You’ve probably heard most of the tips on sleep hygiene by now. No more screens after 10 p.m., keep the bedroom cooler, stick to a regular schedule, and no coffee after 3 p.m. You’ve probably tried them, too, right? Some weeks it seems to help, but other weeks you’re awake again at 3 a.m., staring at the ceiling and counting down the hours until morning.
Eventually, you go to see your family doctor. He or she listens, nods, and might prescribe a sleeping pill. Or sends you on your way with the advice to try again by sticking to a regular routine.
What usually doesn’t come up in that conversation about insomnia is the name of the treatment that, according to Dutch and European guidelines, is the first-line treatment for chronic insomnia. That treatment exists, it has been well-researched, and, unfortunately, most people who need it will never hear about it. We’re going to talk about cognitive behavioral therapy for insomnia, or CBT-i for short.
Insomnia is different from just having a bad night’s sleep
Everyone has trouble sleeping sometimes. A stressful day, a move, a sick child. That’s only human—and actually quite normal.
Chronic insomnia (or sleeplessness) is something else entirely. It’s a sleep disorder with a fairly precise definition: difficulty falling asleep, staying asleep, or waking up too early—at least three nights a week, for at least three months—and, most importantly, with noticeable effects during the day. Not only fatigue, but also slower thinking, a shorter fuse, and more trouble concentrating or making decisions. In short, it really gets in the way.
Anyone who lies awake in bed night after night, worrying, gradually begins to associate the bed with wakefulness rather than sleep. And the harder you try to fall asleep, the more alert your nervous system becomes. That’s the paradox that anyone with insomnia immediately recognizes: the desperation to fall asleep is exactly what keeps you from doing so.
That’s why sleep hygiene doesn’t work—or hardly works—in this case. It focuses on the circumstances surrounding sleep, and for most sleep problems, that’s exactly enough. With chronic insomnia, the problem lies in the learned pattern itself. It’s exactly as Aline Kruit writes in her book: “Sleeping is doing nothing.” And you’ve forgotten how to do that.
What CGT-i Does, and Why It Feels Uncomfortable
Cognitive behavioral therapy for insomnia, usually abbreviated as CBT-I, addresses precisely that learned pattern. The therapy consists of a few components that sound almost too simple on paper.
With sleep restriction, the time you spend in bed is temporarily reduced to roughly the amount of time you actually sleep. This feels unnatural because you’re already tired. The result is that sleep pressure builds up and sleep becomes concentrated in a single, uninterrupted block again. After that, the sleep window is gradually expanded.
Stimulus control helps restore the association between bed and sleep. Go to bed only when you’re sleepy, get out of bed if you’re lying awake, and get up at the same time every morning. This, too, is easier said than done.
Then there’s the cognitive aspect: the beliefs that fuel the anxiety. “If I don’t get eight hours of sleep, I won’t be able to function tomorrow.” “I’m just a light sleeper.” Those thoughts about sleep aren’t just annoying—they literally keep the system awake.
It has now been well documented that it works. Meta-analyses show that people fall asleep faster, spend less time lying awake, and experience a noticeable improvement in their sleep. And because sleep affects mood, concentration, and quality of life, that effect isn’t limited to nighttime. The main difference from sleep medication lies in what happens afterward. A sleep aid works only as long as you take it, and when you stop, the symptoms usually return. With CBT-i, the effect persists, and in the long term, thanks to the fundamental behavioral changes, this approach is therefore more effective than medication.
The NHG Standard on Sleep Problems, revised in 2024, identifies this behavioral approach as the first-line treatment. The 2023 European Insomnia Guidelines do the same and, in fact, advise against sleep hygiene as a standalone treatment.
Why, then, do you hear so little about CGT-i?
That’s the problem. The treatment is available; it’s been studied; it’s included in the guidelines. And yet the vast majority of people with chronic insomnia don’t receive it.
This has little to do with treatment and a lot to do with access. There are simply still too few psychologists and sleep therapists who offer CBT-i; the referral process isn’t always clear to primary care physicians; and waiting lists for specialized sleep care can sometimes stretch to many months in quite a few countries and regions. In the meantime, the patient isn’t sleeping, and the pattern becomes even more ingrained.
That is exactly why so much research has been conducted over the past ten years on online CBT-i, without a psychologist in the room. Whether this is a fully-fledged alternative—and where its limitations lie—is a story in itself. One that is already being written about extensively, including by us. Sign up for the SleepGrip program, which will be launching soon.
Conclusion
What stands out about this whole issue is not that there is no solution. There is one, and it’s right there in black and white in the guidelines your primary care physician is supposed to follow.
What’s also striking is how many people suffer from poor sleep for years without the name of that treatment ever coming up. If you recognize yourself in the pattern of three nights a week for three months, then the question you should ask your doctor might not be “Can you prescribe something?” but rather “Am I a candidate for cognitive behavioral therapy for insomnia?”
Resources
- Riemann, D. et al. (2023). The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. Journal of Sleep Research.
- Trauer, J. M. et al. (2015). Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Annals of Internal Medicine, 163(3), 191-204.
- NHG Standard on Sleep Problems, 2024 Revision. Dutch College of General Practitioners.
- VZinfo / RIVM, based on the CBS Health Survey 2024. Sleep problems, total population.
- Kempenhaeghe (2024). New NHG Guideline: Working Together for a Better Night’s Sleep.
- Morin, C. M. & Jarrin, D. C. (2022). Epidemiology of insomnia: prevalence, course, risk factors, and public health burden. Sleep Medicine Clinics, 17(2), 173-191.
