March is National Sleep Awareness Month, a great time to highlight the important role sleep plays in overall health.
Systemic therapists know something that sleep medicine has taken decades to discover—human problems don’t exist in isolation. When someone can’t sleep, it’s rarely just their problem. It’s a couple problem. A family problem. A relationship problem.
After decades of research on sleep and relationships, the evidence is overwhelming: sleep is fundamentally a dyadic process for most adults. Yet sleep medicine continues to treat it as an individual disorder. This represents a massive opportunity for systemic therapists to step into a clinical gap that our training uniquely prepares us to fill.
I recently completed a systematic review of 38 studies examining couple- and family-based interventions for insomnia and obstructive sleep apnea published between 2000 and 2025. The findings reveal that marriage and family therapists (MFTs) possess exactly the clinical competencies needed to deliver the most effective sleep interventions, yet we remain largely absent from this treatment arena.
The relational nature of sleep
Maria, 42, comes to therapy complaining of chronic insomnia. She’s tried melatonin, meditation apps, and even prescription sleep medication with minimal success. A cognitive-behavioral therapist might focus exclusively on Maria’s sleep hygiene, her catastrophic thoughts about sleep, and her behavioral patterns. That approach works for some people.
But as MFTs, we ask different questions. We discover that Maria’s husband, Carlos, falls asleep instantly while she lies awake ruminating. His snoring jolts her awake multiple times nightly. When she asks him to see a doctor about it, he dismisses her concerns. When she’s exhausted the next day, he suggests she “just relax more.” The insomnia isn’t just Maria’s problem; it’s embedded in their relationship dynamics, their communication patterns, and their capacity for mutual support.
Research confirms what our systemic training teaches us to see. Daily diary studies demonstrate bidirectional effects operating on day-to-day timescales: poor sleep predicts negative partner interactions the next day, and relationship conflict predicts disrupted sleep that same night (Hasler & Troxel, 2010).
The temporal dynamics are striking. When couples argue during the day, sleep efficiency drops that night. When someone sleeps poorly, they’re more irritable, less empathic, and more reactive with their partner the following day. This creates exactly the kind of circular causality MFTs are trained to identify and interrupt.
Why sleep medicine needs MFTs
Sleep medicine offers two gold-standard treatments: cognitive-behavioral therapy for insomnia (CBT-I) and continuous positive airway pressure (PAP) for obstructive sleep apnea. Both work well in controlled trials. In real-world clinical practice, adherence is abysmal. PAP discontinuation rates range from 29% to 83% within the first year. Approximately 30% of patients receiving CBT-I fail to achieve remission.
Why do evidence-based treatments fail so often? Because they ignore the relational context.
Research on PAP adherence reveals that relationship quality predicts who will stick with treatment. In one study, patients reporting higher marital satisfaction averaged 5.2 hours of nightly PAP use compared to 3.1 hours for those in conflicted marriages (Baron et al., 2009). The difference wasn’t medical; it was relational.
Even more revealing, the type of partner involvement matters enormously. Collaborative partner support—where couples work together as a team to solve PAP problems—predicts sustained adherence. Pressuring involvement, such as nagging, criticizing, and excessive monitoring, predicts treatment failure (Baron et al., 2012).
This is systems theory 101. The identified patient doesn’t exist in isolation. The partner’s behavior, the couple’s communication patterns, and the emotional climate of the relationship all shape whether treatment succeeds or fails.
What the research tells us
The most compelling evidence for partner-involved interventions comes from studies that relational therapists are perfectly positioned to implement.
For insomnia: Patients’ perceptions of partner alliance—believing that their partner understands, supports, and collaborates in treatment—predicted 71% greater improvement in sleep efficiency and 54% greater reduction in insomnia severity compared to those reporting low partner alliance (Ellis et al., 2015). Importantly, this effect held even after controlling for general relationship satisfaction, suggesting something specific about therapeutic alliance extends to the couple system.
For sleep apnea: A multidimensional intervention engaging both patients and their caregivers through structured education, peer coaching, and motivational interviewing showed striking results. At six-month follow-up, 73% of the intervention group achieved adequate PAP adherence (≥4 hours nightly) compared to only 48% of controls (Khan et al., 2022).
Qualitative research reveals why partner involvement matters. Couples describe PAP adjustment as inherently dyadic—both partners lose sleep during the learning curve, both experience frustration with equipment problems, and both benefit when treatment succeeds. Partners who felt included in the process provided emotional support, troubleshooting assistance, and encouragement without pressure. Partners who felt excluded or uncertain about their role often oscillated between uninvolvement and counterproductive nagging (Luyster et al., 2016).
The systemic lens MFTs bring
What makes MFTs uniquely qualified for this work? Our training in circular causality, context, and relational process.
Sleep medicine conceptualizes sleep disorders as individual pathology requiring individual treatment. The patient has insomnia. The patient has sleep apnea. Treatment targets the patient’s thoughts, behaviors, and physiology.
MFTs see something different. We see couples negotiating bedtime rituals, synchronizing circadian rhythms, co-regulating emotional arousal, and either buffering or amplifying each other’s stress responses. We see attachment dynamics playing out in the bedroom—anxious individuals lying awake worrying, while avoidant partners seem oblivious. We see pursuer-distancer patterns where one partner desperately seeks help for sleep problems while the other minimizes or withdraws.
Consider the concept of sleep-wake concordance—the degree to which couples are awake or asleep simultaneously throughout the night. Research shows that greater concordance predicts better relationship satisfaction, and that relationship quality moderates how individual differences affect dyadic sleep patterns (Gunn et al., 2015). This is quintessentially systemic thinking: individual characteristics (chronotype, attachment style) interact with dyadic processes (relationship quality, communication patterns) to produce emergent outcomes at the couple level.
Recent polysomnographic research demonstrates that bed-sharing couples synchronize their sleep stages throughout the night—their brains literally coordinate REM and non-REM cycles (Drews et al., 2020). Moreover, the degree of synchronization correlates with relationship depth. Your sleep architecture is shaped by your partner’s presence, and that physiological synchrony reflects relationship quality. This is embodied systems theory.
For 25 years, sleep researchers have been documenting what MFTs have always known: people exist in relationships, and those relationships profoundly shape health and functioning. Sleep is no exception. Our systemic training, our expertise in dyadic and family process, and our skills in restructuring behavioral patterns position us perfectly for this work.
This is an excerpt from an article coming soon in Family Therapy magazine.
Bruce D. Forman, PhD, practices trauma-informed behavioral sleep medicine in Weston, Florida via telehealth. He was previously director of MFT training in the Counseling Psychology program at the University of Miami and has been a member of AAMFT since 1980. His latest book is titled For God’s Sake Go to Sleep: Insights About Sleep from Jewish Tradition & Modern Science.
References
Baron, K. G., Smith, T. W., Czajkowski, L. A., Gunn, H. E., & Jones, C. R. (2009). Relationship quality and CPAP adherence in patients with obstructive sleep apnea. Behavioral Sleep Medicine, 7(1), 22–36.
Baron, K. G., Smith, T. W., Czajkowski, L. A., Gunn, H. E., & Jones, C. R. (2012). The relationship between perceived spousal involvement in CPAP adherence and adherence-related behavioral and psychological processes in patients with OSA. Journal of Clinical Sleep Medicine, 8(6), 667–673.
Drews, H. J., Wallot, S., Brysch, P., Berger-Johannsen, H., Weinhold, S. L., Mitkidis, P., Baier, P. C., Lechinger, J., Roepstorff, A., & Göder, R. (2020). Bed-sharing in couples is associated with increased and stabilized REM sleep and sleep-stage synchronization. Frontiers in Psychiatry, 11, Article 583.
Ellis, J. G., Hampson, S. E., & Cropley, M. (2015). The role of perceived partner alliance on the efficacy of CBT-I: Preliminary findings from the Partner Alliance in Insomnia Research Study (PAIRS). Behavioral Sleep Medicine, 13(1), 64–72.
Gunn, H. E., Buysse, D. J., Hasler, B. P., Begley, A., & Troxel, W. M. (2015). Sleep concordance in couples is associated with relationship characteristics. Sleep, 38(6), 933–939.
Hasler, B. P., & Troxel, W. M. (2010). Couples’ nighttime sleep efficiency and concordance: Evidence for bidirectional associations with daytime relationship functioning. Psychosomatic Medicine, 72(8), 794–801.
Khan, N. N. S., Todem, D., Bottu, S., Badr, M. S., & Olomu, A. (2022). Impact of patient and family engagement in improving continuous positive airway pressure adherence in patients with obstructive sleep apnea: A randomized controlled trial. Journal of Clinical Sleep Medicine, 18(1), 181–191.
Luyster, F. S., Dunbar-Jacob, J., Aloia, M. S., Martire, L. M., Buysse, D. J., & Strollo, P. J. (2016). Patient and partner experiences with obstructive sleep apnea and CPAP treatment: A qualitative analysis. Behavioral Sleep Medicine, 14(1), 67–84.
