Skip to main content

Effective Insomnia Treatments: Investigation of Processes in Mindfulness and Cognitive Therapy

  • Christopher William Lee (a1), Melissa J. Ree (a2) and Mei Yin Wong (a3)

Understanding the underlying mechanisms of recovery from insomnia is an important goal for improving existing treatments. In a randomised controlled trial, 57 participants with insomnia disorder were given either cognitive therapy (CT) or mindfulness-based therapy (MBT) following 4 sessions of CBT. Each participant was assessed on process measures related to CT and MBT. MBT resulted in improvement on mindfulness process measures and the size of the improvement was significantly greater than achieved in the CT condition. Interestingly, CT and MBT both resulted in significant improvement on the cognitive process measures. Treatment outcome on the primary outcome measure (Insomnia Severity Index) was not predicted by type of treatment but was predicted by posttreatment scores on the cognitive process measures. The results suggest that changes in cognitive processes are especially important in treating insomnia, and that there are different therapeutic modalities through which this can be achieved.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Effective Insomnia Treatments: Investigation of Processes in Mindfulness and Cognitive Therapy
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Effective Insomnia Treatments: Investigation of Processes in Mindfulness and Cognitive Therapy
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Effective Insomnia Treatments: Investigation of Processes in Mindfulness and Cognitive Therapy
      Available formats
Corresponding author
Address for correspondence: Dr Melissa Ree, 11 Hamilton St, Subiaco WA 6008, Australia. Email:
Hide All
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Baer, R.A., Smith, G.T., & Allen, K.B. (2004). Assessment of mindfulness by self-report the Kentucky Inventory of Mindfulness Skills. Assessment, 11, 191206. doi:10.1177/1073191104268029
Baer, R.A., Smith, G.T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 2745. doi:10.1177/1073191105283504
Bastien, C.H., Vallières, A., & Morin, C.M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2, 297307. doi:10.1016/S1389-9457(00)00065-4
Bélanger, L., Harvey, A.G., Fortier-Brochu, É., Beaulieu-Bonneau, S., Eidelman, P., Talbot, L., . . . Morin, C.M. (2016). Impact of comorbid anxiety and depressive disorders on treatment response to cognitive behavior therapy for insomnia. Journal of Consulting and Clinical Psychology, 84, 659667. doi:10.1037/ccp0000084
Black, D.S., O'Reilly, G.A., Olmstead, R., Breen, E.C., & Irwin, M.R. (2015). Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: A randomized clinical trial. JAMA Internal Medicine, 175, 494501. doi:10.1001/jamainternmed.2014.8081
Brasure, M., Fuchs, E., MacDonald, R., Nelson, V.A., Koffel, E., Olson, C.M., . . . Kane, R.L. (2016). Psychological and behavioral interventions for managing insomnia disorder: An evidence report for a clinical practice guideline by the American College of Physicians. Annals of Internal Medicine. Retrieved from
Buchheld, N., Grossman, P., & Walach, H. (2001). Measuring mindfulness in insight meditation (Vipassana) and meditation-based psychotherapy: The development of the Freiburg Mindfulness Inventory (FMI). Journal for Meditation and Meditation Research, 1, 1134.
Carney, C.E., & Edinger, J.D. (2006). Identifying critical beliefs about sleep in primary insomnia. Sleep, 29, 444453.
Carney, C.E., & Edinger, J.D. (2008). Overcoming insomnia: A cognitive-behavioral therapy approach workbook. Oxford University Press.
Carney, C.E., & Waters, W.F. (2006). Effects of a structured problem-solving procedure on pre-sleep cognitive arousal in college students with insomnia. Behavioral Sleep Medicine, 4, 1328. doi:10.1207/s15402010bsm0401_2
Chadwick, P., Hember, M., Mead, S., Lilley, D., & Dagnan, D. (2005). Responding mindfully to unpleasant thoughts and images: Reliability and validity of the Mindfulness Questionnaire. Unpublished manuscript.
Charles, J., Harrison, C., Britt, H. (2009). Insomnia. Australian Family Physician, 38, 283.
Chiesa, A., & Serretti, A. (2010). A systematic review of neurobiological and clinical features of mindfulness meditations. Psychological Medicine, 40, 12391252. doi:10.1017/S0033291709991747
Cvengros, J.A., Crawford, M.R., Manber, R., & Ong, J.C. (2015). The relationship between beliefs about sleep and adherence to behavioral treatment combined with meditation for insomnia. Behavioral Sleep Medicine, 13, 5263. doi:10.1080/15402002.2013.838767
Daley, M., Morin, C.M., LeBlanc, M., Gregoire, J.P., Savard, J., & Baillargeon, L. (2009). Insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents. Sleep Medicine, 10, 427438. doi:10.1016/j.sleep.2008.04.005
Edinger, J., & Sampson, W. (2002). An abbreviated cognitive-behavioral insomnia therapy designed for primary care settings. Sleep, 25, A70–A71.
Eidelman, P., Talbot, L., Ivers, H., Bélanger, L., Morin, C.M., & Harvey, A.G. (2016). Change in dysfunctional beliefs about sleep in behavior therapy, cognitive therapy, and cognitive-behavioral therapy for insomnia. Behavior Therapy, 47, 102115. doi:10.1016/j.beth.2015.10.002
Ellis, J.G., Gehrman, P., Espie, C.A., Riemann, D., & Perlis, M.L. (2012). Acute insomnia: Current conceptualizations and future directions. Sleep Medicine Reviews, 16, 514.
Franzen, P.L., & Buysse, D.J. (2008). Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. Dialogues in clinical neuroscience, 10 (4), 473.
Garland, S.N., Carlson, L.E., Stephens, A.J., Antle, M.C., Samuels, C., & Campbell, T.S. (2014). Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: A randomized, partially blinded, noninferiority trial. Journal of Clinical Oncology, 32, 449457. doi:10.1200/JCO.2012.47.7265
Garland, S.N., Zhou, E.S., Gonzalez, B.D., & Rodriguez, N. (2016). The quest for mindful sleep: A critical synthesis of the impact of mindfulness-based interventions for insomnia. Current Sleep Medicine Reports, 2, 142151. doi:10.1007/s40675-016-0050-3
Garland, S.N., Rouleau, C.R., Campbell, T., Samuels, C., & Carlson, L.E. (2015). The comparative impact of mindfulness-based cancer recovery (MBCR) and cognitive behavior therapy for insomnia (CBT-I) on sleep and mindfulness in cancer patients. Explore: The Journal of Science and Healing, 11, 445454. doi:10.1016/j.explore.2015.08.004
Geiger-Brown, J.M., Rogers, V.E., Liu, W., Ludeman, E.M., Downton, K.D., & Diaz-Abad, M. (2015). Cognitive behavioral therapy in persons with comorbid insomnia: A meta-analysis. Sleep Medicine Reviews, 23, 5467.
Hall, M., Thayer, J.F., Germain, A., Moul, D., Vasko, R., Puhl, M., . . . Buysse, D.J. (2007). Psychological stress is associated with heightened physiological arousal during NREM sleep in primary insomnia. Behavioral Sleep Medicine, 5, 178193. doi:10.1080/15402000701263221
Harvey, A.G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40, 869893. doi:10.1016/S0005-7967(01)00061-4
Harvey, A.G. (2005). A cognitive theory and therapy for chronic insomnia. Journal of Cognitive Psychotherapy, 19, 4159. doi:10.1891/jcop.
Harvey, A.G. (2006). What about patients who can't sleep? Case formulation for insomnia. In Tarrier, N., (Ed.), Case formulation in cognitive behavior therapy: The treatment of challenging and complex cases (pp. 293311). New York, NY: Routledge/Taylor & Francis Group.
Harvey, A.G., Bélanger, L., Talbot, L., Eidelman, P., Beaulieu-Bonneau, S., Fortier-Brochu, É., . . . Morin, C.M. (2014). Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 82, 670683. doi:10.1037/a0036606
Harvey, A.G., Dong, L., Bélanger, L., & Morin, C.M. (2017). Mediators and treatment matching in behavior therapy, cognitive therapy and cognitive behavior therapy for chronic insomnia. Journal of Consulting and Clinical Psychology, 85, 975987. doi:10.1037/ccp0000244
Harvey, A.G., Sharpley, A.L., Ree, M.J., Stinson, K., & Clark, D.M. (2007). An open trial of cognitive therapy for chronic insomnia. Behaviour Research and Therapy, 45, 24912501. doi:10.1016/j.brat.2007.04.007
Harvey, A.G., Soehner, A.M., Kaplan, K.A., Hein, K., Lee, J., Kanady, J., . . . Buysse, D.J. (2015). Treating insomnia improves mood state, sleep, and functioning in bipolar disorder: A pilot randomized controlled trial. Journal of Consulting and Clinical Psychology, 83, 564577. doi:10.1037/a0038655
Harvey, A.G., & Tang, N.K. (2012). (Mis) perception of sleep in insomnia: A puzzle and a resolution. Psychological Bulletin, 138, 77101. doi:10.1037/a0025730
Hiller, R.M., Johnston, A., Dohnt, H., Lovato, N., & Gradisar, M. (2015). Assessing cognitive processes related to insomnia: A review and measurement guide for Harvey's cognitive model for the maintenance of insomnia. Sleep Medicine Reviews, 23, 4653. doi:10.1016/j.smrv.2014.11.006
Jacobs, G.D. (1998). Say good night to insomnia: The 6-week solution. New York, NY: Henry Holt.
Larouche, M., Cote, G., Belisle, D., & Lorrain, D. (2014). Kind attention and non-judgment in mindfulness-based cognitive therapy applied to the treatment of insomnia: state of knowledge. Pathologie Biologie, 62, 284291. doi:10.1016/j.patbio.2014.07.002
Morin, C.M., & Benca, R. (2012). Chronic insomnia. The Lancet, 379, 11291141. doi:10.1016/S0140-6736(11)60750-2
Morin, C.M., Blais, F., & Savard, J. (2002). Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia? Behaviour Research and Therapy, 40, 741752. doi:10.1016/S0005-7967(01)00055-9
Morin, C.M., & Espie, C.A. (2003). Insomnia: A clinical guide to assessment and treatment. New York, NY: Kluwer Academic/Plenum Publishers.
Morin, C.M., Vallières, A., Guay, B., Ivers, H., Savard, J., Mérette, C., . . . Baillargeon, L. (2009). Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: A randomized controlled trial. Journal of the American Medical Association, 301, 20052015. doi:10.1001/jama.2009.682
Nakamura, Y., Lipschitz, D.L., Kuhn, R., Kinney, A.Y., & Donaldson, G.W. (2013). Investigating efficacy of two brief mind–body intervention programs for managing sleep disturbance in cancer survivors: A pilot randomized controlled trial. Journal of Cancer Survivorship, 7, 165182. doi:10.1007/s11764-012-0252-8
Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100, 569582. doi:10.1037/0021-843X.100.4.569
Norell-Clarke, A., Jansson-Fröjmark, M., Tillfors, M., Harvey, A.G., & Linton, S.J. (2014). Cognitive processes and their association with persistence and remission of insomnia: Findings from a longitudinal study in the general population. Behaviour Research and Therapy, 54, 3848. doi:10.1016/j.brat.2014.01.002
Okajima, I., Komada, Y., & Inoue, Y. (2011). A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep and Biological Rhythms, 9, 2434. doi:10.1111/j.1479-8425.2010.00481.x
Ong, J.C., Manber, R., Segal, Z., Xia, Y., Shapiro, S., & Wyatt, J.K. (2014). A randomized controlled trial of mindfulness meditation for chronic insomnia. Sleep, 37, 15531563. doi:10.5665/sleep.4010
Ong, J.C., Shapiro, S.L., & Manber, R. (2008). Combining mindfulness meditation with cognitive-behavior therapy for insomnia: A treatment-development study. Behavior Therapy, 39, 171182. doi:10.1016/j.beth.2007.07.002
Ong, J.C., Shapiro, S.L., & Manber, R. (2009). Mindfulness meditation and cognitive behavioral therapy for insomnia: A naturalistic 12-month follow-up. Explore: The Journal of Science and Healing, 5, 3036. doi:10.1016/j.explore.2008.10.004
Ong, J.C., Ulmer, C.S., & Manber, R. (2012). Improving sleep with mindfulness and acceptance: A metacognitive model of insomnia. Behaviour Research and Therapy, 50, 651660. doi:10.1016/j.brat.2012.08.001
Ong, J., & Sholtes, D. (2010). A mindfulness-based approach to the treatment of insomnia. Journal of Clinical Psychology, 66, 11751184. doi:10.1002/jclp.20736
Perlis, M., Aloia, M., & Kuhn, B. (Eds.) (2011). Behavioral treatments for sleep disorders. San Diego, CA: Academic Press.
Perlis, M.L., Giles, D.E., Buysse, D.J., Tu, X., & Kupfer, D.J. (1997). Self-reported sleep disturbance as a prodromal symptom in recurrent depression. Journal of Affective Disorders, 42, 209212.
Qaseem, A., Kansagara, D., Forciea, M.A., Cooke, M., & Denberg, T.D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. Retrieved from
Ree, M.J., & Harvey, A.G. (2004). Investigating safety behaviours in insomnia: The development of the Sleep-Related Behaviours Questionnaire (SRBQ). Behaviour Change, 21, 2636. doi:10.1375/bech.
Ree, M., Junge, M., & Cunnington, D. (2017). Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults. Sleep Medicine, 36, S43–S47.
Riemann, D., & Perlis, M.L. (2009). The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Medicine Reviews, 13, 205214. doi:10.1016/j.smrv.2008.06.001
Roth, T. (2007). Insomnia: Definition, prevalence, etiology, and consequences. Journal of Clinical Sleep Medicine, 3, S7.
Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press.
Semler, C.N., & Harvey, A.G. (2004). Monitoring for sleep-related threat: A pilot study of the Sleep Associated Monitoring Index (SAMI). Psychosomatic Medicine, 66, 242250.
Shapiro, S.L., Carlson, L.E., Astin, J.A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62, 373386. doi:10.1002/jclp.20237
Singareddy, R., Vgontzas, A.N., Fernandez-Mendoza, J., Liao, D., Calhoun, S., Shaffer, M.L., & Bixler, E.O. (2012). Risk factors for incident chronic insomnia: A general population prospective study. Sleep Medicine, 13, 346353.
Sivertsen, B., Krokstad, S., Mykletun, A., & Øverland, S. (2009). Insomnia symptoms and use of health care services and medications: The HUNT-2 study. Behavioral Sleep Medicine, 7, 210222. doi:10.1080/15402000903190199
Sivertsen, B., Omvik, S., Pallesen, S. ale, Bjorvatn, B., Havik, O.E., Kvale, G., . . . Nordhus, I.H. (2006). Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: A randomized controlled trial. Journal of the American Medical Association, 295, 28512858. doi:10.1001/jama.295.24.2851
Sunnhed, R., & Jansson-Fröjmark, M. (2014). Are changes in worry associated with treatment response in cognitive behavioral therapy for insomnia? Cognitive Behaviour Therapy, 43, 111. doi:10.1080/16506073.2013.846399
Tang, N.K., & Harvey, A.G. (2004). Correcting distorted perception of sleep in insomnia: A novel behavioural experiment? Behaviour Research and Therapy, 42, 2739. doi:10.1016/S0005-7967(03)00068-8
Trauer, J.M., Qian, M.Y., Doyle, J.S., Rajaratnam, S.M., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine, 163, 191204. doi:10.7326/M14-2841
Walach, H., Buchheld, N., Buttenmüller, V., Kleinknecht, N., & Schmidt, S. (2006). Measuring mindfulness — The Freiburg Mindfulness Inventory (FMI). Personality and Individual Differences, 40, 15431555. doi:10.1016/j.paid.2005.11.025
Wong, M.Y., Ree, M.J. and Lee, C.W. (2016). Enhancing CBT for chronic insomnia: A randomised clinical trial of additive components of mindfulness or cognitive therapy. Clinical Psychology & Psychotherapy, 23. 377385. doi:10.1002/cpp.1980
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Behaviour Change
  • ISSN: 0813-4839
  • EISSN: 2049-7768
  • URL: /core/journals/behaviour-change
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed