What Is CBT-I? The First-Line Treatment for Insomnia

Most people with long-running insomnia arrive at treatment having already tried many of the obvious things: better sleep hygiene, an earlier bedtime, melatonin, then something stronger, like over-the-counter sleeping pills or a prescribed medication. What almost nobody is offered first is the treatment that both the American College of Physicians and the American Academy of Sleep Medicine say should come first — CBT-I, or cognitive behavioral therapy for insomnia.

What CBT-I actually is

Cognitive behavioral therapy for insomnia is a structured program — usually four to eight sessions — that targets the specific behaviors and beliefs keeping insomnia going, often long after whatever started it in the first place has passed.

That distinction — between what starts insomnia and what maintains it — is the entire basis of the treatment. A stressful period, an illness, a new baby, or a course of medication can set off a run of bad nights. What turns a bad run into a chronic condition is usually what follows: going to bed earlier to catch up, lying awake trying to sleep, spending nine hours in bed to get six hours of sleep, and slowly teaching the brain that bed is a place where you lie awake, stressed and anxious. A repeated cycle of this then becomes its own self-fueled insomnia cycle that becomes hard to break.

CBT-I helps you to reverse that learning. Unlike what many people assume CBT-I is, it is actually much more than just relaxation training or just a list of sleep tips.

What the guidelines say

The American College of Physicians published its clinical practice guideline on chronic insomnia in 2016. Its first recommendation:

"ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence)"

Medication comes second, and conditionally:

"ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence)"2

The American Academy of Sleep Medicine reached the same conclusion. In its 2021 guideline on behavioral and psychological treatments, multicomponent CBT-I received the guideline's only strong recommendation, meaning what clinicians should follow under most circumstances.3

It is worth noting that in the AASM's separate 2017 guideline on insomnia medications, every single drug recommendation is graded a weak recommendation.4 This is less a blanket criticism of the drugs, and not a reason to stop taking one you have been prescribed, but the guidelines have a clear recommendation on what the initial treatment for chronic insomnia should be.

The four components of CBT-I

Sleep restriction (also called time-in-bed restriction) is the component that does a lot of the work to help you sleep better again. This is the one most people find hardest. It temporarily cuts the time you spend in bed to roughly the time you are actually asleep, which consolidates fragmented sleep and rebuilds the pressure to sleep. It sometimes makes things feel worse before they feel better: when this was measured in a laboratory, daytime sleepiness was raised through the first three weeks and vigilance was objectively impaired, with both back to baseline by three months.6

Stimulus control rebuilds the association between bed and sleep. The directive for this is simple: your bed is for sleep. If you are awake and frustrated for a prolonged period, you get up and out of bed. This breaks the association between your bed and feeling frustration, the inability to sleep and anxiety, all of which are currently fueling your insomnia.

Cognitive therapy helps you manage the thinking that keeps the entire insomnia mindset going: catastrophizing about tomorrow, over-monitoring the clock, the belief that a bad night guarantees a ruined day.

Relaxation training lowers the physiological arousal that makes sleep onset difficult.

Delivered together, this combination is what the guidelines mean by multicomponent CBT-I. Each of the individual components on its own is less effective than the combination; in the AASM guideline, each component by itself drops to a conditional recommendation as a treatment for chronic insomnia.

What CBT-I is not

It is not sleep hygiene. This is the most common mistaken substitution, and the AASM's 2021 guideline clearly states that sleep hygiene should not be used as a single-component treatment for chronic insomnia in adults.

Sleep-hygiene advice is not wrong. Caffeine late in the day does interfere with sleep. A large or late dinner can make it harder to sleep soundly. Reducing screens before bed can help your mind start to relax. But telling someone with chronic insomnia just to do these things is a little like telling someone with a broken leg to wear supportive shoes — not unreasonable, but also not the treatment itself.

Who it is for

CBT-I is the recommended treatment for people with chronic insomnia, which has a specific definition:

• difficulty falling asleep, staying asleep, or waking too early
• on three or more nights a week
• for longer than three months, despite adequate opportunity to sleep, and
• with a daytime consequence.5

Two things that resemble chronic insomnia but are actually not: a body clock that runs late rather than sleep being broken, which is a circadian rhythm problem (delayed sleep-wake phase disorder), and a breathing disorder fragmenting your nights (sleep apnea). Both are treated differently, and both are worth ruling out before starting.

If you are not sure which of these describes you, that is the question our four-question insomnia test is built to answer.