Cognitive Behavioural Therapy for Insomnia (CBT-I) - An Effective, Drug Free, Evidence-Based Approach for Long-Term Insomnia by Dr Kari Nightingale
As so many of my patients often struggle with sleep, I wanted to delve deeper into other ways I could help them. Having searched around for good professional courses, I found myself late last year with a group of like-minded clinicians doing a master class in CBTi for Insomnia, run by Oxford Uni. It was fantastic and has given me extra tools to help my patients – without needing to rely on medication.
Sleep problems are extremely common, particularly during periods of stress or hormonal change, and they can easily become self-perpetuating. Cognitive Behavioural Therapy for Insomnia (CBT-I) is an effective evidence-based approach for long-term insomnia and focuses on gently retraining both the body and the brain to sleep more naturally. Two of its core techniques I will outline today are stimulus control and sleep restriction therapy, which can have a powerful impact on restoring healthy sleep patterns.
Stimulus control is based on the idea that the bed and bedroom should act as strong cues for sleep. Over time, however, many people begin to associate the bed with wakefulness instead—lying awake worrying, replaying the day, clock-watching, or actively trying to force sleep. When this happens, simply getting into bed can trigger alertness and stress rather than relaxation. This is a learned response, similar to the classic example of Pavlov’s dogs, who began to salivate purely at the sound of a bell, after it had been repeatedly sounded when food was brought to them for a period of time. In the same way, if the bed becomes linked with poor sleep, frustration, or anxiety, it can start to provoke wakefulness automatically.
The aim of stimulus control is to break this association and rebuild the link between bed and sleep. In practice, this means going to bed only when genuinely sleepy, rather than simply because it feels like “the right time.” The bed is kept for sleep (and sex) only, with activities such as watching television, working, eating, or scrolling on phones moved elsewhere. If sleep does not happen within a short period—around 15 minutes—it is better to get out of bed and sit somewhere quiet and dimly lit, doing something calm and low-key until true sleepiness returns. Preparing this space in advance can make it easier to follow through, for example by having a comfortable chair, a blanket, and a book ready. A consistent wake-up time each morning is also essential, as is avoiding daytime naps, even after a poor night. Together, these steps help the brain relearn that bed equals sleep, not struggle. If stimulus control alone does not lead to improvement after a few weeks, sleep restriction therapy might be tried, depending on your type of insomnia.
Despite its name, sleep restriction is not about depriving someone of sleep, but about consolidating it. When people spend long periods in bed awake, sleep becomes lighter, more fragmented, and less efficient. Sleep restriction works by temporarily limiting time in bed to more closely match the amount of sleep a person is actually getting, which increases sleep “pressure” and encourages deeper, more continuous sleep.
This process always starts with a fixed wake-up time, which anchors the body clock. Bedtime is then adjusted so that time in bed reflects current sleep duration, sometimes with a small buffer added. This may mean going to bed very much later than the person suffering with insomnia is currently doing, which might sound counter-intuitive. However, as sleep becomes more settled and efficient—typically measured by the proportion of time in bed actually spent asleep—time in bed is gradually extended in small steps. Over time, this allows bedtime to move earlier again while maintaining good-quality sleep.
The early stages of sleep restriction can feel challenging, particularly when staying awake until a later bedtime. However, many people report that after an initial adjustment period, they begin to feel genuinely sleepy at night and develop a renewed sense of confidence in their ability to sleep. In this way, sleep restriction is often one of the fastest and most effective components of CBT-I, although it should be tailored carefully and used with appropriate guidance in certain situations.
Using techniques like these, and/or numerous other CBTi strategies you can help reset the sleep system by strengthening natural sleep drive, stabilising the body clock, and reducing the anxiety and effort that so often surround insomnia. While insomnia can feel entrenched and overwhelming, these approaches show that sleep is not lost—it can be retrained.
For those interested in hearing a spoken explanation about these techniques, and more fascinating information about sleep, you might want to listen to sleep researcher Matthew Walker who recently released a podcast episode called A Practical Guide to Insomnia, which offers a clear and helpful explanation of how insomnia develops and how these techniques work in practice.
I know I can use these techniques both for myself, and also for my patients. For many, CBTi, when used with a motivated attitude and with professional guidance, can offer a sense of freedom from what can feel like the heavy chains of insomnia.
Dr Kari Nightingale
GP and British Menopause Society accredited menopause specialist. Accredited lifestyle medicine doctor.
https://www.menopausecare.co.uk/associate-dr-kari-nightingale