Addressing Insomnia with CBT-I Works!

You’ve probably heard most of the tips on sleep hygiene by now. No more screens after ten, a cooler bedroom, sticking to regular times, no coffee after 3 p.m. You’ve probably tried them too? Some weeks it seems to help, other weeks you’re awake again at three o’clock, staring at the ceiling and calculating how many hours are left.

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 choice for chronic insomnia. That treatment exists, it is well-researched, and unfortunately, most people who need it will never hear of it. We are 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 hardly works here, if at all. It focuses on the circumstances surrounding sleep, and for most sleep problems, that is 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 CBT-I Does, and Why It Feels Uncomfortable

Cognitive behavioral therapy for insomnia, usually abbreviated as CBT-I, addresses exactly 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.

With stimulus control, the association between bed and sleep is restored. 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.

The fact that it works has now been well documented. Meta-analyses show that people fall asleep faster, stay awake for shorter periods, and see a noticeable improvement in their sleep. And because sleep affects mood, concentration, and quality of life, this effect is not limited to the night. The difference with sleep medication lies mainly in what happens afterward. A sleeping pill works 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, the approach is more effective than medication thanks to the fundamental adjustment of behavior.

The NHG Standard on Sleep Problems, revised in 2024, identifies this behavioral approach as the first-line treatment. The 2023 European insomnia guideline does the same and actually advises against sleep hygiene as a standalone treatment.

Why You Hear So Little About CBT-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.

That has little to do with the treatment and much to do with access. There are simply still too few psychologists and sleep therapists offering CBT-I, the referral route is not always clear for GPs, and waiting lists for specialized sleep care can sometimes stretch to many months in many countries and regions. Meanwhile, the patient isn’t sleeping, and the pattern becomes even more ingrained.

That is also exactly why so much research has been done over the last ten years into CBT-I via a digital route, without a psychologist in the room. Whether that is a full alternative, and where the limits lie, is a story in itself. One that is already being written about extensively, including by us. Sign up for the SleepGrip program that 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?”

Read also: the price of insomnia and how do you know you’re sleeping poorly?

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.