Insomnia and sleep difficulties

What is insomnia?

Insomnia is a persistent difficulty with falling asleep, staying asleep, or waking too early, despite having adequate opportunity to sleep. It is not simply the occasional bad night. Clinical insomnia involves sleep difficulties occurring at least three nights per week for three months or more, with significant daytime impairment.

There are several patterns, and many people experience more than one:

• Sleep onset insomnia: difficulty falling asleep at the beginning of the night, often lying awake for 30 minutes or more while your mind races
• Sleep maintenance insomnia: waking repeatedly during the night and finding it hard to fall back to sleep
• Early morning waking: waking significantly earlier than intended and being unable to return to sleep, often accompanied by low mood or dread

Insomnia is common in the UK. Research suggests that around a third of adults experience insomnia symptoms at any given time, with roughly one in ten meeting the criteria for chronic insomnia disorder. It affects people of all ages, though it becomes more prevalent in midlife and is more commonly reported by women.

The impact extends well beyond tiredness. Poor sleep is closely linked to difficulties with concentration, memory, decision-making and emotional regulation. Over time, chronic insomnia increases the risk of developing anxiety, depression and physical health conditions including cardiovascular disease and weakened immune function. It also affects relationships, work performance and quality of life.

Many people with insomnia develop a counterproductive pattern. The more you worry about sleep, the harder it becomes. You associate bed with frustration rather than rest, spend longer in bed trying to catch up, or rely on alcohol and over-the-counter remedies. These strategies are understandable, but they maintain the problem rather than resolve it.

What is CBTi?

Cognitive behavioural therapy for insomnia, known as CBTi, is a structured, evidence-based treatment specifically designed for chronic sleep difficulties. It is not the same as general cognitive behavioural therapy (CBT), although it draws on the same principles. CBTi targets the specific cognitive and behavioural patterns that maintain insomnia.

NICE recommends CBTi as the first-line treatment for chronic insomnia in adults, ahead of sleeping pills or any other medication. This reflects the strength of the evidence: CBTi consistently outperforms medication in clinical trials, produces longer-lasting improvements, and carries none of the side effects or dependency risks associated with sleep medication.

CBTi works by addressing the factors that keep insomnia going, rather than simply sedating you into sleep. Most people with chronic insomnia originally developed their difficulties in response to a trigger, perhaps a period of stress, illness, a new baby, or a life change. The trigger may have passed, but the sleep problem persists because of the habits, thought patterns and associations that built up around it. CBTi systematically dismantles these maintaining factors, and the gains tend to be maintained long after treatment ends.

How CBTi works online

CBTi involves several core components, each targeting a different aspect of the insomnia cycle. Your psychologist will tailor these to your specific sleep pattern and circumstances.

Sleep diary. You will keep a daily sleep diary throughout treatment, recording when you went to bed, how long it took to fall asleep, how many times you woke, and when you got up. This gives your psychologist an accurate picture of your sleep pattern and allows you to track progress objectively.

Sleep restriction. This is often the most powerful component of CBTi. It involves temporarily limiting your time in bed to match the amount of sleep you are actually getting. If you are sleeping five hours but spending eight in bed, your initial time in bed is reduced to five hours. This builds sleep pressure, consolidates your sleep into a single block, and breaks the association between bed and wakefulness. As your sleep efficiency improves, time in bed is gradually increased.

Stimulus control. Stimulus control re-establishes the association between your bed and sleep. The core rules are straightforward: go to bed only when sleepy, use the bed only for sleep, get out of bed if you have been awake for more than about 20 minutes, and maintain a consistent wake-up time every day. These rules retrain your brain to recognise bed as a place of rest, not frustration.

Cognitive restructuring. Insomnia is often fuelled by unhelpful beliefs about sleep, such as “I must get eight hours or I won’t function” or “My sleep is permanently broken.” These beliefs increase anxiety around bedtime, which makes sleep harder, which reinforces the beliefs. Cognitive restructuring helps you identify and challenge these patterns.

Sleep hygiene. While sleep hygiene alone rarely resolves chronic insomnia, it forms a useful foundation. Your psychologist will review factors such as caffeine intake, light exposure, exercise timing and bedroom environment, making practical recommendations where appropriate.

Research consistently shows that online delivery of CBTi is as effective as in-person treatment. For many people, online CBTi is actually preferable. You are working on your sleep in your own environment, you avoid the disruption of travelling to a clinic when already exhausted, and flexible scheduling means sessions can be arranged around your energy levels and commitments.

CBTi vs sleeping pills

NICE recommends CBTi as the first-line treatment for chronic insomnia and does not recommend the routine use of sleeping pills for ongoing sleep difficulties. Sleeping pills sedate the brain, but they do not address the underlying causes of insomnia. When you stop taking them, the sleep problem typically returns, often worse than before. Many also carry a risk of dependence and side effects including daytime drowsiness and cognitive impairment.

CBTi works by treating the root causes. It changes the behavioural and cognitive patterns that maintain the problem, and the improvements tend to last. Follow-up studies show that most people who complete CBTi maintain their gains months and years after treatment ends. You are not dependent on anything external. You have learned skills and changed your relationship with sleep.

If you are currently taking sleeping pills, this does not prevent you from starting CBTi. Your psychologist can work alongside your GP to develop a gradual, supported reduction plan if appropriate.

Our approach

At The Online Psychologists, we treat insomnia as the serious clinical condition it is. All of our psychologists are HCPC-registered clinical psychologists with doctoral-level training. When you get in touch, we take the time to understand your sleep difficulties before matching you with a psychologist who has specific experience in delivering CBTi.

A typical course of CBTi involves six to eight sessions, though this is tailored to your progress. Sessions are 50 minutes, delivered via secure video, and cost £125 each. We offer flexible scheduling, including evening appointments, because rigid daytime slots do not work for everyone when sleep deprivation is already affecting your day.

Because insomnia frequently co-occurs with other difficulties, including anxiety, depression and stress, your psychologist will consider the full picture rather than treating sleep in isolation. Where other difficulties are present, treatment can be adapted to address these alongside the insomnia work.

What to expect in sessions

Assessment. Your first session focuses on understanding your sleep difficulties in detail, including your sleep history, current pattern, what you have tried, and any contributing factors such as anxiety, medical conditions or medication. You will be given a sleep diary to complete before your next session.

Sleep diary review and goal setting. Your psychologist will review your baseline data, set realistic goals with you, and agree on your initial sleep schedule. You will understand the rationale behind every recommendation.

Active treatment. Over the core sessions, your psychologist will introduce the main CBTi techniques, adapting the pace to your response. Each session reviews your sleep diary, discusses how strategies are working, troubleshoots difficulties, and introduces new elements as needed.

Between-session work. CBTi requires active engagement between sessions. You will maintain your sleep diary, follow your prescribed sleep schedule, and practise the techniques discussed. This is where the real change happens. Your psychologist will support you through the challenges, particularly during the early stages of sleep restriction.

Consolidation and relapse prevention. As your sleep improves, sessions focus on gradually extending your time in bed, consolidating gains, and developing a plan for managing any future setbacks.

Frequently asked questions

How long does CBTi take? Most people complete CBTi in six to eight weekly sessions. Some see meaningful improvements within the first two to three weeks. If your insomnia is complicated by anxiety or depression, a slightly longer course may be recommended.

Will I need to stop taking sleeping pills? Not necessarily, and certainly not abruptly. Your psychologist can work alongside your GP to develop a gradual reduction plan if appropriate. Many people find that as CBTi takes effect, they naturally need less medication.

Can CBTi help if I have anxiety too? Yes. Insomnia and anxiety commonly co-occur and fuel each other. CBTi directly addresses sleep-related anxiety, and the cognitive restructuring component helps with worry more broadly. Where anxiety is significant in its own right, your psychologist can integrate elements of CBT for anxiety or recommend further support.

Is online CBTi as effective as face-to-face? Yes. Multiple studies and meta-analyses demonstrate that CBTi delivered via video is as effective as in-person delivery. For many people, online treatment is more practical because you are implementing changes in your own sleep environment.

What if I have tried everything and nothing works? Many people who come to us have tried sleep hygiene tips, apps, supplements and medication without lasting success. CBTi is different because it targets the specific mechanisms maintaining your insomnia. It has a strong evidence base even for longstanding, treatment-resistant insomnia.

Do I need a referral or diagnosis? No. You can contact us directly without a GP referral. If your psychologist identifies concerns that require medical investigation, they will recommend you speak with your GP.

Will I be tired during sleep restriction? Yes, particularly in the first week or two. Temporarily limiting your time in bed can increase daytime tiredness before it improves your sleep quality. Your psychologist will monitor this closely and adjust the schedule as your sleep consolidates.

When to seek help

If you have been struggling with sleep for more than a few weeks and it is affecting your energy, mood or daily functioning, specialist support is worth considering. Insomnia rarely resolves on its own once established, and the longer it continues, the more entrenched the patterns become.

Before starting CBTi, it is sensible to speak with your GP if your sleep difficulties are accompanied by loud snoring, breathing pauses during sleep, restless legs, or excessive daytime sleepiness. These may indicate an underlying sleep disorder that requires medical assessment.

If you are experiencing a mental health crisis, please contact your GP, the Samaritans (116 123) or emergency services (999).

If you are ready to address your sleep difficulties, get in touch and we will match you with a clinical psychologist who can help.