Cognitive Behavioural Therapy for Insomnia (CBT-I)

Cognitive Behavioural Therapy for Insomnia is the first-line treatment recommended by NICE and the American Academy of Sleep Medicine for chronic insomnia. Unlike sleeping tablets, which address symptoms without tackling the underlying causes and carry risks of dependence, tolerance, and rebound insomnia, CBT-I targets the cognitive and behavioural processes that maintain insomnia and produces improvements that persist long after treatment has ended. Multiple meta-analyses have demonstrated that CBT-I is as effective as medication in the short term and significantly more effective in the long term.

CBT-I comprises several components. Sleep restriction involves temporarily limiting the time you spend in bed to match the amount of sleep you are actually getting, then gradually increasing it as sleep efficiency improves. This seems counterintuitive — if you are struggling to sleep, why spend less time in bed? — but it works by building up sleep pressure (the homeostatic drive to sleep) and breaking the association between lying in bed and being awake. Stimulus control re-establishes the bed and bedroom as cues for sleep rather than for wakefulness, anxiety, and frustration. The core rules are simple: go to bed only when sleepy, use the bed only for sleep and intimacy, get up if you cannot sleep within twenty minutes, and get up at the same time every morning regardless of how much you slept.

Cognitive restructuring addresses the unhelpful beliefs and anxious thoughts that perpetuate insomnia. Common examples include catastrophising about the consequences of poor sleep ("If I do not sleep tonight, I will not be able to function tomorrow and my whole week will be ruined"), unrealistic expectations ("I need eight hours of sleep every night"), and performance anxiety about sleep itself ("I must try harder to fall asleep"). These thoughts generate arousal that is incompatible with sleep, creating a self-fulfilling prophecy.

Relaxation training (progressive muscle relaxation, diaphragmatic breathing, mindfulness-based techniques) and sleep hygiene education (managing caffeine, alcohol, light exposure, and the bedroom environment) complete the treatment package. A typical course of CBT-I involves four to eight sessions, and most people experience significant improvement within two to four weeks. CBT-I can be delivered individually, in groups, or through digital programmes, making it widely accessible.