Chapter 13

How Effective Is Your Program?

We expect this chapter to be most useful to you after six to eight weeks of actively working your integrated treatment program (not including the initial weeks in which you collected data and formed your treatment plan). If you are still in the thick of treatment, return to this chapter later. If you have been working a behavioral program (stimulus control, sleep restriction, or the combination) for at least six to eight weeks, then it is time to take stock. After you take stock, we will help you figure out your next steps.

Taking Stock

In chapter 1 we emphasized the importance of using data—not just your memory or general sense of things—to track your sleep. Hopefully you have been keeping a sleep log and completing the Sleep Log Summary worksheet throughout your treatment program. If you have not been, go ahead and collect some data for a week or two.

How Are You Sleeping?

Use the Sleep Log Summary from chapter 5 (worksheet 5.2 or 5.3) to see how you are sleeping now compared with before your treatment program. The following list describes some elements you likely will be interested in. Your particular flavor of insomnia coming into this treatment will dictate which of these variables are the most useful measures of progress. You can look at the goals you set on worksheet 5.1 to remind yourself of the changes you were hoping for.

Total sleep time (TST). Take a look at the amount of sleep you are getting each night. Is your TST close to the amount of sleep your body needs? Or do you consider yourself to be sleep deprived on a regular basis? If you are not getting enough sleep, then it is worth comparing your current TST to your pretreatment TST. Is it trending in the right direction, or has it not improved at all?

If you are hitting your body’s target, that is great! And it really does not matter if you are getting more sleep than before treatment. Perhaps you were getting enough sleep before treatment, and you have been working toward having better quality sleep, rather than more sleep. Or maybe before treatment you had some “good” nights (for example, eight and a half hours TST) and some “bad” nights (for example, three hours TST), which balanced out to an acceptable average TST (for example, seven hours). If you now are getting a steady seven hours each night, you likely are feeling much better even though there has been no change in your average TST.

Hours in bed and sleep efficiency (SE). How many hours are you spending in bed? What proportion of that time is spent asleep? Is this different than before the treatment?

This is an area in which we frequently see a lot of improvement. If you are like many of our clients, you were giving sleep a lot of room, and it was occupying only a portion of that space. For example, you may have been setting aside nine hours of sleep opportunity, and getting six hours of sleep. That means you had three unused hours that were dedicated to sleep. Which means you had three fewer hours to live your life. It may be helpful to do a little extra arithmetic to highlight any gains you made: subtract your average hours in bed from twenty-four to see how many hours you are up and about!

We would not expect to see improved SE if you had adapted to your insomnia by spending less time in bed. That is, some people say that they do not bother going to bed until much later than their preferred bedtime, because they know they will not sleep anyway. Others say that when they wake up at 3 a.m. they simply get up and start their day. If this sounds like you, then an increase in time in bed, coupled with an increase in TST, will be a better measure of progress than a change in SE.

Sleep onset latency (SOL). How long is it between “lights out” and when you fall asleep? If it is taking you less than twenty minutes to fall asleep, we consider this to be in the normal range. If your SOL was normal before your treatment program, then you may not see a change on this measure. On the other hand, if you were having trouble falling asleep in the beginning of the night, then we want to see this number go down over the course of treatment.
Awakenings. How many times during the night do you wake up? If you wake once or twice a night and can quickly fall back to sleep, this is completely normal. In fact, some studies suggest that the typical person wakes up for at least thirty seconds six times a night (Smith et al., 2003)! Therefore, we would not necessarily expect treatment to rid you of all awakenings. We also would not expect CBT-I to decrease awakenings caused by a child or bed partner, or by a medical condition (such as an enlarged prostate that makes you have to urinate frequently). If, on the other hand, you were waking multiple times a night without explanation, then we would hope to be seeing fewer awakenings.
Wake after sleep onset (WASO). For how many minutes are you awake in the middle of the night (after you first fall asleep, but before your final awakening)? Even if you only wake up once, this can be a huge disruption if you are awake for a long time. If you had more than twenty minutes of WASO before treatment, we hope your treatment program reduced this to less than ten minutes.

How Do You Feel During the Day?

Now let’s shift our focus from how you are sleeping at night to how you feel and function during your waking hours. Here are the questions we asked you in chapter 1. Answer these questions again, without peeking at your previous responses.

Table 13.1: What Insomnia Is Costing Me Now

Think about how you feel and behave the day after a poor night’s sleep. Also think about the overall, cumulative effect of your ongoing sleep problems. Now look at this list of common daytime consequences of insomnia.

Circle the number of days in a typical week you experience each consequence because of sleep disturbance.

For any items you scored 1 or more, rate how much this affects you:

0 = No big deal; I barely even noticed or thought about it until you asked.

1 = Mild impact/somewhat distressing.

2 = Moderate impact/quite distressing.

3 = Significant impact/extremely distressing.

For example, if you are late to work three times a week, this may not be a problem at all because you have lots of flexibility and you do not mind shifting your work hours (0); or it may cause some personal frustration but no real problems at work or with your after-work plans (1); or it may cause problems with your boss/coworkers/employees/clients, or with other activities because you have to make up the time (2); or it may get you fired or make you lose business (3).

Because of insomnia I… # Days in a Typical Week Impact (0–3)

…am late to work, school, or other activities.

0

1

2

3

4

5

6

7

…stay home from work or school, or cancel professional obligations.

0

1

2

3

4

5

6

7

…perform below expectations or am less productive.

0

1

2

3

4

5

6

7

…socialize less.

0

1

2

3

4

5

6

7

…exercise less.

0

1

2

3

4

5

6

7

…skip evening activities because I am too tired.

0

1

2

3

4

5

6

7

…skip evening activities because I am worried they will disrupt my sleep.

0

1

2

3

4

5

6

7

…have a harder time remembering things.

0

1

2

3

4

5

6

7

…have a harder time focusing or concentrating.

0

1

2

3

4

5

6

7

…am irritable with other people.

0

1

2

3

4

5

6

7

…am more sad, tearful, or anxious.

0

1

2

3

4

5

6

7

…worry about sleep during the day.

0

1

2

3

4

5

6

7

…feel anxious about how I will sleep that night.

0

1

2

3

4

5

6

7

…think about terrible things that may happen because of my insomnia (for example, impact on health, performance, relationships).

0

1

2

3

4

5

6

7

…fall asleep at inopportune times (for example, during meetings or classes, or while watching movies).

0

1

2

3

4

5

6

7

…am too tired to drive safely.

0

1

2

3

4

5

6

7

…feel physically uncomfortable (for example, burning eyes or headaches).

0

1

2

3

4

5

6

7

Now look back at your earlier responses. What has changed? What has stayed the same? Overall, is insomnia costing you less? If so, how much less? Or is insomnia costing you even more? Most often, insomnia is costing people less at this point in treatment. However, sometimes it is costing them more because of the time and effort they are putting into treatment. If this is true for you, know that this increased cost likely will not last much longer.

You also may want to look at your average fatigue rating if you completed this on the Expanded Sleep Log Summary. Has this changed over time? If you are getting more sleep or your sleep is more consolidated, then you may feel better rested. It is also possible that you had an increase in fatigue or sleepiness after starting stimulus control or sleep restriction therapy. If so, we would expect this to be getting better after six to eight weeks of continuous treatment.

Have You Found Your Sweet Spot?

From the very beginning of this book, we have encouraged you to commit fully to your treatment program, in order to give it the best chance of working. This probably required you to be willing to do things that were uncomfortable. We also have encouraged you to be flexible: we have asked you to use effectiveness rather than rigid rules to guide your treatment. This has included shifting your focus from trying to sleep tonight to a longer-term goal of consistent, reliable sleep. Indeed, we have even asked you to be willing to not sleep tonight, in order to decrease your struggle.

Have you found your sweet spot? Are you being rigid enough that you are actually doing the treatment as prescribed, but not so rigid that you are feeding the insomnia spiral with increased anxiety or arousal? Let’s take a look at each part of this equation.

How Closely Have You Followed Your Treatment Program?

It is time to take a really honest look at how closely you have followed your treatment program. You may want to look back at worksheet 5.1 to remind yourself which strategies you selected when you put together your individualized treatment plan. Then, assess your follow-through using these steps:

Here are some examples of what you might ask yourself for each treatment component. If you can answer yes to all of the questions, you did an amazing job using the strategy as it is meant to be used!

Stimulus control therapy. Does my sleep log show that I was in bed awake for no more than twenty minutes at a time? Is “lights out” the same time as when I got “into bed,” such that I did not do other things in bed? Did I do all of my sleeping in bed? Did I get up at the same time each day (and not go back to bed or to sleep), regardless of how much sleep I got? Did I have no daytime naps?
Sleep restriction therapy. Did I limit my time in bed to the amount of sleep I was averaging before treatment (or to five hours if I was averaging less than that)? Did I have a consistent sleep schedule? Did I have no daytime naps? Did I increase my time in bed by fifteen minutes at a time, and no more than once per week? Did I wait until my sleep efficiency was 90% before increasing my time in bed?
Sleep hygiene. Looking at the goals I set in step 2 of worksheet 9.1, did I regularly do what I set out to do? (For example: On how many nights did I engage in my wind-down routine? On how many mornings did I wake “briskly” and rise when I first awoke?)
Cognitive restructuring. Did I pay attention to my thoughts each day? Did I complete thought records for thoughts that were contributing to my insomnia spiral? Did I actually write stuff down, and not “just think about it”? As I identified and challenged distorted or unhelpful thoughts, was I also willing to have those thoughts come into my mind (or did I try to “control” my thoughts such that cognitive restructuring added to my struggle)?
Designated worry time. Did I set aside time during the day and indulge my mind in the type of thinking (worrying, reminiscing, problem-solving, planning, fantasizing, racing) that interferes with sleep? Did I stay on task so that my mind could become satiated? (For example, if you worry at night, did you only worry during DWT, and not veer off into problem-solving?) Did I make sure not to ruminate during my designated time? If my mind was busy when I wanted to be sleeping, did I remind myself that I could think this way, but I would do so at my next designated time?
Mindfulness. Did I practice regularly (five to seven days per week)? Did I try a variety of mindfulness training exercises?
Cognitive defusion. Did I practice regularly (five to seven days per week)? Did I try a variety of defusion exercises?

Why are we encouraging you to take such a close look? Clients often tell us that they did things when they did not, or did not do them fully. For example, people say that they did stimulus control, and their sleep logs show that they were in bed awake for an hour. We are not interested in giving you a poor grade or correcting you with a red pen. We do want you to have accurate information about what you have tried. As you will see, this is essential as you plan your next steps (below) and develop a plan to help you maintain any gains you have made (chapter 14).

There is another reason we want you to have accurate information about what you have and have not tried. When people think they have done what was advised, and they are not sleeping better, this feeds into hopelessness and despair. It adds to cognitive distortions such as Nothing is going to help. If, instead, you realize that you have not implemented the treatment fully, you may shift your thinking to something like: I took a low dose of sleep restriction. Maybe if I do it more fully it will work for me. Now, instead of giving up, you may redouble your effort and tackle whatever roadblocks got in the way of doing the treatment fully.

Have You Used Effectiveness as Your Compass?

In chapter 4 we asked you to think about how you struggle with sleep. Revisit the questions we posed there. Have you been applying any of the components of your treatment program in such a rigid fashion that this has added to your struggle? For example, if your target bedtime in your behavioral program is 10:30, did you become so concerned about varying from this that you gave up an important social engagement? Or were you able to be more flexible and stay out late? Did you find the sweet spot, by going to bed later (demonstrating flexibility) but still getting up at your consistent wake time (sticking with the program)? Finally, did you use this experience to collect data and see what happened when you varied your sleep schedule, so that you can make an informed decision if you are again confronted with this challenge?

The Next Leg of Your Adventure

What you do next will depend on a combination of how much progress you have made toward your goal and how closely you have been following the guidelines of the treatment strategies you have been using. Figure 13.1 provides a visual depiction of the roadmap we use to help people decide on their next step.

Figure 13.1. Where to Go From Here

You are at (or close to) your desired destination. It may be tempting to put this book on a shelf and stop working on your sleep. Instead, turn to chapter 14. This chapter parallels what we do when we are treating someone with CBT-I: we end with a focus on maintaining progress and decreasing the risk of future insomnia.
You have made progress, and you are still moving in the right direction. If you have made significant progress, your first priority will be to keep doing what you have been doing. It is helping, after all! If you have been at all lax in following the strategies you are using, you may want to recommit and follow your program even more closely for even better results. For example, if you are sometimes lingering in bed after your alarm goes off, you can tighten up your stimulus control therapy (SCT) or sleep restriction therapy (SRT) program by getting out of bed more quickly. If you have been using designated worry time and have set time aside five days a week, you can increase this to every day.

You may want to add additional strategies to your current program. Only do so if this will not interfere with your current program. For example, if you are currently using SCT, you may decide to add SRT for a combined approach. However, if you start to limit your time in bed and find that you are having a harder time getting out of bed when you are not sleeping, then we suggest you go back to using SCT without SRT. Remember, we would rather you use one of these core behavioral treatments fully than two watered-down treatments.

You have made progress, but seem to have stalled out. Again, because you have made some progress, we suggest you continue to use the strategies you have been using. However, since you have plateaued short of your goals, we will place a greater emphasis on tweaking your program. Specifically, if you have been closely following your program, then we suggest you add strategies to those you already are using.

If you are not fully following the instructions for each strategy you are using, recommit and follow your program even more closely. Take some time to reflect. What, specifically, is keeping you from following the program more closely? Is it an issue of willingness? If so, does seeing your partial progress make you more willing to follow the program more closely? Might you benefit from rereading the chapter on willingness? Or are you already willing, but running into practical roadblocks (for example, falling asleep unwittingly before your scheduled bedtime)? Can you do some troubleshooting and get around these blocks?

If you are unwilling to more fully commit, or you simply cannot work around other barriers to your current program, then there are two reasonable options. First is to add strategies. This is usually what we would recommend since you are benefiting from what you are doing, even if what you are doing falls short of the “full dose” of the treatment. However, it also is reasonable to change programs if you think you will be able to do something else more fully. For example, if you have been using SCT but have a hard time leaving the bed when you wake up in the middle of the night, you may decide that it is time to try SRT.

You have made little or no progress. With little or no progress after six or more weeks, you will want to start something new. However, if you have not been following your program at all closely, then “something new” may mean recommitting to your current program! Carefully consider what has gotten in the way. Work to increase willingness and decrease practical roadblocks. Or you may decide to “cut your losses” and change programs, rather than put even more time and effort into the program you initially selected, especially if you already have been following your current program closely. If stimulus control has not worked, perhaps sleep restriction will (or vice versa). Or perhaps you can harness the power of both treatments in a combined approach. You also may want to add strategies that you are not yet using, such as cognitive strategies or sleep hygiene.
You are out of gas. If you are feeling so stuck or frustrated that you are ready to abandon your journey toward more restorative sleep, then we encourage you to seek the help of a trained professional. It may be time to be evaluated with an overnight sleep study. Or you may benefit from guidance from someone who is practiced in CBT-I.

Common Questions (and Answers) About Planning the Next Leg of Your Adventure

“What do you mean when you suggest that I add strategies?”

Remember that CBT-I is a multicomponent treatment, and there are a lot of tools available. In chapter 5 we helped you pick the strategies that were best suited to your sleep problems, and that you were most willing to do. We suggested you use SCT, SRT, or the combination as your “core” behavioral program. We also suggested that you select one or more cognitive strategies. Now you can add other strategies to what you already are doing.

Think first about which behavioral strategies you are not currently using. Look back at your work in chapter 5 and see if these strategies are safe for you to use. If they are, consider adding one or more. Now think about which cognitive strategies you are not using. Consider adding one or more of these to your toolkit.

Here is a list to help you organize your thoughts. We did not include willingness in this table because it is so integral to every strategy. That is, you are using willingness every time you work your program.

If you are currently using…

You can add…

Stimulus control therapy (SCT)

SRT and/or sleep hygiene

Sleep restriction therapy (SRT)

SCT and/or sleep hygiene

Combined SCT-SRT

Sleep hygiene

Sleep hygiene

SCT and/or SRT

Cognitive restructuring (CR)

DWT, mindfulness, and/or defusion

Designated worry time (DWT)

CR, mindfulness, and/or defusion

Mindfulness

CR, DWT, and/or defusion

Defusion

CR, DWT, and/or mindfulness

“What do you mean when you suggest changing programs?”

Mostly we are referring to changing from one behavioral treatment program to another. Because behavioral strategies have the best research support, we usually do not suggest changing from a behavioral program to a purely cognitive treatment. And since sleep hygiene alone usually does not work, we usually do not suggest that you move to sleep hygiene as your sole behavioral treatment. What’s left? You can switch from SCT to SRT, or vice versa. Or you can switch from combined SCT-SRT to either SCT or SRT.

You also may choose to change cognitive strategies. For example, maybe you have been using DWT but you realize that you are ruminating (which is the one type of thought process that does not respond well to DWT). You may decide to stop using DWT and use mindfulness and cognitive defusion strategies instead.

“Are all strategies available to me?”

Not necessarily. Be sure to remind yourself whether any of the options you are considering are not suitable (see exercise 5.2).

“Where can I find help if my solo journey is not working for me?”

We suggest you consult with either a physician who is board certified in sleep medicine, or a health provider who specializes in behavioral sleep medicine or CBT for insomnia. Your primary care physician, your insurance company, or a local major medical center may be able to help you locate reputable providers.

Your Next Step

We certainly hope that your sleep, and your relationship with sleep, are better. And we hope these improvements are enough to motivate you to continue on your journey. When you are close to your desired destination, proceed to the next chapter. If you are changing or adding treatment strategies, continue to use a sleep log to track your progress. Read (or reread) relevant chapters so that you are supported in using each treatment strategy correctly. Use willingness and acceptance skills to fully commit to your treatment program and to decrease your struggle with insomnia. Finally, remember to use effectiveness—not rigid rules—as the compass that guides you on the next leg of your journey.