Alternative psychological treatments when CBT-I is not feasible 

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first treatment option proposed to patients with chronic insomnia, but sometimes CBT-I is not accessible or not feasible. In such cases, standard guidelines recommend the following alternatives.

Stimulus Control

  • Stimulus control therapy, a core behavioral component of cognitive behavioral therapy for insomnia (CBT-I), is sometimes also used in isolation as a single intervention. It is designed to reverse conditioned arousal and maladaptive learning that develops when the bed and bedroom become associated with wakefulness, frustration, worry, and effortful attempts to sleep rather. Over time, repeated experiences of lying awake in bed strengthen these negative associations and perpetuate insomnia through classical conditioning mechanisms. Stimulus control aims to dismantle these learned associations and to re-establish the bed as a strong cue for sleep.

    The intervention operates on the principle that sleep should occur as a relatively automatic response to internal sleep drive and external sleep cues, rather than through volitional effort. By systematically restructuring pre-sleep and in-bed behaviors, stimulus control reduces cognitive and physiological arousal at bedtime, which in turn can facilitate sleep initiation and falling back to sleep after nocturnal awakenings.

  • Behavioral changes are implemented through five primary rules:

    • Going  to bed only when sleepy.
      Patients are taught to distinguish sleepiness (e.g., heavy eyelids, head nodding, reduced alertness) from general fatigue or exhaustion. This distinction helps prevent premature bedtimes that prolong sleep onset latency and reinforce wakefulness in bed. Bedtime is delayed until the patient is experiencing clear physiological signs of sleepiness, thereby increasing the likelihood of rapid sleep initiation.

    • Using the bed only for sleep and sex.
       The bed is reserved exclusively for sleeping (and sexual activity) to strengthen the associative link between the bed and sleep. Patients are instructed to avoid activities such as watching television, using electronic devices, reading, eating, working, or worrying in bed. These behaviors commonly become conditioned cues for wakefulness and cognitive arousal in individuals with chronic insomnia.

    • Leaving the bed if unable to fall asleep or return to sleep.
      If the patient is unable to fall asleep or fall back to sleep after a nocturnalawakening, noticing negative mental states or a lack of sleepiness), they are instructed to leave the bedroom and engage in a quiet yet non-aversive activity while awaiting signs of sleepiness. They should return to bed only when clear signs of sleepiness re-emerge. This rule prevents prolonged wakefulness in bed and disrupts the conditioning of the bed as a site of insomnia-related distress.

    • Rising at a consistent time every morning.
      Patients are encouraged to get out of bed at the same time each morning, regardless of sleep duration or quality the previous night. This regular wake time anchors circadian rhythms, stabilizes the sleep–wake schedule, and promotes accumulation of homeostatic sleep pressure for the following night. Lingering in bed while awake is discouraged.

    • Avoid napping.
      Patients are advised to eliminate or strictly limit daytime naps, as napping hinders the build-up of sleep drive and can interfere with nighttime sleep initiation and maintenance. To fight daytime fatigue, patients are encouraged to use alternative alertness-promoting strategies (e.g., light physical activity, exposure to bright light, engaging tasks) rather than sleeping or resting.

  • Stimulus control can initially increase sleepiness and daytime fatigue as patients adjust to delayed bedtimes and consistent rise times. Providers should normalize this transient discomfort and emphasize the importance of adherence for long-term benefit. Clear written instructions, troubleshooting guidance, and supportive coaching improve compliance. Although simple in principle, stimulus control requires careful explanation and reinforcement, as patients often resist leaving the bed when awake or delaying bedtime.

  • When implemented consistently, stimulus control therapy reduces sleep onset latency and wake after sleep onset.

Time in Bed Restriction

  • Time in bed restriction (also referred to as sleep restriction therapy), is a also a core behavioral component of CBT-I that can be used as a single intervention. It is based on the principle that excessive time spent in bed weakens homeostatic sleep drive and perpetuates insomnia by increasing opportunities for wakefulness, conditioned arousal, and negative sleep-related cognitions during the night. By initially limiting time in bed to the amount of sleep a patient can produce at the start of treatment, Time in bed restriction strengthens sleep pressure, promotes faster sleep onset, and reduces nighttime awakenings.

  • The intervention begins with a careful assessment of baseline sleep patterns, typically using 1–2 weeks of sleep diaries:

    An initial time-in-bed “prescription” is then set to closely match the patient’s mean total sleep time, with a minimum time in bed (usually 5–6 hours) to avoid excessive sleep deprivation. Optimal bed and rise times to match the prescribed time-in-bed window are discussed collaboratively with the patient. The patient continues to keep a sleep diary across the intervention. Every 1 or 2 weeks, as sleep efficiency improves and healthy sleepiness resumes, the time-in-bed window is gradually extended in small increments (e.g., 15–30 minutes) until an optimal balance between sleep duration and sleep efficiency is achieved.

  • Although counterintuitive, SRT is one of the most potent CBT-I components and often produces rapid improvements in sleep consolidation. However, it is typically associated with transient increases in daytime sleepiness, fatigue, and irritability during the initial weeks of treatment. Providers and patients should anticipate these effects, normalize them for patients, and emphasize that they reflect the therapeutic mechanism of increasing sleep drive. This intervention may because risks for individuals at elevated risk for adverse effects of sleep loss, including those with epilepsy, bipolar disorder, high fall risk, or safety-sensitive occupations. Such cases would call for careful adaptations or considering other types of interventions. Like stimulus control, SRT benefits from individualized titration, clear written instructions, and ongoing support to optimize adherence and minimize dropout.

Brief Therapies for Insomnia

  • Brief therapies for insomnia (BTIs) are streamlined interventions that prioritize the core behavioral components of CBT-I: typically, stimulus control and/or time in bed restriction. These approaches are designed to increase access to evidence-based care in settings where full CBT-I is not feasible due to time, resource, or workforce constraints.

  • Brief therapies are commonly delivered over 1–4 sessions by a trained provider and may be offered in primary care, specialty clinics, or via telehealth. The structure is highly focused and pragmatic, with rapid implementation of behavioral prescriptions and limited use of formal cognitive techniques. Educational content emphasizes basic sleep regulation, the rationale for behavioral changes, and realistic expectations regarding short-term discomfort and long-term gains.

  • Despite their abbreviated format, brief therapies produce clinically meaningful improvements in sleep onset latency, wake after sleep onset, and sleep efficiency, particularly in patients with uncomplicated chronic insomnia. They may also serve as an entry point to more intensive CBT-I for patients who require additional support.

Relaxation

  • Relaxation therapy is often integrated into CBT-I as an adjunctive component but may be used on its own when CBT-I is not feasible. Relaxation therapy encompasses a range of techniques aimed at reducing somatic tension and cognitive hyperarousal that interfere with sleep initiation and maintenance. It is grounded in the observation that individuals with insomnia frequently exhibit heightened physiological activation (e.g., muscle tension, elevated heart rate) and excessive pre-sleep cognitive activity (e.g., worry, rumination, performance anxiety). Relaxation techniques are used to counter these processes and facilitate the transition from wakefulness to sleep.

  • Common methods include progressive muscle relaxation, diaphragmatic breathing, guided imagery, autogenic training, and mindfulness-based practices. These techniques promote parasympathetic activation, slow breathing and heart rate, and decrease intrusive thought patterns or their impacts. Patients are typically taught one or more techniques during sessions and instructed to practice them daily, first mastering them during the day and subsequently also in the pre-sleep period.

  • While it can reduce pre-sleep arousal and improve subjective sleep quality, its effects on sleep continuity are generally modest when delivered in isolation. Clinical considerations include selecting techniques that match patient preferences and cognitive styles, emphasizing regular practice, and addressing unrealistic expectations (e.g., “trying to relax” as a performance goal). Relaxation therapy may be particularly beneficial for patients with prominent anxiety, stress-related insomnia, or difficulty disengaging from cognitive activity at bedtime.

Clinician/Provider Map for Cognitive behavioural therapy for Insomnia (CBT-I)

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