CBT for Insomnia (CBT-I): How It Works

What is CBT-I?

Cognitive behavioural therapy for insomnia (CBT-I) is a structured treatment that targets the habits, timing and thoughts that keep insomnia going. It’s different from general talking therapy. It usually runs over four to eight sessions with a psychologist or trained clinician, or through a structured online programme.

The American College of Physicians and the European Insomnia Guideline both recommend CBT-I as the first treatment for chronic insomnia in adults.

The main parts of CBT-I

Sleep restriction

This sounds backwards, but it’s one of the most effective parts. You limit your time in bed to roughly the amount you’re actually sleeping, with a fixed wake-up time. This builds sleep pressure, so sleep becomes deeper and more consolidated. As sleep improves, time in bed is gradually extended. It can make you sleepier in the first couple of weeks, so it’s best done with guidance, and isn’t suitable for everyone, such as people with some medical conditions or jobs where sleepiness is dangerous.

Stimulus control

This retrains your brain to link bed with sleep rather than lying awake:

• go to bed only when sleepy
• if you can’t sleep after about 20 minutes, get up and do something calm in dim light, and return when sleepy
• use the bed only for sleep and sex
• get up at the same time every day
• avoid daytime naps

Cognitive therapy

Working on worries and beliefs about sleep, such as “if I don’t get eight hours, tomorrow will be a disaster”, that increase arousal at night.

Relaxation

Techniques such as progressive muscle relaxation and breathing to reduce physical arousal.

Sleep education

How sleep works, and habits that support it.

How well does it work?

A meta-analysis in Annals of Internal Medicine found that CBT-I helped people fall asleep about 19 minutes faster and spend about 26 minutes less awake during the night, with improvements lasting after treatment ended. Unlike sleeping tablets, the benefits tend to persist.

Accessing CBT-I in Australia

• Psychologists: a GP can refer you, and a mental health treatment plan can give eligible people access to Medicare-subsidised sessions.
• Online programmes: structured digital CBT-I programmes, such as those offered by THIS WAY UP, can be done at home.
• Sleep clinics: for complex sleep problems, a GP can refer you to a sleep physician.

Is CBT-I right for me?

It suits most adults with chronic insomnia, including people with pain, anxiety or depression. A GP can check for other sleep problems, such as sleep apnoea, first.

References

1. Trauer JM, Qian MY, Doyle JS, et al. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(3):191-204.
2. Qaseem A, Kansagara D, Forciea MA, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125-33.
3. Riemann D, Espie CA, Altena E, et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res. 2023;32(6):e14035.
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262.
5. THIS WAY UP (St Vincent’s Hospital Sydney). THIS WAY UP online programs.