CBT for Insomnia: It Works, But It Takes Work

Myles Doyle - MTD Psychotherapy

*7 min read*

CBT for Insomnia (CBT-I) is one of the most established psychological treatments for persistent insomnia. Research suggests it improves sleep in around 75–80% of people with insomnia.

That sounds impressive. And it is. But there is something I think people should know before starting CBT-I: it takes work.

Some parts of the treatment are relatively straightforward. Others can be genuinely difficult, particularly during the first few weeks.

Changing the way we think about sleep

CBT-I uses many of the same principles found in Cognitive Behavioural Therapy more generally. After months or years of poor sleep, people understandably develop powerful beliefs about their sleep.

• “If I don't get eight hours tonight, tomorrow will be a disaster.”

• “I've always been a terrible sleeper.”

• “If I wake at 3am, that's it. The night is ruined.”

These thoughts can become part of the insomnia itself. In therapy, we examine these thoughts together. Are they completely accurate? What does the evidence actually tell us?

Through conversation, data, logic and sometimes simple common sense, apparently fixed beliefs about sleep can begin to change.

But talking differently about sleep is only part of CBT-I.

Then comes the difficult bit

One of the core behavioural elements of CBT-I is sleep compression. Put simply, we reduce the amount of time someone spends in bed so that their sleep becomes more consolidated. We want the bed to become strongly associated with sleeping rather than lying awake and trying to force sleep to happen.

The principle makes sense. The reality can be considerably harder.

If you have had a bad night's sleep, your instinct may be to compensate. You might sleep late the following morning or decide to go to bed particularly early that evening.

CBT-I asks you to do almost the opposite. That can mean:

No weekend lie-ins.

No sleeping late after a particularly bad night.

No going to bed early because you are worried about catching up.

No abandoning the routine simply because you are on holiday.

And if you wake during the night and remain awake for around 15–20 minutes, the treatment suggests getting out of bed, going somewhere comfortable and returning to bed when sleepiness returns. At 3am, that can feel like a very big ask.

And CBT-I homework happens twice every day

This is one of the biggest differences I notice between CBT-I and some other forms of therapy.

Someone attending therapy for anxiety, for example, might leave with something to practise or think about during the week. With CBT-I, the behavioural work is waiting for you twice every day.

• Every morning, you have a set time beyond which you need to get out of bed.

• Every evening, you have a set time before which you don't go to bed.

• And during a difficult night where you remain awake for more than 15-20 minutes, you may have to resist the temptation to remain in bed.

You are doing this while tired. That's precisely why it can be hard.

Why put yourself through it?

Because we are trying to rebuild something very important: sleep pressure. The longer we are awake, the greater our biological drive for sleep becomes. By reducing excessive time in bed and keeping the sleep schedule consistent, we help strengthen that natural drive.

And something interesting can then begin to happen.

The cognitive (the logic dialogue with your therapist) and behavioural parts (sleep compression) of CBT-I start supporting each other.

Instead of simply telling yourself, “Perhaps I can sleep better,” you begin accumulating evidence that you actually are sleeping better. Sleep becomes more predictable. A bad night becomes less frightening because increasingly it is an exception rather than the rule.

That real-world evidence helps challenge the negative beliefs that insomnia has built over time.

What happens when treatment finishes?

The aim isn't to spend the rest of your life following a rigid sleep programme. But the habits that rebuilt sleep need to be protected.

I sometimes see clients begin to waver once their sleep has improved. The Sunday lie-in returns. Holidays become an opportunity to stay in bed much longer. After one poor night, they compensate with an early bedtime.

Sometimes they then notice elements of their old sleep pattern beginning to return. That doesn't mean CBT-I has failed. It can be a useful reminder of what helped restore healthy sleep in the first place.

CBT-I has been extensively studied and has a strong evidence base. Research by insomnia specialist Dr Gregg Jacobs reports improved sleep in approximately 75–80% of people with insomnia.

But effective doesn't mean effortless. CBT for insomnia works by changing how you think about sleep and how you behave around sleep. The thinking is mind challenging but the behaviour can be tougher on the body. For many people, however, those difficult few weeks can be the beginning of a very different relationship with sleep.

What you can do?

If poor sleep has become a regular part of your life, it can be easy to start believing that you are simply a bad sleeper and that there is little you can do about it. Insomnia is treatable. CBT for Insomnia provides a structured way of looking at both the thoughts and behaviours that may be keeping poor sleep going. It isn't always easy, but for many people it can make a significant difference.

MTD Psychotherapy and its sister website www.insomniatreatment.ie provides CBT for Insomnia in Co. Meath and online across Ireland. If you would like to explore whether CBT-I might be helpful for you, a free 15-minute consultation is available to help you decide whether it may be right for you.