Cognitive Behavioral Therapy for Insomnia (CBT-I)

Written by Maggie Aime, Health Writer

Methodology

At Sleepopolis, we’re constantly monitoring new sleep health developments in order to keep our articles as up-to-date and accurate as possible.

Just Updated

This article has been updated to reflect more recent medical consensus around CBT-I.

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Long Story Short

• Cognitive behavioral therapy for insomnia (CBT-I) is a first-line treatment for chronic insomnia (1)
• Around 10 percent of adults have an insomnia disorder, while about 30 percent of people in the US experience some symptoms of it. (2)(3)
• The five key components of CBT-I include sleep restriction therapy, stimulus control therapy, cognitive therapy, sleep hygiene, and relaxation techniques. (4)
• CBT-I is effective in 70 to 80 percent of patients with insomnia. (5)
• Despite its effectiveness, up to 40 percent of CBT-I patients prematurely stop treatment. (6)

It’s tough when sleepless nights seem to pile up on top of each other — going to bed early just means more tossing and turning, and staring at the ceiling at 3 a.m. feels like your new routine. If this sounds familiar, this frustrating pattern could be insomnia, a sleep disorder that can stick around for months or years. (7) And it’s not just you. Millions of adults deal with insomnia stealing their sleep night after night. (2)

But counting sheep isn’t your only option for trying to get some sleep. Heard of cognitive behavioral therapy for insomnia (CBT-I)? It’s a first-choice treatment for chronic (long-term) insomnia, and it’s been around for years. (1) CBT-I is impressively effective, too, helping 70 to 80 percent of people with insomnia improve their sleep. (5) Here’s what CBT-I is all about and how it just might help change your sleep for good. 

Note: The content on Sleepopolis is meant to be informative in nature, but it shouldn’t be taken as medical advice, and it shouldn’t take the place of medical advice and supervision from a trained professional. If you feel you may be suffering from any sleep disorder or medical condition, please see your healthcare provider immediately.

What Is Insomnia? 

Getting a good night’s sleep is tough when you have insomnia. This sleep thief can make falling asleep, staying asleep, or getting restful sleep a nightly challenge. (7) Plus, its effects don’t necessarily stop when the sun comes up. During the day, insomnia can leave you fatigued and sleepy, unable to concentrate, and irritable. (8)

Insomnia isn’t the same for everyone. Some people have short-term insomnia, which lasts a few days or weeks. (9) Others deal with chronic insomnia, a long-term problem when sleep issues happen at least three nights per week for three or more months. (10) There’s also insomnia linked to other health issues. No matter the type of insomnia, over time, it can weaken your immune system, throw off your metabolism, and even increase your risk of serious health problems like diabetes and heart disease. (10) 

And it’s not exactly a rare problem. Out of every 10 adults, one likely struggles with an insomnia disorder, and two have occasional insomnia symptoms. (2) On top of that, nearly one in three people in the US deal with insomnia. (3)

What Is Cognitive Behavioral Therapy For Insomnia (CBT-I)? 

“Cognitive behavior therapy for insomnia focuses on identifying and addressing the thought patterns, feelings, and behaviors that are keeping you awake during the night,” Shelby Harris, a clinical psychologist and Sleepopolis’ director of sleep health, tells us. (11) It’s a type of talk therapy that targets sleep issues. (12) It uses cognitive therapy, behavioral therapy, and mindfulness, to treat insomnia, adds Alex Dimitriu, M.D., double board-certified in psychiatry and sleep medicine. (5)(13) Some people call CBT-I “sleep therapy” for short.

Put simply, the “cognitive” part of CBT-I helps you change the thoughts that disrupt your sleep, like those late-night worries. (12) The “behavioral” part focuses on building good sleep habits and eliminating the bad ones. (14)

Despite this, CBT-I isn’t as widely used as you might expect. It turns out less than one in 10 people with insomnia actually get referred for CBT-I. (15) And many people with insomnia struggle with finding time for CBT-I sessions (more on that later), making it difficult to start or continue the treatment. (15) Plus, there’s a shortage of trained CBT-I therapists, so most people dealing with insomnia hear about sleep medications long before learning about CBT-I. (4)

For those who do manage to start treatment, a small study found that about 40 percent of people dropped out of CBT-I treatment plan early. (6) According to the researchers, some people felt they had improved enough, others got too busy or had trouble keeping their appointments. (6)  

How Does CBT-I Work? 

To start, the CBT-I therapist will ask you to keep a sleep diary. (16) They’ll educate you on how sleep and the circadian system (your body’s internal clock) work, Cali Bahrenfuss, a clinical sleep health educator, tells Sleepopolis. (14) This is a first step in changing how you think about and approach sleep, she notes, and once you get the “why” behind good sleep habits, you’re more likely to stick with them. (17)

Then, using CBT for insomnia, your therapist will help you hit the “reset” button on your sleep patterns and behaviors. (14) Let’s face it: dealing with insomnia for a long time can make sleep feel like an enemy. With CBT-I, your goal is to fix your relationship with sleep by changing how you think about it. (14)

CBT-I also helps you see sleep more realistically, Dimitriu tells Sleepopolis. For instance, it might help you realize that one bad night’s sleep won’t ruin your entire day, even if it feels like it might, he says — the idea is to take the pressure off sleep. When you’re not putting tons of pressure on yourself to fall asleep, your body can relax. (11) And when you’re relaxed, your body can do what it naturally wants to do: fall asleep. (14)

Other actionable solutions you might apply through CBT-I extend to how you think about sleep and your sleeping environment. You might work on challenging those middle-of-the-night worries, make your bed a sleep- and sex-only zone, and find personalized relaxation techniques, Dimitriu says. (11) A typical CBT-I program runs for six to eight sessions, each lasting 30 to 90 minutes, and you’ll meet with your therapist once or twice a week. (14)

How Effective Is CBT-I? 

CBT-I helps about 70 to 80 percent of people with insomnia improve their sleep. (5) But, as Bahrenfuss points out, “These numbers can vary greatly depending on the effort put forth by each individual.” In other words, CBT-I isn’t a quick fix. It takes time and commitment. You’ll need to put in the work to make the adjustments needed and apply the skills you learn for the treatment to be effective. (16) 

How does CBT-I compare to other insomnia treatments? Quite well, actually. Research shows it works as well as sleep medications in the short term, which is about the first month or two. (5) Many experts, including Harris, believe CBT-I might even be more effective than sleep medications in the long run, three months or more down the road. (5) Plus, medications used for insomnia can have side effects, Harris adds. This may help explain why well-respected organizations recommend CBT-I as a first choice for treating chronic insomnia. (17)(18)

If you’re looking for how this might apply to you, research shows CBT-I can cut the time it takes you to fall asleep and the time spent awake during the night by about half. (5) This means if you usually spend an hour tossing and turning, CBT-I might reduce that to 30 minutes. However, CBT-I doesn’t always lead to a big increase in total sleep time, with most people getting less than 30 extra minutes of shut-eye. (5) Why? Well, part of CBT-I involves limiting your time in bed at first, which can make it harder to squeeze in more sleep. Plus, according to the researchers, it can be tricky to measure exact sleep time. (5) 

And CBT-I seems to work a bit differently depending on your age. If you’re 55 and over, you might notice smaller changes in your sleep, but for those under 55, CBT-I often makes a bigger impact. (5) Either way, it can be a helpful sleep boost! 

Who Provides CBT-I? 

Several types of professionals are qualified to help you out, including clinical psychologists, psychiatrists, licensed therapists, and sleep specialists.

To find a qualified CBT-I provider, start with directories from reputable groups like the Society of Behavioral Sleep Medicine (SBSM), the Association for Behavioral and Cognitive Therapies (ABCT), or The International Directory of CBT-I Providers. You can also check for facilities accredited by the American Academy of Sleep Medicine (AASM). 

Though these directories can be helpful, it’s worth noting that there’s a shortage of trained CBT-I providers. (4)(5)  So, if you’re looking for a non-physician CBT-I professional, make sure to ask if they’re specifically trained in CBT-I, Bahrenfuss notes.

As for where you can get CBT-I, you can visit a private practice, sleep clinic, or opt for telehealth sessions from home. Group formats are also available. (17)

And yep, there’s an app for that, too! Digital CBT-I (dCBT-I) programs and apps like Go! to sleep and Sleepio have become popular recently. There’s also CBT-I Coach, an app created by the Department of Veterans Affairs to help veterans and others with insomnia. dCBT-I is a growing trend that’s making CBT-I more accessible than ever. (19)(20) Even the AASM supports dCBT-I as a good alternative when in-person options aren’t available. (18) 

Key Components of CBT-I 

A trained CBT-I professional combines several components of the treatment to help reshape your sleep habits. Here’s what you might expect: (4)(14) 

Sleep Restriction Therapy (SRT)

Don’t let the name scare you. According to Bahrenfuss, sleep restriction therapy is not as bad as it sounds and is usually very temporary. 

The idea is simple: limit your time in bed to match the amount of time you’re actually sleeping. If you’re spending hours awake in bed, you might be unintentionally teaching your brain to associate bed with being awake, not asleep. (21)

Here’s how SRT works: Let’s say you normally spend eight hours in bed but only sleep for six. SRT would have you cut your bedtime down to six hours. You would go to bed later at night and wake up at the same time each morning. That way, by the time you go to bed, you’re a bit more tired. As a result, your sleep drive (your body’s natural urge to sleep) increases, and you’re more likely to fall asleep faster and stay asleep longer. (21)

Over time, SRT helps get your sleep-wake cycle back on track. As your sleep improves, you gradually increase your time in bed. But this should only be done under medical supervision, Dimitriu says, and you should never reduce your sleep time to less than five and a half hours. (22)

Still, SRT is just one part of CBT-I. It works best when combined with other techniques, which we’ll cover next.

Stimulus Control Therapy (SCT)

A stimulus is anything that triggers a response in your body or mind. For example, the smell of coffee might make you feel more alert, or the sound of rain might make you feel relaxed. Stimulus control means managing these triggers to get the response you want. (23)

In the case of insomnia, stimulus control therapy (SCT) is about making your bed a trigger for sleepiness, not stress or wakefulness. You do this by setting ground rules for your bedroom, and the goal is to create a strong association between your bed and sleep so your brain thinks it’s sleep time as soon as you hit the sheets. (14)(24)

These ground rules might look like: (14)(25)

• Using your bed only for sleep and sex. No working, eating, or binge-watching your favorite show.
• Getting up and doing something relaxing in another room if you can’t fall asleep after about 20 minutes. Only return to bed when you’re sleepy.
• No clock-watching — turn that alarm clock away from you.
• Keeping a consistent sleep schedule, even on weekends.

With SCT, “laying in bed and stressing out or staring at the clock is not allowed. Neither are emails in the middle of the night or phones,” says Dimitriu. 

Cognitive Therapy

We all have worries that can spiral into negative thoughts about sleep. This is especially true if you’ve been dealing with chronic insomnia. (7) You know, those times when you’re lying awake, convinced that sleep will never come and the next day will be ruined? Cognitive therapy can help with that. (26) It teaches you how to become aware of these thoughts and replace them with more realistic ones.

Here’s what this involves: (12)

1. First, you and your therapist work to find out what negative thoughts or worries you have about sleep. 
2. Next, you look at these thoughts and see if they’re accurate. Are they based on facts, or are they just exaggerated fears?
3. Then, you replace those negative thoughts with more realistic and helpful ones. For example, you might remind yourself, “I can still function well even if I don’t sleep perfectly tonight.”

Sleep Hygiene 

No, we’re not talking about brushing your teeth before bed, though that’s not a bad idea. Sleep hygiene involves creating the right environment and habits for a good night’s rest. (27) Think of it as insomnia self-care practices that work hand in hand with the other parts of CBT-I. 

And don’t think of sleep hygiene as just a pre-bedtime thing. (28) It also involves lifestyle changes to help set yourself up for better sleep, such as: (29)(30)

• Keep a consistent sleep schedule, even on weekends.
• Create a relaxing bedtime routine to wind down. (31)
• Make sure your bedroom is sleep-friendly: dark (blackout curtains are great to help block out light), quiet, and cool.
• Think about where you sleep. The best mattress and pillows can turn tossing and turning into sweet dreams.
• Give your gadgets a bedtime, too. Those blue-light-emitting screens can trick your brain into thinking it’s daytime, so try to unplug an hour or two before bed. (32)
• Watch what you eat and drink: avoid large meals, caffeine, and alcohol close to bedtime.
• Skip the naps, especially in the late afternoon or evening. (33)

Relaxation Techniques

You won’t instantly feel sleepy, but these techniques help relax your body and mind so sleep can come more naturally. “If the body and mind are still very tense and active from the day, sleep can feel forever away,” Bahrenfuss says. 

Here’s a quick look at some go-to relaxation methods:

• Progressive muscle relaxation (PMR): Tense and then relax each muscle group to help your body unwind. (34)(35)
• Breathing techniques: Slow, deep breaths can calm your mind, reduce stress, and reduce your heart rate to make it easier to drift off. (36) Some people find gentle yoga or stretching paired with breathing especially helpful.
• Biofeedback: This method uses technology and sensors to track your body’s physical responses to stress. The idea is to help you identify and manage physical tension throughout the day and at bedtime for better relaxation. But more research is needed to confirm how well it works for insomnia. (37)
• Hypnosis: It might sound a bit out there, but it may help calm your mind and make it easier to fall asleep. (38)(39) Still, we need more research to fully understand hypnosis’ effectiveness on insomnia.
• Meditation: Meditation helps you focus on the now — not on tomorrow’s to-do list or yesterday’s call with your boss — to create a calmer mindset for better sleep. (40) 

Not every relaxation technique will be your cup of tea. That’s okay! Give each method a fair shot, and keep at it. You’ll likely find your sleep zen.

Other Treatments For Insomnia 

CBT-I is a first-line treatment for insomnia and can be a powerful long-term tool, but there are other options. Your healthcare provider might recommend other approaches based on your situation. These include:

• Medications: Prescription sleeping pills, like zolpidem (Ambien) or over-the-counter medication like diphenhydramine (Benadryl) can give short-term help for insomnia, but they can come with side effects. (41)
• Supplements: Natural supplements can help regulate your sleep-wake cycle, with melatonin being a popular choice for short-term use. (42) However, finding the best melatonin supplement can take some trial and error.
• Stress reduction: These include mindfulness, regular exercise, or whatever else helps you manage stress that contributes to insomnia. (43)(44)
• Bright light therapy: This helps you start your day with bright light exposure to help reset your internal clock and improve your sleep patterns. (45)
• Acupuncture: Acupuncture is a traditional Chinese medicine practice that may help some people dealing with insomnia, though more research is needed to fully understand its impact on sleep. (46)

FAQs

The Last Word From Sleepopolis 

CBT-I helps you change how you think about sleep, tweak your bedtime habits, and learn cool strategies to help you sleep better. What’s more, research shows CBT-I works as well as sleep medications in the short term and even better in the long run. Its different components, like sleep restriction and stimulus control, help reset your sleep patterns. Along with cognitive therapy and good sleep hygiene, CBT-I can help you beat insomnia and get better rest.

If you think you have insomnia, make an appointment with your healthcare provider to discuss treatment options and find the right approach for you. 

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