Cognitive Behavioral Therapy for Insomnia (CBT-I)

By Douglas McWilliams M.D., Board Certified Psychiatrist – Columbia, MD

Virtual Appointments Across Maryland, Wisconsin, and Virginia

Part I:What is Cognitive Behavioral Therapy for Insomnia (CBT-I)?

Cognitive Behavioral Therapy for Insomnia, commonly called  CBT-I, is a structured, short-term therapy that targets the thoughts, behaviors, and habits that perpetuate chronic sleep problems. Unlike sleep medications that manage symptoms temporarily, CBT-I produces lasting improvements by changing how you think about and relate to sleep.

CBT-I is recommended as the first-line treatment for chronic insomnia by the American Academy of Sleep Medicine, the American College of Physicians, American Psychological Association, and the American Psychiatric Association — above medication. Research shows that 70–80% of people with chronic insomnia experience significant, lasting improvement with CBT-I. This is typically much better than the response rate and relapse rates of any medications intended for long-term improvement in sleep. Despite the overwhelming evidence supporting it, most people with insomnia have never been offered this treatment option.

CBT-I can be delivered effectively through telehealth, making geography less of a barrier than it once was. The real challenge is finding a provider with dedicated training in the CBT-I protocol — it remains a specialized skill, and relatively few clinicians are fully trained to deliver it. If you’re in Maryland, Wisconsin, or Virginia, I work with patients virtually and have years of specific training in CBT-I for chronic insomnia.

Who can benefit from CBT-I?

CBT-I is appropriate for adults who experience:

• Chronic insomnia (difficulty falling or staying asleep at least 3 nights per week for 3+ months)
• Waking up too early and being unable to return to sleep
• Non-restorative or unrefreshing sleep
• Daytime fatigue, mood disturbances, or difficulty concentrating due to poor sleep
• Insomnia co-occurring with anxiety, depression, chronic pain, or other health conditions
• Dependence on or desire to reduce sleep medications

CBT-I is safe for most adults, including older adults and those with co-occurring mental health conditions. In fact, treating insomnia with CBT-I often improves anxiety and depression symptoms as well.

What does a typical CBT-I Protocol Look Like?

A full course of CBT-I typically involves 8-10 sessions over several weeks, and 3-4 long-term follow up sessions to assure long-term effectiveness and stability. People start to see progress around the mid-treatment mark, but many experience meaningful progress earlier.

CBT-I compared to sleep medications:

Sleep medications are effective in the short term, but the research on long-term outcomes shows they are not sustainable. Studies show that medication’s benefits are largely tied to active use: once you stop, sleep deteriorates back to hold patterns, with relapse rates as high as 40% or more in the months after discontinuation.

CBT-I, by contrast, tends to produce improvements that persist after treatment ends, because the underlying problems have been addressed.

What is involved in CBT-I?

A full course of CBT-I typically runs 8-12 sessions and includes several distinct components — each targeting a different mechanism that sustains chronic insomnia. This series of posts walks through each one in depth:

• Assessment & Sleep Diaries: How CBT-I begins, what your therapist is looking for, and why tracking your sleep matters more than you’d think
• Sleep Restriction Therapy: The most counterintuitive — and most powerful — component of CBT-I
• Stimulus Control: Why your brain has learned to stay awake in bed, and how to retrain it
• Cognitive Restructuring: The thought patterns that make insomnia worse, and how to change them
• Relaxation, Sleep Hygiene & Relapse Prevention: The supporting skills that complete the treatment and keep it working

Ready to get started?

If you’re in Maryland, Wisconsin, or Virginia and struggling with chronic insomnia, I offer virtual CBT-I therapy and a free 15-minute phone consultation to help you decide whether it’s the right fit.

References:

Fleming, L., Randell, K., Harvey, C.-J., & Espie, C. A. (2014). Does cognitive behaviour therapy for insomnia reduce clinical levels of fatigue, anxiety and depression in cancer patients? Psycho-Oncology, 23, 679–684.Link

Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, 165, 125–133. Link

Walker, J., Muench, A., Perlis, M. L., & Vargas, I. (2022). Cognitive Behavioral Therapy for Insomnia (CBT-I): A Primer. Clinical Psychology and Special Education, 11, 123–137. Link

Manber, R., Friedman, L., Siebern, A. T., Carney, C., Edinger, J., Epstein, D., Haynes, P., Pigeon, W., & Karlin, B. E. (2014). Cognitive behavioral therapy for insomnia in Veterans: Therapist manual. U.S. Department of Veterans Affairs.