If you have trouble falling asleep or staying asleep, or you do not feel refreshed in the morning even after a full night’s sleep, you are not alone. Insomnia is a large-scale problem, with one in three people experiencing insomnia in their lifetime, and about one in ten US adults reporting insomnia that is severe and chronic (National Institutes of Health, 2005).
You also are not alone in what insomnia is costing you. Are you exhausted during the day? Do you move more slowly and get less done? Do you have trouble with memory or concentration? Do you worry that others can see that something is wrong? Do you give up activities either because you are too tired or because you worry that the activity will make it hard to sleep? Perhaps you are more irritable than your normal, well-rested self. Maybe you have a lot of anticipatory stress and anxiety about how you will sleep tonight. Insomnia is not only about how you sleep at night. It is also about how you suffer during the day.
Nearly everyone struggles with sleep from time to time, but if poor sleep has become the new norm for you, you may have adopted some behaviors to try to cope (for example, staying in bed longer and longer). You also may be so worried about sleep that you are preoccupied with thoughts about how you will sleep (I have to sleep tonight, I just have to!) or about the possible consequences of sleeping poorly (Tomorrow is going to be awful!). These behaviors and thoughts are perfectly natural responses to poor sleep—and they tend to make insomnia worse, interfering with your body’s ability to naturally self-correct when sleep gets off track. Cognitive behavioral therapy for insomnia (CBT-I) addresses the thoughts (also called cognitions) and behaviors that influence sleep, helping people get out of their own way so their minds and bodies can remember how to sleep again.
Decades of research show that CBT-I works as well as sleep medications by the end of a six-session treatment program, and better than medications when people are interviewed a year after the program (Mitchell et al., 2012). Unfortunately, many communities do not have enough professionals trained to provide high-quality CBT-I, and some people cannot afford the cost of seeing a professional for six sessions. Fortunately, there are many books available to walk you through a standard CBT-I program. These books have been valuable resources for the millions of people who live with insomnia.
So why another book on insomnia? About ten years ago we were approached by a psychiatrist who specializes in sleep medicine. He was desperate for people like us, clinical psychologists trained in cognitive behavioral therapy, to start providing CBT for insomnia. We dove in, excited to be able to offer a treatment that works so well for so many. For the most part, it was very gratifying work, because so many clients responded well and quickly to a brief CBT-I intervention.
However, we also met many people who claimed that they already had tried CBT-I—using a self-help book or very basic instructions from a doctor—without success. We started to see certain patterns, with two main groups of people for whom CBT-I did not seem to be working. The first group of people were those who did not really complete the program. Some became frustrated and gave up on CBT-I when they did not see quick results; others were too scared to fully implement the program, though they generally believed that they had done the treatment as prescribed. The second group of people were those who wanted the program to work so badly that they took it on like military boot camp—they tried very hard and followed all the rules very strictly. Despite all their best intentions and effort, their sleep did not improve, and their lives revolved around sleep, adding to their frustration.
We learned that there is a sweet spot. To successfully use CBT-I you need to:
We teach people to achieve the sweet spot. We blend traditional CBT-I with parts of a treatment called acceptance and commitment therapy (ACT). The addition of ACT strategies has helped many of our clients become more willing to do CBT-I fully, and to stay committed through some initial discomfort, allowing them to benefit from the full power of CBT-I. We will be emphasizing willingness and commitment throughout this workbook. ACT also provides some additional tools for working with the thoughts that impact your sleep, such as mindfulness and cognitive defusion (chapter 12). Finally, ACT’s focus on acceptance (chapter 3) has helped our clients decrease their struggle with sleep and with the daytime consequences of insomnia, changing their relationship with sleep.
You see, your relationship with sleep really does matter. If you try to control sleep, it may end up controlling you! Unfortunately, some people perceive CBT-I and other sleep strategies as more ammunition to control their sleep. We would like to suggest something different: think of all of our recommendations as strategies to promote (rather than control) sleep. The difference may seem subtle, but the result of this shift in perspective can be quite profound.
This hybrid CBT-ACT program is specifically designed to help you with insomnia, which can be defined as difficulty falling or staying asleep, or nonrestorative sleep, with negative daytime consequences such as fatigue or difficulty concentrating. It is not likely to help you if you are sleep deprived simply because you do not have enough time to sleep.
If you can get plenty of good-quality sleep but only at a time that is out of sync with everyone else (for example, if your body can sleep 7 p.m. to 3 a.m., or 3 a.m. to 11 a.m.), you may have a circadian rhythm disturbance. Many people with circadian rhythm disturbances also have insomnia and can benefit from this entire workbook. However, only appendix A directly targets shifting your clock. We do not specifically address circadian rhythm issues related to jet lag and shift work.
Many people with disorders like sleep apnea, periodic limb movements, and restless legs syndrome also have insomnia, and can benefit from this book. However, these conditions need to be treated by a physician, and we encourage you to seek treatment before beginning this program (more on this in chapter 1).
If you have a medical condition like bipolar disorder or a seizure disorder, we strongly encourage you to use this book with the close guidance and supervision of a professional who is trained in CBT-I and has working knowledge of your medical condition. Some components of CBT-I will initially lead to less rest or sleep. This can make seizures and mood instability more likely in people who are vulnerable. With proper supervision, you can benefit from this program even with these vulnerabilities.
This book is not about what works for everyone. It is a book designed to help you figure out what will likely work for you, with your unique physiology, environment, and lifestyle. Unlike some CBT-I therapists, we do not believe that all people need every component of CBT-I, and we tailor the order of the different components or strategies based on our assessment of each patient.
To help you pick which parts of CBT-I are most suited to your sleep problems, in this book we will make extensive use of a sleep log and other assessments (chapter 1). Therefore, we strongly encourage you to read the next chapter and start to complete your sleep log before progressing to later chapters. Effective treatment begins with thorough assessment. Plus, CBT-I relies on ongoing information collection to help you guide the pace and direction of your program.
While you are collecting data with your sleep log, you can complete the rest of the assessments in chapter 1, learn about sleep and about what maintains insomnia over time in chapters 2 and 3, and start working on your relationship with sleep by reading chapter 4. Then, with information from your sleep diaries in hand, we will help you (in chapter 5) create an individualized treatment plan using the strategies outlined in chapters 6–12 that are most suited to your situation. You won’t necessarily be reading all of these chapters. Instead, we will guide you to the chapters relevant to your individualized treatment program. Consistent with our goal of helping you individualize the treatment, with each part of the treatment program we will do a lot of “troubleshooting” to help you take into account your unique circumstances and potential roadblocks.
In chapter 13 we will ask you to reevaluate your sleep and will give you some suggestions for further steps if it is not where you would like it to be. In chapter 14 we will help you keep sleeping well by anticipating and protecting yourself against future sleep disruptors.
The last part of the book is devoted to topics that may or may not be relevant to you. We discuss circadian rhythm problems (appendix A) and insomnia related to menopause (appendix B) because we are so frequently faced with these issues when treating people with insomnia.
Your sleep will not improve just by reading this book. You cannot become proficient at any skill (knitting, woodworking, skiing, golf, swimming, cooking, and so on) just by reading about it. Rather, you have to have direct experience, and practice. Take your time working through this book. Answer the assessment questions we pose. Collect data for a couple of weeks. Work through the exercises in chapter 5 to develop an individualized program. Read thoroughly the chapters related to the strategies you select. Complete the worksheets that will help you personalize each strategy. (You can download the worksheets, listen to guided audio exercises, and access other related material at http://www.newharbinger.com/33438. If you are a clinician, you will find a bonus chapter on how to use this book with your clients.) Consider the possibility that the slower you go, the faster you will get to your goal.
We know how painful and costly insomnia can be. We are optimistic that, with our individualized approach that combines CBT-I and ACT, we can help you build and implement a treatment program that will enable you to sleep better and enjoy life more.