What Works for Chronic Insomnia?

Find out when you need to go beyond sleep hygiene

Tania Hannan

Updated September 19, 2024

A woman using phone while lying in bed in a dark room

Greg Kessler/Getty Images

You’ve heard it a thousand times: Banish screens at night. Limit caffeine and alcohol. Don’t take long naps. Do take a warm bath. Get regular exercise — but not at night. Make sure your bedroom is quiet, dark and cool. But if you’re someone suffering from long-term insomnia, the usual advice around “sleep hygiene” doesn’t cut it.

These guidelines are “really good for maintaining healthy sleep,” says clinical psychologist Michelle Drerup, director of behavioral sleep medicine at Cleveland Clinic. And if you’re having occasional insomnia — trouble falling or staying asleep — reviewing sleep hygiene may help you fix the problem, she says.

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Short-term vs. chronic insomnia

How CBT-I works

How to find treatment

You might realize, for instance, that your sleepless nights happen after Saturday night dinners, when you eat late and have a couple glasses of wine — or that you started having restless nights when you began taking long afternoon naps or stopped exercising regularly. Given the sleep changes that naturally occur with aging, AARP’s Global Council on Brain Health recommends that people 50 and over practice good sleep hygiene to maintain or improve their sleep.

But basic sleep hygiene advice doesn’t resolve insomnia, Drerup says. She’s referring to chronic insomnia, trouble sleeping at least three nights a week for three months or more.

In fact, sleep hygiene can do more harm than good for people with chronic insomnia, says Meg Danforth, a clinical psychologist and behavioral sleep medicine specialist based in Durham, North Carolina. When patients come to her, often after years of struggling to sleep, they tend to be mired in elaborate, rigid sleep rituals — the usual suspects and then some: “ ‘I listen to whale sounds; I have lavender essential oil. I start getting ready for bed at 6 p.m.; I have a weighted blanket; I've banished my husband,’ ” she recounts.

For sleep experts, it’s no surprise these and other well-intentioned steps only ramp up anxiety and frustration. “The biggest thing that distinguishes someone with [chronic] insomnia from a good sleeper is what we call sleep effort, trying to sleep,” Danforth says. “Sleep is about the only thing in life that does not reward hard work. The harder you work at falling asleep, the worse you will do.”

What does work, then? Cognitive behavioral therapy for insomnia, or CBT-I, an evidence-based toolbox of treatments that restores healthy sleep patterns — or, as Danforth tells clients, “lets your body do what it knows how to do, without you trying so hard.”

Short-term vs. chronic insomnia

CBT-I isn’t for garden-variety, short-term sleep trouble — the occasional night or two spent tossing and turning due to stress, excitement or a late-day cappuccino.

Sometimes life circumstances trigger a bout of insomnia that lingers. “We usually say there are as many initial causes of insomnia as there are human beings,” says Danforth, who teaches CBT-I to other clinicians. “A divorce, a breakup, job stress, studying for a bar exam, retirement, a new baby, a new puppy, an injury, COVID — you name it, right now, someone's experiencing it and not sleeping well as a result.”

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Even insomnia that lasts several weeks, though exhausting, typically doesn’t require treatment. “These short-term bouts of insomnia — the vast majority of the time they will resolve on their own,” Danforth says. “The ship is pretty darn good at righting itself.”

For some people, though, insomnia hangs on long after the initial trigger has passed. When it occurs at least three days a week, for at least three months, it’s classified as insomnia disorder or chronic insomnia — two terms for the same thing. When people pass the three-month mark, “it becomes much more likely that they're going to need some intervention,” Danforth says.

How CBT-I works

Insomnia is a complex disorder, and treating it requires a multifaceted approach that, ideally, is personalized to each patient. Over a series of four to eight sessions, CBT-I therapists work with clients on making changes — some short-term, some long-term — that target key parts of the disorder.

People with chronic insomnia tend to have a weak “sleep drive” — an innate process that, when functioning normally, builds throughout the day and evening, creating the need for sleep. “They’re spending too much time … trying to sleep and not enough time being awake and out of bed and moving around and creating a need for deep sleep,” Danforth says. Chronic insomnia is typically characterized not by the number of hours of shuteye as by sleep inefficiency — a high ratio of time spent in bed versus time sleeping — and poor-quality sleep.

Many people with chronic insomnia also have problems with their circadian rhythm, the biological clock that regulates sleep-wake cycles in response to changes in light. “Either they are early birds trying to keep a night owl schedule or night owls trying to keep an early bird schedule, which never goes well,” Danforth says. “Or they have something that we call ‘social jet lag.’” They have different bedtime and wake times on different days, often workdays and weekends.

Several CBT-I techniques target these issues by having clients temporarily restrict the amount of time they spend in bed, to strengthen their sleep drive. “We want to make the body hungrier for deep sleep,” she says. “That helps you to fall asleep more quickly, to get back to sleep more easily and to produce more deep sleep.” CBT-I also uses “stimulus control,” practices that strengthen the association between being in bed and sleeping, like going to bed only when you’re feeling sleepy, rather than at a set time.

The “cognitive” part of CBT-I involves working with clients to recognize and shift beliefs and thought processes that fuel the disorder. Clients also may learn meditation and relaxation techniques. People with insomnia tend to have an “overactive arousal system,” Danforth says. This presents in a number of ways, including being especially vulnerable to insomnia related to stress or ruminating as soon as your head hits the pillow. Thoughts may bounce from Oh my God, why did I say that? to worries about a friend’s health to angst about how you’ll function tomorrow after another night of crummy sleep — basically, says Danforth, “the hamster wheel of doom.”

Providers tailor therapy to the client’s particular sleep patterns — keeping a detailed sleep diary is usually part of treatment — as well as any additional health conditions they have and their lifestyle, Drerup says. “I have to listen to the patient and really be present in understanding where they’re at and knowing what’s going to work for them.” As one of her former trainees put it: To be an excellent provider you have to become a sort of “CBT-I Jedi master.”

CBT-I works for the majority of people, according to decades’ worth of research, including a meta-analysis of 87 randomized controlled trials reported in 2017 in Sleep Medicine Reviews. “The outcomes are the same whether you're older or younger, whether you’re a man or a woman, whether you have just insomnia or you have insomnia and another sleep disorder, or insomnia and chronic pain, or insomnia and depression,” Danforth says.

What’s especially impressive about CBT-I is its staying power. “People oftentimes continue to see improvement [in sleep] after they finish working with someone,” Drerup says, and the effects tend to last. Research shows that some people still experience benefits 10 years after CBT-I treatment, she says.

How to find treatment

Step one: See your primary-care doctor or, ideally, a sleep medicine specialist for an evaluation if you’re experiencing persistent sleep trouble. It’s important to identify any health issues that may be affecting your sleep. A diagnostic test known as a sleep study can reveal issues like sleep apnea (in which breathing stops and restarts repeatedly during sleep) or restless legs syndrome (marked by uncomfortable sensations in the legs and the urge to move them). Thyroid disorders, depression, anxiety and even acid reflux can disrupt sleep, as can certain medications.

If you rule out medical issues or if your sleep trouble persists despite treatment, ask your doctor or a sleep specialist to recommend a CBT-I provider, or check out the International Directory of CBT-I P roviders. CBT-I is often necessary even after health conditions are addressed, says Drerup, as insomnia can develop a life of its own, even when the initial trigger is no longer there.

There’s one big problem with CBT-I: access. Finding a provider can be difficult, and there’s often a wait to see one, Drerup notes. The rise in telehealth over the last few years has improved access to CBT-I, and some providers offer group therapy. There’s a relatively small group of providers who have extensive training in both sleep medicine and psychology, but there are many other CBT-I providers, including physicians, mental health providers and advanced-practice nurses, Drerup says.

Digital programs have been developed to help fill the void. While digital CBT-I doesn’t allow for the personalization that traditional CBT-I offers, it works well for some people and can be a good first step for someone waiting for a therapist, Drerup says. Choosing among digital CBT-I programs can be tricky, so it’s wise to get a recommendation from a health professional.

CBT-I is a long-term investment, Drerup says. But the potential payoff is worth it: efficient, good-quality sleep and the energy and well-being that goes with it.