How cognitive behavioral therapy for insomnia (CBT-I) delivers better sleep

Insomnia is the most common sleep disorder ^[1], affecting up to 10% of the population. It’s characterized by  an ongoing difficulty falling and staying asleep. Over time, not getting adequate rest can take a toll on the mind and body. Constant fatigue can make it hard to function and increase the risk of physical and mental health problems.

If you’re dealing with insomnia, it’s possible to improve sleep habits with professional help. Cognitive behavioral therapy for insomnia (CBT-I) is one of the most effective treatments for insomnia ^[2] in adults. It works by targeting unhelpful thoughts and behaviors related to sleep, which often develop when getting enough rest becomes a source of stress. 

What is CBT for insomnia?

Sleep experts use the following three-factor model to explain what causes chronic insomnia ^[1]. 

• Predisposing factors: Some personality traits, like high emotional reactivity, are associated with a greater risk of insomnia.

• Precipitating factors: Stressful life events, like a sudden or unexpected loss, often trigger the onset of insomnia.

• Perpetuating factors: Unhelpful thoughts and behaviors — like believing you can’t sleep, even when you’re tired — may contribute to lasting insomnia.

CBT-I works by targeting the perpetuating factors part of the model. 

For example, imagine that you started having sleepless nights after a car accident last year. The stress of the event shook you to your core, and you’ve felt unsettled ever since. You’ve healed physically, but you’ve never fully emotionally recovered. 

Even though the car accident was a long time ago, you’re still feeling the effects. You used to look forward to crawling into bed after a long day. Now, you find yourself dreading it. Instead of being a place to unwind, your bedroom now represents tossing and turning, staring at the ceiling, and wishing you could fall asleep. 

In this case, CBT-I could help you replace your negative thoughts about sleep with neutral or positive ones, like, “Rest has been a challenge for me lately, but I know I’m capable of falling asleep.” Changing what you believe about your relationship with rest can help reduce insomnia.

Can CBT-I help with other conditions too? 

CBT-I is considered a frontline treatment for insomnia. It may be a good choice for you if you’re having a hard time sleeping but want to avoid sleep medication or long-term therapies. 

Also, about 40% ^[3] of people with insomnia have a co-occurring mental health condition like depression, anxiety, or attention-deficit hyperactivity disorder (ADHD). Treating insomnia with CBT-I can help people manage symptoms of those conditions.

How CBT for insomnia works

Before starting CBT-I, it may be helpful to seek a medical evaluation. Sometimes, trouble with sleep can result from underlying health problems that therapy alone can’t treat. However, if you’ve been diagnosed with insomnia and want to pursue CBT-I, the following information can help you understand how it works and what you can expect.

CBT-I is a relatively brief form of care, usually lasting an average of six sessions ^[3]. While in treatment, you’ll be asked to keep a sleep diary. Each day, you’ll take some notes on your sleep habits so that you can track your progress over time. You and your therapist will work together to set individualized goals for treatment. 

These strategies ^[4] can help you achieve the goals you set with your therapist: 

• Sleep restriction: If you tend to lie awake, unable to sleep, it can help to restrict the amount of time you spend in bed. Removing yourself from bed when this happens can help promote longer and deeper sleep.

• Stimulus control: Only using your bed for sleep and intimacy can help “train” your brain to associate it with rest. 

• Cognitive restructuring: Having insomnia can make the mere thought of going to sleep stressful. In this part of CBT-I, the therapist will help you change how you think about sleep. 

• Relaxation techniques: Adding meditation, breathing exercises, or body scans to your nighttime routine can help promote relaxation. These activities may signal to your mind and body that it’s time to “power down” for the day.

Like other forms of therapy, you can support your success in CBT-I by playing an active role in the process. You can do this by attending all of your sessions, following your therapist’s recommendations, and applying the skills you’re learning in CBT-I. Research shows that this approach helps about 50% of people reduce symptoms of insomnia ^[1]. And in some cases, CBT-I works as well as or better than sleep medications ^[4].

Getting started with CBT-I treatment

If you’re interested in starting CBT-I, the first step is to find a qualified provider. You can ask an existing provider, like a doctor or psychiatrist, for a referral. Or you can search digital directories or teletherapy platforms for a therapist you can meet with online or in your community.

As you vet potential therapists, keep in mind that, in addition to having CBT-I training, they should also have experience treating sleep disorders alongside other mental health concerns. If you’re unsure about a therapist’s background or approach, don’t be afraid to ask questions when you reach out. Most providers welcome questions and will be happy to provide any information you need to determine whether they might be the right fit for you.

Clinician’s take

A common belief that reinforces insomnia is, ‘If I don’t get eight hours of sleep, tomorrow will be a disaster.’ This kind of pressure can increase anxiety at bedtime and make sleep harder to achieve. Sleep can improve when you shift your focus from forcing sleep to building consistent routines and reducing performance anxiety.

Brandy Chalmers, LPC

Clinical reviewer