttime rumination and worry.

The current study saw that depression was significantly reduced in both groups, but anxiety was significantly reduced only in the ACT group. Further, sleep onset latency improved in both groups, per the sleep diaries of the study, but sleep efficacy only improved in ACT. In addition, although there was no statistical significance, total time spent in bed tended to grow and wake time after sleep onset tended to decline in the ACT group.

The study authors explained that mental health status should be taken into account as a factor that plays an essential role in the treatment of patients with insomnia.

A limitation of this study is that it was a pilot randomized controlled study with a small sample size, necessitating caution in interpretation. Also, this study excluded patients with serious medical or psychiatric conditions and had a high proportion of female participants with higher education levels and married status in the clinical population.

“It is meaningful that ACT has presented an alternative way that can be effective for patients with insomnia who are not effectively treated with traditional CBT-I, by introducing a new context of treatment such as acceptance and defusion rather than change,” concluded the study authors.


1. Shin JW, Kim S, Shin YJ, Park B, Park S. Comparison of acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT) for chronic insomnia: a pilot randomized controlled trial. Nat Sci Sleep. 2023;15:523-531

2. Petrullo J. Having initially worse sleep contributes to greater sleep therapy success. AJMC.com Published January 22, 2023. Accessed July 11, 2023. https://www.ajmc.com/view/having-initially-worse-sleep-contributes-to-greater-sleep-therapy-success

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