Thank you for scheduling an appointment with me. First, I’d like to reassure you that you are likely coming to the right place. I have a lot of experience helping people overcome chronic insomnia and related sleep difficulties. In addition, I see adults individually for a wide variety of other issues, including difficulties with mood, anxiety, and other life challenges such as work and relationships. I am sending you information that can help us get a head start. If you no longer need this appointment, please let us know ASAP so we can offer it to someone else.
I use a highly effective form of therapy called Cognitive Behavioral Therapy for Insomnia (CBT-I). The research shows that CBT-I is more effective than medications, produces more lasting results, and has fewer side effects. For this reason, major medical associations (such as the American Academy of Sleep Medicine) recommend CBT-I as the preferred treatment for chronic insomnia. In my experience, people who make good faith efforts to implement CBT-I experience significant benefits within a relatively short period of time. If they stick with it, most people typically no longer meet diagnostic criteria for insomnia.
Many of the factors that maintain chronic insomnia can be addressed with behavior change. Often, people just need to know what to do and how to do it. CBT-I guided by a therapist is often conducted in about 4-6 sessions over about 2-3 months.
When we meet, I will identify factors that are likely maintaining your insomnia and give you specific treatment recommendations. If you choose to work with me, we can begin to collaboratively develop a customized plan. Follow up sessions are typically scheduled 1 to 2 weeks apart.
If you have not had a medical exam within the past year and since the insomnia began, I encourage you to schedule a check-up with your primary care physician. If you are taking a medication for sleep and wish to discontinue it, I can assist with this in consultation with your prescribing physician.
I have enclosed more information about CBT-I and links to online resources. I look forward to meeting with you.
PS: My office staff have likely already provided you with the “initial paperwork” either in paper form or by sending you links to the online versions of these forms. The latter can be accessed at the links below.
--
Behaviors that help to maintain biological sleep rhythms are maintaining a regular wake time 7 days a week and not going to bed too early (e.g., more than 8 hours before the regular wake time). When a person has been experiencing chronic insomnia, these behaviors alone may not be sufficient to restore sleep rhythms. Fortunately, there is a strategy that is highly effective. It involves temporarily reducing the amount of time the person spends in bed. This increases sleepiness during the sleep period, improves sleep quality, and helps to establish more regular sleep rhythms. This is followed by going to bed progressively earlier until they are getting enough sleep.
Behaviors that strongly associate the bed with sleep are not engaging in wakeful activities in bed (e.g., reading, watching TV) and not remaining in bed for extended periods when unable to sleep. Guidelines that have been shown to be effective for treating insomnia are: (1) Don’t get into bed unless you are sleepy; and (2) If awake in bed for more than 15-20 minutes, stop trying to fall asleep. Instead, get out of bed and engage in a low-key activity and don’t get back into bed until you do feel sleepy.
Third, the person may be too keyed up during the sleep period. This can be the result of muscle tension, a habit of ruminating and worrying while in bed, emotional distress about not sleeping, and trying too hard to fall asleep. Things that people can do to let go of physical and emotional tension include the following: (1) Employing relaxation techniques to let go of tension before getting into bed; (2) Learning meditative skills to let go of thoughts; (3) Maintaining a calm attitude during periods of insomnia; and (4) Refraining from exerting any effort to fall asleep.
A Brief Overview of CBT for Insomnia (CBT-I)
What maintains chronic insomnia and what can be done about it?
Everyone has their own unique story about what contributed to the development of their chronic insomnia. However, there are often three major factors that maintain most people’s insomnia. Each of them can be effectively addressed by specific behavioral strategies.
First, it is likely that the person’s biological rhythms that govern sleep have become disrupted. As a result, they are not sufficiently sleepy when they want to be sleepy. Behaviors that help to maintain biological sleep rhythms are maintaining a regular wake time 7 days a week and not going to bed too early (e.g., more than 8 hours before the regular wake time). When a person has been experiencing chronic insomnia, these behaviors alone may not be sufficient to restore sleep rhythms. Fortunately, there is a strategy that is highly effective. It involves temporarily reducing the amount of time the person spends in bed. This increases sleepiness during the sleep period, improves sleep quality, and helps to establish more regular sleep rhythms. This is followed by going to bed progressively earlier until they are getting enough sleep.
Second, it is likely that the person’s mind has come to associate their bed with being distressed about being awake. This can cause them to experience habitual responses while in bed that that interfere with sleep. Behaviors that strongly associate the bed with sleep are not engaging in wakeful activities in bed (e.g., reading, watching TV) and not remaining in bed for extended periods when unable to sleep. Guidelines that have been shown to be effective for treating insomnia are: (1) Don’t get into bed unless you are sleepy; and (2) If awake in bed for more than 15-20 minutes, stop trying to fall asleep. Instead, get out of bed and engage in a low-key activity and don’t get back into bed until you do feel sleepy.
Third, the person may be too keyed up during the sleep period. This can be the result of muscle tension, a habit of ruminating and worrying while in bed, emotional distress about not sleeping, and trying too hard to fall asleep. Things that people can do to let go of physical and emotional tension include the following: (1) Employing relaxation techniques to let go of tension before getting into bed; (2) Learning meditative skills to let go of thoughts; (3) Maintaining a calm attitude during periods of insomnia; and (4) Refraining from exerting any effort to fall asleep.
In summary, common goals of CBT-I are to restore a person’s biological sleep rhythms, strengthen their mind’s association of their bed with sleep, and help them let go of psychological and physical tension. Other things can contribute to insomnia and there are additional approaches in CBT-I that I have not fully described, but this should give some idea of what is involved.
CBT-I in practice
Implementing the strategies described above can require making significant behavior changes and perhaps learning a new skill (e.g., a relaxation or meditative technique). For this reason, it can be helpful to obtain the support and guidance of a therapist who knows how to guide people through the process. A therapist can help you identify which behavior changes are the most important, customize a general approach to your unique situation and preferences, troubleshoot difficulties, and monitor your progress.
Getting started with CBT-I
I always start with a thorough assessment of factors that could be contributing to maintaining insomnia. This helps to develop the initial treatment recommendations. I then work collaboratively with you to develop the specific treatment plan which will be informed by your preferences and readiness to implement behavior change. When you are ready, you begin implementing behavioral strategies and perhaps learning a new skill.
The key tool we use in CBT-I to guide treatment and monitor progress is a simple form known as a “Sleep Diary.” Each morning, it takes about 1-2 minutes to answer a few questions about your previous night’s sleep. This information is invaluable in understanding patterns and trends. Below is are links to webpages where you can download the Sleep Diary and upload a photo of a completed Diary.
Medication questions
I am not licensed to prescribe (or un-prescribe) medications. If you are taking a prescription medication for sleep we can work with your prescribing physician to factor this into your treatment plan. Many people desire to discontinue sleep medication, and I have helped many people do this in collaboration with their physicians.
Resources
I have a created a website that provides information about the major components of CBT-I and other relevant information: https://sites.google.com/site/cbtforinsomniacbti
You can download a PDF of the Sleep Diary from the website here: https://sites.google.com/site/cbtforinsomniacbti/sleep-diary
You can send me a photo of your Sleep Diary by uploading it to this page: https://www.cognitoforms.com/CorvallisClinic1/drbinggelifileupload
Recommended self-help book: Carney, C. E., & Manber, R. (2013). Goodnight mind: Turn off your noisy thoughts and get a good night's sleep. New Harbinger.
A Brief Overview of CBT for Insomnia (CBT-I)
Everyone has their own unique story about what contributed to the development of their chronic insomnia. However, there are often three major factors that maintain most people’s insomnia. Each of them can be effectively addressed by things that people can learn to do.
First, it is likely that the person’s biological rhythms that govern sleep have become disrupted. As a result, they are not sufficiently sleepy when they want to be sleepy. Second, it is likely that the person’s mind has come to associate their bed with being awake and being distressed. This can result in habitual ways of thinking and behaving that while in bed that can interfere with sleep. Third, the person may be too keyed up during the sleep period. This can be the result of muscle tension, a habit of ruminating and worrying while in bed, emotional distress about not sleeping, and trying too hard to fall asleep.
Common goals of CBT-I are to restore a person’s biological sleep rhythms, strengthen their mind’s association of their bed with sleep, and help them let go of psychological and physical tension.
The best way to restore the biological sleep rhythms is to optimize the person’s sleep-wake schedule. Behaviors that strongly associate the bed with sleep are refraining from engaging in wakeful activities in bed (e.g., reading, watching TV) and not remaining in bed for extended periods when unable to sleep. Ways that people can let go of physical and emotional tension include practicing relaxation and meditative techniques, maintaining a calm attitude during periods of insomnia, and refraining from exerting any effort to fall asleep.
Implementing the strategies described above can require making significant behavior changes and perhaps learning a new skill (e.g., a relaxation or meditative technique). For this reason, it can be helpful to obtain the support and guidance of a therapist who knows how to guide people through the process. A therapist can help identify which behavior changes are the most important, customize a general approach to a person’s unique situation and preferences, troubleshoot difficulties, and monitor progress.
Getting started with CBT-I
I have a created a website that can help guide you in using CBT-I: https://sites.google.com/site/cbtforinsomniacbti. The key tool we use in CBT-I is a simple form known as a “Sleep Diary.” I have enclosed a copy and you can also download a PDF of the diary from the website. The instructions for the diary include a method for you to send a photo of a completed diary to me.
s
Before our first appointment, you have two options regarding your sleep-related behaviors. One option is to make no major changes. A second option would be to follow guidelines that are consistent with CBT-I that may help to begin to improve your sleep. If you have chronic insomnia, it is likely you will still need the additional strategies you will learn with therapist-guided CBT-I, but these could give you a head start.
(1) Set an alarm to wake up to at the same time every morning, and consistently get up soon after it goes off. Avoid sleeping in late.
(2) Go to bed only when you are sleepy and not just when you are merely fatigued. Fatigue is a state of low energy, physical or mental. Sleepiness is a state of having to struggle to stay awake.
(3) Avoid napping. If you do nap, limit it to one nap per day of less than 20 minutes (use an alarm). It is best to time this nap at least 6 hours before bedtime.
(4) Use your bed only for sleep. Sexual activity is ok. But avoid doing other things in bed (such as reading or watching TV).
(5) Limit light exposure in the evening and at night. Keep your lights relatively low. Additional ways to limit
The blue portion of the light spectrum can interfere with sleep.
Amber-colored glasses that block blue light can be obtained (e.g., Uvex Skyper or Uvex S0360X for wearing over eyeglasses). You can get them at the Corvallis Clinic Sleep Medicine Department on the 2nd floor of the Asbury Building or online. If you use electronic devices, consider installing software or using built in settings designed to reduce blue light outpout. F.lux (https://justgetflux.com) is a free program for Windows, Mac, Linux, iPhone, and iPad. Twilight (http://twilight.urbandroid.org) is a free program for Android. On the iPhone, you can use the “Night Shift” setting (Go to Settings > Display & Brightness > Night Shift). If you use a night light, use an amber-colored one.
(6) Keep your bedroom cool and dark.
(7) Get plenty of light exposure during the day, especially soon after awakening.
(8) Engage in physical exercise every day (but not in the hour before bed).
(9) Allow for a “wind down” period before bedtime in which you engage in calming activities. This is a good time for using relaxation techniques.
(10) Avoid substances that disrupt sleep, including caffeine and alcohol, particularly within 8 hours of when you intend to sleep.
(11) Schedule a time to deal with your worries well before bedtime.
(12) If you worry during the night, write the worry down, but don’t dwell on it. Deal with it doing a scheduled worry period the next day.
(13) Refrain from “trying to sleep.” Sleep does not come from effort. It comes from the lack of effort.
(14) Don’t remain awake in bed for long periods (e.g., anything more than 20 minutes), particularly if you are feeling anxious or frustrated. This associates your bed with negative experiences, and this contributes to insomnia. You will most likely be better off if you go to another room and do something interesting but not overly stimulating. Then, return to bed when you feel sleepy and try not to fall asleep somewhere other than your bed. Exercise caution, because getting out of bed during the night may increase the chance of falls. A dim flashlight is recommended, and an amber-colored one is optimal.
(15) Avoid clockwatching. It is better not to know what time it is.
--
Learn to Sleep