End the Insomnia Struggle A Step by Step Guide to Help You

Get to Sleep and Stay Asleep

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 “I’m impressed. This is easily the most comprehensive and practical approach I’ve ever read
on how to treat insomnia. I thought I had a pretty good handle on this topic, but was surprised
to find large gaps in my knowledge, and quite a number of erroneous beliefs (don’t tell
anyone, please!). The authors expertly synthesize acceptance and commitment therapy (ACT)
and cognitive behavioral therapy (CBT) (which is no easy feat) to offer effective treatment for
a wide range of sleep difficulties across the whole spectrum of DSM disorders. So, if you want
to help your clients to sleep better without drugs, you need this book.”
—Russ Harris, author of The Happiness Trap and ACT Made Simple
“This fantastic toolkit is like getting to have two of the smartest, most empathic insomnia
treatment experts in the world be your doctors. Clear instructions and flexible, doable steps
transform the highest-quality treatment into a do-it-yourself plan that will make it possible to
get a good night’s sleep again.”
—Kelly Koerner, PhD, Evidence-Based Practice Institute, Seattle, WA
“For those of us who lie awake at night wondering when sleep is going to arrive and what
tomorrow will be like without it, End the Insomnia Struggle offers hope. In this well-written
and accessible manual, Colleen Ehrnstrom and Alisha Brosse, two experienced clinical
psychologists, take us through the reasons that people can’t sleep, and the behavioral and
cognitive strategies that help them overcome insomnia. Readers will appreciate the handouts
for recording one’s progress in the program and the many recommendations on how to
troubleshoot one’s sleep plan. The one-size-fits-all approach of many cognitive-behavioral
manuals is replaced here with acceptance, mindfulness, and commitment strategies to help you
individualize behavioral sleep tools. A must-read for people with insomnia and the clinicians
who work with them.”
—David J. Miklowitz, PhD, professor of psychiatry and behavioral sciences at the
UCLA School of Medicine, Los Angeles, CA; and author of The Bipolar Disorder
Survival Guide
“End the Insomnia Struggle is a wonderful and much-needed book. Ehrnstrom and Brosse
not only provide clear descriptions of the core tools needed to help promote healthy sleep, they
also pour into each page their wealth of expertise working with people struggling with
insomnia. The result is that they are there with you, as the reader, every step of the way,
guiding you clearly, firmly, and gently along the path to better sleep.”
—Sona Dimidjian, PhD, associate professor in the department of psychology and
neuroscience at the University of Colorado Boulder
“End the Insomnia Struggle is a must-have for anyone struggling to sleep well. Clinical
science has validated a number of very effective strategies for insomnia, but unfortunately,
these strategies are very challenging to put into action. The authors have put their combined
forty-plus years of clinical experience into providing a comprehensive program in a very
straightforward way that a motivated person can actually do on their own, or that counselors
could readily use to guide their clients. The book is user friendly, and addresses all the possible
excuses and roadblocks that might get a person off track. Their distinction between worry
(future-oriented) and rumination (past-oriented) is particularly helpful. I have already made a
list of family and friends to send this book to. Give it a try yourself!”
—Linda W. Craighead, PhD, professor of psychology and director of clinical training at
Emory University, and author of The Appetite Awareness Workbook

Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the
subject matter covered. It is sold with the understanding that the publisher is not engaged in
rendering psychological, financial, legal, or other professional services. If expert assistance or
counseling is needed, the services of a competent professional should be sought.
Distributed in Canada by Raincoast Books
Copyright © 2016 by Colleen Ehrnstrom and Alisha L. Brosse
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
 www.newharbinger.com
Cover design by Amy Shoup
Interior design by Michele Waters-Kermes
Acquired by Catharine Meyers
Edited by Ken Knabb
All Rights Reserved

Library of Congress Cataloging-in-Publication Data on file

 Contents

Introduction
The Sweet Spot
Who Can Benefit from This Book
How to Use This Book

Part 1: Laying a Foundation

Chapter 1: Taking a Look at Your Sleep

Effectiveness as Your Compass
Sleep Log
Common Questions (and Answers) or Roadblocks (and Possible Solutions)
Are You Willing to Start the Sleep Log?
Should You Have an Overnight Sleep Study?
Do You Have a Circadian Rhythm Disorder?
What Is Insomnia Costing You?
Your Next Step

Chapter 2: How Sleep Works

The Physiology of Sleep
Your Sleep Drive
Your Internal Body Clock
A Well-Choreographed Dance
How You Influence Your Sleep Physiology
Your Next Step

Chapter 3: The Insomnia Spiral

How People Get Stuck
A Case Example: How George Got Stuck
 A Balancing Act
Stopping the Spiral

Chapter 4: Willingness: The Opposite of Struggle

Willingness as a Tool for Sleep
Willingness to Make Changes That Are Uncomfortable
The Value of Emotional Discomfort
Willingness to Not Sleep
Acceptance Is Not Resignation
Recognize How You Struggle with Sleep
Your Willingness Plan

Chapter 5: Create Your Own Individualized Treatment Plan

Is Insomnia the Right Place to Start?
Your Insomnia Snapshot
Your Insomnia Treatment Program
Choosing a Behavioral Treatment Program
Alternative Routes for Your Next Step
Choosing Cognitive Treatment Strategies
What to Do About Medications or Herbal Remedies That You Take for
Sleep
Your Next Step

Part 2: Behavioral Strategies

Chapter 6: Retrain Your Brain (Stimulus Control Therapy)

Who Should Use Stimulus Control Therapy?
Stimulus Control Therapy: Detailed Instructions
Common Questions (and Answers) or Roadblocks (and Possible
Solutions)
What to Expect
Your Stimulus Control Therapy Plan
 Your Next Step
How to Evaluate Your Progress and When to Consider a Different Plan

Chapter 7: Quality Over Quantity (Sleep Restriction Therapy)

Who Should Use Sleep Restriction Therapy?
Sleep Restriction Therapy: Detailed Instructions
Common Questions (and Answers) or Roadblocks (and Possible
Solutions)
What to Expect
Your Sleep Restriction Therapy Plan
Your Next Step
How to Evaluate Your Progress and When to Consider a Different Plan

Chapter 8: Combining Stimulus Control and Sleep Restriction

Who Should Use Combined SCT-SRT?
Combined SCT-SRT: Detailed Instructions
Your Combined SCT-SRT Plan
Your Next Step

Chapter 9: Sleep Hygiene

Sleep Hygiene Guidelines
Maintain a consistent sleep schedule.
Have a brisk wakeup, and get natural light within one hour of waking.
Eliminate or limit napping.
Eliminate or limit your stimulant intake.
Avoid activating medications at night.
Limit your use of alcohol and do not drink within three hours of bedtime.
Go to bed neither too hungry nor too full.
Exercise regularly, but not right before bed.
Engage in a wind-down routine.
Dim ambient lighting in the hour before bedtime.
Turn off electronic devices an hour before bedtime.
Sleep on a comfortable bed.
Create a comfortable bedroom environment.
Limit disruptions from your bed partners.
 How to Make Hard Changes
Be Flexible
Increase Willingness
Have Realistic Expectations
Base Decisions on Data
Make a Plan
Your Sleep Hygiene Plan

Summary of Part 2: Behavioral Strategies

Part 3: Cognitive Strategies

Chapter 10: Changing What You Think (Cognitive Restructuring)

Who Should Use Cognitive Restructuring?
Negative Cognitions
Cognitive Distortions
Unhelpful Cognitions
Cognitive Restructuring
Example: George’s Cognitive Restructuring
Challenging Common Cognitive Distortions About Sleep
How Cognitive Restructuring Can Go Awry
Common Questions (and Answers)
Your Cognitive Restructuring Plan
What to Expect
How to Evaluate Your Progress and When to Consider a Different
Strategy
Your Next Step

Chapter 11: Changing When and Where You Think (Designated Worry
Time)
Who Should Use Designated Worry Time?
Designated Worry Time for Chronic Worriers
Designated Worry Time for Insomnia
How to Use Designated Worry Time
 Common Questions (and Answers)
Your Designated Worry Time Plan
How to Evaluate Your Progress and When to Consider a Different
Strategy
Your Next Step

Chapter 12: Accepting Your Thoughts (Mindfulness and Cognitive

Defusion)
Who Should Use Mindfulness and Cognitive Defusion?
Mental Fitness
Mental Fitness and Sleep
Mindfulness
Mindfulness Exercises
Summary of Mindfulness Exercises
Cognitive Defusion
Cognitive Defusion Exercises
Example: George’s Use of Mindfulness and Defusion
How Mindfulness and Cognitive Defusion Go Awry
Common Obstacles (and Possible Solutions)
Your Mindfulness and Cognitive Defusion Plan
What to Expect
How to Evaluate Your Progress
Your Next Step

Summary of Part 3: COGNITIVE STRATEGIES

Part 4: Reviewing Your Progress and Maintaining Your Gains

Chapter 13: How Effective Is Your Program?

Taking Stock
How Are You Sleeping?
How Do You Feel During the Day?
 Have You Found Your Sweet Spot?
How Closely Have You Followed Your Treatment Program?
Have You Used Effectiveness as Your Compass?
The Next Leg of Your Adventure
Common Questions (and Answers) About Planning the Next Leg of Your
Adventure
Your Next Step

Chapter 14: Maintaining Gains Across Contexts

Transitioning from Your Sleep Program
Decide What to Keep in Place
Change One Element at a Time
Use Your Sleep Log
Anticipate Triggers for Sleep Disruption
Responding to Lapses and Relapses
Remember: Sleep to Live, Don’t Live to Sleep
Your Next Step

Chapter 15: Last Words

Acknowledgments

Appendix A: Circadian Rhythm Disorders

Do You Have a Sleep Preference or a Sleep Problem?
Accommodating Your Body’s Natural Rhythm
Shifting Your Body’s Schedule
Behavioral Therapy
Moving Your Bedtime and Wake Time
Deliberate Timing of Your Activities
Routine as an Anchor
Sleep Hygiene
Light Therapy
Advanced Sleep Phase syndrome
Delayed Sleep Phase syndrome
Adding Light
Blocking Light
 Melatonin
Chronotherapy
Summary

Appendix B: Insomnia and Menopause

Treat Your Hot Flashes
Treat Your Sleep Disturbance
Stimulus Control Therapy (SCT)
Hot Flash–Specific Sleep Hygiene
Acceptance-Based Strategies
Your Next Step
References
 Introduction

If you have trouble falling asleep or staying asleep, or you do not feel
refreshed in the morning even after a full night’s sleep, you are not alone.
Insomnia is a large-scale problem, with one in three people experiencing
insomnia in their lifetime, and about one in ten US adults reporting
insomnia that is severe and chronic (National Institutes of Health, 2005).
You also are not alone in what insomnia is costing you. Are you
exhausted during the day? Do you move more slowly and get less done? Do
you have trouble with memory or concentration? Do you worry that others
can see that something is wrong? Do you give up activities either because
you are too tired or because you worry that the activity will make it hard to
sleep? Perhaps you are more irritable than your normal, well-rested self.
Maybe you have a lot of anticipatory stress and anxiety about how you will
sleep tonight. Insomnia is not only about how you sleep at night. It is also
about how you suffer during the day.
Nearly everyone struggles with sleep from time to time, but if poor sleep
has become the new norm for you, you may have adopted some behaviors
to try to cope (for example, staying in bed longer and longer). You also may
be so worried about sleep that you are preoccupied with thoughts about how
you will sleep (I have to sleep tonight, I just have to!) or about the possible
consequences of sleeping poorly (Tomorrow is going to be awful!). These
behaviors and thoughts are perfectly natural responses to poor sleep—and
they tend to make insomnia worse, interfering with your body’s ability to
naturally self-correct when sleep gets off track. Cognitive behavioral
therapy for insomnia (CBT-I) addresses the thoughts (also called
cognitions) and behaviors that influence sleep, helping people get out of
their own way so their minds and bodies can remember how to sleep again.
Decades of research show that CBT-I works as well as sleep medications
by the end of a six-session treatment program, and better than medications
when people are interviewed a year after the program (Mitchell et al.,
2012). Unfortunately, many communities do not have enough professionals
trained to provide high-quality CBT-I, and some people cannot afford the
cost of seeing a professional for six sessions. Fortunately, there are many
books available to walk you through a standard CBT-I program. These
books have been valuable resources for the millions of people who live with
insomnia.

The Sweet Spot

So why another book on insomnia? About ten years ago we were
approached by a psychiatrist who specializes in sleep medicine. He was
desperate for people like us, clinical psychologists trained in cognitive
behavioral therapy, to start providing CBT for insomnia. We dove in,
excited to be able to offer a treatment that works so well for so many. For
the most part, it was very gratifying work, because so many clients
responded well and quickly to a brief CBT-I intervention.
However, we also met many people who claimed that they already had
tried CBT-I—using a self-help book or very basic instructions from a doctor
—without success. We started to see certain patterns, with two main groups
of people for whom CBT-I did not seem to be working. The first group of
people were those who did not really complete the program. Some became
frustrated and gave up on CBT-I when they did not see quick results; others
were too scared to fully implement the program, though they generally
believed that they had done the treatment as prescribed. The second group
of people were those who wanted the program to work so badly that they
took it on like military boot camp—they tried very hard and followed all the
rules very strictly. Despite all their best intentions and effort, their sleep did
not improve, and their lives revolved around sleep, adding to their
frustration.
We learned that there is a sweet spot. To successfully use CBT-I you need
to:

be strict enough with yourself that you are actually doing the
treatment fully and it has the time it needs to work; but
not so strict that your anxiety increases or that you do not allow
yourself to adapt the treatment to your own unique situation and
circumstances.
 We teach people to achieve the sweet spot. We blend traditional CBT-I
with parts of a treatment called acceptance and commitment therapy (ACT).
The addition of ACT strategies has helped many of our clients become more
willing to do CBT-I fully, and to stay committed through some initial
discomfort, allowing them to benefit from the full power of CBT-I. We will
be emphasizing willingness and commitment throughout this workbook.
ACT also provides some additional tools for working with the thoughts that
impact your sleep, such as mindfulness and cognitive defusion (chapter 12).
Finally, ACT’s focus on acceptance (chapter 3) has helped our clients
decrease their struggle with sleep and with the daytime consequences of
insomnia, changing their relationship with sleep.
You see, your relationship with sleep really does matter. If you try to
control sleep, it may end up controlling you! Unfortunately, some people
perceive CBT-I and other sleep strategies as more ammunition to control
their sleep. We would like to suggest something different: think of all of our
recommendations as strategies to promote (rather than control) sleep. The
difference may seem subtle, but the result of this shift in perspective can be
quite profound.

Who Can Benefit from This Book

This hybrid CBT-ACT program is specifically designed to help you with
insomnia, which can be defined as difficulty falling or staying asleep, or
nonrestorative sleep, with negative daytime consequences such as fatigue or
difficulty concentrating. It is not likely to help you if you are sleep deprived
simply because you do not have enough time to sleep.
If you can get plenty of good-quality sleep but only at a time that is out
of sync with everyone else (for example, if your body can sleep 7 p.m. to 3
a.m., or 3 a.m. to 11 a.m.), you may have a circadian rhythm disturbance.
Many people with circadian rhythm disturbances also have insomnia and
can benefit from this entire workbook. However, only appendix A directly
targets shifting your clock. We do not specifically address circadian rhythm
issues related to jet lag and shift work.
Many people with disorders like sleep apnea, periodic limb movements,
and restless legs syndrome also have insomnia, and can benefit from this
book. However, these conditions need to be treated by a physician, and we
encourage you to seek treatment before beginning this program (more on
this in chapter 1).
If you have a medical condition like bipolar disorder or a seizure
disorder, we strongly encourage you to use this book with the close
guidance and supervision of a professional who is trained in CBT-I and has
working knowledge of your medical condition. Some components of CBT-I
will initially lead to less rest or sleep. This can make seizures and mood
instability more likely in people who are vulnerable. With proper
supervision, you can benefit from this program even with these
vulnerabilities.

How to Use This Book

This book is not about what works for everyone. It is a book designed to
help you figure out what will likely work for you, with your unique
physiology, environment, and lifestyle. Unlike some CBT-I therapists, we
do not believe that all people need every component of CBT-I, and we tailor
the order of the different components or strategies based on our assessment
of each patient.
To help you pick which parts of CBT-I are most suited to your sleep
problems, in this book we will make extensive use of a sleep log and other
assessments (chapter 1). Therefore, we strongly encourage you to read the
next chapter and start to complete your sleep log before progressing to later
chapters. Effective treatment begins with thorough assessment. Plus, CBT-I
relies on ongoing information collection to help you guide the pace and
direction of your program.
While you are collecting data with your sleep log, you can complete the
rest of the assessments in chapter 1, learn about sleep and about what
maintains insomnia over time in chapters 2 and 3, and start working on your
relationship with sleep by reading chapter 4. Then, with information from
your sleep diaries in hand, we will help you (in chapter 5) create an
individualized treatment plan using the strategies outlined in chapters 6–12
that are most suited to your situation. You won’t necessarily be reading all
of these chapters. Instead, we will guide you to the chapters relevant to your
individualized treatment program. Consistent with our goal of helping you
individualize the treatment, with each part of the treatment program we will
do a lot of “troubleshooting” to help you take into account your unique
circumstances and potential roadblocks.
In chapter 13 we will ask you to reevaluate your sleep and will give you
some suggestions for further steps if it is not where you would like it to be.
In chapter 14 we will help you keep sleeping well by anticipating and
protecting yourself against future sleep disruptors.
The last part of the book is devoted to topics that may or may not be
relevant to you. We discuss circadian rhythm problems (appendix A) and
insomnia related to menopause (appendix B) because we are so frequently
faced with these issues when treating people with insomnia.
Your sleep will not improve just by reading this book. You cannot
become proficient at any skill (knitting, woodworking, skiing, golf,
swimming, cooking, and so on) just by reading about it. Rather, you have to
have direct experience, and practice. Take your time working through this
book. Answer the assessment questions we pose. Collect data for a couple
of weeks. Work through the exercises in chapter 5 to develop an
individualized program. Read thoroughly the chapters related to the
strategies you select. Complete the worksheets that will help you
personalize each strategy. (You can download the worksheets, listen to
guided audio exercises, and access other related material at
http://www.newharbinger.com/33438. If you are a clinician, you will find a
bonus chapter on how to use this book with your clients.) Consider the
possibility that the slower you go, the faster you will get to your goal.
We know how painful and costly insomnia can be. We are optimistic that,
with our individualized approach that combines CBT-I and ACT, we can
help you build and implement a treatment program that will enable you to
sleep better and enjoy life more.
 Part 1

Laying a Foundation