When You Can’t Sleep: How CBT-I Can Help

Your sleep hygiene is good. Sleep apnea has been ruled out. Yet night after night, you struggle to fall asleep or return to sleep if you wake during the night. You want to try something other than a pharmaceutical to send you off to sleep. Enter CBT-I.

CBT-I stands for Cognitive Behavioral Therapy for Insomnia. It’s a structured, evidence-based psychotherapy approach designed specifically to treat insomnia (difficulty falling asleep, staying asleep, or waking too early and not being able to return to sleep). CBT-I is considered by many clinical guidelines to be the first-line treatment for chronic insomnia before—or instead of—prescribing sleep medications.

CBT-I programs are readily available in one-on-one, group, and even app-based formats, including through Massachusetts General Hospital’s CBT program. This article will look at what insomnia is, how CBT-I works, and how you can find the CBT-I approach that’s best for you.

What Is Insomnia and How Does CBT-I Work?

At some point, many adults have short-term insomnia. This can last for days or weeks and is usually caused by stress. We have something on our minds or hearts that makes restful sleep elusive. But some people have long-term insomnia, also called chronic insomnia. This lasts for three or more months. It may be related to other causes including stress, ongoing poor sleep habits, mental health challenges or medical conditions. Insomnia can also become more common as we age, when we experience changes in activity levels, medications and/or our general health.

CBT-I combines several interlocking components, starting with education, so you understand what normal sleep is, what insomnia is and the gap between them that you want to close. This helps to set realistic expectations.

Behavioral interventions around sleep follow and are designed to strengthen the association between bed/bedroom and sleep, which is called stimulus control. For example, limiting time in bed to more closely match your actual sleep time, then gradually increasing time in bed as sleep improves helps to improve sleep efficiency. Sleep hygiene, where you modify habits that affect sleep (caffeine/alcohol use, exposure to light, sleep environment, screen time) supports better sleep.

Finally, CBT-I programs include relaxation training. Techniques like progressive muscle relaxation, breathing exercises, and guided imagery can help you enter into sleep in a more peaceful and calm way.

Once you have solid fundamentals around sleep education and behavioral interventions and relaxation, cognitive interventions help you to identify and challenge unhelpful thoughts and beliefs about sleep. Reframing or replacing those thoughts with more realistic, less worry-provoking ones are part of this process.

When sleep improves, relapse prevention, where you maintain gains you have made, along with self-monitoring to track adherence to a sleep program, support ongoing success.

Consider CBT-I if:

• Your insomnia is chronic, and lasts for months.
• You prefer to avoid medication.
• Your insomnia co-occurs with other conditions (e.g. anxiety, mild depression, chronic medical illness) that are stable and appropriately managed.

CBT-I is less effective for cases of untreated or unrecognized medical sleep disorders like sleep apnea. And it may not be the right solution if you have difficulty adhering to behavioral change because of a highly variable schedule, shift work or other irregular routines.

Finding the Right Approach to CBT-I

There are many apps and digital platforms that deliver elements of CBT-I. Some are self-guided; others are adjuncts to therapy. Ask yourself these questions when choosing and using apps:

• Does the app include core CBT-I components: sleep restriction, stimulus control, cognitive restructuring, education, sleep diary. If it lacks these key parts, it may be less effective.
• Have you consulted your physician? If insomnia is severe, longstanding, or linked with other health issues, apps may not be enough.
• Do you feel you can use the app consistently and adhere to its requirements? Using CBT-I tools regularly supports progress.
• Does the app you’re considering promise quick fixes? If it does, the app may be less credible.
• How does the app collect data and protect your privacy? If the app collects your sensitive health information, you want to know how it is managed.

CBT-I is a highly effective, structured therapy for insomnia that works by changing both unhelpful thoughts and behaviors around sleep. It’s especially helpful for chronic insomnia and is more durable over the long term compared with many sleep medications. The key is to find the solution that is right for you.