CBT for Insomnia: Secrets for Sound Sleep

This free 1 CE webinar, led by Kevin Cornelius, M.A., LMFT, covers the treatment of insomnia using Cognitive Behavioral Therapy for Insomnia (CBT-I Sleep). This CBT for sleep webinar features Feeling Good Institute therapists LJ Davis, M.A., LPC, CPCS and Anastasia Morrison, MA, AMFT.

Insomnia, characterized by difficulty in falling asleep, maintaining sleep, and early waking, becomes chronic due to thoughts and behaviors that reinforce it. CBT-I therapy is proven to be more effective than medication, addresses these behaviors and thoughts. The core techniques include cognitive restructuring, sleep scheduling, medication tapering, stimulus control, relaxation techniques, and sleep hygiene. Cognitive restructuring involves replacing negative sleep thoughts with positive ones to reduce emotional arousal.

Sleep scheduling improves sleep quality by limiting time in bed and ensuring consistency. The role play and case examples illustrate practical applications, emphasizing the importance of structured sleep routines and gradual adjustments. CBT-I not only improves sleep efficiency but also reduces dependency on medications and their side effects.

The webinar aims to equip professionals and CBT-I coach with skills to offer effective insomnia treatments and improve patients' overall well-being through better sleep.

IN THIS VIDEO:

Jill: Hi, everyone, and welcome to this month's Wednesday CE presentation called CBT for Insomnia, Secrets for Sound Sleep, presented by Kevin Cornelius, L.J. Davis, and Anastasia Morrison, who I will introduce all of them to you in just a moment. And Kevin, you'll have to move us to the next slide.

So let me tell you a little bit about, now I'll keep that slide with pictures on it. Yeah, let me tell you a little bit about our presenters today.

So Kevin Cornelius is a licensed marriage and family therapist and the intensive therapy manager at the Feeling Good Institute in Mountain View. Kevin has been providing cognitive behavioral therapy to teens and adults for nine years and was trained in Team CBT by the creator of it, Dr. David Burns at Stanford University. And he currently provides outpatient therapy to adults across the lifespan who struggle with depression, anxiety, insomnia, and relationship problems. He's a certified level for advanced therapist and trainer in Team CBT, and he's also been certified as a CBT for insomnia therapist by Dr. Greg Jacobs of Harvard Medical School. Kevin provides both inperson and online case consultation and training in TeamCBT, and he'll be leading the presentation for all of us today.

And then we also have LJ Davis. LJ is a licensed counselor across California, North Carolina, and Georgia. Boasting over 16 years of experience, LJ specializes in sleep and insomnia, social anxiety, and depression. And as a level four TeamCBT trainer, LJ not only treats clients, but also trains therapists globally, showcasing his dedication to advancing the field of CBT. LJ loves to travel and is currently running about 10 miles a week, building toward a possible marathon this fall.

Our next featured presenter is Anastasia Morrison. And Anastasia is an associate marriage and family therapist at the Feeling Good Institute in Mountain View, California. She's a TeamCBT level three advanced clinician and also certified in CBT-I for insomnia, specializing in addressing the root causes of poor sleep and guiding individuals toward becoming normal sleepers. Anastasia leverages her expertise to provide effective treatment for insomnia. She's also passionate about working with couples using research-based methods like EFT. Anastasia has experience working with anxiety and OCD. Additionally, she enjoys working with tech industry professionals, and she's a parent of two and closing in soon on 25 years of marriage, which feeds her interest in how to maintain loving, lasting relationships, in addition to one with her cat.

So I'm very pleased to have all three of these presenters presenting to you today. And I actually am very excited about this topic of CBT for insomnia, because I think that so often, even if people present to us for different kinds of problems, very frequently, people are asking for help with sleep. And so I think that you're all in for a treat and you'll learn a lot today. Okay, next slide.

Let me just tell you briefly about the Feeling Good Institute, and then we're going to quickly move into the content of the presentation today. So our mission at the Feeling Good Institute is to alleviate suffering by elevating the practice of therapy. So we were started by a group of clinicians originally mentored by Dr. David Burns at Stanford University. We train and certify therapists in the processes of CBT that are known to be most effective, including the use of measurement, empathy skills, increasing motivation and reducing resistance, as well as the kind of classic cognitive and behavioral therapy skills that are evidence-based. All the therapists at Feeling Good Institute are highly skilled and vetted, and we're all engaged in a weekly system of continuous improvement.

You probably heard, if you were at last month's webinar, a lot about the deliberate practice model, and all of us are engaged in really kind of upping our game week over week using deliberate practice. We also have flexible services to meet clients' needs. So we have video-based treatment across the US and Canada, and then treatment centers in New York, Silicon Valley, Canada, and Israel. So we see people in person as well as online, and we do weekly sort of traditional 50- minute sessions with many of our patients, but we also have an intensive therapy program where people come in from out of town, or we do it on video some of the time as well, where people can get a concentrated amount of therapy many hours a day, many days a week, in order to really accelerate progress. And we also have some lower fee options as well. Next slide.

So the last thing I'll say, and then I'm turning it over to Kevin, is how can you get your CE credit today? Well, you have to be here for the full hour, and at 5 of 1 Pacific time, we'll drop the link to the CE survey in the chat box. You have to complete the CE survey while you're here in the presentation today at 1 o'clock in order to get your CE credit. So please be present, complete the CE survey, and then within a week, so not today, not tomorrow, but within a week after we go through attendance and all of that, you'll receive your Certificate of Completion via email as long as you completed the survey today. Okay. And now I think I'll be turning it over to you, Kevin.

Kevin: Terrific. Thank you so much, Jill. And thank you to everybody for joining us. It's really exciting to have you all here. This is a topic that LJ, Anastasia and I are also very passionate about, and we're really happy to be sharing this information with you. You can see the plan for today here, and we have a lot that we want to share with you, so I'm going to get started right away here.

So today, you know, you can see here what our learning objectives are. Please note that today is a brief introduction to CBT for insomnia. If you were going to use CBT-I effectively with your clients, you're going to want to get some more training after today. And at the end of the presentation, we're providing you with some resources. For example, I'll just mention that I went through an excellent training program by Dr. Greg D. Jacobs of Harvard Medical School that taught me a structured, comprehensive program for providing CBT-I. And of course, Dr. Jacobs' program is not the only way to go, but I found it very useful, and some of what I'll be presenting today is based on Dr. Jacobs' work. And I also just want to mention that, you know, one of the goals here today is that hopefully you'll get inspired to learn more about CBT-I so that you can offer these services to your clients.

It's a wonderful set of skills to have to really help people improve their lives by improving their sleep. And we're going to start today with some background information, just discussing what is insomnia. So when we talk about insomnia, we mean a sleep-wake disorder with one or more of three primary symptoms. The first would be challenges falling asleep, or sleep-onset insomnia, an inability to maintain sleep, which we would call sleep-maintenance insomnia, and then early morning wakefulness, so waking at least 30 minutes before the desired time and before sleep reaches six and a half hours. And that's often accompanied by an inability to go back to sleep at all. Other symptoms of chronic insomnia are that sleep difficulty is present at least three nights per week and for a period of at least three months or longer.

The patient struggles with sleep, even with ample opportunity, and there's no other sleep-wake disorder or substance problem or coexisting mental health condition that would explain the insomnia experience. And I'd like to talk about how insomnia often develops. So insomnia is initially a common response to stressful life events. A subset of people develop chronic insomnia, which persists in the absence of those initial stressors. Thoughts and behaviors are what maintain and strengthen insomnia, creating a chronic learned insomnia. To conquer insomnia, these negative thoughts and behaviors must be replaced with CBTI techniques. And recent studies demonstrate that CBTI is highly effective, moves the majority of those with insomnia into the range of normal sleepers, works better than sleeping pills, and is now considered the treatment of choice for insomnia. So we do want to touch briefly on problems with sleep medications.

A lot of people will come into treatment having tried sleep medications and may be even dependent upon them when they enter CBTI. And that's really unfortunate because medications are just not the answer for solving a chronic insomnia problem. They can be addictive. There are often negative side effects, including a daytime hangover effect of medications. And a big problem is that when patients stop taking the sleep medications, often the insomnia just returns because the root causes of insomnia, thoughts, and behaviors are not addressed by medications. So in summary, the combination of worry about sleep and maladaptive sleep habits can transform a brief period of insomnia into a case of learned chronic insomnia.

Treatment of chronic insomnia must focus not on the initial upsetting events, but rather on changing the thoughts and behaviors that play the primary role in perpetuating insomnia. And since these thoughts and behaviors are learned, they can also be unlearned using a multifactorial CBTI intervention that is sleep-focused, short-term, and structured. And recent studies demonstrate that CBTI is highly effective, moves the majority of those with insomnia into that normal range, and doesn't have those side effects of sleeping pills. So that's why it is considered ideal.

Okay, we're going to talk about what are the core techniques of CBTI. So there are six core techniques. You can see them listed here, and I'll go into a little bit of detail about each one.

Cognitive restructuring simply means replacing negative sleep thoughts with positive sleep thoughts. And it's very powerful. People really can change their sleep quality by changing the way that they think about their sleep. Sleep scheduling, that includes reducing time in bed in order to increase sleep efficiency. And that helps the brain associate the bed with sleep instead of associating the bed with restlessness and frustration.

Sleep medication tapering often needs to be included as a part of the treatment. And personally, I'm not a doctor, so I would only do this in cooperation with the patient's doctor. I would share with them the schedule that I was planning on learning. We follow a special schedule for tapering off the sleep medications, and I'll just mention that the schedule I use is from that program I mentioned by Dr. Jacobs, and it's been shown to help 90% of patients eliminate the need for sleep medications.

Stimulus control, that is simply using habits to make the cue for drowsiness and sleep instead of the cue for wakefulness and stress. And that includes habits like not working in bed, not using a smartphone in bed, not getting into bed unless drowsy, and more. We also want to include relaxation techniques. We can use guided relaxation recordings that can teach the patient to relax and increase their drowsiness. And that's, of course, better than the alternative, which is lying in bed awake, restless, and frustrated with increased stress exacerbating the insomnia.

Sleep hygiene involves important habits for improving the amount and quality of sleep. And these habits include behaviors like increasing exercise. The patient can take a hot bath two hours before bedtime. They can use light exposure in the morning if they have sleep onset insomnia or use exposure to bright light in the evening if they are awakening too early in the morning. Reducing or eliminating the use of caffeine, nicotine, and alcohol should be considered for proper sleep hygiene.

Now in our presentation today, we're going to be focusing on what are two of the primary things that really need to be addressed first. We're going to be looking at cognitive restructuring and sleep scheduling. So let's talk about cognitive restructuring. These techniques are essential in managing insomnia. They enable patients to recognize, challenge, and replace negative sleep thoughts with more accurate adaptive cognitions called positive sleep thoughts. So these positive sleep thoughts improve sleep because they short circuit the cycle of emotional arousal, psychophysiological activation, and insomnia. And it's important for patients to recognize that cognitive restructuring is not the same as denying their insomnia, but rather it means to think about insomnia in a less negative and distorted way. And we're going to give you an example of how we can teach something to patients that would help them create positive sleep thoughts that talk back to a very important negative sleep thought.

So we're going to take a poll right now. We want to ask everyone to just think about what do you think is the ideal number of hours that people need in order to be healthy? And we'll just take a few moments for people to answer these, and then we will let you know what the results are. I can see how many people are answering, so I'll just give us another 15 seconds or something like that to try to get us up to 100% participation here. So if you haven't answered the poll yet, go ahead and cast your vote.

Okay, I'll go ahead and end the poll, and then I'll share the results so that you all can see them.

Jill: Kevin, are you able to see the results?

Kevin: I can, yeah. So this is a little bit of a complicated answer, actually. The thing that's most important to address is that most patients, when they come in for treatment, they're going to think that eight hours is what they have to have, and they're not getting their eight hours. So therefore, they're unhealthy, and they're not going to be able to function during the day. The truth is, and I'm going to look at my information and give it to you more properly here.

And by the way, we can see that 41% of you saw that seven hours was the ideal range, which is ding, ding, ding, the answer we're looking for. It's not that eight hours or six hours or nine would be wrong. It's just that the ideal number would be seven, and I'm going to explain that to you here in just a moment. Is it okay if I close? That won't change anything? Okay, so studies show that the lowest mortality rate for all causes is associated with seven hours of sleep, and higher mortality occurs at eight or more and six or less. And that suggests that the ideal healthy amount of sleep may actually be seven hours. An average sleep is between six and eight hours. Core sleep, which is the minimum amount required for good health, is five and a half hours. So that's not to say that everyone is going to feel super great with five and a half hours sleep. I wouldn't feel great with that.

Most people need additional optional sleep in order to feel their best, but you can see how a patient could know that, oh, as long as I got five and a half, I'm at least getting my core sleep. I'm getting what my body needs. Maybe I won't feel my absolute best, but it doesn't mean that I'm not going to be able to function today. So a couple of things to keep in mind is that studies also show that the effects of a poor night of sleep are not as great as we think. The evidence of the effects of a lack of sleep on people show that the only consequence of a lack of sleep is potentially having low mood. And this is on insomnia subjects. If it was a different sleep-wake disorder, that might be different. But for insomnia patients, really low mood is the negative consequence potentially.

Low mood is not necessarily a given. In fact, all of us here today can probably think of many times when we were up late for positive reasons, like a party or a vacation or a special event, and we did not have low mood the next day because we associated less sleep with a positive experience. So let's consider how we can use this information to help a patient who's in treatment. Oops, I'm not able to. Now I can move my slide. Okay.

So one of the negative sleep thoughts that the patient might record is they're telling themselves, I need eight hours of sleep every night to stay healthy. And we can teach them the positive thought to talk back to that, which is my performance will not suffer significantly if I get my core sleep, something like that. And then they also might be telling themselves, I'm going to have a terrible day today because of my sleep. I won't be able to work well. And they can replace that with the positive thought in most cases, the worst thing that may happen if I don't sleep well is that my mood will be impaired during the day. Now the negative sleep thoughts and the positive sleep thoughts that counter them are recorded on a sleep diary that the patient fills out every morning. And the sleep diary is also a place for the patient to record details like what time they got into bed, turned the lights out, how long before they fell asleep, the time they woke up, the time they got out of bed, that total time in bed versus the total sleep time and other factors. So the sleep diary is an essential piece of the patient taking advantage of sleep scheduling. And that's a technique that LJ is now going to talk about. So take it away, LJ.

LJ Davis: Thank you, Kevin. And before I get started, I just want to say I've noticed I've gotten several chats that have come to me and I'm not able really to look at them during the presentation. So if you're sending chats to me, I'm probably not going to have time to answer them, unfortunately. So maybe just copy and paste those over to Jill instead.

Jill: Yeah, I'll just say I put something in the chat box saying if you have any questions, send them my way. So all questions should come to me and not to any of the other presenters. I'm putting together a whole list of all the questions that I'll be asking during the Q&A. Thanks, LJ. Awesome.

LJ Davis: Thank you, Jill. And thank you, Kevin, for the introduction there. And I think each part is kind of a core part. And so I'm going to say sleep scheduling is to me the core of CBTI, though the cognitive restructuring is also a core. And the sleep scheduling is so important because somebody who's a healthy sleeper is spending most of their time in bed typically asleep. The studies are like 90 to 95% of time in bed is asleep. And that's what we call sleep efficiency, just the time somebody is asleep divided by the amount of time that they're in bed. Whereas somebody with insomnia often will be spending a great deal more time in bed than they are asleep. And that will lower their sleep efficiency down to somewhere in the vicinity of 65% or sometimes a fair amount of variation around that average number. And so what we need to do with somebody who's having problems with insomnia before we try to increase the quantity of their sleep is to increase that sleep efficiency, which will have a few key effects.

One of which is it will increase the quality of their sleep, moving from having a lot of light sleep or the kind of waking up and going back to sleep. And I'm sure many of us have spent a night or a morning in bed where we're kind of there dozing in and out. Sometimes it can feel lovely, but if that's the way sleep is always going for you, you're not going to be getting the deep sleep that you need. And so the sleep scheduling is going to concentrate the time that they're in bed to improve that quality of sleep. And the way that we will do that, if we want to go on to the next slide and talk about sleep scheduling, Kevin mentioned a sleep diary. And that's something I give to any patient I'm working with on insomnia before I start to do any sleep scheduling, I'll give them the sleep diary so that they will keep track for a week of the amount of time that they're in bed. So it would tell me what time they go to bed. Also what time they actually try to go to sleep, because a lot of times people will go to bed, but then they will read or scroll on their phone. Or back in the day, we used to watch TV, but it's probably phones more now, excuse me. And we want to know that time difference too, where they're spending that time in bed, not even trying to go to sleep yet, as well as in the morning. A lot of times people with insomnia will wake up and they'll stay in bed longer, trying to like catch a little more sleep. Just let me catch up a little bit more.

Also, as their sleep problems get worse, they will start going to bed earlier and earlier. I say this as somebody who's struggled with insomnia myself in the past, and I know that I certainly did that. My bedtime usually is like 10 to 11, but when I was struggling with sleep, I'd get so tired so early, I would start with like 9.30 and then nine o'clock. But then I was waking up all through the night as a result. So once we get that sleep diary that tells us how much time that they're actually sleeping, we'll also work with them. If you want to click, Kevin, work with them to find out what is the earliest time that they need to wake up each day. So if somebody has a certain day that they have to get up earlier to get the kids off to school or whatever, earlier day for church or synagogue or whatever might make their earliest time of day, then we would want to know that. And that's going to be their wake up time throughout the week. This is going to be our anchor point for the whole of sleep scheduling is having a very consistent time to wake up. And then once we know what that earliest time is, and we've got the sleep diary, we can hit the next step. Please, Kevin, calculate their sleep window. So once again, we know how much time they're actually sleeping and we know what time they're going to get up. So let's imagine that they're actually sleeping six hours per night. We're going to add 30 minutes onto that to get their sleep window.

So that would be a six and a half hour sleep window. If they have to give up at seven each morning, then we will count backwards from that six and a half hours to set that time to go to bed. And so that would be, you know, 1230, which a lot of people will be shocked when their person who's helping them with insomnia has been going to bed later than they've been going to bed. And that's what I found to be pretty common is usually it's like, Hey, you're going to have to stay up a little while. And then we have to do some, some planning on what you can do to keep yourself awake, but also not be keeping yourself overstimulated so that you're actually able to go to sleep at that time. The other key thing about that sleep time, thank you, Kevin, is it is the earliest time you can get into bed. So if it gets to 1230 and our imagined person is not actually tired, then we would say, well, don't get into bed. You need to do something relaxing, have a cup of warm milk if you're into that or, or, um, you know, do a little crochet or crossword puzzle or whatever it is that you enjoy that you might get drowsy while you're doing it. Um, and then once you get drowsy, you can go on to bed because we want them really to be building that association between in bed, I'm tired and I go to sleep. We want to make that falling asleep as easy as possible. And so Kevin and I are going to do a little role play now just to show how we might work through this sequence of things with a client. Are you ready, Kevin?

Kevin: I'm ready to go.

LJ Davis: Okay. Awesome. Well, Kevin, it has been great talking with you last week about insomnia. And now you have come back to me with this really good sleep diary. I'm really appreciate you taking the time to fill that out. I know it's kind of an annoying thing to have to do every morning. And in some ways it's like putting in your face that you're struggling with sleep each day. And so just admire a lot that you've put the work into doing that. Um, and if we look at it, it looks like, you know, some days you're sleeping more and some days you're sleeping less. And I'm sure there's lots of things with your schedule that show up there, but, but on average, it looks like you're actually getting about five and a half hours of sleep per night. Does that look, does that sound about right? Does that look right to you, Kevin?

Kevin: That seems accurate. Yeah.

LJ Davis: Okay. So, so we know you're sleeping for about five and a half hours per night. And so we're going to add 30 minutes onto that. We're going to let you spend six hours per night in bed maximum for this coming week. I know, right? It's been so much more than that. What are your thoughts there, Kevin?

Kevin: Yeah. Uh, I guess it just seems weird to spend less time in bed in order to get more sleep, but you know, I'm, I'm putting my trust in you, but this is the way to go. But yeah, I've been spending a lot more time in bed than that.

LJ Davis: Yeah. I appreciate that.

Kevin: And it really is counterintuitive. Like we have this thought, if I'm not sleeping well, let me spend more time in bed. And if that worked, we probably wouldn't be here today.

LJ Davis: So you're, you're right that it is odd, but I've also just found this approach so much more effective. So thank you for putting trust in me and being willing to try this out. The, the next part is what is the day that you have to get up earliest in the morning? Is there a certain day when you have to get up earlier for one reason or another?

Kevin: Yeah, I would say on Tuesdays I have to get up at five.

LJ Davis: Okay. So this may sound a little hard too, Kevin, if five o'clock is your wake up time on Tuesdays, could we agree that you would set five o'clock as your wake up time? Not just on Tuesday, but all seven days of the week.

Kevin: Okay. No, no sleeping in on the weekend.

LJ Davis: That's, that's exactly right. Yeah. I know that's a big one for people, but yeah. And to be clear, this is just for the course of the time that we're working together and working on this insomnia. I like to think of this as sleep quality training. And so we're going to put this structure around your sleep for right now to improve the quality of your sleep. And once you're sleeping well through the night, then we can also start to expand the amount of time that you need to sleep until we can tell from the sleep diaries that you're getting the amount of sleep you need.

You're not feeling as tired through the day and you're able to fall asleep easier and, and all of those things. And once we've accomplished that, then we can start to, to withdraw some of this structure too, so that you can go back to sleeping. Like somebody who doesn't have a sleep problem. You can go back to, you know, maybe having the occasional nap or, or being more flexible with your schedule once we've got things set up. How does that sound? Would you be willing to give this a try for, you know, four to six weeks at least?

Kevin: Totally. Yeah. That sounds, that sounds doable.

LJ Davis: Okay. Awesome. Well, I look forward to seeing how this is all worked out next week. We'll say end scene. Thank you, Kevin, for that role play. Thank you. Yes. I think the next slide will be back to you. Oh no, it's me still. Sorry.

So then here's just another, or a case example. This is somebody I worked with a few months back and I'm going to call them Charlie, which is not their real name. And I'll say they're in one of the three states that Jill mentioned I'm licensed in so we can give them even multi-geographic anonymity. But they were referred to me by their doctor. And basically the way they told the story to their doctor was they, just one night, all of a sudden they lost the ability to sleep and that really troubled them. And so the next night, like they went through the process a lot faster than I think most people do. Cause it was like one night they didn't sleep well. And the next night they're like, Oh my goodness, I really need to go to bed early so that I will catch up on the sleep that I missed last night. And then they didn't sleep well that night either. And then that just sort of compounded over time where they were not sleeping as well at night. They were going to bed quite early by the time that I met with them, I think around eight o'clock in the evening and then sort of wrestling through the night until five or six in the morning. I don't remember entirely which one it was. They were in bed for a really long time, but they were still not sleeping very well. And the doctor had given them some sleeping medication and depending on the medicine, what happened for them is fairly typical. It worked for a little while because it gave them a boost in their confidence and their ability to sleep.

But then, when they had a sleepless night or two again, they kind of lost that confidence. For that particular medication, it sort of stopped working for them. They went back to the doctor, and eventually, the doctor sent them to me. So, we really had to have some difficult conversations with them about how insomnia works. They were very much like Kevin just was in that role play, where they understood the rationale after I explained it. Still, each time when I said, "Okay, you're going to have to wake up at 6:00 every morning all week," they're like, "Oh, but I love to sleep so much! Why on Earth would I give that up?" Similarly, with going to bed a little bit later at night, they were very concerned about how they were going to stay up for that time. We worked to set up a Cozy Corner in their living room, which would have their puzzle books that they liked doing, word searches, and a few other things that were kind of Creature Comforts. This way, they could stay there and be comfortable in the evening. When they got drowsy and reached their right time, then they could go off to bed. Then, it was really a pretty dramatic change how quickly things started to turn around for them once we had that all set up.

Honestly, I think the first week was a little slow to set in as they were still getting used to this new schedule. By the second week, they were getting their 90% time in bed asleep. So, we were able to slowly increase the amount of time they were in bed. With them, we were doing about 15 to 20 minutes each week. We would add on while we were also working on some of the stimulus control things that Kevin talked about, as well as the cognitive restructuring. We even tried some experimental methods like checking how tired they really felt throughout the next day. One of their big concerns had been that they often felt drowsy driving to and from work. Within four weeks to a month and a half, they came in one day and said, "I'm not actually feeling drowsy anymore on the way to work." That was a huge realization that this was really working for them. After that, we spaced out our appointments a little more.

By the end of it, I probably saw them a total of six times, if I'm remembering right. By the end, they were sleeping well. It was clear to both of us that we were ready to complete treatment. I haven't seen them clinically since then, but I saw them maybe a month ago in town. They gave me a thumbs-up as I walked by, so I take that to mean it has continued to work for them. As I talked about with Kevin, we did start to pull away some of the structure too at the end, so they could go back to what I think of as sleep in the wild, as opposed to this highly structured sleep that we used to get things rolling again. Wonderful. Well, thank you, LJ. That was fantastic. I want to talk about our next piece that we want to introduce today.

Here at the Feeling Good Institute, we use the Team CBT model developed by Dr. David Burns, as Jill mentioned earlier. It includes really powerful methods for lowering resistance to treatment, making changes in sleep thoughts, behaviors, and using the sleep scheduling that LJ was demonstrating. That can be really challenging, and many patients may understandably have resistance to the changes they're being asked to make when we use CBT-I techniques. For example, let's see here... Am I on the right spot? Yeah. So, we're going to be asking them to keep a sleep diary and to write every day. They're going to be recording all those details that we talked about. That's a lot of work, and it's a new thing for them that they're going to have to incorporate into their morning. So, it seems likely that they would have some resistance to doing that, going to bed and getting out of bed at regular times. That takes a lot of discipline. It's not easy sometimes, so there's going to be resistance there. Of course, reducing that time in bed in order to increase sleep efficiency and the quality of sleep, that's really hard to do, especially for patients who see that as counterintuitive.

Anastasia, who is with us, is now going to tell us about some really excellent tools from Team CBT for addressing resistance that could be helpful for a patient who's resistant to using sleep scheduling techniques. Go ahead, Anastasia. Are you still with us?

Anastasia: Apologies, I was muted. Thanks, Kevin. As Kevin mentioned, an insomnia patient may have resistance to doing some of the work recommended to get over their insomnia. I'm going to introduce and walk you through three Team CBT tools, which are paradoxical in nature and serve to boost motivation and reduce potential resistance. I'm going to focus specifically on the recommendation to do sleep scheduling with this example.

The first one is something called the Triple Paradox. It's a chart that we fill in with the client where they generate all the good reasons to maintain their current sleep habits and basically why not to do the sleep scheduling. We bring all those thoughts to conscious awareness explicitly. We do this because prior sleep habits can be immensely rewarding and we need some strong tools to look at this and see if we can reduce resistance and increase motivation. Specifically, we're going to be looking at the advantages of maintaining their current sleep habits and spending as much time in bed as they want whenever they want. Okay, that's the first thing we do with the Triple Paradox. Secondly, we would look at the disadvantages of using the sleep scheduling or implementing this new habit. Lastly, we'll look at the core values of maintaining their current sleep habits. After we walk through the Triple Paradox, I'll also briefly demonstrate two other Team CBT methods that work with resistance. I'll pause and point those out when I do a role-play with LJ to demo this.

Okay, but the next method is called the Pivot Question. This is what we ask after we've completed the Triple Paradox table and have come up with a lot of good reasons to not do the work, in this case, the new sleep scheduling. We ask them this question, the Pivot Question. We ask a question that serves to put them in the driver's seat and paradoxically inquire as to why they would want to do the sleep scheduling after all. We let them answer that.

The third and last method is called Externalization of Resistance. It continues with these similar goals in mind, making sure if the client really wants to do the work, putting them in the position to argue for change, which is much more powerful than just telling the client what to do.

LJ and I will now do a demo and demonstrate a role-play with the client around the sleep scheduling and implementing these three Team CBT resistance tools. So, you can skip to the next slide now, Kevin, so LJ and I've talked about this concept of sleep scheduling. As you know, this means adjusting your time to wake up around the same time daily and going to bed around a certain time. During this therapy, it's a powerful intervention. As you can imagine, people may have some hesitancy in implementing this. You probably have some really good reasons that come up as to why to maintain your present sleep habits. I'd like to use some methods with you that work with this, to look at those explicitly and explore them up front, if that's okay.

LJ Davis: Okay, sounds good. Let's do it.

Anastasia: Great. So, this triple paradox chart that we have pulled up has three columns in it, and we're going to fill them out together. The first column lists the advantages of maintaining your current sleep habits. The second column will look at the disadvantages of implementing the sleep scheduling. The last column lists the core values of maintaining your current sleep habits while identifying values that are important and positive to you. So, why don't we start with the first column, LJ? What are some advantages of your current sleep habits, and we'll try to come up with three, if you can?

LJ: Well, the first thing is, you said I'm going to have to get up and then get out of bed when I wake up in the morning. Honestly, the best hour of my day most days is that first hour when I wake up but I'm still kind of drowsy, and I just sort of stay there in bed. It's cozy and warm. So, that first hour of the morning, just relaxing in bed, is heaven. And you're telling me I would have to give that up.

Anastasia: Yeah, that's an advantage of your current sleep habit, that extra hour in the morning feels really heavenly, I have to get, right. Okay, so we're going to write that one down under the first column there. Go ahead. Can you think of any others?

LJ: Right now, I have some real flexibility about when I wake up. Like if it's the weekend and I want to sleep in, I can do that. If it's a workday and I need to get up a little early and get some things done before I go to the office, I can do that. I just can wake up whenever I want to or whenever I need to, and that's awesome.

Anastasia: So, another advantage of your current habit is flexibility to wake up when you want. Alright, yeah, absolutely. Let's write that one down as well. Can you think of one more?

LJ: You know, you're telling me I can't get in bed until a certain time either. There are a lot of times when I'm really tired already earlier in the evening, and I just want to get in bed. You know, that's all.

You know, I've been thinking that going to bed early might give me the best chance to get some extra rest. So, not being able to do that under my current schedule is another, um, drawback. Basically, I won't have the option to go to bed earlier, right? Yeah, that's true. These are really specific advantages of your current schedule, no question about it. Let's move on to the second column, if you don't mind. Now, let's think about some disadvantages of implementing this sleep schedule. It's kind of similar to what I just said, but it'll be a real drag having to get up at the same time every day, like I've got to get up at 6:00 AM no matter what, and some mornings that's just going to be tough.

Anastasia: Yeah, absolutely. So, let's write that one down. Can you think of any more? Well, this is just going to take effort. The way I've been doing things has been effortless—I do what I want when I want without having to think about it. But now I'll have to set an alarm, pay attention, and make sure I stick to this schedule. It's going to take some work.

LJ: Yeah, it will require some change on your part. Okay, let's jot that one down too. Can you think of one more disadvantage? You know, one thing I really love in life is staying out late and going to sing karaoke. I've always been able to do that without worrying too much about how it affects me the next day because I could just sleep in. I think I might have to cut back on karaoke and not stay up as late anymore.

Anastasia: Ah, I see. So, cutting back on karaoke and not being able to stay up as late as often. Alright, that's another disadvantage. Great, you're doing a fantastic job, LJ. Let's move on to the third column and look at those core values that really reflect something important about you. The first one that comes to mind is flexibility. I see myself as a free spirit, having an easygoing nature, just going with the flow. That's been my thing.

LJ Davis: So, one of your values is being an easygoing, free-spirited person, and this new schedule might go against that somewhat.

Anastasia: Yeah, exactly. Can you think of another core value?

LJ Davis: Well, I've always believed in listening to my body. When my body says I'm sleepy, I feel like I should be in bed. Trusting what my body tells me is really important.

So, another core value is trusting and listening to your body. That's significant to you, and this schedule might contradict that. Yes, for sure. Can you think of a third one? I value pleasure. That first hour in the morning when I'm cozy in blankets and quilts—it's fantastic. It's important to value my own pleasure.

Anastasia: Absolutely, valuing comfort and nurturing your body in those moments. Alright, LJ, those are all great reasons. You've provided really specific and authentic responses that make a lot of sense. What you're saying is very understandable. Now, let me ask you a question. With all these benefits and concerns we've discussed—like having the freedom to do karaoke and staying up late whenever you want, or enjoying that heavenly hour in the morning—why bother implementing this sleep schedule?

LJ Davis: Well, all those things are true, and they do sound appealing, but overall, my current way of living isn't really working out for me. I spend most of my time feeling incredibly tired or relying on energy drinks to get through the day just so I can enjoy karaoke late at night. It's causing more misery than pleasure in my life right now.

Anastasia: You bring up some good points, LJ. But isn't it going to be a drag to get up early at the same time every day?

LJ Davis: Yeah, that's true, but feeling like I want to go back to bed at 10 AM every day at work—that's a drag too. The way I'm living now is more of a drag than getting up at the same time every day. Besides, it won't be forever, right? It's just until things get better. So, while it is a drag, I think it's worth it to try and improve my overall well-being.

Anastasia: Okay, I understand. But what about that extra hour you'll lose in the morning? That's going to be rough.

LJ Davis: You know how to hit me where it hurts. I do love that hour, but it's not an even trade. Sacrificing that hour for better sleep each night might actually bring more pleasure into my life than that one hour in the morning.

Anastasia: Alright, LJ. Thanks for sharing that. That concludes our role-play demonstration of addressing resistance using these team CBT tools. We used the Triple Paradox, asked the Pivot Question, and did Externalization of Resistance. These techniques put you in a position to argue for change or discuss your concerns more effectively, which can be powerful for motivating change, as David Burns puts it.

Kevin: Alright, LJ, you did a great job with your responses. Now, let's move on to our presentation wrap-up.

We've gathered some fantastic resources here that can really enhance your understanding of CBTi. First off, there's "Say Good Night to Insomnia" by Dr. Gregg D. Jacobs. It's not just a great read for patients wanting to apply techniques themselves, but it's also incredibly insightful for clinicians to grasp the methods and the core techniques involved.

LJ has recommended another gem, "Good Night Mind" by Colleen Carney and Rachel Manber. LJ, could you share why this book stands out for you?

LJ: It's a patient-friendly guide that's concise yet effective. It really walks people through everything we've discussed today.

We've also included "Feeling Good" by Dr. David D. Burns. It's geared towards the general public but offers invaluable insights into assessing resistance and empowering patients to overcome it, making our methods even more impactful.

Additionally, there's CBTforInsomnia.com, where you can explore comprehensive training in CBTi. It's a top-notch program if you're looking to dive deeper.

Before Jill takes over for some Q&A, I'd like to add one more resource. There's a helpful app called Insomnia Coach, developed by the VA specifically for CBTi. It's free and highly recommended.

LJ Davis: Jill, over to you for the questions, but please stick around till the end for our CE survey. The response today has been overwhelming, with over 60 questions flooding in! To keep things on track, we've focused on the most common and pertinent queries.

QnA Session

Jill: Now, don't forget to fill out the CE survey linked in the chatbox for your credits. Also, mark your calendars for our upcoming events in August and next month. We're excited to continue these valuable discussions and training opportunities.

Thanks to all our presenters for their expertise today. We hope you found this session informative and practical for your practice. Remember, if you're interested in furthering your skills in Team CBT or have any questions, reach out to us at certification@feelinggoodinstitute.com.

Your feedback matters, so please share your thoughts with us. We're here to support you in any way we can. Have a wonderful day ahead, everyone!

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