ANCSLEEP BLOG

What to Do When CBT-I Fails: Next Steps for Persistent Insomnia

Cognitive behavioral therapy for insomnia, commonly called CBT-I, is often considered a first-line treatment for chronic insomnia. But what happens when you complete CBT-I and still struggle to fall asleep, stay asleep, or wake up feeling rested?

First, it is important to know that ongoing insomnia does not necessarily mean you “failed” CBT-I. Insomnia is complex, and sleep problems can have multiple causes. Some people need more time, additional support, modifications to their treatment plan, or evaluation for another underlying sleep or medical condition.

If CBT-I has not provided the improvement you expected, the next step is to better understand why.

What Is CBT-I?

CBT-I is a structured treatment designed to help address the thoughts, behaviors, and habits that contribute to chronic insomnia.

Unlike simply following general sleep hygiene recommendations, CBT-I typically uses several techniques to improve the relationship between your bed, your sleep habits, and your ability to fall asleep.

Common Components of CBT-I

CBT-I may include:

• Sleep restriction or sleep compression
• Stimulus control
• Cognitive restructuring
• Relaxation techniques
• Sleep scheduling
• Education about sleep and insomnia

CBT-I Takes Time and Consistency

CBT-I does not usually work overnight. Some components, particularly sleep restriction or sleep compression, may temporarily make you feel more tired before your sleep begins to improve.

For this reason, completing treatment consistently and giving the techniques adequate time to work is important.

Does CBT-I Ever Fail?

CBT-I can be highly effective for many people with chronic insomnia, but no treatment works for everyone.

If your sleep has not improved, there may be several possible explanations.

The Treatment May Need to Be Adjusted

Insomnia treatment is not always one-size-fits-all. Your sleep schedule, work hours, medical conditions, medications, and other factors may affect which strategies are most appropriate.

Your Sleep Window May Not Be Appropriate

Sleep restriction and sleep compression involve limiting time in bed to better match the amount of sleep you are actually getting. If the schedule is too restrictive or does not fit your lifestyle, it may be difficult to maintain.

A qualified provider may be able to adjust the approach based on your individual sleep patterns.

You May Have an Undiagnosed Sleep Disorder

Insomnia symptoms can sometimes overlap with other sleep disorders.

For example, a person may believe they simply have difficulty staying asleep when repeated awakenings are actually being caused by a breathing or movement disorder.

Potential conditions that can interfere with sleep include:

• Obstructive sleep apnea
• Restless legs syndrome
• Periodic limb movements
• Circadian rhythm disorders
• Parasomnias

Learn more about the sleep disorders evaluated by Anchorage Sleep Center.

Could Sleep Apnea Be Affecting Your Sleep?

Sleep apnea can cause repeated disruptions in breathing throughout the night. Some people wake up frequently without realizing that breathing disturbances are occurring.

Symptoms may include:

• Loud snoring
• Gasping or choking during sleep
• Witnessed pauses in breathing
• Morning headaches
• Excessive daytime sleepiness
• Frequent nighttime awakenings

If these symptoms are present, a sleep evaluation may be more appropriate than simply continuing to intensify insomnia treatment.

Consider Other Medical Causes of Insomnia

Persistent sleep problems are not always caused by a primary sleep disorder.

Pain Can Interfere With Sleep

Chronic pain may make it difficult to fall asleep or cause frequent nighttime awakenings. Treating insomnia without addressing the underlying pain may not provide enough relief.

Mental Health Conditions May Affect Sleep

Anxiety, depression, post-traumatic stress, and other mental health conditions can significantly affect sleep.

Stress Can Keep the Body in a State of Alertness

Even when you are physically tired, ongoing stress may make it difficult for your mind and body to relax.

For some people, CBT-I works best when combined with appropriate treatment for anxiety, depression, or other underlying conditions.

Review Your Medications and Substances

Some medications and substances can interfere with sleep.

Common Sleep Disruptors May Include

• Stimulant medications
• Some antidepressants
• Corticosteroids
• Certain asthma medications
• Decongestants
• Excessive caffeine
• Nicotine
• Alcohol

Do not stop a prescribed medication without talking to your healthcare provider. However, discussing your medication list with a qualified professional may help identify factors contributing to persistent insomnia.

Alcohol Is Not a Reliable Sleep Treatment

Alcohol may make some people feel sleepy initially, but it can disrupt sleep later in the night.

If you are using alcohol regularly to help yourself fall asleep, speak with a healthcare professional about safer long-term strategies.

Make Sure You Are Treating the Right Type of Sleep Problem

Not everyone who believes they have insomnia is experiencing the same underlying problem.

Could Your Circadian Rhythm Be the Problem?

Sometimes a person's preferred sleep schedule does not match their work or social schedule.

For example, a person who naturally becomes sleepy very late at night may struggle to fall asleep at an earlier bedtime. This may be related to a circadian rhythm issue rather than a lack of sleep ability.

Shift Work Can Also Complicate Treatment

Night-shift workers may struggle with sleep because they are trying to sleep during the day, when light exposure, noise, and the body's natural circadian rhythms may make sleep more difficult.

CBT-I strategies may need to be adapted for people who work nontraditional schedules.

What to Do Next When CBT-I Is Not Working

If you have completed CBT-I and are still experiencing significant insomnia, avoid assuming that there are no other options.

Talk to Your CBT-I Provider

Your provider can help determine whether:

• The treatment was completed as intended
• Your sleep schedule needs to be adjusted
• Certain strategies need to be modified
• Another condition may be interfering with treatment
• Additional treatment may be helpful

Keep Tracking Your Sleep

A sleep diary can provide valuable information about patterns that may not be obvious from memory.

Consider tracking:

• Bedtime
• Wake time
• Estimated time to fall asleep
• Number of nighttime awakenings
• Caffeine and alcohol use
• Daytime naps
• Exercise
• Stress levels

This information may help your provider identify patterns and determine whether additional evaluation is necessary.

Consider a Sleep Evaluation

If insomnia persists despite treatment, a comprehensive sleep evaluation may be appropriate.

What Can a Sleep Specialist Do?

A sleep specialist can review your symptoms and medical history and help determine whether additional testing is needed.

Depending on your symptoms, a sleep study may help identify conditions affecting sleep, including breathing disorders or abnormal movements during sleep.

Anchorage Sleep Center provides diagnostic testing and treatment for a variety of sleep disorders.

Your Insomnia May Have More Than One Cause

It is possible to have both insomnia and another sleep disorder.

For example, a person may develop anxiety about sleep after experiencing repeated nighttime awakenings from an untreated condition such as sleep apnea.

Treating only one part of the problem may not fully restore healthy sleep.

Are Medications an Option After CBT-I?

In some situations, medication may be considered as part of a broader treatment plan.

Sleep medications should be individualized based on the type of insomnia, other medical conditions, medications, and potential risks.

Medication Is Not Always the Next Step

The appropriate next step after CBT-I depends on why treatment did not provide enough improvement.

A healthcare professional may recommend:

• Modifying CBT-I
• Treating an underlying sleep disorder
• Addressing pain or another medical condition
• Treating anxiety or another mental health condition
• Adjusting medications that may interfere with sleep
• Considering medication when appropriate

Do Not Start or Stop Sleep Medication on Your Own

Over-the-counter and prescription sleep medications can have side effects and may not be appropriate for everyone.

Always speak with a healthcare professional before starting, stopping, or changing sleep medication.

When Should You Seek Additional Help?

Consider speaking with a healthcare professional if you continue to experience:

• Difficulty falling asleep
• Frequent nighttime awakenings
• Early morning awakenings
• Excessive daytime sleepiness
• Chronic fatigue
• Loud snoring or gasping during sleep
• Unexplained nighttime movements
• Difficulty staying alert while driving or working

Persistent insomnia is not something you simply have to accept.

Contact Anchorage Sleep Center to learn more about evaluation and treatment options for ongoing sleep problems.

The Bottom Line

If CBT-I did not work as expected, it does not mean you failed—or that nothing else can help.

Persistent insomnia may mean that your treatment needs to be adjusted or that another sleep, medical, or mental health condition is contributing to your symptoms. A thorough evaluation can help identify what may be interfering with your sleep and guide your next steps.

Anchorage Sleep Center offers evaluation and treatment for a range of sleep disorders. If you continue to struggle with insomnia despite CBT-I, speaking with a sleep professional may help you find a clearer path forward.

Please click the orange button below to take a free online sleep test and talk with one of our sleep health professionals. 

A cool bedroom is often recommended for better sleep, but there is a difference between a room that is comfortably cool and one that is so cold that it keeps you awake.

If you regularly wake up shivering, keep adding blankets throughout the night, or find yourself adjusting the thermostat every evening, your bedroom temperature may not be optimized for sleep. A programmable thermostat or timer system on an air conditioning unit may help create a more consistent and comfortable environment from day to night.

What Is the Best Temperature for Sleeping?

Sleep experts often recommend a cool bedroom environment. For many adults, a temperature in the range of approximately 60 to 68 degrees Fahrenheit can be comfortable for sleep, although the ideal temperature varies from person to person.

Your body naturally changes temperature throughout the day and night. As bedtime approaches, core body temperature begins to decrease, helping support the transition toward sleep.

Why a Cool Room Can Support Sleep

A bedroom that is too warm may make it difficult for your body to release heat and can contribute to:

• Difficulty falling asleep
• Restless sleep
• Frequent awakenings
• Sweating at night
• Feeling uncomfortable under blankets

Cooler Is Not Always Better

Turning the air conditioner as low as possible does not necessarily improve sleep.

A bedroom that is too cold may also lead to:

• Shivering
• Muscle tension
• Frequent awakenings
• Dryness or discomfort
• Difficulty falling asleep
• Waking up because your blankets have shifted

The goal is to create an environment that helps you stay comfortably cool—not uncomfortably cold.

Can Sleeping in a Room That Is Too Cold Affect Your Sleep?

Yes. While cool temperatures can promote sleep, excessive cold may become disruptive.

Shivering Can Interfere With Relaxation

Shivering is your body's attempt to generate heat. If your body is working to maintain its temperature, it may be more difficult to relax into a comfortable, restful state.

You May Wake Up More Frequently

Even if you do not fully remember waking, discomfort caused by temperature changes may contribute to lighter or more fragmented sleep.

You may spend enough hours in bed but still wake up feeling as though you did not sleep well.

Why Bedroom Temperature May Need to Change Throughout the Day

The temperature that feels comfortable when you are awake may not be the temperature that feels comfortable when you are sleeping.

Your Sleep Environment Changes Overnight

Your needs can also change from one part of the night to another.

For example:

• You may prefer a slightly warmer room before bed.
• Your room may cool naturally overnight.
• The outdoor temperature may drop during the night.
• You may need less air conditioning once you are fully asleep.
• Morning temperatures may become cooler than expected.

A static A/C setting may not always provide the same level of comfort throughout the night.

How A/C Timers Can Help Regulate Temperature

If your air conditioning unit has a timer or programmable setting, you may be able to create a schedule that adjusts the temperature automatically.

Start With a Comfortable Evening Temperature

You may want the room slightly cooler as you prepare for bed but not so cold that you feel uncomfortable.

Program the A/C to Adjust After You Fall Asleep

If your air conditioner tends to make your room too cold overnight, consider using a timer to reduce cooling after you have fallen asleep.

For example, you may:

1. Turn the A/C on before bedtime to cool the room.
2. Set a timer to reduce cooling after several hours.
3. Allow the room to gradually become slightly warmer overnight.

The exact timing will depend on your bedroom, climate, bedding, and personal preferences.

Using a Timer System for Day and Night Temperature Changes

A programmable thermostat or smart A/C system can make it easier to create different temperature settings throughout the day.

Daytime Settings

When you are awake, your preferred temperature may depend on activity level, clothing, sunlight, and outdoor conditions.

You may want a different temperature while:

• Working from home
• Exercising
• Cooking
• Relaxing
• Completing household activities

Evening Settings

As you begin preparing for bed, gradually lowering the temperature may help create a comfortable sleep environment.

Consider Cooling the Room Before Bed

Instead of waiting until you get into bed to turn on the air conditioner, try cooling the bedroom before your intended bedtime.

This may help you enter a comfortable sleep environment rather than waiting for the room to cool after you are already trying to fall asleep.

Overnight Settings

If your room tends to become too cold overnight, program the system to adjust.

You might experiment with:

• Turning the A/C off after several hours
• Increasing the temperature by a few degrees
• Switching to a fan
• Using a thermostat schedule that gradually changes overnight

How to Find the Right Temperature for Your Sleep

The ideal bedroom temperature is personal.

Instead of dramatically changing the thermostat every night, try making small adjustments and paying attention to how you sleep.

Try a Temperature Experiment

For several nights, keep track of:

• Your bedroom temperature
• How quickly you fall asleep
• How often you wake up
• Whether you wake up feeling too hot or cold
• How rested you feel in the morning

Change One Thing at a Time

Try adjusting the temperature by one or two degrees rather than making major changes.

Give yourself several nights to adjust before deciding whether a temperature is working.

Don't Forget About Bedding

Your thermostat is only one part of your sleep environment.

Adjust Your Blankets Before Lowering the A/C

If you are waking up cold, consider whether your bedding is appropriate for the temperature.

You may prefer:

• Lighter sheets
• A thinner blanket
• Layered bedding
• Breathable fabrics
• A heavier comforter

Layering Can Give You More Control

Using multiple light layers may make it easier to adjust your comfort level throughout the night than relying on one very heavy blanket.

Should You Use a Fan at Night?

For some people, a fan can help circulate air and make a room feel more comfortable.

A Fan May Help You Feel Cooler Without Lowering the Thermostat

Air movement can help reduce the feeling of heat, meaning you may not need to set the air conditioner as low.

Avoid Direct Airflow if It Makes You Too Cold

If you regularly wake up feeling cold or uncomfortable, try pointing the fan away from your body or reducing its speed.

The goal is comfortable airflow—not constant cold air blowing directly onto you.

Other Ways to Control Your Bedroom Temperature

You may be able to improve your sleep environment without constantly changing your A/C setting.

Use Curtains or Blinds

Blocking sunlight during the day can help prevent your bedroom from becoming excessively warm.

Keep Doors Closed When Appropriate

Closing doors may help maintain a more consistent temperature in your bedroom, depending on your home's heating and cooling system.

Consider a Smart Thermostat

A programmable or smart thermostat can automatically adjust temperatures based on the time of day.

You may be able to create separate schedules for:

• Morning
• Daytime
• Evening
• Overnight

Automate Your Sleep Environment

Automation may be especially helpful if you frequently forget to adjust the thermostat before bed or wake up because you are too cold.

A consistent schedule can reduce the need to make temperature adjustments in the middle of the night.

When Temperature Is Not the Only Problem

A comfortable bedroom temperature can support good sleep, but it will not treat an underlying sleep disorder.

Consider talking to a healthcare professional if you continue to experience:

• Chronic insomnia
• Excessive daytime sleepiness
• Loud snoring
• Gasping or choking during sleep
• Frequent unexplained awakenings
• Persistent fatigue despite adequate sleep

Learn more about the sleep disorders evaluated and treated by Anchorage Sleep Center.

The Bottom Line

A cool bedroom can support healthy sleep, but a room that is too cold may become just as disruptive as one that is too warm. The best sleep temperature is ultimately the one that allows you to fall asleep comfortably and remain comfortable throughout the night.

Using a programmable thermostat or timer on your air conditioning unit may help regulate your bedroom temperature as your needs change from day to night. Try cooling your room before bed and then adjusting the temperature later in the night to prevent the room from becoming excessively cold.

Small changes, including thermostat timing, airflow, and bedding, can work together to create a more comfortable sleep environment.

Anchorage Sleep Center provides evaluation and treatment for a variety of sleep disorders. If you continue to struggle with poor sleep despite improving your sleep environment, contact Anchorage Sleep Center to learn more about your options.

If you or someone you know struggles with sleep, please click the orange button below for a free online sleep test. 

You wake up at 2:30 a.m., glance at the clock, and expect to drift back to sleep within minutes. Instead, your mind starts racing, you toss and turn, and before you know it, an hour has passed.

If this sounds familiar, you're not alone.

Most adults wake up briefly several times throughout the night, often without realizing it. The problem isn't waking up—it's when you can't fall back asleep. Frequent nighttime awakenings followed by prolonged periods of wakefulness can leave you feeling exhausted the next day and may signal an underlying issue affecting your sleep.

Let's explore why this happens and what you can do about it.