Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills

Insomnia is a common 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 sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep. Cognitive behavioral therapy for insomnia, sometimes called CBT-I, is an effective treatment for chronic sleep problems and is usually recommended as the first line of treatment.

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 identify 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?

The cognitive part of CBT-I teaches you to recognize and change beliefs that affect your ability to sleep. This type of therapy can help you 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 your 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 reduces 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 longer 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're worried about becoming dependent on sleep medications, or if medications aren't effective or 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.

Insomnia and other disorders

Insomnia is linked to a number of physical and mental health disorders. Ongoing lack of sleep increases your risk of health conditions such as high blood pressure, heart disease, diabetes and chronic pain. Some medications, including over-the-counter medications, also can contribute to insomnia.

If you have a condition or medication that's linked to insomnia, talk to your doctor about how best to manage these along with sleep problems. Insomnia is unlikely to get better without treatment.

Finding help

There are a limited number of certified Behavioral Sleep Medicine specialists, and you may not live near a practitioner. You may have to do some searching to find a trained practitioner and a treatment schedule and type that fit your needs. Here are some places to look:

  • The American Academy of Sleep Medicine website allows you to search for a certified sleep center, such as Mayo Clinic Center for Sleep Medicine.
  • The Society of Behavioral Sleep Medicine website offers a directory for finding a behavioral sleep medicine provider.

The type of treatment and frequency of sessions can vary. You may need as few as two sessions or as many as eight or more sessions, depending on your sleep expert, the program and your progress.

When calling to set up an appointment, ask the practitioner about his or her approach and what to expect. Also check ahead of time whether your health insurance will cover the type of treatment you need.

If available in your area, meet with a sleep medicine specialist in person for your sessions. However, phone consultation, CDs, books or websites on CBT techniques and insomnia also may be beneficial.

Who can benefit from cognitive behavioral therapy for insomnia?

Cognitive behavioral therapy for insomnia can benefit nearly anyone with sleep problems. CBT-I can help people who have primary insomnia as well as people with physical problems, such as chronic pain, or mental health disorders, such as depression and anxiety. What's more, the effects seem to last. And there is no evidence that CBT-I has negative side effects.

CBT-I requires steady practice, and some approaches may cause you to lose sleep at first. But stick with it, and you'll likely see lasting results.

Sept. 28, 2016 See more In-depth

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