By Douglas McWilliams, MD| Columbia, MD | Virtual Appointments Across Maryland, Wisconsin & Virginia
This is Part 2 of a series on Cognitive Behavioral Therapy for Insomnia (CBT-I). Start with Part 1 → for an overview of what CBT-I is and how it compares to sleep medication.
It Starts With an Assessment
Chronic insomnia is not one-size-fits-all. One person taking hours to fall asleep has a different clinical picture than another person who wakes up at 3 AM unable to return to sleep. Someone whose insomnia relates to a stressful life event may need a different treatment than someone whose insomnia has persisted for twenty years with no clear trigger.
A thorough assessment gives your doctor the information needed to tailor the CBT-I protocol to your specific needs and identify any factors (medical, psychological, or behavioral) that may be contributing to your sleep difficulties. It may also uncover reasons why CBT-I may not be the best option for treatment.
What a CBT-I Assessment Covers
In the first session or two, your doctor will ask about:
Your sleep history and current pattern
- How long you’ve had insomnia, and whether there was a triggering event
- What your sleep looks like on a typical night (bedtime, time to fall asleep, number of awakenings, wake time)
- Whether your insomnia is characterized by difficulty falling asleep (onset), staying asleep (maintenance), or both
- How much your sleep varies night to night
Daytime impact
- How insomnia affects your mood, energy, concentration, and daily life
- Whether fatigue drives daytime napping (and how that might be affecting nighttime sleep)
Sleep-related behaviors and beliefs
- What you do when you can’t sleep (stay in bed? Watch TV? Check your phone?)
- How much time you spend in bed relative to how much you sleep
- What thoughts and worries you have about sleep — including fears about the consequences of poor sleep
Medical and psychiatric history
- Any conditions that may affect sleep (chronic pain, depression, anxiety, sleep apnea, restless legs)
- Current medications, including any sleep aids
- Caffeine, alcohol, and substance use
Screening for other sleep disorders
CBT-I is designed for insomnia. If symptoms suggest another sleep disorder — obstructive sleep apnea, restless legs syndrome, a circadian rhythm disorder — your doctor will note this and may recommend a different approach.
The Sleep Diary: Your Most Important Tool
Before any behavioral interventions begin, you’ll be asked to start keeping a sleep diary. This is a daily log you complete each morning that tracks the previous night’s sleep. Most CBT-I protocols collect at least one to two weeks of diary data before beginning the active treatment components.
A standard sleep diary tracks:
- Time you got into bed
- Time you turned out the lights and tried to sleep
- How long it took to fall asleep (your estimate — not the clock)
- Number of times you woke during the night
- Total time spent awake during the night
- Final wake time
- Time you got out of bed
It does not ask for clock-watching precision, just an estimate.
What the Sleep Diary Reveals
The sleep diary provides crucial information:
It helps correct memory bias. People with insomnia reliably underestimate how much they actually sleep. The experience of lying awake feels longer and more continuous than it often is. After two weeks of honest sleep diary data, many people are surprised to find they’re sleeping more than they initially thought. This doesn’t mean the insomnia isn’t real, but helps draw attention towards the ways insomnia can negatively distort perception.
It reveals problematic patterns. Is your sleep worse on Sunday nights? Better when you’ve exercised? Worse after alcohol? The diary makes these connections visible in a way that retrospective memory cannot.
It gives you a calculation of sleep efficiency. This is the most clinically important number derived from the sleep diary. Sleep efficiency is the percentage of time in bed you actually spend sleeping.
Sleep Efficiency = Total Sleep Time ÷ Total Time in Bed × 100
For example: if you spend 10 hours in bed but sleep only 5.5 hours, your sleep efficiency is about 55%. Healthy sleepers typically have a sleep efficiency of 85% or above. This number directly informs one of the most powerful interventions in CBT-I — sleep restriction therapy — which is the subject of the next post in this series.
It creates a baseline. It gives you data that can be measured and graphed to show changes over time — and hopefully improvement with treatment.
Sleep Education: Understanding What’s Happening
Alongside the diary, the early phase of CBT-I focuses on psychoeducation. This is a scientific discussion of sleep that explains the rationale for the interventions that follow.
Key concepts your therapist will cover include:
The two-process model of sleep regulation. The circadian rhythm (an internal biological clock that determines when you feel alert or sleepy across a 24-hour cycle) and sleep drive (a homeostatic pressure that builds the longer you’ve been awake and dissipates during sleep).
Sleep architecture. How normal sleep cycles through different stages and how this can become impaired.
Hyperarousal. A chronically elevated state of physiological and cognitive activation that causes difficulty relaxing and increased anxiety.
Common sleep myths. Many false beliefs people hold about sleep are factually incorrect and clinically harmful.
What Comes Next
Once the assessment is complete and two weeks of sleep diary data have been collected, the active phase of CBT-I begins. The next intervention — and for many people the most impactful — is sleep restriction therapy: a structured, counterintuitive approach to consolidating sleep that produces results within weeks. This will be discussed in Part 3.
Working with a CBT-I Therapist in Maryland, Wisconsin, or Virginia
CBT-I can be delivered effectively through telehealth, making geography less of a barrier than it once was. The real challenge is finding a doctor with dedicated training in the CBT-I protocol — it remains a specialized skill, and relatively few clinicians are fully trained to deliver it. I provide virtual CBT-I therapy to adults across Maryland, Wisconsin, and Virginia and offer a free 15-minute phone consultation to answer your questions.
Disclaimer: This blog post is for informational purposes only and does not constitute medical or mental health advice. Please consult a licensed healthcare professional for evaluation and personalized treatment recommendations.