CBT-I is an effective and efficacious treatment modality. However, many patients come to clinic having previously failed CBT-I. This chapter addresses the possible reasons why CBT-I could fail, how to approach patients who have previously failed CBT-I, and how to address the problems often seen in these patients. There are a number of reasons that CBT-I might have failed—perhaps the patient was not a good candidate for CBT-I in the first place, the CBT-I they received was not administered properly, or there was some element of the treatment that was not suited to their condition. In any case, many of these patients are pessimistic, cautious, or apprehensive about re-initiating therapy. This can be because they are afraid that their problems are not fixable, or that behavioral sleep medicine is not equipped to address their problem, or that that therapy cannot help them. Whatever the reason, there are several approaches that may benefit these patients. For example, more thorough assessment may identify problems that need to be addressed. A more deliberate attempt to maximize therapeutic alliance and rapport will help address unhelpful beliefs and attitudes, as well as fears. Some slight modifications to CBT-I may help adapt the treatment to better fit this patient's problem.
