Chapter 5

Create Your Own Individualized Treatment Plan

You may remember from the introduction that cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent treatment, and not all people with sleep difficulties need all components. You may also remember that we often add elements of another treatment, called acceptance and commitment therapy (ACT), to help our clients get even better results. Not all people need these strategies, either. In this chapter we will help you use your sleep logs and the other assessments from chapter 1 to choose the treatment elements most suited to your particular “flavor” of sleep problem. We will also help you decide where to start. This will be a bit like a “choose your own adventure” book: you will jump around between chapters depending on your specific needs.

Let’s start with an overview of the different types of strategies that make up our hybrid CBT-ACT treatment for insomnia. First, there are behavioral strategies. These form the backbone of CBT-I. We almost certainly will suggest that you use one of two behavioral programs—stimulus control (chapter 6) or sleep restriction (chapter 7)—or their combination (chapter 8). These are the two treatment components that we think are most essential. Sleep hygiene (chapter 9) is another behavioral treatment that you might add to stimulus control or sleep restriction.

Second, there are cognitive strategies, or strategies to work with the thoughts, attitudes, and beliefs that may be adding to your insomnia spiral. Dr. Allison Harvey and her collaborators (2014) have found that adding cognitive therapy to the behavioral treatment of insomnia leads to better results. We can help you identify and change thoughts that may be feeding your insomnia using something called cognitive restructuring (chapter 10). We can help you move sleep-interfering thought patterns—such as worrying, problem-solving, or planning—from the bedroom and bedtime to a different place and time during the day, using something called designated worry time, or DWT (chapter 11). And we can help you step back from your active mind and decrease what is called “cognitive hyperarousal” using strategies from ACT, such as mindfulness and cognitive defusion (chapter 12). You may benefit from all of these strategies. However, we will help you prioritize so you can learn really well one or two skills for working with your thoughts, instead of spreading your resources too thin.

As you read in the previous chapter, willingness (or acceptance) is another strategy from ACT that we make extensive use of. A small minority of our patients tell us that they are not worked up about their sleep. Most come back after a couple of weeks saying that they are becoming more aware of their stress or anxiety about sleep! So nearly everyone we have worked with ultimately benefits from acceptance strategies, which is part of the reason we put this so early in the book. Plus, for the behavioral programs to work, you need to be willing to do them—and do them fully.

We will be encouraging you to start with your core behavioral program (stimulus control therapy [SCT] and/or sleep restriction therapy [SRT]). If, by the end of this chapter, you are not willing to do this, then we will ask you to read about both treatments in case more information makes you more willing. If you still are not willing, you will start with cognitive strategies.

We will cover a lot of ground in this chapter. Here is our itinerary:

Worksheet 5.1 will help you pull together the work you do to create your personalized treatment plan. Fill it out one section at a time as you read the relevant section of this chapter. Remember to keep collecting data with your sleep log as you work through this chapter. Let’s get started planning your adventure!

Worksheet 5.1: My Personalized Treatment Plan

Use this worksheet to pull together the work you’ll do with exercises 5.1 and 5.2, and tables 5.1 and 5.2. This will help you get started and stay on track.

My First Step Will Be:

  • Consulting a medical professional
  • Treating a circadian rhythm disorder (appendix A)
  • Treating insomnia (chapters 6–14)

My Destination (Treatment Goals)

Carefully consider where you want your adventure to take you. Be specific. Be realistic.

  • I hope to: sleep more ( hours of sleep on a typical night)

    fall asleep more quickly (within minutes of lights out)

    have fewer awakenings (no more than per night)

    not wake too early (sleep until at least : )

    have less fitful/more restorative sleep

    be in bed less/have fewer hours dedicated to sleeping (no more than hours between bedtime and final wake time)

    be less anxious about sleep

    have fewer daytime consequences of sleep

My Insomnia Program Road Map

I am going to start with this core behavioral treatment program:

  • Stimulus control therapy (chapter 6)
  • Sleep restriction therapy (chapter 7)
  • Combined stimulus control and sleep restriction therapy (chapter 8)

I also will work on my sleep hygiene:

  • Yes, I will read chapter 9 and consider whether there are some changes worth making.
  • No, I have good sleep hygiene and do not want to put energy here.

These are the cognitive treatment strategies I plan to learn and practice. (Note: If you plan to use more than two, mark with an asterisk (*) the one or two strategies that you will focus on first.)

  • Increasing willingness/decreasing struggle (chapter 4)
  • Cognitive restructuring (chapter 10)
  • Designated worry time (chapter 11)
  • Cognitive defusion (chapter 12)
  • Mindfulness (chapter 12)

Here is what I plan to do about the sleep aids (such as medications or herbs) that I currently use:

Aid

KeepUsing

Stop Using

ConsultDoctor

Before

During

After

Is Insomnia the Right Place to Start?

Complete exercise 5.1 using the work you did in chapter 1. This decision tree (a method of narrowing down your choices) will help you decide if you should start by treating insomnia. For each box, circle “yes” or “no” and follow the related branch. To summarize, if you are excessively sleepy during the day and you answered yes to a number of the screening questions for sleep apnea, restless legs syndrome (RLS), or periodic limb movement disorder (PLMD), we suggest that you start with a visit to a medical doctor to see if you should have a sleep study. If you are an extreme “night owl” or “morning lark,” we suggest that you first work on this circadian rhythm issue. If you start with a medical consultation and do not have a neurological condition that needs medical treatment, we ask you to return here to treat your sleep problems. If you treat either a neurological condition or a circadian rhythm issue and continue to have insomnia, we also suggest you return here. If you treat a neurological condition or circadian rhythm issue and are sleeping well, congratulations! You can donate this book to someone who still is not sleeping well!

Exercise 5.1: Are you treating insomnia or something else?

Your Insomnia Snapshot

Once you have two weeks of sleep log data, we encourage you to start a Sleep Log Summary. On worksheet 5.2 you can record your weekly averages for:

Each of these numbers can be lifted right off of your sleep log. Although this may seem redundant, we find it quite helpful. By tracking your weekly averages over time, the worksheet will help you focus on overall patterns and trends. It is all too easy to hyperfocus on some particular night of sleep. This tends to be counterproductive, especially if your mind keeps focusing on your worst nights!

If you are a numbers person, and really like data, then the expanded version of the Sleep Log Summary in worksheet 5.3 may be the one for you. This worksheet guides you in pulling out from your sleep log even more data. Instead of looking at three variables, you will calculate and record weekly averages for seven. If we were treating you, we would be paying attention to all of the following variables to get a more complete picture of your sleep pattern:

For each of these variables, calculate your weekly average. That is, add your SOL for each night of the week, then divide the total by the number of nights for which you have data. Then do the same for WASO, awakenings, and fatigue.

Whichever format you choose, we encourage you to complete the Sleep Log Summary throughout your treatment program to help you track your progress. If you do not care to do this, please still complete it now for a pretreatment “snapshot.” We will ask you in chapter 13 to again complete it for a couple of weeks. This will allow you to compare your insomnia before and after the treatment program.

Worksheet 5.2: Sleep Log Summary (Simple)

Average

Treatment(s)

Week

Start Date

Hours Asleep

Hours in Bed

Sleep Efficiency

(Pretreatment)

1

(Pretreatment)

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Sample

Average

Treatment(s)

Week

Start Date

Hours Asleep

Hours in Bed

Sleep Efficiency

(Pretreatment)

1

08/06/15

5.5

7.1

77.5%

(Pretreatment)

2

08/13/15

5.75

9

63.9%

Drop the rope! Lean in.

3

08/20/15

5.5

8

68.8%

SRT 6 hrs. Bedtime routine.

4

08/27/15

5.5

6

91.7%

SRT (6.25). Add DWT.

5

09/03/15

6

6.25

96.0%

SRT (6.5). Add mindfulness.

6

09/10/15

5.8

6.5

89.2%

SRT (6.5–6.75). Add defusion.

7

09/17/15

6.25

6.65

94.0%

SRT (6.75–7).

8

09/24/15

6.75

6.93

97.4%

SRT (7–7.25). Stopped DWT.

9

10/01/15

6.75

7.18

94.0%

Worksheet 5.3: Sleep Log Summary (Expanded)

Average

Treatment(s)

Week

Start Date

Hours Asleep

Hours in Bed

Sleep Efficiency

SOL (min)

WASO (min)

Awakenings

Fatigue

(Pretreatment)

1

(Pretreatment)

2

3

4

5

6

7

8

Average

Treatment(s)

Week

Start Date

Hours Asleep

Hours in Bed

Sleep Efficiency

SOL (min)

WASO (min)

Awakenings

Fatigue

9

10

11

12

13

14

15

16

Sample

Average

Treatment(s)

Week

Start Date

Hours Asleep

Hours in Bed

Sleep Efficiency

SOL (min)

WASO (min)

Awakenings

Fatigue

(Pretreatment)

1

08/06/15

5.5

7.1

77.5%

10

86

1

7.8

(Pretreatment)

2

08/13/15

5.75

9

63.9%

65

130

2.5

6.7

Drop the rope! Lean in.

3

08/20/15

5.5

8

68.8%

30

120

1

5.3

SRT 6 hrs. Bedtime routine.

4

08/27/15

5.5

6

91.7%

15

15

0.25

7.5

SRT (6.25). Add DWT.

5

09/03/15

6

6.25

96.0%

15

0

1

7.3

SRT (6.5). Add mindfulness.

6

09/10/15

5.8

6.5

89.2%

45

0

0

5.8

SRT (6.5–6.75). Add defusion.

7

09/17/15

6.25

6.65

94.0%

25

0

0

4.2

SRT (6.75–7).

8

09/24/15

6.75

6.93

97.4%

5

5.7

0.25

4.1

SRT (7–7.25). Stopped DWT.

9

10/01/15

6.75

7.18

94.0%

18

7.7

0.14

2.6

Now, take a few moments to complete the first two sections of worksheet 5.1. What will your first step be? Where do you want to end up? Use your insomnia snapshot to think about how you want your sleep to be different. Set specific goals.

Your Insomnia Treatment Program

When we meet with clients, we use their data and their preferences to help them build an individualized treatment program that has a high likelihood of success. In this section we will help you do the same.

Choosing a Behavioral Treatment Program

Both stimulus control and sleep restriction are highly successful, both according to research and in our own clinical experience. Some clinicians who provide CBT-I always combine the two. We are in favor of this if you are completely willing and able to use a combined approach and there are not significant risks. However, many of our clients are not willing or able to do “the full shebang.” We firmly believe that doing one treatment program fully works better than doing two “watered-down” programs. Plus, you may respond to just one of the programs, so doing a combined program may be a bigger “dose” of treatment than you need.

So where should you start? You should know up front that, nine times out of ten, we think either program will work equally well. In these cases we help people pick the one that they are most willing to do. However, your sleep pattern or sleep-related behaviors may lead us to recommend one treatment over the other.

You should also know that many people we work with start out being unwilling to do one of the programs, and then become willing once they understand the treatment rationale and how successful the program is. Many think they will hate a certain aspect of the program (such as getting up earlier) and then actually really like it. We will address many of these issues when we discuss each program in depth in the next two chapters. For now, feel free to use your initial instinct about which you are more willing to do to help you select where to start.

To help you decide which program to use, carefully review table 5.1, which compares and contrasts the two treatment programs and their combination.

Table 5.1: A Comparison of Stimulus Control, Sleep Restriction, and Their Combination

Stimulus Control

Sleep Restriction

Combination
What you do (simplified)

Go to bed when sleepy. If you are awake in bed for more than twenty minutes at any point during the night, leave the bedroom. Return to bed when sleepy. Repeat as needed. Have a consistent wake time, no matter how much you slept. No daytime naps.

Limit your time in bed to the number of hours you are currently sleeping. Increase your time in bed by fifteen minutes after a week of sleeping 90% of the time you are in bed. Have a consistent sleep schedule. No daytime naps.

Limit your time in bed to the number of hours you are currently sleeping AND leave the bed if you are not sleeping. Have a consistent sleep schedule. No daytime naps.
Can be used with these sleep patterns

Awake for stretches of time when first going to sleep, in the middle of the night, and/or because waking too early.

Awake for stretches of time when first going to sleep, in the middle of the night, and/or because waking too early.

Sleep is fitful, restless, or unrefreshing, but you aren’t actually awake for any stretch of time.

Multiple very brief awakenings.

Awake for stretches of time when first going to sleep, in the middle of the night, and/or because waking too early.

May also have fitful sleep or many brief awakenings.
The program is especially well suited if you…

…sleep better away from your own bedroom;

…feel yourself getting tense or anxious as you approach bed; and/or

…do things in your bedroom other than sleep and have sex (like read, watch TV).

…are in bed for much more time than you are sleeping (for example, if you are sleeping less than 85% of the time you are in bed).

…want to be aggressive and are willing to do both programs (fully) at the same time.

Stimulus Control

Sleep Restriction

Combination
You should not do the program (or should not do it without the help of an experienced professional) if you…

…have balance issues, a medical condition, or medications that put you at risk for falling if you leave the bed at night;

…have an injury or mobility issue that makes it hard to get in and out of bed multiple times;

…use CPAP or a similar device and have a hard time putting it on or getting settled with it.

…have a bipolar mood disorder, seizure disorder, or other medical condition that is made worse by too little rest.

…have any of the factors that suggest you should not do one of the programs.
What you may like about this program

You can have a full night’s sleep if you happen to have a “good” night.

You will not be lying in bed awake for long stretches of time.

Once in bed you can stay there and rest even if you are not sleeping.

You do not have to make any decisions about when to get in and out of bed.

You regain hours of your life to do things other than “try to sleep.”

You will not be lying in bed awake for long stretches of time.

You regain hours of your life to do things other than “try to sleep.”

Aggressive treatment may lead to quicker results.
What may be uncomfortable about this program

Making decisions about whether you have been awake long enough to get out of bed.

Leaving the comfort of your bed/bedroom.

Disturbing your bed partner or housemates by getting up and down.

Giving up the occasional night of adequate sleep you may be getting.

Being awake and out of bed when you are exhausted.

You may have fewer hours in bed resting than with either program on its own.

Now take a look at your sleep log data. Do you have stretches of time in bed when you are awake for at least thirty minutes? Do you have fitful or restless sleep (indicated by wavy lines on your sleep log) or lots of brief awakenings during the night (indicated by horizontal lines)? Is your “sleep efficiency” (the amount of time in bed that you are asleep) under 85%? Use this information to work through exercise 5.2. For each box, circle “yes” or “no” and follow the related branch. Use this decision tree and the information in the table above to help you choose stimulus control therapy, sleep restriction therapy, or their combination. Record your choice on worksheet 5.1.

Now consider whether to add sleep hygiene to whichever core behavioral program you choose. You probably have seen sleep hygiene guidelines in popular media. If you are reading this book, chances are good that you have already addressed this “low-hanging fruit.” Sleep hygiene alone is not likely to give you the restorative sleep you are seeking. However, having your behaviors in line with the sleep hygiene recommendations may help the other programs work better. That is why we suggest you add sleep hygiene to stimulus control and/or sleep restriction, rather than using it as a stand-alone treatment.

Again, look at your sleep log data: do you consume caffeine, nicotine, or alcohol? Do you exercise right before bed, or not at all? Think about your sleeping environment: is your room too cold or too hot? Too light? Too noisy or too quiet? Is your mattress uncomfortable, or do you sleep in a chair? Do pets or people disturb your sleep? Consider the hour before you retire: do you go, go, go right up until bedtime? Do you use electronic devices or have bright lights on? If you answered yes to any of the above, we suggest you read chapter 9 to learn more about how these behaviors and environmental conditions can interfere with sleep. Then you can decide if it is worth making some changes. Go ahead and mark worksheet 5.1 with your decision about whether you will read this chapter.

Exercise 5.2: Should you use stimulus control, sleep restriction, or both?

Alternative Routes for Your Next Step

There are four reasonable paths to take at this juncture.

  1. If you are eager to get started, you can skip ahead to the chapter or chapters related to the behavioral treatment program you selected. Once your behavioral program is under way, return here to build your plan for working with your thoughts.
  2. Alternatively, you can finish working through this chapter and complete worksheet 5.1 before launching your behavioral program.
  3. If you are not willing to do either behavioral program, you can jump to chapters 6 and 7 to learn more about each. If this helps you become willing, you can return here to continue to develop your plan using worksheet 5.1.
  4. If you are still unwilling to start SCT or SRT, continue to work through this chapter. You will start treatment with cognitive strategies. You may want to work specifically on the thoughts that are getting in the way of doing the behavioral treatment. These usually are some variation of I do not want to, I am too scared to, or Why bother? Nothing will help.

Choosing Cognitive Treatment Strategies

As explained in chapter 3, the way you think can impact your physiological arousal, which can affect your ability to sleep. Sometimes the content of your thoughts, or what you are thinking, increases arousal (for example, If I do not sleep well tonight I’ll be absolutely miserable tomorrow. I cannot stand another day like that!). Other times, it is the process of thinking that interferes with sleep. That is, regardless of what you are thinking about, having a busy mind is likely to increase arousal and interfere with sleep. Here is a brief summary of the strategies we review in chapters 4 and 10–12 that may help you shift your thinking, facilitating a better night’s sleep.

Table 5.2: Summary of Cognitive Strategies

Strategy

Description

Target

Helps most with…

Cognitive Restructuring

(chapter 10)

Identify and challenge thoughts that are not fully true (for example, I cannot stand another day of exhaustion; or Everyone needs eight hours of sleep).

Identify and modify thoughts that are unhelpful (If I fall asleep now, I’ll get six hours of sleep…if I fall asleep now, I’ll get five hours…)

Thought content

…correcting myths about “normal” sleep.

…catastrophic thoughts about what will happen if you do not sleep.

…thoughts that interfere with willingness to change behaviors.

…negative thoughts about other things in your life that increase stress or anxiety and (therefore) physiological arousal.

Designated Worry Time

(chapter 11)

Set aside time during the day to worry, worry, worry. At all other times (including while in bed), if you catch yourself worrying, remind yourself that you can worry during your designated time, and refocus on something else.

Thought process

…a busy or active mind while in bed. Although designed for worry, this strategy can be modified to target most thought processes (such as planning, problem-solving, or fantasizing).

Mindfulness Practice

(chapter 12)

Practice paying attention on purpose, in the present moment, and without judgment.

Thought process

…a busy or active mind while in bed.

…high stress or anxiety (and, therefore, physiological arousal) any time of day.

Strategy

Description

Target

Helps most with…

Defusion Strategies

(chapter 12)

Learn to step back from your thoughts and hold them less tightly. Examples: picture your thoughts on the tickertape at the bottom of a TV screen, or floating away in balloons; sing your thoughts; speak thoughts in a funny voice (for example, Donald Duck); thank your mind for the thought (Thanks, mind!).

Thought process

…a busy or active mind while in bed.

…catastrophic thoughts about what will happen if you do not sleep.

…thoughts that interfere with willingness to change behaviors.

Acceptance/ Willingness Strategies

(chapter 4)

Decrease arousal by accepting what is, rather than struggling against it.

Take more effective action by being more willing to have uncomfortable sensations and emotions.

Thought content and thought process

…thoughts about how you will sleep tonight.

…thoughts about the consequences of insomnia.

…hesitancy or resistance to doing some or all of the treatment program.

…struggle against other things in your life (which creates more physiological arousal).

As already mentioned, you may benefit from all of these strategies, and you are welcome to work through the chapters in sequence. As psychologists, we have a mental map of which strategies we suggest for whom. If you prefer to focus your attention on one area, here are some things that would cause us to suggest that you start with a particular strategy if you were sitting in our office.

If you are very anxious about how your sleep will be each night, or if you are deeply fearful that your sleep problems will lead to dire consequences (for example, that you will lose your job, default on your mortgage, and have to live on the streets), then we would often start with (1) cognitive restructuring, and (2) acceptance strategies. We would coach you to use cognitive restructuring during the day in order to examine more closely your catastrophic thinking about your sleep. Once you are in bed, we would coach you to practice acceptance by “dropping the rope” and relaxing into whatever this night brings.

If you are lying awake for stretches of time and your mind is busy—with fantasy, worry, problem-solving, or planning—we would start with designated worry time.

If you are not really sure what you are thinking about sleep or what your mind is doing at night, we would help you become more aware using mindfulness.

If you have very strong beliefs about why treatment will not work or why you cannot do the treatment as described, we would probably start with defusion, although cognitive restructuring may be an equally good option.

Based on everything you have just read, which cognitive strategies will you include in your treatment program? With which will you start? Record your plan on worksheet 5.1.

What to Do About Medications or Herbal Remedies That You Take for Sleep

If you are not currently using any sleep aids, you can skip this section and pour your energy into your behavioral program and one or more cognitive strategies. But what if you are using sleep aids? By “sleep aids” we mean anything you put into your body that is intended to help you sleep. This includes things you can buy with or without a prescription. It includes things that are “natural” (such as melatonin, chamomile, or marijuana) or manufactured (such as Ambien [zolpidem], Lunesta [eszopiclone], trazodone, or Seroquel). We are going to use the term “sleep aid” instead of “medication” because many people only think of prescription pharmaceuticals or their over-the-counter counterparts (such as Unisom or Benadryl) when we say “medication.”

Let’s face it: you would not be reading this book if you were perfectly happy to use sleep aids and they were working fully and not causing unpleasant or unsafe side effects. Or to put it another way, you are either wanting to add CBT-I to your sleep aids for even more improvement, or you want to use fewer or no sleep aids. Here are some common questions that you may have, and our typical responses. Please keep in mind that we are not medical doctors. The information provided here is for educational purposes only, with the goal of helping you be a more informed consumer. Please consult with your physician before tinkering with medications in any way. Use worksheet 5.1 to jot down your thoughts about what you want to do with each sleep aid you use.

Can I do this treatment if I’m using sleep aids?

Yes, as long as you still experience symptoms of insomnia and the sleep aids do not interfere with your ability to follow the treatment guidelines (for example, being too groggy to get out of bed when you are supposed to). However, we sometimes think that sleep aids are actually making a person’s sleep problem worse. For example, some sleep aids alter the architecture of sleep (that is, the structure and pattern of sleep). Others may increase your morning fatigue. This may worsen the daytime consequences of insomnia, or just make you think you slept more poorly than you did. If you have specific questions about how your sleep aids affect sleep architecture or other brain functions, consult your medical provider or pharmacist.

Sleep aids also can interfere with CBT-I. They may make you even less confident in your body’s ability to sleep unassisted, feeding the very thinking we are trying to counter. On the other hand, you may have a lot less anxiety and physiological arousal just knowing that you have access to a sleep aid that works in the short term.

It is not about sleep aids being “right” or “wrong.” It is about what works, not only tonight, but in the long run.

What should I expect if I stop using a sleep aid I’ve been using regularly?

If you stop a sleep aid you have been taking nightly, you may experience what we call “rebound insomnia”—an initial period of worsening of symptoms. The severity of symptoms may be even worse than before you started the sleep aid. We have witnessed rebound insomnia when people have come off of sedative hypnotics like zolpidem (Ambien) and eszopiclone (Lunesta), benzodiazepines like clonazepam (Klonopin) and lorazepam (Ativan), and marijuana. But we have also worked with people who have come off of these sleep aids and not had rebound insomnia.

The reason it is important to know about the potential for rebound is that the way you respond to any rebound symptoms can make a really big difference. If you think, See, I really am dependent on that pill! then you are likely to get right back on the sleep aid, and be distressed. If you have anxious thoughts like, Oh no! Am I back to square one? Is this the start of a really awful period? then you will feed into the insomnia spiral that we described in chapter 3. If, instead, you come off of a sleep aid willing (there’s that word again!) to experience rebound symptoms, then you may stay off the sleep aid and be relaxed enough for your body to self-correct.

In general, you are less likely to experience rebound insomnia or uncomfortable withdrawal effects if you come off a sleep aid slowly, gradually decreasing the dose.

If I want to come off of sleep aids, should I do it before, during, or after my CBT-I program?

It depends. Some clinicians always wean patients off of sleep aids before starting CBT-I. There are some compelling reasons for approaching treatment this way. First, this approach ensures that you are treating your insomnia as it actually is, rather than how it is with sleep aids. For example, sometimes people tell us that they used to have trouble falling asleep; now, with a sleep aid, they fall asleep quickly but have lots of awakenings. Second, if you come off of sleep aids before CBT-I, you do not run the risk of rebound insomnia later, which could feel like a real setback after successful CBT-I. Third, the effects of the sleep aid may make it hard to follow the behavioral program guidelines. For example, you may wake up too groggy to get out of bed quickly. Finally, if the sleep aid is working well enough, you will not have the opportunity to use stimulus control therapy or sleep restriction therapy.

We generally recommend starting CBT-I even before coming off of sleep aids if you are very anxious about this change and want some specific tools in your toolbox first. We also encourage you to start CBT-I if you are coming off of a medication very slowly and do not want to wait months before getting additional help.

How should I use CBT-I if I am sleeping well now, but I want to stop using sleep aids?

First, we encourage you to hone cognitive skills now. If you do experience a sleep disruption, you can use these skills to respond in a way that does not feed the insomnia spiral. These skills also can help you manage concerns you have about stopping the sleep aids. We also encourage you to plan a behavioral treatment program: decide which strategies you will use, read the relevant chapters, and complete the related worksheets as fully as you can. This will allow you to respond quickly if insomnia does return after you stop the sleep aids.

Can I occasionally take something to get just one good night’s sleep while I’m doing stimulus control or sleep restriction?

We encourage you not to do this except in the most extenuating of circumstances. Both programs rely, to some degree, on you consistently getting less sleep in order to build your sleep drive (see chapter 2). What we consider to be “extenuating circumstances” is different for different people. It will depend on your medical and mental health history, as well as your current roles and responsibilities.

I’m using melatonin and do not want to stop. What’s the best way to take it?

Melatonin is a hormone that your body naturally releases as the sun goes down. It sets in motion a cascade of events that tells your brain when to sleep. Melatonin levels remain high throughout the night. Your body then stops releasing it during the day.

There is widespread disagreement about whether melatonin supplements help, hurt, or have no impact on insomnia. Some clinicians think it is fine to take melatonin any time of night, since it is normal to have high levels of melatonin throughout the night. Others believe that an increase in melatonin well after sunset (for example, at bedtime or in the middle of the night) will confuse your body clock and throw off your circadian rhythm. These clinicians suggest taking melatonin earlier than most people take it, such as between 7 and 9 p.m.

There is greater agreement that properly timed melatonin can help treat sleep issues related to shift work, jet lag, and circadian rhythm problems. If you do take melatonin supplements, the sleep physicians we work with suggest lower doses (0.3–3 mg) than many of our clients report taking.

What if I take a medication for another medical condition?

Some medications that are prescribed for insomnia may also be prescribed for something else. For example, trazodone may be prescribed for depression, quetiapine (Seroquel) may be prescribed for bipolar disorder or psychosis, and a benzodiazepine may be prescribed for anxiety. This is one reason we ask you to consult your physician before making any changes to your sleep aids—we do not want you to unknowingly stop treatment for a different condition.

Some medications may be contributing to your insomnia. For example, stimulating medications like Wellbutrin (bupropion), Adderall (dextroamphetamine/amphetamine), and decongestants (like pseudoephedrine) can interfere with sleep if taken too late in the day. If you take any medications, you may want to ask a pharmacist if any of them could be contributing to your sleep problems. Then talk to your physician about whether taking the medication at a different time or dose might be helpful.

What about medical (or recreational) marijuana?

Like any sleep aid, marijuana can mask your actual sleep pattern, interfere with your ability to implement CBT-I fully, stop working over time, and create rebound insomnia when you decrease or stop use.

Your Next Step

At this point in the program, you have some basic education about how sleep works, how your behaviors and thoughts can maintain sleep problems over time, and how CBT-I can help you change your behaviors and thoughts to restore your sleep (and your relationship with sleep). You have either determined that you should start by treating insomnia, or you diverted from this program to treat a neurological condition (such as sleep apnea) or a circadian rhythm disorder, and have returned here because you also have insomnia.

Hopefully you have continued to keep a sleep log. You have been practicing being willing to not sleep, accepting whatever this particular night brings. You have worked through the exercises in this chapter and you have created your personalized treatment plan. If you are willing to do whichever behavioral program you landed on, you will now proceed to the relevant chapter or chapters and start your program! Once you have started, you will start reading about and practicing the cognitive strategies that are part of your program.

If you are not ready to start a behavioral program, we invite you to read the next two chapters to see if more detailed information increases your willingness. If it does, you will start your behavioral program and then move on to cognitive strategies. If it does not, you will start with cognitive strategies, specifically targeting those thoughts and feelings that are keeping you from doing a behavioral program. If you are still stuck, consider using this book with the help of a trained professional, or with a “buddy” in your life who also has sleep difficulties.

Finally, if you have been using sleep aids, you may continue to use them, or you may decide to decrease or discontinue your use of them either before, during, or after the program. You may want to consult a professional to decide which timing is best for you, or for help with how to taper off of the sleep aids.

Ready? Let’s go!