CBT for insomnia (CBT-I) is a structured, drug-free treatment for long-term sleep problems, and it is the treatment current guidelines recommend first. [edinger-2021-aasm] [riemann-2023-european] In a review of 20 randomised trials, it shortened the time to fall asleep by about 19 minutes and the time awake in the night by about 26 minutes. [trauer-2015-cbti] This guide covers what it involves, what the evidence shows, how to start, and what to watch for. In the US the same treatment is spelled cognitive behavioral therapy for insomnia. Our overview of sleep covers the wider picture.
What is CBT for insomnia?
CBT for insomnia is a short, structured programme that changes the habits and thoughts keeping poor sleep going, usually over several weeks. The programmes in the trials combined at least three of five parts: cognitive therapy, stimulus control, sleep restriction, sleep hygiene and relaxation. [trauer-2015-cbti]
- Stimulus control. Re-linking the bed with sleep: go to bed when sleepy, get out of bed if you are awake and restless, keep a fixed wake time, and keep the bed for sleep.
- Sleep restriction. Limiting time in bed to roughly the time you actually sleep, then widening it as sleep becomes more solid.
- Cognitive work. Questioning beliefs such as “I will be useless tomorrow if I do not sleep tonight”, which keep you alert at night. Our guide to overthinking at night covers the same loop.
- Relaxation. Methods such as slow breathing or muscle relaxation that lower arousal before bed. Our guide to relaxation techniques for sleep covers them.
- Sleep hygiene. Habits around caffeine, alcohol, light, napping and the bedroom.
Those one-line descriptions are our plain-language summaries, and real programmes differ in what they include and how they order it. The American Academy of Sleep Medicine recommends the multicomponent programme and does not suggest sleep hygiene as a single-component treatment, which matches our guide to sleep hygiene. [edinger-2021-aasm]
Does CBT for insomnia work?
On average, yes, and the biggest gains were in how quickly people fell asleep and how long they lay awake. A review of 20 randomised trials with 1,162 adults with chronic insomnia compared face-to-face, multi-part CBT-I with inactive comparators and measured sleep with diaries. After treatment, people fell asleep about 19 minutes sooner and spent about 26 minutes less awake after first falling asleep. [trauer-2015-cbti]
| Measure after treatment | Average change | 95% confidence interval |
|---|---|---|
| Time to fall asleep | 19 minutes shorter | 14 to 24 minutes |
| Time awake after falling asleep | 26 minutes shorter | 15 to 37 minutes |
| Sleep efficiency (share of time in bed spent asleep) | 9.9 percentage points higher | 8.1 to 11.7 |
| Total sleep time | 7.6 minutes longer | -0.5 to 15.7 minutes |
Total sleep time barely moved and the change was not statistically significant, so in these trials CBT-I mostly changed how efficiently people slept rather than adding hours. The changes seemed to be sustained at later time points and no adverse outcomes were reported, although the review said its estimates at later time points were less clear. [trauer-2015-cbti]
Read that with its limits in view. The review included only insomnia that did not coexist with other medical, sleep or psychiatric conditions, and every programme was delivered face to face, so it cannot say how well the same programme works for everyone. [trauer-2015-cbti]
Guidelines point the same way. The American Academy of Sleep Medicine gives multicomponent CBT-I a strong recommendation for adults with chronic insomnia disorder. [edinger-2021-aasm] The 2023 European Insomnia Guideline recommends that people with insomnia, with or without other medical or mental health conditions, are offered CBT-I as the initial treatment. [riemann-2023-european]
Is sleep restriction safe?
It is usually done with guidance because it can make you sleepier at first. In a small uncontrolled study of 16 people with insomnia, a four-week sleep restriction protocol increased daytime sleepiness during the first three weeks and made lapses on a vigilance test more frequent, and both returned to baseline by three months. [kyle-2014-sleep-restriction]
So in the early weeks, avoid driving or other risky tasks when you feel drowsy. If you have bipolar disorder, ask your clinician before cutting your time in bed, because sleep loss is widely regarded as a trigger for manic episodes. Our guide to bipolar disorder and sleep covers why.
How do you start CBT for insomnia?
Ask a doctor or therapist for CBT-I by name, or use a digital programme. The 2023 European guideline says CBT-I may be delivered by a clinician face to face or digitally, preferably with some guidance. [riemann-2023-european] A meta-analysis of 11 randomised trials with 1,460 participants found that internet-delivered CBT-I improved insomnia severity and several sleep measures after treatment. [zachariae-2016-internet]
While you arrange that, here is our practical outline of the two simplest parts. It is not a full programme.
- Keep a sleep diary for two weeks. Note when you went to bed, when you got up, roughly how long you took to fall asleep and how long you were awake. The trials measured sleep with diaries, and a diary shows a therapist where to start.
- Pick a wake time you can keep every day, weekends included.
- Go to bed when you feel sleepy, not just tired.
- If you are awake and restless, get up. Go to another room, keep the light low and do something calm until you feel sleepy. Programmes differ on the exact rule, so follow your therapist’s version if you have one.
- Keep the bed for sleep. No work or scrolling in it.
- Leave sleep restriction until you have guidance, for the reasons above.
A quiet reset out of bed
If you are awake and restless, get up and sit somewhere dim, away from your bed. Do something calm, such as reading a paper book or listening to quiet music, and start the timer so you are not watching the clock.
10:00
Go back to bed when you feel sleepy, not when the timer ends. If you are still wide awake, repeat the reset.
Done. Go back to bed only if you feel sleepy, and keep the same wake time tomorrow.
Is CBT for insomnia right for you?
It is worth asking about if poor sleep is long-lasting and affects your days. Use the checklist below as a prompt for a conversation, and read our guides to why you cannot sleep and waking at 3am if you are still working out what is going on.
Is it worth asking about CBT for insomnia?
Tick anything that is true for you. This is a prompt for a conversation, not a test, and it produces no diagnosis.
0 of 5 ticked
Several of these fit. Ask a doctor or therapist about CBT for insomnia by name, and bring a sleep diary if you have one.
A few of these fit. Try a steady wake time for two weeks and note what changes. If sleep is still poor, ask about CBT-I.
Few of these fit, so this may be an ordinary rough patch. Our sleep hygiene guide covers habits that help, and the insomnia self-assessment can give a clearer picture.
When to seek help
Speak to a doctor if trouble sleeping has lasted several weeks, if it affects your mood, work or safety, or if you snore loudly or stop breathing in your sleep. Other conditions can cause or worsen insomnia, and the trials behind CBT-I left them out, so a clinician’s judgement matters. Do not stop or change sleep medication on your own.
Our insomnia self-assessment is a screener and not a diagnosis, and it can help you decide whether to have that conversation. If you have ADHD, our guide to ADHD and sleep covers what changes.
If you feel unable to keep yourself safe, contact your local emergency services or a crisis helpline.
How MyFreud can help
Whether a steadier wake time is changing your days is hard to judge from memory. Daily mood tracking in MyFreud shows the pattern across weeks, so you can compare how you feel after nights when you kept to your wake time and nights when you did not. It does not replace a sleep diary, a doctor or a therapist.
Download MyFreud and start today: App Store or Google Play.