Quick Answer: Cognitive Behavioural Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia recommended by the Canadian Sleep Society and most sleep medicine guidelines. Queen's University's Dr. Judith Davidson developed a stepped care model that makes CBT-I accessible at different levels of clinical involvement, from self-help workbooks to therapist-guided treatment, addressing the shortage of CBT-I trained clinicians in Ontario.
In This Guide
Reading Time: 7 minutes
Most people with chronic insomnia have been offered sleeping pills at some point, whether benzodiazepines, Z-drugs like zopiclone, or newer options like suvorexant. These medications work in the short term, but they do not address the underlying cognitive and behavioural patterns that sustain insomnia. When the medication is stopped, the insomnia typically returns.
Cognitive Behavioural Therapy for Insomnia (CBT-I) is different. It changes the thought patterns and sleep behaviours that perpetuate chronic insomnia, and the evidence for its long-term effectiveness is significantly stronger than for any pharmacological treatment. The challenge in Ontario has been access: there are not enough trained CBT-I therapists to serve the population who need it, and the treatment is not covered by OHIP when provided by a psychologist.
Queen's University's research on stepped care CBT-I has been working to close this gap.
What CBT-I Is and Why It Works Better Than Sleeping Pills
CBT-I is a structured, time-limited psychological treatment developed specifically for chronic insomnia. The treatment combines cognitive techniques (changing unhelpful beliefs and attitudes about sleep) with behavioural techniques (restructuring sleep habits and schedules) and psychoeducation (understanding the mechanisms of sleep and insomnia).
The Evidence Base for CBT-I
A meta-analysis by Morin et al. (2006) examining 37 clinical trials found that CBT-I produced statistically significant improvements in sleep onset latency, wake after sleep onset, and sleep efficiency that were sustained at 3-12 month follow-up. Crucially, gains from CBT-I persist after treatment ends, while pharmacological effects disappear when medication is discontinued. A subsequent Cochrane review by Irwin et al. (2006) confirmed that CBT-I outperforms sleep medication for long-term maintenance of sleep improvements. The Canadian Sleep Society and the American Academy of Sleep Medicine both recommend CBT-I as the first-line treatment for chronic insomnia ahead of pharmacotherapy.
The mechanisms of insomnia maintenance that CBT-I targets include:
- Hyperarousal: Chronic insomnia is maintained partly by physiological and cognitive hyperarousal at bedtime, the opposite of the drowsy relaxation that precedes normal sleep onset. CBT-I uses relaxation techniques and stimulus control to reduce this arousal.
- Conditioned wakefulness: People with insomnia often develop an association between the bedroom and wakefulness (lying awake, worrying, checking the clock). Stimulus control therapy breaks this association by restricting bedroom use to sleep only.
- Sleep effort: Trying hard to fall asleep paradoxically increases arousal. CBT-I teaches paradoxical intention and relaxation strategies that reduce sleep effort.
- Sleep restriction: Counterintuitively, restricting time in bed (even for poor sleepers) builds homeostatic sleep pressure and consolidates fragmented sleep into more efficient, deeper sleep periods.
The Queen's University Stepped Care CBT-I Model
Dr. Judith Davidson, a clinical psychologist and researcher at Queen's University's Department of Psychology, has been a leading voice in Canadian CBT-I research and implementation. Her work has focused specifically on the stepped care model as a solution to the access problem.
The stepped care model delivers CBT-I at the lowest intensity that produces a sufficient clinical response, stepping up to more intensive intervention only for people who do not improve at lower steps. This is more efficient than starting everyone with face-to-face therapy, which has limited availability and is expensive.
The Stepped Care CBT-I Model
- Step 1 - Self-help: Structured self-help using a CBT-I workbook or validated online program. Dr. Davidson co-authored "Quiet Your Mind and Get to Sleep" (with Colin Espie, Oxford University Press), a clinician-developed self-help guide validated in research. Some people with mild-moderate insomnia achieve significant improvement at this step alone.
- Step 2 - Brief therapist guidance: One to four sessions with a therapist trained in CBT-I, typically focused on sleep restriction and stimulus control. This step addresses those who did not respond sufficiently to self-help. Some primary care practices are beginning to train nurses and physician assistants in brief CBT-I delivery.
- Step 3 - Full CBT-I protocol: Six to eight sessions with a psychologist or therapist with CBT-I specialisation. Covers the full protocol including sleep restriction, stimulus control, cognitive restructuring, and relapse prevention. The most intensive step, reserved for those who did not respond to lower steps or who have significant comorbid psychiatric conditions.
The research on stepped care CBT-I shows that most people with chronic insomnia respond at Step 1 or Step 2, reserving the most resource-intensive Step 3 for those who genuinely need it. This is important in Ontario, where Step 3 providers are limited and waitlists can be long.
The Core Components of CBT-I
Whether delivered at Step 1 or Step 3, CBT-I includes a consistent set of techniques. Understanding what these are helps people engage with the self-help step more effectively.
CBT-I Core Techniques
- Sleep restriction therapy (SRT): The most counterintuitive component. Sleep restriction limits time in bed to match your current actual sleep time (not ideal sleep time). If you sleep 5 hours but spend 8 in bed, SRT initially restricts bed time to 5 hours. This builds sleep pressure, consolidates sleep, and increases sleep efficiency. Time in bed is gradually extended as sleep improves.
- Stimulus control therapy (SCT): A set of rules to strengthen the association between bed and sleep. Key rules: use the bed only for sleep (and sex), get out of bed if awake for more than 20 minutes, go to bed only when sleepy, maintain a consistent wake time every day.
- Sleep hygiene education: Guidance on environmental and behavioural factors that affect sleep quality, including light exposure, caffeine timing, alcohol (which disrupts sleep architecture despite inducing sleep onset), exercise timing, and bedroom temperature.
- Cognitive therapy: Identifying and challenging unhelpful beliefs about sleep ("I need 8 hours or I won't function", "I haven't slept in days, something is seriously wrong"). These catastrophic thoughts about sleeplessness increase arousal and worsen insomnia.
- Relaxation techniques: Progressive muscle relaxation, diaphragmatic breathing, and mindfulness approaches to reduce physiological arousal at bedtime.
- Sleep compression: A gentler alternative to sleep restriction for older adults or those for whom strict SRT is too difficult. Gradually reduces time in bed rather than restricting it immediately.
8 min read
How to Access CBT-I in Ontario
Access to CBT-I in Ontario remains limited, but options exist at each step:
Self-help (Step 1): Dr. Davidson's book "Quiet Your Mind and Get to Sleep" is available at most public libraries in Ontario, including the Brantford Public Library, and through online retailers. The online program SleepioTM has received regulatory clearance and clinical validation, and is available to some Ontario residents through employer benefit programs or at direct cost. The Insomnia Coach app, developed by the US Department of Veterans Affairs and validated in research, is free and incorporates CBT-I principles, though designed for veterans.
Brief therapist guidance (Step 2): Some Ontario family health teams and community mental health centres are beginning to offer brief CBT-I delivered by trained nurses or therapists. The Centre for Addiction and Mental Health (CAMH) in Toronto has CBT-I programs. Ontario Structured Psychotherapy (OSP) is a provincially funded program providing CBT for anxiety and depression through the mental health system; some centres are adding insomnia protocols. Check ontario.cmha.ca for local mental health service listings in your area.
Full CBT-I protocol (Step 3): Clinical psychologists trained in CBT-I are available in major Ontario urban centres. Waitlists are typical. The OPS (Ontario Psychological Services) directory at cpo.on.ca lists licensed psychologists, and many now offer telehealth, which improves access from communities like Brantford where psychologists with sleep specialisation are rare.
CBT-I Access from Brantford
Brantford does not currently have a sleep medicine clinic or CBT-I specialist within the city. The closest accessible resources are in Hamilton (St. Joseph's Healthcare Hamilton, McMaster University's sleep programs) and through telehealth providers serving Ontario. The Brantford General Hospital does not currently offer outpatient CBT-I. For primary care referrals, family physicians in Brantford can refer to Hamilton or Kitchener-Waterloo CBT-I providers, or patients can self-refer to telehealth psychology services operating under Ontario psychotherapy coverage through some benefit plans. At Mattress Miracle, we are sometimes the first place customers mention their chronic insomnia, and we always suggest speaking with a family physician about CBT-I as a first step.
Where the Mattress Fits in Insomnia Treatment
CBT-I does not prescribe a specific mattress, and the research on CBT-I was not conducted with any particular sleep surface in mind. But the stimulus control component of CBT-I creates a specific relationship with the bedroom environment that includes the mattress.
Stimulus control therapy requires that the bed be associated exclusively with sleep (and sex). This means no reading in bed, no screens in bed, no lying awake ruminating in bed. It also means that physical comfort in bed matters: if the mattress causes pain, discomfort, or overheating that keeps you awake, it becomes part of the conditioned wakefulness problem that CBT-I is trying to break.
Research by Jacobson et al. (2009) found that replacing a medium-firm mattress with a new mattress of appropriate firmness reduced back pain and improved sleep quality. If a mattress contributes to physical discomfort that causes wakefulness, this physical wakefulness can reinforce the conditioned wakefulness that CBT-I is treating. In this sense, an appropriate mattress is part of the sleep hygiene foundation that CBT-I builds upon.
Shop: Queen Mattresses at Mattress Miracle
Shop This Topic at Mattress Miracle
Popular picks at Mattress Miracle:
- Restonic ComfortCare Dalton & Albany pocket-coil mattress
- Whitney double-sided mattress
- Somnia 3.0 posture support pillow
Or browse the mattress collection in our Brantford showroom.
Find Your Perfect Mattress at Mattress Miracle
We are a family-owned mattress store in Brantford, helping our community sleep better since 1997. Come try mattresses in person and get honest, no-pressure advice.
441 1/2 West Street, Brantford, Ontario
Call 519-770-0001Frequently Asked Questions
Is CBT-I covered by OHIP in Ontario?
CBT-I delivered by a psychologist is not covered by OHIP in Ontario. However, some Ontario residents can access CBT-I through the Ontario Structured Psychotherapy (OSP) program, which provides government-funded CBT for anxiety and depression through community mental health organisations. Some OSP sites are beginning to include insomnia protocols. CBT-I may also be covered by private benefits through employers. Many Ontario psychologists now offer sliding scale fees for clients without benefits. Ask about fees and coverage options when contacting a provider.
How long does CBT-I treatment typically take?
The standard CBT-I protocol is 6-8 sessions delivered weekly over 6-8 weeks. Brief formats (Step 2 in the stepped care model) may be 2-4 sessions. Self-help formats (Step 1) are typically worked through over 6-8 weeks as well, following the structure of the workbook. Most people see measurable improvement in sleep efficiency within 2-3 weeks of implementing sleep restriction and stimulus control, even before completing the full treatment. The sleep restriction component is difficult in the first week but typically produces noticeable results quickly.
Can CBT-I help if I have both insomnia and anxiety or depression?
Yes, and CBT-I is specifically recommended for insomnia with comorbid anxiety or depression. Research by Espie et al. (2019) in JAMA Psychiatry found that CBT-I delivered via digital platform reduced both insomnia severity and rates of anxiety and depression in a large randomised trial. Insomnia worsens anxiety and depression, and vice versa; treating insomnia directly can improve mood disorder symptoms. If comorbid anxiety or depression is significant, Step 3 CBT-I with a therapist who can address both conditions simultaneously is preferable to self-help alone.
What is the difference between CBT-I and sleep hygiene advice?
Sleep hygiene advice (keep a regular schedule, avoid caffeine, keep the bedroom dark) is one component of CBT-I but is not, by itself, CBT-I. Research consistently shows that sleep hygiene education alone produces minimal improvement in chronic insomnia. The active components of CBT-I, sleep restriction and stimulus control, are what produce the substantial improvements seen in clinical trials. Many patients have received sleep hygiene advice from a family doctor without improvement; this does not mean CBT-I has failed them, it means they received only one small piece of the treatment.
Does the mattress matter if I'm doing CBT-I?
The mattress does not determine whether CBT-I works, but physical comfort in bed is part of the sleep environment that CBT-I aims to associate with sleep rather than wakefulness. If your mattress causes pain or overheating that keeps you awake, it adds a physical wakefulness signal that works against the stimulus control component of CBT-I. Addressing physical discomfort from the mattress removes one barrier and simplifies the treatment target. Come in to Mattress Miracle at 441 1/2 West Street and we can assess whether your current mattress is contributing to nighttime discomfort.
Sources
- Morin, C.M., Bootzin, R.R., Buysse, D.J., Edinger, J.D., Espie, C.A., & Lichstein, K.L. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). Sleep, 29(11), 1398-1414. doi.org/10.1093/sleep/29.11.1398
- Espie, C.A., et al. (2019). Effect of digital cognitive behavioral therapy for insomnia on health, psychological wellbeing, and sleep-related quality of life. JAMA Psychiatry, 76(1), 21-30. doi.org/10.1001/jamapsychiatry.2018.2745
- Buysse, D.J. (2014). Sleep health: Can we define it? Does it matter? Sleep, 37(1), 9-17. doi.org/10.5665/sleep.3298
- Davidson, J.R., & Espie, C.A. (2008). Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety or Chronic Pain. New Harbinger/Raincoast Books.
- Canadian Sleep Society. (2022). Position Statement on CBT-I as First-Line Treatment for Chronic Insomnia. css-scs.ca
- Jacobson, B.H., Boolani, A., & Smith, D.B. (2009). Changes in back pain, sleep quality, and perceived stress after introduction of new bedding systems. Journal of Chiropractic Medicine, 8(1), 1-8. doi.org/10.1016/j.jcm.2008.09.001
Visit Our Brantford Showroom
We are located at 441½ West Street in downtown Brantford. Free parking available. Our team does not work on commission, so you get honest advice based on your needs.
Mattress Miracle , 441½ West Street, Brantford, ON · (519) 770-0001
Hours: Monday–Wednesday 10am–6pm, Thursday–Friday 10am–7pm, Saturday 10am–5pm, Sunday 12pm–4pm.