How Cognitive Behavioral Therapy for Insomnia (CBT-I) Works

Cognitive behavioral therapy for insomnia (CBT-I) is used to treat difficulty falling or staying asleep, the defining characteristics of insomnia. In fact, CBT-I is recommended as the first-line treatment for chronic insomnia, before using sleeping pills or other medication.

What is CBT-I? Learn about this behavioral treatment and why it may be just the thing to help you get the rest that you need and help you to avoid the use of sleeping pills.

What IS CBT-I?

Cognitive behavioral therapy for insomnia (CBT-I) is a treatment program that can help people who have difficulty falling asleep, staying asleep, or find that sleep is unrefreshing. It offers benefits in dealing with chronic insomnia, defined as three episodes of sleep difficulty per week for three months without another cause.

CBT-I relies on the basic psychotherapy principles of CBT while designing the techniques specifically for insomnia. A number of studies have shown CBT-I to be safe and effective in treating insomnia. A 2024 review of studies involved more than 31,000 people who received CBT-I for an average of six weeks.

Benefits of improved sleep quality associated with specific CBT-I interventions included:

• Cognitive restructuring techniques (new patterns and behaviors centered on sleep)
• Third-wave therapy components (mindfulness, acceptance, and commitment practices)
• Stimulus control training (behavioral changes surrounding sleep, like napping)
• Sleep restriction practices (limiting time in bed)

There's some evidence that in-person therapy sessions that center on a combination of these techniques offer the best chance of success when compared with online or tech-assisted care. However, online CBT-I programs also appear to offer benefits when used with sleep diaries, sleep hygiene education, and other elements.

The Components of CBT-I

The interventions used in CBT-I therapies can vary in how they're used and the results they deliver. Most people engaged in CBT-I sessions will learn about circadian rhythm and other sleep-related information to better understand insomnia and other sleep disorders.

Information alone doesn't necessarily improve their sleep quality, though. Specific techniques of CBT-I are used to help people limit their insomnia episodes.

Sleep Hygiene

Part of how well you can sleep depends on lifestyle choices you make and the environment in which you sleep. These factors are sometimes evaluated with the Sleep Hygiene Practice Scale, in a series of 30 questions about your sleep habits.

Sleep hygiene factors can include:

• How your schedule helps (or limits) your ability to get enough sleep (seven hours for most adults)
• Screen time (phones, computers) in the hours before you try to sleep
• Your diet, and how you eat and drink before bedtime
• Whether exercise is a part of a healthy lifestyle to boost sleep success
• How light, temperature, and other environmental factors affect your sleep

CBT-I therapy typically includes education about healthy sleep habits. However, there's a lack of evidence to show that it improves insomnia as much as other CBT-I interventions.

Sleep Restriction

Sleep restriction, sometimes called sleep consolidation, is a technique used to limit the amount of time a person spends in bed so that it matches the target amount of sleep desired.

With CBT-I, you're taught skills to achieve this goal. Time in bed is restricted to the average sleep duration plus 30 minutes, and then it is increased or decreased depending on sleep efficiency (the amount of time you're actually asleep compared with being in bed).

Some studies have shown that sleep restriction improves sleep quality and limits how often you wake up after falling asleep. Researchers continue to assess how promising sleep restriction techniques might be used without including other components of CBT-I.

Stimulus Control

Stimulus control is a behavioral intervention used to retrain people to use their beds for sleep and sex only. This CBT-I intervention encourages people to:

• Get up and out of bed at the same time each day
• Avoid daytime naps
• Go to bed only when sleepy
• Get out of bed if they find they can't sleep

With stimulus control, people no longer eat in bed, scroll on the phone, read, or engage in any other activity that isn't sleep, except for sex. It's been associated with improved sleep efficiency and sleep latency (how long it takes you to fall asleep).

Cognitive Restructuring

Cognitive restructuring aims to identify and change the thoughts and feelings that lead to unhealthy sleep patterns. For example, it helps a person to deal with intrusive thoughts when trying to fall asleep. Constructive worry also can be used to explore thoughts that keep you awake.

A study of CBT-I used to help smokers, and people trying to quit smoking, also found that learning to deal with their thoughts and reframe them was helpful when they tried to sleep.

Third-Wave Therapy

The third-wave therapy elements of CBT-I involve mindfulness practices. These therapies are used as a form of meditation and self-awareness. They can help people with acceptance and control over their thoughts and emotions.

Acceptance and commitment therapy focus on accepting the feelings and thoughts associated with insomnia. Mindfulness can offer benefits when used with other insomnia therapies like stimulus control.

Relaxation techniques, including abdominal breathing and muscle control exercises, may help as part of CBT-I but may not be effective on their own.

What to Expect

A typical CBT-I program is generally scheduled with a provider for an average of six weeks, though some sessions continue for 16 weeks or more. They typically last 30 to 60 minutes. Some CBT-I options include online or app-driven programs.

Each week, your progress will be closely monitored with the use of sleep logs and other elements. Feedback and specific guidance will be provided to advance you toward your goals.

Who Benefits?

No matter why you have insomnia, or for how long you have had it, CBT-I can effectively help to end it. It even helps those who have a general medical condition that interferes with sleep, including those afflicted with pain or mood disorders such as anxiety or depression.

This individualized program will address the specific goals you have related to your insomnia. For some, this may mean falling asleep more easily, sleeping through the night, sleeping without the use of pills, or improving daytime fatigue.

CBT-I can also help young children and adolescents who experience insomnia.

How to Find a CBT-I Specialist

The specialized training required for CBT-I is key to optimal care but it limits the number of medical professionals who can provide the service. If you are interested in finding a CBT-I specialist near you, consider the list provided by the American Board of Sleep Medicine.

Larger hospital groups or academic centers associated with major universities may also offer group therapy classes or workshops in your area. There are also several apps and online programs to consider. In addition, there are a handful of books based on therapy techniques.

It can also be helpful to ask for a referral to a local board-certified sleep doctor who may be able to provide you with additional guidance on resources in your area. Our Doctor Discussion Guide below can help you start that conversation with a doctor.

Insomnia Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Download PDF

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Summary

Cognitive behavioral therapy (CBT) with a specific focus on insomnia, called CBT-I, can help to improve sleep quality, efficiency, and more. It relies on CBT psychotherapy principles and techniques to help change the thoughts and behaviors that may contribute to insomnia.

Specific interventions, including cognitive restructuring and third-wave mindfulness practices, have been shown to be effective. CBT-I and some of its components are recommended by the American Academy of Sleep Medicine, but there's limited evidence for some techniques (such as biofeedback).

Talk to your healthcare provider about CBT-I and how you can benefit from intervention.