Marriage and family therapists (MFTs) 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 MFTs 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 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
Consider this scenario: 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. A 2024 meta-analysis of 62 studies with more than 43,000 participants found a moderate correlation (r = 0.34) between relationship quality and sleep quality (Wang et al., 2024). 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 spousal 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 MFTs 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.
One randomized trial even demonstrated that couples therapy focused on improving marital quality produced secondary sleep benefits. Husbands whose marital satisfaction improved showed a 36% reduced risk of insomnia at follow-up (Troxel et al., 2016). You don’t even have to target sleep directly—improve the relationship, and sleep often improves as a byproduct.
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.
Practical clinical recommendations
Based on the evidence, here’s what MFTs can do immediately:
Screen for sleep problems in every couple assessment. Ask about sleep quality, bed-sharing arrangements, and whether either partner’s sleep affects the relationship. Many couples won’t mention sleep problems unless directly asked, yet sleep disturbance often underlies presenting complaints about irritability, low libido, or “growing apart.” I also like to recommend using a free, validated screening tool available online (sleephealthscreen.com) to screen for 13 sleep disorders in minutes.
Assess the relational context of sleep disorders. When clients report insomnia or sleep apnea, explore: How does your partner respond when you can’t sleep? Do you feel supported or criticized? Does your partner’s sleep behavior affect yours? Are bedtime and wake times sources of conflict? What have you tried together to address this?
Provide psychoeducation to both partners. When sleep problems exist, include partners in understanding the disorder and its treatment. Partners often have misconceptions (“he’s just lazy” about PAP non-use, or “she’s too anxious” about insomnia) that create judgment rather than support.
Identify and modify relationship patterns that maintain sleep problems. Partners often inadvertently reinforce poor sleep through excessive reassurance, enabling extended time in bed, or modeling sleep-incompatible behaviors. Other couples have conflicts that spike arousal right before bedtime. These are behavioral sequences MFTs excel at restructuring.
Distinguish collaborative from pressuring partner involvement. Help couples understand that nagging about PAP use or sleep schedules backfires. Collaborative involvement means working together as a team, joint problem-solving when challenges arise, and supporting without controlling.
Refer strategically to sleep medicine while maintaining therapeutic coordination. MFTs shouldn’t diagnose sleep disorders or prescribe PAP—that requires sleep medicine expertise. But we can prepare couples for sleep consultations, help them implement treatment recommendations, troubleshoot adherence barriers, and address the relational impacts that sleep specialists often miss.
Consider sleep as a treatment outcome in couples therapy. When working with distressed couples, include sleep quality in outcome assessment. Improvements in communication, conflict resolution, and emotional intimacy often yield sleep benefits without sleep-specific interventions.
Special populations where MFTs can lead
The research on cancer patients and their caregiving partners reveals particularly compelling opportunities for MFT involvement. Sleep disturbance affects both cancer patients and bedpartner caregivers at similar rates. Dyadic sleep interventions that address both partners’ sleep simultaneously show excellent feasibility and preliminary efficacy (Kim et al., 2023).
Patient distress affects both partners’ sleep.
This makes perfect sense from a systemic perspective. Caregiving stress disrupts caregiver sleep. Poor caregiver sleep impairs caregiving capacity. Impaired caregiving affects patient outcomes. Patient distress affects both partners’ sleep. Breaking into this cycle at any point requires addressing the dyadic system, not just the identified patient.
Similar logic applies to other medical populations where patients and partners experience concurrent sleep disturbance—chronic pain conditions, PTSD, dementia care—all represent potential applications for systemically informed dyadic sleep interventions that MFTs are trained to deliver.
When sleep problems exist, include partners in understanding the disorder and its treatment.
The path forward
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.
Yet, MFTs remain largely absent from sleep medicine. We’re not typically included in multidisciplinary sleep centers. We’re not usually consulted when patients struggle with CBT-I or PAP adherence. Insurance panels often credential sleep interventions only for psychologists with specialized training.
This needs to change. The evidence base now exists to support MFT involvement in sleep treatment. Our systemic training, our expertise in dyadic and family process, and our skills in restructuring behavioral patterns position us perfectly for this work.
We don’t need to become sleep specialists. We need to bring our relational expertise to a field that desperately needs it. When someone presents with a sleep problem, we should immediately ask: Who else is affected? How do relationship dynamics maintain this pattern? What systemic interventions might interrupt the cycle?
The next time a client mentions insomnia or sleep apnea, don’t just refer out. Ask about their partner. Explore the relational context. Consider involving the partner in treatment. You might be the only clinician who sees the full picture.
Sleep problems are relationship problems. And relationship problems are exactly what MFTs are trained to treat.
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 is a Professional member of AAMFT, joining in 1980. His latest book is titled For God’s Sake Go to Sleep: Insights About Sleep from Jewish Tradition & Modern Science.
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.
Kim, Y., Tsai, T. C., Steel, J. L., Ramos, A. R., Laurenceau, J.-P., & Troxel, W. M. (2025). Protocol of testing the feasibility and acceptability of two brief dyadic sleep interventions for adults with cancer and their bedpartner caregivers. Pilot and Feasibility Studies, 11(1), Article 82.
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.
Troxel, W. M., Braithwaite, S. R., Sandberg, J. G., & Holt-Lunstad, J. (2016). Does improving marital quality improve sleep? Results from a marital therapy trial. Behavioral Sleep Medicine, 15(4), 330–343.
Wang, L., Wang, J., Guo, M., & Zhu, C. (2024). The association between couple relationships and sleep: A systematic review and meta-analysis. Sleep Medicine Reviews, 78, Article 101980.
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