Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills

Insomnia is a serious disorder, and effective treatment can be crucial to getting the sleep you need. Explore safe, effective, nondrug insomnia treatments.

By Mayo Clinic Staff

Insomnia is a common problem characterized by trouble falling asleep, staying asleep or getting restful sleep, despite the opportunity for adequate sleep. Cognitive behavioral therapy for insomnia, often called CBT-I, is an effective insomnia treatment for chronic sleep problems.

Cognitive behavioral therapy for insomnia is a structured program that helps you identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Unlike sleeping pills, CBT-I helps you overcome the underlying causes of your sleep problems.

To make effective changes, it's important to understand sleep cycles and learn how beliefs, behaviors and outside factors can affect your sleep. To help decide how to best treat your insomnia, your sleep therapist may have you keep a detailed sleep diary for one to two weeks.

How does cognitive behavioral therapy for insomnia work?

Cognitive behavioral therapy for insomnia aims to improve sleep habits and behaviors. The cognitive part of CBT-I teaches you to recognize and change beliefs that affect your ability to sleep. For instance, this may include learning how to control or eliminate negative thoughts and worries that keep you awake. The behavioral part of CBT-I helps you develop good sleep habits and avoid behaviors that keep you from sleeping well.

Depending on your needs, your sleep therapist may recommend some of these CBT-I techniques:

  • Stimulus control therapy. This method helps remove factors that condition the mind to resist sleep. For example, you might be coached to set a consistent bedtime and wake time and avoid naps, use the bed only for sleep and sex, and leave the bedroom if you can't go to sleep within 20 minutes, only returning when you're sleepy.
  • Sleep restriction. Lying in bed when you're awake can become a habit that leads to poor sleep. This treatment decreases the time you spend in bed, causing partial sleep deprivation, which makes you more tired the next night. Once your sleep has improved, your time in bed is gradually increased.
  • Sleep hygiene. This method of therapy involves changing basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, drinking too much alcohol, or not getting regular exercise. It also includes tips that help you sleep better, such as ways to wind down an hour or two before bedtime.
  • Sleep environment improvement. This offers ways that you can create a comfortable sleep environment, such as keeping your bedroom quiet, dark and cool, not having a TV in the bedroom, and hiding the clock from view.
  • Relaxation training. This method helps you calm your mind and body. Approaches include meditation, imagery, muscle relaxation and others.
  • Remaining passively awake. Also called paradoxical intention, this involves avoiding any effort to fall asleep. Paradoxically, worrying that you can't sleep can actually keep you awake. Letting go of this worry can help you relax and make it easier to fall asleep.
  • Biofeedback. This method allows you to observe biological signs such as heart rate and muscle tension and shows you how to adjust them. Your sleep specialist may have you take a biofeedback device home to record your daily patterns. This information can help identify patterns that affect sleep.

The most effective treatment approach may combine several of these methods.

Cognitive behavioral therapy vs. pills

Sleep medications can be an effective short-term treatment — for example, they can provide immediate relief during a period of high stress or grief. Some newer sleeping medications have been approved for long-term use. But they may not be the best long-term insomnia treatment.

Cognitive behavioral therapy for insomnia may be a good treatment choice if you have long-term sleep problems. You may want to try it if you're worried about becoming dependent on sleep medications, if medications aren't effective or if they cause bothersome side effects.

Unlike pills, CBT-I addresses the underlying causes of insomnia rather than just relieving symptoms. But it takes time — and effort — to make it work. In some cases, a combination of sleep medication and CBT-I may be the best approach.

Feb. 11, 2014 See more In-depth