Can Talk Therapy Help You Sleep Better?

Addressing the reasons behind insomnia is an alternative to medication

Vladimir Godnik / Getty Images

By:

Sari Harrar

En español

Published January 13, 2022

If bedtime’s a battle with insomnia instead of a refreshing slide into dreamland, here’s news: A short course of therapy — in person, over the phone or online with video — can retrain your brain for better sleep. “Cognitive behavioral therapy for insomnia [CBT-I] is as effective as sleeping pills in the short term and more effective in the long term,” says Michelle Drerup, a sleep psychologist at the Cleveland Clinic Sleep Disorders Center. “It addresses the factors behind insomnia rather than putting a Band-Aid on it.”

For many, it works. Six CBT-I sessions helped more than 60 percent of people in their 30s through 60s with insomnia get improvements like falling asleep faster, waking up less often, logging more sleep and feeling less tired and anxious during the day in a 2020 University of Michigan study. A 2021 study of 29 people in their 60s through 90s found similar results, researchers from the Icahn School of Medicine at Mount Sinai report. The findings are noteworthy for older adults, who face a higher risk for sleep problems and make frequent use of prescription and over-the-counter snooze aids that raise risk for confusion, falls, urinary trouble, constipation and even memory problems. Other recent studies find it works for insomnia in cancer survivors, during menopause and in people with chronic arthritis pain — and can slash risk for insomnia-related depression by 51 percent in older adults, too.

Yet CBT-I may be the best-kept secret in sleep medicine.

“Often, people aren’t aware it exists,” says J. Todd Arnedt, professor of psychiatry and neurology, director of the Behavioral Sleep Medicine Program at the University of Michigan and author of that 2020 study. Research suggests that primary-care doctors may not know about CBT-I or may think people aren't interested in it, even though two major medical groups, the American College of Physicians and the American Academy of Sleep Medicine, recommend it as first-line treatment for chronic insomnia. And people may mistakenly think it will mean months hashing out their feelings on a therapist’s couch. “It’s very different than talk therapy,” Drerup notes. “CBT-I is much more goal-directed. You’re learning a set of skills.”

Inside CBT-I

In CBT-I, a trained therapist helps you assess and change thoughts, beliefs and habits that fuel insomnia. It usually involves four to six sessions. The process reduces stress and anxiety at bedtime, retrains your brain and body to strengthen your natural “sleep drive” so you can fall asleep when you pull up the covers, and even resets your body clock for more regular sleep, Drerup and Arnedt say. Therapy begins with a lesson on the biology of sleep and homework: a daily sleep log that tracks when you got in bed, fell asleep and woke up, and any disruptions. “Data in the sleep log guides treatment and individualizes the plan,” Drerup says. “And we track it to see outcomes.”

You’ll track sleep-robbing thoughts and beliefs — like “I’ll never get to sleep tonight and tomorrow will be lousy” — that can stir up fear, anxiety and stress as bedtime looms. “What happens over time for people, no matter what triggered the insomnia, they develop anxiety and worry around sleep,” Drerup says. CBT-I helps you counter these with real-world replacements such as, “I’ve been OK the next day on less sleep” or “It’s normal to wake up during sleep, I’ll fall asleep again.” Arnedt says: “Unhelpful thinking exacerbates insomnia. People freak out that they won’t be able to function the next day. In extreme circumstances, they call in sick from work or cancel social events. That just feeds the beast. It’s important to keep a balanced perspective and not be extreme about how you think about bad and good nights.”

You’ll also adopt a new sleep schedule. Instead of going to bed earlier in an attempt to get more sleep, you may be asked to stay up later until you feel sleepy and/or to get out of bed if you’re not sleeping. The goal is to “squeeze the wakefulness” out of your sleep routine, accustom your brain and body to solid “consolidated” sleep, and help your mind link your bed with sleeping, not tossing and turning, Arnedt says. That could mean several weeks of short sleep — as little as five or six hours per night, he says — because you’ll also be instructed to get up at the same time every morning. This helps reset your body clock. “Oftentimes you have to go through some challenges. It’s not magic,” he says. Working with a therapist can help you cope. Once you’re sleeping soundly, you’ll add back more sleep time, by going to bed earlier, until you arrive at the best sleep number for you. (Most people need seven to eight and a half hours per night, but the normal range is six to 10 hours, he says.)

Conventional sleep hygiene — like having a quiet, dark, comfortable bedroom and cutting off caffeine early in the day — is covered, but “it’s a small part of CBT-I,” Drerup says. “It’s not effective on its own against insomnia. ... Yes, if I’m drinking a pot of coffee at 5 p.m., it’s probably not good for my sleep. But when people make those changes they can still be frustrated that they can’t sleep.” In fact, if you’ve tried sleep hygiene tips and they haven’t worked, it’s a great time to try CBT-I, she says.

Should you try it?

If you have chronic insomnia, defined as trouble falling asleep or staying asleep three or more nights per week for three months or longer, it’s worth talking with your primary care physician about CBT-I. Same goes if you’ve been taking sleep medication for insomnia and haven’t given CBT-I a try, the experts say. But first, get evaluated for other serious sleep disorders, like obstructive sleep apnea, they add. “There could be multiple reasons you’re having trouble falling asleep,” Arnedt says. Some private insurers cover it, he and Drerup note — but many don’t, so be sure to check whether yours does.

Ask your primary care physician for a referral to a trained CBT-I practitioner, or look for one on the member directory of the Society of Behavioral Sleep Medicine. Sessions don’t have to happen in person. CBT-I via telemedicine video calls were just as effective as in-person appointments in Arnedt’s 2020 study. And audio-only telephone CBT-I was effective in a 2021 University of Washington study of people with insomnia and osteoarthritis. That’s great news if you’re not computer savvy or don’t have a great internet connection. “One of the biggest takeaway messages of our study [is that] this powerful intervention strategy can be effective when delivered over the phone,” says lead study author Susan McCurry, research professor emeritus at the University of Washington.

You can also start with online CBT-I, like the Cleveland Clinic’s Go! to Sleep program. It doesn’t include individual, one-to-one care from a therapist, Drerup notes. “Web programs not guided by a therapist are effective, but not as effective as working one-on-one,” she says. “It’s a really great place for someone who hasn’t been on sleep medications and who’s self-directed. You have the motivation to engage in the program.”

One-to-one sessions are better, she says, if you want to taper off sleep medications during CBT-I or have other health conditions that contribute to sleep problems, such as pain or depression. “It can be hard getting up in the morning if you have depression,” she says. “A computer CBT-I program will say you need a consistent wake time, but it doesn’t problem-solve around it with you.”

Sari Harrar is a contributing editor to AARP publications who specializes in health and science.

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