Cognitive Behavior Therapy for Insomnia in Those with Depression: A Guide for Clinicians 1st

expected functioning, will reduce anxiety about sleep. Also implicit in SC instructions is the idea of acceptance when sleep is not forthcoming. In other words, clients who practice good SC learn to behave, and eventually think like a person who is not preoccupied with sleep. Clients who practice this rule increase the drive for deep sleep and unlearn conditioned arousal but they also covertly challenge the idea that one MUST sleep simply because one wants to or because it is a particular time. In essence, clients are learning not to engage in sleep effort. Many clients are unaware that they are challenging these beliefs, but if a client is adhering to this rule, they are inadvertently building their confidence as someone who can cope with sleep loss, and someone who need not exert effort to sleep because they trust their body to produce sleep when it is truly needed. The following is a sample dialogue with Kelly, a case example from Chapter 10, for setting up standard wake times as a behavioral experiment: Therapist: Given all you just learned about how your sleep system works, I wonder if you are willing to try a few strategies to get your sleep system back on track. Client: I can give it a try. Therapist: If we know that getting up at the same time every morning helps to set the clock and also ensures that you start building enough sleep drive for deep sleep the next night, then can we experiment over the next two weeks with a set time to get out of bed and keep track of the results? Client: [Smiles]. I might be able to do it for two weeks. I’m not sure if it will work for me. I already get up at the same time five times a week. Therapist: [Picks up sleep diary for them to look at together]. I see that your alarm is set for the same time five times a week, but are the rise times and final awakening times the same on this diary? Client: Well no, sometimes I just keep hitting the snooze button and stay in bed longer, but it’s because I am really tired. Therapist: Yes, of course. And what about the weekend? Client: Again, I am really tired so that’s why I stay in bed. Therapist: Understandable. But we know that the habits reported on this sleep diary, however good they feel in the moment, are the habits associated with recurring insomnia week after week—this is why you are here. So I wonder what happens if you test out a standard get out of bed time and we compare the two diaries in two weeks’ time. Client: You think my sleep could get better in two weeks? Therapist: We won’t know unless we try. We can keep track of the experiment with your sleep diaries. This way, you don’t have to take my word for it. You will be able to see your sleep system in action and how this simple change will help it to improve your sleep. Are you willing to do this over the next two weeks? Client: I’m skeptical, but willing to try it out. As stated, it is often helpful for clients to see these recommendations as time limited so framing the steps of various protocols as BEs encourages willingness. For example, see Figure 6.2. This client is testing out the belief: “I’m tired and need to save my energy so that I have enough resources to deal with things.” This belief is very common in people with insomnia. Fatigue is a key feature of both insomnia and depression and BA 90 Cognitive Factors and Treatment

is an effective strategy for improving mood but beliefs about needing to rest in order to manage fatigue, often get in the way of activation. Resting is a common sense strategy for improving fatigue so by the therapist merely saying that resting increases fatigue is often not particularly compelling. It may be more effective for clients to achieve belief change through an experiential learning process. While resting when tired can truly feel good in the short run, excessive rest can have a negative effect on motivation. The adage that an object at rest, stays at rest, is particularly poignant in this circumstance. Spending long periods on the couch watching television or on the computer tends to lead to further time on the computer or television. In addition, it tends to produce boredom and lethargy. Conversely, engaging in goal directed activities can have positive effects on motivation and energy, as there is momentum in such a strategy. Further, moving around increases blood flow and oxygenation, whereas staying at rest can create deconditioning and muscle shortening which can lead to aches and pains. Lying down activates the parasympathetic nervous system, but being upright activates the sympathetic branch. Excessive rest can also have a negative effect on sleep because it may lead to dozing or napping, and mitigate the build-up of drive for deep sleep. Excessive rest can have negative mood consequences as well because people can become anxious or feel badly about themselves if they have a low rate of goal-directed activity. For example, if a client has a to-do list of 5 items for the week and at the end of the week, little on the list was accomplished, it can inspire self-focused rumination about what is wrong with them that they are unable to meet goals or worry about the consequences of not getting the needed tasks completed. Worry and rumination can lead to increased sleep effort and further worry (e.g., the person may go to bed with the thought, “I had better get some sleep tonight or else I will not be able to get the items on my list accomplished”). Lastly, rest can have negative effects on mood because without movement and leaving the house, the possibilities for positive reinforcement are diminished. Rest is often done in solitude or with little active social engagement, which leads to a less rewarding life, and fewer exposures to situations that could provide regulatory input into the circadian system. Thus, when a client is encouraged to engage in a BE like the one presented in Figure 6.2, generally, contrary to their beliefs, they will notice an improvement in either fatigue, mood and/or sleep with activation, and/or a worsening of fatigue, mood and/or sleep with conservation. In addition to the standard protocol instructions of CBT-I, there are other behavioral experiments that specifically target belief changes. Given that each client can present with their own unique set of beliefs and concerns, theoretically there can be as many different types of experiments as there are clients. That said, there are several common experiments we test in those with insomnia and depression fairly consistently. Another common belief is that: “I need to scan my body to figure out if I have enough energy and resources to [do a task].” Such body scanning is what Harvey (2002) refers to as monitoring. The belief that body monitoring is helpful can be tested with an instruction to focus intensely (for 15 minutes) on fatigue symptoms followed by 15 minutes of focus on the present environment, e.g., sounds, smells, sights, and tactile information in the environment. In each case the client can rate mood and fatigue and compare the differences. Generally, solely to be searching for signs of fatigue will most certainly yield evidence of fatigue and perception of greater intensity. Conversely, when one is focused outward on the here and now they will tend to feel better. Cognitive Factors and Treatment 91

Another testable belief is, “I need to fix my depression and feel more motivated before I can do [any task, including the behavioral recommendations in CBT].” A belief that motivation needs to come first to perform tasks can be tested by asking the client to do one task without the sensation of motivation and monitor the results. The essential point is that behaving and experiencing the outcome is often superior to verbal delivery of information, and is less vulnerable to resistance and often self-perpetuating in a positive 92 Cognitive Factors and Treatment Belief to test: I’m tired and need to save my energy so that I have enough resources to deal with things. Week One Experiment: Spend one week conserving energy as much as possible. Track sleep efficiency (SE) on sleep diary, mood and fatigue. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Felt nice to do nothing ☺ achy SE was 64%--sleep was crappy Fatigue 8/10 Bored and depressed 8/10 SE = 62% Overall fatigue = 9/10 Achy and bored; depressed 8/10 Fatigue 9/10 SE = 64% Too boring in house (went shopping) Fatigue 6/10 SE = 69% Depression 6/10 Ruminating Depressed 9/10 Aches and very tired 9/10 SE = 64% Depressed 6/10 Couldn’t take it-- shower and go for a walk SE = 65% Fatigue = 6/10 Depressed 9/10 Fatigue 9/10 SE = 62% Week Two Experiment: Plan activities to expend energy. Track sleep efficiency (SE) on sleep diary, mood and fatigue. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Laundry, showered, walk and dinner with friend SE was 81% Fatigue 5/10 Depressed 5/10 Showered, read, walk, cleaned closet Depressed 6/10 SE = 82% Fatigue 5/10 Showered, paid bills, walk, made dinner Depressed 2/10 (felt good today) Fatigue 4/10 SE = 84% Out with a friend Fatigue 2/10 SE = 69% Depression 2/10 Visited Mom, went to store to switch out phone Depressed 3/10 Fatigue 5/10 SE = 84% Depressed 5/10 Showered, walk, out for coffee, bought gifts SE = 85% Fatigue = 6/10 Brunch, skating, grocery shopping, clean house Depressed 3/10 Fatigue 3/10 SE = 82% Figure 6.2 Behavioral experiment tracking example

direction, thus less prone to relapse. Readers are encouraged to read Ree & Harvey (2004) for more on insomnia-focused behavioral experiments. Coping Cards: Encouraging Negative Thought-Incongruent Behavior Often, in-session, the client can begin to see a range of alternative possibilities and is able to process the information that disconfirms their long held negative beliefs about sleep. Clients may feel ready to make a behavior change in session, but then when they get home, they may find themselves overcome by old automatic thinking and emotions and therefore unable to implement new strategies. Coping Cards are “notes to the self” to be read at times when information processing may undermine the commitment to the behavioral goals. Once a particular type of information processing is activated, information that is congruous with the negative mood and thoughts is over attended to at the expense of disconfirming information. If the client writes a message to them - selves at a time when information processing is more open to a range of information, and then reads this alternative when they feel more stuck, it may prompt them to engage in a more adaptive behavior. A note to the self on a smart phone, cue card, note pad, or post-it note can be an effective lifeline that encourages behavior change and increases self-efficacy. In the example below, we see the therapist establishing the mood-thought-behavior connection in order to encourage the client to make a behavioral change. Rather than buying into the client’s formulation that particular circumstances or moods (e.g., feeling horribly in the morning) determine behavior (e.g., whether or not to set an alarm clock for the morning), the therapist suggests an alternative coping behavior (e.g., setting and turning on the alarm clock at a different time, when mood is less negative). While the therapist is making the thought-mood-behavior connection, the client spontaneously suggests a method akin to the Coping Card. In most circumstances, the therapist will introduce the idea. Therapist: How did things go last night? Were you able to set the alarm? Client: No. Therapist: What got in the way? Client: I don’t know. Therapist: Did you have the thought, “I should set my alarm” last night? Client: Yes, but I felt so horribly last night because I’m so tired that I knew I wasn’t going to be able to do it. The idea of setting the alarm was not at all appealing. Therapist: I get it. And how did you feel the next morning? Client: Well, horrible—even worse. I was exhausted. Therapist: You responded to feeling horribly by doing something that made you feel even more horrible. Sounds a bit like a trap. Maybe the way to get out of this trap is to respond to this situation in a different way. If not setting an alarm makes you feel horrible the next morning, could we experiment with setting the alarm and gathering information on whether your mornings could be less horrible? Client: Well, that was my plan. Therapist: Right, but you followed your feeling rather than your plan. This resulted in feeling more horrible and you started to criticize yourself for not following the Cognitive Factors and Treatment 93

94 Cognitive Factors and Treatment plan, which also worsened your mood. Instead of tying the “on” button of your alarm clock to how you feel—what if your alarm was turned on during the day when you feel better? Your alarm clock can be turned on at any time, right? Client: I never thought about this. I could turn it on when I got home—take the decision out of it. Therapist: Can you think of anything that could get in the way? Client: I wonder if I would turn it off before bed if I was feeling really bad. Therapist: Well, we could wait and see if this is a problem or we could try something to minimize the likelihood of this happening. Client: I could put a post-it note on the clock like: “DO NOT TURN OFF, NO MATTER WHAT!” Therapist: Do you think this would help? Client: I do. The idea of the note kind of makes me laugh. I think if I saw the note it would change my mood a little. I think this may work. I am going to start turning on my clock when I get back from work, before my mood plummets, and I will stick a funny note on it to remind me not to turn it off. It is often most helpful to have the client write the coping card in session. We keep a small stack of post-it notes and index cards for this purpose. It is often helpful to have several reminders on the card including a reminder of the desired behavior. Some choose to put reminders on their smart phones. Shifting Information Processing Using Stimulus Control The Stimulus Control instruction to get out of bed when unable to sleep is important for giving up sleep effort and addressing conditioned arousal but there may be other benefits as well. When people are lying in bed attempting to sleep, they unknowingly go in and out of a very light stage of sleep but are often unaware of any sleep at all. The reason why they misperceive or underestimate sleep has many possible explanations Stay up until 11 PM If you fall asleep, you will be awake later. This will fix your sleep problem. Turn on the lights. Don’t lay down. Invite a friend over. I would rather sleep than nap. Go out and visit Louie. Figure 6.3 Coping card example

(Harvey, 2002; Lundh & Broman, 2000; Perlis et al., 1997). Most theories suggest a role for arousal (Bonnet & Arand, 1996, 1997; Perlis et al., 1997, 2000; Tang & Harvey, 2004). For example, high frequency brain activity intrudes into the onset of sleep and is perceived as wakefulness rather than sleep. The consequence is that staying in bed trying to sleep could result in a confusional state between wakefulness and sleep. In addition, information processing, problem solving and emotion regulation are less than optimal while in this transitional stage between wake and sleep. Ever heard of the saying, “things will look better in the morning?” That may well be true in part because looking at things when half asleep is not likely to feel positive. Getting out of bed creates a shift into full wakefulness, ends the light stage of sleep, and as a result, increases lucidity. While lucid, information processing, problem solving and emotion regulation is more optimal so that the client has a better chance to become calm and ready to return to bed. Summary • A cognitive model for insomnia (Harvey, 2002; Morin, 1993) emphasizes the role of beliefs about sleep self-efficacy and fatigue in activating negative thoughts about sleep or fatigue. These thoughts lead to increased monitoring in the environment for sleep or fatigue threats as well as increased safety and avoidance behaviors that interfere with sleep. There are similarities across cognitive theories of sleep and depression; namely attentional bias towards negative information (depression) and sleep or fatigue threats (insomnia). • Cognitive therapy attempts to address cognitive causal factors and may also act by addressing cognitive barriers to adherence. • Cognitive Therapy does not have APA level evidence as a monotherapy but nonetheless is a common element in CBT packages for insomnia. • There are a variety of cognitive techniques used in insomnia treatment including Thought Records, Socratic Questioning, Behavioral Experiments, and Coping Cards. These can all be used simultaneously to discover alternative thoughts and enhance outcomes. Cognitive Factors and Treatment 95

7 Encouraging Adherence and Troubleshooting Potential Barriers There are many successful trials of CBT-I in those with MDD-I (Edinger et al., 2009b; Kuo et al., 2001; Lichstein et al., 2000; Manber et al., 2008; Morawetz, 2001; Watanabe et al., 2011). In each of these trials CBT-I was delivered unaltered. Nonetheless, CBT-I is a demanding treatment and MDD-I clients can present with specific barriers that can interfere with tolerating the rigors of the protocols, and make following the treatment more challenging. In this chapter, we provide some troubleshooting strategies for the more common problems. Cognitive therapy, as stated in Chapter 6, is an important tool for increasing adherence. We have included in this chapter some cognitive strategies that can be utilized for troubleshooting resistance, but the reader is directed to Chapter 6 to understand the theoretical underpinnings of such techniques. Most problems of non-response or suboptimal response to CBT-I in those with or without a comorbid condition, amount to difficulties following all of the strategies. It is important to check in every session with the client’s experience with following the recommendations. The first step in addressing non-adherence is a troubleshooting assessment. Throughout this assessment, it is important to gather as much information as possible about the factors that may be interfering with adherence. In addition, the assessment affords an opportunity to intervene as well. It is important not to assume the reason behind nonadherence. Query for the antecedents, the presumed barrier to adherence and the consequences. There are many reasons why someone has difficulty following an instruction such as getting out of bed at a same time. These rules are not easy to follow, especially when one is experiencing fatigue and low mood, so it is always important to validate these experiences and acknowledge that it is difficult but not impossible to focus on behavior change to improve sleep. Approach the situation empathetically and openly, and foster a spirit of curiosity. What follows is a series of common troubleshooting scenarios with Kelly, a case study from Chapter 10. Troubleshooting Difficulties with the Morning Discomfort Therapist: So, the last time we met, we discussed quite a long list of recommended changes to your sleep routine and I wanted to check in with how things went over the last two weeks.

Client: It was ok but I really couldn’t get up at 5:30 AM—I just couldn’t. Therapist: I see. I would like to get some more information so that we can understand what got in the way if that’s ok? [Client nods yes]. There was so much to remember from last week, can we start by checking in with what you remember about why we are setting a rise time each morning? Client: To build sleep drive? Therapist: Excellent. That’s right, to build enough drive for deep sleep the next night and the nights to come. Can you remember any other reasons? Client: I’m not sure. . . . Therapist: There was another reason that related to the clock, does this sound familiar? Client: Sort of . . . I need to set my clock each morning around the same time? Therapist: That’s true. You sound like you are referring to your alarm clock. I was alluding to your biological clock. Getting up at the same time every morning can help to set your biological clock so that over time your brain learns when to go to sleep and when to wake. But you are correct that setting the alarm clock can help you to wake at the same time each morning. So, can you tell me more about what happened in the morning? Were you able to set the alarm and get out of bed at 5:30 on any morning? Client: The first morning, but then no. Therapist: [looking at the sleep diaries] I love that you started off right away with the recommendation, what happened this first morning that you were able to do it? Client: I think I was pretty eager for the treatment to work, but I didn’t notice sleeping any better the next night so I may have lost my drive? Therapist: So by the second morning you felt unmotivated or perhaps discouraged? Client: Maybe. I don’t know. I was so tired. I just couldn’t get up. I would think I’ll just lie here for a few minutes but then an hour would go by . . . I don’t know. Therapist: Were you sleeping during this time? Client: No. Therapist: So you would notice that you felt tired and you would have the thought, “I can’t get up.” Client: I guess. Therapist: Did you have any other thoughts? Client: I’m not sure. . . . that it was too cold to get up? Therapist: You mean you noticed that you were cold? Client: Not that I was cold, but that if I get up I will be cold. I’m so comfortable and warm in the morning and I can’t imagine getting up. I hate the feeling of getting up and feeling cold. In fact, it’s not so much I’m too tired to get up—I’m used to feeling tired when I get up. I just can’t face the idea of the shock of feeling cold. It feels so awful to suddenly be cold. It makes me feel achy and it seems like it takes an hour before I feel comfortable. Therapist: I can see why this would be unpleasant and make it more difficult to stick to your plan. If we were to find a solution to this problem, would you be able to get out of bed at 5:30 AM, or do you think there is something else? Client: No. I think that would help. Therapist: I notice that after three days the final awakening is past 5:30 AM. Did you continue to set an alarm? Adherence and Troubleshooting Barriers 97

Client: No. I knew I couldn’t do it so I figured what is the point? Therapist: So on one hand, getting out of bed at the same time would probably fix your sleep problem, which is important to you, but on the other hand, getting out of bed and feeling cold would feel unpleasant. If this is an issue of physical discomfort, can you think of a way to help with the discomfort of transitioning from a warm bed to a cold room? Client: I tried programming the thermostat to warm up the room in the morning but it didn’t work because I felt even toastier in the morning and I didn’t want to get up [smiles]. Therapist: I guess that’s off the list, even though it sounded like a good idea. Any other ideas? Client: No. If I could just get my bed to hover downstairs maybe that would work [smiles]. Therapist: [laughs] maybe that’s a good idea . . . I don’t know of a way to get your bed to hover, but what if you were to wrap yourself in your blanket and leave the room? Client: So that I stay warm? Therapist: What do you think? Is it worth a try? Client: That might work. I’ll try it. I could sit on the couch for a bit. Therapist: Anything else that would make it easier? Client: I could have some nice warm socks next to the bed to put on before my feet hit that cold floor. Therapist: That’s brilliant! And you could still combine this with the blanket idea? Client: Ok. I can do all of that. Therapist: What about the alarm? This was a secondary problem with sticking to the plan. Are you willing to set it now that you have this strategy for physical comfort in place? Client: Yes, I think so. Therapist: Any other possible problems? Client: No I actually think this might work. Therapist: Great. Let’s write down the blanket, warm socks, and alarm ideas on the bottom of your recommendations sheet. In this case, the nonadherence was related to thoughts about how uncomfortable and cold it is out of the bed in the morning. Devising a plan in which one transitions with some warmth to a seated position in another room, can be a helpful way to make following the rule of getting out of bed at the same time every morning less aversive. Sleep Inertia For some, the feeling of grogginess in the morning is aversive and is taken as a sign to stay in bed. There are many ways to help with this issue. First, attributing sluggishness exclusively to a poor night’s sleep is unhelpful and most often inaccurate. It is not unusual to experience temporary sleepiness upon waking up. This state is called sleep inertia; a transitional state which often relates to the stage of sleep out of which the person is roused (e.g., Tassi & Muzet, 2000). Waking from deep sleep will produce more sleep inertia than waking from N1 sleep. Although sleep inertia can also result from sleep 98 Adherence and Troubleshooting Barriers

deprivation, this is not typically the case in insomnia and assuming that how one feels in the morning relates only to poor sleep will increase sleep anxiety and likely sleep effort as well. Similarly, assuming that sleep inertia is predictive of a poor day of functioning can lead to behavior that would confirm this belief (i.e., it can become a self-fulfilling prophesy for a bad day). The therapist can begin to shift these attributions by providing psychoeducation that sleep inertia is experienced universally by good sleepers and those with insomnia alike, most often lasts less than 30 minutes, and is simply a product of the stage of sleep occurring just prior to waking-up. Therefore, sleep inertia is not thought to have much bearing on how one will feel the rest of the day. Such challenging of unhelpful thinking about the significance of this state is one way to address problematic outcomes that result from more negative attributions. Another way to help with this problem is to encourage the client to devise a behavioral experiment. If the belief is, “Sleep inertia is related to how poorly I slept, so it means I will feel badly all day,” this can be tested by an experiment wherein the client uses techniques that can minimize the time spent in sleep inertia and then monitor what happens during the rest of the day. This can be compared to a week in which the client applies no coping strategies. Some coping techniques to enhance alertness and diminish sleep inertia are to encourage movement (physical activity such as taking the dog for a walk, showering, and turning on lights or going outside to enhance exposure to bright light). Another possible experiment would be to have the client rate the severity and duration of the sleep inertia each morning and then perhaps have a phone alarm set for several time points in the day to cue the client to rate their level of fatigue at each time point. Most clients will discover that morning sleep inertia does not correlate well with their daytime fatigue and function. This will tend to diminish the significance of the inertia for the client. Eveningness or Night Owl Tendencies There are many other reasons people have for having difficulty adhering to a set wake time. One important reason relates to being a night owl, or an eveningness chronotype. Those who have a delayed sleep phase sometimes are faced with waking close to the nadir of their circadian rhythm, so melatonin has not switched off and the alerting signals from the clock have not yet begun. Getting up at such a time can be challenging. There are many possible solutions to this problem. One way is to set-up the environment to encourage a slight shift away from eveningness, towards an earlier bed and rise time. Setting an earlier rise time and sticking to it every single day will expose the client to light earlier in the day and should result in at least a slight advance of their natural tendency. That is, the nadir of their rhythm will move to an earlier hour. This should eventually allow the client to wake more easily at these times. Emphasizing that such a shift can take place and that difficulty rising will only be temporary may be helpful in increasing adherence. Nevertheless, for some the night owl tendencies may feel too overwhelming to adhere to this recommendation, and so more help is needed. Solutions to difficulties rising at a standard time tend to focus on implementing strategies either in the morning, evening, or both. Morning strategies target ways to get out of bed and to increase alertness. The first goal in trying to shift someone earlier is to get them out of bed. In most cases this will Adherence and Troubleshooting Barriers 99

be accomplished with an alarm clock. Setting an alarm does not guarantee that someone will hear the alarm or get out of bed, but without the alarm there is almost no chance that the person will wake spontaneously. So it is an essential first step in solving the problem. The therapist should attempt to determine what the client’s history has been when the alarm sounds. If the client reports being unaware of the alarm sounding, he will need a louder alarm. There are a variety of very loud alarms available including ones with very high decibels, ones that vibrate in addition to sounding, and ones that employ flashing strobe lights. Most clients use a more conventional clock and these may be inadequate. Some clients will report that they are in the habit of pressing the snooze button, often unaware that they have done so. One solution for this may be multiple staggered alarms across the room that may be just annoying enough to force the sleepiest individuals to get out of bed to shut the alarm off. Additionally, some find it helpful to use the alarm as a cue to at least slide their legs over the side of the bed. When legs dangle over the edge of the bed, it creates discomfort in the lower back and can increase arousal until the person can get out of bed entirely. When someone else lives with the client, another solution may be to ask this person to be the backup plan to the alarm. Whatever the method(s), once awake, it may be helpful to use some of the sleep inertia strategies discussed above, including movement or physical activity, and/or light (either going outside, turning on bright lights, or using a bright light box). For some clients, scheduling enjoyable morning activities such as going out for a coffee and/or meeting a friend, can be helpful in looking forward to the morning and motivating to getting out of bed on time. Another possibility for helping night owls to begin to rise earlier is to focus on interventions in the evening. There are a few possibilities for evening management, including decreasing the level of light exposure in the evening and/or limiting the amount of late evening activity. It may be particularly important to decrease evening light exposure in clients taking St. John’s Wort as there is some evidence that this compound increases light sensitivity (Schey et al., 2000). Curtailing light exposure can be achieved by minimizing the overall number of lights in the room and using soft lighting, or lighting high in red or amber wavelengths (i.e., the part of the light spectrum associated with melatonin release) and low in alerting (blue wavelength) light. Use of blue spectrum blocking sunglasses if outside or free downloadable programs for com - puter screens, (e.g., f.luxTM) can minimize the degree of blue light absorption (i.e., light in the 440–460 nm wavelength range). With regard to activity level, those who are night owls often become most alert in the evening hours so it may take longer for them to disengage from tasks in the evening. Activity begets more arousal and more activity, so clients should be encouraged to create a buffer zone of quiet relaxing activities about 1–2 hours before bed time, which may be a helpful way to start winding down. Early Morning Awakenings Early morning awakenings (EMAs), or waking up an hour or so earlier than desired, may be an indication of “morningness,” or a side effect of depression, or both. Differentiating these conditions can be accomplished during the assessment by asking the client if the EMAs were present prior to depression onset. A positive response suggests an advanced chronotype which means that the nadir of the circadian rhythm 100 Adherence and Troubleshooting Barriers

comes earlier than average, implying that melatonin has switched off earlier and the alerting signals from the clock are already fairly high well before the client’s desired wake time. Such an individual may also feel sleepy long before their desired bed time. Such a tendency may need to be taken into consideration when determining the bed time and rise time for SRT and SC. In other words, for such morning-types, learning to sleep beyond their habitual rise time may prove too difficult and it may turn out to be easier to align the prescribed schedule with their inherent tendency. Depressed individuals with a more neutral chronotype may eventually be able to be trained to sleep later, but for morning-types who may not know that they are more of an early bird the rise time may need to be earlier than initially desired. It should be noted that some clients may express ambivalence about morningness. There are those that see an advanced chronotype as negative. Common stereotypes exist that early birds are boring and cannot have an active social life because they go to bed early. Many clients are unaware that chronotype is largely genetic so some psychoeducation is important. Additionally, it is helpful to use cognitive techniques such as TRs, Socratic questioning or BEs to modify beliefs about an earlier chronotype. In truth, early birds are not prohibited from having an active, satisfying social life. They can certainly stay up later for special events especially if they are physically active during the event. In addition, after their insomnia abates, they can take a brief nap prior to going out to manage their level of sleepiness. They may find some friends in their circle who enjoy morning activities. Clients can make a list of the possible benefits of getting up early in the morning, such as having increased time for goals such as exercise, alone time, or a chance to beat the traffic on a morning commute. On that same list, they can make another column in which they list the things they worry they will lose by shifting their schedule earlier. In a final column, clients can troubleshoot ways they could continue doing the activities listed in the second column (i.e., moving some activities to different times or use time gained by waking early). Once the list is complete, BE’s can test the belief that “life is unsatisfactory with an earlier schedule.” In most cases the results of the BEs demonstrate that the clients sleep better, feel better during the day, and are more productive, by implementing some of the strategies on the final column of their list. Another strategy to foster greater acceptance of shifting one’s schedule earlier is to use analogies. This is a technique most commonly associated with Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999), discussed in Chapter 8. One analogy is a story in which a child always wanted to be a center in basketball. Center is the position in basketball generally held by one of the tallest members of the team. The child dreamed of being a star center but grew-up to be a short young man. Despite being short he continued to try out for center and every year he did not make it to the team. Finally a coach said he could join the team but only if he was willing to try the guard position [this is typically reserved for the shortest members on the team]. The boy steadfastly insisted that he was a center and would not like to be a guard. The coach told him that it was his choice but reminded him he was playing outside of his strengths, and encouraged him to try something new. The young man relented and became a star guard for his team. He found that he had skills that suited being a guard and he found that he quite enjoyed playing the position. He also knew the center position so well that he had a talent for getting the ball to the center to score. By shifting his perspective and playing within his game, he was able to combine the best of both Adherence and Troubleshooting Barriers 101

worlds, with amazing results. The purpose of the analogy is to present scenarios that clients can relate to as a way of helping them to understand the general concept and more easily shift their perspective. The key, of course, is to find the right analogies that fit the client’s experience and help them to easily relate it to the behaviors that they are trying to change. Troubleshooting Difficulties with Bedtime Staying Awake Until the Prescribed Bedtime A ubiquitous problem in the practice of CBT-I is when clients return to subsequent treatment sessions and explain, “I can’t stay up until my earliest bedtime. I’m way too sleepy.” If nothing else, if the client is truly sleepy and not just tired, this is ironic since when they first presented they complained of an inability to get sleepy and fall asleep. It can therefore be suggested that this shift is good news and confirms that the client is on the right track and building a healthier sleep drive. That is, if the treatment is working the client should start experiencing increased sleepiness. In essence, in CBT-I we are attempting to shift the client’s focus away from sleep, over which they have little control, to strategies to stay awake, over which they can have much better control. The client should be warned from the outset of therapy that increased sleepiness in the first few weeks is likely and can make it more difficult to continue staying up until the prescribed bedtime. When sleepiness is a problem, if the client is getting close to their prescribed bedtime and sleep is going well, the best solution to the problem is to begin extending time in bed according to SRT protocol. That is, add 15 or 30 minutes depending on how robust the sleep and how sleepy the client. However, there will be numerous occasions in the early going of treatment when the client gives over to sleepiness at variable hours, resulting in dozing or going to bed much earlier than prescribed. There are several things to consider. First, it is always important to help clients understand the distinction between what is meant by sleepy versus fatigued. Those with insomnia have high levels of fatigue but rarely have pre-treatment sleepiness. The following dialogue demonstrates how the therapist can help the client make this distinction and uses this to encourage the client to stay awake longer: Therapist: I wonder if we are using the word sleepiness to mean the same thing. Although people tend to use the word fatigue and sleepy interchangeably, they actually represent different things. When I say “sleepy,” I mean it as a description of the state right before falling asleep. It is the propensity to fall asleep, or the struggle to stay awake. This means that if given an opportunity to sleep while feeling sleepy, you would fall asleep and fairly quickly. Fatigue on the other hand is exhaustion, whether it is physical, mental, or emotional, and it is associated with a strong desire to sleep, but if given an opportunity, sleep would not necessarily occur (or at least not quickly). Fatigue is the same as feeling tired or run down. So sleepiness is associated with falling asleep, fatigue is not. Therefore, one can be fatigued without necessarily being sleepy. Does this make sense? Client: I think so. Well then I almost never feel sleepy. But I feel fatigued almost every waking minute. 102 Adherence and Troubleshooting Barriers

Therapist: That is actually fairly common for people with insomnia. So you felt “too tired,” meaning too fatigued, to follow the recommendations? Client: Yes I felt so tired that I had to go to bed before the time we said. Therapist: I see. So you didn’t feel sleepy but because you felt tired you went to bed. Do I have this right? Client: Yes. Therapist: But it seems from your diaries that when you go to bed tired but not sleepy, you often do not go to sleep or seem unable to stay asleep. Does that seem right? Client: Yes, I guess that’s true. Therapist: Well since you don’t often experience sleepiness currently, we need to create a situation in which you will experience it because when you feel sleepy, sleep will happen more naturally. Going to bed when you are fatigued, doesn’t allow sleepiness to occur. You say that you feel fatigued every waking minute, so what made you go to bed at the time that you did? Client: I just get so tired of feeling tired. There’s nothing to do and I am so desperate to sleep. Therapist: That makes sense. But what if we could find something for you to do until sleepiness sets in and then you could actually fall asleep rather than tossing and turning in bed for hours? Client: I can’t imagine there could be something I could do because I am so tired. Therapist: Fair enough, but is it worth discussing, given that the only way you can get a break from this pattern is to set up a situation wherein you start to experience sleepiness? Client: Sure. Fatigue and dozing in the evening often can be helped by having the client engage in evening activation. Evening activation simply refers to scheduling activities that are likely to succeed in keeping the client awake. Some examples would be scheduling joint activity with other people, engaging in activities that require one to stay in motion (i.e. folding laundry, sorting photos, baking cookies, etc. or doing more activities to maintain alertness). One thing to note is that eye strain is relatively common in those with fatigue, so briefly holding a cool cloth over the eyes while seated, can help with the temptation to close the eyes for prolonged periods. Particularly in people with depression, there is inadequate build-up of a drive for deep sleep, increased fatigue, greatly reduced activity, especially goal-directed activity in the 24 hour period, and decreased availability of potential reinforcers in the environment. As a result, it’s as if their entire day serves as a wind-down in prepara - tion for bed. This may prematurely stunt deep sleep drive build-up and may reflect a preoccupation with sleep or an avoidance strategy; both of which are potentially sleepand mood-interfering. For people with MDD-I the therapist will do well to consider BA throughout the day as a way to not only bring the client into contact with positive reinforcers but also to help build healthier sleep drive for the night. That said, it is especially important in such cases, to work on evening scheduling of activities whether inside or outside of the home, with a termination of the activities and a demarcated drop into wind down activities one hour before bed. Another strategy is to make sure that people with MDD-I refrain from putting on nightclothes like pajamas until just Adherence and Troubleshooting Barriers 103

before their prescribed bedtime. For some clients with MDD-I, putting on nightclothes occurs right after work or directly after dinner; some may remain in pajamas all day. This is a change-worthy habit because it increases sleep preoccupation. It is always important to identify instances of over-focusing on sleep during the day or night because it will almost always lead to increased anxiety about sleep and sleep effort. Delaying Bedtime While some people struggle to stay awake or out of bed before the prescribed bedtime, others have the opposite problem in that they remain engaged in activities well into the morning hours, delaying bedtime significantly. This might be a positive thing for building sleep drive but for some, the delay in bedtime often results in a delay in rise time as well. As a result, their schedule becomes more and more delayed. From the outset it is important for a thorough assessment of the cause of delaying bedtime. For those who are night owls, mood and energy may be best in the evening, and this may be the first time in the day when they feel good. It is thus understandable that a client would feel compelled to take advantage of a time in which they start to feel awake and alert, and avoid going to bed. In such cases it can be helpful to engage the client in a discussion of the consequences of not following their schedule goals, e.g., they will become shifted later, they will have greater difficulty adhering to the scheduled rise time, they are likely to experience increased fatigue, they may wind up missing appointments in the morn - ing, and they may engage in negative self-talk about not following goals. Solutions include starting the wind-down period (i.e., the buffer zone) an hour earlier to encourage greater disengagement, and largely troubleshooting adherence to a standard rise time discussed earlier in this Chapter (i.e., increasing morning activity, manipulating light exposure in the morning and before bed, and use of alarm clocks, etc.). Ultimately, adhering to an earlier standard rise time should have some impact on shifting the person’s circadian clock earlier, which in turn should allow them to get sleepy and disengage earlier. Troubleshooting Common Problems in Depression Anhedonia Waiting for the feeling of motivation to do something is a common strategy that we may all use from time to time. However, waiting for motivation in a disorder character - ized by motivation deficits, often interferes with goal pursuit. It is a faulty assumption that the feeling of motivation must always precede behavior. To demonstrate this truth, ask your client to think about examples of things they do despite not feeling like it. There are many things that people do for which they feel little to no internal motivation. For example, many people will admit that there are days that they may not feel like getting up and going to work, and yet they swing their legs around off the bed, get up, shower, eat breakfast, and go to work; all without feeling like it. Likewise, imagine if you always waited first for motivation. If one were to listen to the thought “I don’t feel like going into work today,” it is easy to see how quickly life might become that much more difficult and unworkable. It is precisely this kind of difficulty that people with depression find themselves in when they wait for motivation to come before action. Waiting for motivation often results in inaction, decreased positive reward, social 104 Adherence and Troubleshooting Barriers

isolation, and continual depressed mood and anhedonia. The alternative is to set up a plan for how one would like their day to go and then to follow this to determine if life works better or worse. Such strategies are used in BA (Dimidjian et al., 2006; Lejuez, Hopko, & Hopko, 2001; Martell, Dimidjian, & Herman-Dunn, 2013). Even if not engaged in a full BA protocol, it is helpful to use tenets from BA to help with motivation issues. For more detail, see Chapter 9. Briefly, instead of using an internal state to guide behavior (i.e., behaving from the Inside-Out), clients can use a plan that can eventually lead to different contingencies and thereby change their internal state. In other words, they can follow a plan, not a feeling (i.e., behaving from the Outside-In). By setting up an “Outside-in” instead of an “Inside-out” strategy and by collaborating on a plan with a chain of positive contingencies, the client is more likely to achieve their desired goal. Clients may not at first be able to articulate a full plan to get out of bed that is highly likely to succeed, but they may be able to identify a strategy for: setting an alarm, devising a backup to the alarm, keeping their eyes open, sitting upright in bed, getting out of bed, staying out of bed, and a reward system for being out of bed. It is important to break down all the components of getting up and the identified barriers as well as discuss morning contingences that will increase the likelihood of getting out of bed shortly after the alarm rings. Setting-up the strategy to make behaviors more likely and easier is a prominent focus in BA. There are as many contingency plans and strategies as there are clients for getting out of bed in the morning. Some possibilities include: keeping blinds or curtains open in the bedroom, using a timer for the lights in the morning, using the alarm as a cue to stand up or sit up, setting an alarm clock to loudly broadcast a news channel to provide a transition, using the sound of the alarm as a cue for the feet-on-the-floor technique (i.e., swinging legs over the edge of the bed), setting the coffee on a timer the night before, keeping a coping card with positive thoughts next to the bed, walking directly to the bathroom to take a shower, using multiple and staggered alarm clocks throughout the bedroom, eliciting help from others to help with getting out of bed, taking a blanket and going to a different room to sit until more fully awake as a transition, scheduling morning activities (maybe with other people), and setting up a reward system for mornings in which the goal is met. The key is to explore the idea that behaviors can and do occur in the absence of motivation. Further, it is important to help the client discover that their life often goes better when they set it up in this way. For depressed clients who do not have enough of these examples already in their lives or who can’t remember what that is like, behavioral experiments can again be useful to help the client begin to discover the value of outside-in strategies. Using Sleep or the Bed as an Escape In those with MDD-I, there are some who use the bed as an escape. Such avoidance is a common perpetuating factor in depression (Martell et al., 2013). Avoidance maintains low mood because it limits access to positive reinforcement, i.e., there are few opportunities for positive reinforcement in the bedroom especially if one cannot sleep and lays awake tossing and turning. Moreover, although avoidance initially alleviates tension, the net result is that protracted escape becomes confining, and the world of the client shrinks. Such tendencies can be addressed in a variety of ways. Socratic questioning and/or Thought Records can challenge unhelpful thinking about the role of avoidance. Once a client has had psychoeducation about sleep regulation Socratic Adherence and Troubleshooting Barriers 105

questioning about the consequences of using the bed for escape can serve as a check to see how much the client has retained or understood of the sleep regulation rationale. Clients should be able to explain that increased time in bed decreases drive for deep sleep, decreases regular input into the body clock, increases fatigue, increases condi - tioned arousal, decreases positive reinforcement, thwarts goal pursuit, and maintains negative mood. Another strategy is to create ambivalence as a way of enhancing motivation. The therapist can create such ambivalence by presenting two contradictory arguments sideby-side. The following dialogue demonstrates how exploring the pros and cons (both short term and long term) of self-imposed isolation can create the desired client ambivalence: Therapist: From what I understand, life seems overwhelming so you believe it is better to remain in your room when you’re home. Have I got that right? Client: Yes. It just feels better to stay tucked away in my room. Therapist: But at the same time you are also tired of feeling tired, you want better sleep and you have said repeatedly that you are lonely. Sounds like you are at an impasse? Reflecting the two sides of the problem, or “sharing the dilemma” allows the therapist to refrain from arguing for adherence (which can only encourage resistance) and encourages the client to take responsibility for a shift. If the client argues for maintaining avoidance, the choice and consequences are highlighted. Therapist: So it sounds like at this point, you would prefer not to explore ways to increase your time out of your bed because it is too hard. Would it be a better use of our time to shift our goals away from improving sleep and fatigue, and towards acceptance? Clarifying how the behavior is contrary to their goals often causes clients to shift and consider behavior change. However, in cases in which the client agrees that sleep should no longer be a treatment target—this becomes their choice and it may be a reasonable decision for that moment in time. Smoking is never a healthy choice and is always changeworthy but people may not be ready to make a change. Likewise, knowing that we can successfully improve someone’s sleep does not mean that they are ready to make the con - siderable effort needed to make this happen. Clients sometimes come to the conclusion that their sleep isn’t bad enough for them to keep a schedule 7 days per week and get out of bed when unable to sleep. This decision reflects some degree of increased confidence in the ability to cope with the consequences of sleep and might actually bode well for decreases in sleep anxiety and arousal. Treatment can shift towards other therapy goals and/or acceptance when clients no longer consent to sleep-focused treatment. Troubleshooting Fatigue The Belief that Fatigue Precludes Following Behavioral Recommendations Some clients will explain, “I am too exhausted to follow any recommendations.” This makes sense because central fatigue is generated when there is a mismatch between 106 Adherence and Troubleshooting Barriers

the estimated resources needed to complete a task and the perceived personal resources one has to allocate to the task (Chaudhuri & Behan, 2004). In the case of CBT-I, clients will often estimate the resources needed to complete the task of following sleep schedule recommendations as impossibly high, given that they estimate their personal resources as too low to meet the demands of this task. This is why it is necessary to collaboratively build contingencies to lighten the resource demand of the sleep schedule. The task of rising 2 hours earlier than desired has higher resource demand than being awoken 2 hours earlier by a loved one who has filled the apartment with the smell of coffee, slipping into a warm robe and slippers, and getting into a nice, hot shower. The second part of the equation for central fatigue is an estimation that personal resources are deficient to meet the needs of the task. In those with insomnia, there are beliefs of low self-efficacy (Edinger et al., 2008), a sense one cannot cope with the consequences of fatigue (Morin, 1993), a tendency to selectively scan and focus on evidence that one is fatigued (Harvey, 2002), and a tendency to think repetitively about fatigue (Carney et al., 2010b). Thus, especially those with MDD-I are highly likely to perceive themselves as deficient of resources. Again therefore, it is helpful to break down the task so that it has less of a resource demand (as above), however it is also important to explore the deficiency beliefs. In truth, most people with insomnia, including those who are depressed, are often amazing in their ability to cope long-term with sleep disruption. Insomnia is chronic and often lasts for years and years and despite this, people with insomnia have a disproportionately low level of disability. In many ways they are expert copers. In a ten-year insomnia history, there may be some difficult experiences, but there will be over 3700 days of coping as well. The therapist can use Socratic questioning to help clients discover their own amazing strengths. The Belief that Fatigue is Dangerous and/or Rest is Essential Some clients believe, “I NEED to rest, I am exhausted.” Behind this belief is the idea that there is a need to compensate for poor sleep and to resist compensating is hazardous to one’s safety or health. It is important to reinforce with the client the rationale for being out of bed when unable to sleep (i.e., to reverse conditioned arousal). They also can be educated that the body has a natural mechanism to compensate for sleep loss (i.e., sleep drive), and with insomnia, the lost sleep creates too great an opportunity for sleep, rather than too little an opportunity. Thus the sleep of those with insomnia tends to be quite variable rather than consistently poor and with the compensatory behaviors in which they tend to engage, their overall total sleep average is usually not much less than normal (i.e., 6 hours). The therapist can use Socratic questioning to uncover the depth of understanding of these very important facts about the sleep system. In addition to difficulties with the rationale, it is important to query catastrophizing about the consequences of fatigue. Outside of the context of insomnia, resting when tired can be an adaptive strategy in moderation, but the sleep system is a homeostatic system (Chaudhuri & Behan, 2004) and while too little resting causes exhaustion, the excessive resting seen in both people with depression and insomnia also maintains fatigue (Kohn & Espie, 2005). Often, clients have heard news stories about links between sleep loss and early deaths, cancer, cardiovascular disease, dementia, diabetes, etc. It is natural to assume that such research applies to insomnia as well, but in actuality these studies Adherence and Troubleshooting Barriers 107

are less likely to apply to people with insomnia with the exception of those with chronically low average total sleep times (less than 4–6 hours per night on average) (Fernandez-Mendoza et al., 2010). Such research often employs epidemiologic methods that assess sleep disruption with one or two broad sleep-related questions. Querying sleep in this way includes people with all kinds of sleep disruption and excessive daytime sleepiness such as those with sleep apnea, periodic limb movement disorder, shift work sleep disorders, circadian rhythm disorders, and/or those with chronic voluntary sleep restriction. The links between sleep and early mortality, cardiovascular disorder, and diabetes have been established in these disorders (e.g., Folkard & Tucker, 2003; Irwin et al., 2008; Spiegel, Tasali, Leproult, & Van Cauter, 2009), but not in insomnia. In cases of catastrophizing, it may be helpful to use either psychoeducation, or Socratic questioning, or a Thought Record to challenge unhelpful thinking that equates the consequences of general sleep disruption with those of insomnia. As has been stated before, most clients with insomnia have had their problem for years rather than days or months by the time they are in your office. It does not take much prompting on a TR or with Socratic questioning to demonstrate that despite hundreds and often thousands of nights of insomnia, the client remains in otherwise reasonable health. Finally, behavioral experiments can also be set up to test the hypothesis that fatigue is dangerous (see Chapter 6 for the energy conservation versus energy expenditure experiment). It is ultimately counterproductive to stay in bed when tired because it reinforces a belief that fatigue can be dangerous, it delays the build-up of sleep drive, it associates the bed with wakefulness, and the consequence of lying in bed for long periods is typically more fatigue and lethargy, not less. Experiments that explore the link between moderate activity and fatigue versus inactivity and fatigue can be helpful. For those combining CBT-I with CBT-D or BA, activity monitoring (see Figure 9.2 in Chapter 9) is an excellent way for a client to make the links between wakeful inactivity and increased fatigue experientially. Explore what contributes to feeling fatigued during the day and create ambivalence about fatigue-producing habits such as inactivity, poor food choices, substances, etc. Many people with insomnia will tend to attribute all negative daytime effects to poor sleep and tend to ignore the variety of factors that can produce fatigue (i.e. boredom, tension, depression, dehydration, extended time on computers, etc.) The following dialogue demonstrates how the therapist can help the client discover new reasons for their fatigue. The dialogue takes place within the context of a concurrent BA protocol, such as BABIT (see Chapter 9), however one can assign activity monitoring and schedule activities within the context of CBT-I for clients with decreased activities. Therapist: So you said you cannot do anything about your sleep because you are too fatigued. Do you think there is anything you could do to help your fatigue? Client: Well, no, because I’m tired because of my sleep. Therapist: What else might account for your fatigue? Client: Nothing. I’m tired because of my sleep. Therapist: I wonder if it is possible that other things cause fatigue too? We talked about jetlag like symptoms occurring with irregular bed and wake times when the body 108 Adherence and Troubleshooting Barriers

clock has difficulty adjusting to the variability of the sleep and activity schedule. What are some of the symptoms that occur with this schedule variability? Client: Feeling grouchy, irritable, fuzzy-headed . . . and I guess fatigued. Therapist: That’s right. So could this have a small role in the fatigue you are feeling? Client: Maybe but I can’t keep a schedule because I’m so tired I can’t change it. Therapist: Ok. If we look at your activity log, do you notice any patterns between your highest fatigue ratings and what you are doing? Client: The highest is 8, and it happened 3 times—watching TV on the couch. Therapist: What about the lowest rating? Client: The lowest was 4, which happened once when I went out to see my friend Jake downtown. Therapist: What’s the difference between these two types of activities? Client: I guess sitting on the couch is not really an activity, or may be low activity. Therapist: Do you see a connection between low activity and fatigue and greater activity and feeling less fatigued? Client: Maybe . . . Therapist: I want you to stand up right now and stretch in whatever way feels comfortable to you. [after client stops stretching] How do you feel now? Client: A little better. Feels good to stretch. Therapist: Moving muscles, getting greater circulation and oxygen has a positive effect. Constricting flow and staying in the same position for a long time increases fatigue. Do you think dehydration or nutrition have any impact on fatigue? Client: I guess so. In fact, now that I think of it I feel weak and tired if I haven’t eaten or had anything to drink for long hours. Junk food can also backfire on me. Therapist: Ok. So you have had these experiences. What about coffee—have you ever experienced an energy crash a few hours after you have a coffee? Client: Yes, definitely. I am so tired I usually have another coffee. Therapist: This suggests caffeine withdrawal. As it is eliminated from our system, we get withdrawal symptoms of fatigue. Having another coffee will get rid of the symptoms but then you will face them again later. How about your medication? Do you think this contributes to your level of alertness or fatigue? Client: Unfortunately my sleeping pill makes me feel groggy the day after I take it. So, I guess so yes. Well, I guess the answer is that there are a bunch of things that make me tired. Therapist: And we have many tips to help with fatigue, including being active, eating well, staying hydrated, limiting caffeine, increasing bright light exposure, or taking a shower. When we blame fatigue on sleep exclusively and believe there is nothing we can do to manage it, suddenly there is a lot riding on fixing the sleep problem. Can you see how this belief might get in the way from making changes to improve the situation? Client: Yes, definitely. Comorbid Pain and Mobility Issues There may be circumstances (e.g., pain, mobility, frailty) in which there are concerns about a client getting out of bed in the middle of the night. When providing SC instructions about getting out of bed it is important to remind all clients, and especially Adherence and Troubleshooting Barriers 109

ones with mobility concerns, about turning on enough light to provide for a safe path to where they are going. Some clients may be reluctant to do so out of fears it will make them more alert and/or concerns about waking up other family members. Given that most light sources in the house will not have high concentrations of blue spectrum light, the chances of the light activating the person is negligible. This may be particularly true as we age (Herljevic, Middleton, Thapan, & Skene, 2005; Verriest & Uvijls, 1977). Research studies on light and alertness often recruit young healthy sleepers rather than people with insomnia across the age spectrum, so it is not known how such factors affect those with insomnia. Giving up the effort to sleep should create enhanced sleepiness while out of bed and do much more to ease arousal than any amount of standard room light can do to boost arousal. Concerns about disturbing family members by turning on a light is understandable but the client can often trouble-shoot including using low level night lights along the floor, or closing bedroom doors so the light from other rooms will not shine into the bedroom. Moreover, it is always helpful to remind clients that the recommendation to get out of bed is only temporary until reconditioning takes place, so most family members are tolerant of these measures knowing they are short term, and especially if they typically sleep through it anyway. These issues aside, there may be valid reasons for safety concerns in some clients. For those who are frail, in pain, and/or have significant mobility issues getting out of bed may be risky or even ill-advised. In such cases, a technique called counter control may be a useful alternative to the standard SC instruction (Hoelscher & Edinger, 1988). Counter control is a technique in which the client still gives up the effort to sleep but does not leave the bedroom or bed (Davies, Lacks, Storandt, & Bertelson, 1986). The instructions are to sit up in bed and engage in an enjoyable restful activity until sleepy. Once the client is sleepy, they can turn off the light, stop the activity, and once again see if they are able to sleep. The crucial element to counter control is that the client does not engage in any sleep effort nor allow themselves to remain in bed feeling frustrated or upset about sleep. Traditional stimulus control is still preferable because with counter control, the client is doing wakeful activities while in bed so there still could be concerns about conditioned arousal, however, given the hope that they are not in bed engaged in sleep effort, it is a reasonable compromise for those who may be unable to get out of bed. The support for counter control suggests that it is best for issues with waking up in the middle of the night (Hoelscher & Edinger, 1988) so the other SC rule about not going to bed until sleepy still applies. One other consideration in those with pain and mobility issues is resting. Rest may be necessary for certain physical conditions; however, excessive resting is associated with increased pain and fatigue as well as lightened sleep. Using the bed or bedroom for rest rather than only for sleep may strengthen the bed as a cue for pain and suffering and weaken the bed as a cue for sleep. Thus for those with physical conditions that neces - sitate resting, it is advised that if possible clients rest in positions other than supine and not in the bed or bedroom. Finding ways to safely and gradually increase activity and provide resting guidelines is an important intervention strategy for such clients. Relationship Issues Sexual activity is often an exception to the Stimulus Control recommendation to avoid doing wakeful activities in bed. Many individuals may find that following sexual activity, 110 Adherence and Troubleshooting Barriers

they are actually more relaxed and prone to sleepiness. However, when sex is alerting for the client we encourage them to consider moving sex to another place and/or time at least during treatment to re-establish the bed as a place solely for sleep. In such cases, it is important to ask clients whether they foresee any difficulties in raising this issue with their partner. Some clients may be uncomfortable discussing with their partner the possibility of moving sex to a place other than their bed or a time other than bedtime during treatment. There are a variety of possible issues that require follow-up inquiry. Especially for clients with depression they may be prone to engaging in “mind-reading” and assuming their partner will say no. In truth, partners of people with insomnia often are quite willing to support treatment recommendations because in addition to wanting to help their partner, their partner’s insomnia often impacts them negatively. If clients are making assumptions about their partners, it is important to work with them about their belief and see if they are willing to test their negative assumption. Some clients may need assertiveness or other communication skills training before tackling sensitive, intimate communication with their partners. Sometimes this assessment reveals significant relationship issues—a common problem for people with insomnia, and this may require additional work. Lastly, both people with insomnia (Carney et al., n.d.) and people with depression report libido problems (Cyranowski, Frank, Cherry, Houck, & Kupfer, 2004; Johnson, Phelps, & Cottler, 2004). This is further complicated by the fact that those with depression may experience sexual dysfunction as a result of their pharmacologic treatment for depression (see Lane, 1997). Thus, this simple assessment of whether there are any barriers to moving sexual activity out of the nocturnal bed and/or to a different time can reveal a range of issues and potential treatment targets, which do not relate to sleep directly but could nonetheless have an impact on well-being and thus, indirectly—sleep. Another common problem in relationships is the fact that many partners do not necessarily share the same circadian tendencies. That is, sometimes owls live with larks or vice versa. Part of the insomnia problem may be due to, for example, an “owl” client who is consistently going to bed with their “lark” partner earlier than when they themselves are sleepy. In the first weeks of treatment, it is not uncommon that clients will complain that their bed partner will be unhappy that they are going to bed later and not coming to bed with the partner. Again, one way to handle this is to remind the client that the initial schedule for time in bed is temporary and may eventually be shaped to work out closer to that of their partner. However, if the client and/or their bed partner are still not persuaded, some troubleshooting discussions will be needed. One possible solution is to have the client go to bed at the earlier hour with their bed partner to cuddle and spend some quality time, but then to leave the bedroom once their bed partner has fallen asleep. Then the client can return to bed but not before their prescribed bedtime at the earliest. In this way the client is spending some time with their partner in their bed, albeit awake, but again is not engaging in any sleep effort at that time. Similar problem solving can be accomplished for “lark” clients who wake earlier in the morning than their “owl” partners. In the best of all possible worlds the therapist might consider bringing bed partners into CBT-I sessions. From the very first assessment to the last session, including bed partners can help enrich the assessment (especially of intrinsic sleep problems such as apnea, periodic limb movements or parasomnias), help with adherence to protocols, and Adherence and Troubleshooting Barriers 111

provide support and optimize treatment response (for more see Rogojanski, Carney, & Monson, 2013). Further, it should be noted that the instructions for stimulus control and sleep restriction protocols are not necessarily intuitive at first blush. When that client goes home to describe these protocols to a bed partner, without sufficient provision of the rationales, it is possible that bed partners could unwittingly sabotage the clients efforts by encouraging them to do things like gain more rest, go to bed earlier, or sleep in later when they haven’t slept well. Having the bed partner in the office from the first session can eliminate this problem in that the bed partner is instructed in the rationale along with the client. This usually allows for better collaboration between client and partner. Cognitive Issues People with insomnia and depression can suffer from cognitive issues and the amount of material covered, especially in session 1, can be a lot to retain. One novice mistake is to deliver the psychoeducation material (contained in Chapter 1) like a general lecture. There should be ample information from the assessment that should permit tailoring of the educational material to the specific client presentation. More importantly, psycho - education should be collaborative and emerge as a two-way conversation. Although the therapist is the expert on sleep, the client is an expert on their own sleep experience. The therapist should use questioning to elicit examples of each sleep regulation concept as well as have the client pick out examples from their sleep logs that could be acting as maintaining factors in their insomnia. Such active two-way engagement is an important therapy technique to enhance retention of the materials. It is important to check in and ask questions about how much the client heard and understood, while normalizing any memory issues the client is having as part of the their disorder. Use repetition and begin every session with a bridge from the last session. This is done by asking the client to recall what they remember from last week and use questions to try and elicit any information missing from their bridging attempt. In clients with memory issues, providing handouts and writing down homework so that they can bring the information home, is a helpful way to ensure that clients follow treatment recom - mendations. Some clients like to make a note on their phone or on a coping card if they have concerns about remembering the material. In clients with traumatic brain injury (TBI) we use a sleep diary with a larger font and only the following key variables: Day; Into Bed; Time to Fall Asleep; Total Time Awake During the Night; Time you Woke Up; and Time Out of Bed. With TBI it is crucial to use handouts for retention. Also it may be necessary to break the information normally covered in session one into two sessions: Stimulus Control during the first week and Sleep Restriction and Sleep Hygiene the following week. The rest of the sessions will tend to look the same as CBT-I in those without TBI. In sum, for some clients, retention, understanding, and accommodation of the material may take longer and require a few more sessions to bring to fruition. Troubleshooting: Assessing or Modifying Therapist Beliefs Therapists need to be mindful that they bring a set of personal beliefs to the therapeutic relationship. As always, being aware of and ensuring that these beliefs do not intrude 112 Adherence and Troubleshooting Barriers

into therapy is essential to good practice. In addition to therapists’ personal beliefs about psychotherapy, therapists also have their own beliefs about sleep. If a therapist believes that people need 8 hours to function or they don’t believe sleep need is controlled by a homeostatic system that produces an adequate amount for health if given an adequate opportunity, they may have greater difficulty implementing CBT-I. Below we discuss common therapist beliefs that can interfere with competent delivery. Beliefs that Underestimate Clients’ Abilities to Make Change If a client does not adhere to a schedule prescription, it is important to avoid making assumptions about the cause. For example, if the therapist concludes “Of course my client cannot follow a prescription—they have anhedonia, so they can’t follow recom - mendations,” then logically, little can be done until the anhedonia is resolved. This is evidence of the same kind of inside-out thinking that creates a barrier for clients and was tackled earlier in the chapter as problematic. There are many reasons why people have difficulty following prescriptions and spending time discovering the reasons behind this resistance is the key to increasing the likelihood of adherence. A key core belief in depression is hopelessness (Beck, 2008) and it is important not to collude with the client in this unhelpful assumption. An important therapist activity is to use Socratic questioning to help the client to discover instances that disconfirm hopelessness and to help the client design experiments to test the belief of hopelessness. Numerous studies have demonstrated conclusively that CBT-I can be effectively delivered without any modifications in people with insomnia with various comorbid problems including depression, pain, hopelessness, and anhedonia (Kuo et al., 2001; Lichstein et al., 2000; Manber et al., 2008; Morawetz, 2001), so this belief is worthy of testing. For therapists who are just now learning CBT-I for the first time, remember that, as with our clients, when learning anything new there is a tendency at the first sign of discomfort to resist and to return to old, more comfortable patterns of behavior. Hence, when meeting resistance from clients who say that they cannot engage in some instruc - tion because they are too depressed, anxious, worried, etc. there may be a tendency for the therapist to quickly abandon CBT-I in favor of therapies with which they have more familiarity, facility, and history. It is important for therapists to monitor for their own beliefs about insomnia and their clients. Depression symptoms may pose barriers to insomnia treatment implementation but barriers can be assessed and problem-solved within the context of CBT-I and improving sleep is as important for improving depression as is improving depression for sleep (Manber et al., 2008). Beliefs that Sleep Diaries are Unnecessary It is not uncommon for novice CBT-I therapists to have unhelpful beliefs about sleep diaries. Such unhelpful beliefs include: “Sleep diaries are not accurate, we should use objective measures instead,” “I can’t ask my client to do this, it is too much work,” or “Tracking sleep will worsen my client’s sleep problem.” The belief that “objective” measures of sleep are preferable is unhelpful and inaccurate in a variety of ways. First, it is a myth that objective measures of sleep are somehow “truer” measures of sleep. Adherence and Troubleshooting Barriers 113

Sleep is a construct, defined and measured in a variety of ways. One objective measure of sleep is overnight polysomnography (PSG). During a PSG study, sleep is defined by particular patterns of electrical activity in the brain. This definition of sleep using this method is somewhat arbitrary. The first consensus system was derived by visually examining 30 second periods (because this is what fit on a PSG page) and labeling whether it is sleep or not sleep. Sleep is coded when the brain wave activity is slower than alpha with low voltage amplitude for greater than 50 percent of the 30 second period (Rechtschaffen & Kales, 1968). However, there are many problems with this way of defining sleep. In the example provided above, 14 of the 30 seconds could be characteristic of wakefulness, but we may categorize it as sleep. This may or may not match with the perception of the sleeper, because they are aware that there was substantial wakefulness (i.e., 14 of the 30 seconds) in this period. For example, in some with insomnia, their sleep looks fairly normal using this criteria, but they have large subjective complaints and measuring the degree of high frequency brain wave intrusion (via spectral analysis) reveals poor sleep depth that correlates with the subjective complaint (Krystal et al., 2002). Consensus clinical assessment guidelines do not support the use of the PSG as routine practice in those with insomnia and depression (Kushida et al., 2005). Other problems with relying on PSG include the fact that the sleep lab can either create so much anxiety that the degree of sleeplessness is exaggerated or the sleep lab is such a novel environment that conditioned arousal is reversed and the degree of sleeplessness is under-represented. So PSG is not at all preferable to prospective sleep diaries. Another way to conceptualize sleep is the relative absence of or gross reduction of motor movement. This is the way it is defined in actigraphy. Actigraphs are often worn on the wrist and use accelerometers to sample movement and store the data. The sampled data are analyzed using algorithms for what movement patterns are most typical of rest versus activity. Many apps use accelerometers and profess to measure sleep. There are multiple problems with valuing this particular definition or measure - ment of sleep. Accelorometers that are used clinically are often subject to many validation tests of the algorithm. Even with these many validation studies, we know that this form of measurement can be dubious in insomnia, owing to the fact that sleepless people can lay awake with minimal movement (Blood et al., 1997; Chambers, 1994; Hauri & Wisbey, 1992). Algorithms associated with smart phone apps or wearable devices such as the Fitbit TM are not subjected to the same rigorous validation and have been shown to be even less accurate than clinical actigraphs (Montgomery-Downs et al., 2012). In contrast, sleep diaries reflect a subjective perception of sleep, and Insomnia Disorder is a subjective disorder. The diagnosis is based on the client’s complaint of sleeplessness. Despite some reasonable suggestions (Lichstein et al., 2003) there are no consensus quantitative criteria for insomnia because morbidity cutoffs are not reliable. That is, occasional severe sleep loss can be similar to mild, chronic loss (Lineberger et al., 2006). Although subjective perception is most important in insomnia disorder, not all subjective measures are the same. The best evidence suggests that prospective measurement of subjective data is superior to retrospective measurement (Coates et al., 1982), and sleep diaries are a prospective measure. Subjective retrospective measures such as the PSQI or the ISI have appeal because they are brief and have good psychometric properties. Unfortunately, the psychometric properties of the PSQI may 114 Adherence and Troubleshooting Barriers

be somewhat questionable when used in those with comorbid psychiatric disorders because of the confound of the PSQI with anxiety (Hartmann et al., 2015). The question of whether the ISI may be preferable in those with MDD-I has not been investigated to date. Nevertheless only sleep diaries capture the variability of sleep (Wohlgemuth, Edinger, Fins, & Sullivan, 1999) as well as the sleep indices needed for sleep scheduling (Buysse et al., 2006). That is, it is near impossible to carry out effective sleep restriction therapy without sleep diaries. It is true that people with insomnia most often underestimate sleep diary total sleep time, and overestimate sleep onset latency and wakefulness after sleep onset relative to absolute PSG estimates of the same values (Coates et al., 1982; Spielman, 1986). However, the evidence for sleep diary reliability is strong, e.g., the agreement between PSG and diaries is high (kappa = .9), as well the sensitivity (92.3 percent) and specificity (95.7 percent) (Rogers, Caruso, & Aldrich, 1993). Because of the importance of subjective complaints and the reliability of the measure of longer periods (i.e., 2 weeks), and problems with retrospective subjective measures, PSG and actigraphy, the sleep diary is the gold standard measure in the field of insomnia (Carney et al., 2012). Sleep Diaries with Improbable Values In a small proportion of cases of people with insomnia, there is a phenomena called paradoxical insomnia, or sleep state misperception (SSM). SSM occurs when there are consistently improbably low sleep total values in conjunction with intact functioning. It is not possible to go without any sleep for more than a few days without considerable efforts in place to do so. Moreover, even in cases of low total sleep time, sleep is variable so any consistent report (i.e., every single night) of little to no sleep is likely inaccurate. For example, clients with SSM might report getting 0–2 hours of sleep a night for months or years and yet report surprisingly reasonable daytime functioning. Although sleep diaries have validity as evidence, ultimately the construct they measure is sleep percep - tion so the perception of the client’s sleep may not match what their bed partners report, or what the PSG or actigraphy suggests. The degree of that discrepancy deter mines the degree to which the perception represents typical or paradoxical insomnia. In the case when the therapist suspects that the diary data may reflect SSM, it is important to consider how, when, or if to raise this issue with a client. There needs to be a strong working alliance before raising this issue or it can be interpreted as evidence that the therapist does not believe that the sleep problem is “serious” or that the therapist believes the client is fabricating the data. Either interpretation can cause a rift in the therapeutic alliance. If raising these issues is not possible given the current relationship, it is important to take time to develop this relationship before raising it. Luckily, the discrepancy fades with time-in-bed restriction; so one possibility is simply to arbitrarily select 5 or 6 hours for the TIB prescription. Below are some possibilities for trouble - shooting this problem in those with an established therapeutic relationship. There are many possible reasons for SSM, including hyperarousal. Hyperarousal often occurs in chronic insomnia and one result of hyperarousal is increased fast wave activity intruding into sleep which can interfere with the amnestic effects that should result during sleep (Perlis et al.). This phenomenon seems particularly severe in SSM. Even good sleepers will have brief arousals during the course of every night, and Adherence and Troubleshooting Barriers 115

during these arousals the person might process information like a sound in the room, the feel of the sheets, or the sight of the clock. These arousals are extremely brief and in normal sleepers there seems to be no memory trace for the experience. So, for the good sleepers it is as if the arousal never occurred. In insomnia, and particularly in SSM, the intrusion of fast brain wave activity is severe enough that it appears to inhibit the amnesia for these small arousals so that the individual with SSM remembers every little sound, sight and sensation. Therefore, although they might be sleeping most of the time, they encode the time passed, as “awake” time. The problem with doing CBT-I in someone with SSM, is that compared to people with more typical insomnia, sleep and wake estimates from those with SSM will be so far off that to match a sleep restriction prescription to the clients total sleep time estimate, would exceed the lower limits of time-in-bed that are safe. In other words, in SRT we recommend that the restriction of TIB match the client’s estimate of TST plus 30 minutes but never drop below 5 hours. In clients with SSM their estimates average total sleep time per day might be anywhere from zero to 4 hours. The problem therefore, is that to do SRT with these clients the TIB prescription will have to be somewhat arbitrary. Although someone reports 0 minutes of total sleep time, we cannot restrict TIB to 0 + 30 minutes. In this case the therapist might simply have to choose 5 hours as the starting point for restriction. A word of caution here is that for clients with SSM there is the possibility that the arbitrary prescription for SRT might be much lower than the client is actually sleeping even though they do not perceive it. This sets up the possibility of creating more extreme sleep deprivation in these clients than is typical early in the treatment. That is, if the client estimates that they are sleeping 15 minutes per night but is actually sleep 7 hours per night, and the therapist restricts this client to 5 hours, this is more sleep deprivation than usually occurs in more typical insomnia where the deprivation set up by SRT is mild. These clients will complain of very little sleep but often will be surprised how well they are functioning. This is because they are actually getting much more sleep than they think. One sign that the dose of restriction is too high is that in the early going of restriction the client may perceive more sleep at night but para doxically may report much worse sleepiness and fatigue during the day because now they are getting significantly fewer hours than when they started. This may force the therapist to reconsider the SRT dose. At the very least these clients should be carefully monitored for sleepiness and warned that they should not engage in any activities where sleepiness would become a danger. The good news is that eventually the misperception tends to minimize when drive for deep sleep builds and overrides hyperarousal as the treatment progresses. In the meantime there are consequences to SSM that can interfere with treatment. Those reporting little to no sleep tend to be quite anxious. They use dichot - omous language such as “I don’t sleep at all” and understandably, they have extremely low sleep self-efficacy. In one study, participants wore actigraphs and then reviewed the actigraph data with the experimenter and compared it to the sleep logs during the same period (Tang & Harvey, 2004). After the actigraph and log review session, the discrepancy between the two modalities diminished, which suggests that it may be possible to modify misperception with an exercise in which the client can see the dis - crepancy. Additionally, by providing an explanation of the hyperarousal phenomena above, clients can understand that the therapist does not believe that the client is 116 Adherence and Troubleshooting Barriers

fabricating or exaggerating their sleep complaints, rather, the therapist suggests that hyperarousal may be providing confusing feedback to the client’s perceptual systems. It is important to encourage the client to look for any evidence that they might have been sleeping so that they can try to catch even an extra minute on the sleep diary. Clients can be reassured that as the treatment progresses, the misperception will diminish, which primes them to expect or look for more sleep time. Additionally, it may be helpful to explore with the client the consequence of selfidentifying as someone who “doesn’t sleep.” There was a study in which those with insomnia were given fake feedback based on an actigraph they wore (Tang & Harvey, 2004). One group was told that based on their actigraph data, they slept much more than they thought and the other group was told that based on their actigraph data, they slept much less than they thought. The next day, the group who were told they slept better rated their daytime symptoms as less severe than the group who were told that they slept worse; suggesting that perception of sleep is a key variable to assess and modify. SSM can be managed better in treatment once clients have an understanding that: 1) extreme lows in average total sleep, especially “no sleep,” are not possible, 2) misper - ception is a result of a neuropsychological (i.e., extreme cortical hyperarousal) process in insomnia, 3) misperception diminishes with sleep deprivation, and 4) there is a negative, self-fulfilling prophesy consequence to labeling oneself as a non-sleeper. Troubleshooting What Activities to do During Stimulus Control Many clients have concerns that leaving the bedroom will make them more alert. They may be concerned that they will find activities too interesting and they will not become sleepy. They may have read that light will make them so alert that they will not be able to return to sleep. Perhaps the first best answer to these concerns is to say that the client could potentially be right but that maybe it doesn’t matter. There is lots to explore with this concern. Most light sources in the house will not have the light intensity (e.g., lux) or high concentrations of blue spectrum light, to significantly activate the person; however, even if the light provides some activation, the argument is that staying in bed is more risky and detrimental to sleep than getting out of bed. That is, the rationale for SC is to recondition the bed to become a cue for sleepiness and sleep rather than arousal and anxiety. We know that pairing the bed with wakefulness promotes wakefulness. We don’t know if leaving the room promotes wakefulness. Getting out of bed, unpairs the bed with wakefulness, increases sleep deprivation, which increases sleep pressure, and is counter to sleep effort (in other words, the client is now engaged in efforts to stay awake which will make it more likely that they will become sleepy). It is important for the client to see that none of this relearning is likely to happen in one night. Stimulus control is not magic. Alternatively, staying in bed could potentially shield the client from light that may or may not alert them, but now they are: 1) reinforcing conditioned arousal, 2) engaging in sleep effort, which paradoxically increases the likelihood of wakefulness, 3) staying in an environment with few distractions from excessive mentation, and 4) engaging in the same pro-insomnia behavior that they were unsuccessfully using pre-treatment but hoping for a different result. One way to test Adherence and Troubleshooting Barriers 117

this concern is to use a BE in which two weeks are spent following SC. The therapist can use Socratic questioning to help the client see that even if they are awake longer by getting out of bed, if they don’t compensate for lost sleep and stick to their schedule, there is a hidden benefit to becoming activated out of bed—this will build healthier sleep drive and eventually produce better sleep. In CBT-I time should be spent not only reviewing the numbers on the sleep diary but also the therapist should be asking exactly how the time spent awake was passed. It is also important to note that clients who get out of bed but then try not to do anything as a way of getting bored and sleepier faster, are still engaged in sleep effort and this is not likely to be any more productive than tossing and turning in bed. Learning to get up and read a good book, even if it is engrossing, is much more conducive to acceptance and relaxation. In this way, becoming more awake and getting less sleep in the first nights of treatment can be reframed as a positive sign that the client is learning to let go of sleep effort and the treatment is working well. In essence, clients should learn that they might need to lose a few battles to ultimately win the war. No matter what the therapist should always be checking on the clients understanding and acceptance of the rationale. Any situations in which a client is catastrophizing about the possibility that any particular recommendation will increase sleep deprivation, is an opportunity to ask them about the rationale: “and if it is true, and you are to remain awake longer, what is the benefit with respect to sleep drive?” Is it Time for a Sleep Specialist Consultation? Troubleshooting mainly consists of two tasks: 1) assessing whether the sleep schedule is correct and 2) addressing partial or total non-adherence. To assess whether the schedule is correct, the therapist assesses: 1) whether the scheduled sleep opportunity is at the right time given the client’s chronotype, 2) whether the TIB is too short (i.e., is there too much sleepiness present?), and 3) whether the TIB prescription is too long of an opportunity (i.e., are the insomnia complaints persisting?) Sleep schedule trouble - shooting is contained in Chapter 5, so we will not re-review here; this chapter focused on nonadherence. If the sleep schedule appears correct and there appears to be good adherence but no improvement in insomnia, it may be time to refer to a sleep specialist. Likewise, if insomnia is improved, the client appears to be sleeping well for a reasonable number of hours and time-in-bed has been sufficiently extended, but sleepiness remains, this too may signal the need for a referral. CBT-I is a highly successful treatment in which most clients respond well. However, we know that some people do not have an optimal response, so it is best to refer them on for a second opinion, as well as an assessment of possible occult sleep disorders. Some clients do not appear to have risk factors for sleep disordered breathing or neurological disorders during sleep at intake, but after failing CBT-I, a sleep study may reveal that an occult sleep disorder either accounts for resistant insomnia or hampers treatment response. Sleep disorder centers have multidisciplinary teams that can help the management of complex cases. Thus, when there is a case of non-response especially when there has been good adherence, it is important to refer to a sleep specialist. 118 Adherence and Troubleshooting Barriers

Summary • Rise-time difficulties may relate to issues of comfort, eveningness, or aversion to sleep inertia. • Early morning awakenings can be a sign of phase advance rather than insomnia per se. • Bedtime difficulties may relate to chronotype, as well as too short or too long of a buffer zone. • Motivation, anhedonia, cognitive issues, and hopelessness are common features of depression and are workable in the context of CBT-I. • Modifications may be necessary to Stimulus Control rules in those with pain and mobility issues or medical frailty. • Some instances of non-response may relate to therapist beliefs which results in only partial or under dosed delivery of the treatment. It is important to be aware of our own biases when treating clients. • In cases of non-response despite good adherence, the client should be referred to a sleep specialist for evaluation and further treatment. Adherence and Troubleshooting Barriers 119

8 Rumination Strategies for Insomnia Rumination is a common issue for people with depression (e.g., Nolen-Hoeksema, 1991) and it is also an important issue for people with insomnia (see Carney et al., 2006, 2010, 2013). Rumination is a form of repetitive thinking. The content of the repeated thoughts differs slightly in those with insomnia only versus those with depression; although there is some overlap in content (Carney et al., 2006). In the presence of fatigue, the content tends to focus on somatic symptoms and why (i.e., past-focused thoughts) the symptoms are occurring; inevitably leading to the conclusion that the cause of the fatigue is the previous night’s sleep. Such is the type of rumination we see in insomnia but also MDD-I. In contrast, in MDD but not in insomnia only, the thought content in rumination tends to focus on negative aspects of the self. In the context of anxiety, thoughts tend to be future-oriented and catastrophizing (i.e., worry). That is, if someone with insomnia was lying awake, unable to sleep, the content would focus on the future, e.g., “If I don’t get to sleep, I won’t be able to function tomorrow” (e.g., Carney et al., 2010; Harvey, 2002). In each of these scenarios, the thoughts are repetitive and difficult to escape. Many people with depression and insomnia believe that ruminating helps them to solve problems; that is that rumination is useful. Indeed, repetitive thought may, at times, be helpful to solve problems, as this type of reflection can sometimes lead to insights and the generation of solutions. However, in the presence of negative mood, the types of thought that tend to be generated are mood-congruent and inherently unhelpful. An experiential way to help someone reflect on the process of rumination is to engage in an in-session rumination based on Watkins, Moberly, and Moulds (2008) study (Watkins et al., 2008). In this study, participants either focused on abstract or concrete aspects of an emotional scenario, such as a conflict. Thus, in-session, ask the client for a recent rumination episode; inquire as to how much time was spent on ruminating. Next, ask what solutions were generated and whether any solutions were implemented. The answer to this question, if the client is indeed ruminating, is most often no. Then reflect, for example, “You estimate that you spent 40 minutes ruminating without a solution? Is it possible that the cost-benefit ratio does not work out in your favor?” If the client persists in the belief, the therapist can set up a behavioral experiment and ask the client to test it out. Therapist: You said that maybe you just didn’t have enough time for rumination to result in a solution? Client: Maybe.

Therapist: Can we try a little experiment to see whether that is true? That is, can we test if rumination is helpful? Client: OK. Therapist: I would like to set aside 15 minutes right now to try this experiment. Before we do, you said that you didn’t have any solutions to the problem with your neighbor even though you thought about it for 40 minutes this morning causing you to be late. I wanted to confirm that you don’t have a solution yet? Client: That’s right. I’m not sure what I can do and it’s driving me crazy. Therapist: Can I get a mood rating from you right now please? Client: I’m about 65 percent sad, and about 80 percent frustrated. Therapist: Ok, thank you. During the 15 minutes, I will ask you to intensify your thinking about your conflict with your neighbor to generate solutions. I want you to really analyze why and what caused it to happen, as well as analyze the implications of the conflict with your neighbor. Can you do that please? Client: So, why it happened and the implications of it? Therapist: Yes. Does that sound ok? Client: Yes, that’s typically what I am thinking about anyway—why and thinking about how I could prevent it or how I can get rid of the problem. Therapist: Ok, great. I will set our timer. After 15 minutes. Therapist: OK thank you. Can I get another mood rating now please? Client: I sort of feel worse. My neighbor is such a jerk. The more I think about it, the more I realize that he is such a jerk to treat me like that. Therapist: Sounds like this brought up negative thoughts for you. What is your negative mood rating right now after that exercise? Client: Frustration is more like 90 percent and I feel really down, maybe 80 percent. Why do I let people treat me like that? Therapist: So you were thinking about the “whys”—“Why do I let people treat me like that?” and it made you feel pretty lousy. What about any new solutions? Client: [Sighs and shakes head no.] Therapist: Can we try something else? Client: Sure Therapist: Let’s take the same situation, but instead of focusing on the why, start by exclusively focusing on the “what” of the problem. Tell me the concrete, specifics details without thinking about why at all. If you find yourself asking a why question, just take a breath and refocus. Tell me everything in as much vivid detail as possible and in chronological order. I will set the timer again. After 15 minutes. Therapist: OK. Can I get a negative mood rating now please? Client: I’m calmer now. Maybe because time has passed? Feeling down is like 50 percent and frustration is lower too, maybe 60 percent. When I think about it, the main thing he said was that he had some sort of weed killer he could give me. It just made me mad because I thought he was saying my place is a mess. That I’m not taking care of my responsibilities, which made me mad because I’m tired and depressed. I’m doing the best I can. I should take better care of my lawn. I just didn’t appreciate the insinuation. Rumination Strategies for Insomnia 121

Therapist: This is a pretty big shift in both mood and perspective. In the first 15 minutes, we focused on the why and you had no solution and felt worse. We can add this to the 40 minutes this morning that resulted in feeling worse, continuing to feel stuck and being late. You shifted your focus away from trying to figure out the why to just remaining at the level of what took place and what happened? Client: I don’t know. I think I have a few possible solutions. I can take the free weed killer because I sort of know I need to do it or I don’t have to. I don’t really know if he was trying to be snarky. I can see that maybe he wasn’t and IF he was being snarky, that seems a little lame to me and maybe not worth getting upset over. Therapist: When we balance the amount of time rumination takes and the toll on your mood, along with the observation that it rarely leads to a solution, I wonder if it shifts your opinion in some way? Client: It does. The idea is that rumination, and other repetitive thought processes including worry, can sometimes change simply by examining the process of thought rather than the content and observing its outcomes, perhaps through a behavioral experiment or a log of rumination and its outcomes. In Chapter 9, we discuss that the TRAP and TRAC worksheet (a blank version is included in Appendix D) can be used to identify triggers to the rumination (an avoidance pattern) and to develop alternative coping responses to the rumination. For example, rumination can be addressed behaviorally by using it as a cue to engage in BA, including activation in the form of Stimulus Control, i.e., leaving the bedroom when it occurs in bed. Alternatively, rumination may be addressed via strategies that reflect on the process rather than the content per se. That is, there does not have to be any challenge at all; rather there can be a noticing of thoughts without engagement, acceptance, and through acceptance, paradoxically, comes change. In addition, when one takes an observing and accepting stance to thoughts, even if a change in thoughts does not occur, the experience of rumination itself becomes less disruptive. In other words, the rumination stops generating as much negative emotion. In clients with insomnia, the tendency to ruminate in response to feeling tired is negatively correlated with attending to one’s activities in the moment, whereas adopting a nonevaluative stance toward thoughts and feelings, and allowing them to come and go rather than fighting them, allows one to be more fully engaged in life (Moss Atlin, Atwood, Khou, Ong, & Carney, 2013). Such is the premise of mindfulness and acceptance-based techniques. Indeed, in Mindfulness Based Treatment for Insomnia (MBTI) rumination about insomnia symptoms as measured by the DISR Scale (Carney et al., 2013b) (see Appendix C) decreases with mindfulness treatment. Metacognitive Approaches Metacognition is, in essence, thinking about thoughts. The mere act of reflecting about thoughts, one’s thought process, and the consequences of such patterns can be a powerful agent of change. In Chapter 6, we reviewed a process for direct challenges as a path to modifying thinking. The process of learning a new way of thinking about thoughts, that is, that thoughts are not facts and can thus be challenged and modified, 122 Rumination Strategies for Insomnia

was purported by Beck to be a pathway to establishing a new relationship to thoughts, or “decentering” (Beck et al., 1979). There is some evidence that interrupting troublesome thoughts and re-appraising their veracity or utility via CT may result for some, in decentering (Ingram & Hollon, 1986). However, for many, Socratic questioning and TRs may not result in decentering. This was part of the impetus for the development of Mindfulness Based Cognitive Therapy (MBCT). In recognition that mood-triggered repetitive thought in the form of rumination was the most important predictor of relapse and recurrence in depression (Nolen-Hoeksema, 1991, 2000; Segal et al., 2006), the MacArthur Foundation funded three experts in repetitive thought to develop a preventative strategy for relapse prevention (Segal, Williams, & Teasdale, 2002). Their focus of finding a preventative treatment was on rumination and facilitating decenter - ing. Thus, we will turn our attention to rumination in the context of MDD-I. Metacognitive approaches to the treatment of depression are part of the “third generation” cognitive behavioral therapies and include ACT and MBCT. Before discussing what these interventions are, we briefly review empirical evidence for their efficacy in the context of depression and then, after describing the theoretical foundation and techniques, we discuss the application of these techniques and theoretical constructs to the context of insomnia, concluding with a brief review of emerging evidence for the efficacy of metacognitive approaches in the treatment of insomnia. Empirical Support for Metacognitive Treatments for Depression There is empirical support for the efficacy of ACT and MBCT for depression treatment, including evidence for their efficacy when delivered as self-help interventions (Zettle, 2015). Hoffman and colleagues conducted meta-analyses of mindfulness based therapy, which included both MBCT and Mindfulness Based Stress Reduction (MBSR) inter - ventions for anxiety and depression (Hofmann, Sawyer, Witt, & Oh, 2010). These investigators identified four studies that included individuals with diagnosis of depres - sion (chronic depression, treatment resistant depression, residual depression, and those with history of depression) and concluded that there is a large pre- to post-treatment effect (Hedges’s g = 0.95) for improving mood symptoms in these four samples (Hofmann et al., 2010). Piet and Hougaard (2011) conducted a systematic review and meta-analysis of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder and reported that MBCT significantly reduced the risk of relapse or recurrence, with a relative risk reduction of 34 percent (Piet & Hougaard, 2011). Two of the six studies reviewed compared MBCT with maintenance antidepressant medica tion and found no significant differences in depression relapse rates (Ruiz, 2012). A review paper of studies that directly compared ACT to CBT for depression (Ruiz, 2010) reported comparable efficacy (Hedges’s g = 0.25). Key Concepts and Techniques Used in Metacognitive Treatments for Depression Metacognitive approaches are focused on second-order rather than first-order change. First-order change refers to wholesale alterations in behaviors, for example by changing frequency and/or intensity or eliminating behaviors or by changing thoughts, beliefs or Rumination Strategies for Insomnia 123

schemas, in order to change behaviors. In contrast, second-order change aims to change one’s relationship or the context of one’s thought. ACT and MBCT for depression are focused on promoting psychological flexibility, responding to stressful situations reflectively, rather than reflexively, and increasing commitment to valued-based actions (Bishop et al., 2004). In doing so, these interventions can be viewed as aiming to change individuals’ relationships with their thoughts and experiences rather than to directly address their depressive symptoms through altering depression-related behaviors and thoughts. In the context of these two therapies psychological flexibility refers to expanding one’s options regarding behavior and thought, while including a willingness to tolerate negative experience. With such willingness the hope is that one can consider taking small steps towards a valued goal as a viable course of action. Acceptance is a central construct in both ACT and MBCT. It involves the active and aware embrace of all thoughts and experiences and, when appropriate, not attempting to change them. As opposed to passively tolerating or resigning, acceptance is an active process that involves a deliberate decision to hold negative thoughts and feelings and not to avoid or escape the experience. Acceptance is not always intuitive. It is said in ACT work that minds are programmed to want to find problems and fix them. However it is the rigid application of this stance that often gets individuals stuck in rumination without positive outcome. Taking a fixing stance may be helpful in relation to things over which we have control, but when the same attitude is applied to things over which we have no control (e.g. sleep and/or mood), this often results in spiraling frustration, anxiety, and increased depression. Given that it is difficult for minds to grasp the concept of acceptance, the use of metaphor is often a powerful tool to be employed. Likening acceptance to experiences that the client can relate to, often can help the client gain greater understanding of the concept. For example, one metaphor to convey what it is like to have or hold a thought without engaging the thought (acceptance without fixing) is that it is like watching the TV news with the ticker scrolling at the bottom of the picture. It is hard to concentrate on both the story and read the ticker at the same time, however, one can learn to focus on the story and not read the ticker. The point is that one does so not by making the ticker go away, but rather keeping it in the periphery of vision, knowing that it is there, but at the same time not interacting with it. In addition to metaphor there are several techniques that are used for promoting acceptance, including a) adopting an observing stance, in which a negative thought or experience is watched dispassionately, as one might watch leaves floating by on a stream, b) distancing from a thought by giving it a shape, size, color, or another descriptive quality, such as “interesting,” c) repeating the thought or a key word out loud until only its sound without meaning remains, almost as if it were a tongue twister, d) labeling the thought as merely an event in one’s mind (e.g., “I am having the thought that I am no good”) rather than a reflection of attending to and fusing with its content (e.g., “I AM no good”). Acceptance is promoted not as an end in itself but to increase psychological flexibility by broadening the range of reaction options. This is often accomplished because as one becomes more accepting of thoughts, feelings, and emotions, by definition it allows one, in essence, to put a bit of distance between themselves and these characteristics and therefore to gain a better perspective for what they are as opposed to the more catastrophic interpretations of what they are. For example, by using the technique of distancing one might be able to describe a pounding, racing heart as being 124 Rumination Strategies for Insomnia

like a basketball that is being dribbled inside their chest. As such one may then be willing to have the basketball dribbling occur a while longer rather than having to stop it immediately, because when thinking of it that way they see it as not as bad as they first thought. Once a person is willing to allow symptoms to be as they are, they are more able to entertain options for behavioral action. Such acceptance can also be a very important construct in insomnia. Commitment to values-based actions is a second central construct in ACT and is the vehicle for change that complements acceptance of what cannot be changed. It refers to deliberate actions that are congruent with and motivated by values that are important to the individual. Depression is associated with reduction in engagement in appetitive behaviors that were important to the individual in the past. ACT involves helping individuals with depression identify and reconnect with what really matters to them in life (i.e., their values) and commit to actions that are congruent with these values. For example, an individual with depression who valued fitness and health, and therefore was committed to and derived pleasure from going to the gym may have stopped exercising due to anhedonia. If this person identifies health promotion as an important value, then commit - ment to live in accordance with their values in this example would mean committing to resuming exercising and taking small steps to gradually re-engage in an exercise routine. In this way value-based action supports BA. In Chapter 9 we discuss why BA may have important input into the sleep regulatory system. As discussed above, MBCT was initially developed as an approach to relapse prevention in depression. Whereas in traditional CBT relapse, prevention is focused on identifying automatic dysfunctional depressogenic thought and changing their content, MBCT aims to reduce future risk of relapse and recurrence of depression by focusing on changing the individual’s relationship with such thoughts. Originally, MBCT was called Attentional Control Therapy because of the focus on teaching clients to continually bring their attention to a stated target (e.g., the breath, a part of the body, etc.) (Segal et al., 2002). MBCT teaches clients in remission from depression to become more aware of their thoughts and feelings in response to their experiences and relate to their thoughts and feelings as passing events in the mind. In that way, MBCT helps individuals to decenter, or disengage from habitual ways of interpreting and responding to their experiences, which have historically put them at risk for depression recurrence. Mindfulness mediation is a core technique of MBCT. It involves nonjudgmental awareness of bodily sensations, thoughts, and feelings. MBCT also includes exercises designed to help people apply awareness skills into daily life. The aim is to replace habitual, “automatic” patterns of mindless reacting to cognitive-affective experiences. Rather, individuals are encouraged to observe these experiences and act intentionally and mindfully. The idea is that observance and acceptance of automatic depressogenic thoughts allows for disengagement from the thoughts and increases one’s ability to identify new ways to deal with challenges and stressful situations. Metacognitive Approaches to Insomnia In an elegant series of experiments, Bonnet and Arand provided support to the idea that insomnia is a disorder of hyperarousal (Bonnet & Arand, 1997). Hyperarousal can Rumination Strategies for Insomnia 125

be experienced physiologically, through body tension and autonomic arousal, emotion - ally, through negative high arousal emotion, such as anxiety, and through cognitive processes, such as racing thoughts, and thoughts that increase arousal. CBT-I sometimes incorporates relaxation methods to address physiological arousal and cognitive therapy to address cognitive arousal. Ong, Ulmer and Manber (2012) have proposed a two-level model of arousal in insomnia, which supports the use of metacognitive techniques in insomnia (Ong et al., 2012). They distinguish between cognitive and metacognitive sleeprelated cognitive arousal. Primary cognitive arousal refers to thoughts related to the inability to sleep, such a thought that insufficient sleep will lead to negative and unacceptable daytime consequences. Secondary or metacognitive arousal refers to how one relates to thoughts about sleep in terms of the meaning, emotional valence, and degree of attachment one has to these thoughts. Secondary cognitive arousal is likely to increase primary cognitive arousal because it could create a bias in the attention to and perception of sleep-related threats. For example, the degree to which one accepts the middle of the night thought, “My day is going to be shot unless I fall quickly back to sleep” as fact, rather than an event in one’s mind will likely lead to additional thoughts about negative outcomes of not falling asleep, which, in turn, further escalates hyperarousal. By using metacognitive techniques, without necessarily changing the content of the thought, the person can detach from the threat perception thus reducing the probability of additional thoughts about the threats related to insufficient sleep. In this way the person is more likely to defuse threatening internal experience and decrease hyperarousal. Garland, Gaylord, and Park (2009) posit that de-centering occurs with mindfulness because mindfulness can facilitate the reappraisal of stressful events and distressing thoughts (Garland et al., 2009). Thus, mindfulness allows an individual to “de-center” from initial stress inducing appraisal (e.g., “my day will be shot”), adapt a different perspective, and reappraise the situation, which is likely to attenuate the original activation of the stress response system, thus halting (or at least reducing) further escalation of hyperarousal. Mindfulness meditation helps cultivate adopting an objective stance about sleepless - ness. This applies to the middle of the night experience as well as to the experience during the day. For example, an objective nonjudgmental awareness of the tendency to attribute low energy during the day to sleeplessness at night could lead to the insight that being absorbed in the frustration makes it more likely that the state of low energy will continue to interfere with the day’s activities. Another metacognitive technique is the Chinese finger trap analogy, which provides an experiential demonstration of the importance of letting go of efforts in certain situations, including sleep and fatigue. Below is an exchange with a client named Kelly, whose case is presented in Chapter 10. Therapist: So tell me about the increased use of energy drinks this week. Client: I really can’t take how tired I feel. I think I’m going to end up in the hospital. Therapist: You worry that you would end up in the hospital because you are tired? Client: You know when you hear that someone was admitted due to exhaustion? Therapist: I see. So does the difficulty following the schedule, the difficulty refraining from napping attempts and the increase in caffeinated drinks all relate to trying to manage or escape feeling tired? Client: Yeah. I really hate it. I can’t take it. 126 Rumination Strategies for Insomnia

Therapist: You can’t take it. I see. Do you think the strength of your aversion to feeling tired may play a role in this problem? Client: You mean it’s all in my head somehow? Therapist: Not exactly. What I meant to say was whether the fact that you need to avoid this sensation at all costs, increases your attention to it and may unwittingly increase the likelihood of detecting any sensations of fatigue? Client: Maybe. But I do feel tired. Therapist: I don’t doubt that for a minute. But if all this energy is focused on resisting the experience of fatigue, isn’t a fair amount of attention and energy being devoted to the very experience that you don’t like? Client: Maybe. Therapist: There is a saying, “that what you resist, persists,” what do you think about this? Client: If you are saying I shouldn’t “resist” feeling fatigued, that doesn’t make sense to me. I can’t take feeling tired, so I have to do something about it. Therapist: Have you ever heard of a Chinese Finger trap? Client: I think so. Therapist: I have one right here [hands it to client]. The person places their index fingers in each end and they have to solve how to get their fingers out. Client: [inserts fingers] I can’t. I’m stuck. I can’t pull them out. Therapist: Often the first solution someone tries is to resist, to pull out, to struggle against the puzzle, but what happened when you used this strategy? Client: It starts to squeeze and get tighter and I get stuck. I can’t feel anything to release it either. Therapist: What is the opposite of struggling? Client: Not struggling? Relaxing? That doesn’t seem to be working either. Wait. I did it. Therapist: So what did you do? Client: If you push in, rather than struggle, it works. Therapist: Why do you think I gave you this puzzle to try? Client: I guess you don’t want me to struggle with feeling tired? That you want me to push in? Does that mean you want me to try to feel tired? To induce it? Therapist: You could induce it, I suppose, but I was thinking of something a little different. I want you to imagine that you were having a party and there was someone who you really did not want to come. You didn’t invite them but you were really focused on the idea about whether they might show up uninvited. You worried for weeks before the party and tried to think of ways to keep them out if they showed up. Maybe you even hired security for the door to keep them out. How much fun is the anticipation for the party and how much fun would you have at the party, waiting to see if they showed up? Client: Probably not much fun. Therapist: And what if they got in anyway? Would it ruin things? How much fun would you have at your party now? Client: None. I couldn’t have fun until they were gone. Therapist: And even if you managed to get rid of them, knowing they could return would be distracting again, no? Rumination Strategies for Insomnia 127

Client: OK, I get the finger trap thing and this too, struggling against something NOT happening makes it worse. It takes up all your energy and ruins the party so to speak. But what is the equivalent of pushing your fingers in here? Therapist: You don’t have to like the party guest, in this case fatigue, and you don’t have to necessarily invite or induce it, but what would happen if you were open to its presence? What if you focused your attention on the invited guests and the party at hand instead? Could the shift in attention lessen the negative impact of fatigue? Client: Maybe. That would be hard. Therapist: It’s sort of like your low back pain. You told me that the pain improved after attending the chronic pain group. Given how the pain group did not work on your herniated disks at all—how would you explain why the group was so helpful? Client: I learned that I could turn down the volume on the pain. The pain doesn’t go away but it fades to the background. I focus on other things and the pain decreases. I get it about feeling tired now. I need to turn down the volume. In the context of CBT-I mindfulness meditation can also help restore the automaticity of the process of falling asleep as awareness of levels of alertness, sleepiness, and fatigue increase and acceptance counteracts sleep effort. The information can be used in a matter of fact way to guide one’s behavior: if feeling sleepy, go to sleep; if fatigued, rest, but not in bed; and if in a state of high arousal, focus on behaviors that reduce arousal. As discussed earlier, individuals who have experienced insomnia for a long time exert much effort in order to control sleeplessness. In some cases this effort compromises engagement in other activities that used to promote their sense of well-being and were consistent with their value system, such as socializing with friends, exercising, etc. For example, having lost sight of some of their life values in the service of symptom management they cancel or do not schedule social activities so that they can go to bed earlier (Carney & Edinger, 2006) or because they do not have the energy, use the time that was previously dedicated to morning exercise for sleeping in. These avoidant, safety behaviors were described in the previous chapter. In insomnia, as in depression, commitment to personal non-sleep-related values can guide deliberate actions that do not involve sleep effort. Such actions may include adherence to treatment recom - mendations that might initially appear counter intuitive, such as limiting the time spent in bed, or not engaging in safety behaviors, such as cancelling social engagement and sleeping in. The steps involved in helping clients develop a plan for value-based commitment to action are: identifying one’s values, and helping clients realize the cost of maladaptive sleep-related behaviors that are not consistent with those values (e.g., canceling a social engagement is not consistent with the value of staying connected with people). The discrepancy can then naturally lead to changes in these maladaptive behaviors. Again, the other side of this equation is that in order to live in congruence with these values, one must be more willing to accept the presence of uncomfortable thoughts, feelings, and emotions (e.g., in the name of valued connection with others, one might have to accept the thought that “I might fall asleep while sitting listening to my friends”). The therapist should keep in mind that when asked to state their values clients often respond with statements about their goals and aspirations rather than their values. However, values provide a direction for attainable actions but are not in themselves attainable 128 Rumination Strategies for Insomnia

targets. The Life Compass (Dahl & Lundgren, 2006) is a tool to help clients identify their values. The Life Compass exercise encourages clients to rate the importance of various life domains, such as family, friendships, work, spirituality, etc. Therapist: You said that your insomnia gets in the way in several areas of your life, specifically you mentioned that you are no longer socializing or working out. I would like us to do an exercise called the Life Compass. I want to ask about aspects of dimensions of your life and I want you to tell me about the importance of these areas of your life. What about your relationship with your daughter? How important is this area? Client: This is one of the most important things in my life. Barb and I have a good relationship. I wish I were more present with her. I used to call her more often and go out for lunch with her. Therapist: I see. So family relationships are a top priority; one of your most import - ant values. Although it sounds as though your current lifestyle may not reflect this? Client: Yes. Plain and simple, I am tired. I feel preoccupied with just trying to survive. Just trying to function, you know? So I try to rest when I can and arranging activities with my daughter, being present is what I value but not something I feel able to do given how crappy I feel. Therapist: I see. What about other relationships, perhaps starting with family relationships? You mentioned you have a brother? Client: Absolutely. This is similar. I feel a little disconnected right now from my brother [starts crying]. It’s the same. I’m tired and I think I am so focused on surviving that I have lost sight of what’s important. Therapist: OK. So feeling tired and focusing energy on resting and conserving energy has disconnected you from living a life in tune with your values? Client: [nods] Therapist: What about friendships? How important are friendships in your life? Client: Yes, very important. Maybe not quite as high as family but pretty close. I have good friendships. Although, now that I am thinking about it, I have good friends but I am not really spending time with them or spending much energy on them. I wish that we went out more and I know that it is me. I don’t say yes so I am letting how crappy I feel affect my relationships. Therapist: OK. I was going to ask you about romantic relationships and then I remembered that you actually told me that while you are feeling depressed and not sleeping well, you feel ambivalent about relationships because you really wish you had someone but your motivation is low for trying to meet someone. Do I have that right? Is this low in importance, or not as valued as other areas of your life? Client: No, it is something I value. It’s sad. I wish I had someone but I never do anything about it. When you feel tired and your sex drive is low, it’s so hard. Therapist: OK. I have written these down in your values or life compass column and you can see how I wrote down the barriers you cited in the last column. These are things getting in the way of living your valued life or living in a way that matches your values. I would like to explore other things you may value like leisure or hobbies, your work, spirituality, health? Rumination Strategies for Insomnia 129

Client: OK. But it is going to be the same. Hobbies are important. I like knitting, but I am not. I want to work out but I don’t. I like yoga and I know it helps my back, but I haven’t gone for two years. There are ideas I have for work—but I am in a rut and doing things that don’t work that well and that I don’t enjoy, instead of trying something that would make me feel more fulfilled. It’s so depressing, but what am I supposed to do? I am exhausted and just trying to get through each day. Therapist: It’s your belief that you have to get rid of the sleeping problem or the depression to live your valued life? Client: Well yes. If you are tired, you can’t do anything. Therapist: In fact you have been doing something, right? You are using a strategy to get by, and that is to conserve your energy and cut back on everything. Has this allowed you to live the life you would like? The life you described in your life compass? Client: It doesn’t really feel like a choice, but no, it doesn’t give me what I want. Therapist: Is it possible that the strategies you are currently using actually block you from your valued life, the life that you want? Client: Yes, although it seems impossible to think of a way in which it could be different. Therapist: I wonder if you could conceive of a life in which living in a way that is more consistent with your valued life would work better for you? That is, I wonder if we could explore a world in which you could be living your valued life alongside your fatigue. Client: What do you mean by: alongside my fatigue? Therapist: Well, right now it sounds like you give up a lot of what you value when you are fatigued. But I wonder, when you are conserving energy does that make you feel less fatigued, or less depressed? Client: I don’t think so. In fact, I know there are many times when I go home to rest but I continue to feel exhausted and sad. Therapist: At the same time you are missing out on valued pieces of your life, correct? Client: Without a doubt. Therapist: So I ask you—which is better, to be fatigued and home alone or fatigued and with your daughter, or friends? Client: Well when you put it that way, I guess the answer is simple. I would rather be with people. Therapist: Even if you are fatigued? Client: Yes I guess I would say that. Therapist: This is what I mean by living a valued life alongside your fatigue. Client: I can see what you mean and would be excited to think about ways that I could get back to some of the things that are important to me. I guess we would need to talk about what that looks like but yes, I am open. Thus in the example above, the exercise leads the client to re-appraise the strategies they are currently using to cope as blocking themselves from their valued life. The ambivalence this exercise creates can help to facilitate change towards living a life more commensurate with the client’s values. 130 Rumination Strategies for Insomnia

Mindfulness-Based Treatment for Insomnia (MBTI) Ong, Shapiro, and Manber (2008) have developed and tested a mindfulness-based intervention for insomnia that they later named MBTI (Ong et al., 2008). Although the treatment was originally developed as a group intervention, there is no reason to believe it cannot be implemented in an individual therapy format. MBTI combines mindfulness meditation and three behavioral components of CBT-I, sleep restriction therapy, stimulus control, and sleep hygiene introduced in a manner consistent with mindfulness principles. For example, the stimulus control instruction to get out of bed when unable to sleep is discussed using the language of awareness and acceptance: “I am not in a state conducive to sleep so I might as well be fully awake.” Similarly the stimulus control instruction to go to bed only when sleepy is discussed using the language of awareness: “I notice that I am not sleepy now; I might as well wait until I become sleepy.” MBTI discourages the therapist from being directive when introducing the behavioral components of CBT-I. For example, concepts central to the rationale for stimulus control (i.e., conditioned arousal) and sleep restriction therapy (i.e. the importance of the sleep drive) are introduced by the therapist who then encourages the clients to discuss how the ideas apply to them. Barriers to adherence with the behavioral components of CBT-I are addressed through discussions of mindfulness principles, such as flexibility and promoting decentering from the immediate distress or re-connecting with commit - ment to value-based actions. Each session begins with formal mindfulness meditations that include both quiet (e.g., body scan, breathing, or sitting meditation) and movement meditation (e.g., yoga, walking, or stretching meditation). Each week, the mindfulness group facilitator engages the group in inquiry; that is, questions about the experience, e.g., “What do you notice in your body?” Between session work includes implementation of the behavioral components of CBT-I and a 30–45 minute daily meditation practice. The session by session outline is presented in Table 8.1. Rumination Strategies for Insomnia 131 Table 8.1 MBTI Session outline Weekly Topics Therapy Activities Introduction Introduce concept of mindfulness and model of insomnia; lead through first mindfulness practice Stepping out of auto pilot Start with meditation and inquiry; discuss sleep hygiene Paying attention to Start with meditation and inquiry; discuss sleepiness, fatigue sleepiness and wakefulness and wakefulness; introduce sleep restriction Working with sleeplessness Start with meditation and inquiry; adjust sleep restriction; introduce stimulus control The territory of insomnia Start with meditation and inquiry; troubleshoot Acceptance and letting go Start with meditation and inquiry; relevance of acceptance and letting-go Revisiting the relationship Start with meditation and inquiry; discuss reactions to sleep with sleep (reactions to bad nights); discuss informal meditation Eating, breathing, and Start with meditation and inquiry; relapse prevention for sleeping mindfulness insomnia Source: Adapted from Ong and Scholtes (2010)

Empirical Support for Metacognitive Treatments for Sleep Research on the efficacy of metacognitive therapies examined the effects of mindfulness meditation and MBSR on sleep quality in non-insomnia samples with or without sleep complains (cancer clients, individuals with depression and insomnia, adolescents with sleep complaints who completed substance abuse program, and adults with anxiety disorders and sleep dissatisfaction) as well as insomnia samples. Controlled and uncon trolled studies of MBSR for individuals with a variety of cancer diagnoses (not selected for insomnia diagnosis) yield some but not definitive evidence for the potential benefits of MBSR on sleep (Carlson & Garland, 2005; Carlson, Speca, Patel, & Goodey, 2004; Shapiro, Bootzin, Figueredo, Lopez, & Schwartz, 2003). For example, Shapiro and colleagues found that the practice of mindfulness techniques was associated with reporting feeling refreshed in the morning but no differences in sleep quality between the MBSR and the control (Shapiro et al., 2003). Britton and colleagues randomized individuals with depression and insomnia to MBCT or a wait-list control (Britton et al., 2010). Participants in both groups reported reductions in subjective sleep onset latency (based on sleep diaries). Within the active treatment group, more time spent in meditation practice was associated with less self-reported time awake after sleep onset. However, objectively measured number of middle of the night awakenings using polysomnography was significantly greater among participants in the MBCT group than control. They also had more wakefulness, in fact, the amount of time spent in mindful - ness meditation practice in that study was positively correlated with these two indices of cortical arousals. These intriguing findings suggest that the observed improvement in subjective sleep is not likely to be related to a reduction in hyperarousal. Bootzin and Stevens (2005) conducted a pilot study that combined a mindfulness component with CBT-I in adolescents with a substance abuse history and sleep complaints (Bootzin & Stevens, 2005). This study, which had high attrition rate, found some improvements in sleep and reductions in relapse of substance abuse among treatment completers. In an open trial, Yook and colleagues (2008) found that among people with anxiety dis - orders, MBCT improved sleep quality and reduced scores on a worry questionnaire and the two effects were related (Yook et al., 2008). Empirical evidence on the efficacy of mindfulness based interventions in samples of individuals with confirmed diagnosis of insomnia disorder is promising. Uncontrolled small studies of MBSR (Britton, Shapiro, Penn, & Bootzin, 2003) and MBCT (Heidenreich, Tuin, Pflug, Michal, & Michalak, 2006) reported improvements in sub jective time awake after sleep onset and total sleep time among individuals with DSM-IV defined primary insomnia. These studies also found reductions in cognitions related to rumination and worry. Ong et al. (2008) evaluated an intervention that combined mindfulness meditation and the behavior components of CBT-I (MBTI) and found that half of the sample experienced at least 50 percent or greater reduction in self-reported total wake time and all but two participants no longer had clinically significant insomnia at the end of the treatment (Ong et al., 2008). This study also found a significant correlation between the number of meditation practice sessions during treatment and reduction in hyperarousal (Ong et al., 2008). A 12-month follow-up of participants supports the long-term benefits of adding mindfulness to behavioral therapy for insomnia, with 61 percent of participants experiencing no relapse (Ong, 132 Rumination Strategies for Insomnia

Shapiro, & Manber, 2009). More recently evidence that mindfulness meditation might be a viable treatment option for adults with chronic insomnia comes from a randomized controlled pilot study in which participants with insomnia were randomized to MBCT, MBSR, or a self-monitoring control. The results indicate that those who received a metacogni tive intervention (MBSR or MBTI) had significantly greater reductions in the number of minutes they spent awake after sleep onset, overall insomnia severity, and pre-sleep arousal. Importantly, remission and response rates in MBTI and MBSR were sustained from post-treatment through follow-up and were highest among those who received MBTI at the 6-month follow-up. Gross and colleagues (2011) randomized individuals with chronic primary insomnia to receive either MBSR or eszopiclone. Participants in both groups experienced signifi - cant improvements in subjective and objective (actigraphic) sleep from baseline to posttreatment. Within the MBSR group, there were improvements in subjective and objective latency to sleep onset as well as subjective total sleep time and sleep efficiency. Because the study was not adequately powered to establish non-inferiority (i.e., equiva - lent efficacy), the absence of significant differences between groups is not interpretable. Although we are unaware of a study evaluating ACT as a standalone therapy for improving sleep or insomnia, there is a case report in which ACT was combined with CBT-I (Dalrymple, Fiorentino, Politi, & Posner, 2010). Although not definitive, together these studies suggest that the integration of metacognitive techniques into CBT-I might contribute to improve outcomes. Summary • Rumination has been implicated as a key process in both insomnia and depression. In depression, rumination is a key predictor of relapse. • There are a variety of strategies for rumination including experiments that teach clients about the unhelpful outcomes of rumination, and experimenting with alternative coping responses to rumination including stimulus control at night and BA during the day, and metacognitive strategies. • Metacognitive treatments target the process of repetitive thought rather than the content. One of the main agents of change is a process called decentering. • Metacognitive treatments include MBCT, MBTI, MBSR, and ACT. • There is promising support for metacognitive approaches in addressing rumina - tion, as well as improving outcomes for depressive relapse (Segal et al., 2002) and insomnia relapse (Ong et al., 2009). Rumination Strategies for Insomnia 133

9 Combining Depression and Insomnia Therapies Although there may be subjective sleep benefits with effective depression treatment for some, there still often remain objective sleep problems and a high rate of residual subjective sleep problems even after successful depression treatment (Carney et al., 2007b). The issue of residual sleep problems is of great concern because persistent issues with sleep are predictive of depressive relapse (Paykel et al., 1995). Thus, it is essential to target comorbid insomnia along with depression, and fortunately there are several treatment options available. One possibility is to pair a depression treatment such as pharmacotherapy or psychotherapy with a sleep medication. There is evidence that combining sleep and antidepressant medications produces greater depression treatment response (i.e., almost 10 percent higher remission rates), as well as greater sleep improvement, than antidepressants alone (Fava et al., 2006). There also exists evidence for improving sleep by combining antidepressant medications with a low dose of the sedating antidepressant trazodone (e.g., Kaynak et al., 2004), although, unlike sleep medications, there appears to be no additive depression benefit. An alternative is to combine the therapy of choice for chronic insomnia (i.e., CBT-I) with an effective depression treatment. Indeed CBT-I has amassed considerable evidence for treating insomnia in those with depression (Edinger et al., 2009a; Kuo et al., 2001; Lichstein et al., 2000; Morawetz, 2001; Taylor, Lichstein, Weinstock, Sanford, & Temple, 2007; Vallieres et al., 2000) and even has some evidence for improving depression in the absence of depression therapy (Morawetz, 2001). Despite evidence that CBT-I has been shown to produce recovery from depression (e.g., Morawetz, 2001), the current state of the literature would suggest that both conditions receive clinical attention concurrently. One promising option is combining pharmaco - therapy for depression with CBT-I. Adding CBT-I to antidepressant medication produces superior results for both depression and insomnia as opposed to treating depression alone (Carney, Atwood, & Shapiro, 2013a; Manber et al., 2008). Moreover the effect sizes and proportion responding to the combined treatment is superior to combining antidepres - sant therapy and pharmacotherapy for insomnia (Fava et al., 2006) (i.e., when compared to a hypnotic medication + antidepressant medication, CBT-I + antidepressant medica - tion, it nearly doubles the MDD remission rate) (Manber et al., 2008). Additionally, there may be drawbacks to pharmacotherapy for depression including resistance to medications because of personal beliefs, side effects, or failed past antidepressant trials,

and SSRIs can actually worsen leg movements and disrupt sleep further (Dorsey et al., 1996). Thus, one option is to combine two psychological therapies. Cognitive-behavioral therapeutic approaches have several overlapping features that allow for easy integration, however some parts are so different that one issue that must be considered is whether to administer the two treatments sequentially or concurrently. There are no treatment development studies or sequencing studies to inform such questions. It seems reasonable, and is probably common clinical practice, to use case formulation to decide when, how and what components to introduce for specific clients (for more on case formulation, see Manber & Carney, 2015). Alternatively, by com - bining the treatments concurrently there may be aspects of each treatment that complement the other. In other words, there may be aspects of CBT-I that may help with CBT-D and vice versa. For example, there are both depression-specific and sleepspecific reasons to want someone with depression to get out of the bed in the morning. From a sleep perspective, setting a regular rise time: 1) helps to set the body’s biological clock, 2) it reinforces stimulus control (i.e., that the bed during particular hours is a signal for sleep only), and 3) it helps to build the homeostatic sleep pressure needed for deep sleep on subsequent nights. Likewise, there are also theoretical reasons for an earlier rise time in those with depression. For example, selective REM sleep deprivation helps with mood (Vogel et al., 1980) and REM sleep is more likely to occur in the latter half of the night, thus, setting an early and regular rise time has a good chance to inadvertently restrict some degree of REMS in those with depression. Additionally, one side effect of CBT-I is decreased time in bed (TIB) both during the day (i.e., naps) and in the 24-hour period (i.e., refraining from going to bed until sleepy and getting up at a set rise time each morning). Decreased TIB at night means that there will be increased time out of bed and greater exposure to light cues and the chance for increased activity and increased exposure to reinforcers. In other words, getting out of bed early provides an opportunity for BA. In fact, perhaps some of the depression benefits of CBT-I (e.g., Lachowski, Maich, & Carney, 2014; Manber et al., 2008) may relate to inadvertent BA because of the increased time out of bed in a 24-hour period (Lachowski et al., 2014). BA has been demonstrated to be an efficacious treatment for depression (Chambless et al., 1998; Cuijpers, Van Straten, & Warmerdam, 2007; Dimidjian et al., 2006). In addition to being an effective treatment, the straightforward therapy goals and tasks make it an attractive therapy in training clinics (Sturmey, 2009). There are two prominent versions of BA with considerable overlap but some differences in foci. One version of BA (Lejuez et al., 2001) builds activity scheduling around stated goals that arise during a structured values assessment. The values assessment queries whether there are unmet goals or needs in domains in the client’s life such as hobbies, health, relationships, occupation, etc. For example, a client who is no longer socializing due to depression, but for whom friendships are an important source of enjoyment, social activity scheduling component would be an important part of their treatment. A second version of BA is associated with Neil Jacobson (Dimidjian et al., 2006; Jacobson, Martell, & Dimidjian, 2001) and although the focus is also on scheduling, the primary target is to decrease avoidance. These two BA packages have substantial overlap and the skills and goals of the two approaches have been combined into a single package by others (e.g., Puspitasari, Kanter, Murphy, Crowe, & Koerner, 2013). Combining Depression and Insomnia Therapies 135

Behavioral Activation and Behavioral Insomnia Therapy (BABIT): An Integrated Treatment While conducting a National Institute of Mental Health funded trial combining anti - depressant medication with CBT-I, the first author (CEC) encountered an interesting problem. Whereas it made sense that participants would be leery of the placebo antidepressant condition, instead, potential participants declined participation if they were required to take an active antidepressant medication (over 200 people cited this as the reason for not participating). This was a problem for the trial but it also highlighted a problem among some people with both depression and insomnia; negative attitudes towards pharmacologic remedies. There were some who declined because they generally disliked taking medications of any kind, and some who declined because they had previous experiences with medication that they described as negative. We discovered that many of those with anti-medication attitudes had two or more failed antidepressant trials in the past. Indeed, it is worth noting that chronic insomnia is predictive of a poorer response to antidepressant medication therapy (Thase et al., 1997). We communicated to these potential participants that it was important for them to receive depression treatments too and there was a willingness to engage in depression treatment, but a resistance to the intervention if it was pharmacological. Out of this clinical need, arose an integrated treatment called Behavioral Activation and Behavioral Insomnia Therapy, or BABIT. The behavioral components of CBT for insomnia and CBT for depression were selected because the evidence for behavioral components for insomnia is superior to the cognitive components (Morin et al., 1999b, 2006). Moreover, as noted above, BA is a simple treatment to train therapists, it is very brief, and it is effective. We knew that integrating treatments could make the length of therapy longer, so our aim was to create an effective therapy that could be easily disseminated (i.e., easy to train novice therapists) but equally important was the need to keep it relatively brief. There were many possible ways to integrate the treatments including simple sequencing. The first sequence to consider was to deliver the depression treatment first, followed by the insomnia therapy second. This is based on a conventional belief that depression is the more serious of the two disorders and therefore should be treated first, and perhaps, also, is the fact that about half of those who recover from depression appreciate a recovery in their insomnia as well (Carney et al., 2007b). However, this sequence posed a problem in that the participants were presenting to our sleep programs complaining chiefly of their insomnia and were willing to forego depression treatment in order to participate in insomnia-focused treatment. The second sequencing option was to deliver the insomnia treatment first, followed by the depression treatment second. Those who presented for the insomnia and depression treatment were people who identified as having both depression and insomnia, but the chief complaint was most often insomnia. Perhaps of greater importance is that there is an empirical basis for treating insomnia first in that insomnia treatments have been shown to boost depression response (Manber et al., 2008) and even treating insomnia only can lead to depressive remission (e.g., Morawetz, 2001). However, just because clients may view their insomnia as the primary force in their depression does not mean that this will be true. Therefore a third option was to treat depression and insomnia concurrently. Treating insomnia and depression 136 Combining Depression and Insomnia Therapies

concurrently is relatively simple because the best evidence for a schedule of CBT-I is four biweekly sessions (e.g., Edinger, Wohlgemuth, Radtke, Coffman, & Carney, 2007). This allows for the BA treatment to start in weeks 1 and 2 while simultaneously collecting the two weeks of baseline sleep diaries, and then to start the behavioral insomnia treatment in week 3. In such a leap frog type model, depression-focused treatment could resume while clients were testing out their insomnia strategies, and then the insomnia strategies could receive troubleshooting attention subsequently on a biweekly schedule. In combining the two therapies one could also consider the mechanisms of the two treatments and integrate them more fully to potentiate the two therapies. For example, as stated, activation helps with fatigue but it also could increase adherence to the prescribed rise time and restriction of napping strategies. A decreased time-bed in the 24 hour period allows for greater opportunities for activation. Decreased time-in-bed also reduces using the bed as an avoidance strategy. Both BA and BIT have repetitive thought strategies to decrease rumination. Thus, we sequenced the treatment based on what we viewed as key effective components of the therapies that when integrated would produce the most synergistic effect. We began with a manual modeled closely on Lejuez and Hopko’s BA treatment (Lejuez et al., 2001), however, in discussing mood and mood-related goals, we integrated discussion of sleep and sleep goals as well. We presented them as having a strong influence on one another and emphasized that strategies that targeted mood often have a pro-sleep and pro-energy effect, and pro-sleep strategies often have a positive mood or antidepressant effect. We formally inserted the insomnia components from (Edinger & Carney, 2008) at session 4, 6, 8, and 10, but often, because of the potentiating effect of the mood components (e.g., scheduling activities) two sessions were enough with check-ins on sleep at the agenda-setting portion of the sessions. We also integrated components of Martell’s (Martell et al., 2013) BA treatment because avoidance and rumination were prominent features of those who we were seeing, and we needed a structured tool for the student therapists to address these target problems. This decision was made after two focus groups with the study therapists. The first author (CEC) attended a workshop on BA with Dr. Martell and proposed the integration of an avoidance model along with the TRAP or TRAC worksheet (see later) and how to use rumination as a cue for activation during the day or stimulus control at night. At the same group of meetings, we determined that adding 2 sessions to the 12 session treatment was permissible if it was not possible to get through all of the material in 12 sessions. At the time of this writing, the session mode and median was 13 and the mean number of sessions was 12.4 (SD = 1.4). The lowest number of sessions in completers was 9 and the highest number of session was 14. To determine if an additional session is needed, we discuss this with participants at session 12 and have them generate pros and cons of adding additional sessions, and also collaborate on an agenda for how the additional sessions are to be used. Even at 13 sessions, this is a very brief therapy. BABIT sessions are conceptualized as occurring across 3 distinct modules of treat - ment. In Table 9.1, we provide a description of the typical therapy activities across the three modules. Although the rows match up with the number of sessions, this is meant as a guide only because therapists are encouraged to work with the clients’ goals flexibly to drive the focus of the session content. For example, if the Life Area Assessment reveals relationship goals primarily, then this will drive the focus of that Combining Depression and Insomnia Therapies 137

138 Combining Depression and Insomnia Therapies domain of the treatment. Some clients may receive only one CBT-I session (with a SRT and CS focus) and need only one brief check in about the sleep schedule. In such cases, sleep is quickly resolved and we focus on the other aspects of the case that require attention, for example, the case formulation may be driven by avoidance and rumina - tion. Other cases require extensive focus on scheduling activities to address sleep and fatigue. That is, for some, the focus may be decreasing time-in-bed and increasing activity, while increasing goal-directed and pleasurable activities and exposure to light during high fatigue periods during the day. Thus, the modules provide an outline of focus and typical therapy activities but therapists are trained to identify the key perpetuating factors for the case and adjust focus accordingly. In addition, the case form - ulation is shared with the client in the first module and we solicit feedback from the Table 9.1 Description of module content in BABIT Module BABIT session activities 1 Introduction to BT; monitor activities Behavior-mood-sleep-energy link; Anti-depressant versus Pro-depression behaviors Life area assessment; setting goals; start sleep diary monitoring 2 Refine and set goals; continue sleep diary Working on sleep-specific goals; Pro-sleep versus Pro-Insomnia behaviors; SRT and SC Prescription; Scheduling activities to help with rise time and scheduling a winddown period before bed Goal setting; scheduling activities with a focus on how these may facilitate sleep goals (e.g., scheduling evening activities to address evening dozing); avoidance psychoeducation Introduce TRAP or TRAC Adjust TIB if needed and troubleshoot adherence to sleep and activity schedule; add other CBT-I components if needed; use TRAP or TRAC to target fatigue avoidance and add alternative pro-energy coping TRAP or TRAC; scheduling activities; psychoeducation on rumination Adjust TIB if needed; continue with TRAP or TRAC, goal setting Use rumination as a cue for SC at night and activation during day Continue with TRAP or TRAC, goal setting, rumination strategies Adjust TIB if needed; continue with TRAP or TRAC, goal setting, rumination strategies 3 Planning for termination; continue working on goals, ensure client can calculate sleep diary variables and make time-in-bed prescription adjustments independently Assign Relapse Prevention Letter to Self; discuss what are likely to be future goals post-termination using the Life Area Assessment Termination and relapse prevention

client on whether it matches with their experience. Once there exists some agree ment on the maintaining factors of the case, this allows the client and therapist to collab orate on mutually agreed upon goals for treatment. The sharing of the case formulation and devising initial goals for treatment occurs in module 1—a module focused on orienting to treatment, a life area assessment, establishing a model of depression and insomnia, and beginning activity monitoring and then sleep monitoring. Once module 1 is com - plete, most often after 2–4 sessions, we proceed to behavior change in the second module of the treatment. Module 1: Introduction, Setting Goals, and Uncovering Behavior-MoodSleep-Energy Link The premise for BABIT is that there are behaviors that perpetuate depressed mood, as well as behaviors that facilitate neutral or positive mood. We expand this idea to include the notion that there are behaviors that perpetuate insomnia and fatigue, and those that lead to quality sleep, and energy, respectively. The rationale for BABIT provided at session 1 is based on Hopko and Lejuez’s ideas about identifying perpetuating factors for depression and behaviors that are antithetical to depressed mood, as well as Spielman’s (1987) ideas about perpetuating factors in insomnia. In BABIT, these ideas are broadened to include insomnia, and fatigue. As noted above, the two BA approaches by Lejuez and colleagues (2001) and Jacobson and colleagues (2001) have different foci but the skills in each package are largely complementary. As a result, the two approaches are easily integrated into BABIT wherein values are assessed and treatment goals are derived across domains. In the same assessment, avoidance patterns and behaviors are identified that are associated with negative mood, poor sleep and low energy. Avoidance behaviors are also identified in the activity monitoring that begins in week 1, and throughout treatment, including when there are instances of non-adherence with homework. Once these targets are identified, treatment focuses on increased activation, goal pursuit and replacement of avoidance behaviors with mood-, sleep- and energycongruent behaviors. Mood and energy targets impact sleep positively because of the greater regularity of activities, which can positively impact the biological clock and increased activity can generate greater sleep drive. Additionally, there is greater activity to combat fatigue and the negative arousal associated with negative mood; thus fatigue and rumination are attenuated. All sessions begin with a presentation of the agenda for that session and an invitation for the client to add to the agenda. All sessions also include an assessment of mood, suicidal ideation, and sleep for the week; we compare this with separate sleep and mood measures (in our clinic, this is the BDI-II and ISI) and take note of elevations on suicide items and follow-up with a risk assessment as needed. Following this, as therapy begins, but before explaining the rationale to the client, we provide a sheet with two visual analog scales (based on Lejuez et al., 2001) one for depression and one for insomnia (see Figure 9.1a and b). We explain that depression encompasses a range of symptoms that can include insomnia and fatigue and they vary day to day and from person to person. We further explain that at one point or another when these symptoms are of a particular severity and occur chronically for most of the day for a minimum of 2 weeks, we arbitrarily call this Major Depressive Disorder and Combining Depression and Insomnia Therapies 139