Why sleep hygiene isn't enough for chronic insomnia
For healthcare professionals and wellbeing practitioners who encounter poor sleep in their work
I remember a time before I came to specialise in sleep when I actively avoided asking patients about their night. I recall the sense of unease as a little old lady revealed that night after night, she barely slept, and the best I could do was check she was avoiding avoiding caffeine and suggest a wind-down routine. Something in me instinctively recognised this just wasn’t going to be the fix she wanted, or needed.
When patients complain about their sleep, sleep hygiene is the go-to advice. Certainly NICE recommends it, and frankly, unless you are a prescriber, you probably haven’t had enough training to confidently recommend anything else.
So when someone mentions they aren’t sleeping well, you offer the familiar basics: reduce caffeine, keep regular bed and wake times, avoid screens before bed, make the bedroom cool and comfortable. None of this is bad advice.
The problem is that for someone with chronic insomnia (difficulty falling or staying asleep three nights a week, for three months or more), it just isn’t enough.
Sleep hygiene earns its place when someone normally sleeps well but has had a temporary disruption or there’s an obvious lifestyle or environmental factor. Checking the basics is sensible. I still do this in my own practice.
The key is proportion: check the basics, address anything relevant, then move on.
Otherwise, we risk making sleep worse, not better.
What sleep hygiene actually is
Sleep hygiene is the everyday stuff that nudges sleep in the right direction:
a regular sleep and wake time
morning light
movement
avoiding late caffeine or alcohol
winding down before bed and avoiding screens close to sleep
a comfortable, quiet bedroom
It’s the sleep equivalent of dental hygiene. Good general practice, sensible, and worth checking as part of any assessment, but certainly not the complete solution for a long standing problem.
The problem comes when it’s offered, or inferred to be, a treatment for insomnia.
Is sleep hygiene evidence-based? What the research actually shows
Sleep hygiene on its own is not an effective treatment for chronic insomnia. In clinical trials of CBT for Insomnia, the first-line, internationally recommended insomnia treatment, it’s commonly used as the placebo arm, precisely because, although sensible, it doesn’t address the mechanisms that maintain insomnia.
What I frequently see in practice, is that sleep hygiene has been presented as a treatment (possibly the only one), and then when they try these things but find they still don’t sleep, they may conclude that they are the problem. That their insomnia is different, their case is unique andthat insomnia is something they will just have to live with.
Then they stop seeking help, assuming there’s no point.
Why chronic insomnia persists — even when the original cause has gone
By the time someone has chronic insomnia, the original disruption is often long past. It might have been illness, stress, a life event, menopause, pain or simply a run of bad nights.
But over time, the person takes the understandable step of trying harder to sleep and prevent further bad nights. They go to bed earlier, stay in bed longer, cancel things, monitor their sleep, worry about tomorrow. We call this sleep effort.
All of this makes sense. The problem is that the response to the sleep problem gradually becomes part of what keeps it going.
A few poor nights become wrapped in anxiety, effort, frustration and self-blame until the wrapping is as significant as the original disturbance.
Sleep hygiene wasn never designed to address these underlying psychological and behavioural mechanisms that grow around the initial sleep disturbance.
Why giving patients more to do can make insomnia worse
There’s also another issue. Sleep hygiene, delivered without setting context, can actually make sleep worse.
People with chronic insomnia are usually already trying very hard to sleep. Then we give them another list of things to do.
Before long, bedtime becomes a project.
When sleep becomes something we have to get right, we start paying more attention to it. We notice whether we’ve followed the routine properly, how long we’ve been awake and how many hours remain until morning.
Sleep should never feel like an exam.
Think of a good sleeper you know.
How is their sleep hygiene? What do they do to prepare for sleep? How much time do they spend thinking about it?
The answer is usually revealing. People who sleep well generally aren’t doing very much to make themselves sleep. They may have routines and preferences, but sleep isn’t a project they are working on.
They’re just going to bed. Sleep tends to happen in the background.
For someone with chronic insomnia, it has often moved into the foreground. Sleep has become something to think about, monitor and manage.
How to have a more helpful conversation about insomnia
You don’t need to be an insomnia specialist to have a useful conversation about sleep.
By the time someone tells you they aren’t sleeping, they’ve usually tried a lot. They may be exhausted and frightened. They may believe their brain is broken or that they’ve lost the ability to sleep.
If the response is simply another list, it can unintentionally reinforce that belief.
Instead, ask what they’ve already tried. Listen for things such as excessive time in bed, compensating for poor nights, clock watching, avoiding activities because of sleep, or elaborate bedtime routines.
Normalise before you advise
Before offering anything practical, acknowledge what the person has already been through.
“It sounds like you’ve tried a lot already.”
Or:
“I can understand you feel frustrated your sleep hasn’t got any better, even though you’ve done all the right things.”
This matters because people with chronic insomnia can become convinced that they are somehow doing sleep wrong.
A useful way of explaining sleep hygiene is:
“Many people think sleep hygiene is meant to be a cure for insomnia, but it’s not. It’s a bit like dental hygiene. Brushing your teeth won’t fix a cavity.”
If there are aspects of sleep hygiene worth addressing, frame them as part of the picture rather than the entire solution:
“I think it would be really sensible for you to reduce your caffiene intake in the afternoon. I’m not suggesting this is going to fix your insomnia, we probably need to look at other approaches too, but it gets one thing out of the way.”
“Sleep hygiene is only ever the starting point in treating insomnia.”
That shift, from what are you doing wrong? to what is maintaining the problem?, can be surprisingly important.
Knowing when sleep hygiene has reached its limits
If someone has persistent or significant insomnia, it’s time to think beyond sleep hygiene.
CBT for Insomnia (CBT-I) is the evidence-based, NICE-recommended treatment for chronic insomnia. It isn’t a more extensive version of sleep hygiene. It targets conditioned arousal, excessive time in bed, sleep-related worry, compensatory behaviours and the effort to control sleep.
You don’t need to treat the insomnia yourself.
You do need to recognise when someone has moved beyond the point where another list is likely to help, explain that there is a specific treatment, and signpost appropriately, to a digital or in-person CBT-I.
The takeaway - Mechanisms matter more than rules.
We don’t need to stop talking about sleep hygiene. We need to stop asking it to do a job it was never designed to do.
Use it as a brief check. Address anything relevant. Then look at the person in front of you.
If sleep has become a performance task, if they’re spending hours awake in bed, compensating for every bad night, monitoring themselves constantly or relying on elaborate routines, more rules may simply add another layer.
Sometimes the most helpful thing you can offer isn’t another piece of advice. It’s an explanation of why they’re struggling, reassurance that they haven’t failed and a clear indication that there is somewhere else to go.
Louise Berger is a Behavioural Sleep Medicine Specialist and CBT-I practitioner working in the UK. She works with adults experiencing chronic insomnia and complex sleep disorders. This piece is part of a series written for healthcare professionals and wellbeing practitioners who encounter poor sleep in their work.
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