Socratic questioning in CBT: Examples and techniques for therapists
Summary
Help clients implement sleep hygiene protocols by establishing a consistent sleep schedule, building a relaxing bedtime routine, and optimizing their sleep environment.
Use sleep diaries and validated assessment tools to identify patterns, monitor sleep efficiency, and guide treatment decisions.
Help clients apply sleep restriction techniques carefully by adjusting time in bed based on sleep efficiency and gradually increasing sleep opportunities as sleep improves.
Incorporate clinical sleep improvement strategies such as CBT-I, cognitive restructuring, mindfulness, and relaxation exercises to reduce sleep-related anxiety.
Recommend sleep-tracking apps to clients and seek referral for a sleep study when symptoms suggest an underlying sleep disorder or problems persist despite intervention.
Quality sleep is crucial to health and well-being. However, nearly a third of adults in the U.S. do not get enough of it.
Sleep hygiene protocols can help by providing practical ways for clients to get a better night’s sleep and wake up feeling refreshed.
In this article, we explore clinical sleep improvement strategies, what sleep assessment tools work best, when to refer for a sleep study, and how to address sleep anxiety.
What is sleep hygiene?
Sleep hygiene is the practice of using sleeping strategies to promote restful sleep. Clients may report insomnia for a wide range of reasons, including:
Stress
Drinking too much caffeine
Poor sleeping habits, like watching TV in bed or scrolling social media before bedtime
Disruptions from partners or children
Underlying medical issues or sleep disorders
Addressing insomnia or disrupted sleep with clinical sleep improvement strategies and sleep hygiene protocols is a good first step toward identifying the underlying cause of sleeping difficulties.
Clinical sleep improvement strategies
Getting enough good-quality sleep is essential for physical and mental health. Poor sleep hygiene can have wide-ranging effects, including lowered immunity, mood disturbances, fatigue, increased stress levels, decreased performance at school or work, and difficulty concentrating.
Poor quality sleep can even increase safety risks, such as the risk of accidents from driving while drowsy and an increased risk of chronic health conditions like diabetes and stroke.
Clinical sleep hygiene protocols involve behavioral, psychological, and or pharmacological interventions, including:
Exercise: Research shows that any level of physical activity (light, moderate, or vigorous exercise) is associated with improved sleep quality and a reduced risk of insomnia.
Medication: Drugs that promote sleep include over-the-counter medications like antihistamines or prescribed hypnotic drugs such as benzodiazepines. However, these medications can affect quality of life, causing residual effects such as oversleeping, drowsiness, headaches, dry mouth, nightmares, and difficulty concentrating. Sleep medication can also increase safety risk due to “hangover” effects and impaired functioning.
Cognitive behavioral therapy for insomnia (CBT-I): Recommended as the first-line approach by the American Academy of Sleep Medicine and the American College of Physicians, CBT-I involves a six- to eight-week therapy program with a trained clinician that includes psychoeducation, sleep restriction and relaxation strategies, stimulus control, and cognitive therapy.
Behavioral recommendations: Sleep hygiene tips include keeping a consistent bedtime schedule, aiming for at least seven hours of sleep per night, creating a relaxing bedtime routine, avoiding going to bed unless feeling tired, turning off electronics at least 30 minutes before bedtime, creating a relaxing bedroom environment, keeping their room comfortable and cool, avoiding eating large amounts of food before bedtime, exercising regularly, avoiding caffeine in the late afternoon and evening, avoiding alcohol before bedtime, limiting exposure to bright lights in the evenings, and getting out of bed if they don’t fall asleep within 20 to 30 minutes.
What sleep assessment tools work best?
There are various clinical and non-clinical sleep assessment tools.
For outpatient therapists treating standard insomnia, the assessment tools that work best are validated clinical questionnaires and client sleep diaries. Validated tools like the Insomnia Severity Index (ISI) or the Pittsburgh Sleep Quality Index (PSQI) allow clinicians to establish an objective baseline and measure therapeutic progress directly in session.
In contrast, specialized diagnostic tools used in medical sleep centers are reserved for identifying complex organic disorders. Known as polysomnography (a formal sleep study), this laboratory testing tracks physiological data including brainwave activity (EEG), heart rate (ECG), eye movements (EOG), muscle activity, respiratory sensors, and oxygen saturation.
Non-clinical assessment tools include consumer wearable devices (like watches and rings) and smartphone apps that track general sleep/wake patterns and breathing cycles.
Some research shows that wearable technology and sleep diaries can provide valuable data. However, researchers highlight the need to standardize these tools.
How to implement sleep restriction
Sleep restriction is a clinical sleep improvement strategy used in CBT-I and and is often included as part of broader sleep hygiene protocols. It works on the principle that people with insomnia spend time in bed (TIB) awake instead of sleeping.
Using data from a client's diary, time in bed is deducted from their sleep opportunities to help reassociate the bed with sleep and promote sleep efficiency. Sleep efficiency is calculated as the percentage of total sleep time divided by TIB.
For example, if a client spends eight hours in bed but only sleeps for four hours, their TIB is reduced to four hours. (Note: In practice, clinicians should establish a safe floor of 5 hours for TIB to prevent severe daytime fatigue.) The clinician then re-evaluates sleep efficiency. If the score is above 90%, their TIB is increased by 15-minute increments. However, if sleep efficiency is less than 90%, their TIB decreases by 15 to 30 minutes. This process continues until the person feels they are achieving their sleeping goals.
Before implementing sleep restriction, clinicians should consider which sleep assessment tools work best for the individual, evaluate factors such as sleep anxiety, and determine whether referral for a sleep study is warranted. Sleep-tracking apps and relaxation techniques may also support treatment adherence and help monitor progress throughout the intervention.
How to address sleep anxiety
Addressing sleep anxiety is an important component of sleep hygiene protocols and clinical sleep improvement strategies.
Sleep anxiety can be managed in several ways:
Cognitive restructuring to challenge and reframe anxious thoughts.
Mindfulness and meditation to help create separation from anxious thoughts and promote relaxation.
Cognitive Behavioral Therapy for Insomnia (CBT-I) strategies to promote associating bedtime with sleep.
Establishing a nighttime routine that involves relaxation strategies and other sleep hygiene protocols.
Which relaxation techniques are most effective?
There is substantial evidence supporting the effectiveness of relaxation techniques for reducing tension and anxiety, including progressive muscle relaxation, DBT mindfulness techniques, guided imagery, body scan exercises, and box breathing.
Sometimes, the most effective clinical sleep improvement tool comes down to client preference and a willingness to try new tools until they find one that works for them.
What apps help track sleep?
Sleep-tracking apps can support clinical sleep improvement strategies by helping users monitor sleep patterns, identify trends, and track the effectiveness of interventions such as sleep hygiene protocols or CBT-I. Popular options include:
Sleep Cycle: Uses smartphone sensors to estimate sleep stages and provides insights into sleep quality and consistency.
Calm: Primarily a meditation app that also offers sleep stories, guided relaxation exercises, and sleep tracking features.
Headspace: Provides mindfulness exercises, sleep meditations, and tools designed to promote healthy sleep habits.
Autosleep: Designed for Apple Watch users, offering detailed sleep metrics such as sleep duration, quality, and readiness.
Pillow: Integrates with Apple devices to track sleep duration, heart rate, and other sleep-related data.
While sleep-tracking apps can increase awareness of sleep patterns, they are not a substitute for professional assessment. Individuals with persistent sleep difficulties, significant daytime fatigue, or symptoms suggestive of a sleep disorder may benefit from consultation with a healthcare provider or sleep specialist.
When to refer for a sleep study
If clients still experience challenges sleeping after trying these sleep hygiene protocols, then this may highlight the need for further clinical sleep improvement strategies and investigations into sleep disorders such as sleep apnea, narcolepsy, and/or restless leg syndrome.
You may also refer the client to a sleep doctor if clinical sleep improvement strategies don’t work.
Sources
Caruso, C., & Chosewood, C. (2020). Improve sleep: tips to improve your sleep when times are tough. Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention. (2024). About sleep.
Fitzgerald, T., & Vietri, J. (2015). Residual effects of sleep medications are commonly reported and associated with impaired patient-reported outcomes among insomnia patients in the United States. Sleep disorders.
Markwald, R. R., Iftikhar, I., & Youngstedt, S. D. (2018). Behavioral strategies, including exercise, for addressing insomnia. ACSM's health & fitness journal.
National Academies of Sciences, Engineering, and Medicine. (2023). Sleep disorders and tools for assessment. National Academies Press.
Ng, A. E., Black, L. I., & Adjaye-Gbewonyo, D. (2026). Short sleep duration and sleep difficulties among adults: United States, 2024 (NCHS Data Brief No. 559). National Center for Health Statistics.
Ramar, K., Malhotra, R. K., Carden, K. A., Martin, J. L., Abbasi-Feinberg, F., et al., (2021). Sleep is essential to health: An American Academy of Sleep Medicine position statement. Journal of Clinical Sleep Medicine.
Scott, A. J., Webb, T. L., Martyn-St James, M., Rowse, G., & Weich, S. (2021). Improving sleep quality leads to better mental health: A meta-analysis of randomised controlled trials. Sleep medicine reviews.
Solodar, J. (2025). Sleep hygiene: Simple practices for better rest. Harvard Health Publishing.
University of Chicago Medicine. (n.d.). Sleep disorder diagnosis & treatment.
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