Table Of Content“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.”
—R uss 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 treat-
ment experts in the world be your doctors. Clear instructions and flexible, doable steps transform
the highest-q uality treatment into a do-i t-y ourself plan that will make it possible to get a good
night’s sleep again.”
—K elly Koerner, PhD, Evidence-B ased 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-w ritten 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-s ize-
fits-a ll approach of many cognitive-b ehavioral manuals is replaced here with acceptance, mindful-
ness, and commitment strategies to help you individualize behavioral sleep tools. A must-r ead for
people with insomnia and the clinicians who work with them.”
—D avid 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-n eeded 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.”
—S ona Dimidjian, PhD, associate professor in the department of psychology and
neuroscience at the University of Colorado Boulder
“End the Insomnia Struggle is a must-h ave 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-p lus years of clini-
cal experience into providing a comprehensive program in a very straightforward way that a moti-
vated 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-o riented) 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!”
—L inda W. Craighead, PhD, professor of psychology and director of clinical training at
Emory University, and author of The Appetite Awareness Workbook
End the
Insomnia
Struggle
A Step-by-Step Guide to Help You
Get to Sleep and Stay Asleep
Colleen Ehrnstrom, PhD, ABPP
Alisha L. Brosse, PhD
New Harbinger Publications, Inc.
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 ser-
vices. 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 1
Part 1: Laying a Foundation
1 Taking a Lok at Your Slep 7
2 How Slep Works 25
3 The Insomnia Spiral 31
4 Wilingnes: The Oposite of Strugle 41
5 Create Your Own Individualized Treatment Plan 49
Part 2: Behavioral Strategies
6 Retrain Your Brain (Stimulus Control Therapy) 7
7 Quality Over Quantity (Slep Restriction Therapy) 93
8 Combining Stimulus Control and Sleep Restriction 111
9 Slep Hygiene 19
Part 3: Cognitive Strategies
10 Changing What You Think (Cognitive Restructuring) 139
11 Changing When and Where You Think (Designated Worry Time) 153
12 Accepting Your Thoughts (Mindfulness and Cognitive Defusion) 165
End the Insomnia Struggle
Part 4: Reviewing Your Progress and Maintaining
Your Gains
31 w o H E e v t i c e f f sI ru o Y ? g a m r o r P 183
41 ainM aitnin g aiGn s so r c A nCo ts x e t 195
51 t Las dr o W s 203
kncA de l w o neg m t s 205
nepA di x A : dac i r C ani yth R m h drDoi s s r e 207
nepA di x B : nI mnos a i and neM e su a p o 215
nere f e R s e c 219
iv
Introduction
f 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-
I 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-r ested 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 pre-
occupied 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-c orrect 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-s ession 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-q uality 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.
End the Insomnia Struggle
eTh t e e w S t o p S
So why another book on insomnia? About ten years ago we were approached by a psychia-
trist who specializes in sleep medicine. He was desperate for people like us, clinical psy-
chologists 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-h elp book or very basic instructions from a doctor—w ithout 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—t hey 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 strat-
egies 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
2
Introduction
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-A CT 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-q uality 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 distur-
bances 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 com-
ponents 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 assess-
ment of each patient.
3
