AppCBT toolsTherapistsArticlesHelpProvider PlatformGet the app

Sleep and CBT for Insomnia: What It Involves and What Helps

Almost everyone has a bad night now and then. When bad nights start to repeat, it is natural to try to fix them, and many of the usual fixes quietly make sleep harder. This article explains how sleep works in simple terms, why insomnia tends to persist, and what cognitive behavioral therapy for insomnia (CBT-I) involves.

This is general information, not medical advice, and it says nothing about medication. If sleep trouble goes on for months, please see a doctor.

Two processes behind sleep

The two-process model of sleep, proposed by Alexander Borbély, is the standard picture.

Sleep pressure (also called sleep drive). The longer you are awake, the stronger the pull to sleep. Sleep releases the pressure.

The body clock (the circadian process). An internal clock, set mostly by light and by regular times, marks day and night. It likes a steady rhythm.

Good sleep happens when pressure is high and the clock says "night" at the same time. Both processes can be weakened by well-meant habits. A nap releases some pressure, so there is less at night. Early bedtimes mean lying in bed before the pressure is high enough. Sleeping in shifts the clock later.

Why insomnia persists: the 3P model

Arthur Spielman's 3P model helps explain why a short bad patch can become long-lasting insomnia.

  • Predisposing factors: a tendency to be a light sleeper, to worry, to react to stress with arousal.
  • Precipitating factors: the trigger, such as a stressful month, an illness, a new baby.
  • Perpetuating factors: what you do about the poor sleep: napping, long time in bed, drinking more coffee, worrying about the day ahead, watching the clock.

The trigger usually passes. The perpetuating habits and beliefs are what keep insomnia going, and they are where treatment works.

Sleep effort and worry about sleep

Colin Espie's research describes a pathway of selective attention to sleep, intention to sleep, and sleep effort. Normal sleep is largely automatic. When it is threatened, we start to monitor it, try to make it happen and control it, and that effort itself switches the body on. Sleep is one of the few things that gets worse when you try harder.

Allison Harvey's cognitive model of insomnia adds worry. Worry about sleep and its daytime effects causes arousal and distress, which makes us watch for signs of poor sleep, which confirms the fear. Beliefs play a part too. Researchers measure them with a scale called the DBAS, and typical beliefs include "I need eight hours or I can't function" and "I have no control over my sleep".

An example: Dan at midnight

Dan lies in bed at midnight, trying very hard to sleep. He has checked the clock three times: "If I fall asleep now, I get five hours." He napped on Sunday after a bad night, and went to bed an hour early on Monday. The bed has slowly become a place for lying awake and worrying.

His case is a typical 3P story. A stressful month was the trigger. Naps, early bed times, clock-watching and the belief "I can't function without eight hours" are the perpetuating factors.

What CBT-I involves

CBT-I is not a list of gentle tips. It is a structured, multi-component treatment, and it is recommended as the first treatment for chronic insomnia in major guidelines. Its main parts are:

  • Sleep restriction (and a gentler version, sleep compression). It limits the time in bed to match the sleep you actually get, then extends it as sleep improves. This builds sleep pressure. It can cause sleepiness at first, and it is not right for everyone, so it should be done with a clinician. CopingCard does not set a sleep window for you.
  • Stimulus control. It rebuilds the link between bed and sleep: one fixed get-up time every day, bed when sleepy rather than only tired, the bed used for sleep, and getting up for something calm if awake for a long time.
  • Cognitive therapy for sleep. It works on worry and beliefs about sleep, using the same logic as in other CBT: look at the thought, test it, and find a more workable way of seeing it.
  • Arousal reduction. Wind-down routines, relaxation or mindfulness to lower the alertness that keeps sleep away.
  • Sleep hygiene as education. Advice on caffeine, alcohol, light and routines is useful context, but on its own it is not effective, and guidelines do not recommend it as a single treatment.

CBT-I usually takes six to eight sessions (brief versions use fewer), with a clinician or through an online program. Online (digital) CBT-I has been tested in large trials and improves insomnia, with benefits for mood and wellbeing as well.

Sleep, mood and anxiety

Sleep and mood affect each other. Poor sleep makes low mood and anxiety harder to bear, and low mood and anxiety make sleep lighter. CBT-I has been studied in people with depression and anxiety as well, and improving sleep often helps the other problem too. That is one reason sleep is worth working on directly and not only as a side effect of feeling better. It is also why a clinician can place sleep work inside a wider plan, in the same way that other CBT methods are chosen by what keeps a person's difficulties going.

A two-minute sleep diary

Each morning, note roughly when you went to bed and got up, how long you think it took to fall asleep, and how rested you feel. Do not check the clock at night to fill it in. A rough guess is enough. After a week or two you will see your own pattern, which is often different from how the nights feel.

What to expect

In the first days of a behavioral approach you may feel sleepier than usual. That is the sleep pressure building, and it is part of how the method works. Take care if you drive when drowsy. Change takes weeks, not nights. Some nights will still be poor. That does not erase what you are building.

Safety and when to see a doctor

Please see a doctor if sleep trouble lasts for months, or if it comes with loud snoring or pauses in breathing (possible sleep apnea), restless legs, or very sleepy days. If you work nights, or live with bipolar disorder or epilepsy, check with your doctor before changing your sleep routine, because changes to sleep can affect these conditions. Poor sleep and low mood often go together. If your mood is low for two weeks or more, or you have thoughts of harming yourself, please talk to a doctor or therapist, open the Crisis tab, or contact local emergency services.

How to use CopingCard for this

  • Use My check-ins to log how well you slept and how many hours.
  • A Coping Card can hold a few of your rules: "Same get-up time. Bed is for sleep. If awake for long, up for something calm."
  • If worries keep you awake, use Worry Trees earlier in the evening to sort what you can act on tomorrow.
  • A Meditation in the evening can help with winding down.

Summary

Sleep depends on sleep pressure and the body clock. Insomnia often persists through habits and worry, and through the effort to sleep. CBT-I is a structured treatment with sleep restriction, stimulus control, cognitive therapy, arousal reduction and education, and sleep restriction is done with a clinician. Sleep hygiene alone does not work. If trouble lasts for months, see a doctor.

Sources

  • Borbély, A. A. (1982). A two process model of sleep regulation. Human Neurobiology, 1, 195-204.
  • Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987). A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America, 10(4), 541-553.
  • Espie, C. A., Broomfield, N. M., MacMahon, K. M. A., Macphee, L. M., & Taylor, L. M. (2006). The attention-intention-effort pathway in the development of psychophysiologic insomnia. Sleep Medicine Reviews, 10(4), 215-245.
  • Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40(8), 869-893.
  • Morin, C. M., Vallières, A., & Ivers, H. (2007). Dysfunctional Beliefs and Attitudes about Sleep (DBAS). Sleep, 30(11), 1547-1554.
  • Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987). Treatment of chronic insomnia by restriction of time in bed. Sleep, 10(1), 45-56.
  • Lichstein, K. L., et al. (2001). Relaxation and sleep compression for late-life insomnia. Journal of Consulting and Clinical Psychology, 69(2), 227-239.
  • Edinger, J. D., et al. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2), 255-262.
  • Qaseem, A., et al. (2016). Management of chronic insomnia disorder in adults. Annals of Internal Medicine, 165(2), 125-133.
  • Espie, C. A., et al. (2019). Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life. JAMA Psychiatry, 76(1), 21-30.