Therapy for insomnia: CBT-I, sleeping without pills and finding help online

When do bad nights become insomnia?

The NHS says you have insomnia if you regularly^[3]:

• find it hard to go to sleep
• wake up several times during the night
• lie awake at night
• wake up early and cannot go back to sleep
• still feel tired after waking up
• find it hard to nap during the day even though you’re tired
• feel tired and irritable during the day
• find it difficult to concentrate during the day because you’re tired

Insomnia lasting less than 3 months is called short-term; 3 months or longer is long-term^[3]. The US National Heart, Lung, and Blood Institute (NHLBI) describes chronic insomnia as sleeplessness on 3 or more nights a week for more than 3 months that cannot be fully explained by another health problem, and notes it happens “even if you have the time and the right environment to sleep well”^[4]. NHS Every Mind Matters adds that a few nights of bad sleep are usually nothing to worry about^[10].

Why do stress and worry keep you awake?

Stress, anxiety or depression come first in the NHS list of the most common causes of insomnia, which also includes noise, a room that is too hot or cold, alcohol, caffeine, jet lag and shift work^[3]. NHS Every Mind Matters explains that when you feel stressed or anxious, your body may feel more alert and your mind may be full of worrying thoughts^[10]. The NHLBI names worries about school or work, relationships, money or the death of a loved one, and adds a trap many poor sleepers know: “Worrying about whether you will get enough sleep and watching the clock can also raise your risk of insomnia or make it worse.”^[5]

If daytime worry or low mood is the bigger problem, our pages on anxiety and stress and depression explain the help for those.

What is CBT for insomnia (CBT-I)?

The American Academy of Sleep Medicine describes CBT-I as a specific type of cognitive behavioural therapy that “addresses the thoughts and behaviors that keep you from sleeping well”^[7]. The NHLBI calls it a 6- to 8-week plan to help you fall asleep faster and stay asleep longer, and lists its parts^[6]:

• Cognitive therapy helps you feel less nervous about not being able to sleep.
• Relaxation or meditation therapy teaches you how to relax and fall asleep faster.
• Sleep education helps you learn good sleep habits.
• Sleep restriction therapy gives you a set amount of time in bed, which is increased as your sleep improves.
• Stimulus control therapy helps you link bed with sleep: going to bed only when sleepy, getting up if you cannot sleep, and using the bed only for sleep and sex.

The Academy’s guideline says treatment is guided by a sleep diary you keep throughout, and typically runs 4 to 8 sessions^[1]. Improvement is usually gradual, but “the benefits are durable beyond the end of treatment”^[1]. Shorter behavioural programmes of 1 to 4 sessions also exist^[1].

Is therapy for insomnia better than sleeping pills?

Guidelines put therapy first. The American College of Physicians recommends CBT-I as the initial treatment for chronic insomnia in all adults (a strong recommendation, based on moderate-quality evidence). Where CBT-I alone has not worked, it recommends that patient and doctor decide together whether to add medicine, weighing benefits, harms and costs (a weak recommendation, based on low-quality evidence)^[2]. The American Academy of Sleep Medicine gives multicomponent CBT-I its only strong recommendation, and suggests not relying on sleep hygiene tips on their own as a treatment for chronic insomnia^[1].

On medicines, the NHS says GPs now rarely prescribe sleeping pills for insomnia, because they can have serious side effects and you can become dependent on them; when they are prescribed, it is only for a few days, or weeks at the most, if insomnia is very bad or other treatments have not worked^[3]. Pharmacy sleep aids “cannot cure insomnia” and should not be taken for longer than 1 to 2 weeks^[3], and the NHLBI says research has not proven that melatonin is an effective treatment for insomnia^[6]. Whether to start, change or stop any sleep medicine is a decision to make with a doctor; the NHS says to check with your doctor before taking anything for sleep problems^[3]. Don’t stop a prescribed sleep medicine without talking to your doctor first: the American Academy of Sleep Medicine notes that stopping some drugs can bring withdrawal symptoms, including insomnia^[7].

What can I try myself tonight?

The NHS says insomnia usually gets better by changing your sleeping habits, and suggests^[3]:

• only going to bed when you’re sleepy
• waking up and getting out of bed at the same time every day
• relaxing for at least 1 hour before bed, for example with a bath or a book
• keeping your bedroom dark and quiet
• exercising regularly during the day, but not in the 4 hours before bed
• no alcohol, tea, coffee or smoking in the 6 hours before bed
• no big meal late at night, and no screens right before bed
• not napping during the day
• not sleeping in after a bad night, but keeping to your usual hours

It also says not to drive when you feel sleepy^[3]. Our guidance: if a racing mind is what keeps you up, the stimulus control rule above, getting up rather than lying there, can be hard to stick to alone; a therapist trained in CBT-I can help you keep to it.

When should I see a doctor about sleep?

The NHS advises seeing a GP if changing your sleeping habits has not helped, you have had trouble sleeping for months, or insomnia is making it hard to cope with daily life^[3]. A doctor will look for the cause, because insomnia can come from conditions such as restless legs syndrome, an overactive thyroid, the menopause, long-term pain or many medicines^[3].

See a doctor too if your breathing stops and starts while you sleep, you make gasping, snorting or choking noises, or you always feel very tired during the day: these are main symptoms of sleep apnoea, which the NHS says can be serious if it is not diagnosed and treated^[11]. NICE says people who may be at higher risk of other sleep disorders, such as in pregnancy, should have a medical assessment before being referred to Sleepio, a digital CBT-I programme^[8]. A therapist cannot diagnose these conditions.

Is CBT-I right for everyone?

Not always in its standard form. The American Academy of Sleep Medicine says sleep restriction therapy may be unsuitable for people in high-risk jobs, such as drivers or heavy machinery operators, and for people prone to mania or hypomania or with poorly controlled seizures^[1]. Early in treatment, people can feel more tired, sleepy, irritable or unfocused, though these effects usually ease by the end^[1]. Our guidance: if any of this applies to you, tell the therapist at the start, and involve your doctor.

Can CBT for insomnia be done online?

Yes. The American Academy of Sleep Medicine says CBT-I visits “can be performed in person, using video/telemedicine, and even using programs available online”^[7], and the NHLBI says it can be done in person, by telephone or online^[6]. The Academy’s guideline found too little evidence to recommend one delivery method over another; it says one-to-one, in-person CBT-I from a trained provider is the most studied^[1]. In the UK, NICE recommends Sleepio, a digital self-help programme that includes CBT-I, in primary care for people who would otherwise be offered sleep hygiene or sleeping pills, but notes there is no direct evidence comparing it with face-to-face CBT-I^[8]. Unlike a programme such as Sleepio, Bliss Therapy means a live 50-minute video call with a psychologist each time: 20 there list sleep problems, from €35 (about £29), and 15 of them list CBT. For how online CBT works in general and what it costs, see online CBT therapy.

How do I get help for insomnia where I live?

Wherever you live, a family doctor is usually a good first step, especially for sleep: they can rule out medical causes and tell you what is available and covered locally. You can also go straight to a private therapist, in person or online. On Bliss Therapy, for example, sessions with a psychologist who lists sleep problems start from €35 (about £29), though no therapist replaces a doctor ruling out a medical cause.

In the UK. A GP may offer CBT, face to face with a therapist or through an online self-help programme, and can refer you to a sleep clinic if you have signs of another sleep disorder such as sleep apnoea^[3]. In Scotland, NHS inform suggests trying an online CBT course such as Sleepio^[12]. If stress, anxiety or depression is behind your sleeplessness, and you live in England, you can refer yourself to NHS talking therapies for anxiety and depression if you are registered with a GP and aged 18 or over (16 or over in some areas)^[13]. For every route, see how to find a therapist in the UK.

In the US. Start with a primary care provider, who can check your health and refer you on, and ask your insurer which providers your plan covers^[14]. HealthCare.gov says Marketplace plans must cover behavioural health treatment, including psychotherapy and counselling, with benefits depending on your state and plan^[17]. FindTreatment.gov lets you search for care confidentially^[15], and SAMHSA’s National Helpline, 1-800-662-4357, offers free referrals around the clock^[16]. If sleeplessness comes with thoughts of suicide, call or text 988^[18].

How do I find a therapist who offers CBT-I?

Ask directly whether they deliver CBT-I, not just CBT in general. The American Academy of Sleep Medicine notes that patients may struggle to locate a skilled CBT-I provider in their region^[1], and points to the Society of Behavioral Sleep Medicine directory of providers who offer CBT-I^[7]. Our guidance: good first questions are whether they will ask you to keep a sleep diary, whether they use stimulus control and sleep restriction, how many sessions they expect, and how they will work with your doctor if a medical cause needs checking. You can put those questions to psychologists on Bliss Therapy in a free first session, which 9 of those who list sleep problems offer; their profiles show methods, languages and price. For the difference between psychologists, psychiatrists and counsellors, see who does what.

Therapy for insomnia on Bliss Therapy

20 English-speaking psychologists on Bliss Therapy list sleep disorders on their profiles. Their 50-minute online sessions start from €35 (about £29), the middle price is €55 (about £46), and 9 offer a free first session. 15 of them list CBT and 11 list mindfulness-based approaches.

• You pick the therapist yourself; every profile shows their methods, languages and price.
• 9 offer a free first session, a chance to ask whether they offer CBT-I before you pay anything.
• You pay per session, with no subscription, and book online.
• Between them they speak 13 languages, so you can describe your nights in the language you think in.

Bliss Therapy is not a sleep clinic. Our psychologists do not diagnose sleep disorders such as sleep apnoea and do not prescribe sleeping pills, and listing sleep disorders does not make them sleep specialists: ask each one whether they offer CBT-I and how they have trained in it. If you have signs of a medical sleep problem, see a doctor first^[11]. For a sense of what a full course could cost, see online therapy costs.

Our therapists are based outside the UK and the US, so they are unlikely to be on UK registers, and their sessions are unlikely to be covered by US health insurance. Ask about their training and their registration in the country where they practise.