Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach 2nd

38 The influence of the internal circadian clock on the sleep/wake cycle is apparent if one studies the relationship between the body’s 24-hour temperature rhythm and the timing of the sleep period. Suppose a person is placed in a place like a cave, away from daylight, external clocks, and all other time of day indicators. In this situation, the person will continue to show a consistent temperature rhythm and sleep/wake pattern that complete a full cycle about every 24 hours. In most people, there is a close relationship between the temperature cycle and the sleep/wake pattern they show. This relationship is shown in the Circadian Temperature Rhythm Graph included in your workbook. [Direct patient to the graph in the workbook or show him the copy provided in Figure 3.1.] As shown by this graph, the main sleep period begins when body temperature is falling and later ends after the body temperature begins rising again. Hence, although the 24-hour temperature cycle shown does not control the human sleep/wake pattern, the temperature rhythm reflects the working of the body clock and can be used to predict when sleep is likely to occur in the 24-hour day. In the real world, exposure to daylight, work schedules, mealtimes, and other activities work together with our body clocks to help us keep a stable sleep/wake pattern. However, significant changes in our sleep/wake schedule can interfere with our ability to sleep normally. This may be caused by what is often called “ jet lag.” If, for example, a man who lives in New York flies to Los Angeles, he initially is likely to have some difficulty with his sleep and to experience some daytime fatigue once he arrives in California. This occurs because the 3-hour time-zone change places his new desired sleep/wake schedule at odds with his “body clock” that is “stuck” in his old time zone. This situation is shown in the second graph included in your workbook. [Direct patient to the graph in the workbook or show him the copy provided in Figure 3.2.] The man’s body clock remains on New York time and initially lags behind the real world clock time in California. This traveler is likely to become sleepy 3 hours earlier than he wishes and to wake up 3 hours before he prefers on the initial days of his trip. Fortunately, with repeated exposure to the light-dark pattern in the new time zone, the body clock resets and allows the traveler to

12:00 AM 6:00 AM 12:00 PM 6:00 PM 12:00 AM 6:00 AM 12:00 PM 6:00 PM 12:00 AM 6:00 AM 12:00 PM 6:00 PM 12:00 AM Circadian Temperature Rhythm Biological Wake Time Biological Bedtime Circadian Temperature Variation Sleep Sleep Figure 3.1 Circadian Temperature Rhythm.

12:00 AM 6:00 AM 12:00 PM 6:00 PM 12:00 AM 6:00 AM 12:00 PM 6:00 PM 12:00 AM 6:00 AM 12:00 PM 6:00 PM 12:00 AM Desired Bedtime Circadian Temperature Rhythm Desired Sleep/Wake Schedule Circadian Variation Biological Bedtime Figure 3.2 Effects of Jet Lag.

41 “get in sync” with the new time zone. However, this traveler is again likely to experience temporary problems with his sleep and daytime fatigue when he first returns to New York. In addition to our body clock, getting older usually leads to changes in our sleep. As we age, we tend to spend more time awake in bed and less time in the deepest parts of sleep. Because sleep becomes more “shallow” and broken as we age, we may notice a decrease in the quality of our sleep as we grow older. Although these changes set the stage for the development of sleep problems, they do not guarantee such problems. However, because of these changes, it is probably unrealistic to expect that you will again have the type of sleep you enjoyed at a much younger age than you are now. Finally, before attempting to change your sleep habits, it is important that you understand the effects of sleep loss on you. This understanding is important because many who have sleep problems make these problems worse by what they do to make up for lost sleep. For example, people may take daytime naps, go to bed too early or “sleep in” following a poor night’s sleep in order to avoid or recover lost sleep. Although these habits seem logical and sensible, they all may serve to continue the sleep problems. In fact, these habits are usually the opposite of what needs to be done to improve sleep. How we sleep at night is in part dependent on the amount of sleep drive or “debt” we have acquired throughout our waking day. In general, the longer the period of wakefulness between our last episode of sleep and our current attempt to sleep, the higher our sleep drive becomes and the more likely it is that we will fall asleep easily and sleep soundly for an extended period of time. For example, a person is much more likely to sleep for a long time after being awake for 16 hours in a row than after being awake for only 2 hours. Because of this fact, losing sleep one night may lead to getting more or better sleep the following night, assuming that no napping occurs during the daytime before retiring at the usual bedtime the subsequent evening. It is important to remain awake through each day in order to build up enough sleep drive to produce a full night’s sleep. Extended periods of sleep loss, of course, may have some bad effects as well. If people are totally deprived of a night’s sleep, they usually

42 become very sleepy, have some trouble concentrating, and generally feel somewhat irritable. However, they typically can continue most self-paced daytime activities even after a night without any sleep at all. When allowed to sleep after a longer than normal period of being awake, most people will tend to sleep longer and more deeply than they typically do on a normal night. Although people tend not to recover all of the sleep time they lost, they do typically recover much of the deep sleep they lost during longer than usual periods without sleep. Hence, your body’s sleep system has some ability to make up for times when you don’t get the amount of sleep you need. Since you have kept a sleep diary for a couple of weeks, you have probably noticed that you occasionally had a relatively good night’s sleep after one or several nights of poor sleep. Such a pattern suggests that your body’s sleep system has an ability to make up for some of the sleep loss you experience over time. Although your sleep is not normal, you can take some comfort in this observation. The important point to remember is that you do not need to worry a great deal about lost sleep, nor should you actively try to recover lost sleep. Needless worry and attempts to recover lost sleep will only worsen your sleep problem. This information is not intended to “make light” of your sleep problem. You do indeed have a sleep problem that needs to be treated. This discussion is intended to help you to understand your problem. With this knowledge you should now understand the purpose for the treatment recommendations I’m making. Do you have any questions about what you have just heard? Behavioral Treatment Regimen The behavioral treatment regimen uses stimulus control and sleep restriction strategies to standardize the patient’s sleep/wake schedule, eliminate sleep incompatible behaviors that occur in the bed and bedroom, and restrict time in bed (TIB) in an effort to force the development of an efficient, consolidated sleep pattern. The majority of behavioral recommendations included in this regimen are standard for all patients. However, the TIB prescriptions provided are based on a pre-treatment estimate (derived from sleep diaries) of each patient’s

43 sleep requirement. Since TIB prescriptions may vary from patient to patient, these prescriptions allow for the tailoring of this regimen to fit each patient’s specific sleep needs. Refer the patient to the Sleep Improvement Guidelines sheet in the workbook and provide a brief justification for each behavioral recommendation included in the regimen. This worksheet provides a list of “recommendations” to follow and also includes spaces for noting the patient’s standard wake-up time and suggested earliest bedtime. You may use the following sample dialogues as you review each sleep rule with the patient: Guideline # 1: Select a Standard Wake-Up Time Emphasize the importance of choosing a standard wake-up time and sticking to it every day, regardless of how much sleep the patient actually gets on any given night. This practice will help the patient develop a more stable sleep pattern. As discussed earlier in the session, changes in your sleep/wake schedule can disturb your sleep. In fact, you can create the type of sleep problem that occurs in jet lag by varying your wake-up time from day to day. To maintain a reliable and predictable sleep pattern, it important that your body clock becomes trained into one specific sleep/wake schedule. By sticking to a standard wake-up and rising time, you will accomplish this task and establish a more consistent and satisfying sleep pattern. By adhering to this recommendation you should soon notice that you usually will become sleepy at about the right time each evening to allow you to get the sleep you need. Guideline # 2: Use the Bed Only for Sleeping Explain to the patient why it is critical that the bed only be used for sleeping and sexual activity. While in bed, you should avoid doing things that you do when you are awake. Do not read, watch TV, eat, study, use the phone, work on your computer, engage in social media with a smartphone or other

44 electronic device, or do other things that require you to be awake while you are in bed. If you frequently use your bed for activities other than sleep, you are unintentionally training yourself to stay awake in bed. If you avoid these activities while in bed, your bed will eventually become a place where it is easy to go to sleep and stay asleep. Sexual activity is the only exception to this recommendation. However, if you are someone who often feels more alert after sex or you cannot predict if you will feel alert or relaxed afterward, you may want to consider moving sexual activity to earlier in the evening and/or consider places other than the bed in which you sleep. If this is of concern to you, talk to your partner and find an arrangement that works well for both of you. Guideline # 3: Get up When You Can’t Sleep Many people linger in bed for minutes, or even hours, when they can’t fall asleep. Lying in bed awake and trying harder and harder to go to sleep only increases anxiety and frustration, which usually delay the onset or return of sleep. Never stay in bed, either at the beginning of the night or during the middle of the night, for extended periods without being asleep. Long periods of being awake in bed usually lead to tossing and turning, becoming frustrated, or worrying about not sleeping. These reactions, in turn, make it more difficult to fall asleep. Also, if you lie in bed awake for long periods, you are training yourself to be awake in bed. Remember that we are all passive recipients of sleep. There is nothing one can do to bring on sleep, in the moment on demand. Therefore lying in bed for extended periods hoping for sleep or engaging in activities to bring sleep on simply don’t work. When sleep does not come on or return quickly, it is best to get up, go to another room, and only return to bed when you feel sleepy enough to fall asleep quickly. Generally speaking, you should get up if you find yourself awake for 20 minutes or so and you do not feel as though you are about to go to sleep.

45 Guideline # 4: Don’t Worry or Plan in Bed Bedtime is not the time to attempt problem-solving, or to engage in thinking or worrying. Engaging in these sorts of activities only serves to keep the mind awake, making it extremely difficult to fall asleep. Do not worry, mull over your problems, plan future events, or do other thinking while in bed. These activities are bad mental habits. If your mind seems to be racing or you can’t seem to shut off your thoughts, get up and go to another room until you can return to bed without this thinking interrupting your sleep. If this disruptive thinking occurs frequently, you may find it helpful to routinely set aside a time early each evening to do the thinking, problem-solving, and planning you need to do. If you start this practice you probably will have fewer intrusive thoughts while you are in bed. Guideline # 5: Avoid Daytime Napping Strongly recommend to the patient that he or she refrain from taking daytime naps. If the patient absolutely must take a daytime nap, instruct him or her to keep it to less than an hour and to complete it before 3 P.M. However, the patient should do all that he or she can to avoid or limit taking naps, even if strongly tempted to do so. You should avoid all daytime napping. Sleeping during the day partially satisfies your sleep needs and thus will weaken your sleep drive at night. Let’s suppose for the moment that you require 7 hours of sleep per night to function at your best in the daytime. If on a particular occasion you decide to take a 2-hour daytime nap, in doing so you would be “spending” 2 hours of your 7-hour sleep requirement and therefore have only 5 hours left to “spend” the subsequent night. Hence, refraining from daytime napping allows you to build your sleep drive through the day so you can spend your entire daily compliment of sleep through the night.

46 Guideline # 6: Go to Bed When You Are Sleepy, but Not Too Early Advise the patient to attempt sleep only when he or she is feeling sleepy. In general, you should go to bed when you feel sleepy. However, you should not go to bed so early that you find yourself spending far more time in bed each night than you need for sleep. Spending too much time in bed results in a very broken night’s sleep. If you spend too much time in bed, you may actually make your sleep problem worse. I will help you to decide the amount of time to spend in bed and what times you should go to bed at night and get out of bed in the morning. Determining Time-in-Bed Prescriptions As briefly discussed inChapter 2, youwill usethe patient’s pre-treatment sleep diaries to determine how much time he or she should stay in bed. First, calculate the average total sleep time (ATST) displayed by the patient as shown on his or her completed sleep diaries. Once this value is calculated, we recommend that the patient’s time-in-bed prescription be derived using the following formula: Time in Bed (TIB) = Average Total Sleep Time ( ) ATST + 30 minutes Traditional applications of this treatment protocol advocate the use of ATST as the amount of time the patient should initially allot in bed for sleep. However, ATST as a TIB prescription does not allow for normal sleep onset time and normal middle of the night awakenings that occur spontaneously or to use the restroom. Moreover, insomnia sufferers, as a group, tend to underestimate their sleep times. Hence, use of ATST as the TIB prescription may result in an actual reduction of the patient’s usual sleep time. In our experience, use of the prescription, ATST + 30 minutes, which accounts for the time it takes to fall asleep as well as a few normal, brief nocturnal arousals, is a more reasonable starting point for most of the patients we encounter. To illustrate how a TIB prescription is determined, consider the sleep diary data shown in Figure 3.3. This diary presents 6 days of data as well

Today’s Date 4/5/08 3/5 3/6 3/7 3/8 3/9 3/10 Averages 1a. How many times did you nap or doze? 2 times None None None None None None 1b. In total, how long did you nap or doze? 1 hour 10 min. 2. What time did you get into bed? 10:15 p.m. 11:00 PM 11:30 PM 11:15 PM 10:30 PM 11:15 PM 10:30 PM 3. What time did you try to go to sleep? 11:30 p.m. 11:30 PM 11:30 PM 11:15 PM 11:00 PM 11:15 PM 10:50 PM 4. How long did it take you to fall asleep? 55 min. 20 min 35 min 75 min 45 min 15 min 20 min 5. How many times did you wake up, not counting your final awakening? 6 times 2 1 3 2 1 2 6. In total, how long did these awakenings last? 2 hours 5 min. 25 min 15 min 10 min 10 min 25 min 30 min 60 min 40 min 90 min 30 min 45 min 7. What time was your final awakening? 6:35 a.m. 6:30 AM 7:00 AM 7:15 AM 7:30 AM 7:00 AM 7:15 AM 8. What time did you get out of bed for the day? 7:20 a.m. 7:00 AM 7:30 AM 7:30 AM 7:45 AM 7:15 AM 7:30 AM Time in Bed 480 min 480 min 495 min 555 min 480 min 540 min 505 min Total sleep time 360 min 405 min 355 min 365 min 360 min 410 min 375.8 min Figure 3.3 Sleep Diary Time in Bed Calculation.

48 as calculations of the average total sleep time (ATST) and average time in bed across this 6-day period. Note in this example, the patient slept 375 minutes per night, on average, but had an average time in bed of 505 minutes (i.e. almost 8.5 hours) per night. The ATST falls between 6 and 6.5 hours and, as such, does not seem at all abnormal. However, there is a marked discrepancy between the average time slept and the average time in bed. Given the data shown, the TIB prescription derived using the above formula would be 405 minutes or 6.75 hours. Hence, that TIB prescription would be used as the initial time allotment for the nocturnal sleep period. Of course, patient preferences should be considered when establishing the initial TIB allotment, and it is perfectly acceptable to round the TIB prescription identified in this example to either 6.5 hours or 7 hours if this helps with the patient’s sleep scheduling and initial acceptance of the protocol. It should be noted that in practice it is preferable to derive the initial TIB prescription from sleep diary data collected for 2 or more weeks so that a more stable estimate of ATST can be made. Once the initial TIB prescription is determined, it is important to help the patient choose a standard wake-up time and earliest bedtime so that the prescription can be followed. In doing so, it is important to have the patient consider both “ends” of the night. A patient may initially decide that 7:00 A.M. is a desirable wake-up time. That choice may seem reasonable to the patient with the TIB prescription derived in the preceding example. However, if the initial TIB prescription is much shorter, say 6 hours, this wake-up time would result in an earliest bedtime of 1:00 A.M. Upon discovering this fact, the patient may wish to select an earlier wake-up time so that bedtime can be earlier during the night. Whatever bedtimes and wake-up times are chosen, it is important to involve the patient in this decision-making process. Adherence to the TIB prescription will usually be best when the patient takes an active role in selecting his or her own bedtimes and wake-up times. Managing Patients’ Expectations and Treatment Adherence Once the treatment regimen has been explained and an agreed-upon sleep schedule has been established, it is helpful to provide the patient some additional information about the likely course of treatment and the importance of treatment adherence. Most treatment-seeking

49 insomnia patients are notably distressed by their sleep/wake disturbances and desire rapid relief from such symptoms. However, as is the case with most psychological and behavioral interventions, the current treatment produces improvements gradually and requires consistent treatment adherence on the patient’s part to achieve optimal results. In our experience, most patients who show consistent adherence to the behavioral regimen described earlier show marked reductions in their wake time during the night within the first 2 to 3 weeks of treatment implementation. Improvements (increases) in average sleep time at night are less dramatic and occur much more gradually during treatment. However, many patients continue to appreciate some sleep time improvements even after formal treatment (therapist contact) ends. Of course, patients who do not adhere well to the treatment recommendations may improve more slowly or not at all. Thus, encouraging consistent treatment adherence is highly important to the treatment process and outcome overall. You may wish to use the following sort of dialogue to emphasize these points to the patient: Now that we have discussed what you are to do to improve your sleep, you should understand that it is important to follow all of the recommendations we have discussed consistently each and every day of the week. If you are able to do that, you likely will start to see some improvements in your sleep within the next 2 to 3 weeks. What you are likely to notice first is that the time you take to get to sleep and the amount of time you spend awake during the night will decrease significantly. Although you may not see large changes in the amount of time you sleep each night during this time period, your sleep should start to become more solid and restorative. However, if you do not follow the recommendations we have discussed consistently, your progress will likely be much slower or you may not see any significant changes in your sleep. Thus, it is important that you follow the treatment recommendations we discussed consistently so that you obtain the types of results you are seeking. As you begin this treatment at home, it is also important for you to understand that the sleep schedule we agreed upon for you today may leave you feeling a little sleepy in the daytime, particularly during the first week as you get adjusted to this new schedule. If you notice an

50 increase in sleepiness, avoid activities wherein your sleepiness might be dangerous to you, such as driving long distances or operating hazardous machinery. If you continue to feel sleepy in the daytime beyond the first week, that usually means we have limited your time in bed at night too much and you would benefit by increasing this time somewhat. If this is the case, when you return for your next session we will review your sleep diaries and make the needed adjustments in your nightly sleep schedule to address this problem. If needed, we can consult by phone prior to your next visit to determine what adjustments may be required. Moreover, we can continue to make such adjustments from session to session until we arrive at the schedule that works best for you. It is important that you follow the treatment recommendations consistently from week to week and chart your progress on the sleep diaries in your workbook. This will allow us to assess your progress and determine what, if any, changes in your schedule might be needed. Managing Patients Unable to Attend Routine Follow-Up Sessions It is desirable to provide patients with one or more return visits to encourage and reinforce treatment adherence, resolve difficulties they are having with treatment enactment, and assist them in making TIB adjustments. However, we encounter some patients who live a great distance from our clinic or for other reasons are not able to return for follow-up sessions. Both our clinicalexperiences and our recent research findings (Edinger, Wohlgemuth, et al. 2007) suggest that some patients are able to achieve significant sleep improvements over time following only one session wherein the information covered in this chapter is presented. However, in such cases, it is useful to give the patient instructions that will enable him or her to make needed TIB alterations to establish an optimal sleep/wake pattern. For such individuals, you may use the following sample dialogue: You should try this sleep/wake schedule for at least 2 weeks and determine how well you sleep at night and how tired or alert you feel in the daytime. If you sleep well most nights and are as alert as you would like to be in the daytime, then you probably should

51 make no changes in your time in bed each night. If, however, you find you are sleeping well at night, but you feel tired most days, you should try increasing your time in bed at night by 15 minutes. If, for example, you begin with 7 hours in bed per night the first week and find that you are tired in the daytime despite sleeping soundly at night, you should try spending 7 hours and 15 minutes in bed each night during the second week. If, with this amount of time in bed, you continue to sleep soundly at night but still feel sleepy in the daytime, you can add another 15 minutes to the time in bed during the third week, and so on. However, when you notice an increase in the amount of time you are awake in bed each night, you will know that you are spending too much time in bed at night. If this occurs, you should decrease your time in bed by 15 minutes per night each week until you find the amount of time that enables you to sleep soundly through the night and feel reasonably alert in the daytime. You should also decrease your time in bed after the first 2 weeks if the initial amount of time in bed we choose together today does not reduce your time awake in bed each night. To help you make decisions about changing your time in bed, it may be helpful to consider some simple guidelines. If you routinely take more than 30 minutes to fall asleep or you are routinely awake for more than 30 minutes during the night, you probably should reduce the amount of time you spend in bed each night. You also should consider decreasing your time in bed if you find that you routinely awaken more than 30 minutes before you plan each morning. Of course, the key word here is “routinely.” Occasional nights during which you have a somewhat delayed start to your sleep or you have more wakefulness than usual once you get to sleep should not be viewed as reasons for changing your sleep schedule. Only when such occurrences are frequent or routine should you try a somewhat shorter time in bed. In the end, the best guideline to use is how you feel each day. If you are satisfied with how you generally feel in the daytime, you can assume that the sleep you are obtaining at night is sufficient.

52 Providing Basic Sleep Hygiene Education In addition to providing the Sleep Improvement Guidelines mentioned earlier, the patient should be given some standard sleep hygiene education and instructions so as to encourage lifestyle practices that promote sleep quality and daytime alertness. These recommendations are a common component of behavioral insomnia therapy, have good “face validity,” and are easily understood by the majority of patients. To facilitate the patient’s acceptance of and adherence to these recommendations, the following rationale should first be provided to the patient: The sorts of daytime activities in which you engage, the foods and beverages you consume, and the surroundings in which you sleep may all influence how well you sleep at night and how you feel in the daytime. Thus, in addition to making the specific changes to your sleep habits that we have discussed, you also may benefit from making some changes to your lifestyle and bedroom to promote a more normal sleep/wake pattern. Once this general rationale has been presented, the patient should be given the specific sleep hygiene recommendations described in the following instructions: Recommendation 1: Limit your use of caffeinated foods and beverages such as coffee, tea, soft drinks with added caffeine, or chocolates. Caffeine is a stimulant that may make it harder for you to sleep well at night. You should also know that caffeine stays in your system for several hours after you consume it. Therefore we recommend that you limit your caffeine to the equivalent of no more than 3 cups of coffee per day and that you not consume caffeine in the late afternoon or evening hours. Recommendation 2: Limit your use of alcohol. Alcoholic beverages may make you drowsy and fall asleep more easily. However, alcohol also usually causes sleep to be much more broken and far less refreshing than normal. Therefore, we recommend against using much alcohol in the evening or using alcohol as a sleep aid. Recommendation 3: Try some regular moderate exercise such as walking, swimming, or bike riding. Generally, such exercise performed in

53 the late afternoon or early evening leads to deeper sleep at night. Also improving your fitness level, no matter when you choose to exercise, will likely improve the quality of your sleep. However, avoid rigorous exercise right before bed because that activity may make it harder to get to sleep quickly. Recommendation 4: Try a light bedtime snack that includes such items as cheese, milk, or peanut butter. These foods contain chemicals that your body uses to produce sleep. As a result, this type of bedtime snack may actually bring on drowsiness. Recommendation 5: Make sure that your bedroom is quiet and dark. Noise and even dim light may interrupt or shorten your sleep. You can block out unwanted noise by wearing earplugs, running a fan, or using a so-called “white noise” machine that is specifically designed to screen sleep-disruptive noise. Also, if possible, eliminate the use of nightlights and consider using dark shades in your bedroom so that unwanted light does not awaken you too early in the morning. Recommendation 6: Make sure the temperature in your bedroom is comfortable. Generally speaking, temperatures much above 75 degrees Fahrenheit cause unwanted wake-ups from sleep. Thus, during hot weather, we suggest you use an air conditioner to control the temperature in your bedroom. Before closing the session and assigning homework, review the patient’s expectations for treatment and encourage consistent treatment adherence. Also ask the patient if he or she has any questions about today’s session. Homework The following summarizes the homework to be assigned to the patient at the close of this first treatment session. • Instruct patient to review sleep education material in the workbook (or listen to the audiotape recording if one was made), as well as the behavioral sleep improvement guidelines and sleep hygiene recommendations outlined.

54 • Instruct patient to continue recording his or her sleep habits using the sleep diaries provided in the workbook. • Review treatment expectations and encourage consistent treatment adherence. • For patients who cannot return for routine follow-up, review methods for adjusting TIB prescriptions if necessary, based on the information provided in today’s session.

55 (Corresponds to Chapter 4 of the Workbook) Materials Needed • Patient’s completed sleep diaries • Audiotape to record sleep education segment of session (optional) • Constructive Worry worksheet and instructions for completion • Thought Record Outline • Review and comment on sleep diary findings showing progress and treatment adherence • Provide cognitive rationale to patient • Discuss Constructive Worry technique • Discuss use of Thought Records • Design a behavioral experiment • Assign homework Treatment Rationale Specifically targeting cognitive change may be important for increasing adherence to the sleep habit changes discussed in the previous chapter, as well as eliminating sleep-interfering thoughts. As a result, Session 2 is devoted to addressing patients’ unhelpful beliefs about sleep and outlining strategies for controlling sleep-disruptive mental overactivity Session 2: Cognitive Therapy Components CHAPTER 4

56 and arousal in bed. You may use the following sample dialogue to begin the session: Today we will be focusing on the role of thoughts and beliefs about sleep in insomnia, but before we do, I’d like to check in on your experience with some of the recommendations from last session. Review the patient’s completed sleep diaries and check in on the patient’s adherence and response to each of the sleep habit changes recommended during the previous session. Ask about the patient’s experiences and difficulties encountered in enacting these changes. Be sure to praise all instances of adherence. In areas of nonadherence or inconsistent enactment, try to frame it positively: I can see that you had some trouble getting out of bed in the morning, but I also notice that you were able to do this on two of the mornings. That’s great. Let’s return to this issue at the end of this session and see if we can figure out a way to increase this to 7 days a week. Cognitive Rationale for the Patient Begin a discussion about the role of thoughts and beliefs in the maintenance of insomnia. You may use the following sample dialogue: Last week we focused on changing behaviors that had negative effects on sleep. Today, we will discuss the role of your thoughts in insomnia and give you strategies to help with any problems you may be having in this regard. Specifically, we will focus on how thoughts and beliefs can cause insomnia or at least make it worse. What role do thoughts play in insomnia? Some people don’t even consider that how we think and how we feel can have a huge impact on how we sleep. It turns out that what and how we think affects how we sleep, how we feel, and how we deal with periods of sleep loss. Much previous research as well as conversations with insomnia patients have led us to conclude that there is a particular way of thinking associated with insomnia. We call it the “Insomnia Brain” because most people tell us that this way of thinking is not typical of how they normally think, but since they have had insomnia, their type of thinking has changed and the way they view sleep has changed, too. The Insomnia Brain tends to be very “noisy” and very focused on the effects of not sleeping. Let’s take

57 a few minutes to examine the Insomnia Brain and we’ll offer some strategies for managing this unhelpful state of mind. Negative thoughts in the Insomnia Brain spread like wildfire. All the thoughts are negative, and they are usually related in some way. Positive thoughts don’t make it in. Most people with insomnia tell us, “I don’t understand it, I am not usually a worrier, but once I get into bed I think about the weirdest things and I have no control.” This is the Insomnia Brain—and it can seem unrelenting. Do you have difficulty shutting your mind off at night? The problem is that we cannot sleep when our brain is alert. Moreover, the more this happens in your bed on a nightly basis, the more likely it is to continue to happen. This is because it becomes an unintentional and unwanted mental habit. The good news is that all habits can be broken if you have the right strategy. Do you tend to get upset about not sleeping or worry about whether or not you will be able to manage during the day? Many people with insomnia will say, “I wasn’t worried at all today but as soon as my head hit the pillow, it was like a switch went off.” Does this ever happen to you? It means that your bed has become a signal for worry and upset. There are ways to change this signal. Remember your homework from last session? You were to leave the room when you were unable to sleep. One of the most effective strategies for quieting an active mind is to leave the bedroom when your mind starts to take over. This will break the habit. It may take several attempts at first but your brain will eventually get the picture that your bed is not the place for it to be active. This practice may have other benefits, too. Taking the Insomnia Brain out of bed results in becoming more clear-headed and being better able to switch off your troublesome thinking. Most people tell us that the worry they could not switch off in the bedroom became a non-worry in the living room. So, do yourself a favor and get out of the domain of the Insomnia Brain temporarily. You can return to the bed when you are no longer worrying or problem-solving. Some people are concerned that getting out of bed will limit their opportunity for sleep, but the chance of you sleeping while your brain is active in bed is very low. Getting this type of mental activity under control by spending a few minutes out of bed will increase your chances of being able to sleep.

58 Assess if the patient has any questions and whether any of this discussion seems to be personally applicable. Reinforce the patient’s identification with the problem. For example, if the patient says, “I definitely worry in bed about every little thing.” Be sure to say, “Ok, then it’s going to be important for us to focus on this and for you to complete some additional homework over the next 2 weeks.” Constructive Worry Many people with insomnia complain of “unfinished business” following them into the bedroom and creating arousal/distress in bed. Indeed, problem-solving in the pre-sleep period has been implicated as one of the strongest predictors of difficultiesfalling asleep (WicklowandEspie 2000). Espie and Lindsay (1987) were among the first to report positive results for an early evening procedure that targeted pre-sleep worry. Similarly, Carney and Waters (2006) demonstrated that a single night of using an early evening procedure called Constructive Worry results in decreased pre-sleep arousal. As a result, providing a tool to manage nocturnal worry is often helpful. If nighttime worry is a significant issue, it is important to pair this procedure with stimulus control (i.e., the instruction to leave the bedroom when problem-solving or worrying) and other stress management techniques such as relaxation and/or time management techniques. Introduce the exercise with a rationale like the following: While most people find that getting out of the bed is enough to address their nighttime worry problem, some continue to worry. Some bedtime worries are a result of keeping so busy during the day that no time is available to deal with the worries. Sleep is the first opportunity that is quiet enough for your brain to try to complete its unfinished business. Could this be you? The Constructive Worry worksheet is taken from Carney and Waters (2006), and copies for the patient’s use are provided in the workbook. A sample completed worksheet is shown in Figure 4.1. The following instructions also appear in the workbook and should be used as a guide when completing the worksheet with the patient in session. 1. Write down the problems facing you that have the greatest chances of keeping you awake at bedtime, and list them in the “Concerns” column.

59 2. Then, for each problem you list, think of the next step you might take to help fix it. Write it down in the “Solutions” column. This need not be the final solution to the problem, since most problems have to be solved by taking a series of steps anyway, and you will be doing this problem-solving task again tomorrow and the day after until you finally get to the best solution. • If you know how to fix the problem completely, then write that down. • If you decide that this is not really a big problem, and you will just deal with it when the time comes, then write that down. • If you decide that you simply do not know what to do about it, and need to ask someone to help you, write that down. • If you decide that it is a problem, but there seems to be no good solution at all, and that you will just have to live with it, write that down, with a note to yourself that maybe sometime soon you or someone you know will give you a clue that will lead you to a solution. CONCERNS SOLUTIONS 1. The air conditioning isn’t working in the car 2. Money! 1. Could ask my wife if she has time to take it in 2. Could call tomorrow for a Saturday appointment 1. Will make an appointment with our financial planner tomorrow 2. Will agree to that project for extra income 3. Will cut out my latte over the next month 4. I will wait until my credit card is due to pay it Figure 4.1 Constructive Worry Worksheet Sample.

60 3. Repeat this for any other concerns you may have 4. Fold the Constructive Worry Worksheet in half and place it on the nightstand next to your bed and forget about it until bedtime. 5. At bedtime, if you begin to worry, actually tell yourself that you have dealt with your problems already in the best way you know how, and when you were at your problem-solving best. Remind yourself that you will be working on them again tomorrow and that nothing you can do while you are so tired can help you any more than what you have already done; more effort will only make matters worse. Review the Constructive Worry worksheet with the patient and ask him or her to try to fill it out at a convenient and consistent time each day. An early evening time is often the best time, although other times may work as well if the evening time is not convenient. However, performing this exercise right before bed is ill-advised, as it may result in some unwanted spill-over into the sleep period. If the patient has difficulty thinking of any worries on a particular day, instruct the patient to write down “No Concerns.” Also, be sure to ask the patient if he or she foresees any barriers to completing this exercise. Finally, engage in problem-solving with the patient to reduce such barriers to adherence. Thought Records Cognitive restructuring is most often associated with the seminal text Cognitive Therapy of Depression by Aaron Beck and colleagues (1979). Beck et al. wrote about fears of becoming ill as a result of insomnia and the discrepancy between objective and subjective sleep time estimation in people with major depression. These observations are common features of people with insomnia, irrespective of whether they have major depressive disorder. Beck’s early writings were applied to insomnia by Morin (1993), who developed a cognitive therapy tailored specifically for insomnia. Morin suggested the use of the Thought Record to restructure some unhelpful or inflexible thoughts and beliefs about insomnia (1993). In line with these works, we have found the following instructions to be useful: In addition to nighttime worry, sometimes we have thoughts or beliefs about sleep that can actually make sleep worse. Most beliefs about

61 sleep boil down to a fear about whether we will be able to cope with the insomnia. It is common for people with insomnia to worry about whether they will lose control over their abilities to sleep, whether they will become sick as a result of the insomnia, and even whether they may “go crazy” if their insomnia persists. These worries can be very frightening, so it is often helpful to take a more critical look at the types of beliefs that lead to such distress. The Thought Record is a very simple tool, yet we find that it is a very powerful instrument. It’s powerful because it curbs the Insomnia Brain’s tendency to be negative and consider only the worst-case scenarios of sleep loss. Balanced thoughts also challenge those beliefs that generate anxiety. Finally, we find that this tool helps people see that they are not powerless; their efforts toward changing their sleep habits produce improvements in their sleep and in their daytime fatigue and mood. It is important to complete a Thought Record in session so that the patient understands it well enough to complete it between sessions. If the patient has trouble completing the Thought Record outside the session, he or she can refer to the sample completed copy in the workbook. You may use the following sample dialogue to help the patient complete a blank Thought Record during the session. Blank copies of the record for the patient’s use are included in the workbook. Let’s walk through an example of a Thought Record to help with troubling thoughts or beliefs about sleep. Think of a time, perhaps even last night when you had strong feelings or upsetting thoughts related to your insomnia. What were you doing or where were you when you had these feelings or thoughts? Write them down in the Situations column. What kind of mood or feelings were you experiencing? Write down feelings in the Mood column. What are you thinking or what were you thinking when you began to feel this way? Are you concerned about how you will deal with another day with this insomnia? Are you predicting that you’ll never sleep? Write these down in the Thoughts column; even if some of your thoughts seem to be untrue or silly, it is important to write them down. There are no wrong thoughts to write down. The next step is to look at why this thought may seem true. What’s the evidence for this thought? Write this down in the Evidence for the Thought column. Most people can remember a time when they

62 had difficulty dealing with their insomnia. The Insomnia Brain remembers this as “evidence” that you can’t deal with insomnia. But this is probably not the whole story. It is important to look more critically at these beliefs, and one way to do this is to think about whether this thought is true 100% of the time. For example, we may focus on the one instance in which we performed poorly at work and discount the thousands of times we have performed fine even though it was difficult. Or we overlook that there are small things that don’t support the thought. For example, we may forget that there have been times when we have felt good after a poor night’s sleep; or when we felt poorly after a good night’s sleep; or we jump to conclusions or focus on the worst possible outcome. Write all this evidence down in the Evidence Against the Thought column. Examining the evidence against the belief forces the Insomnia Brain to focus on thoughts that are less anxiety-provoking or less frustrating. The last step in this process is to consider both the evidence for and against the belief and to think of a thought that lies somewhere in the middle. This thought should consider that there may be some part of the evidence for the belief that may be true, but it should take into consideration that there is plenty of evidence against the belief. For example a balanced, alternative to the thought, “I’m never going to make it through tomorrow” is: “I sometimes feel groggy at work after a poor night, but not always, and I always seem to cope pretty well with it.” Write this new thought down in the Adaptive/ Coping Thought column. Most people tend to feel a little better after completing this exercise. Try it over the next week or two until our next visit and we’ll review it then. In reviewing the Thought Record with the patient, it is important to indicate that the patient’s thoughts and feelings are valid. It is also important to acknowledge that you know it may seem difficult to the patient to change his or her thoughts given how automatic they are. Ask the patient to explore whether there may be costs to having such strong conviction in these thoughts and whether these thoughts may be adding to the problem (i.e., emotional reasoning). This may be done by highlighting what Greenberger and Padesky (1995) call the thought-mood connection. For example, if the patient is having the thought, “I’m never going to get to sleep,” ask him how he feels when

63 he thinks he is never going to get to sleep. Hopeful or hopeless? Is it setting up a self-fulfilling prophesy? It is also important to recognize that patients may present many types of “cognitive errors” (Beck 1995) during both the in-session exercise and when using the Thought Record at home. It is very important to review such “errors” when patients present them, although it is not helpful to label them as “errors.” It is more helpful to explore them without labeling, and instead talk about particular “thinking styles” or “thought patterns” that occur when people’s moods are disturbed. The following are the most common unhelpful “thinking styles” or “thought patterns” we encounter in our insomnia patients when using Thought Records with them. Misattribution:  people with insomnia tend to attribute any cognitive troubles or negative mood to poor sleep, and they discount several other factors. For example, it is normal to experience some grogginess for the first 30–60 minutes upon awakening. It is called sleep inertia. Many people with insomnia who experience this upon awakening believe that this is evidence that they had a poor night’s sleep and predict that they consequently will have a bad day. Similarly, it is normal to experience an increase in sleepiness and a decline in mental and emotional functioning in the early afternoon. This is a normal phenomenon called the “post-lunch dip.” It corresponds to a “dip” in one’s body temperature after lunch. This is often the time when people with insomnia nap, cancel appointments, or leave work. They believe that this dip is evidence that they cannot function. Providing education on this phenomenon and focusing on coping strategies to ride out sleep inertia or the circadian dip (i.e., exposure to fresh air, activity, coping statements such as “this is just temporary”) will be helpful for patients. Emotional reasoning: Some patients focus on their feelings as facts. For example, they believe that the presence of anxious feelings is evidence that they will not sleep. Such a belief will lead to further anxiety when sleep does not come quickly. All-or-none thinking:  “I didn’t sleep last night.” Explore with your patient the cost of thinking “I don’t sleep.” Is it increased anxiety? It is often helpful to train patients to “find the missing sleep” in their sleep diaries and to “catch themselves asleep.” Did they miss parts of the plot of the television program they were watching? When patients report that they have been awake “all night long,” ask what they were doing.

64 It is highly unlikely that they were lying motionless in their bed for 8 hours without sleeping. Some patients have difficulty with sleep perception because their brain activity is “noisier” than most people when they sleep (Krystal, Edinger, et al. 2002). Some people need the reassurance that their body is “sleeping” from an objective standpoint and is thus restoring and protecting itself; however, it feels like very poor or “no” sleep because of the mental activity. Self-fulfilling prophesy:  People with insomnia often predict that their day will be terrible because they had poor sleep—is it possible that they approach their day in a way thatensures this will betrue? It has been said, “Whether you think you can or you cannot, you are right either way.” There is tremendous power in the mind’s ability to create a reality consistent with its beliefs. As a result, it is important to give the patient the option of creating a self-efficacious, coping reality instead of a bleak one. Catastrophizing: “I’m going to go crazy.” The fear of serious mental or physical illness as a consequence of the insomnia is a common fear for insomnia sufferers. It is important to follow their fears to their most catastrophic conclusion to understand someone’s fear of insomnia. This has been described elsewhere(Burns 1980) asthe “downward arrow”method. The following case vignette demonstrates the use of this approach: CASE VIGNETTE THERAPIST: “You told me that you start to worry as soon as you notice that you have been in bed an hour without sleeping. Can you tell me a little about the thoughts or images you experience when you notice the clock?” PATIENT: “I think, ‘Oh God, I have a big day at work tomorrow. If I don’t get to sleep, I’ll be useless at work.’ ” THERAPIST: “You’re worried you’ll be useless at work, what would that mean?” PATIENT: “I could get into trouble.” THERAPIST: And then what? What would be the worst-case scenario?” PATIENT: “Well, I’d get fired, I guess. Well I probably wouldn’t get fired, but that’s what I am worried about.” THERAPIST: Well let’s stay with this fear for a moment. Can you get a picture of getting fired because of your insomnia?

65 PATIENT: Yes, I’ve pictured it many times. My boss is telling me my work has been slipping and I look like I’m sleep-walking, so he’s going to let me go.” THERAPIST: And then what? PATIENT: Well, I could never do well on a job interview feeling the way I do, so I don’t think I could get another job. Well, maybe I could. . .” THERAPIST: Let’s stay with this a moment if you can. So you might not be able to find another job? PATIENT: Well yeah, and then I  can’t pay my bills and then I’m homeless. THERAPIST: So you’re homeless and then what? PATIENT: Well that’s it. I’m homeless. I  can’t take care of myself and I’ll be like that forever I guess. THERAPIST: Wow, it sounds like there’s a lot riding on whether you get to sleep tonight. Maybe by looking at this chain of events operating below the surface we can understand why you become so anxious when you can’t sleep. Losing an hour of sleep triggers a chain of thoughts that leads to you becoming homeless forever. No wonder you are so upset when you get into bed. Do you think we could take a closer look at this belief? Exploring this fear and empathizing that it’s no wonder the patient is worried about sleep when the stakes seem so high (i.e., it feels as though she may become ill), are good starting points for modification of this belief. Many patients are surprised that they have such catastrophic beliefs lurking beneath the surface. Mind-reading:  Some people with insomnia believe that others are “noticing” their poor performance. They may worry about this out of a fear of negative evaluation from others. This belief is often untrue because most people with insomnia function quite well. What tends to be different after a poor night’s sleep is the amount of extra effort required to do regular tasks (Espie, Broomfield, et al. 2006). Even if the following belief is true, “People notice that I am incompetent at work because of my insomnia,” exploring whether it is true 100% of the time and exploring the consequences of holding such a belief can be helpful. For example, if there are fears of negative evaluation, believing that this

66 is true will result in increased anxiety in performance situations. We know that anxiety can interfere with performance; thus fears of poor performance will result in poorer performance. It is helpful to explore whether this formulation may apply to the patient and whether it would be useful to modify this belief. Overgeneralization:  Over-focusing on a single instance (i.e., I  had trouble completing my crossword puzzle this morning) as proof that their beliefs are true (“. . . so, I am mentally useless at work today.”) Encourage patients to see the range of evidence because people with insomnia tend to cope extraordinarily well 90% of the time. Discounting the positive/Exclusive focusing on the negatives: There are often hundreds of instances of coping and good functioning within the day that are discounted in lieu of one instance wherein functioning was lower (e.g., the patient forgets about one appointment). There are likely times when the patient may have had a poor night and still managed to have a good day. Similarly, there are often instances in which the patient may have voluntarily had a night with no sleep (i.e., stayed out late with friends) and had a good day afterward. Finally, many patients discount that there are days in which they had a good night’s sleep and did not have a good day. Explore all of these scenarios with your patient. Although we have focused on cognitive “errors,” is it important to keep in mind that it is the “adaptiveness” of the beliefs that is important to explore, not whether or not they are “true.” In other words, it is important to explore the consequences of the belief (i.e., does the belief increase anxiety?), because some beliefs are true to some extent. When beliefs become so rigid that they cause emotional arousal, it may be important to modify them. The goal is to give patients choices when their thoughts are activated. We want them to get into the habit of forcing themselves to consider alternative thoughts in addition to their negative thoughts. If they successfully establish this new mental habit, they will have a choice. If their current thinking pattern continues, it allows the Insomnia Brain to focus only on confirmatory evidence (i.e., that they can’t cope, things are hopeless, etc.). Forcing the Insomnia Brain to consider evidence to the contrary of their reflexive thinking will be uncomfortable at first, but soon it will become a habit, and these thoughts will lose their negative potency.

67 Completing a Thought Record on a daily basis provides insomnia patients with the sort of rote training they need to alter their automatic thoughts and to establish the style of thinking that enhances their success at sleeping. In working through the Thought Record in session, you may note that some patients have difficulties completing one or more of the columns. Some people mistake moods and thoughts, some peoplethink that they have no thoughts (i.e., their mind is blank), some have trouble generating evidence, and others have difficulty integrating the evidence into a balanced thought. Greenberger and Padesky (1995) have many suggestions for helping patients who have these difficulties. The Situations column can be completed by asking the patient: Who was with you when you started feeling bad? What were you doing? Where were you? When did it happen? For example, a patient may tell you about a situation in which he or she started worrying about their ability to sleep that night. When probed with these questions, an individual can usually fill in the blanks, and tell you that he or she was in the living room with his or her spouse watching television after dinner. Moods are best described using one word. When patients need multiple words to describe a mood, they are most likely describing a thought instead. The Thoughts column can be challenging for some patients. You want to elicit what was going through the patient’s mind during the upsetting situation. Ask the patient to focus on the emotions as clues to what he or she was thinking. For example, if the mood is anxious, ask the patient to try to identify what caused the anxiety. It is then often helpful to have the patient consider the most extreme scenario by asking the following series of questions: You said you were anxious about waking up in the morning. What is the worst possible thing about waking up in the morning? What is the worst-case scenario? Also, ask the patient if this situation reminds him or her of other similar situations. This usually results in generating some thoughts or images. If the patient had difficulty naming a mood and was instead listing “thoughts,” be sure to make note of these thoughts so that you can present them as fodder for the Thoughts column later. You can give patients the following hint to help identify thoughts in the future: The next time you are experiencing a strong emotion, ask yourself to notice what is going through your mind.

68 Most automatic thoughts in insomnia patients relate to a fear that something is very wrong with them and that they are helpless to change it. Eliciting catastrophic statements from the patient’s thoughts is helpful to get at the core beliefs. For example, a patient is afraid of setting the alarm and reports the thought, “If I set the alarm then I know I will only have 7 hours to sleep and every hour that goes by, I’ll be thinking that I  have to get up.” Ask the patient why having only 6 hours or 5 hours of sleep is distressing, and what is the worst-case scenario imagined for that situation. Then, take the worst-case scenario (e.g., getting fired from a job because sleep loss is causing unacceptably poor work performance) and reflect it back to the patient, such as: Gosh, if you think you are going to get fired because of your insomnia, it sounds as though there really is so much riding on you getting to sleep each night. This will either elicit more catastrophic statements, or the patient may engage in reporting evidence against the thought because the catastrophic nature of the thought is disconcerting. When generating automatic thoughts, it is usually important to generate several thoughts and not stop at one. One technique for facilitating the recording of multiple thoughts is to lead the patient to the next thought by repeating how he or she was thinking and feeling and to ask what happened next, “So you were feeling anxious and thinking, ‘I’m going to have to call in sick.’ And then what?” Most patients do not have difficulty generating evidencefor thethought in the EvidencefortheThought column, becausethethoughts areseen as very compelling. One common problem is the tendency to rush through the evidence and say, “Yeah, but I know that’s not really true.” It’s important to spend some time on the evidence for the belief and reflect that the patient isn’t “crazy” so there must be a good reason to have this belief. Exploring the kernel of truth in the evidence for the belief is really important. Generating items for the Evidence Against the Thought column can be challenging for some patients. Keep track in earlier sessions of any evidence the patient cited that is contrary to the belief. For example, the patient may talk about a horrible day in which nothing catastrophic happened. Or the most feared situation (e.g., “going crazy”) has not occurred, despite the fact that the patient has suffered from years of insomnia. Focusing on evidence of the patient’s effective coping can also help here. The following questions may also help:

69 • If someone you cared about thought their insomnia problem was hopeless, would you tell them, ‘Yeah, you’re right, it is hopeless’? Why not? Why wouldn’t this be helpful? • Are you discounting your strong coping skills? I’m impressed by the tremendous coping resources you seem to have. • Has there been a time in the past when you had very little sleep and functioned well? • Have there been times in the past when you had lots of sleep and felt poorly during the day? • Have there been situations when this thought is not true 100% of the time? For example, you say you get headaches when you have insomnia, do you have headaches every single day? The “cognitive errors” discussed earlier may also help patients with this column. Generating an Adaptive/Coping statement can be difficult for patients. Some patients will focus on the evidence for the belief and have difficulty incorporating the evidence against the belief. Others will want to focus exclusively on the evidence against the thought, which is equally problematic. One of the easiest formulas to derive a coping statement is to start with a statement from the evidence for the belief column, and follow it with a “BUT,” and then a statement from the evidence against the belief column. For example, “I sometimes forget things at work, BUT, sometimes I forget things even if I had a decent night’s sleep.” Encourage the patient to modify this statement until it seems believable and it is something that can be remembered. Often, patients will report that their mood is not quite as negative following the exercise. Positively reinforce even tiny improvements in mood, as this is evidence that there has been some input into the Insomnia Brain. For example, “OK, so you are 5% less anxious? That’s still an improvement from 5 minutes ago. Small victories are important in this process, so good for you.” After jointly completing a Thought Record (see Table 4.1 for an example), ask if the patient has any questions and instruct him or her to attempt to challenge one troublesome sleep-related belief per day. Patients also may be encouraged to additionally use the Thought Record whenever they are upset by their thoughts. Remember, the goal

70 in therapy is for the therapist to be replaced by the patient’s mastery of this new skill (i.e., the Thought Record). To gain mastery over the technique requires successful in-session exploration of records, as well as much between-session practice. Given the brevity of this treatment, there will likely be one or two opportunities to go through a Thought Record in session. Be sure to make the most of these few opportunities and troubleshoot any problems with the technique. Dealing with Resistance The best way to manage resistance is to reduce the likelihood that it will occur. It is important for the therapist not to directly challenge beliefs; rather, encourage the patient to scrutinize the belief. Patients who are directly challenged on a belief may be more likely to respond with reactance (Brehm and Cohen 1962). That is, they are more likely to argue on behalf of the unhelpful belief. Collective empiricism (Beck 1995) is the cornerstone of cognitive therapy. Effective therapists help patients to explore the utility of holding the belief so strongly. Socratic questioning is often helpful in this regard. Socratic questioning is achieved by leading a patient through a series of questioning designed to create uncertainty about the unhelpful belief. It is important to be efficient in your questioning because a long, unfocused series of questions can make the session feel like an interview. This is best done by having a clear idea of the conclusion you wish for the patient to reach. In the example that follows, the therapist wants the patient to consider stress as an additional explanation for her headaches and to focus on ways to manage the headaches. CASE VIGNETTE Therapist: So, you’re afraid that you are going to become seriously ill because of your insomnia? Patient: Definitely, I feel horrible, and I’m starting to get these really bad headaches. Therapist: And the headaches are evidence that you may be getting sick? Patient: Yeah. My doctor ran some tests and said it was stress but I’m sure there is something else wrong.

71 Therapist: That must be scary to think that you have an undetected illness. I’m relieved that the tests haven’t revealed a serious illness. Wouldn’t it be good news if it were stress-related? Patient: I guess. I don’t see how it could be stress. Therapist: How much do you know about the kind of body changes stress produces? Patient: Not much. I guess it makes you tense. Are the headaches because of the tension? Therapist: I’m not sure. Do you think they could be? Patient: I don’t know. I can’t believe it’s stress. Therapist: Isn’t having insomnia stressful? Patient: It definitely is. Therapist: Maybe we could spend a few minutes talking about stress symptoms and how to manage them? One final issue that may surface in therapy is when thoughts are related to believing that CBT will not work. It is important to explore resistance to therapy in a nonjudgmental, curious way. Many patients have tried several treatments and are understandably frustrated and scared that they are losing control over their ability to sleep. Highlighting the ambivalence is often important in this regard. CASE VIGNETTE Patient: I haveinsomnia because of my chronic fatiguesyndrome, not because I have bad sleep habits. Therapist: You may be right. But if we could improve your sleep, wouldn’t you like to try? Patient: I’ve tried a dozen pills and nothing works. I’ll never sleep better until they find a cure for chronic fatigue syndrome. Therapist: It must be frustrating to have tried so many treatments in the past and nothing works. To try so many medications in the past makes methink that youwould really liketo improve yoursleep. Would you like to try a new approach over the next couple of weeks? Would it hurt to try something that may help you sleep better? Patient: Well yeah, it may hurt. If something else doesn’t work, things will seem hopeless. Therapist: Sounds like you’ve been feeling hopeless about your sleep. Is this something worth talking about?

72 This brief interchange highlights how a patient’s initial resistance to CBT might be addressed. An additional cognitive technique that is particularly effective in modifying unhelpful beliefs is to design an experiment to test whether the belief is less true or unhelpful. Verbal challenges, such as the one above, can work well for some patients, but nonverbal, experimental approaches are often more persuasive. Dr. Allison Harvey has written extensively about various behavioral experiments, and arguably behavioral experiments form the backbone of her cognitive therapy (Harvey, Sharpley, et al. 2007). Below are a series of Harvey’s experiments summarized in Rae and Harvey (2004). In some ways, much of the behavioral recommendations in CBT can be construed or presented as an experiment that tests the belief that sleep effort is needed to produce better sleep. For example, when a patient believes that she is unable to cope without lying down during the day, it will be difficult for her to follow the “no napping” rule. It is more useful to believe that resisting a nap during the treatment will result in improved sleep quality, but merely telling the patient that she should believe it is often not helpful. Instead—ask the patient to test this belief. The patient could examine the sleep quality from her diaries wherein naps occurred and see the relationship between a week with naps and poor sleep quality and fatigue. Ask her to gather data about her sleep quality and fatigue during the next week in which she resists napping. Experiencing that sleep quality is poor and fatigue is higher when a nap strategy is used can be more convincing than being told to simply resist napping. There are also beliefs that can more subtly undermine treatment, and behavioral experiments can modify them to a more adaptive degree. For example, one of the most common sleep-interfering beliefs a patient may possess is that he has a limited store of energy and therefore must limit what he does, and hence limit his activity. Fatigue management strategies generally focus on maintaining manageable activity levels since fatigue tends to beget more fatigue. Being active when feeling exhausted is counterintuitive, and resting when feeling fatigue is often compelling. Rather than telling a patient that expending a moderate amount of energy results in greater energy, asking him to test whether conserving energy actually results in greater feelings of vigor can be a powerful force of cognitive change. One way to test this belief is to ask him to test what

73 effect conserving energy has on his fatigue and sleep each day. For the following week, ask him to test the effect of keeping active on his fatigue and sleep. Most people report that resting maintained the feelings of sluggishness overall and that their sleep was disturbed. Those who expend energy often notice that their mood and energy levels increase with some activity. Homework • Instruct the patient to continue recording his or her sleep habits using the sleep diaries provided in the workbook. • Ask the patient to fill out the Constructive Worry worksheet in the early evenings and bring completed forms to the follow-up session, if applicable. • Ask the patient to also complete Thought Records on a daily basis or whenever he or she is bothered by a particular thought or feeling and bring them to the follow-up session, if applicable. • Design a behavioral experiment to test any beliefs that are sleep- or treatment-interfering and collect data from the experiment to bring to the next session.

74 Managing the Insomnia Brain Some strategies for managing the Insomnia Brain are to: 1. Leave the room temporarily when your mind is active. You can return to the bedroom when your thoughts have become more manageable and you are no longer worrying. 2. Use Constructive Worry if your worries continue to follow you to bed. This will mean setting aside time to do this in the early evening. 3. Use Thought Records when you are having persistent feelings or thoughts about your sleep problem. Challenge your Insomnia Brain when it is causing problems and you’ll soon have mastery over it! Be patient and kind to yourself. It will take some time for this to become a new habit. Sleep Sleep Sleep Sleep Sleep Figure 4.2

Table 4.1 Thought Record Example Situation Mood (Intensity 0–100%) Thoughts Evidence for the thought Evidence against the thought Adaptive/Coping statement Do you feel any differently? Sitting at my desk thinking how sluggish I feel Down (75%) Frustrated (100%) Worried (80%) Tired (100%) I’m never going to get through today I’m going to mess up I need to get some sleep I can’t concentrate I’m going to get sick if I keep going like this I can’t keep going on like this What’s wrong with me? Last week I made a mistake on my report I’ve already stopped exercising I’m starting to feel less like doing things I’ve made mistakes at work when I have had a good night’s sleep I’ve had insomnia for over a year and haven’t been sick I notice I feel a little better after lunch I always seem to have an OK day despite my insomnia I don’t feel my best, but the truth is, I always make it through (70%) Just because I don’t feel at my best, doesn’t mean that anything bad is going to happen (75%) I’ve noticed there are things I can do to cope with the fatigue, so it is not hopeless (80%) Down (30%) Frustrated (60%) Worried (10%) Tired (70%)

76 Constructive Worry Instructions When we have problems, we tend to use our problem-solving skills to make our lives better and to relieve ourselves of anxiety. It is not surprising that some of us may use our problem-solving skills at the wrong times and places, namely bedtime. We may think about a problem, trying to solve it, but unfortunately, the anxiety caused by the problem will keep us awake. Constructive worry is a method for managing the tendency to worry during that quiet time when sleep is supposed to be taking over. During the early evening (at least 2 hours before bed) take about 15 minutes to do thisexercise. Here’s how it is done(see Table 4.2): 1. Write down a problem(s)facing you that hasthe greatest chance of keeping you awake at bedtime, and list them in the “Concerns” column. 2. Then, think of the next step you might help fix it. Write it down in the “Solutions” column. This need not be the final solution to the problem, since most problems have to be solved by taking steps anyhow, and you will be doing this again tomorrow night and the night after until you finally get to the best solution. • If you knowhowto fix the problem completely, thenwritethat down. • If you decide that this is not really a big problem, and you will just deal with it when the time comes, then write that down. • If you decide that you simply do not know what to do about it, and need to ask someone to help you, write that down. • If you decidethat it is a problem, but thereseems to be no good solution at all, and that you will just haveto live with it, writethat down, with a note to yourself that maybe sometime soon you or someone you speak with will give you a clue that will lead you to a solution. 3. Repeat this for any other concerns you may have. 4. Fold the Constructive Worry sheet in half and place it on the nightstand next to your bed and forget about it until bedtime. 5. At bedtime, if you begin to worry actually tell yourself that you have dealt with your problems already in the best way you know how, and when you were at your problem-solving best. Remind yourself that you will be working on them again tomorrow evening and that nothing you can do while you areso tired can help you any more than you have already done; more effort will only make matters worse. 6. An additional benefit of Constructive Worry may be less anxiety during the daytime.

77 Table 4.2 Constructive Worry Worksheet CONCERNS SOLUTIONS 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3.

79 Once patients are provided the behavioral and cognitive strategies discussed in the previous two chapters, they usually benefit from one or more follow-up sessions to (1)  assist them in making needed adjustments in their TIB prescriptions; (2)  encourage and reinforce their adherence to treatment recommendations; and (3) “troubleshoot” the problems they may be having with the behavioral or cognitive techniques they have been taught. There are no new materials needed during these follow-up sessions. The therapist should be guided by the patient’s self-report of progress, as well as by a review of completed sleep diaries, Constructive Worry worksheets and Thought Records. You should review all of these “homework” materials that the patient brings to the session and provide guidance as needed, using the information that follows. Adjusting Time-in-Bed Recommendations The method for making adjustments in TIB prescriptions was discussed in Chapter 3. Review the patient’s completed sleep diaries each week and determine his or her average sleep efficiency during the week prior to the current session. Sleep efficiency is calculated by dividing the patient’s average total sleep time (ATST) over the time period since the previous session by the average time spent in bed (ATIB) and then multiplying the result by 100% (Sleep Efficiency  =  (ATST/ATIB) × 100%). If the patient’s sleep efficiency is > 85% and the patient has noted daytime sleepiness with the current TIB prescription, suggest a 15-minute increase in TIB. Suggest a 15-minute decrease in TIB if the patient’s sleep efficiency is < 80%. If the patient is sleeping soundly CHAPTER 5 Follow-Up Sessions

80 most nights and feeling alert in the daytime, then no TIB adjustment is needed. At times patients will develop problems with excessive sleepiness as a result of restricting their TIB to the initially prescribed amount. This problem may occur in some insomnia patients who markedly underestimate their sleep time on their pre-therapy sleep diaries. Excessive sleepiness also may be common among patients who have a comorbid sleep disorder such as sleep apnea. Other patients may experience increased anxiety when limits are placed on the times they allot for sleep. The following two case examples demonstrate the types of adjustments that can be made to address these difficulties. CASE EXAMPLE #1 Ms. T was a 72-year-old retired schoolteacher who presented with primary sleep maintenance insomnia. Initial evaluation showed that she manifested many sleep-disruptive habits, such as frequent napping while watching the evening news and remaining in bed as much as 10 hours on some of her more difficult nights. Given these findings, CBT was initiated. Pre-treatment sleep diaries had shown Ms. T’s average sleep time at night to be approximately 6.5 hours, so she was initially restricted to 7 hours in bed each night at the start of treatment. Five days after her first appointment she phoned the therapist with concerns about markedly increased daytime sleepiness. In fact, she noted that she had fallen asleep in her car after having stopped for a traffic light. Because of this, she had become concerned about driving her car and wondered what she should do. Questioning of the patient indicated that she had adhered to the TIB restriction very strictly and she was sleeping very soundly on most nights. However, she continued to feel sleepy in the daytime and had to constantly fight off naps. Hence, the therapist suggested she increase her time in bed by 30 minutes per night to try to reduce this sleepiness. He also suggested that she ask her husband to take over all driving responsibilities until she returned to the clinic for follow-up one week later. Upon her presentation for her ensuing appointment, she reported reduced daytime sleepiness with the increased time in bed. Her sleep diaries showed that she was sleeping fairly well at night with very few extended awakenings. As she

81 continued to report some mild sleepiness, the therapist suggested she add another 15 minutes to her TIB each night. After trying this new TIB prescription, she reported an elimination of her daytime sleepiness and a continuation of improved sleep at night. CASE EXAMPLE #2 Ms. C was a 66-year-old retired female who presented with severe sleep-maintenance insomnia that developed after her retirement. Following an assessment that suggested she suffered from a chronic insomnia disorder, she was started on a course of CBT. After 2 weeks of following this regimen she returned to the clinic, anxiously explaining that her sleep had gotten worse. Furthermore, she reported that the strict behavioral regimen made her very anxious and she felt under too much pressure to sleep. To address this problem, a more lenient TIB prescription was established and the patient was allowed to take a brief (30 min.) daytime nap each day if she felt the need to do so. With these changes, the patient was able to relax and gradually showed nocturnal sleep improvements over the ensuing month of treatment. Reviewing and Reinforcing Treatment Adherence In addition to assisting patients with setting their sleep and wake times, use the follow-up sessions to reinforce the patient’s adherence to the prescribed CBT regimen and completion of the Constructive Worry worksheet and Thought Records. Assess patient adherence by reviewing the sleep rules and recommendations integral to this program (see Chapter 3 for list of sleep rules) and asking the patient about his or her compliance with each one. You should freely compliment the patient who closely follows all treatment recommendations and completes the cognitive homework exercises. In doing so, however, it is particularly useful to point out the relationship between the patient’s treatment adherence and improvement noted by his or her sleep logs or other outcome measure being used (see Chapter 2 for a list of measures and self-reports). For example, you may make comments like, You have done an excellent job following through on the strategies we discussed last time. As you can see, your efforts have paid off. Your diaries show that you are

82 now sleeping much better. Keep up the good work! In providing such comments, it is important to remain genuine and to avoid patronizing the patient. Thus, language that feels comfortable and consistent with your usual interactional style should be used in reinforcing compliance. Troubleshooting: Behavioral Component When implementing CBT for insomnia, you will find that not every patient shows a quick and perfect response to your therapeutic efforts. However, your mastery of this intervention will depend largely on developing troubleshooting skills to determine those factors that lead some patients to show less than optimal initial responses to treatment. Skillful troubleshooting relies heavily on your recall of the essential elements that need to be present to assure a good night’s sleep. As discussed earlier in this text, a good night’s sleep is a function of having adequate sleep drive at bedtime, following a consistent sleep/wake schedule, and having low levels of mental and physical arousal when sleep is attempted. When patients show a less than optimal response to treatment, it is usually because one or more of these conditions is not being met. Thus, the process of troubleshooting involves ascertaining if the patient is maintaining practices that reduce sleep drive, lead to improper timing of sleep, and/or produce too much arousal immediately prior to or after retiring to bed. To a great extent, troubleshooting consists of assessing patient adherence to the sleep improvement guidelines and sleep hygiene recommendations. Often a lack of treatment response is traceable to the patient’s misunderstanding of, or nonadherence to, treatment recommendations. By far, the most common compliance problems are patients’ failures to adhere to a standard wake-up time, to get out of bed during the night when they are unable to sleep, and to refrain from unintentional sleeping during the daytime. A careful review of sleep diaries should be employed to identify noncompliance with prescribed wake-up times. Also, specific questioning of the patient to determine the occurrence of daytime or evening napping episodes and extended periods of wakefulness spent in bed should be conducted. When such problems are identified, review the behavioral regimen with the patient and consider methods the patient can use to avoid these practices in

83 the future. When a patient is reliably following the CBT behavioral regimen and sleep hygiene recommendations yet still has sleep complaints, it is often because the patient is remaining too mentally aroused when trying to sleep. Typically this difficulty is mediated by underlying unhelpful beliefs about sleep that raise sleep-related performance anxiety or by failing to allot sufficient wind-down time in the evening prior to going to bed. In such cases, probing about the patient’s potential sleep-disruptive beliefs and pre-bed routines may identify targets for further cognitive and behavioral change efforts. The following series of case examples demonstrate how patients’ difficulties enacting the sleep improvement guidelines and sleep hygiene recommendations may be managed during follow-up sessions. CASE EXAMPLE #3 Mr. X was a 61-year-old patient who presented to our sleep center with a complaint of sleep-maintenance insomnia. Evaluation of this patient suggested that he suffered from primary insomnia and warranted a trial of behavioral therapy. He was provided our CBT treatment as described in this manual. After 1 week of treatment, he reported back to our center noting little improvement. From a review of his sleep diaries and a discussion with him, it was discovered that he failed to adhere to a standard wake-up time as instructed. In fact, on three of the nights during the first week of treatment, he stayed in bed over 2 hours beyond his prescribed wake-up time reportedly to compensate for periods of wakefulness during the night. Also, he admitted to failing to get out of bed during extended periods of wakefulness because he thought that if he would lie in bed long enough he would eventually go to sleep. Although he adamantly denied daytime napping he did admit to some unintentional dozing around 7:00 P.M. each evening while he was reclining on the couch watching TV. To correct the patient’s sleep problem, the therapist first explained the deleterious effect that the noted variance from the treatment regimen would continue to have on Mr. X’s sleep. Subsequently, the patient and therapist jointly decided that the patient would place his alarm clock in a location far from his bed so that he could not reach it without getting up. This measure was used to force the patient to

84 get out of bed at the selected wake-up time. In addition, the therapist helped the patient decide what activities he might do instead of lying in bed when he experienced extended nocturnal awakenings. Specifically, the patient was instructed to consider watching TV, reading magazine articles, or listening to music. Finally, the patient was encouraged to refrain from reclining while watching TV in the evening and to have his wife help him remain awake during the early evening hours. At a follow-up session 1 week later, the patient showed markedly improved compliance and a reduction in his sleep maintenance difficulty. CASE EXAMPLE #4 Mr. M was a 52-year-old college professor who presented with sleep onset and maintenance difficulties. After a thorough assessment it was determined that he would likely benefit from CBT. Following 2 weeks of this treatment, Mr. M returned to the sleep clinic noting marked improvement in his sleep onset problem but continued intermittent difficulties maintaining sleep. Upon questioning by the therapist, it was discovered that Mr. M followed the recommendation of getting out of bed in the middle of the night when he could not sleep. However, on such occasions, he typically watched a late night talk show on television and found he did not want to return to bed before he saw the ending of this show. Since Mr. M’s TV watching seemed to be extending his middle-of-the-night awakenings, he was discouraged from continuing this practice and was encouraged to engage in light, recreational reading instead. The patient subsequently complied with this recommendation and soon became able to sleep through most nights. CASE EXAMPLE #5 Mr. R was a 47-year-old professional who presented with an 11-year history of difficulty initiating and maintaining sleep. The initial evaluation suggested a history of sleep difficulties that reportedly were sometimes caused by conflicts with coworkers and supervisors. Nonetheless, the patient appeared to often allot 9 or more hours for sleep at night and he reported that he preferred to keep his bedroom TV playing so that he would have something to distract him

85 if he did awaken during the night. When the CBT regimen was introduced, he appeared somewhat skeptical, particularly when it was suggested that he stop watching TV in his bedroom and that he reduce his time in bed. Although the patient stated that he would try the regimen, he showed evidence of only marginal compliance when he returned for his subsequent treatment session. Specifically, he continued his former practice of keeping the TV on all night, and he often stayed in bed at least 1 hour more than recommended. Although Mr. R continued to voice skepticism, he eventually did agree to conduct a series of “behavioral experiments” on himself to test the effects of each of the disputed CBT suggestions. Hence, during the subsequent 2 weeks he agreed to remove himself from his bedroom when he couldn’t sleep instead of watching TV in bed. When, on a subsequent visit, he reported being surprised that this strategy did lead to gradual sleep improvement, he agreed to reduce his time in bed to an amount that closely approximated the therapist’s suggestions. Upon his subsequent return, he again agreed the experiment had benefited him. Although the patient noted that he would not agree to avoid sleeping in on weekend mornings, he did agree to stay in bed no longer than 1 hour beyond his weekday rising time. Since the patient had made reasonable progress and he seemed very resistant to further changes, the therapist chose to commend him on his accomplishments and refrained from attempts at additional interventions that very likely would have been met with excessive resistance. CASE EXAMPLE #6 Ms. Q was a 45-year-old employed woman with difficulty initiating sleep and subsequent daytime fatigue. She readily accepted the sleep hygiene recommendation to exercise regularly, as she indicated she believed that exercise would help her sleep more soundly at night and give her more pep in the daytime. However, 4 weeks into treatment, she had failed to establish any regular exercise program. She complained that she has difficulty finding time for exercise due to her ongoing work and family responsibilities. The therapist suggested that she try to integrate some exercise by using stairs instead of the elevator whenever possible at her worksite and taking a brisk 20-minute walk around the parking deck at work during her lunch

86 break at least 3 times per week. Ms. Q found these suggestions helpful and subsequently was able to initiate this plan over the subsequent several weeks. By the conclusion of treatment she reported that she was beginning to see the benefits of her exercise on her sleep and daytime energy level. CASE EXAMPLE #7 Mr. J was a 51-year-old divorced man who lived alone. He had long had problems sleeping and had developed the habit of having 1–2 shots of bourbon in the evening shortly before bedtime. Typically the patient had little difficulty falling asleep but he often awakened and could not return to sleep easily. Whereas the patient’s enactment of most treatment recommendations was very acceptable, his sleep diaries showed that he continued to consume alcohol close to bedtime several nights per week. Often when he did so, his subsequent sleep was rather fragmented. To address this problem the therapist used the patient’s sleep diary data to highlight the association between his bedtime alcohol consumption and subsequent poor sleep. The therapist also suggested that the patient move his alcohol consumption to an earlier time in the day so that it did not interfere with his sleep. In response to this suggestion the patient reduced his use of alcohol and generally refrained from alcohol consumption after his evening meal. Subsequent to these changes the patient’s nighttime awakening problem diminished. Troubleshooting: Cognitive Component Constructive Worry:  The most common problem reported with this procedure tends to be allotting insufficient time to complete it. Troubleshooting this problem requires encouraging patients to examine their schedules and prioritize a 15–30 minute block in which to complete the worksheet. It may also help to check with the patient’s understanding of the rationale. If the rationale is not understood, it will be less likely that patients will make the scheduling of this activity a priority. Sometimes patients become so activated that they have trouble completing this task. In such cases, it is important to complete one example in the follow-up session to ensure that the

87 patient has the ability to complete the exercise and to reduce the likelihood of becoming too aroused to successfully complete it on their own. Cognitive restructuring: There are a number of potential problems that can occur with patients completing a Thought Record. Such barriers include difficulty remembering to complete one, difficulty with completing one or more of the columns, a denial that thoughts are contributing to the problem, or predicting that it will not be helpful. Such problems can usually be worked through in session. For example, the problem of not remembering to complete a Thought Record can be addressed by scheduling this task around the same time each day. Problems completing one or more columns are best solved by completing a number of Thought Records in session. The questions you ask to direct a patient through the Thought Record should be written down, so that the patient can refer to these questions when completing one on his or her own. Those patients who regularly use the Thought Records typically report that they are extremely helpful in making a cognitive shift. Patients who present doubts about the usefulness of Thought Records may be encouraged to try using this instrument as a behavioral experiment. For example, you can ask the patient to complete the Thought Record for 2 weeks and “suspend judgment” about whether it is helpful until then. Agreeing to evaluate the effectiveness at a later date is often satisfactory to the patient. When reviewing whether the Thought Records were helpful, look at all the available data, including any possible mood improvements in the final column (i.e., Do you feel any differently?”), or possible improvements in sleep. Often times, the problem to “troubleshoot” in regard to Thought Records is that the patient resisted the assignment and did not complete one. It is important to assess reasons for noncompletion in an open and nonjudgmental fashion. Are they convinced it will not be helpful? Some find it contrived, and will say, “I know my thoughts are irrational, but that’s what I feel.” It is important to validate that the patient’s thoughts and feelings are valid. It is also important to validate that it must seem as though it would be difficult to change, given how automatic these thoughts are. Ask to explore whether there may be costs to having such strong conviction in these thoughts and whether these thoughts may be adding to the problem (i.e., emotional reasoning). In addressing such