What Is Cognitive-Behavioral Therapy for Insomnia (CBT-i)?

Cognitive-behavioral therapy for insomnia (CBT-i) is a type of short-term therapy model that specifically addresses chronic insomnia. Patients are treated over the course of about 6 to 8 weeks.

It is considered the most effective non-medical intervention to manage insomnia. The American College of Physicians (ACP) considers CBT-i as the first line of defense against insomnia and recommends that it be tried before medication.

The therapy has five main components:

1. Consolidation of sleep
2. Stimulus control
3. Utilization of relaxation techniques
4. Sleep hygiene instruction
5. Cognitive therapy

Techniques of Cognitive-Behavioral Therapy for Insomnia (CBT-i)

The goal of CBT-i is to help you make positive lifestyle changes and to change your mindset about falling asleep. To that end, CBT-i focuses on five main components. Your therapist will walk you through these and help you implement them.

Let’s take a deeper look at the five techniques used to CBT-i:

Consolidation of Sleep (Sleep Restriction)

If you’ve ever experienced insomnia, you know that a lot of your night is spent in bed, not sleeping. The sleep restriction facet of CBT-i limits the amount of time you can spend in bed, tossing and turning.

As your insomnia resolves, you would increase that time, of course, and get more sleep. But the idea is to restrict the amount of time you spend in bed struggling with sleep.

Stimulus Control

Stimulus control involves restricting what you are allowed to do in bed. Usually, this means that you are only allowed to sleep or have sex in your bed.

Relaxation Techniques

Your therapist will teach you relaxation techniques to relax your body and mind so you can more easily go to sleep. These might include deep breathing techniques, progressive muscle relaxation, and mental focusing/imagery meditation techniques.

Sleep Hygiene

Sleep hygiene involves the everyday practices that train your body to fall asleep more easily. These techniques may include:

• Having a set bedtime and wake time and sticking to these, even on weekends
• Avoiding caffeine after the morning hours
• Avoiding alcohol in the evening
• Refraining from nighttime snacking
• Getting regular exercise during the day
• Dimming the lights an hour or so before bedtime
• Avoiding screens an hour or two before bedtime

Cognitive Therapy

Many of the therapy techniques used in CBT-i are based on the theories of cognitive behavioral therapy (CBT), which teaches patients to become more aware of their thoughts and how these thoughts affect their feelings and behavior. As such, your therapist may have you consider your negative thoughts surrounding sleep and try to change them to more positive or neutral ones.

So, thoughts like “I will never get to sleep,” or “I’m going to have a horrible day tomorrow because I can’t fall asleep,” may be changed to thoughts like, “I can trust my body to fall asleep when it’s ready” and “Even if I don’t get much sleep, I will be okay tomorrow.”

What Cognitive-Behavioral Therapy for Insomnia (CBT-i) Can Help With

CBT-i is specifically meant to address insomnia, a disorder affecting approximately 6% and 10% of adults. Insomnia is defined as the inability to fall asleep or stay asleep.

Insomnia can affect all aspects of a person’s life and lead to sleep deprivation, decreased productivity at work, emotional disturbances, and cognitive deficits.

The official term for insomnia is “chronic insomnia disorder,” a psychiatric condition recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 TR).

Benefits of Cognitive-Behavioral Therapy for Insomnia (CBT-i)

The main benefit of CBT-i is that it can help relieve your insomnia.

CBT-i Can Be as Effective as Medication

Some studies have found that CBT-i is just as effective as sleep medication to help you sleep but without the negative side effects of common sleep medications.

Additionally, CBT-i doesn’t just put a Band-Aid on the problem: it helps you learn to overcome your insomnia and offers longer-lasting results than medication.

CBT-i Can Address Other Issues That Accompany Insomnia

In addition to insomnia, CBT-i can address some of the co-morbidities that accompany insomnia. According to the American Psychological Association (APA), CBT-i can treat some of the mood disturbances caused by insomnia. For example, it can decrease symptoms of depression as well as symptoms of suicidal ideation.

Effectiveness

Again, the American College of Physicians (ACP) considers CBT-i the first treatment that should be considered when a patient presents with insomnia. This is based on the fact that there is evidence supporting CBT-i as an effective technique for managing insomnia.

Here’s what the research says:

• A 2015 systematic review and meta-analysis published in Annals of Internal Medicine found that CBT-i is an effective treatment for adults who live with insomnia. Effectiveness was sustained over time and there were no adverse effects of treatment.
• A randomized control trial published in a 2015 issue of Sleep found that even a “single shot” of CBT-i had benefits. In the study, patients were given one session of CBT-i, along with an informational pamphlet. Even this one session was effective for between 50% and 60% of patients. The study research suggests that one more “booster” session could make it even more effective.
• A systematic review and meta-analysis from 2022, published in Sleep Medicine Reviews found that CBT-i had a positive effect on decreasing insomnia for patients. However, according to the study researchers, the effect was modest, not strong. Furthermore, they found no evidence that digital (apps and websites) CBT-i was effective. The study researchers contend that more research needs to be done to fully understand the effectiveness of CBT-i.
  

Things to Consider

Overall, CBT-i is considered an effective, low-risk way to manage insomnia. Unlike using sleep medications to combat insomnia, there are no negative side effects of the treatment and often, people experience more long-term positive effects.

Therapists Trained in CBT-i Remain Limited

According to the APA, one pitfall to CBT-i is that the number of therapists who are trained in the technique is limited, so it can be difficult to find treatment. However, with the increased access to online therapy, it may be becoming easier to find a CBT-i trained therapist who is accessible to you.

You Might Experience Increased Sleep Deprivation at the Beginning

As the American Academy of Sleep Medicine (AASM) points out, some possible negatives of the treatment are that at first, you might experience an increase in sleep deprivation. This is likely because of the “sleep restriction” element of the treatment, where the hours you are allowed to remain in bed are limited. This is temporary and should resolve quickly.

It Takes Time to See Results

The other challenge is that many people might expect a “quick fix,” but CBT-i can take time and effort. This may frustrate some people who feel desperate for results. Again, treatment usually lasts about 6 to 8 weeks so patience can go a long way.

How to Get Started

If you are interested in trying CBT-i, your first task will be to find a therapist who is trained in this technique. As the APA points out, it can be challenging to find someone because there isn’t an abundance of trained CBT-i therapists at this time.

Thankfully, with the emergence of telehealth, you may be able to find a therapist who will do a video call with you, even if there isn’t a therapist available to see you locally.

If you are searching for a CBT-i trained therapist, consider the following sources:

• Worldwide CBT-i Directory from The University of Pennsylvania
• Society of Behavioral Sleep Medicine
• American Board of Sleep Medicine

Although there is limited research regarding the effectiveness of digital CBT-i, several apps and online programs are available. For example, the U.S. Department of Veteran Affairs created the CBT-i Coach app, which can be used in conjunction with therapy to help you manage your insomnia. It can be used alone, though that’s not its intended purpose.

What to Expect in CBT-I Therapy

All CBT-i therapy experiences will be a little different, but your therapist will likely spend some time getting to know you. They will try to understand what is going on when you struggle to sleep. All aspects of your sleep experience will be discussed, including your daily habits, sleep environment, and the types of thoughts you experience surrounding sleep.

After this, your therapist will devise a plan of care based on the five components of CBT-i and your particular needs. As such, ideas for how much time you should spend in bed will be discussed, and what type of sleep hygiene steps to take will be addressed. You will be given ideas for relaxation techniques, and you will likely spend some time discussing your thoughts around sleep and how to reframe them in a more positive light.

If you have further questions about your insomnia, any side effects you are experiencing, or whether CBT-i therapy is the best choice for you, consider reaching out to your physician or a mental health professional.