Can't Sleep? CBT Tools for Restful Nights—for You and Your Patients

Insomnia plagues millions of adults in the United States today and can contribute to a variety of other mental health struggles—including depression, anxiety, and suicidal thoughts.

In this highly practical webinar, LJ Davis will share one of the most important tools in Cognitive Behavioral Therapy for Insomnia (CBT-I), the first-line treatment for insomnia according to the American College of Physicians. You'll learn how to screen for sleep apnea, utilize a Sleep Diary to understand sleep challenges, create a healthy sleep routine to improve sleep quality, and gradually increase sleep time to enhance sleep quantity. Don't just manage insomnia—overcome it with evidence-based techniques you can apply immediately in your practice. You'll walk away with powerful strategies to help both yourself and your patients achieve restful nights.

IN THIS VIDEO: 

Jill Levitt: Hi everyone, I'm gonna we're going to get started today so welcome to this month's webinar called can't sleep CBT tools for restful nights for you and your patience and in just a few minutes I'll introduce you to our awesome presenters LJ Davis and Kevin Cornelius. I'll just go over a few administrative things first so most importantly how you get your CE Credit today just make sure that you're here till the end of the webinar it's a 1-hour webinar and you can access the CE survey in the chat box today we'll drop it in the chat box for you go ahead and click on the link complete the CE survey right away today and then you'll receive your CE certificate of completion via email within about a week okay. So let me just start out briefly by telling you who we are at Feeling Good Institute because we bring you these free webinars monthly. So kind of just to give you a little snapshot about what we're all about here at Feeling Good Institute and share with you our mission which is to make a difference in people's lives through elevating the practice of therapy. So our story started with really one big goal which was to make therapy better and help people who are going through tough times and we achieve this by training and certifying therapists in effective therapy techniques. We have a comprehensive kind of five level TEAM-CBT certification system that provides a path to Mastery in TEAM-CBT and we have Treatment available in over 35 States across the US and Canada and we offer therapy both online and in person and we have an intensive one-on-one Therapy Program where people will fly into town or travel to feeling good Institute or sometimes do it online where they do many hours of therapy a day many days a week in order to get better faster. We also have a lower fee Therapy Program as well. And this slide is kind of new I've gotten some feedback from webinars where people say how come you don't introduce yourself because I usually just jump in and introduce our presenters but I'm always facilitating these and so I just wanted to share with you a little bit about myself and then we'll move on quickly and kind of why I'm excited to bring these free monthly webinars to you. So I'm a clinical psychologist and also the director of training at the Feeling Good Institute. And I was originally trained by really some of the the world's best and most prominent CBT leaders in our field in Boston in New York and Philadelphia on the East Coast but my effectiveness as a therapist I believe really dramatically increased when I started working with David Burns out here in California over 17 years ago and the framework that David Burns created which is called TEAM-CBT really changed the way that I practice it taught me kind of step by step how to make therapy more effective. And so I'm excited to share his approach with you in our monthly webinars and in our core skills for effective therapy course and our FastTrack to level three course which I'll share with you at the very end of the webinar if you're interested in learning more from us.

So that's just a little bit about me and now let me introduce to you this month's awesome presenters. I'll start with LJ Davis. LJ is a licensed professional clinical counselor who practices across California, Northern North Carolina and Georgia boasting over 16 years of experience and LJ specializes in sleep and insomnia social anxiety and depression. And as a level four TEAM-CBT trainer LJ not only treats clients but also trains therapists globally. Next is Kevin Cornelius and Kevin's a licensed marriage and family therapist and also our intensive therapy manager at Feeling Good Institute in Mountain View. Kevin has been providing CBT to teens and adults for nine years and he was also trained in the TEAM-CBT model by David Burns at Stanford University. Kevin currently provides Outpatient Therapy to adults across the lifespan who struggle with depression anxiety insomnia and relationship problems. he's a level four Advanced therapist and trainer in TEAM-CBT and also has been certified as a CBT for insomnia therapist by Dr Greg Jacobs of Harvard Medical School. so you're definitely in for a treat with LJ and Kevin. and so I'll turn it over to LJ and I'll come back on with you guys for Q&A right.

LJ Davis: Thank you so much Jill and Jill said she was going to introduce herself and really told a lot about TEAM as well which I think was great. But I'll just say what an honor it is to get to work with Jill who has had such an influence on the field and trained with such incredible people so thank you Jill. And we can see here that the plan for today starts with introductions and we're through that part now so that's great and then in just a minute I will turn things over to Kevin and he will take us through the basics of CBT-I getting some of the the definitions that we need to know to be on the same page together as well as going through some of the the basic tools of CBT-I and then we'll look at one of those really basic tools the sleep diary together excuse me which we'll use for information gathering and then also to see how to set up and expand the sleep window which will be the second part and then as Jill said we'll save some time for Q&A at the very end. As we're going along though if you have questions that come up I'd recommend chatting those to Jill and then she'll be gathering those questions up and collecting them so we'll have them there at time for the Q&A. And then here are a couple of our learning objectives these are the two official objectives though I hope you will learn a lot more we'll be going over a lots of things so the first one is to identify two contraindications for Sleep Quality training. And the Sleep Quality training which is also classically called Sleep Restriction is one of the main things we'll be focused on but it's important to know these contraindications and we'll also make sure you know how to teach clients how to complete a sleep diary going forward. And so now I'm going to turn it over to Kevin who will start us off with the basics of CBT for insomnia.

Kevin Cornelius: Okay great thank you so much LJ. and you know the the first thing that we want to do is just talk about a definition for insomnia and this is pulled out of the DSM I believe you know where we have a complaint or dissatisfaction with sleep quantity or quality and there needs to be one or more of the following symptoms present. The difficulty initiating sleep or maintaining sleep and that's those problems are often characterized by frequent awakenings during the night or problems returning to sleep after awakenings. And then many people will wake up too early and they won't be able to go back to sleep and these one or more of these symptoms would need to be present at least three nights a week for three months or longer and cause a lot of problems in life. You know it's important to rule out other disorders that that that might be responsible for the for the Sleep disruption and of course if there's substance abuse or or other life circumstances that could be contributing to the sleep problems we want to take that into consideration before making this diagnosis and choosing to use CBT-I for treating the sleep problems. Okay so we want to think a little bit about how much of a problem is insomnia with the with the general population and we've got some statistics here from the American Academy of sleep medicine. 30% of us adults have some symptoms of insomnia and 10% have insomnia severe enough to have daytime consequences and those consequences would be on a person's mood, their level of productivity and it also can have a big impact on relationships. So we can see that insomnia can really impact people in in many areas of life and is a serious problem that we're happy to share some wonderful techniques for helping people with these problems. and when we're using CBT for insomnia we're going to be looking at these four primary areas. So to begin with cognitive restructuring and many of you may be already familiar with CBT cognitive therapy cognitive restructuring for mood problems is when we change the way that we feel by changing the way that we think. When we're talking about insomnia we're talking about changing our sleep problems by addressing negative sleep thoughts that exacerbate and prolong sleep problems and really turn them into a chronic learned insomnia because those of us who are struggling with insomnia are telling ourselves things that are disrupting our sleep.

So part of the CBT for insomnia program is going to be doing some education with the client to help them understand that they may have some beliefs about sleep that are getting in their way. A classic one would be if somebody's not getting eight hours of of sleep per night, they may be telling stressing themselves out by saying you know oh no I can't be healthy if I don't get eight hours of sleep a night and the reality is is that most people get between six and eight hours that's a healthy range of sleep and and and understanding that and taking off that pressure to always get eight hours is an important way of addressing a negative sleep thought that leads to an insomnia problem. And there are others and and when you probably will get additional training before practicing CBT-I you'll learn other sleep thoughts to look out for and how to counter them. With stimulus control, what we really want to do is create a mental connection to the bed as a place for restfulness and sleep that's what we really want is that mental association. We don't want the bed to become or remain a source of struggle and frustration and so we're going to be working with the client to for instance save the bed for sleep and sexual activity only. And some people have developed some pretty unhelpful habits of working in bed reading their phone in bed maybe watching TV whatever they might be doing that's contributing to the problem of that stimulus control would solve. Sleep quality training is hugely important this is going to it's often been referred to as sleep restriction or sleep rescheduling and that's where we're going to be addressing the amount of time that's being allotted for sleep to make sure that there's a higher percentage of time where the person is is sleeping and not in bed awake. And that's by reducing the amount of time in bed we can help the patient build a sleep drive and improve their quality of sleep. And this is one of those areas where probably all these areas patients are going to give a little push back and have a little resistance to the methods that we're going to be introducing and if you look at the previous webinar that LJ and Anastasia Morrison and I did on CBT-I earlier in the year which you can find on Feeling Good Institute website and I believe Jill's going to put the link for that in the chat we addressed that pretty well in that seminar where methods of TEAM-CBT that you can use to increase motivation and lower resistance to to things are difficult to do like sleep quality training. And then the final piece would be sleep medication tapering the reason why we mention that is because there really is unfortunately no medication that's really effective for treating insomnia. They all have drawbacks often a long half-life that causes drowsiness during the day, they're often addictive and they also do not address the the causes of insomnia which are negative sleep thoughts and negative sleep behaviors and so when the person stops taking the medication they go back to their sleep problems. So you know for me and personally and probably also LJ you know I'm I'm not a medical doctor so I don't you know set a medication tapering schedule without coordinating with the patient's doctor and and getting a buy in and setting up what that program is going to be but it has to be included if the CBT-I is going to be effective. Okay, now we do want to speak a little bit about sleep apnea which we would want to rule out before we would be using CBT-I. It's a dangerous disease with important implications for stroke or heart disease and there's this great tool called stop bang that's an acronym that I won't describe the whole thing to you but there's a link that LJ has provided at the end of the presentation where you can see this tool but it's a really great brief test that you can have somebody take in order to assess if they need to have a sleep study to see if they are actually struggling with sleep apnea.

LJ Davis: All right, thank you so much Kevin. I really appreciate that and one thing Kevin said as he was talking there briefly is that it would be a good idea to get more training on CBT-I like today's training will give you some great ideas and teach you how to use some of the tools but to really be able to put the model into full effect. I know the training I did was a three-day training so there's quite a bit more more to cover but we do want to share these tools with you as well. So the first thing before we jump into the Sleep Diary and Sleep Quality training we do want to look at a couple of the contraindications. as we noted earlier Sleep Quality training is sometimes called Sleep restriction because we are going to tighten the amount of time the patient or client is in bed. I've also heard it called time in bed restriction which is probably the most accurate name for it those still a little bit off-putting for people so that's why I like Sleep Quality training better. But the first one is bipolar disorder and the second one is epilepsy and both of these having a little bit of sleep dep deprivation can sometimes have pretty significant consequences and so we want to be mindful of that. And the Sleep Quality training time and bed restriction can lead to a slight loss of sleep at times and so we want to be aware of that and it's a loss of sleep that then we will build from to get more sleep but we would not want to accidentally set up a Bipolar person to have a manic episode from having that that extra sleep deprivation and the same thing someone with epilepsy sleep deprivation can increase the chances of seizures so just a couple of things we would want to be careful of. The good news is with those populations the other aspects of CBT-I can still be helpful and we can do some sleep scheduling and sort of sleep structuring with them just not quite as intensive an intervention as the full Sleep Quality training that we're going to describe today. And then we'll start off talking about the Sleep Diary and Sleep Quality training by talking about the rationale for it why do we want to do this and you can see on the screen here because people with insomnia a lot of times are spending a lot of time in bed. They the strategy makes perfect sense to me and it's one I've engaged in in the past when I've had sleep difficulties of like if I'm not getting enough sleep maybe if I spend more time in bed and get myself more opportunity I'm going to catch more sleep. You know if I go to bed especially early that was my vulnerability if I go to bed especially early then I'm just going to you know really make up for the sleep I've been losing tonight and or for some people I'll just stay in bed longer in the morning and also try to make that up. And the problem is when people are doing that they tend to have long stretches of time where they're sort of going in and out of sleep and so they're getting a really low quality sleep and they're getting a light sleep and Kevin mentioned the phrase sleep drive earlier that light sleep will will reduce their overall sleep drive. But then when they get into bed they won't have as much sleep drive, they won't sleep as well and they won't sleep as deeply. If we can really concentrate that window of time that they're in bed they're more likely to get the deep and restful sleep that they want to. I have a couple of different metaphors I use for sleep drive and one of them is like it's it's the gas in the tank that will drive you through the night. And if you're spending extra time in bed you're not putting gas in the tank during those times in you're maybe even taking gas out of the tank if you're going in and out of sleep and so we want to eliminate that to really have a full tank of gas that can drive our our clients into a really good state of sleep that next night.

You see here that a little bit more on the rational as humans we have three main types of sleep. There's when I first was trained it was called light sleep sometimes people now call it core sleep because it makes up actually the bulk of our time in bed sometimes the majority sometimes a plurality just depending on on what's going on. And then there's deep sleep and REM sleep and all three of them are important and have their function but when we wake up and really feel refreshed it's usually because we've gotten more of that deep sleep and so we really want to increase their sleep drive so that when they go to bed they have the best opportunity to really get that good deep sleep. They'll also get more REM sleep which is also important for memory and other things and one of the things that's really interesting about Sleep Quality training or time and bed restriction is it's not uncommon that our clients will come back even on the first week when they are obviously spending less time in bed and might even look like they're getting less sleep and they'll say how much more refreshed they feel even though they're getting less obvious sleep the Sleep Quality is already improving and they feel more refreshed by going through this intervention. And so the first step we want to go through with our clients is to get them to fill out a sleep diary. When our clients first come in I'm sure we've all had clients who've talked about their sleep this way they'll say oh I never get more than four hours of sleep per night or I never get more than five hours of sleep per night. and there's a good reason for that they're not being dishonest but our memories for our sleep are not very good and so when we look back over the week, we'll just kind of pick what seems like the overall pattern to us and not notice how much variation there is so that the first thing I want to do with a new client who's wanting to work on insomnia is get them started filling out a sleep diary and you see an example here on the screen. And Kevin mentioned earlier at the end of the presentation and the slides you can get from the training site where you logged in today there'll be a link for resources and you can get the Sleep diary there. You can also get the stop bang assessment for rather screening tool for sleep apnea and there's actually lots of other tools there too that we won't be going over in the workshop today and won't be talking about, but this is going to be our main information gathering tool. And I just want to go over it really quickly because it's pretty straightforward but there are some places that are sometimes a little bit unclear. And so if you look at the first two boxes the first one is what time did you get into bed and then what time did you try to go to sleep. And this is going to be really helpful when we first start off not just with our Sleep Quality training but also with some of the stimulus control that Kevin was talking about. Because if we see our client you know this example client on this one is getting to bed getting into bed at 10:15 but not trying to go to sleep till 11:30 so there's something they're doing there and we can target that in the stimulus control. There's also a fair chance that during that time they may be dozing in and out some and not even realize it and that's another reason we'd want to be aware of that time when we're thinking about their sleep window and sleep efficiency. So there's the time they got into bed there's the time they actually tried to go to sleep and then there's how long did it take you to fall asleep. So of course we all know when we lie down and try to go to sleep we usually don't fall asleep instantaneously so that's just about that gap between the time we tried to go to sleep and when we actually did go to sleep. And we'll talk about some keys to the Sleep Diary in just a moment about how we want our clients to think about that and record that information.

Then the next one is how many times did you wake up not including your final awakening and so just how many times do you wake up at the night and in the example we have here three times. And then the next box is make your best guess how long did those last so if you were to add those three times together how much did it last for and you see for this person it was an hour and 10 minutes. And then six and seven are kind of like those first two at the top, what time did you wake up for the last time and then what time did you get out of bed. And there's another place where we might be curious about stimulus control or it might be that our client here is like staying in bed to try to catch extra sleep like we were talking about. But we can see they they woke up at 6:35 but then they stayed in bed until 7:20 and it's recently turned cold here in Georgia sometimes I want to do that too and just like enjoy that cold it's a little hard or enjoy that warmth it's a little hard to to get out of bed. And then for somebody who's not sleeping well there's also that temptation or that desire to try and catch as much sleep as we can. And then you see the last two boxes here one is just a subjective rating of what their Sleep Quality was like and and in this case the person that said it was poor that night before which can make sense when they were awake so long and it took so long to go to sleep. And then the bottom box is for comments and comments could be anything that might have an effect on their sleep. So sometimes if a client is taking sleep medicine or if we're in that sleep medicine taper I'll have them sort of making sure to let me know what they're doing with their medicine in that box. You see this person said I had a cold which may you know have affected their breathing or something that could affect their sleep. you know caffeine consumption alcohol consumption things that were particularly stressful you know that the kids were up all night whatever it might be could go in that box that would also be helpful information. And then here are just a few keys to the Sleep Diary the first one is we want them to keep it out of the bedroom. Some people will really want to give us the best information they can and I love that but if they're keeping it in the bedroom and trying to like take notes on it at night that's actually going to be disruptive to their sleep so we don't want them to do that. and at the same time our sleep memory fades quickly like I was saying before when clients come in and just reflect on the previous week's sleep they'll have a hard time really giving you an accurate report. You can think of this the same way as like trying to remember a dream when I first wake up I can usually remember my dreams fairly well not always great but by lunchtime I couldn't tell you what that dream was and it's the same thing with our sleep as the day goes our memory of it will fade so we want them to do it as soon as possible in the morning. And I usually suggest to clients that they put it somewhere where they'll see it early in the morning and remember to fill out the Sleep diary. And then number three is one that is a little tricky for people sometimes we don't want them to have clocks that they can see in the bedroom. so if you think about it there were a few spots on there where we asked them to put specific times but once they try to go to sleep and once they wake up for the final time or between the time when they try to go to sleep and when they wake up for the final time we don't ask for specific hours. We want them to guess estimate how long did it take me to fall asleep so if I went to bed and went to sleep easily maybe it was 5 10 minutes if it took me longer than I maybe like you know about a half hour, about an hour and that goes into number four. We actually don't want perfectionistic data we would rather have their their Impressions. At its heart insomnia is a subjective disorder and so we're really wanting to get what their subjective experience is when they're feeling at the Sleep Diary that's what's going to be most helpful for us to understand what they're experiencing and then be able to target our interventions in the best way. And then point five here we'll use the information we get from the Sleep diary to calculate sleep efficiency which is just basically how much of the time that they're in bed are they actually sleeping and then also to set up their sleep window. And now Kevin and I are going to do a little bit of a role play about the Sleep Diary and how we would present it to a client. so, Kevin you ready to unmute and we'll get started.

Kevin Cornelius: You bet, Yes.

LJ Davis: Okay awesome. Well Kevin it's great to see you again here today or today maybe for the first time actually and I'm so excited to help you get the better sleep that you've been wanting. I know how much of a struggle it has been and you've told me you really want to be sleeping better and feel well-rested. And I want to introduce you to really what's going to be our first tool and kind of our anchor as we go through a lot of the the steps in this process and it's called a sleep diary and it's going to be how we find out with as much detail as is possible and maybe even as is desirable about what's going on with your sleep. And the first thing I want to talk about is just how to approach the Sleep diary we don't want you to have it in the bedroom with you at night. I don't know if you're the sort who would be tempted to do that so you could get good information but we do want it somewhere where you'll see it first thing. So where do you think you could put it so that when you get up in the morning it'll be available to you.

Kevin Cornelius: I think I could have it on the counter in the bathroom.

LJ Davis: Okay awesome that that works. I'm myself I'm too messy when I brush my teeth and I think my sleep diary would get wet if I did that. But if that works for you that's great. if it does prove to be a problem other places sometimes people put it's like on the kitchen counter if they make coffee first thing in the morning or on the table somewhere when they get up. So that that's great that the bathroom sounds wonderful and then the next part you'll see on here we'll go through what each box is about in just a minute but you'll see that it asks about specific times or it asks about how long you were awake or how long it took to fall asleep. And what's going to be a little bit strange is I'm going to ask you not to look at any clocks while you're doing that and can I just check in do you do you usually have clocks in the in the bedroom.

Kevin Cornelius: Yeah I have like a stand for my phone and so it makes this nice clock there that I can look up and see.

LJ Davis: Okay that that makes good sense to me. I'm guessing that's probably like your arm too and make sure you wake up in.

Kevin Cornelius: Yeah.

LJ Davis: And those sorts of things. Well for most people I don't know if this is true for you when they're having problems with their sleep and they wake up you know at 2:30 in the morning and they look over and see the clock says 2:30 it's kind of stressful for them and it actually makes it a little harder for them to go back to sleep. Does that happen for you when you wake up you're like maybe feeling frustrated or anxious about your sleep at that point.

Kevin Cornelius: That's true, yeah.

LJ Davis: Okay so actually what I want you to do is is when you go to bed tonight and and going forward in our work together can you just like I don't know if you can put your phone face down so you'll still be able to hear the alarm you could put it in another room if you don't need the alarm but that I know that may not be practical. or you can turn it around so it's facing away from you. What would be a good solution for you with that clock.

Kevin Cornelius: Yeah I can just turn it around that would be fine.

LJ Davis: Okay awesome and then when you do that we just want you to use your memory as best as possible to get these time come right the next morning. So we're not looking for like super precise data, we won't really just what it feels like to you and that that will give us our best best idea than looking at the clock does that make sense.

Kevin Cornelius: It does and in fact you know I can probably just rely on my Apple watch because it tells me you know sleep data so I can know how long I was asleep and all that.

LJ Davis: I'm so glad you brought that up and I love that idea. it kind of shows me how how much you want to really get the data right and at the same time weirdly it's better if we get your impressions than if we get that data from the Sleep watch and there's a couple of reasons for that. One is I really want to know what your experience is and and getting the data from the Sleep watch doesn't quite capture that as well. The other thing is the watches are not as accurate as people taking the the Diaries tend to be. I don't know if you've had this experience but I know I was talking to a friend of mine and he said you know he could be sitting and reading for a while before bed and then when he goes to bed when he wakes up the next morning the watch will say he was actually asleep during that time he was reading. So the watches are not super accurate. And so you know they're kind of fun to look at and what not but for the Sleep diary if you could give me your experience that would be better. would that be okay for you.

Kevin Cornelius: Sure I can get I can, yes it sounds like that's the best way to go so.

LJ Davis: Okay awesome. and then let's just talk a little bit about the different sections of the Sleep diary. You see there's a little difference in the first two boxes the first one is about what time you got in bed so if you're getting in bed and then like watching TV or reading or you know email whatever it is you might do go ahead and put that down as the time you got in bed. And then the next box is when you've really shut everything down you've put the book away turned off the TV turned off the lights whatever whatever you do to actually start trying to go to sleep that's the time we're wanting to put down is when you try to go to sleep. Does that make sense?

Kevin Cornelius: Yeah.

LJ Davis: Okay and then the next boxes are pretty straightforward how long did it take you to fall asleep again your best memory and then how many times did you wake up in the middle of the night. And that's not counting when you woke up to stay but the you know if you woke up for five minutes that would be one if you woke up for an hour that would be one as long as you went back to sleep afterwards and so just count how many times that was and then below that make your best guess as to how much time those all added up to and put that in that box. And then the the rest of it is pretty straightforward, we want to know what time you woke up in the morning what time did you actually get out of bed because a lot of times there's a gap there and then tell us how good the sleep was and anything else in the comments that you know were there cats screaming outside your window all night that were waking you up or or you know anything else that would might go in the comments. Caffeine consumption, if you've had alcohol you know sometimes it can help us fall asleep but then we end up waking up later as a result so it can be disruptive to our sleep too. So just anything that might have affected your sleep can you put that down in the comments box. I'm really looking forward to getting this information Kevin because it's going to just like launch launch our path forward. and so next week we can we'll talk some more today about other things you can do but starting next week then we can really get into the Sleep Quality training and some of the other stuff that'll be really helpful for you.

Kevin Cornelius: All right.

LJ Davis: Awesome. Thank you Kevin for for that demonstration. And then once Kevin comes back or or our client comes back and we're just going to use this sample information right now. And I want to sort of knock a little bit on the table and say this is a good time if you've found yourself with your attention waving I know that I've had that happen sometimes we're about to do a little bit of a math calculation and if you've zoned out this might be a good moment to tune in and be as clear as we can. So we're going to talk about how to calculate sleep efficiency which is one of the core ideas of the Sleep Quality training. So the first thing we need to do is find out how much time was the client in bed. And we can see this person got into bed at 10:15 and they got out of bed at 7:20 and just a little simple you know math I was able to figure out that's nine hours and five minutes. and I changed that into purely minutes because minutes make it easier for us to do calculations with. And then the next part is the time of sleep. And so here we want to start with the time they started trying to sleep until their final awakening. So it was 11:30 p.m. they started trying to sleep and their final Awakening was 6:35 so that's you I do the math there and I get a total of 7 hours and 5 minutes between 11:30 and 6:35 which I then convert into 425 minutes. And then we need to figure out how much time they were awake during that window. So if we look at box three it took them 55 minutes to fall asleep and then in box five they were awake for an hour and 10 minutes during their three awakenings so if we add those two together 55 minutes and an hour and 10 minutes comes out to two hours and 5 minutes which is 125 minutes total. It’s worth noting too all these calculations there's there are several of them but they're all things we can perform on the calculator that's on our phone or any other calculator we might have. And then the last part is we want to get their time asleep we subtract that time that they were awake that 1 hour and 25 minutes from the time they were trying to sleep which is 425 minutes so we see that comes out to 300 minutes or 5 hours. and then to get the sleep efficiency, we just do a division where we divide the amount of time they were asleep by the amount of time they were in bed and that comes out to 0.55 and you know that's 55%. So so we now know at least on this one night this client had a sleep efficiency of 55%. And then the next part is how to set a sleep window. And so I've made up a sleep diary here for somebody named Alex. and we can see that Alex over the course of the week we won't do all the math together again to go through all this but Alex averaged 5 hours and 30 minutes of sleep per night. And to get the length of his sleep window then we're going to add 30 minutes on to that five and a half hours and there a couple of reasons why we do that. One of them is that most people actually under report their sleep a little bit you know when they're spending that extra time in bed and getting those light sleep moments or some of those kinds of things they probably will not put that in the sleep down because they don't even realize they're having like little two-minute naps off and on through that time. Also we want to give a little bit of a a cushion there if Alex is sleeping for five and a half hours a night even though we're going to do this time and bed training this Sleep Quality training, he's not going to instantly fall asleep when he goes to bed and he may still need to wake up and go use the bathroom at some point in the night or whatever it might be and so we want to give a little bit of cushion there beyond the 5 and a half hours to get it up to asleep window of six hours. And you also see on here that I never give an initial sleep window below six hours and rarely do I give a sleep window at all below six hours.

One of the the things we know about sleep is that to be healthy in a physical way we need about five hours and 30 minutes and and the vast majority of people are actually getting that even if they don't recognize it and so we don't want to do anything that would keep Alex from getting that five and a half hours of sleep if possible. So we add that 30 minutes to get six hours and then we know six hours is how much time we want him to spend spend in bed. And if we look at his sleep diary we can see you know five mornings a week he's getting up at 6:00 am and but not getting out of bed until 6:30 and so we can just have a little conversation with Alex. and we want to find out what's the earliest time that he has to get up and that's going to become our anchor. And I'll ask Alex to make 6:00 a.m. or 6:30 a.m., where imagining here that he chose 6:00 a.m. so I'll ask him to say okay we're going to make 6:00 a.m. your wake up time 7 days a week. We want to keep that consistent that's going to be our Anchor Point and then as early as bedtime we just count back six hours which the math is very convenient here if we take away six hours that basically means he can go to bed at midnight. Which you'll see is much later than when he was getting in bed some night so this is a pretty good sign that this is going to be a helpful intervention for Alex that we'll be able to he'll be really good in tired when he gets to that earliest bedtime. and my best guest is that he will then start to get that increased quality of sleep that we're really going for. And now Kevin and I are going to do another little role play where we'll sort of talk about the Sleep window with the client and discuss the findings of the Sleep diary and and set the wake time and and bedtime and some of those things. so you ready Kevin.

Kevin Cornelius: All right.

LJ Davis: Awesome. Well, Kevin welcome welcome back this week and week and thank you so much for filling out the Sleep Diary. It's really going to give us some great information to work from and you know looking it over I don't know if you did any of the math to figure this out but it looks like on average you're getting about five and a half hours of actual sleep per night. Does that sound about right to you.

Kevin Cornelius: I think that's true yeah.

LJ Davis: Okay so what we're going to do we're going to use that five and a half hours to set your sleep window but we're actually going to give you 30 bonus minutes on top of that. So your sleep window will be 6 hours and that's how much time we want you to start spending in bed at night. That way we'll really improve your sleep quality. And you'll notice that you've been spending about seven and a half to nine and a half hours in bed most nights. You're spending like an hour and a half sometimes even or no sorry you're spending two hours more in bed than you're asleep most nights and sometimes even more than that. And what happens when we're in bed so much more than we're sleeping is that the quality of our sleep really decreases. And what we really want to do is get a really powerful sleep drive and that's going to improve the quality of your sleep. You won't have lots of light sleep where you're kind of going in and out and things like that that are often happening when you're in bed as much as you are. But instead you'll have a big solid chunk of sleep. And the way that we do that we really want to maximize your sleep drive. And we can think of your sleep drive as as being like a balloon for for some reason in my imagination it's always a red balloon but anyway you'll have this this nice red balloon and as soon as you get out of bed in the morning and start doing things it's like we're blowing up that balloon and we're just filling it full of air filling it full of air and we want to keep doing that throughout the day. And we don't want to get in bed before you're ready to go to sleep because anytime we spend napping is also something we'll talk more about we don't want to do any napping during the day right now. There's certain situations where we may but we'll we'll talk about that but when you get that balloon really big and full it's got lots of air in it then at night when you let go of the neck of the ball it's going to have enough air in there to really propel you to sleep more through the night than you have been and you'll get bigger chunks of higher quality sleep. does that make sense.

Kevin Cornelius: Yes it does.

LJ Davis: Okay well great so we're going to use this time that we talked about the six hours to set you a new sleep window. And if you think about the seven days of the week which day or days do you have to get up the earliest.

Kevin Cornelius: Yeah it's like weekdays, I have to get up at at 5:45.

LJ Davis: Okay so on weekdays you have to get up at 5:45 and so then what I'm going to ask you to do and this is one of the parts that can be challenging is to get out of bed at 5:45 seven days a week so that we really have a consistent sleep schedule. I know that's a big ask and I wouldn't make it if I didn't know how important it is. So is that something you think you could do is is even on the weekends when you've probably been wanting to sleep in a little bit more get up at 5:45 so we could really get your sleep problems taken care of.

Kevin Cornelius: Yeah I it's gonna be hard LJ but you know I trust you if you say that that's necessary I'll do that but I do like my extra sleep on Saturdays.

LJ Davis: And my my real hope is that we'll take care of your your sleep challenge and eventually we'll get back to what I call sleep in the wild. This is not a permanent lifestyle change but this is a necessary step to to get over the the insomnia and then you can start to loosen up on some of these once we've accomplished that. So glad to hear you can do that and then your sleep window is six hours so if you're waking up at 5:45 we're just going to count back six hours from that and that means 11:45 p.m. will be your earliest bedtime. And I want to be clear with you what I mean when I say earliest when you get to 11:45 if you're not sleepy we still don't want you to get into bed. So a couple of things about that is sleepy means like really genuinely sleepy like I'm having a hard time holding my eyes open or sometimes even my head is starting to nod, I really feel like I'm about to fall asleep not just tired not just like I'm kind of yawning a lot because I'm sure if you've been among a group of people at 5 o'clock in the afternoon if one of them yawns lots of people will yawn but they're not all ready to fall asleep. So yawns are not a good indicator. Does that make sense?

Kevin Cornelius: Yeah.

LJ Davis: Okay and then but if you are sleepy then that's when you can go ahead and get in bed and my experience is for most people the harder part is actually to stay awake until 11:45 like you've been getting in bed you know at 9:30 a lot of nights and I imagine you're really sleepy at that point. So can we talk about what you can do to stay awake until 11:45 and I could give you some ideas if if you want. Some people work on a puzzle or do a little light housework or I know for me like I I enjoy watching TV and I don't want to watch anything too stressful at that time but if I sit on my nice cozy couch I'll be out. It doesn't work for me to do that but we've got some bar stools that are wood and that kind of got me sitting up and a less comfortable posture. I can sit and watch TV there or even stand up. so what do you think will work for you to help you make sure you can stay awake until 11:45.

Kevin Cornelius: Yeah I think I'll go for the light housekeeping job and I'm sure my partner would appreciate that and that might make things a little more Harmony at home too.

LJ Davis: Okay awesome well that you get it two birds with one stone there so that's great yeah. Just work on that that housekeeping there and well I look forward to seeing you next week. Of course keeping the Sleep Diary so we get the information of how this goes this coming week and I look forward to to see how that goes for you.

Kevin Cornelius: Great.

LJ Davis: All right. Thank you so much Kevin. I'm seeing our time this is going a little bit slower than I'd hoped so I'll try to be quick and thorough going forward. So once they have started the Sleep Quality training then of course we start with that compressed window of time for sleep but we don't want to hold them there we're hoping that it will get to grow. And sometimes that happens quickly and sometimes it takes a little bit more time. But just some guidelines to think about each week if their sleep efficiency is 85% or greater then we can add a little bit of time to their sleep window and then 15 or 20 minutes are my typical additions there. And you know when I first say it 15 minutes doesn't sound like much but if you think about like two weeks then they have a half hour more sleep than they were getting when they came in and by the end of a month it could be an hour more sleep and of course that can keep going depending on where things started and what their ultimate sleep need is. If the Sleep efficiency is 80 to 85% I usually just hold steady there. Sometimes it takes a couple of weeks or a little bit longer even for everything to take effect and we may need to talk more about the stimulus control or some of the sleep faults that are getting in the way. Use some of the other CBT-I tools as well as the Sleep Quality training to start getting that effect and if their sleep efficiency is less than 80 we may consider shrinking the window. So like I said before I'd be hesitant to go below six hours but if their initial sleep window was maybe six and a half hours then they're not getting the Sleep efficiency we won't we may want to actually take away 15 minutes to try to really help them get that effect and start moving in the right direction. And then over time what almost always happens is their sleep window will start to grow because they'll be getting that good sleep efficiency and we can add on more time. And as that happens then we want to start paying attention to daytime fatigue, are they still feeling as tired as they did during the day. And when we get to a place where they're not feeling tired in the day and they're not sleepy before bedtime then we may have found their sleep need. And like Kevin said earlier we have this cultural myth of like eight hours of sleep is the right amount of sleep but the truth is that's an average and and that means you know some people need six hours of sleep. There's some people who need nine hours of sleep there's some some outliers who go even outside of those two things. So by using the Sleep diary we're going to find out what this person's actual sleep need is and that'll be a really helpful piece of information for them as they're going forward. and I put in a couple of questions that we got before when we did our earlier one because we didn't get a chance to get to them. We kind of already address the Apple watch or Fitbit question in the roleplay but again subjective experience and the accuracy of those devices are reasons we might not want to do that or why I wouldn't want to do that.

Another question which I thought is a really good one is which should I treat first insomnia or a mood disorder. And my thoughts on that is that there's we have to use our clinical judgment there. Depending on the severity of the mood disorder or whether it's presenting risks to their health and safety or to the health and safety of others of course we want to take those things into account and then there's some amount of like what are they more willing what are they more motivated towards is also a helpful thing to take into account. And it is true that improving sleep has been found to help people reduce depression symptoms so you know that may be a way to think about it. and then just in my experience that I can often do a combination like I may need to spend one or two sessions really getting the CBT-I part of things rolling and then once we have that we can sort of keep following up a little bit while we also do some mood work as part of our work together. And then the last one is what about CBD or other supplements and as Kevin said earlier neither he nor I are doctors and so we would not suggest people do any particular sort of biological intervention that's beyond our scope of practice. So I just steer clear for those reasons. Also though I'm pretty skeptical of over-the-counter supplements including melatonin. They're they're pretty poorly regulated and there've been lots of studies that have come out of them not actually having in them what they say they have in them, sometimes having other things in them sometimes just not having the active ingredient at all the dosages being really variable. So I'm just I don't mess with supplements. if a client's already taking them like I don't necessarily like tell them stop taking that thing right away but I will want us to start talking about that. And in the same way that we might do a a medication taper we might want to consider that with other supplements they're taking. And then about CBD specifically I don't have as much information about it as I would like but I know THC you know comes from the same plant reduces people's REM sleep. and sometimes people use it for that reason if they have nightmares they'll be using THC to reduce that REM sleep but it it does create a problem of dependence because when we have a drug suppressing our REM sleep when we don't use that drug there'll be a bounce back and so people who are using THC to avoid nightmares will get just a flood then of Dreams and Nightmares when they stop using it. And so that's something I would also want to take into account. Then we promised a slide with resources earlier. this will be in your package so I'm not going to go into a lot of detail here but I do want to highlight the top one cbtiweb.org/resources/assessment that's where you'll find the Sleep Diary, the stop bang and like I said lots of other tools there's also insomnia coach and doze app both of those are are apps that have been designed with CBT-I principles and then the book I usually get my insomnia clients to read is called good night mind it's by Colleen Carney she's an excellent clinician around sleep and she's who I got most of my CBT-I training from. So that said I'll move us over to Q&A time.

Q&A Session