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Guide XV-123

Sleep in everyday life

A 14 · L 74 · M 1224 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the American Academy of Sleep Medicine (AASM) 2021 clinical practice guideline on behavioural and psychological treatments for chronic insomnia disorder in adults (Journal of Clinical Sleep Medicine, 2021; DOI 10.5664/jcsm.8986; Edinger et al.). Read alongside the European Insomnia Guideline 2023 (Riemann et al., Journal of Sleep Research 32(6), e14035), the American College of Physicians 2016 guideline (Qaseem et al.), NICE HealthTech guidance HTG624 on Sleepio, and NHS and CDC public-health advice. Where these differ, the AASM 2021 grading is used for treatment strength and the European guideline for assessment and cautions.

Sleep is an everyday health behaviour, not a psychotherapy. This guide covers what a psychotherapist does with it: asking about sleep as part of routine care, assessing insomnia and spotting other sleep disorders, giving accurate public-health information, delivering cognitive behavioural therapy for insomnia (CBT-I) only where trained to, referring on, and working with what sleep means in the client's life. The guidelines agree on the core message. Multicomponent CBT-I is the first-line treatment for chronic insomnia in adults: the AASM rates it a strong recommendation, the ACP recommends it as the initial treatment for all adults with chronic insomnia disorder, and the European guideline recommends it for adults of any age, including those with comorbid conditions, delivered in person or digitally [source: AASM 2021 via read.qxmd and Guideline Central; Qaseem et al. 2016; Riemann et al. 2023]. Sleep hygiene on its own is not an effective treatment: the AASM suggests clinicians do not use it as a stand-alone therapy [source: AASM 2021 via read.qxmd].

How change happens, as the CBT-I literature frames it: sleep is regulated by sleep drive and the body clock, and insomnia is kept going by learned arousal in bed, compensatory habits (more time in bed, irregular hours, napping, lying in) and anxious beliefs about sleep. Behavioural components restore the bed as a cue for sleep and consolidate sleep; cognitive components reduce sleep-related worry and unhelpful beliefs [source: Manber & Carney 2015, chapter structure; Riemann et al. 2023]. Full protocol detail belongs to the Domain II guides: cross-refer II 069 CBT-I and II 068 stimulus control and sleep restriction.

2. Framework

This is a therapist-side pathway, not a manualised protocol. The stages below organise what the guidelines say about assessment, treatment and escalation [synthesis, built on the sources cited in each stage].

Stage A: Asking about sleep (every client).

  • Goal: find sleep problems early. CDC advice is that healthcare providers should routinely ask patients about their sleep and discuss problems such as snoring and excessive daytime sleepiness [source: CDC 2016 release].
  • Format: a few questions at intake and at review.
  • Move on when: the client reports regular difficulty falling or staying asleep, early waking, or daytime impairment; when there are signs of another sleep disorder; or when sleep is changing alongside mood.

Stage B: Assessment.

  • Goal: confirm insomnia, judge its duration and severity, and screen for other conditions.
  • What it involves: a clinical interview on sleep and medical history, sleep questionnaires and a sleep diary, which together form the core assessment in the European guideline (Grade A). The guideline advises a diary of at least 7 to 14 days. It names the Insomnia Severity Index as the established severity measure and the Sleep Condition Indicator as an alternative. Actigraphy is not recommended for routine use. Polysomnography is indicated for suspected comorbid sleep disorders and treatment-resistant insomnia, which is a medical decision [source: Riemann et al. 2023].
  • Duration framing: the NHS describes short-term insomnia as lasting under 3 months and long-term insomnia as lasting 3 months or more [source: NHS 111 Wales].
  • Move on when: the diary and interview are complete, and red flags for other sleep, medical, medication or psychiatric causes have either been routed to a doctor or ruled out.

Stage C: Formulation and pathway decision.

  • Goal: choose among delivering CBT-I yourself (only if trained), referring to a behavioural sleep medicine provider or a CBT-I service, a digital CBT-I programme, or medical or sleep-medicine referral first.
  • Criteria: the client's preference; your competence; access; comorbidities. The European guideline urges caution with digital CBT-I in comorbid insomnia, especially with acute mental disorders. NICE says people who are eligible for and can access face-to-face CBT-I should not be referred to Sleepio, and people at higher risk of other sleep disorders, including pregnant people, need a medical assessment first [source: Riemann et al. 2023; NICE HTG624].

Stage D: Treatment.

  • CBT-I is typically four to eight sessions, individual or group, delivered by certified health professionals, mainly clinical psychologists or psychotherapists [source: Riemann et al. 2023].
  • NICE describes Sleepio as weekly interactive CBT-I sessions plus sleep diaries, designed to be completed in 6 weeks [source: NICE HTG624].
  • Components: psychoeducation and sleep hygiene, relaxation, stimulus control, sleep restriction, and cognitive techniques [source: Riemann et al. 2023]. Protocols and parameters are in II 069 and II 068.
  • Move on when: diary and severity measures show improvement and the client can apply the strategies alone. If there is no adequate response, go to Stage E.

Stage E: Review, maintenance and escalation.

  • Goal: relapse prevention, or escalation if CBT-I is not enough.
  • What it involves: medicine is considered only when CBT-I is not sufficiently effective, through shared decision-making with the prescriber [source: Riemann et al. 2023; Qaseem et al. 2016]. Treatment-resistant insomnia is an indication for polysomnography and sleep-medicine review [source: Riemann et al. 2023].
  • The psychotherapist never advises on starting, stopping or changing any medicine [synthesis].

3. Guiding principles

  • CBT-I first. For chronic insomnia, the first recommendation is CBT-I, not sleep tips or medicine. In practice, offer or refer to CBT-I before anything else [source: AASM 2021; Qaseem et al. 2016; Riemann et al. 2023].
  • Sleep hygiene is not a treatment on its own. Give hygiene advice only as one part of CBT-I or as general health information, and do not stop there for chronic insomnia [source: AASM 2021; Riemann et al. 2023].
  • Assess before you intervene. Do not start behavioural sleep changes until other sleep disorders, medical and medication causes, and psychiatric red flags have been screened [source: Riemann et al. 2023].
  • Ask about mental health actively. The European guideline notes that patients may not volunteer mental disorders, so ask about mood, anxiety, trauma, substance use and suicidal thoughts directly [source: Riemann et al. 2023].
  • Stay inside your competence. Deliver CBT-I's active components only after training. Otherwise refer to a behavioural sleep medicine provider; the Society of Behavioral Sleep Medicine keeps regional provider listings and a board-certification route [source: SBSM registries page; competence framing is synthesis].
  • No home-made sleep schedules. Time-in-bed changes belong inside CBT-I delivered by a trained clinician, with the cautions in II 068. This guide gives no schedules or sleep windows [synthesis, consistent with Riemann et al. 2023 cautions].
  • Respect contraindications. Stimulus control and sleep restriction are contraindicated in any form of epilepsy and in conditions that sleep loss could worsen. Evidence for CBT-I in bipolar disorder is insufficient. In practice, route these clients to sleep medicine or a specialist [source: Riemann et al. 2023].
  • Daytime safety. Treatment can increase sleepiness in the early weeks, so review sleepiness and driving. The NHS advises not driving when sleepy [source: Riemann et al. 2023; NHS 111 Wales].
  • Medicines belong to the prescriber. Over-the-counter sleep aids and prescribed hypnotics are for the client to discuss with a doctor or pharmacist; you never advise on them [source: NHS 111 Wales; synthesis].
  • Measure. Use the diary and a validated severity measure at baseline and review, so decisions rest on data rather than impressions [source: Riemann et al. 2023].
  • The client's life sets the frame. Shift work, caregiving, new parenthood, pain, housing, noise and cultural or religious night practices shape what is possible. Formulate with these rather than against them [synthesis; CDC notes employers' role for shift workers].
  • Avoid feeding sleep anxiety. Population sleep-duration recommendations (such as the AASM and Sleep Research Society recommendation reported by CDC) are public-health guidance, not a nightly target. Present them so they do not become a new source of performance worry [source: CDC 2016 release; synthesis on presentation].
  • Combine with existing therapy. Treat insomnia alongside depression, anxiety or trauma work rather than waiting for them to resolve, in line with the guideline's view that CBT-I helps people with comorbidities [source: Riemann et al. 2023; Manber & Carney 2015, chapter on comorbid disorders].

4. Intervention inventory

The guideline-graded treatments are listed below in outline only: multicomponent CBT-I (strong); multicomponent brief therapies, stimulus control, sleep restriction and relaxation (each conditional); and sleep hygiene, which the AASM suggests clinicians do not use alone [source: AASM 2021; Guideline Central summary]. The cognitive techniques are those named by the European guideline [source: Riemann et al. 2023]. The other items are therapist-side procedures (screening, referral, collaboration, meaning-making) marked [synthesis] unless a source is cited. Full protocols for CBT-I and its behavioural components are in II 069 and II 068. Example language throughout is illustrative wording, not drawn from any manual.

4.1 Routine sleep enquiry

  • Purpose / when: finding sleep problems in any client, at intake and at reviews. CDC advises providers to ask routinely about sleep, snoring and daytime sleepiness [source: CDC 2016 release].
  • Steps:
    1. Ask how the client is sleeping, how long it has been like this, and how it affects the day.
    2. Ask about snoring, pauses in breathing seen by a bed partner, and unintended dozing.
    3. Ask about shift work, caregiving, caffeine, alcohol and nicotine.
    4. Record the answers and flag anything that needs Stage B.
  • Example language (illustrative): "Sleep affects almost everything we work on, so I ask everyone. How have your nights been lately, and how are you during the day?"
  • Watch for: clients who play sleep down because it seems minor. It is working when sleep problems are named early and routed to the right stage.

4.2 Structured insomnia assessment

  • Purpose / when: when insomnia is suspected, to confirm it, judge duration and severity, and plan care [source: Riemann et al. 2023].
  • Steps:
    1. Take a sleep history: onset, course, nights affected, what has been tried, and daytime effects.
    2. Take a medical and medication history, then ask about substances and self-medication.
    3. Give a validated severity measure (Insomnia Severity Index or Sleep Condition Indicator), using a licensed copy and not reproducing items.
    4. Start a sleep diary (4.3).
    5. Classify as short-term or long-term using the NHS 3-month framing [source: NHS 111 Wales].
  • Example language (illustrative): "I'd like to understand your sleep properly before we change anything. Can we go through a typical night from evening to morning?"
  • Watch for: daytime impairment that is more than tiredness, such as sleep attacks or collapse with emotion; route these to a doctor. It is working when you have a baseline severity score and a clear picture of the pattern.

4.3 Sleep diary

  • Purpose / when: a prospective record for assessment and for tracking treatment. The European guideline advises at least 7 to 14 days [source: Riemann et al. 2023].
  • Steps:
    1. Explain each field: bedtime, estimated time to fall asleep, wakings, final waking, getting up, naps, caffeine, alcohol, and a rating of the night.
    2. Ask for estimates filled in each morning, not clock-watching through the night.
    3. Review it together each session and look for patterns, not single nights.
    4. App or wearable data can supplement the diary but do not replace it; actigraphy is not for routine use [source: Riemann et al. 2023].
  • Example language (illustrative): "Rough guesses each morning are fine. Please don't check the clock at night, because that tends to wake you up more."
  • Watch for: clock-watching, perfectionism about filling it in, and missed days. It is working when the diary is completed most days and shows patterns you can discuss.

4.4 Screening for other sleep disorders and medical contributors, then routing to sleep medicine

  • Purpose / when: before any behavioural sleep work, because insomnia can coexist with or mask other conditions [source: Riemann et al. 2023].
  • Steps:
    1. Obstructive sleep apnoea: screen with a tool such as STOP-Bang. A positive screen needs a home sleep apnoea test or polysomnography, which a doctor arranges [source: Riemann et al. 2023].
    2. Restless legs: ask about uncomfortable urges to move the legs in the evening. The European guideline names the International Restless Legs Syndrome Study Group scale for severity [source: Riemann et al. 2023].
    3. Ask about parasomnias (sleepwalking, acting out dreams, night terrors), nightmares, narcolepsy features, circadian patterns (very late or very early sleep timing), pain, menopause, thyroid and neurological conditions, and pregnancy [source: NHS 111 Wales; NICE HTG624; synthesis for the list].
    4. Ask about medicines that disturb sleep, alcohol and self-medication [source: Riemann et al. 2023].
    5. Refer to the GP or physician with a short summary. Ask for sleep-clinic referral where another sleep disorder is suspected [source: NHS 111 Wales].
  • Example language (illustrative): "Some of what you describe, the loud snoring and the dozing while driving, is something a doctor should check before we work on your sleep habits. Can I write a short note to your GP?"
  • Watch for: a client keen to skip the medical step. Explain that untreated apnoea or restless legs will limit what therapy can do. It is working when red flags have been routed and medical findings are in your formulation.

4.5 Psychiatric screening around sleep

  • Purpose / when: at assessment and throughout, because insomnia often occurs alongside mental disorders that clients may not volunteer [source: Riemann et al. 2023].
  • Steps:
    1. Screen for depression, anxiety, PTSD and nightmares, and substance use.
    2. Ask about bipolar features: periods of little need for sleep together with raised energy or mood. CBT-I evidence in bipolar disorder is insufficient, so involve the psychiatrist or sleep medicine [source: Riemann et al. 2023].
    3. Assess suicidal thoughts directly using your service's standard risk assessment, especially where insomnia and low mood coexist [synthesis].
    4. Give crisis resources where relevant: 988 (US); Samaritans 116 123 (UK and Ireland).
  • Example language (illustrative): "Sometimes sleep changes go with mood changes. Have there been times you needed very little sleep but felt full of energy?"
  • Watch for: reduced need for sleep without tiredness, which can be an early sign of mania. Contact the treating team the same day if this appears [synthesis]. It is working when comorbid conditions are identified and co-managed.

4.6 Psychoeducation on how sleep is regulated

  • Purpose / when: early on, to give a model the rest of the work builds on. The topics follow the structure of Manber and Carney's CBT-I planner: sleep regulation and the role of arousal [source: Manber & Carney 2015, table of contents].
  • Steps:
    1. Explain two systems in plain words: sleep drive, which builds the longer we are awake, and the body clock, which times sleepiness and alertness.
    2. Explain arousal: worry, effort and frustration in bed keep the brain alert.
    3. Link the client's own habits to the model, for example extra time in bed and naps reducing sleep drive.
    4. Check understanding by asking the client to explain it back.
  • Example language (illustrative): "Sleep isn't something we can force. It's more like hunger. It comes when the conditions are right, and trying hard tends to push it away."
  • Watch for: the client hearing "just relax" as blame. It is working when the client can explain their own pattern using the model.

4.7 Sleep hygiene as one component, never the whole treatment

  • Purpose / when: general health information for anyone, and one part of CBT-I. It is not a stand-alone treatment for chronic insomnia [source: AASM 2021; Riemann et al. 2023].
  • Steps:
    1. Share public-health advice. The NHS lists consistent sleep and wake times, a wind-down before bed, a dark and quiet bedroom, and comfortable bedding. It advises limiting smoking, alcohol, tea and coffee, large late meals and late exercise before bed, avoiding screens just before bed, avoiding daytime naps, and not lying in after a poor night [source: NHS 111 Wales]. CDC adds removing TVs, computers and phones from the bedroom [source: CDC 2016 release].
    2. Choose one or two items that fit the client's pattern rather than handing over the whole list.
    3. If insomnia is chronic, go on to CBT-I or refer, and do not stop at hygiene.
  • Example language (illustrative): "These tips help many people, but on their own they rarely fix long-standing insomnia. Think of them as groundwork for the main treatment."
  • Watch for: rigid rule-following that becomes another source of anxiety, and clients who already "tried everything". It is working when the tips support CBT-I without becoming the focus.

4.8 Formulation and pathway choice

  • Purpose / when: after assessment, to decide who delivers what [synthesis; Manber & Carney 2015 ground treatment planning in case conceptualisation].
  • Steps:
    1. Summarise the factors that started the problem and the factors keeping it going (habits, arousal, beliefs, life demands), plus any comorbidities.
    2. Choose the pathway with the client: CBT-I with you if you are trained; referral to a behavioural sleep medicine provider or CBT-I service; digital CBT-I where suitable (4.9); or medical review first.
    3. Agree how sleep work fits alongside current therapy goals.
    4. Write down the plan and the review point.
  • Example language (illustrative): "From what we've mapped, worry in bed and the long lie-ins are keeping this going. There's a well-tested treatment for exactly that. Let's decide together who's best placed to deliver it."
  • Watch for: pressure to start everything at once. It is working when the client can say what the plan is and why.

4.9 Referral to CBT-I: in person, behavioural sleep medicine, or digital

  • Purpose / when: when you are not trained in CBT-I, when comorbidity calls for a specialist, or when the client prefers another format.
  • Steps:
    1. In-person CBT-I: find a local CBT-I service or a behavioural sleep medicine provider. The Society of Behavioral Sleep Medicine lists providers by region, including telemedicine [source: SBSM registries page].
    2. Digital: in England, NICE recommends Sleepio in primary care for people who would otherwise be offered sleep hygiene or sleeping pills. It should not replace face-to-face CBT-I for people who can access it, and pregnant people and others at higher risk of other sleep disorders need a medical assessment first [source: NICE HTG624].
    3. Weigh the European guideline's findings: guided digital CBT-I outperforms unguided, fully automated programmes have dropout above 50%, and digital CBT-I needs caution in comorbid insomnia with acute mental disorders [source: Riemann et al. 2023].
    4. Check access barriers NICE names, such as no internet, limited digital skills, sensory, cognitive or dexterity impairment, or limited English [source: NICE HTG624].
    5. Keep seeing the client for the other therapy work. Ask for consent to share information with the sleep provider.
  • Example language (illustrative): "The best-supported treatment is CBT for insomnia. I can refer you to someone who specialises in it, or there's a guided online programme. Which suits you better?"
  • Watch for: dropout from digital programmes. Ask about progress at each session. It is working when the client engages with the programme and diary data improve.

4.10 Delivering multicomponent CBT-I (trained clinicians only)

  • Purpose / when: chronic insomnia in adults, including with comorbid conditions. This is the AASM's strong recommendation [source: AASM 2021; Riemann et al. 2023].
  • Steps (outline; full protocol in II 069):
    1. Assessment and diary baseline (4.2, 4.3).
    2. Psychoeducation and sleep hygiene (4.6, 4.7).
    3. Behavioural components: stimulus control (4.11) and sleep restriction (4.12).
    4. Relaxation (4.14) where arousal is prominent.
    5. Cognitive techniques (4.15 to 4.18).
    6. Relapse prevention (4.21). The European guideline describes four to eight sessions, individual or group [source: Riemann et al. 2023]. Choose and order the components from the formulation, as Manber and Carney's case-formulation approach describes [source: Manber & Carney 2015, publisher description].
  • Example language (illustrative): "Over the next several sessions we'll use your diary to make targeted changes. Some will feel hard at first, especially in the early weeks."
  • Watch for: early tiredness, discouragement and diary gaps. It is working when severity scores fall and the diary shows sleep that is more consolidated and less effortful.

4.11 Stimulus control (outline; detail in II 068)

  • Purpose / when: to rebuild the link between bed and sleep when the bed has become a place of wakefulness and frustration. The European guideline describes a set of primary instructions with this aim; the AASM gives a conditional recommendation as a single component [source: Riemann et al. 2023; AASM 2021].
  • Steps (principles only; the full instruction set is in II 068) [synthesis]:
    1. Use the bed for sleep, not for waking activities.
    2. Go to bed when sleepy rather than at a forced time.
    3. If sleep does not come or the client is lying awake and frustrated, get up, do something calm elsewhere, and return when sleepy.
    4. Keep a regular rising time, consistent with the NHS advice not to lie in after a poor night [source: NHS 111 Wales].
  • Contraindications: any form of epilepsy, and conditions that sleep loss could worsen [source: Riemann et al. 2023]. Think about falls risk when getting up at night for older or frail clients [synthesis].
  • Example language (illustrative): "Right now your bed has learned to be a place for lying awake. We want to teach it again that it's for sleep."
  • Watch for: getting up at night becoming a stimulating activity, such as screens or work. It is working when the client finds bed less frustrating and sleep comes more readily.

4.12 Sleep restriction (outline only; no schedule given here)

  • Purpose / when: to strengthen sleep drive and consolidate sleep by limiting time in bed to match the sleep actually being obtained, then extending it gradually as sleep improves. This is how the European guideline describes it; the AASM gives a conditional recommendation as a single component [source: Riemann et al. 2023; AASM 2021].
  • Steps:
    1. Deliver it only inside CBT-I by a clinician trained in it. The time-in-bed calculation, adjustment rules and safety thresholds are in II 068 and are not reproduced here.
    2. Before starting, assess suitability. Review daytime sleepiness and its effect on driving throughout [source: Riemann et al. 2023].
    3. Contraindications: epilepsy and conditions that sleep loss could worsen [source: Riemann et al. 2023]. Bipolar disorder: evidence is insufficient, so involve the psychiatrist or sleep medicine [source: Riemann et al. 2023]. Untreated sleep apnoea and safety-critical jobs need medical input first [synthesis].
    4. If you are not trained, refer (4.9).
  • Example language (illustrative): "This part of the treatment works by building up your natural sleep pressure. It can make you more tired for a while, so we'll plan around driving and work together."
  • Watch for: marked sleepiness, near-misses while driving, and low-mood or manic shifts. Stop and seek medical review if these appear [synthesis]. The European guideline reports more tiredness and reduced vigilance in the first weeks, and a large nurse-delivered trial found no increase in serious adverse events compared with sleep hygiene [source: Riemann et al. 2023]. It is working when sleep becomes more consolidated on the diary.

4.13 Brief multicomponent behavioural therapy

  • Purpose / when: a shorter combined behavioural package, for settings with fewer sessions available. The AASM gives multicomponent brief therapies a conditional recommendation [source: AASM 2021]. The exact contents and session structure of specific brief protocols are [uncertain: not verified].
  • Steps: deliver only from a named protocol and with training. Otherwise refer. Use the same assessment, diary and cautions as for 4.10 to 4.12 [synthesis].
  • Example language (illustrative): "There's a shorter version of the behavioural treatment that focuses on a few key changes. It suits some people well."
  • Watch for: the same cautions as sleep restriction. It is working when diary and severity scores improve over the shorter course.

4.14 Relaxation

  • Purpose / when: to reduce bodily and mental arousal at bedtime. The AASM gives a conditional recommendation as a single component. The European guideline names abbreviated progressive muscle relaxation, autogenic training and imagery as most common, with no single method superior [source: AASM 2021; Riemann et al. 2023].
  • Steps:
    1. Choose a method with the client.
    2. Practise it in session first.
    3. Practise daily at a neutral time before using it at bedtime, so it is a skill rather than a demand to sleep [synthesis].
    4. Review practice in the diary.
  • Example language (illustrative): "We're not using this to knock you out. It's practice in letting your body settle, and sleep tends to follow on its own."
  • Watch for: relaxation-induced anxiety, trauma reminders with body-focused methods (offer eyes open or an alternative), and using relaxation as an effort to force sleep. It is working when the client reports less arousal at bedtime.

4.15 Cognitive restructuring of sleep beliefs

  • Purpose / when: when catastrophic or rigid beliefs about sleep and its consequences drive arousal. Cognitive restructuring is one of the cognitive techniques the European guideline names, and Manber and Carney give sleep-related cognitions their own chapter [source: Riemann et al. 2023; Manber & Carney 2015, table of contents].
  • Steps [synthesis on procedure]:
    1. Collect the thoughts that come up at bedtime and the next day, for example "If I don't sleep tonight, tomorrow will be a disaster."
    2. Examine the evidence against the diary, including days that went acceptably after poor nights.
    3. Build balanced alternatives.
    4. Test them with small behavioural experiments.
  • Example language (illustrative): "Let's check that prediction against your diary. After your worst nights last week, what actually happened at work?"
  • Watch for: reassurance-seeking dressed up as restructuring. It is working when beliefs are held less tightly and bedtime worry falls.

4.16 Cognitive control (worry handled before bedtime)

  • Purpose / when: for clients whose minds race with the day's concerns in bed. "Cognitive control" is named by the European guideline [source: Riemann et al. 2023]. The procedure below is [synthesis] and its fit with the guideline's version is [uncertain: not verified].
  • Steps [synthesis]:
    1. Set aside a short period in the early evening, away from the bedroom.
    2. Write down current concerns and a possible next step for each.
    3. Close the notebook as a sign the work is done for the day.
    4. If worries come up in bed, remind yourself they are already written down.
  • Example language (illustrative): "Give your worries an appointment earlier in the evening, so they don't need to come to bed with you."
  • Watch for: the period becoming long rumination. Keep it contained, and link with any generalised anxiety work. It is working when the client reports less mental activity in bed.

4.17 Paradoxical intention

  • Purpose / when: for clients whose effort to sleep is itself the problem (performance anxiety about sleep). Paradoxical intention is named by the European guideline [source: Riemann et al. 2023].
  • Steps [synthesis]:
    1. Explain that trying to sleep keeps the brain alert.
    2. Invite the client to lie comfortably in the dark and gently let go of the goal of falling asleep, staying quietly awake without screens or activity.
    3. Review what happened to effort and anxiety.
  • Example language (illustrative): "Tonight, rather than trying to sleep, see what happens if you simply rest with your eyes open and let sleep do its own thing."
  • Watch for: confusion with stimulus control. Agree which rule applies when, and do not combine them without a plan. It is working when sleep effort and frustration fall.

4.18 Imagery training

  • Purpose / when: to occupy attention at bedtime with neutral or pleasant imagery instead of worry. Imagery training is named by the European guideline; imagery also appears among its relaxation methods [source: Riemann et al. 2023].
  • Steps [synthesis]:
    1. Build a calm, detailed scene with the client, using several senses.
    2. Rehearse it in session.
    3. Use it in bed when worry starts.
  • Example language (illustrative): "Let's build a scene you can walk through in detail, somewhere calm and a little bit boring, in a good way."
  • Watch for: imagery that turns distressing, for example in trauma. Switch to neutral, non-personal content. It is working when the client can shift attention away from worry.

4.19 Mindfulness and acceptance-based approaches

  • Purpose / when: as an adjunct for clients who struggle with effort and control around sleep. The European guideline reports supporting evidence for mindfulness and ACT but says more research is needed [source: Riemann et al. 2023].
  • Steps [synthesis]:
    1. Introduce non-judging awareness of wakefulness and sleep-related thoughts.
    2. Practise daytime exercises.
    3. Link the practice to reducing the struggle at night, alongside CBT-I rather than instead of it.
  • Example language (illustrative): "What if being awake at 3 a.m. were just a fact for a while, not an emergency?"
  • Watch for: using acceptance as a new technique to force sleep. It is working when the client struggles less with nights.

4.20 Daily rhythm, wind-down and behavioural activation framing

  • Purpose / when: to support regular sleep and wake times, which both NHS and CDC advise, and a calm wind-down, without prescribing exercise or schedules [source: NHS 111 Wales; CDC 2016 release]. The European guideline lists light therapy and exercise as possible adjuncts to CBT-I [source: Riemann et al. 2023].
  • Steps:
    1. Use behavioural activation (II 040) to plan valued daytime activity and social contact, so the day is not organised around tiredness [synthesis].
    2. Agree a personally meaningful wind-down routine.
    3. For physical activity, state that public-health guidelines exist and route to the client's physician or a qualified exercise professional (see IX 061). Give no durations, intensities or frequencies [synthesis].
    4. Light therapy is a medical adjunct; route to the doctor or sleep medicine rather than advising devices [synthesis].
    5. Nutrition and caffeine: give public-health information only. Screen for disordered eating if food or weight comes up, and refer to a registered dietitian or eating-disorder service (National Alliance for Eating Disorders); see IX 103 [synthesis].
  • Example language (illustrative): "Rather than planning the day around how tired you are, let's plan a few things that matter to you, and see how that affects the evenings."
  • Watch for: activity planning that turns into rigid health rules. It is working when the client's days feel fuller and the evenings calmer.

4.21 Monitoring and relapse prevention

  • Purpose / when: throughout treatment and at the end [synthesis; measurement follows Riemann et al. 2023].
  • Steps:
    1. Repeat the severity measure and review the diary at agreed points.
    2. Near the end, write a personal plan: early warning signs, which strategies to restart after a bad patch, and when to come back or see the GP.
    3. Normalise occasional poor nights.
  • Example language (illustrative): "Everyone has bad nights. The plan is about what you'll do so a few bad nights don't turn back into insomnia."
  • Watch for: return of compensatory habits such as lie-ins and long naps after stress. It is working when the client handles setbacks with the plan.

4.22 Collaboration with the prescriber about sleep medicines

  • Purpose / when: when a client takes, wants or wants to stop sleeping tablets or over-the-counter sleep aids. Guidelines place medicine after CBT-I and decide it through shared decision-making [source: Qaseem et al. 2016; Riemann et al. 2023]. The NHS warns that sleeping pills can cause dependence and that over-the-counter aids are only for short-term use [source: NHS 111 Wales].
  • Steps:
    1. Never advise starting, stopping or changing a medicine.
    2. With consent, tell the prescriber that CBT-I is under way.
    3. Support the client in raising their questions with the doctor or pharmacist.
    4. If the prescriber plans a taper, coordinate psychological support around it [synthesis].
  • Example language (illustrative): "That's an important question for your doctor. Shall we write down what you want to ask, and I can let them know we're doing sleep work?"
  • Watch for: stopping medication suddenly without medical advice, and drowsiness affecting driving. It is working when care is joined up and medicine decisions sit with the prescriber.

4.23 Sleep in the client's life: context and meaning

  • Purpose / when: when sleep is shaped by work, family, culture, faith or history [synthesis].
  • Steps [synthesis]:
    1. Map the life context: shift work (CDC notes employers can adjust schedules and support shift workers [source: CDC 2016 release]), caring roles, babies and young children, noise and housing, pain, and menopause [source: NHS 111 Wales lists several of these].
    2. Ask what sleep means to the client: rest, safety, loss of control, or a contested shared space with a partner or family. Ask about cultural and religious practices such as night prayer, fasting periods, napping traditions and co-sleeping, and treat them as fixed points to plan around, not habits to correct.
    3. Where trauma made the night or bed unsafe, coordinate with trauma-focused work.
    4. Use the Cultural Formulation Interview where cultural or religious meaning is central.
  • Example language (illustrative): "Your early prayers matter to you, so let's build the plan around them rather than asking you to give them up."
  • Watch for: imposing one cultural ideal of sleep. It is working when the plan fits the client's actual life and values.

4.24 Daytime sleepiness and driving safety

  • Purpose / when: at assessment and during any behavioural sleep treatment [source: Riemann et al. 2023; NHS 111 Wales].
  • Steps:
    1. Ask about dozing in passive situations and while driving.
    2. Advise not driving or operating machinery when sleepy [source: NHS 111 Wales].
    3. Escalate marked sleepiness to the physician. Follow local rules on driving and medical fitness, where applicable, with medical advice [synthesis].
  • Example language (illustrative): "If you ever feel yourself nodding off at the wheel, please pull over and don't drive until we've discussed it with your doctor."
  • Watch for: minimising near-misses. It is working when sleepiness is monitored and acted on.

5. Handling problems

  • Diary non-completion. Shorten the diary to the essentials, link it to a morning habit, review it at the start of every session, and explore perfectionism or clock-watching [synthesis].
  • No improvement despite good adherence. Re-check for other sleep disorders, medicines and substances, and comorbid mental disorders. Treatment-resistant insomnia is an indication for polysomnography and sleep-medicine review [source: Riemann et al. 2023].
  • Early-treatment tiredness and discouragement. Predict it beforehand. The European guideline reports raised sleepiness in the first weeks. Review driving, and contact the treating clinician if it is marked [source: Riemann et al. 2023; synthesis on response].
  • "I've tried sleep hygiene, it doesn't work." Agree. Explain that guidelines do not treat hygiene alone as a treatment for chronic insomnia, then offer CBT-I [source: AASM 2021; synthesis on wording].
  • The client wants tablets or wants to come off them. Validate the wish, route the question to the prescriber, and never advise on medicines (4.22) [source: Qaseem et al. 2016; synthesis].
  • Sleep anxiety worsens with monitoring or wearables. Drop to minimal recording, reduce checking, and use 4.15 to 4.19 [synthesis].
  • Mood shifts. Reduced need for sleep with high energy suggests possible mania: contact the psychiatrist or treating team the same day and pause behavioural sleep changes. With low mood and hopelessness, assess suicide risk with your service's standard practice and give crisis resources: 988 (US); Samaritans 116 123 (UK and Ireland) [synthesis; bipolar caution from Riemann et al. 2023].
  • Nightmares and trauma. Treat nightmares within trauma-focused care or refer. Avoid body-focused relaxation if it triggers distress [synthesis].
  • Pregnancy and the postnatal period. Medical assessment comes first [source: NICE HTG624 on pregnancy]. Postnatal sleep loss is driven by infant care, so focus on support, sharing night care and mood screening rather than restriction techniques [synthesis].
  • Epilepsy and other conditions sleep loss could worsen. Stimulus control and sleep restriction are contraindicated. Use cognitive, relaxation and educational components and refer to sleep medicine [source: Riemann et al. 2023].
  • Older or frail clients. Think about falls when getting up at night, and coordinate with the physician [synthesis].
  • Shift workers, carers and parents. Formulate around fixed demands and involve the employer or family only with consent [synthesis; CDC 2016 on shift work].
  • Digital programme dropout. Expect it with fully automated programmes. Add guidance through check-ins, or move to in-person CBT-I [source: Riemann et al. 2023].
  • Rupture over referral to a doctor or sleep clinic. Explain the reason (untreated apnoea or restless legs limit therapy), keep the therapy relationship going in parallel, and invite the client's concerns about medicalisation [synthesis].
  • Scope drift into exercise or diet prescriptions. Hold the boundary: point to the existence of guidelines and route to the physician, a qualified exercise professional or a registered dietitian (IX 061, IX 103) [synthesis].
  • You are not trained in CBT-I. Deliver assessment, psychoeducation and support, and refer for CBT-I (4.9). Consider training through recognised behavioural sleep medicine routes [source: SBSM registries page; synthesis].

Sources

Cross-references: II 069 CBT-I; II 068 stimulus control and sleep restriction; II 040 behavioural activation; IX 061 exercise therapy; IX 103 nutritional psychiatry.

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