CBT For Insomnia: How Therapy for Sleep Disorders Works

Can’t sleep? Wondering how to fall asleep faster? You’re not alone. One in four Americans develops insomnia each year. For some, sleep problems are a temporary inconvenience – but for others, they are a chronic, and possibly detrimental, concern.

Here are some frequently-asked questions about insomnia, answered – as well as a thorough look into treatment options like cognitive behavioral therapy (CBT) for insomnia, which can provide an effective alternative to sleep medications.

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Is insomnia treatable? How long does treatment for insomnia take?

Yes! Most of my clients are able to resolve their insomnia within nine sessions, without medications. In some cases, we’re able to work through it in a few weeks. If clients are very strict, their insomnia can improve within even just a few days.

The most typical type of insomnia entails lying in bed, worrying about not sleeping, and finding it increasingly hard to fall asleep – this is a pattern that’s very treatable.

What does insomnia treatment entail?

Insomnia treatment has three major steps:

  1. Screening for medical issues and assessing sleep by a qualified provider.
  2. Targeting issues and methods to treat the insomnia particular to your case.
  3. Gradually employing techniques to correct sleep problems.

What happens in the first therapy session for treating insomnia?

First, we assess whether insomnia is due to medical or psychological reasons.

We conduct full evaluation and screening for medical conditions. These include restless legs, snoring, witnessed apneas or leg movements in sleep by bed partner, hypnopompic or hypnagogic hallucinations, cataplexy, sleep paralysis, excessive daytime sleepiness. In some cases, we may need to conduct lab tests to rule out iron deficiency (low ferritin can lead to leg movements at night), kidney pathology, and liver pathology.

We also look at sleep hygiene – is your work space separate from your sleep area? Are you looking at your phone or laptop right before you go to sleep? Does your body know to think of your bed as a space for sleep?

One of the biggest mistakes clients can make is taking a phone and computer to bed. As hard as it seems not to do that, the bright monitor of phones can wake you up. We allow for absolutely no electronics in your bed. If you can’t go to sleep, rather than looking at your computer or phone, it’s more helpful to read a physical book, or something along those lines that is more calming.

Finally, we develop a treatment plan that starts with documenting the client’s sleep experience for one week, and then putting together a sleep schedule.

Find therapists who have specialties in treating insomnia below:

What does documenting sleep look like?

We have patients document what their sleep habits looks like for a week. Although most clients want to reach solutions right away, we can’t dive in until we have more information.

We’ll use iPhone apps, like Sleep Cycle, to track sleep. There are also a few wearables for tracking, which give us more accurate information about people’s sleep.

Some clients may think, for example, they’re only sleeping one hour a night – but it may turn out they’re actually sleeping for four. In some cases, we overblow our sleep issues, when in reality we just need to practically apply some strategies to help us feel rested.

Based on this data, we’ll develop a customized program – for example, having clients not sleep until a certain time, or waking up at a certain time but not taking any naps.

What are some examples of customized programs?

Sometimes it’s as simple as working on sleep hygiene, environment, and thoughts around sleep that can conquer insomnia.

In select patients, we can use a form of sleep restriction or sleep timing program.

If you can’t sleep for the first 30 minutes, get out of bed. For that one night, you may not go to sleep at all, but sleep will eventually be corrected with work on concurrent thoughts and expectations about fatigue.

People may also have their sleep shifted forward and not sleep until very late and we use a form of early awakening to shift the sleep back. Once you set a schedule and you get tired enough, in conjunction with cleaning up your sleep environment and your mental approach, your body starts to associate the bed with sleep.

These programs can be difficult initially because we’re going to make you more tired first. For some clients, for example those with a mood disorder, depression, or bipolar disorder, this is not recommended. But for others, these are some of the ways to reset and jumpstart your sleep schedule.

This is a similar concept as the treatment for many anxiety disorders. We often go towards the insomnia – meaning we physically make you not sleep, to set the groundwork for an eventually healthy sleep pattern.

What is the next session of therapy for insomnia like?

By the second session, the patient can be anxious – and may no longer want to be doing this.  

I tell them that they will be tired – that’s the whole goal.

We’ll evaluate what time they were able to fall asleep. Were they able to fall asleep right away? Were they able to get out of bed then go to sleep when they got sleepy?  Were they able to eventually get to seven to eight hours of sleep?

Then, we develop a plan for the next few weeks from there. Some clients may benefit from having access to video or audio that they can listen to between sessions.

Without a psychiatrist customizing a suggested plan for me, is it possible for me to look at my data and create a plan?

Yes, I think this is possible but would initially run it by your primary care doctor who can be of help or check to see if anything medical is going on. There are many online resources to help examine sleep hygiene or your sleep environment and not remaining in bed for more than 30 minutes when you can’t sleep is typically critical.

It’s important to note that it is tricky to do this on your own. It’s hard not to have someone across from you saying “It’s okay, keep going, this is just like training for a race.” If the person gets really frustrated, they may quit if they’re on their own. That motivation to continue and the support in developing the right treatment plan are what a therapist can help you with.

What are signs that insomnia is getting bad enough that you should speak with a professional about sleep disorders?

Some signs include (but aren’t limited to) falling asleep at the wheel while driving, having suicidal thoughts and/or becoming suicidal, and when sleep deprivation has negative impacts on your social interactions.

When should someone consider sleep medications?

Sleep medications should only be used short term, and under the supervision of a doctor or prescriber – as even those over-the-counter can have numerous risks. I do prescribe sleep medications, but often in very particular situations, or in the context of someone who needs them because of a medical or psychiatric problem that we are working on simultaneously.

What should I look for in a therapist for help with insomnia?

Most importantly, a therapist helping you with insomnia should have training in CBT-i (cognitive behavioral therapy for insomnia). They should conduct thorough assessments to ensure medical conditions are ruled out (alone if qualified or in partnership with your primary care doctor), and develop treatment programs that are individually tailored. Therapists should also provide homework to monitor ongoing progress outside of sessions.

Other resources you recommend?

The following resources may prove helpful for individuals who are struggling with sleep issues:

Find a therapist who specializes in insomnia near you:

Find vetted therapists with specific training in the treatment of sleep disorders on Zencare, below!

On the following pages, you can search by therapist fees and location; watch  introductory videos for each provider; and book free initial calls to find the best insomnia therapist for you.

Note that many therapists who specialize in insomnia treatment have specialized training and education and are less likely to be in-network with health insurances. If you have trouble finding a therapist who takes your health insurance, consider applying for out-of-network benefits from your health insurance to offset the cost of treatment.