Sleep Training for Adults: How CBT-I Rewires Your Brain for Better Sleep

Struggling with insomnia?

When we hear the concept of sleep training, we think of harried, sleepless parents trying to “teach” their infants to sleep through the night. But sleep training for adults is growing in popularity as more of us struggle to get enough Zzzzs and a growing body of research underscores the importance of sleep.

Sleep training is the layman’s term for Cognitive Behavior Therapy for Insomnia.

It’s been around for at least 20-30 years and is now considered “the gold standard of treatment for chronic insomnia,.” says Alberto Ramos, M.D., MS, FAASM, FAAN, a sleep neurologist at the University of Miami Health System.

The American Academy of Sleep Medicine (AASM), the American College of Physicians, and the Sleep Foundation are among the medical organizations that back its use. Most health insurance plans also cover CBT‑I, classifying it as a behavioral health treatment. This includes CBT-I services offered through telehealth.

The therapy is also spreading worldwide. For example, the World Sleep Technology‑Integrative model is a designed to replace fragmented, single‑method sleep interventions with a multi‑dimensional system for improving sleep health. Its foundation? CBT-I.

There’s a good reason for CBT-I’s growing popularity. “It’s an evidence-based therapy that works to retrain you to sleep better,” adds Dr. Ramos, who is also the research director of the Sleep Medicine Program at the Miller School of Medicine. 

And unlike previous treatments, CBT-I “has fewer risks and has been shown to work better in the long-term” — without pills, he says.

Guided by a CBT-trained sleep specialist, the program can last between 6 to 8 weeks. It consists of several components that aim to change the thoughts and behaviors that lead to insomnia.

Sleep Restriction Therapy

This trains the patient to spend less time in bed waiting to fall asleep. In other words, the goal is to match the time you go to bed to the actual amount of sleep you’re getting. “The idea is to eliminate long periods of wakefulness in bed,” Dr. Ramos explains. “You go to bed only when you feel sleepy.” He thinks a better label for this kind of therapy is sleep consolidation because, in truth, the patient is not told to sleep less, only to spend less time tossing and turning.

To tighten the “sleep window” the patient and the clinician will first determine how many hours is actually spent in sleep every night. This information helps to schedule the ideal hour for bedtime as well as the wake-up time. Adjustments can be made every week as needed over the course of the program. Several studies, including a 2021 meta-analysis of clinical trials, have shown that Sleep Restriction Therapy significantly improves sleep efficiency, total sleep time and insomnia severity.

Stimulus control

This reset strategy seeks to help the brain associate the bed with sleep — not eating, worrying, watching TV, reading emails, or scrolling on your phone.

If a patient is unable to fall asleep or fall back asleep after about 20 minutes, he or she is instructed to get out of bed and do a non-stimulating activity, like reading a boring book. The patient shouldn’t “watch the clock” and instead take their cues from how she feels, returning to the bedroom only after feeling sleepy again.

Cognitive therapy

The goal here is to reduce sleep-related worry, so that bedtime doesn’t become a source of anxiety. People who suffer from insomnia can catastrophize about sleep, which increases arousal and makes getting to sleep harder. Cognitive therapy helps people identify and change those thoughts. It is best used with other behavioral modifications, like sleep restriction and stimulus control.

Sleep hygiene

This involves setting up a consistent sleep-wake schedule; keeping the bedroom quiet, dark and cool; avoiding naps, especially late in the afternoon; stopping the intake of caffeine, alcohol and nicotine several hours before bedtime, and exercising regularly to help build sleep drive. While sleep hygiene is not enough for chronic insomnia, it does help with sleep quality and duration.  

Relaxation and stress reduction techniques

Though not the primary drivers of insomnia improvement (as are sleep restriction and stimulus control), employing a stress reduction strategy helps prepare your body for sleep by calming your nervous system. This includes slow breathing, progressive muscle relaxation, different meditation and mindfulness practices, and even yoga and gentle stretching.

Not everyone is an initial candidate for CBT-I, however. People who have sleep apnea, circadian rhythm disorders, chronic pain or certain psychiatric comorbidities must have their condition treated before a clinician can use these strategies.

On the other hand, anyone who has chronic insomnia (defined as having difficulty falling or staying asleep at least three nights per week for at least three months) can benefit from CBT-I. 

That said, “the person has to commit to several sessions over several weeks [of the therapy],” Dr. Ramos adds. “This means following the rules [particularly on sleep restriction and stimulus control], and that can be a challenge for some.”

Written by Ana Veciana-Suarez. Medically reviewed by Alberto Ramos, M.D., MS, FAASM, FAAN.

Tags: behavioral sleep therapy, Dr. Alberto Ramos, sleep and wakefulness, sleep efficiency improvement, sleep retraining techniques