Cognitive Behavioural Therapy for Insomnia Simply Explained

1. What It Is About

Cognitive behavioural therapy for insomnia is a programme against persistent sleep problems. Persistent means: the symptoms have been present for months. The programme is not a single measure, but consists of several components and runs over several weeks. Usual are six to eight sessions, individually or in a group 2, 8, 12.

The components include a sleep diary in which one records in the morning how the night was. With sleep restriction, one initially spends less time in bed and gets up at the same time every day. Stimulus control means: the bed is for sleeping, not for ruminating. This is joined by work on thoughts about sleep, for example the worry of not managing the day without sleep. Relaxation exercises are also part of it.

The programme is delivered in person, in groups, as self-help or via the internet. In studies it is compared both with waiting lists and with other procedures such as Tai Chi or mindfulness meditation.

2. What Studies Show

Best evidenced is: the procedure works in adults with persistent insomnia. The American professional society for internal medicine recommends it to adults with chronic insomnia as first-line treatment 1. This recommendation is based on a large summary of studies.

In a study with 45 adults who had post-traumatic stress disorder in addition to insomnia, each person received individual treatment over eight weeks. Afterwards 41 % of them slept again without the symptoms of insomnia; in the group waiting for treatment it was none 8.

Another study involved 123 older people with chronic insomnia. Compared were behavioural therapy, Tai Chi and a sleep seminar, each over four months. Behavioural therapy outperformed the other two groups in eliminating insomnia, and the improvements in sleep quality and exhaustion lasted longer 7. After 16 months the participants in behavioural therapy also had elevated levels of an inflammatory marker in the blood less often 7.

The programme has also been studied as self-help. A summary of 20 studies found improvements in sleep efficiency, time to fall asleep and time awake after falling asleep; dropout from self-help was similarly rare as from accompanied treatment 13.

For the digital form a summary of 33 studies is available; sleep complaints decreased afterwards 4. A further summary of 22 studies looked at people who had a mental illness in addition to insomnia, for example depression or alcohol dependence 6. For children with sleep problems an overview names behavioural therapy as one of several approaches 14.

3. What Remains Unclear

One difficulty is comparability. Under the same name run programmes with six sessions, self-help books and automatic applications on the internet, each with a different extent of guidance and contact. It is plausible that part of the differing results stems from how the programme was delivered, and not from the procedure itself.

Many studies rely on sleep diaries and questionnaires. In the comparisons with other procedures the groups were small: 90 participants for Tai Chi Chih and 111 for mindfulness-based stress reduction 9, 10. In the study with breast cancer survivors, after 15 months 43.7 % responded under behavioural therapy and 46.7 % under Tai Chi Chih; Tai Chi Chih was therefore not inferior 10.

Which component contributes the largest share to success has not yet been decided. For gut microbiome and viral infections the present material contains no own studies on behavioural therapy; the investigative work still stands out 11, 14.

4. What This Means in Everyday Life

Anyone who informs themselves about the procedure encounters very different offers: in person in a practice, in the group, as a book or as a programme on the internet. Research shows that it depends strongly on whether a programme is actually carried out, with fixed times and regularity.

In the study with 123 older adults the improvement in insomnia after 16 months was accompanied by lower inflammation values in the blood 7. So far this is only a hypothesis: the connection suggests that the inflammation values follow sleep and not the other way round; the study cannot separate this direction, however.

In a case series with 127 men and 174 women the improvement did not differ between low and high depressive burden, yet the more heavily burdened group adhered less often to fixed getting-up times and bedtimes 12. What remains to be clarified is how the effect looks beyond one year and whether this lower participation changes the results 12.

All details with study numbers and sources: detailed page on Cognitive Behavioural Therapy for Insomnia (CBT-I). For children: Cognitive Behavioural Therapy for Insomnia (CBT-I) for Children.