When older adults struggle with depression or anxiety, doctors often recommend Cognitive Behavioral Therapy, or CBT. This talk therapy has decades of research showing it works well across different age groups. But there's a problem: when researchers look closely at how older adults respond to standard CBT, the results are inconsistent. Sometimes it works great, and sometimes it doesn't help as much as it does for younger people.
Why would a therapy that's proven effective suddenly become less reliable when someone crosses into their senior years? The answer might seem obvious: aging changes us. Our bodies change, our brains process information differently, and our life circumstances shift dramatically. Yet most CBT programs are designed the same way regardless of who's sitting in the therapy room.
If you've ever struggled with insomnia, you know how desperate you can become for a good night's sleep. Cognitive Behavioral Therapy for Insomnia, known as CBT for insomnia, is the recommended first treatment for sleep problems. But there's a catch: one of its most effective techniques is also one of the hardest to follow.
Sleep Restriction Therapy is a core part of CBT for insomnia that sounds counterintuitive. Instead of spending more time in bed trying to sleep, patients are told to limit their time in bed to match how much they actually sleep, with a minimum of just 5 hours. The idea is to build up sleep pressure and strengthen the association between bed and sleep.
This approach works, but it requires major lifestyle changes and can cause some rough side effects in the short term. People report feeling fatigued, irritable, moody, and excessively sleepy while adjusting to the new schedule. These negative effects can make people want to quit the therapy altogether.
Now imagine trying to stick with this challenging regimen without a therapist sitting across from you each week. That's the reality for people using internet based CBT for insomnia programs. With a shortage of trained sleep therapists and long waiting lists, online programs have become an increasingly common way to deliver this treatment. But researchers wondered: can people actually follow through with Sleep Restriction Therapy when they're mostly on their own?
A team of researchers interviewed 23 people who had participated in an online CBT for insomnia program to understand what helped or hindered their ability to follow through with Sleep Restriction Therapy. The participants had varying levels of success. About half consistently implemented the technique, while others either rejected it from the start, stopped partway through, or had inconsistent adherence.
Several personal factors emerged as important. People who tended to be more compliant and obedient generally found it easier to follow the sleep restriction guidelines. Those with low tolerance for frustration struggled more. Interestingly, if someone had tried Sleep Restriction Therapy before and had a bad experience, they were less likely to stick with it the second time around.
On the flip side, some factors helped people stay committed. Those who felt their insomnia was severely affecting their quality of life were more motivated to push through the difficult parts. Having support from family or friends made a difference. When people felt the online program fit their individual needs well, they were more likely to follow through. And those who were satisfied with the guidance they received from their online coach tended to stick with it.
The timing of improvements mattered too. People who noticed positive changes early on, whether in their sleep quality or daytime functioning, were much more likely to continue with the therapy. Those who only experienced negative effects without any early improvements often gave up.
The study revealed some interesting patterns about online coaching. Many participants wanted more intensive support, especially when they were first starting Sleep Restriction Therapy. Some people in the study had the option to contact their coach when needed but didn't reach out even when they were struggling. This suggests that people having serious doubts or difficulties might need coaches to check in proactively rather than waiting for patients to ask for help.
The researchers also found that Sleep Restriction Therapy could worsen some existing health conditions. People with chronic pain reported increased discomfort, and some felt the fatigue triggered symptoms similar to past depressive episodes. This raises important questions about how to monitor and adjust the treatment for people with other health concerns.
Based on their findings, the researchers developed a model for how to better tailor online insomnia therapy. They suggest that before starting treatment, therapists should assess factors like how compliant someone tends to be, their frustration tolerance, whether they've had previous negative experiences with sleep restriction, and what other health conditions they have.
Once treatment begins, the model suggests monitoring several things: how committed the person is, whether they have social support, if they're experiencing negative effects on their mood or other health conditions, whether they're satisfied with their coaching, and whether they're seeing any improvements in their sleep.
The flexibility of the program also mattered. While there was a suggested pace for moving through the sessions, people appreciated being able to go at their own speed. Some wanted to fully adjust to the sleep restriction before moving forward, while others preferred to follow the recommended schedule closely.
This research highlights a key tension in mental health treatment. Online programs can reach far more people than traditional therapy, addressing the shortage of trained specialists. But treatments that require significant behavior change and can cause temporary discomfort may need more support than a purely self guided program can provide.
The findings suggest that one size doesn't fit all when it comes to online insomnia treatment. Some people might do well with minimal guidance, while others might need regular check ins or even the option to skip or modify the sleep restriction component. Some might benefit from starting with a gentler approach and working up to full sleep restriction.
What's particularly valuable about this research is that it goes beyond simply asking whether online CBT for insomnia works and digs into the messy reality of how people actually experience it. The voices of real patients reveal the practical and emotional challenges that statistics alone can't capture.
The researchers are clear that their model needs to be tested further with larger studies using quantitative data. The interviews don't prove cause and effect, and it's possible some participants were rationalizing their decisions rather than reporting their true motivations. But the model provides a starting point for making online insomnia therapy more personalized and effective.
For anyone considering online treatment for insomnia, this research offers some reassurance. Having trouble with Sleep Restriction Therapy doesn't mean you're failing or that the treatment won't work for you. It's genuinely difficult, and many people struggle with it. The key may be recognizing when you need more support and being open about what's working and what isn't.
As mental health care continues to move online, understanding these nuances becomes increasingly important. Technology can expand access to effective treatments, but only if those treatments are designed with a realistic understanding of human behavior, motivation, and the challenges people face in their daily lives.
Simon, L., Steinmetz, L., Berghoff, N., Rehm, C., Neumann, L. M., Küchler, A. M., ... & Baumeister, H. (2025). Barriers and Facilitators of Sleep Restriction Therapy in Internet‐Delivered CBT‐I: A Qualitative Content Analysis and the Development of a Treatment Path Model. Journal of Sleep Research, e70018.
When you go to therapy, you expect your therapist to provide effective treatment. For conditions like depression and anxiety, Cognitive Behavioral Therapy, or CBT, has decades of research showing it works. But here's a problem: just because a therapy is proven effective doesn't mean every therapist delivers it as intended.
Health systems have invested billions of dollars to train therapists in CBT and other evidence based treatments. Yet some research suggests many providers don't implement these treatments the way they're supposed to. This creates a need for quality monitoring to make sure patients are getting the care that actually helps.
