Insomnia treatment (CBT-I) and sleep difficulties, online across NZ

What is insomnia?

Insomnia is trouble falling asleep, staying asleep or waking too early, at least three nights a week for three months or more, with daytime effects such as fatigue, poor concentration or irritability, despite having the chance to sleep. Chronic insomnia is a condition in its own right, and clinical guidelines recommend CBT-I as the first treatment.

How insomnia takes hold

Almost everyone has a stretch of bad sleep after something stressful: a new baby, a redundancy, a bereavement, a roster change, a move to a new town. For most people sleep settles once life does. For some, it doesn't, and the reason is usually not the original stress but what we do in response to it.

Imagine a shift-working nurse coming off a run of night shifts, or an Auckland commuter whose alarm goes at 5am to beat the motorway. A few bad nights in, they start going to bed earlier "to catch up", lying in on the weekend, napping on the couch after work, having a wine to switch off, and checking the clock every time they surface. Each move is sensible. Together they teach the brain that bed is a place of lying awake, stretch the hours in bed well beyond the hours of sleep, and build a layer of worry about sleep itself.

That last part is central. Psychologist Allison Harvey's cognitive model of insomnia describes how worry about not sleeping ramps up the body's alertness, which makes sleep less likely, which confirms the worry. People start monitoring for signs of tiredness all day and treating every yawn as evidence of damage. By this point the insomnia has its own engine, and treating it means dismantling that engine rather than finding the original cause.

Why CBT-I is first-line, and why sleep hygiene alone usually isn't enough

Cognitive behavioural therapy for insomnia (CBT-I) is a short, structured programme that changes the behaviours and thinking that keep insomnia going. The American Academy of Sleep Medicine's 2021 clinical practice guideline gives multicomponent CBT-I its only "strong" recommendation for chronic insomnia in adults. The 2023 European Insomnia Guideline recommends it as the first-line treatment for adults of any age, including people with other health conditions. Healthify, New Zealand's health information site, describes CBT-I as very effective, reporting that up to 80 percent of people in studies experience improvement.

Sleep hygiene, the familiar list about caffeine, screens, cool dark rooms and regular bedtimes, is sensible advice, but the same AASM guideline specifically recommends against using it on its own to treat chronic insomnia, because the evidence does not show it works as a standalone treatment. If you have already tried the list and it hasn't helped, that is not a sign your insomnia is unusually bad. It is the expected result.

Sleeping tablets are a separate conversation to have with your GP. Guidelines generally position them as short-term options when CBT-I is not available or not enough. If you are taking medication for sleep, you can still do CBT-I, and you should not change your medication without talking to your prescriber.

Sleep restriction, in plain language

The name puts people off, so here is what it actually is: matching the time you spend in bed to the time you are actually asleep. For a week or two you keep a simple sleep diary. Suppose it shows you are in bed from 9.30pm to 6.30am, nine hours, but asleep for about six of them. Your psychologist helps you set a sleep window closer to six and a half hours, with a fixed wake time, so you might go to bed at midnight and get up at 6.30am every day, including weekends.

The first week or so is hard. You will probably feel more tired, not less. That is the point: you are rebuilding "sleep pressure", so that when you do get into bed you fall asleep faster and stay asleep. As your sleep becomes more solid, the window is extended by about fifteen minutes at a time until you land on the amount of sleep your body actually needs, which for many adults is less than they assumed.

Because of the short-term tiredness, your psychologist checks first that this is safe for you, and adapts or skips it for some people, for example those with certain health conditions or in safety-critical jobs. There are gentler versions, including "sleep compression", which narrows the window gradually.

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Stimulus control: teaching your brain that bed means sleep

If you have spent months lying awake in bed, scrolling in bed, worrying in bed and watching the clock in bed, your brain has learned that bed is where you are awake and tense. Stimulus control re-teaches the association. The rules are simple and the discipline is in following them:

• Go to bed only when you are actually sleepy, not just tired, and not because it is "bedtime".
• If you have been awake for what feels like fifteen to twenty minutes, get up. Go to another room, keep the lights low, and do something quiet and boring. Go back only when sleepy. Repeat as often as needed.
• Use the bed for sleep (and sex) only. No phone, laptop, work or lying there "resting".
• Get up at the same time every day, whatever kind of night you had.
• No daytime naps while you are retraining.

Getting out of a warm bed at 3am in a cold Dunedin flat in July is unpleasant, so planning matters: a dressing gown and socks within reach, a chair and a dull book in the next room, the heater on a timer. The AASM guideline lists stimulus control as an effective component on its own; combined with sleep restriction and the cognitive work below, it forms the core of CBT-I.

Worry at night

For many people the problem is not the body but the mind, which seems to save its sharpest thinking for 1am: the conversation with your manager, the mortgage, the thing you said at the barbecue in 2019, and underneath all of it, "if I don't sleep I'll be useless tomorrow".

CBT-I treats this directly. You learn to catch the beliefs that put pressure on sleep ("I need eight hours", "a bad night ruins the day", "I've lost the ability to sleep") and test them against your own diary, which usually tells a less dramatic story. You schedule a "worry window" earlier in the evening, with pen and paper, so that the brain has somewhere else to do its planning. You practise relaxation or a brief mindfulness exercise, not as a sleep trick but as a way of lowering arousal. And you learn to stop fighting wakefulness, because trying hard to sleep is one of the most reliable ways to stay awake.

Where night-time worry is one piece of broader anxiety or a low mood that is also present in the day, your psychologist will say so and suggest how to work on both. Insomnia and anxiety or depression often arrive together, and treating the sleep problem frequently helps the rest.

When to see your GP first: sleep apnoea and other causes

Not all poor sleep is insomnia, and some causes need a doctor rather than a psychologist. Please see your GP first, or alongside, if any of these apply:

• Possible sleep apnoea: loud snoring, pauses in breathing or gasping that a partner has noticed, waking unrefreshed however long you were in bed, and heavy daytime sleepiness. Your GP can arrange a sleep assessment. Sleep apnoea is treated medically, not with CBT-I.
• Drowsiness while driving or in a safety-critical job: Healthify advises seeing your healthcare provider urgently.
• Physical symptoms disturbing sleep: restless or twitching legs, pain, reflux, frequent urination, hot flushes, breathing difficulty.
• Medicines or substances that may be affecting sleep, which your GP or pharmacist can review.

Mindwell psychologists do not diagnose medical sleep disorders. If a GP has ruled these out, or you have a treated condition and the insomnia has outlasted it, CBT-I is likely to be appropriate. The European guideline is explicit that CBT-I is recommended even where other health conditions are present.

Why CBT-I works well online

CBT-I is one of the therapies with the clearest evidence for video delivery. A randomised trial published in the journal Sleep compared six sessions of CBT-I by telemedicine with six sessions face-to-face in 65 adults with chronic insomnia. Telemedicine was non-inferior on insomnia severity both at the end of treatment and three months later, daytime functioning improved similarly, and participants rated their relationship with the therapist the same in both formats.

There are practical reasons it suits video. CBT-I is structured and diary-driven, so sessions are spent reviewing your week's sleep data on screen and adjusting the plan. You are talking about your bedroom from your bedroom, so questions about light, noise, the cat and the alarm clock get real answers. And there is no 7pm drive across town after a terrible night.

If you would rather try a structured programme on your own first, Just a Thought offers a free online "Managing Insomnia" course for New Zealanders based on CBT principles. Therapist-delivered CBT-I makes more sense when self-help has not been enough, when anxiety or low mood are tangled up with the sleep problem, or when you want someone to adjust the plan with you week by week.

What to expect at Mindwell

Three psychologists on our team work with sleep difficulties. Katherine Lee, a Registered Psychologist, lists sleep among her focus areas alongside anxiety, perinatal mental health and grief. Jake Meads, Counselling Psychologist, and Jeremy Mason, Clinical Psychologist, both list sleep and insomnia among their areas of practice.

CBT-I is usually brief. Your first 50-minute session covers your sleep history, your current pattern, medicines and health, and what has been tried; you then start a sleep diary. Most people need somewhere between four and eight sessions, often weekly or fortnightly, with the plan adjusted each time based on the diary.

Sessions are $199 + GST ($228.85 incl. GST), paid at booking, with receipts for insurance claims. You do not need a GP referral, and you can book a specific psychologist or the first available. If your GP is already involved in your sleep care, your psychologist can, with your consent, send them a brief summary of the plan.

Related support: Anxiety therapy · Chronic pain management · Depression counselling · Postnatal depression and anxiety