If you work in mental health, you will encounter clients with insomnia regularly. Sleep difficulties are closely linked with many psychological presentations, and they often sit alongside anxiety, depression, trauma, and neurodivergence. Understanding how to assess and treating insomnia is therefore a valuable part of your clinical toolkit, whether sleep is the presenting concern or something that emerges once you begin working together.
This post covers what insomnia is, what tends to cause it, and the strategies that are most effective in supporting clients to sleep well again.
What Is Insomnia?
Insomnia involves persistent difficulty falling asleep, staying asleep, or returning to sleep after waking, along with daytime impairment such as fatigue, low mood, irritability, or difficulty concentrating. The difficulty occurs despite adequate opportunity for sleep, which is part of what distinguishes it from sleep deprivation caused by a busy schedule or external demands.
Insomnia is generally described in two ways:
- The first relates to how long it has been present. Acute insomnia refers to brief episodes of disturbed sleep that last for a few days or weeks, often in response to a stressor such as a work deadline, illness, or a significant life change. Chronic insomnia refers to ongoing difficulty sleeping that occurs at least three nights per week and persists for three months or more.
- The second way of describing insomnia relates to whether it occurs on its own or alongside another condition. Primary insomnia is not directly attributable to another health condition, whereas secondary insomnia occurs in the context of an underlying issue such as anxiety, depression, or chronic pain.
In practice, the relationship between sleep and mental health tends to be bidirectional, so poor sleep can worsen a psychological condition while that same condition continues to disrupt sleep. For this reason, many clinicians now treat insomnia in its own right rather than assuming it will resolve once the associated condition improves.
What Causes Insomnia?
Insomnia rarely has a single cause. It usually develops through a combination of factors that predispose a person to sleep difficulties, trigger an initial episode, and then maintain the problem over time. Common contributors include:
- Anxiety and chronic stress
- Depression and bipolar disorders
- Chronic pain and other ongoing medical conditions
- Certain medications
- Poor sleep hygiene and an irregular sleep schedule
- Lifestyle factors such as shift work or frequent travel across time zones
- Neurodivergence, including ADHD and being Autistic
Neurodivergence deserves particular attention here, as sleep difficulties are highly prevalent among Autistic and ADHD clients and are often overlooked or misattributed. Differences in circadian rhythm, sensory sensitivity, difficulties with the wind-down period before sleep, and a tendency toward delayed sleep phase can all play a role. Standard sleep advice does not always account for these differences, so adapting your approach for neurodivergent clients tends to produce far better outcomes than applying a generic protocol.
How Is Insomnia Treated?
The most effective methods for treating insomnia is cognitive behavioural therapy for insomnia (CBT-I), and it is recommended as the first-line intervention for chronic insomnia. CBT-I is a structured, time-limited therapy that helps clients identify and change the thoughts, behaviours, and physiological patterns that maintain their sleep difficulties. Rather than masking the symptoms, it addresses the factors keeping insomnia in place, which is why its effects tend to be durable.
CBT-I usually draws on several components, and you can tailor the emphasis depending on what is maintaining a particular client’s insomnia.
Understanding the biology of sleep
Helping clients understand circadian rhythms, their individual chronotype, and the sleep drive that builds across the day gives them a framework for the rest of the work. When clients understand why certain behaviours help or hinder sleep, they are far more likely to follow through with them.
Sleep hygiene education
Sleep hygiene covers the everyday habits that support good sleep, such as keeping a consistent sleep and wake time, managing light exposure, limiting caffeine and alcohol, and creating an environment that supports rest. Sleep hygiene alone is rarely enough to resolve chronic insomnia, so it works best as one part of a broader plan rather than a standalone intervention.
Stimulus control therapy
Stimulus control helps clients rebuild the association between the bed and sleep. This involves using the bed only for sleep and intimacy, getting out of bed when unable to sleep, and returning only when sleepy, so that the bedroom stops being a place associated with frustration and wakefulness.
Sleep restriction therapy
Sleep restriction temporarily limits the time a client spends in bed to match the time they are actually sleeping, which strengthens their sleep drive and consolidates sleep. As sleep efficiency improves, time in bed is gradually increased. This component is often the most powerful, and it benefits from careful explanation and monitoring so that clients feel supported through the initial adjustment.
Cognitive Therapy for Treating Insomnia
This component focuses on identifying and gently shifting unhelpful thoughts and beliefs about sleep, such as catastrophic predictions about the consequences of a poor night or rigid expectations about how much sleep is required. Reducing the worry and pressure surrounding sleep often lowers the arousal that interferes with it.
Arousal Reduction and Emotional Regulation for Treating Insomnia
Many clients arrive at bedtime in a state of heightened physiological and cognitive arousal. Techniques that support down-regulation, such as paced breathing, progressive muscle relaxation, and structured worry or wind-down time earlier in the evening, can help clients move into a state more compatible with sleep.
Where Do Medications Fit Into Treating Insomnia?
Pharmacological options such as sedatives may have a role for some clients, particularly in the short term or where insomnia is severe. They are generally not recommended as a first-line or long-term treatment for chronic insomnia, given the risk of dependence, tolerance, and other side effects, and given that the benefits often fade once the medication is stopped. Where medication is involved, this sits within the prescribing clinician’s remit, and psychological treatment can run alongside it. CBT-I remains the recommended first-line approach because it addresses the maintaining factors directly and tends to produce lasting improvement.
To learn more about psychopharmacology check out this post:
The Role of the Psychologist in Treating Insomnia
Insomnia is a common sleep disorder that can quietly undermine a client’s mood, concentration, relationships, and overall quality of life, and it frequently interacts with the very conditions that bring clients to therapy in the first place. As a psychologist, you are well placed to assess sleep, deliver CBT-I, and adapt your approach for the individual in front of you, including neurodivergent clients whose needs are often missed. Treating sleep directly can improve not only how rested your clients feel, but how well they respond to the rest of the work you do together.
Want to learn how to assess and treat insomnia effectively? My online training program, Treating Insomnia, is a comprehensive two-hour self-paced workshop that counts towards your professional development.
I have also developed a practical guide designed for both allied health professionals and their clients, which includes specific adaptations for Autistic and ADHD clients who struggle with sleep.
