You might have heard of cognitive behavioral therapy, or CBT, a popular and well-researched type of psychotherapy. But did you know it can help people with sleep issues?
CBT-I, a form of CBT, is a successful treatment for insomnia. It involves actions like changing what you do when you can’t sleep and reframing anxious thoughts related to sleep. The distinctive difference between CBT and CBT-I is the inclusion of the principles and practice of sleep medicine, explains Michael Perlis, director of the Behavioral Sleep Medicine Program at the University of Pennsylvania.
For the past 15 years, Perlis and Donn Posner have taught care providers how to deliver cognitive behavioral therapy for insomnia, or CBT-I. Their course used to “get something like 25 to 40 people”, says Posner, an adjunct clinical associate professor at the Stanford University School of Medicine and president of Sleepwell Consultants. This year, 435 people have expressed interest in taking it.
Data supporting the effectiveness of CBT-I has been around for about 30 years, Posner explains, but only now is it finally “starting to come onto the radar”.
An increasing number of people are worried about their shut-eye but turn to habits that don’t help their sleep in the long run, such as melatonin and sleeping in. In reality, easy fixes are often not the best for getting back into the flow of good sleep – and the foundations of CBT-I can help explain why.
When does sleep become a problem?
Poor sleep is quite common. According to a 2024 Gallup poll, 57% of US adults said they would feel better if they slept more.
About one-third of adults experience acute insomnia, which can last a few days or weeks. And roughly one in 10 suffer from chronic insomnia, defined as happening more than three nights a week for at least three months.
Acute insomnia is almost always the result of some stressor, explains Posner, though not always a negative one. You might have a cold or jet lag; you might be excited for an upcoming event. If the stressor goes away, insomnia is likely to follow suit.
But if insomnia becomes chronic, it can persist even if the stressor has gone away, Posner says. This is because other factors, like going to bed early to make up for sleep loss or worrying about insufficient sleep, can perpetuate insomnia.
Insomnia is linked to a host of issues spanning mental and physical health. These include fatigue, decreased quality of life and an increased risk for disease.
What is CBT-I?
CBT-I targets difficulties related to initiating and maintaining sleep. It combines cognitive therapy, behavioral interventions and educational interventions.
Its core components are Sleep Restriction Therapy (SRT) and Stimulus Control Therapy (SCT). A provider typically teaches these elements and the individual then practices at home.
SRT might sound intimidating, but it’s more about cutting down time in bed while awake than restricting sleep time. Eventually, this leads to improved sleep efficiency.
SCT is intended to strengthen the link between sleep cues – like the bed, bedroom and bedtime – and falling asleep easily and sleeping well. This can look like avoiding any behavior in the bedroom that isn’t sleep or sex and only lying in the bed when you’re sleepy.
There are also two supplemental elements: sleep hygiene and cognitive therapy. Sleep hygiene promotes healthy habits that support sleep, like avoiding alcohol before bed. The cognitive element is about adjusting or reframing unhelpful behaviors and ways of thinking, for example, thoughts like “I can’t fall asleep without a sleeping pill” or “I am afraid of having another sleepless night.”
CBT-I is typically delivered over five to eight sessions, which can last 30 to 90 minutes. However, the length of treatment depends on how adherent a patient is, Posner explains. He compares it to physical therapy: if you do all the assigned exercises, you will likely graduate from treatment sooner.
Who can CBT-I help?
Data from multiple controlled clinical trials suggests that 70% to 80% of people with chronic insomnia who try CBT-I end up with improved sleep. Research also suggests these gains last.
In the early 2000s, research turned to how well CBT-I can help with secondary insomnia – insomnia that arises from a primary event, like a medical illness or mental disorder – says Perlis.
Originally, researchers assumed that treating the primary condition would stop the insomnia too. However, now it’s increasingly understood that even if other conditions improve, chronic insomnia generally doesn’t stop if left untreated.
Studies show that CBT-I is a promising treatment for insomnia that’s co-morbid with other conditions, like chronic pain and anxiety. Further, there are “halo effects”, explains Perlis. For example, when treating insomnia co-morbid with depression, the depression tends to improve.
It’s also possible that CBT-I may benefit people with daytime fatigue and sleepiness and people with poor sleep who don’t have chronic insomnia yet.
Principles of CBT-I can also help people who generally need help with sleep. For example, Perlis says getting out of bed is better than tossing and turning for hours. During this time, you should do something enjoyable, like reading a book and only return to bed when sleepy.
“Yes, you may lose a bit of sleep, but this will assist with getting over the transient insomnia and reduce your sense of dread when awake at night,” he says.
How does CBT-I compare to other insomnia treatments?
CBT-I is a highly regarded treatment. It’s recommended by the American College of Physicians (ACP) and the US Department of Veteran’s Affairs as the first-line therapy for chronic insomnia.
Experts often encourage people with insomnia to adopt habits like getting enough physical activity during the day, which some research suggests is comparable to CBT-I when it comes to long-term effectiveness. Doctors also might prescribe medications: according to the CDC, in 2020, roughly 10% of adults had taken sleep medication in the last 30 days.
Perlis co-authored a 2012 review of five studies comparing CBT-I with prescription and non-prescription medications, which concluded that CBT-I is as effective as medications for treating insomnia and its effects possibly more durable. It also doesn’t come with the side effects linked to some sleep medications, like impaired memory and nausea, linked to some sleep medications.
Perlis and the other authors identified two main disadvantages to CBT-I. First, people with chronic insomnia might not see improvements until a few weeks into treatment, and second, at the start of the therapy, the process might cause some to feel more tired. These hurdles can cause some to drop out of treatment prematurely. Accordingly, CBT-I is underutilized partly because some people stop too soon. There’s also a lack of qualified providers, which makes it easy to turn to medications or other drugs like melatonin first.
“There are not enough of us who know how to really do this therapy well to meet the need because the need is epidemic,” says Posner. “But it is getting better.”
How to get CBT-I therapy for insomnia?
You should speak with a medical professional if you’re concerned about your sleep. Posner says that often, people seek help after suffering from insomnia for too long.
According to Perlis, about 1,000 people worldwide are knowledgeable CBT-I providers. You can search for one via the University of Pennsylvania International CBT-I Provider Directory.
When evaluating whether or not to work with a therapist claiming to deliver CBT-I, Perlis says: “If they say the core approach for the treatment of insomnia is either relaxation or sleep hygiene, patients might want to look a little further.” Proper CBT-I requires SRT and SCT.
How you receive CBT-I also matters. While research suggests that learning about CBT-I through something like a self-help book can be beneficial, face-to-face interventions have the greatest evidence of good results. This could mean meeting in person or, some early research indicates, through video-based tele-health.
The American Academy of Sleep Medicine recommends that people who can’t access CBT-I delivered by a therapist try it through an app while they wait for an appointment. For example, the US Department of Veterans Affairs created a free app.
“The data is quite clear that those types of things [apps] are a nice start, but they’re not as good as face-to-face therapy,” says Posner.
