Certificate Course in Cognitive Behavioral Therapy for Insomnia (CBT-I): Evidence-based Insomnia Interventions for Trauma, Anxiety, Depression, Chronic Pain, & more
Program Information
Objectives
Select assessment tools that screen for other sleep disorders and identify insomnia treatment targets as it relates to case conceptualization.
Teach clients about the science of sleep and the causes of chronic insomnia for purposes of client psychoeducation.
Ascertain key perpetuating factors for chronic insomnia to understand the etiology of chronic insomnia.
Collaboratively design a sleep schedule with clients using a sleep diary to improve client’s sleep efficiency and daytime functioning.
Combine stimulus control and sleep restriction therapy to address the three major causes of chronic insomnia.
Select counter-arousal strategies to target hyper arousal in clients.
Modify a client’s distorted beliefs about sleep using cognitive therapy techniques to improve adherence and decrease sleep related anxiety.
Explore three models of CBT-I delivery and implementation issues for different practice settings.
Select CBT-I treatment components to target perpetuating factors in clients with comorbid insomnia.
Use cognitive and behavioral strategies to improve adherence with depressed clients.
Modify treatment recommendations for clients who have symptoms of high sleep anxiety.
Anticipate and resolve common treatment challenges in clients with PTSD such as sleep avoidance, fear of loss of vigilance and nightmare awakenings.
Apply CBT-I techniques to clients with mild traumatic brain injury.
Develop strategies to re-associate bed with sleep in clients with chronic pain.
Combine CBT-I with a guided hypnotic taper to reduce rebound insomnia and psychological dependence in clients who wish to decrease or discontinue their use of sleep medication.
Implement clinical treatment strategies to improve CPAP adherence in clients with co occurring obstructive sleep apnea.
Combine behavioral interventions with evidence-based strategies, such as light therapy and strategically-timed melatonin, to “reset the clock” in clients with circadian rhythm sleep disorders.
Use imagery rehearsal therapy to improve frequency and intensity of recurrent nightmares in clients with or without PTSD.
Practice using advanced case formulation techniques to accurately select combination and order of CBT-I components.
Outline
DAY 1: Assessment and the Basics of CBT-I
Assessment
Goals of assessment
Clinical tools for assessing insomnia
Screen for other sleep disorders
When to make a referral to a sleep clinic
Contraindications for CBT-I
Sleep and its Regulation
Normal sleep architecture
Two-process model of sleep: Circadian rhythm and sleep drive
The arousal system
What causes chronic insomnia?
Key perpetuating factors for chronic insomnia
Behaviors that interfere with “buildup” of sleep drive
Behaviors that interfere with the optimal timing of sleep
Conditioned arousal and physiological/ cognitive hyperarousal
Perpetuating factors and CBT-I
Step-by-Step Guide to CBT-I: Stimulus Control and Sleep Restriction Therapies
Stimulus Control (SC): Addressing conditioned arousal
Rules for re-associating the bed with sleep
Identify and overcome potential obstacles to adherence
Sleep Restriction Therapy (SRT): Restoring the sleep drive
How to present rationale
Calculate time-in-bed prescription
Placing the time-in-bed window
Identify and overcome potential obstacles to adherence
Sleep extension
Combining SC and SRT
The myth of sleep hygiene
Step-by-Step Guide to CBT-I: Cognitive Therapy and Counter-arousal
Counter-arousal strategies: Quieting an active mind
Establishing a buffer zone
Processing strategies (including constructive worry and rumination strategies)
Mindfulness and relaxation therapies
Cognitive therapy: Identify and change distorted thoughts about sleep
Thought Records
Behavioral Experiments
Socratic Questioning
Implementation Issues
Models of Delivery
Four session individual therapy format
Seven session group therapy format
Single session CBT-I
CBT-I and hypnotic medication
Practice guidelines: CBT-I as first line treatment for chronic insomnia
Combining CBT-I with sleep medication
Positive and negative effects of sleep medications
Use of ineffective sleep medications
Promote non-contingent use of sleep medication
Strategies to support hypnotic discontinuation
DAY 2: Delivering CBT-I in the Context of Comorbidities
Depression
CBT-I and MDD
Troubleshooting adherence in depressed patients
Anhedonia
Sleep or bed as avoidance
Fatigue and fatigue management strategies
Rumination in depression
Case examples
Sleep and antidepressants
Anxiety
Sleep effort: Core target of CBT-I
Covert manifestations of sleep effort
Cognitive restructuring of sleep anxiety
Paradoxical Intention
Troubleshooting adherence with anxious clients
When SRT/SC increase anxiety
Counter control and sleep compression
High sleep anxiety vs high arousal
Panic Disorder and nocturnal panic
OCD and CBT-I
Trauma
Sleep and PTSD
CBT-I trials in PTSD
Behavioral targets in clients with insomnia vs PTSD
Common treatment challenges in clients with PTSD
Nightmares and nightmare treatments
Traumatic Brain Injury (TBI)
Comorbid TBI
Sleep and TBI
Efficacy of CBT-I in mild TBI (mTBI)
Modify insomnia treatment for mTBI
Chronic Pain
Efficacy of CBT-I for those with chronic pain
Chronic pain and stimulus control
Common treatment challenges in clients with chronic pain
Pain medications and other considerations
Hypnotic Discontinuation
Combined guided hypnotic taper approach
Factors sustaining hypnotic dependence
Unhelpful beliefs
Learning
Strategies to support client during hypnotic taper
Psychoeducation about psychological dependence and rebound insomnia
Cognitive therapy to target unhelpful beliefs
Sample taper schedules
DAY 3: Co-Occurring Sleep Disorders and Advanced Case Formulation
Co-Occurring Sleep Apnea
Obstructive sleep apnea (OSA)
Morbidity and mortality of OSA
Relationship of nocturia and OSA
Sleep apnea treatments
Obstacles to treatment adherence
Physical comfort
Mechanical problems
Social and other factors
Psychological factors
Improve adherence
Work with stages of change
Respond to common concerns
CPAP desensitization for claustrophobia
Treating insomnia in patients with comorbid OSA
Circadian Rhythm Sleep Disorders
Using light to leverage circadian timekeeper
“Exogenous” circadian challenges
Cope with shift work
Adjust to jet lag
“Endogenous” circadian disorders: Advanced and delayed sleep phase
Phototherapy for delayed sleep phase
Imagery Rehearsal Therapy for Nightmares
Nightmares and nightmare disorder
Differential diagnosis
Assessment
Self-monitoring via nightmare log
Combine nightmare log and sleep diary
Imagery Rescripting and Rehearsal
Psychoeducation and rationale
Nightmares and trauma
Shaping imagery skills
IRT steps
Prazosin for nightmares
Advanced Case Formulation in CBT-I
Case conceptualization: Asking the right questions