The 5 Most Common Questions People Ask Me About CBT-I

What Is Cognitive Behavioral Therapy for Insomnia?

Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the first-line treatment for insomnia. The approach, described by the Sleep Foundation (2022), consists of the following components: 

• Cognitive restructuring (working with thoughts)
• Behavioral interventions (sleep restriction and stimulus control)
• Psychoeducational interventions (working with a professional who can explain things to you)

When I was going through insomnia, I tried CBT-I twice. Let’s just say it didn't go well. You can read a detailed account of my own experience here.

Since writing my previous blog on sleep restriction, I’ve learned a lot more about sleep and coached a lot more people with insomnia. The many questions I get about CBT-I prompted me to write a more in-depth post that explores the most common among them. Keep in mind, my knowledge is always evolving! So, it’s possible that whatever views I hold today, could change.

In fact, I hope they do — change is the only constant.

Let’s take a look…

1. Does CBT-I Work for Everyone?

CBT-I is considered the go-to treatment for insomnia, but does it work for everyone? The short answer is no, it doesn't. And that’s okay.

While CBT-I is effective for about 75% of people who use it, my experience as a coach and someone who went through the therapy personally suggests a much wider range of outcomes.

Here are a few factors that could be skewing my perception:

1. It's likely that the people who fully recover from insomnia using CBT-I are not interacting with me, so I don't get to hear their success stories. 
   
   
2. Also, those who are currently using CBT-I and finding success are going to stick with it (understandably so). This, too, means they wouldn’t be seeking me out or coming into my community.

But, many people come to me after finding the therapy completely ineffective. Or, they are helped early on, but then sleeplessness returns and they find themselves having to implement sleep restriction all over again.

This is not a particularly sustainable or encouraging model in my opinion.

Because it's touted as the “gold standard” approach, more and more people are becoming aware of CBT-I. This is wonderful because we need WAY more support for the ever-increasing numbers of people struggling with insomnia. In no way do I wish to criticize anyone helping others in the sleep space.

If you are currently finding success with CBT-I, that’s great, absolutely stick with it. But if you are doing the therapy and it’s not helping, you are not alone. Poor outcomes aren’t nearly as unusual as you might think.  

I failed miserably with CBT-I (twice) and still made a full recovery.

You can too.

2.  What Happens if CBT-I Doesn’t Help Me?

If CBT-I doesn’t work for you, cross it off your list and move on to the next thing that will.

One of the things that terrified me when I was going through insomnia was the fear that I was going to run out of things to try. That I'd eventually get to the point where I’d tried so many things that there wouldn’t be anything left to help me.

Plus, when the “gold standard” doesn't even work, how do you not feel hopeless?

Here’s the thing…

Our brains are neuroplastic — they're changing all day, every day, 24/7.

So, you could read a book, do a sleep program, try a behavioral technique, or watch a YouTube video multiple times and your brain is going to experience it differently every single time.

There’s no end to your options for recovering from insomnia.

If something doesn’t work, it’s still a stone on the path. It’s the stone that will lead you to the stone that carries you out of insomnia for good.

Don't lose heart! 

3.  How Long Does It Take for CBT-I to Work?

While it’s hard to say how something will resonate for every single person, my experience with a CBT-I-based app suggests a couple of different outcomes using sleep restriction specifically:

 

1. Some people do well with a restricted sleep schedule and experience improvements rather quickly. A strong sleep drive and more structure is all that is needed to get on a good track again, so improvement can be seen in as little as 1-2 weeks.
   
   
2. Other people go in the opposite direction and regress right away — hyperarousal increases at the mere mention of restricting sleep. For these folks, sleep restriction can be a special form of torture. It’s not helpful in any way and can push a person even further into the fear of not sleeping.
   
   

Which is why I deeply disagree with the use of sleep restriction for some people.

In terms of recovery in general, I always recommend detaching from a timeline as much as possible. Timelines create pressure and performance anxiety, two of the very things that can keep sleep from happening.

As much as we want to control the path, we must also accept that there’s no standard timeline for healing of any kind.

4. Why did CBT-I Make Me Worse?

Unfortunately, this is a question I get asked often and one I desperately wondered as well.

I view insomnia primarily as a fear or anxiety about not sleeping. At some point in time, probably during a stressful life event, we start interacting with sleep differently. Maybe we start doing things to try and sleep, or we start thinking there’s something wrong with our ability to sleep. The brain begins to view being awake at night as a “threat.” This leads to hyperarousal around bedtime which can prevent sleep from happening. 

People with insomnia already have an existing fear of losing sleep. So the idea of further restricting sleep can create a firestorm of panic and anxiety, making sleep even more elusive.

This plunges the nervous system into even higher states of hyperarousal.

Intensified fear combined with the disappointment of the “gold standard” not working can produce feelings of failure or hopelessness. When a stressor goes beyond the nervous systems ability to cope, a trauma may set in, leading to greater states of hypervigilance and arousal around anything having to do with sleep. 

Sadly, I've seen this happen to many people, myself included. 

If you experienced increased levels of fear or anxiety during sleep restriction, you did nothing wrong. It doesn't mean you weren't disciplined, or you didn't try hard enough, or you weren't 100% dedicated to your recovery.

It means that you were SO dedicated that you would have done anything to get better. Pat yourself on the back and give yourself a TON of credit for your courage.

There is a kinder, gentler approach — suffering is NOT required to recover from insomnia.

5. Is CBT-I the Most Effective Treatment for Insomnia?

I think CBT-I can be an effective treatment for insomnia, but it’s not the only approach or even the most desirable one in my opinion. The main flaw I see with CBT-I is its premise that sleep is a controllable process.  

The desire to control sleep is what creates the problem in the first place.

Sleep, by its very nature, is a passive process — it happens in the absence of effort. Trying to control the uncontrollable results in a perpetual state of tug-of-war between sleep drive and hyperarousal. If only we could problem-solve our way to sleep!

In my opinion, CBT-I is essentially sleep hygiene on steroids. And I have yet to meet a single person who recovered long-term from insomnia using sleep hygiene.

Stimulus control and sleep restriction do have merit, but they don't get to the underlying root of insomnia, which is a fear or anxiety about not sleeping.

The cognitive part of CBT-I teaches you to recognize and change the beliefs that affect your ability to sleep. This can be a useful part of recovery. However, I often see this aspect of the therapy skipped altogether or done in a way that isn't particularly helpful for the client. 

In my experience, clients do well once they understand what their brains are doing and why. There is an immediate relief that comes with knowing your brain isn't broken. 

I think one of CBT-I's most beneficial components is its use of Spielman's 3 P model of understanding. The model can bring some useful clarity to the insomnia experience — you can find an easy breakdown of it here.

I hope this brought some insight and answers to your questions! 

Much love,

Beth Kendall MA, FNTP

Holistic Sleep Coach

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DISCLAIMER: I am not a medical doctor and this is not medical advice or treatment. My goal is to empower you with information. Please make all health decisions yourself, consulting sources you trust, including a caring health care professional.