What is CBT-I?

CBT-I (Cognitive Behavioral Therapy for Insomnia) is a behavioral treatment approach specifically developed for treating insomnia. It consists of several treatment components – based on cognitive behavioral therapy (CBT)¹ principles – that are commonly used together to treat insomnia. Because it is a multi-component approach, there isn’t one authoritative or manualized version of CBT-I; instead you’ll find different variations with slightly different emphases based on the researcher or the author of the protocol.

CBT-I is considered to be the most effective non-medication-based treatment for insomnia (and in fact has been shown by research studies to be more effective than medications in the long term) and is overwhelmingly recommended as the first line treatment for insomnia.² CBT-I is the modality that I have been trained in and utilize at my clinic (day job) to treat clients with insomnia, with great efficacy. I created this primer for anyone who wanted to learn more about the specifics of CBT-I.

A brief history of CBT-I

As I mentioned earlier, CBT-I isn’t a single structured intervention created at one point in time, but one that is made up of multiple components and has had many contributors as it evolved over the years. Prior to the 1970’s, teaching relaxation techniques (including progressive muscle relaxation) was the primary behavioral/psychological tool for treating insomnia. In the early 1970s, psychologist Richard Bootzin developed a method called stimulus control therapy,³ which focused on preserving the bed and bedroom as a cue for sleep, and which turned out to be a critical component of CBT-I. In the late 1970s, the concept of “sleep hygiene” as we now understand it in sleep medicine was introduced by psychologist Peter Hauri.⁴

In the late 1980s, Dr. Spielman and his colleagues developed sleep restriction therapy,⁵ a technique designed to increase sleep efficiency by initially limiting the time in bed to the actual amount of sleep reported by patients. Dr. Spielman also conceptualized insomnia to be made up of a combination of predisposing, precipitating, and perpetuating factors, instead of having a single cause – a concept known as the “3P” model of insomnia,⁶ which is foundational in CBT-I theory.

From this point on, research and development of behavioral techniques for treating insomnia accelerated, and a coherent framework began to coalesce under the Cognitive Behavioral Therapy umbrella. In the 1990s through the early 2000s, the body of knowledge in behavioral sleep medicine grew considerably as many studies validated the efficacy of multi-component CBT-I treatment. Notable pioneers of this era include Charles Morin,⁷ Michael Perlis,⁸ and Jack Edinger,⁹ among others. Since then, CBT-I has been studied and validated in multiple ways: on multiple populations, on populations with co-occurring medical/psychological conditions, and with different combinations of CBT-I components.

Today, a wide consensus of clinical practice guidelines recommends Cognitive Behavioral Therapy for Insomnia as the first line treatment for insomnia, from authoritative bodies such as the American College of Physicians (ACP), the National Institutes of Health (NIH), and the American Academy of Sleep Medicine (AASM).

Important sleep and insomnia concepts in CBT-I

Typically, CBT-I starts with some education about how sleep works and about how insomnia develops. According to the dominant model of the sleep biology, called the two-process model,¹⁰ sleep is regulated by two independent biological mechanisms which interact with each other: 1) the homeostatic sleep drive, which is a physiological pressure to sleep that builds while you’re awake, and 2) the circadian rhythm, which is your body’s way of regulating alertness and sleepiness in sync with nature and your environment. Stages of sleep and sleep architecture are sometimes covered, but not necessary to CBT-I.

Next, to explain how chronic insomnia develops, CBT-I turns to the “3P” model of insomnia by Dr. Spielman,¹¹ which I mentioned above. According to this model, individuals have predisposing factors that may make them more vulnerable to disrupted sleep, such as age, family history of insomnia, or tendency towards worry/anxiety. Then, precipitating factors – typically, life events such as an injury, increased stress, a move, or a new baby – can push the individual above the threshold, triggering a bout of acute insomnia. Finally, perpetuating factors refer to behaviors and thoughts that the individual may have adopted during this period of sleeplessness in order to cope, but which are maladaptive and actually perpetuate insomnia symptoms. Thus, even when the precipitating factors (which are usually temporary) resolve and go away, the disrupted sleep is maintained. The two main classes of perpetuating factors have been shown to be: excessive time in bed (going to bed earlier, sleeping in, taking naps) and non-sleep activities in the bed/bedroom (watching TV, reading, using smartphone). You’ll see that these are important areas of intervention in CBT-I.

Core components of CBT-I

While CBT-I, by virtue of its name, is a cognitive and behavioral approach, few sleep experts will deny the fact that it is primarily a behavioral intervention. While CBT-I does have useful cognitive components, the behavioral components are what make up the indispensable core of this intervention, and in fact research generally shows that behavioral-only CBT-I implementations tend to be just as effective as cognitive and behavioral CBT-I implementations. The following are what are considered to be the core components of CBT-I.

Sleep hygiene education. This is probably where most providers (doctors, psychologists, specialists) start with a client complaining of insomnia symptoms, especially if it is their first time trying to address their sleep problems. Through sleep hygiene education, clients are encouraged to change health and lifestyle behaviors that affect sleep (eg. diet, exercise, alcohol/caffeine use), as well to optimize their sleep environment and routines. Interestingly, studies have shown that while an important part of CBT-I, sleep hygiene alone is not an effective intervention in treating insomnia. In other words, once poor sleep has developed into chronic insomnia, it takes more than just following helpful sleep hygiene tips to fix your sleep.

Stimulus control therapy. The fancy-sounding term ‘stimulus control’ simply refers to the technique of controlling the pairing of a stimulus (in our case, the bed) with a conditioned response (sleep). The rationale is that the insomnia-sufferer has inadvertently learned to associate the bed with being awake instead of with sleep – through repeated reinforcement of behaviors such as watching TV, using smartphone, clock watching, worrying, or even tossing and turning – and thus triggers wakefulness just by getting into bed. The goal is to remove these other ‘pairings’ and only strengthen the bed-sleep pairing through repeated reinforcement. This involves not only refraining from engaging in non-sleep activities in bed, but also refraining from getting into bed unless sleepy and even getting out of bed when you’re unable to fall asleep or fall back asleep. Unlike sleep hygiene, both stimulus control therapy and sleep restriction therapy (below) have been shown to each be effective standalone treatments for insomnia, even without the other components of CBT-I, though usually delivered through multi-component CBT-I.

Sleep restriction therapy. This treatment addresses the insomnia-sufferer’s mismatch between the amount of time they spend in bed versus the amount of time they actually report being asleep. Through restricting the amount of time the client is allowed to spend in bed to roughly the amount of time asleep calculated from baseline data, the goal is to achieve a faster sleep onset and more consolidated sleep (less awakenings). In other words, by setting a later bedtime and disallowing sleeping in, the client should have a much higher sleep drive at their bedtime and even throughout the day – resulting in falling asleep and staying asleep more efficiently. Then, when this is happening reliably, the “time in bed” gets slowly increased so as to increase the total quantity of sleep.

Non-core (or optional) components of CBT-I

Relaxation training. The goal of relaxation training is to teach clients how to get to a state of physical and mental relaxation, in order to facilitate falling asleep. This can be very important for individuals who have a difficult time “shutting off” their brain or find their “mind racing” when they get into bed. Most common techniques include progressive muscle relaxation, diaphragmatic breathing, meditation, and guided imagery.

Cognitive therapy. A byproduct of longstanding insomnia is that people start to develop negative habits of thought, in addition to behaviors, related to their sleep. These can be negative attitudes, expectations, false beliefs, and excessive worrying, and they can contribute to the perpetuation of disrupted sleep. Cognitive therapy focuses on dispelling sleep “myths”, correcting negative expectations, and altering unhelpful mental habits. The effect is that cognitive therapy can improve compliance with the behavioral components and/or increase the treatment gains made through CBT-I.

Other. Here are a few other notable mentions. Paradoxical intention is a technique in which the client tries to stay awake instead of to fall asleep. This takes the focus off of worrying about falling asleep (which perpetuates insomnia), reduces the performance anxiety, and paradoxically helps to fall asleep more easily. Biofeedback is a method of using observable biological signs such as heart rate, muscle tension, body temperature, and brain activity to teach clients how to voluntarily achieve relaxation. Lastly, phototherapy is a treatment involving exposure to bright lights to help cue and reinforce the body’s circadian rhythm. This typically involves using a light box that generates very bright light first thing in the mornings, and is most useful for treating a “delayed phase” type of insomnia (in which you have difficulty falling asleep plus difficulty waking up in mornings).

CBT-I in a treatment setting

CBT-I is not a structured or manualized treatment, so there isn’t one definitive way to implement it, as you can see above. It can be brief and utilize just two or three components, or be comprehensive and more lengthy. It can be delivered in individual therapy sessions, group sessions, or a combination of both – though most typically individual sessions. The provider doing the treatment is usually a mental health practitioner (psychologist, licensed counselor, social worker) or a primary care provider (physician, nurse practitioner), who is trained in CBT-I. Length of treatment ranges anywhere from 4 to 8 sessions, though some brief behavioral protocols manage to do it in 2 face-to-face sessions and 2 phone calls). The first session is usually focused on assessing the sleep problems and making sure that CBT-I is appropriate. During the first few weeks is also when baseline sleep data is collected and calculated, so no changes to the sleep routine and schedule are typically made at the beginning of treatment. Sleep diaries, or sleep logs, are an important tool for gathering sleep data, and are typically required over the course of treatment. Finally, while it is a highly effective treatment for insomnia, CBT-I is still not a magic wand, and requires consistency and a commitment to following through with the behavioral changes prescribed.

I hope this information about CBT-I has been helpful to you. For links to more resources on insomnia and CBT-I on the web, check out my resources page. There are also books and apps which help you complete this intervention on your own, without needing to meet with a specialist. I think that is a great option for people with mild to moderate insomnia and who don’t have other complicating conditions. If you’ve read through my insomnia guide, you’ll recognize the concepts above, but explained differently. I try to weave together the CBT-I components in a conceptual package that I think makes the most sense, especially for those who are just trying to learn how to fix their sleep, not necessarily learn about CBT-I.

1. Cognitive behavioral therapy (CBT without the I) emphasizes the ability to make meaningful changes in one’s life by addressing maladaptive thoughts and behaviors, rather than by psychoanalyzing the problems.
2. American College of Physicians (ACP), the National Institutes of Health (NIH), and the American Academy of Sleep Medicine (AASM), among others.
3. Bootzin RR. A stimulus control treatment for insomnia. Proceedings of the American Psychological Association. 1972;7:395-6.
4. Hauri P. The sleep disorders. Current concepts. Kalamazoo: Scope Publications, Upjohn; 1977.
5. Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep. 1987;10:45-56. [PubMed: 3563247]
6. Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America. 1987; 10(4), 541-553.
7. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: A meta-analysis of treatment efficacy. The American Journal of Psychiatry. 1994; 151 (8): 1172–80.
8. Perlis ML, Giles DE, Mendelson WB, Bootzin RR, Wyatt JK. Psychophysiological insomnia: the behavioural model and a neurocognitive perspective. J Sleep Res. 1997;6:179–188.
9. Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001 Apr 11;285(14):1856-64.
10. Borbély, AA. A two process model of sleep regulation. Human Neurobiology, Vol 1(3), Oct 1982, 195-204.
11. Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America. 1987; 10(4), 541-553.