If your insomnia patients aren’t getting better despite trying multiple interventions, the problem is rarely effort — it’s framework. Most clinicians were never taught a systematic way to evaluate and treat insomnia, which means the factors actually maintaining the condition often go unaddressed. Here’s what to look for.
Nobody Wants to Treat Insomnia — Here's Why I Leaned In Anyway
Near the end of my psychiatry residency, I was preparing to apply for sleep medicine fellowship. I was chatting with one of my attendings in the sleep clinic at Henry Ford Hospital when he gave me a piece of advice I’ve never forgotten.
“Tell them you want to treat insomnia. You’ll get in for sure.”
Why? Because nobody wants to treat it.
I understood exactly what he meant. Even after completing my sleep medicine fellowship — with a solid CBT-I foundation — and coming in as a psychiatrist with both CBT and psychodynamic training, I’d still feel a quiet dread when I saw an insomnia patient on my schedule. I knew that visit was going to run long in a slot that wasn’t built for it.
And I was better equipped than most.
The Real Reason Insomnia Patients Stay Stuck
Here’s what I kept noticing: most clinicians don’t have a clear framework for evaluating or treating insomnia. So they do what’s available to them — cycle through medications, revisit sleep hygiene, maybe refer for CBT-I that the patient never follows through on.
The insomnia persists, the patient comes back, and the frustration compounds for everyone involved.
That revolving door isn’t a failure of effort. It’s a framework problem.
Understanding why insomnia treatment isn’t working requires looking beyond the obvious. Chronic insomnia is almost never maintained by a single factor. It’s a combination of biology, behavior, and cognition — and treating only one thread rarely unravels the whole knot.
3 Things That Are Commonly Missed in Clinical Practice
1. Targeting the wrong perpetuating factors
The 3P model of insomnia — predisposing, precipitating, and perpetuating factors — is foundational in behavioral sleep medicine, but it’s often skipped in training. The perpetuating factors are what keep insomnia alive long after the original trigger is gone: time in bed awake, irregular schedules, conditioned arousal, catastrophic thinking about sleep. When treatment doesn’t address these specifically, patients don’t get better — even with the right medication or the right referral.
2. Trying to force sedation instead of rebuilding sleep drive
One of the most counterintuitive aspects of insomnia treatment is that trying harder to sleep often makes things worse. Increasing sedating medications, spending more time in bed, or napping to compensate can undermine sleep drive and deepen conditioned arousal. Effective insomnia treatment works with the brain’s natural sleep systems — not against them.
3. Missing the cognitive and behavioral layer entirely
Even when clinicians address the biological piece, the behavioral and cognitive side often goes untouched. Rigid beliefs about sleep, hyperarousal in the bedroom, and anxiety about not sleeping are powerful perpetuating factors that medications don’t touch. CBT-I and ACT for insomnia work because they directly dismantle these patterns — but only when they’re properly implemented.
Watch: Part One of a Three-Part Series on Insomnia
If you’ve ever felt stuck with an insomnia patient who isn’t responding, this is where I’d start.
In this first video I walk through these three commonly missed factors in clinical practice — including why trying to force sedation can backfire, and how targeting the wrong perpetuating factors keeps patients stuck in a cycle that’s hard to break.
▶ Watch Part One Here — it’s the framework I wish I’d had in residency.
About the Author
Nishi Bhopal MD is board certified in both Psychiatry and Sleep Medicine (ABPN). She specializes in non-pharmacological insomnia management and holistic, integrative sleep medicine, and teaches clinicians evidence-based frameworks for evaluating and treating chronic insomnia through The Clinical Sleep Kit program.
