Cognitive Behavioral Therapy for Insomnia (CBT-I)

Medical Disclaimer: The following content should not be used as medical advice or as a recommendation for any specific supplement or medication. It is important to consult your health care provider prior to starting a new medication or altering your current dosage.

Cognitive behavioral therapy for insomnia (CBT-I) is a treatment for chronic insomnia that addresses the habits and thought patterns that interfere with sleep. CBT-I is often recommended as the initial treatment for chronic insomnia.

Around 10% to 15% of adults in the United States experience chronic insomnia. Chronic insomnia is a sleep disorder in which a person has difficulty falling or staying asleep three or more times each week for at least three months. If left untreated, chronic insomnia can cause daytime sleepiness, mood changes, and increase the risk of other health conditions.

If your doctor has recommended CBT-I, knowing what to expect can help you get the most out of treatment. We’ll help you get familiar with the components of CBT-I, how CBT-I compares to medication, and whether this therapy is right for you.

How Does CBT-I Work?

CBT-I helps to identify and correct the underlying causes of insomnia while establishing more helpful sleep habits. Experts believe that there are a variety of causes of chronic insomnia, which fall into several categories:

  • Predisposing factors: Predisposing factors such as genetics, childhood experiences, and certain health conditions can increase your risk of developing chronic insomnia.
  • Precipitating factors: Precipitating factors like a stressful or traumatic event, an illness, or an injury may trigger sleep issues.
  • Perpetuating factors: Perpetuating factors are behaviors or ideas that make it more difficult to sleep, like watching television in bed, napping excessively, or staying in bed too long after having trouble falling asleep.
  • Conditioned arousal: Conditioned arousal occurs when your bed or bedroom is no longer associated with sleep and is instead associated with anxiety and sleep difficulties.

CBT-I addresses both the perpetuating factors and conditioned arousal that contribute to chronic insomnia. CBT-I uses a combination of cognitive and behavioral interventions to address the way you think about sleep as well as your actions and habits around bedtime.

Treatment often involves working directly with a mental health professional. CBT-I can be administered by psychiatrists, psychiatric nurse practitioners, therapists, or nurses. In addition to one-on-one talk therapy, group, telephone, and online CBT-I formats can be effective.

Cognitive Interventions

Cognitive aspects of CBT-I include sleep education, cognitive therapy, and relaxation training.

Sleep education is often the first step in CBT-I treatment. Sleep education involves learning about the causes of insomnia and how sleep works. Topics may include your circadian rhythm and your body’s sleep drive, which is the need for sleep that builds throughout the day.

Cognitive therapy is an aspect of CBT-I that helps you identify and confront unhelpful thoughts that contribute to sleep issues. A provider can help you combat anxiety triggered by sleep problems and discover beliefs about sleep that may be keeping you up at night.

CBT-I also helps you learn, practice, and employ relaxation techniques that can be used at bedtime. Exercises such as progressive muscle relaxation, controlled breathing, and mindfulness meditation can help you unwind and prepare your mind and body for sleep.

Behavioral Changes

Behavioral components of CBT-I aim to eliminate poor sleep habits and encourage healthy behaviors that promote quality sleep. This includes improving sleep hygiene, sleep restriction therapy, sleep compression, and stimulus control therapy.

Improvements in sleep hygiene help you develop healthy behaviors and habits that promote sleep. Examples of sleep hygiene practices include:

  • Keeping your bedroom cool and quiet
  • Avoiding caffeine and alcohol later in the day
  • Maintaining a regular sleep schedule

Sleep restriction therapy helps cut down on the time spent awake in bed. Many people with chronic insomnia try to reduce their symptoms by spending an excessive amount of time in bed. Unfortunately, this can perpetuate insomnia by making it more difficult to fall asleep the following night.

Sleep restriction therapy usually begins with keeping a diary of your sleep habits for one to two weeks to get a better understanding of your sleep patterns. Then, with the help of your therapist, you choose a sleep schedule that determines when to get in and out of bed every day.

By limiting time spent in bed and daytime napping, you should begin to feel more tired at the end of the day and fall asleep more easily as the therapy progresses.

At first, sleep restriction therapy can make a person feel more tired during the day. An alternative option for people who may be sensitive to temporary sleep loss is sleep compression. Sleep compression is similar to sleep restriction therapy, but reduces the time spent in bed more gently.

Stimulus control therapy is another technique that can help you fall asleep faster once you get into bed. The goal is to only get into bed when you feel ready for sleep. This helps to rebuild the association between lying in bed and falling asleep. Tactics for stimulus control therapy include:

  • Only going to bed when you feel sleepy
  • Only using your bed and bedroom for sleep and sex
  • Getting up if you can’t fall asleep and returning a bit later when you feel tired
  • Getting up at the same time every morning
  • Avoiding daytime naps

Does CBT-I Work?

Research shows that CBT-I is an effective treatment for chronic insomnia. CBT-I can also work well for people experiencing insomnia who have other health issues. Insomnia symptoms usually improve slowly as the therapy progresses over several weeks, with improvements often persisting even after treatment ends.

Most research has focused on CBT-I provided through one-on-one, in-person therapy sessions Other delivery methods have been found to have promising results, including video sessions, telephone sessions, group therapy, and web-based therapy.

How Does CBT-I Compare to Medication?

CBT-I is more effective for treating insomnia than medication alone. Both short- and long-term studies have shown that CBT-I is equally effective with or without medication. Many professional organizations recommend starting with only CBT-I because it helps people develop healthy sleep habits and avoid potential side effects of medications.

CBT-I is widely accepted as the first-line treatment for chronic insomnia. However, not everyone responds to CBT-I. In these cases, medication can be added to further improve symptoms.

Is CBT-I Right For You?

Most people diagnosed with chronic insomnia are good candidates for CBT-I. Cognitive behavioral therapy for insomnia is also a good choice for those who want to avoid medications and for people with other mental or physical health conditions.

Risks of CBT-I

While CBT-I is a safe treatment for chronic insomnia, certain groups of people may be at a higher risk for unwanted side effects. The initial stages of sleep restriction therapy can result in temporary sleep loss. Some people are more sensitive to sleep loss and, as a result, are more likely to have an adverse reaction. This includes:

  • People with seizure disorders
  • People with untreated bipolar disorder
  • Anyone recovering from an injury, surgery, or illness
  • People already experiencing excessive daytime sleepiness
  • People facing occupational safety risks such as transportation workers

People starting CBT-I should discuss any concerns or pre-existing health conditions with their healthcare team. The therapist or provider can adapt the treatment plan to accommodate a person’s individual needs.

For some people, starting CBT-I treatment can cause anxiety. It may be uncomfortable for people who have never tried therapy, but many people find it helpful to remember that they will be working with a trained professional.

When to Talk to a Doctor

It’s normal to experience occasional, temporary sleep disruptions, but when sleep loss begins to affect your day-to-day life, it’s time to talk to a doctor. Your doctor can give you a comprehensive evaluation and provide a diagnosis or refer you to a sleep specialist if needed.

People experiencing insomnia struggle to fall asleep and stay asleep at night. These symptoms are common in adults. When left untreated, insomnia may become chronic and contribute to an increased risk of health consequences.

In addition to talking to your doctor about finding a CBT-I provider, professional organizations like the Society of Behavioral Sleep Medicine can help you find nearby sleep specialists experienced in providing CBT-I. Psychology Today also has a helpful online therapist directory that allows you to search for insomnia specialists in your area.

CBT-I Online

Online CBT-I is an option for people who don’t have access to an in-person therapist or feel more comfortable using online tools. Online alternatives include telemedicine-based CBT-I and self-guided online programs.

Telemedicine involves using your phone or video chat to communicate with your healthcare provider. This allows you to receive one-on-one CBT-I treatment even if you live in an area that lacks trained specialists.

Another option is self-guided CBT-I in the form of online programs or smartphone apps. These programs allow you to access CBT-I tools through your smartphone, tablet, or computer. Examples of self-guided programs include the SHUTi program and the Sleep Ninja app.

Frequently Asked Questions about CBT-I

CBT-I is a short treatment, usually lasting four to eight sessions over a six- to eight-week period.

CBT-I is usually provided by a trained professional that can help you work through the multiple treatment strategies. Fortunately, there are other options if you lack access to or aren’t comfortable with one-on-one, in-person therapy.

Group therapy, telemedicine-based CBT-I, and online-based sessions are all effective ways to receive CBT-I. There are also apps that can give you access to CBT-I through your smartphone or another device. However, you’ll need to be self-motivated to make sure you revisit the app and complete the therapy program on your own.

Alternative insomnia treatments include medication and brief behavioral treatment for insomnia (BBT-I). But CBT-I is the first-line treatment for chronic insomnia because it’s one of the most effective treatments available.

However, CBT-I may not work for everyone. For people who don’t respond to CBT-I alone, their healthcare provider may recommend combining CBT-I with medication.

Brief behavioral treatment for insomnia (BBT-I) is a shorter program of behavioral therapy that doesn’t have the cognitive portion of CBT-I. While there’s not as much evidence to support BBT-I, it may be a good choice for people who lack access to CBT-I or want a shorter program.