Cognitive behavioural therapy, or CBT, is one of the therapies most often offered on the NHS. It looks at how thoughts, feelings and behaviour affect each other and helps you notice patterns of thinking that keep you stuck. It’s practical and structured, and usually short-term. For a lot of people, it helps.

For others it doesn’t quite land. If you’ve tried CBT and come away feeling you did it wrong, or that it missed something, you’re in good company. Here are some of the reasons it happens, what’s different about CBT for sleep, and a few other approaches worth knowing about.

CBT starts from the idea that the way we read a situation shapes how we feel about it and what we do next. If you think “I’ll never cope with tomorrow”, you’re likely to feel anxious, and anxiety changes what you do. You might put things off, or lie awake going over it.

In CBT you learn to catch those thoughts, look at the evidence for them and try out other ways of seeing things. There’s usually work between sessions too, such as keeping a record of your moods or practising a new approach in daily life.

CBT asks a lot of you. You need to be able to step back from a thought and examine it, put words to what’s happening, and keep going with tasks between sessions. That’s hard when you’re severely depressed, exhausted, living with chronic fatigue or simply overwhelmed.

Some people need CBT adapting to suit them, for example with more visual materials and a slower pace. That includes people with a learning disability, dementia or a brain injury.

CBT also works mainly with the present and with what you can put into words. Some distress sits lower down, in the body and the nervous system, and doesn’t shift much when you reason with it.

Trauma can go on affecting the nervous system long after the event. You might know perfectly well that you’re safe now and still feel the alarm go off. When a belief such as “I’m not safe” or “I’m not good enough” grew out of trauma, questioning it on a worksheet can feel beside the point.

Standard CBT may not reach the intense emotional and nervous-system responses that can come with complex trauma. Trauma-focused forms of CBT are designed for exactly this, and are recommended for PTSD in the UK alongside EMDR, which is described below. Some people with complex trauma find they need a slower, body-aware way in before either feels possible.

Adapted to the person, CBT can help with some of the day-to-day difficulties that come with ADHD: managing time, organising tasks, getting started, and handling big feelings when they arrive fast. It can also help Autistic people with anxiety, transitions and unexpected changes to routine.

The adapting matters. For many Autistic people, distress comes from real things – sensory overload, being left out, stigma, and a world built for neurotypical people. A therapy that frames those reactions as faulty thinking has misread the situation. It can also push people further into masking, hiding their natural ways of being to fit in, which is exhausting over time. There’s more on this in Masking and rest.

If you’d like to try CBT and you’re ADHD, Autistic or both, look for a therapist with experience of working with neurodivergent people. A good one will adjust how they work to fit your communication style and sensory needs.

If sleep is your main difficulty, the CBT you’re most likely to be offered is CBT for insomnia, or CBT-I. It’s the recommended first approach for long-term insomnia in the UK, and it’s quite a different animal from the CBT described above.

Much of CBT-I is practical. It works on the habits and timings that keep insomnia going: keeping a regular sleep window, getting up when sleep isn’t coming, and rebuilding the link between bed and sleep. There’s some work with thoughts too, mostly the worries about sleep that crowd in at night.

Some parts can be hard going for ADHD and Autistic people, and one part, sleep restriction, isn’t safe for everyone. A good practitioner will adapt it to you. If CBT hasn’t suited you before, CBT-I may still be worth trying. I’m trained in CBT-I and integrate it into my own work, adapted for neurodivergent clients and alongside a body-based approach.

CBT-I is designed for insomnia. If you sleep well once you’re asleep but your sleep runs late, your body clock may be set later than the day you’re expected to live, and the approaches for that are different. When it might be a sleep disorder explains more.

If CBT hasn’t worked for you, try not to be discouraged. Different approaches suit different people, and finding the right one can take time.

Psychodynamic Therapy

Psychodynamic therapy grew out of psychoanalysis. It looks at how past experiences, early relationships and feelings outside your awareness shape how you think, feel and act now. The aim is to bring those patterns into view so they can be understood and worked through. It tends to be less structured than CBT and more open-ended in length.

Somatic Therapy

Somatic therapy works with the connection between body and mind. It starts from the idea that stress, trauma and difficult feelings show up in physical sensations and in the nervous system. Sessions usually combine talking with attention to the body, and may include mindfulness, breathing or movement. The aim is to help your nervous system settle, and to let feelings come through at a pace that feels safe.

Acceptance and Commitment Therapy (ACT)

ACT belongs to the same broad family as CBT, but it takes a different line on difficult thoughts. Rather than challenging them, you learn to notice them and let them be there while you get on with what matters to you. Uncomfortable thoughts and feelings are part of life, and struggling against them can add to the load.

EMDR

Eye movement desensitisation and reprocessing (EMDR) is a structured therapy for processing traumatic memories. While you hold a distressing memory in mind, the therapist guides you through bilateral stimulation, such as following their hand with your eyes or listening to sounds that alternate between your ears. Over time the memory tends to lose some of its emotional charge. EMDR is recommended for PTSD in the UK and is used for other difficulties too.

The research behind these approaches varies. EMDR and trauma-focused CBT have the strongest evidence for PTSD, while research on somatic therapies is at an earlier stage.

In England, you can refer yourself to NHS Talking Therapies for CBT and some other therapies, and some services offer CBT-I. Your GP can also refer you. If you’re looking privately, check your therapist is registered with a professional body such as the BACP, UKCP or, for CBT, the BABCP.

If you’d like to work with me, you can find out more at heatherdarwallsmith.com.

It’s fine to ask a therapist how they work before you start, and to try someone else if it doesn’t feel right.
If you’re struggling to cope or having thoughts of harming yourself, talk to your GP, or call Samaritans free, day or night, on 116 123.