A bad night usually leads to a reasonable response: go to bed earlier, stay there longer and try to make sleep happen. If the next day is demanding, the stakes rise further. The clock is checked, the remaining opportunity is calculated and every sign of wakefulness begins to feel like evidence that tomorrow will be a disaster.
Unfortunately, sleep is sensitive to exactly this kind of monitoring. Chronic insomnia is not simply the absence of tiredness. Many people are exhausted but physiologically and mentally alert, with the bed having become a place for effort, planning, frustration and threat.
The sleep effort problem
Sleep is an automatic process. We can create conditions that make it more likely, but we cannot perform it on command. The harder someone tries to cross the line into sleep, the more closely they monitor whether it is working. That monitoring recruits wakefulness.
This explains the maddening contrast between dozing on the sofa and becoming wide awake after moving to bed. On the sofa, sleep was allowed to arrive unnoticed. In bed, it becomes a test. The person is no longer simply resting; they are assessing, predicting and trying to control an involuntary state.
None of this means insomnia is “just anxiety”. Pain, medication, hormonal change, breathing disorders, restless legs, alcohol, irregular schedules and many medical or psychiatric conditions can contribute. Assessment matters, particularly when there is loud snoring, gasping, unusual movements, severe daytime sleepiness or a sudden change in sleep.
Why sensible compensation can prolong the problem
After poor sleep, people naturally extend their time in bed, cancel activity, nap and protect the next night by going to bed early. These strategies can be useful during acute illness or brief sleep loss. When insomnia has become chronic, however, they may reduce sleep pressure and make the sleep window less predictable.
Long periods awake in bed also teach the brain an unhelpful association: bed is where we struggle. Cognitive behavioural therapy for insomnia, or CBT-I, deliberately changes that learning. It typically includes a consistent rising time, a carefully set sleep window, leaving the bed when wakefulness becomes prolonged, work on catastrophic beliefs and adjustments to habits that interfere with sleep.
The sleep-window component should be used thoughtfully, particularly where there is bipolar disorder, epilepsy, high falls risk, certain medical conditions or safety-critical work. It is more precise than simply “sleep less”, and individual advice is preferable when the clinical picture is complicated.
What the newer evidence says
A 2024 network meta-analysis compared CBT-I, sleep medication and combined treatment as the initial approach for chronic insomnia. It included 13 trials and 823 participants. CBT-I produced better long-term remission than medication alone, and the evidence did not clearly show that starting with combined treatment was better than CBT-I by itself.
A newer review of CBT for insomnia delivered in ordinary clinical services found improvements broadly comparable with those in tightly controlled efficacy trials. That is encouraging, although most included studies had a considerable risk of bias, so the very large effect sizes should not be treated as a promise to every person.
Medication may still be appropriate, depending on the person, the cause and duration of sleep difficulty, other health conditions and prescriber advice. The more modest point is that chronic insomnia often needs treatment for the processes maintaining it, not only a stronger attempt to produce sedation.
Learning to have an imperfect night
CBT-I includes practical behavioural changes, but there is also an emotional task: allowing a night to be uncertain. People often need to test predictions about what they can and cannot do after poor sleep, reduce clock checking and stop conducting a morning post-mortem that labels the entire day before it begins.
This is not pretending sleep loss has no effect. It is usually unpleasant, and safety decisions still matter. The aim is to replace “I must sleep now or tomorrow is ruined” with a more accurate position: “I would strongly prefer to sleep, and I can rest without forcing the next moment.”
Paradoxically, the night often becomes easier when wakefulness is no longer treated as an emergency. Sleep is then given the conditions in which it does its best work: enough pressure, a stable rhythm and less supervision.
Research drawn on
- Furukawa Y, Sakata M, Furukawa TA, Efthimiou O, Perlis M. Initial treatment choices for long-term remission of chronic insomnia disorder in adults. Psychiatry and Clinical Neurosciences. 2024.
- Öst L-G, Brattmyr M, Enebrink P, et al. Cognitive behavioral therapy for adult insomnia disorder in routine clinical care. Cognitive Behaviour Therapy. 2025.