Study compares and confirms effectiveness of two psychotherapy approaches for treating insomnia

While cognitive-behavioral therapy showed faster results, the effect of acceptance and commitment therapy was more lasting, shows a study conducted at the University of São Paulo with 227 volunteers.

By Maria Fernanda Ziegler  |  Agência FAPESP – A study conducted at the University of São Paulo (USP) in Brazil with 227 volunteers evaluated the effectiveness of two different approaches to psychotherapy in the treatment of insomnia. The results, published in the Journal of Consulting and Clinical Psychology, indicate that so-called cognitive-behavioral therapy (CBT), which focuses on working on behaviors and thoughts related to sleep, showed faster effects. Acceptance and commitment therapy (ACT), which aims to increase the individual’s psychological flexibility, had better effects after a few months of treatment, even without specific guidance on sleep.

“This is great news for people with insomnia. It was already known that CBT was effective in treating insomnia and produced excellent results. However, our study is the first to evaluate the response to ACT in a large number of participants and compare it to CBT and no treatment. This is important because not all patients improve with CBT,” says Renatha El Rafihi-Ferreira, professor at the Department of Clinical Psychology at USP’s Institute of Psychology and first author of the article.

It is estimated that one in four people worldwide suffer from symptoms of insomnia. In most cases, it is short-lived and caused by one-time events such as stress or illness. Chronic insomnia affects 10% of the population. This rate includes people who have difficulty falling asleep or staying asleep, as well as those who wake up before their desired time at least three times a week for three months or longer.

In the FAPESP-funded study, the 227 participants diagnosed with insomnia were divided into three groups. One group received group CBT sessions, another group received ACT, and the third group was placed on a supposed waiting list and did not receive any treatment. The goal was to compare the three situations at the end of the six-week period. The clinical trial assessments and interventions were all conducted online.

As the researcher explains, the two approaches follow different logics. While CBT focuses on sleep habits and hygiene, as well as modifying beliefs and thoughts about the causes and consequences of insomnia, ACT seeks to understand the individual’s relationship with sleep, as well as analyzing the function of the behaviors that perpetuate insomnia.

For example, a person with very poor sleep hygiene – who doesn’t exercise, comes home late, has little room in their routine for sleep and self-care – in CBT will follow recommendations to address this routine using behavioral techniques and changes in beliefs (understandings that the individual has about themselves, the world and others). In ACT, the focus would be on understanding the function of maintaining a certain behavior or lifestyle that causes the patient to have habits that are harmful to sleep.

El Rafihi-Ferreira explains that ACT aims to develop the individual’s flexibility by increasing their ability to connect with the present (including through mindfulness). “In this way, the patient will first learn to accept the sleep problem and then commit to solving it. Insomnia is a problem that affects the individual’s life in many ways, causing them to focus much more on their difficulty and ignore many other aspects of life. By shifting the focus from the complaints to accepting the feelings and thoughts associated with the problem, ACT can be a good treatment option,” she explains.

It is worth noting that in order to avoid the discomfort of spending a sleepless night, it is relatively common for people to choose behaviors that can interfere with sleep, such as scrolling through their cell phone screens before bed or drinking alcohol in an attempt to fall asleep. “ACT proposes an openness to feeling this discomfort, which we call acceptance, combined with a commitment to achieving what’s really important to the person in the long run, which is their values, even if they have to feel discomfort in the short run. Perhaps because ACT has a more global approach, working on issues far beyond these bad sleeping habits, it doesn’t show results as quickly as CBT,” she explains.

According to El Rafihi-Ferreira, this is the third in a series of studies comparing cognitive-behavioral therapy and acceptance and commitment therapy for people with chronic insomnia.

In the first study, both therapies had similar effects in improving insomnia. “In this first trial, we included specific behavioral strategies for sleep in the ACT, such as the orientation to use the bed only for sleep and sex, a strategy that’s present in the CBT protocol,” the researcher says.

The second study used ACT without specific behavioral sleep strategies. “In this study, in the first few weeks, ACT showed an improvement in insomnia in 50% of the participants, while CBT showed an improvement in 65% of them. However, six months after the end of treatment, the ACT participants continued to improve, increasing from 50% to 56% of participants with reduced insomnia complaints, while in the CBT the percentage decreased over time from 65% to 58%,” she says.

“This shows that ACT is better in the long term, while CBT results are obtained in the short term, although they are more difficult to maintain,” she says.

The third study conducted with 227 insomniacs, showed that CBT had better results in the short term and that ACT and CBT were similar in the long term. “This study showed that the difference between the two therapies is very small and that both are effective. However, the CBT protocol includes guidelines that are difficult for some patients to follow. For example, the orientation to get out of bed when they wake up in the middle of the night. Our study showed that even without these specific sleep recommendations, CBT is also effective,” she says.

In addition to the article, the study resulted in a book for psychologists and other health professionals with more details about the two types of psychotherapy. There are also case reports of patients with insomnia. The work won an award at the 2023 Congress of the Association for Contextual Behavioral Science (ACBS). The researcher also received an award from the American Psychological Association (APA) in 2024 for the series of studies conducted.

Impacts

Sleep deprivation has a significant economic impact, as it is associated with increased susceptibility to infections, obesity, cardiovascular problems and psychiatric disorders such as anxiety and depression. It also reduces productivity and increases absenteeism and healthcare utilization. It is estimated that an insomniac requires six times more medical care than a person who sleeps well.

“As well as improving the individual’s overall quality of life, treatments for insomnia have an impact in terms of public health, reducing healthcare costs and improving productivity at work, for example. That’s why it’s so important, especially for low- and middle-income countries like Brazil, to show that a different approach to psychotherapy, delivered in a group and in online format, has such efficient effects,” says the researcher.

Another point highlighted by the researcher is that, with evidence of its efficacy, ACT could emerge as a hope for patients who are refractory to CBT or who have not been able to follow the guidelines of the therapy in the long term. El Rafihi-Ferreira explains that one of the most effective techniques for insomnia in the CBT protocol is also one of the most difficult for patients to adhere to.

This is because the bedtime restriction technique in the CBT protocol calculates the individual’s bed time and sleep time, and then creates a sleep window with bed times and wake times that are close to the individual’s total sleep time. For example, if a person spends nine hours in bed for but only sleeps six hours, their sleep window will be six hours. According to the strategy, the partial deprivation of bed and sleep time would result in an increase in sleep pressure, which would have the effect of reducing night time awakenings. Then, under professional supervision, the time spent in bed is gradually increased.

“Although effective, this technique is difficult to adhere to. Our study showed that, even without this technique, ACT was also effective for insomnia. This could make it easier to treat those who are unable to follow this type of guidance,” she says.

The article “Acceptance and Commitment Therapy Versus Cognitive Behavioral Therapy for Insomnia: A Randomized Controlled Trial” can be read at: psycnet.apa.org/fulltext/2025-05522-002.html.

The study “Acceptance and commitment therapy-based behavioral intervention for insomnia: a pilot randomized controlled trial” is available at: www.scielo.br/j/rbp/a/GJXW97vNSPqkH7Vp5xS7BmF/?lang=en.

And the article “A Pilot Randomized Controlled Trial (RCT) of Acceptance and Commitment Therapy Versus Cognitive Behavioral Therapy for Chronic Insomnia” can be found at: www.tandfonline.com/doi/full/10.1080/15402002.2022.2071272.

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