What Happens During CBT-I Therapy?

CBT-I, or Cognitive Behavioral Therapy for Insomnia, usually begins with an assessment of your sleep. The CBT-I therapist will assess your sleeping patterns and habits, explore things that may be worsening sleep, discuss your concerns and goals for sleep, and will screen for potential medical sleep problems like sleep apnea. This is followed by several weeks of structured changes designed to strengthen sleep reduce the habits, thoughts, and anxiety that maintain anxiety. Treatment often include sleep tracking, adjusting sleep schedules and time in bed, improving the bed-sleep connection, and changing how you respond to night time awakenings and worry about sleep.

Completing a daily sleep log or sleep diary is an important component to CBT-I

What is CBT-I Therapy?

CBT-I, or Cognitive Behavioral Therapy for insomnia, is an evidence-based, structured therapy targeted specifically to the treatment of insomnia. It is considered the gold standard treatment for insomnia and is more effective than sleep medications in the long term*. CBT-I goes beyond sleep hygiene because it targets the disruption of the circadian rhythm, strengthens associations between bed and wakefulness, and the worries, thoughts, beliefs or anxiety that underpin insomnia. CBT-I is also different from regular CBT. CBT is an umbrella term for therapeutic strategies and modalities that focus on the connection between thoughts, emotions, and behaviors; CBT-I combines that theory with sleep science to create a therapy that targets insomnia specifically.

The Initial Assessment

You can expect your sleep therapist to assess a variety of factors when beginning CBT-I. This can include:

• when you go to bed and wakes up

• how long it takes to fall asleep

• nighttime waking

• naps

• medications and substances

• medical and mental-health factors

• anxiety about sleep

• daily routines that affect sleep

You can also expect your CBT-I therapist to screen for medical sleep conditions like sleep apnea and refer you for a sleep study if needed.

The Sleep Diary

Tracking sleep via a sleep diary is a vital component of CBT-I. The sleep diary provides a picture of how much time you're spending in bed, how much of that time you're actually sleeping, and patterns in your sleep habits. Your CBT-I therapist will use this information to create a strategy for improving sleep.

The Interventions

CBT-I is built on five primary interventions: sleep education, sleep scheduling, sleep disrupting thoughts, stimulus control, and relaxational strategies.

Sleep Education

The foundation of CBT-I is on understanding what sleep is, how it works, and how a better understanding of sleep can improve the quality of sleep.

Sleep Scheduling

CBT-I often involves sleep restriction or compression. Sleep restriction is used temporarily to increase sleep drive and align sleep habits with the body's natural circadian rhythm. This is done in a carefully curated way based on the data from the sleep diary.

Sleep Disrupting Thoughts

Common refrains like, "If I just fall asleep right now I can still get 5 hours of sleep", "If I don't get 8 hours of sleep I won't be able to function tomorrow", or your mind going into overdrive as soon as your head hits the pillow are common complaints I hear from clients. Our mind can really get in the way of sleep. CBT-I helps to mitigate the impact of a restless or anxious mind on sleep.

Stimulus Control

If you have spent many nights lying awake in bed worrying or feeling frustrated, it's possible bed and bedtime have become a cue for you to feel this way. CBT-I works to change these associations through something call stimulus control.

Relaxational Strategies

The CBT-I therapist can you help you learn strategies to prepare your mind and body for sleep.

How Long Does CBT-I Take?

CBT-I is often delivered as a relatively short-term treatment, but the exact length depends on the severity and duration of insomnia, medical considerations, co-occurring anxiety, and how treatment is adapted to the individual. Many people find their sleep improving after several sessions. Sessions are usually once every 1-2 weeks.

Is CBT-I Difficult?

In all honesty, some parts of CBT-I can be difficult. The treatment will possibly ask you to make changes to your sleep schedule or habits. If your treatment plan includes sleep restriction then this may make you feel temporarily more tired. Like with many other things, CBT-I can sometimes feel worse before you feel better. CBT-I is focused on long term changes, not quick fixes.

Where Do I Find a CBT-I Therapist?

How to Find a CBT-I Therapist

CBT-I is a specialized therapy with limited providers. While you may find a provider local to your area, you may need to consider online telehealth CBT-I with a provider licensed in your state. Thankfully, CBT-I works well and is just as effective online via telehealth as it is in-person. The CBT-I Directory from the UPenn Perelman School of Medicine is a good place to start for finding a trained CBT-I provider.

*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.

About the author: Katie Bernard, LCSW, is a Florida therapist specializing in Cognitive Behavioral Therapy for Insomnia and anxiety therapy for adults. She provides online therapy throughout Florida and limited in-person care in Sarasota | Lakewood Ranch.