Clinical Management of Insomnia Using Cognitive Therapy

Transcription

1 BEHAVIORAL SLEEP MEDICINE, 4(3), Copyright 2006, Lawrence Erlbaum Associates, Inc. Clinical Management of Insomnia Using Cognitive Therapy Lynda Bélanger École de Psychologie Université Laval Quebec, Canada Josée Savard École de Psychologie and Center for Cancer Research Université Laval Quebec, Canada Charles M. Morin École de Psychologie Université Laval Centre de Recherche Université Laval Robert Giffard Quebec, Canada Cognitive therapy has been shown effective in the treatment of several psychological and health-related disorders. It is also increasingly used in the management of insomnia. This article outlines some principles and applications of this therapeutic approach as adapted to the treatment of insomnia. Based on Beck s model, this psychotherapeutic approach seeks to modify sleep-related dysfunctional beliefs and thoughts and maladaptive cognitive processes involved in the exacerbation and perpetuation of insomnia. This is accomplished through the use of several cognitive restructuring procedures. After outlining a conceptual model of insomnia, which emphasizes the mediating role of dysfunctional cognitions in the development and maintenance of chronic insomnia, the rationale and general principles of cognitive therapy for insomnia are presented, followed by a description of the treatment procedures, clinical case illustrations, and practical implementation issues. Future directions include the need to refine cognitive interventions and to examine the unique contribution of this therapeutic component to the overall efficacy of multifaceted cognitive behavioral therapy. Increasing recognition of the mediating role of emotional, behavioral, and cognitive factors in insomnia has stimulated much interest in the development, valida- Correspondence should be addressed to Charles M. Morin, École de Psychologie, Université Laval, Quebec, Canada G1K 7P4. cmorin@psy.ulaval.ca

2 180 BÉLANGER, SAVARD, MORIN tion, and utilization of cognitive behavioral therapy (CBT) for the management of insomnia. CBT is a multicomponent intervention that aims at curtailing sleep-incompatible behaviors, attenuating arousal, and altering sleep-related dysfunctional cognitions, all of which are hypothesized to play a major role in maintaining and exacerbating insomnia over time. It includes procedures such as stimulus control, sleep restriction, relaxation, and cognitive restructuring therapy (Morin & Espie, 2003). CBT has received extensive controlled evaluations and has become the treatment of choice among psychological interventions for persistent insomnia (Morin, Bootzin, Buysse, Edinger, Espie, & Lichstein, in press; National Institutes of Health, 2005). Results from controlled clinical trials indicate that 70% to 80% of patients with primary insomnia benefit from CBT and that treatment gains are well sustained over time (Morin, Culbert, & Schwartz, 1994; Morin, Colecchi, Stone, Sood, & Brink, 1999; Murtagh & Greenwood, 1995; Smith et al., 2002). Behavioral procedures such as stimulus control, sleep restriction, and relaxation are relatively well known and have been extensively evaluated as single therapies for insomnia; however, although cognitive therapy is increasingly incorporated into multicomponent approaches, less attention has been devoted to describing and evaluating the efficacy of this therapeutic component in the management of insomnia. The goal of this article is to outline some basic principles of cognitive therapy and illustrate implementation of some cognitive therapy procedures in the clinical management of insomnia. Although several models, techniques, and adaptations of cognitive therapy have been described, the approach presented in this article is based predominantly on Aaron Beck s classic model of cognitive therapy as applied to various clinical conditions (A. T. Beck, 1976; A. T. Beck, Rush, Shaw, & Emery, 1979; J. S. Beck, 1995). It addresses sleep-related dysfunctional beliefs and thoughts, as well as maladaptive cognitive processes, through the use of standard cognitive restructuring techniques. First, we outline a conceptual model of insomnia with an emphasis on the mediating role of dysfunctional cognitions as a factor implicated in the development and maintenance of chronic insomnia. The rationale and general principles of cognitive therapy for insomnia are then presented, followed by a description of treatment procedures, clinical case illustrations, and practical implementation issues. THE ROLE OF COGNITIONS IN INSOMNIA Cognitive therapy was originally developed and validated for the treatment of depression (A. T. Beck et al., 1979). Since Beck s pioneering work (A. T. Beck, 1976; A. T. Beck et al., 1979), cognitive therapyhas been adapted for a wide range of disorders (e.g., anxiety, substance abuse, and personality disorders), and outcome research has provided extensive evidence supporting its efficacy for those conditions (DeRubeis & Crits-Christoph, 1998). It is only since the early 1990s, however, that cognitive therapy procedures have been formally used in the treatment of insomnia

3 COGNITIVE THERAPY 181 (Edinger, Hoelscher, Marsh, Lipper, & Ionescu-Pioggia, 1992; Jacobs, Benson, & Friedman, 1993; Morin, Kowatch, Barry, & Walton, 1993; Sanavio, Vidotto, Bettinardi, Rolletto,& Zorzi, 1990), and a conceptual model, based on Beck s theory and emphasizing the major role of dysfunctional cognitions in insomnia, has been proposed (Morin, 1993). Although cognitive therapy has been used mostly within the broader cognitive behavioral paradigm, preliminary evidence suggests that this therapeutic component mayplayan important role in mediating sleep improvements and in maintaining long-term therapeutic outcome (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001b; Morin, Blais, & Savard, 2002). Evidence supporting its efficacy is discussed later in this article. According to Spielman s model of insomnia development (Spielman, Conroy, & Glovinsky, 2003), several predisposing, precipitating, and perpetuating factors are involved at different times during the course of insomnia. Age, gender (female), hyperarousal, prior history of insomnia, and an anxiety-prone personality represent some of those factors that may predispose to insomnia. Sleep disturbances are often precipitated by stressful life events such as a separation, the death of a loved one, or hospitalization (Bastien, Vallières, & Morin, 2004). Sleep usually normalizes after the stressor has faded away or the person has adapted to its more enduring presence. For some individuals, however perhaps those more vulnerable to insomnia sleep disturbances may develop a chronic course and be maintained by factors other than the original precipitating event. In chronic insomnia, a person s responses to the initial sleep difficulties mainly one s behaviors, beliefs, attitudes, and interpretations contribute to maintain or even exacerbate sleep disturbances over time (see Figure 1); such cognitive and behavioral responses are believed to determine in large part whether sleep disturbances will fade away or develop a chronic course (Morin, 1993). In this model, insomnia is more likely to persist over time if a person interprets this situational insomnia as a sign of danger or loss of control and begins to pay more attention to sleep, sleep loss, and daytime consequences of sleep difficulties. Furthermore, monitoring sleep and daytime consequences of sleep loss may maintain insomnia by triggering autonomic arousal and emotional distress, which in turn trigger selective attention to sleep-related threat cues (Harvey, 2002; Semler & Harvey, 2004). Excessive worrying about sleep and the fear of not sleeping mayalso lead the person to develop poor sleep habits, such as taking naps or staying in bed for prolonged periods trying to force sleep, which tend to dysregulate the sleep-wake cycle and homeostatic drive and interfere with the subsequent sleep episode (Edinger et al., 2000). As shown in Figure 1, these cognitive responses (e.g., worrying, unrealistic expectations, and faulty appraisal) may become dysfunctional and feed on the vicious cycle of insomnia, emotional distress, maladaptive sleep habits, and more sleep disturbances. Such a chain reaction produces a state of hyperarousal (physiological and emotional), which is incompatible with the relaxation state required to initiate sleep (Espie, 2002). Then, it is often essential to directly address patients

4 182 BÉLANGER, SAVARD, MORIN FIGURE 1 A cognitive behavioral model of chronic insomnia. From Insomnia: Psychological Assessment and Management (p. 57), by C. M. Morin, 1993, New York: Guilford. Copyright 1993 by Guilford. Reprinted with permission. underlying beliefs regarding sleep and insomnia. For instance, even if patients agree to reduce the amount of time spent in bed to improve sleep continuity (as in sleep restriction), they may continue to experience sleep disturbances unless the underlying concerns about the consequences of sleep loss have also been addressed in treatment. Likewise, a patient may agree to comply with stimulus control instructions proscribing daytime napping and staying in bed when awake; yet, unless the underlying concerns and beliefs for engaging in such practices are directly addressed/confronted, it may be more difficult to eliminate such practices. Several other pathways may lead to chronic insomnia. Nevertheless, the main point is that, regardless of what triggered the sleep disturbances initially, poor sleep habits and dysfunctional sleep cognitions are almost always involved in perpetuating or exacerbating sleep disturbances over time. The following discussion of treatment focuses predominantly on unhelpful beliefs about sleep and maladaptive processes arising from those faulty beliefs. COGNITIVE THERAPY PRINCIPLES APPLIED TO INSOMNIA Cognitive therapy (CT) is a psychotherapeutic intervention aimed at guiding patients, through Socratic questioning, collaborative empiricism, and guided discovery, at re-

5 COGNITIVE THERAPY 183 evaluating the accuracy of their thoughts and beliefs and altering these when necessary (J. S. Beck, 1995). This approach rests on the underlying assumption that an individuals affects, physiological reactions, and behaviors are largely determined by the way they perceive and structure the world (A. T. Beck, 1976). A key premise of this approach is that cognitions are based on one s assumptions and attitudes developed from previous experiences and those cognitions directly influence behavioral patterns. Thus, in the context of insomnia, although sleep difficulties may be triggered by a genuine stressful event, some people will resume normal sleep when the stressor fades away or when they adapt to its more permanent presence, whereas others will continue experiencing persistent sleep disturbances, partly because of increased attention to sleep, faulty appraisal or interpretations, and expectations of further sleep difficulties. It is in this manner that a self-fulfilling prophecy (i.e., fear of not sleeping and of its potential consequences, emotional distress, further sleep disturbances) may contribute to the maintenance of insomnia over time (see Figure 1). The basic clinical procedures and treatment targets described (following) have been adapted by our group and evaluated as part of a broader CBT approach for the management of insomnia (Morin, 1993). In this approach, cognitive therapy techniques are used to alter dysfunctional beliefs and expectations about sleep to decrease emotional arousal and attention to sleep-related threat cues (Harvey, 2002).This is done by guiding patients in identifying their maladaptive sleep cognitions, challenging their validity, and reframing them into more adaptive substitutes through cognitive restructuring techniques (J. S. Beck, 1995) and behavioral-experiments homework (Bennett-Levy, Butler, Fennell, Hackman, Mueller, & Westbrook, 2004). Most individuals with sleep difficulties entertain a number of erroneous beliefs about sleep and sleeplessness that usually fall into one of the following categories: unrealistic expectations of sleep requirements, misconceptions about the causes of insomnia, distorted perception of its consequences, and faulty beliefs about sleep-promoting practices (Morin, 1993). Treatment Targets Unrealistic sleep expectations. Individuals with insomnia often entertain strong beliefs regarding the amount of sleep they need. For example, the belief that 8 hr of sleep per night is absolutely essential for optimal functioning the next day is common in poor sleepers. Although the average duration of sleep in noncomplaining good sleepers varies between 7 and 8.5 hr per night, individual differences in sleep needs exist, just as weight and appetite, for example, vary across individuals. Trying too hard to achieve a given sleep standard can cause performance anxiety, which, in turn, increases arousal and exacerbates the sleep problem. Individuals with insomnia also tend to compare their sleep with that of others and tend to worry when they realize that they take longer to fall asleep or wake up

6 184 BÉLANGER, SAVARD, MORIN more often than others. Night-to-night variability in sleep is also observed within individuals. Although this will mostly go unnoticed in good sleepers, poor sleepers tend to worry about any change in their sleep pattern and interpret this as a loss of control over their ability to sleep and a threat to their well-being. CT will challenge unrealistic expectations and guide patients to reexamine sleep needs and the link between total sleep time at night and daytime functioning. Misconceptions about the causes of insomnia. Individuals with insomnia commonly attribute insomnia to external causes (e.g., chemical imbalance, hormonal changes, pain, and aging). Although these may be genuine contributing factors, the exclusive attribution to external causes is likely to reinforce the faulty belief that nothing can be done to improve sleep and that one is condemned to live with sleep problems for the rest of his or her life or until the cause has been eliminated. Such attributions are likely to produce a sense of helplessness and to reinforce the perception that one is a victim without any resource to overcome insomnia. CT will challenge some of those unidimensional attributions and guide patients to consider other possible contributing factors to sleep disturbances, particularly those over which he or she may have some control. Distorted perception of insomnia consequences. Acommonreactionto the occurrence of insomnia is to worry over sleep loss and to ruminate about its consequences (e.g., If I can t sleep tonight, I won t be able to function tomorrow ; Insomnia can seriously affect my physical health ). Individuals with insomnia often blame their sleep problem for everything that goes wrong during the day fatigue, performance decrements, and mood disturbances. Although some of these consequences may indeed result from poor sleep, the exclusive attribution of all daytime impairments to insomnia is counterproductive and, ultimately, perpetuates insomnia. As for causal attributions, CT will challenge those perceived consequences and guide patients to examine other factors that may have no relationship to sleep as potentially contributing to daytime impairments. This can decrease the amount of attention and monitoring of sleep-related threats. Faulty beliefs about sleep-promoting practices. Many individuals with insomnia believe that the best way to fall asleep or to return to sleep after awakening is to stay in bed and try harder. Another widespread belief is that staying in bed later in the morning or taking naps during the day will minimize the consequences of sleep loss. Although these strategies may be useful in the short term, particularly for acute insomnia, they are more likely to perpetuate sleep difficulties through the induction of performance anxiety (staying in bed and trying harder) and alteration of circadian rhythms (daytime naps). Although these practices are addressed through behavioral interventions such as stimulus control and sleep restriction, it

7 COGNITIVE THERAPY 185 may be useful to also challenge the underlying beliefs through cognitive interventions, as they may represent significant barriers to changing sleep behaviors. Other sleep-disturbing thoughts. Patients with insomnia also often present other anxiety-provoking thoughts at bedtime that interfere with their sleep for example, worrying over an exam, thinking about the next day s workload, or thinking about a past negative life-event. These thoughts can also be targeted during treatment, and restructuring strategies may be used in the same manner as for sleep-specific dysfunctional thoughts. Doing this may help consolidate treatment gains and generalize them to other life situations. CLINICAL PROCEDURES The cognitive therapy model proposed in this article is aimed at delineating and testing specific misconceptions and misperceptions about sleep and insomnia by guiding patients in (a) identifying negative automatic thoughts that are hypothesized to maintain the target problem; (b) recognizing the connections between cognitions, emotions, physiological functioning, and behaviors; (c) examining the evidence for and against their distorted automatic thoughts; (d) substituting more realistic interpretations for these biased cognitions; and (e) learning to identify and modify their core beliefs that predispose to distorted perceptions of the problem. Cognitive therapy requires skillful interventions, especially when attempting to change strongly ingrained beliefs. To be effective, it must be led in a collaborative manner, with patients taking an active role in identifying and proposing more rational alternatives to their automatic thoughts and beliefs. Moreover, care should be taken as to not lead patients to think that the therapist holds the ultimate truth about their sleep and that they are inadequate. It is the patients thoughts that are to be challenged, not the patients themselves. Also, when introducing new information or during restructuring interventions, the therapist should make sure patients understand the rationale of the intervention. Finally, although the mode of interaction is one of collaborative empiricism, the establishment of a therapeutic relationship based on support, empathy, and warmth remains essential to secure collaboration. Introducing the Patient to Cognitive Therapy As a preliminary step to implementing cognitive therapy, it is important to provide patients with a brief explanation of the role of cognitive factors in insomnia. It is often easier to start off with examples, unrelated to insomnia, that can trigger various emotions as a function of one s interpretations. The same situation (e.g., not being selected for a job) may produce different emotions (e.g., anger, depression, relief) depending on how an individual appraises that situation. The important

8 186 BÉLANGER, SAVARD, MORIN point is to illustrate how a person s interpretation or appraisal of a given situation modulates the types of emotional reaction to that situation. Collaboratively, the clinician and the patient elicit several examples to illustrate this relationship between thoughts, emotions, and behaviors. Once the rationale is understood and the importance of targeting erroneous thinking about sleep is integrated, the next step is to identify patient-specific dysfunctional sleep cognitions. Identifying Automatic Thoughts and Dysfunctional Beliefs About Sleep The first, and possibly most important, task to undertake in cognitive therapy for insomnia is to guide patients in identifying their dysfunctional thoughts about sleep. Many patients are unaware of these thoughts and of their role in the development and maintenance of sleep disturbances and related emotional consequences. It is important to point out to patients that these thoughts continually flow through their mind in response to external events. Self-monitoring is usually the most effective strategy to identify automatic thoughts. It can be achieved in the office through the use of Socratic verbal questioning and imagery recollection. Starting from a recent example when the patient had trouble sleeping, the therapist guides the patient to identify his or her automatic thoughts and associated emotions. The therapist can ask questions such as, What was running through your mind when you were unable to sleep? How did you feel at that time? Here is an example: Therapist: Close your eyes and listen to this carefully. It s 4:00 AM, and you have been tossing and turning for the past hour and you can t get back to sleep. You have an important meeting tomorrow that you can t miss. Now, can you tell me what goes through your mind right at this moment? Patient: Well, I feel that I m getting worried and tensed. No matter how hard I try to go back to sleep, nothing seems to work. I have to get back to sleep pretty soon otherwise I ll be a mess tomorrow. I have only three hours left to sleep, I must get back to sleep or I ll have a lousy day tomorrow. I ll be irritable and won t be able to concentrate properly. I might even have to sleep in and then I ll be late for that meeting. In this scenario, the therapist might explore what evidence or past experiences would support the beliefs that one can fall asleep simply by trying harder or that it is impossible to accomplish anything after a poor night s sleep. Instructing patients in keeping track of their sleep-related automatic thoughts (or a sample of those thoughts) on a daily basis represents an efficient way for patients to consolidate their learning experience. The automatic thought record (A. T.

9 COGNITIVE THERAPY 187 Beck et al., 1979) is a very useful assessment tool to monitor a wider variety of dysfunctional thoughts than those reported during sessions. Table 1 presents an example of this daily record, with the standard three-column format. Patients are asked to identify (a) the situation or event that led to the unpleasant emotion, (b) the automatic thoughts and/or images that went through their mind at that time, and (c) the emotional reactions (e.g., helplessness, anxiety, and anger). The emotion s intensity is rated on a scale from 0 to 100. Patients should pay particular attention to their automatic thoughts when they have trouble sleeping at night or have trouble functioning during the day, or simply when they worry about sleep, and they should be encouraged to keep this record on a daily basis. The more compliant patients are in keeping this record, the easier it will be to identify their dysfunctional thinking about sleep, and the easier it may be to revise it during therapy. Self-report questionnaires are also useful tools for clinicians to identify and select relevant targets for the intervention. In our clinical practice and research, we use the Dysfunctional Beliefs and Attitudes About Sleep scale (Morin, 1993; Morin, Stone, Trinkle, Mercer, & Remsberg, 1993), a 30-item self-report scale designed to assess sleep-related beliefs and attitudes that are often endorsed by individuals with insomnia. Patients indicate the extent to which they agree with each statement on a 0 10 Likert-type scale. The content of the items reflects several themes, such as faulty causal attributions (e.g., I feel that insomnia is basically the result of aging ), misattribution or amplification of the perceived consequences of insomnia (e.g., I am concerned that chronic insomnia may have serious consequences for my physical health ), unrealistic sleep requirement expectations (e.g., I need eight hours of sleep to feel refreshed and function well during the day ), decreased perception of control and predictability of sleep (e.g., I am worried that I may lose control over my abilities to sleep ), and faulty beliefs about sleep-promoting practices (e.g., When I have trouble getting to sleep, I should stay in bed and try harder ). These beliefs are presumed to be instrumental in maintaining sleep disturbances. When used for cognitive therapy purposes, responses that fall toward the upper quartile (i.e., tends to strongly agree with the statement) represent potential treatment targets for cognitive restructuring therapy. A copy of this in- TABLE 1 Example of a Self-Monitoring Form of Sleep-Related Thoughts Situation Automatic Thoughts Emotions Watching TV in the evening Lying in bed awake at 4 a.m. Unable to accomplish tasks efficiently at work I must have some sleep tonight, I have so much to do tomorrow I will never find a way to get over this problem I knew this would happen after such a poor night s sleep Anxious: 80% Helpless: 90% Irritable: 60%

10 188 BÉLANGER, SAVARD, MORIN strument is presented in the Appendix. A revised and abbreviated 16-item version is also available and currently under validation. Challenging and Replacing Dysfunctional Sleep Cognitions Once patient-specific sleep cognitions have been identified, their validity should be examined. The main task is to encourage patients in viewing their thoughts as only one of many possible interpretations rather than absolute truths. A variety of probing questions is suggested to guide patients in evaluating the validity of those cognitions (see Figure 2). The next step consists of finding alternatives to the dysfunctional thoughts by using cognitive restructuring techniques. For that purpose, two columns are added to the daily thoughts record (A. T. Beck et al., 1979). First, more rational and realistic thoughts are identified (column 4), and second, the associated emotions are reassessed as a function of this alternative thinking (column 5; see Table 2). Self-monitoring is still very useful at this stage to help patients modify their thinking about sleep and realize how much the emotional reaction changes depending on the nature of the thoughts running through their minds. To promote compliance with self-monitoring homework, it is helpful to rehearse or model this task during therapysessions. Several cognitive restructuring techniques can be used to challenge and reframe dysfunctional cognitions. They include procedures such as reappraisal, reattribution, decatastrophizing, and hypothesis testing. This can be accomplished through questioning and verbal exchanges during therapy sessions and with the complementary use of behavioral experiment homework as needed (for detailed instruction on these techniques, see J. S. Beck, 1995, and Bennett-Levy FIGURE 2 Examples of probing questions. Note. From Cognitive Therapy: Basics and Beyond (p. 109), by J. Beck, 1995, New York: Guilford. Copyright 1995 by Guilford. Reprinted with permission.

11 COGNITIVE THERAPY 189 TABLE 2 Example of an Automatic Thought Record Used for Cognitive Restructuring Situation Automatic Thoughts Emotions Alternative Thoughts Emotions Awake in bed in the middle of the night I won t be able to function tomorrow Anxious: 80% There is no point in worrying about this now, worrying will only make things worse. Sometimes I can still function after a poor night s sleep Anxious: 25% et al., 2004). These will be illustrated along with the cognitive error(s) they are targeting in the following clinical vignettes. Clinical Presentations/Vignettes This section presents examples of narratives illustrating how cognitive restructuring techniques may be used to modify dysfunctional sleep cognitions. Vignette #1. Kimberly is a 38-year-old lawyer working in a well-reputed law firm. Ever since she has started working there, she has been suffering from insomnia at least 4 nights per week. She is convinced that her capacity to concentrate decreases significantly after a poor night s sleep and that this is detrimental to her work efficiency. Moreover, she claims she is much more irritable on those days. In the following vignette, the therapist attempts to decatastrophize her distorted perception about the consequences of insomnia. Therapist: Let s look at this concern that you re not able to function during the day after a poor night s sleep. Have there been times when this has happened? Patient: Of course, there have! Therapist: Would you say that every time you have had a poor night s sleep you were unable to function the next day? Patient: Well, maybe not every time. Therapist: Can you remember times when you were able to function fairly well during the day despite having slept poorly the preceding night? Patient: Yes, I guess it has happened sometimes Therapist: On the contrary, have there been times when you have had difficulties functioning or have had no energy during the day, even though you had slept well the night before? Patient: Yes, that has happened several times as well.

12 190 BÉLANGER, SAVARD, MORIN Therapist: So, it sounds like your level of functioning is not entirely dependent on the quality of your sleep. Would you agree with that assessment? Patient: Yes. I have never realized that before. Therapist: Good! Now, what can you conclude from that? Patient: Well, maybe that insomnia is not the only cause of poor functioning during the day and that, although I may sometimes feel less efficient during the day after a poor night s sleep, most of the time I can still function pretty well. Vignette #2. Mary is a 52-year-old hairdresser. She has been suffering from insomnia since her early adulthood. She is convinced that insomnia is detrimental to health. She considers herself more prone to get sick because of her sleep difficulties. The following vignette provides another example of how to use decatastrophization to revise dysfunctional thinking about the consequences of insomnia. Therapist: How do you feel when you re going to bed thinking that you might get sick because of insomnia? Patient: I feel very anxious! Therapist: Do you think this anxiety may have an effect on your capacity to fall asleep? Patient: It s obvious that it does not help me fall asleep! Therapist: That s right! Anxiety is incompatible with sleep. Do you think that this strong belief that you could get sick because of insomnia should be changed? Patient: How can I change it? It is so true! Therapist: Have you ever read in the newspaper that someone died because of insomnia? Patient: (Laughs). No, I haven t. Therapist: Would you say that poor sleepers all have more illnesses than good sleepers? Patient: Probably not. I know people who sleep well who have more health problems than I do. Therapist: Now, as a person with sleep difficulties, do you think you are healthier than some good sleepers? Patient: Well, I can easily catch all kinds of respiratory infections, but I have had no major illness so far, compared to some of my friends who do not have sleep difficulties but are dealing with serious diseases. Therapist: What can you conclude from that? Do you think that insomnia is really dangerous for your health? Patient: Probably not. At least, it does not seem to be the only factor involved in the development of illnesses.

13 COGNITIVE THERAPY 191 Therapist: You re right and we might even add that excessive worrying about not sleeping may be even more detrimental to your health than insomnia per se. Vignette #3. Alfred is a 67-year-old man. He has retired from work recently. He used to be a good sleeper, but he has recently begun to wake during the night and to stay awake for increasing periods of time. During the assessment phase, Alfred told his therapist that he hesitated to seek help for his sleep difficulties because he thought insomnia was a fact of aging, that he needed to accept this, and that nothing could be done to help him. In the following, the therapist uses reattribution techniques to modify this misconception about the causes of insomnia. Therapist: During the evaluation, you told me that insomnia was an inevitable consequence of aging. How do you feel about that? Patient: I feel discouraged and hopeless. Therapist: How old are you? Patient: I am 67 years old. Therapist: Do all of your acquaintances, which are about the same age as you are, have sleep disturbances? Patient: No. I guess not, but there are a few. Therapist: So, you re telling me that not all older people suffer from insomnia. Is it possible that other factors may be involved in insomnia? Patient: Hum I guess so, but I don t know which ones. Therapist: Are there any events, or activities you do during the day, that may affect your sleep negatively? Patient: Yes, for example, when I have an appointment with my doctor, I worry days in advance and I have more trouble sleeping then. Therapist: Okay. Now, are there any events, or activities you do during the day, that seem to improve your sleep? Patient: Hum, I noticed lately that when I am physically active during the day, or when I go to bed later in the evening, I sleep more soundly. Therapist: Good! So, do you think that other factors than age may affect your sleep? Patient: I guess so. Therapist: Does that mean that something can be done to improve your sleep? Patient: I guess so too. Therapist: Now, tell me, do you think that it may be possible that insomnia is not necessarily an inevitable consequence of aging? Patient: I d rather say that age is not the only cause of insomnia and that some of the causes can be changed. Therapist: Indeed! How do you feel about that now?

14 192 BÉLANGER, SAVARD, MORIN Patient: I feel reassured and more confident that I can do something to improve my sleep! Vignette #4. Suzan is a 29-year-old teacher. She has been having difficulties initiating sleep for several years now, which she finds abnormal considering the ease with which most people around her, including her husband, fall asleep. In the following example, the therapist uses reappraisal to modify unrealistic sleep expectations. Therapist: You said that you become very anxious when you see your husband falling asleep in less than five minutes. What is typically going through your mind at that moment? Patient: Well, I think What s wrong with me? There is no reason why I shouldn t sleep like him. It s abnormal to take so long to fall asleep! Therapist: You told me you were a teacher. Is there a colleague you particularly admire? Patient: Definitely Peter J. He is dynamic, funny, and can always capture the children s attention. Therapist: How would you describe your own teaching? Patient: Well, I am not as funny, but I guess I am dynamic in my own way, and the kids seem to like me Therapist: How would you feel if you were to constantly compare yourself to Peter J. while you were teaching? Patient: I would feel extremely anxious. Therapist: What do you think would happen to your teaching then? Patient: It would be very bad. But why are you asking me about my teaching? Therapist: Because, in some ways, sleep is like teaching. There are a great deal of differences across people s sleep; just as some teachers do not capture the children s attention the same way or, say, have stronger abilities to teach math classes and others are better at teaching language classes. In a sense, some people are better sleepers than others but that does not mean that your sleep is bad. There is another similarity. Sleep and teaching are both vulnerable to anxiety; the more anxious you feel, the worse you teach and the worse you sleep. Patient: Oh! I see what you mean. Therapist: Then, what alternative thoughts should you try to entertain next time you see your husband falling asleep almost instantly? Patient: That I shouldn t necessarily aim at falling asleep as easily as he does; that I m not abnormal for that. Therapist: Then, what do you think might happen? Patient: Well, I guess it would be easier to fall asleep if I felt less anxious about my ability to fall asleep, and put less pressure on myself.

15 COGNITIVE THERAPY 193 FIGURE 3 Practical recommendations for patients. PRACTICAL IMPLEMENTATION ISSUES Cognitive therapy is predominantly verbal in nature and relies heavily on Socratic questioning, collaborative empiricism, and guided discovery. Cognitive therapy uses a variety of procedures to change cognitions; some of those strategies are purely cognitive in nature, and others may be more performance based (i.e., behavioral experiments; J. S. Beck, 1995). The level of cognitive therapy that is necessary (e.g., addressing core beliefs) varies across patients and has to be adapted to the severity of their problem and their capacity to identify and question their own thoughts and emotions (see Figure 3). Receptiveness to CT Some patients may not be receptive to this type of intervention or may be reluctant to question and monitor their beliefs and attitudes. It is important to verify whether such reluctance is due to a resistance to consider psychological factors as potential contributing factors to insomnia or to a lack of insight into one s problem. Once the nature of the difficulty has been identified, it is important to work it through with the patient. Sometimes it may be necessary to take a step back and reexamine the conceptual model of insomnia. It may also be useful to revise the possible causes of insomnia, with an emphasis on the role of unhelpful thoughts and beliefs in the etiology of dysfunctional behaviors and negative emotions that serve to maintain insomnia. The idea is not to try to convince the patient that there is no biological cause to their sleep difficulty, but rather to help them understand that there are usually several causes to insomnia and that they can have an active role in controlling some of them namely, the psychological factors. Planning specific behavioral experiments at this stage is also quite useful. These can be presented as tests for

16 194 BÉLANGER, SAVARD, MORIN patients to conduct by themselves to discover how some of their thoughts impinge on their sleep difficulty (Ree & Harvey, 2004). Therapeutic Alliance Although cognitive therapy is goal oriented, it is essential for the therapist to establish a sound therapeutic relationship with the patient, conveying empathy and support (J. S. Beck, 1995). One must be careful not to communicate the idea that the perceived consequences of insomnia are the result of exaggeration. There is a fine line between bringing a patient to reduce the degree of attention given to the consequences of insomnia (e.g., fatigue, dysphoria, poor concentration) versus saying that insomnia has no consequence and that it is all a matter of their imagination! In fact, it is important for the clinician to recognize that, indeed, insomnia produces negative consequences on daytime functioning and may impair quality of life; once this is acknowledged, the clinician and patient can work collaboratively to reduce the degree of attention given to those factors and to examine other factors, in addition to insomnia, that might explain such daytime impairments. Time Allocated to CT and Required Training Implementation of cognitive therapy procedures for insomnia usually requires more time in the clinic than implementation of behaviorally based procedures such as stimulus control and sleep restriction therapies. The latter tend to be more prescriptive and, after explaining the procedures and their rationale, the patient is entirely responsible for implementing them at home. Effective implementation of cognitive therapy requires more verbal exchanges and depends largely on skillful verbal interventions from the therapist; there are also homework assignments, some of which may involve behavioral experiments, but a large part of the actual therapeutic work (i.e., cognitive restructuring) is conducted during the therapy sessions. Effective implementation of cognitive therapy may require a higher level of psychotherapeutic skills and more clinical training than with some behaviorally based procedures. Most health care practitioners (e.g., primary care physicians, nurses) can learn how to implement behavioral interventions such as stimulus control and sleep restriction therapies with minimal guidance and supervision, whereas cognitive therapy is likely to require more psychotherapy training. Although clinical psychologists and other mental health practitioners are likely to have adequate generic psychotherapy training, and possibly cognitive therapy training, few will have had the opportunity to use this treatment modality specifically with patients presenting insomnia complaints. Such training would be best obtained through specialized internship rotations or workshops in behavioral sleep medicine. Although clinical experience suggests that cognitive therapy is useful as a single therapy for insomnia, and it has been shown effective for other conditions (e.g., major depression), there is limited empirical evidence at this time to support this claim. For

17 COGNITIVE THERAPY 195 this reason, we use cognitive therapy as one therapeutic component incorporated to a multifaceted intervention. Its implementation is usually spread over several sessions, with an introduction in the second or third therapy session, a more focused approach during the subsequent three to four sessions, and a consolidation toward the end of treatment. On the other hand, some patients may not need formal cognitive therapy, as didactic teaching about good sleep practices, sleep requirements, and the impact of insomnia may be sufficient to correct their erroneous beliefs. For instance, presenting the negative effects of excessive daytime napping, or of spending too much time in bed, may be sufficient to change the patients perceptions regarding the usefulness of these strategies and consequently encourage them to change these maladaptive behaviors. In our own clinical and research practice, we introduce cognitive therapy after behavioral procedures (such as sleep restriction), unless it is manifest that dysfunctional sleep cognitions impinge on compliance with behavioral recommendations. For example, compliance with some behavioral procedures (e.g., leaving the bed when awake in the middle of the night) is particularly difficult for some patients. Some may feel that their situation and reasons for not complying are unique and genuinely prevent them from applying a given procedure. For example, patients with back pain often argue that they are more comfortable lying than sitting so it is best for them to remain in bed. This may be addressed through cognitive interventions to increase compliance with a given procedure. On the other hand, behavioral strategies such as stimulus-control and sleep restriction may be extremely useful in helping revise the dysfunctional cognitions about sleep. For example, a patient initially believing that 8 hr of sleep are necessary for optimal daily functioning may modify it when applying sleep restriction strategies limiting his or her time in bed and sleep time. Behavioral strategies for insomnia then serve as potent behavioral experiments to test the validity of dysfunctional beliefs. Ultimately, the optimal sequencing of different therapeutic components must rely on the initial functional analysis and on clinical judgment. Comparative studies are needed to evaluate the relative efficacy and potency of different treatment sequences involving cognitive and behavioral procedures. Finally, sleep is influenced by many factors, including circadian, homeostatic, psychological, behavioral, and cognitive factors. Although the objective of this article was to emphasize the role of cognitions in insomnia and how to alter those factors, it is important to keep in mind that cognitive therapy is rarely implemented in isolation. In our clinical practice and research studies, cognitive therapy is almost always used as one therapeutic component integrated into a multifaceted intervention aimed at targeting each of the potential contributing factors to insomnia. CONCLUSIONS AND FUTURE DIRECTIONS Cognitive therapy represents an important clinical tool to directly address some unique perpetuating factors in persistent insomnia. Accordingly, it has become an

18 196 BÉLANGER, SAVARD, MORIN integral component of most multifaceted treatment protocols for insomnia (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001a; Espie, Inglis, & Harvey, 2001; Espie, Inglis, Tessier, & Harvey, 2001; Morin et al., 1999; Morin et al., in press). Cognitive therapy presents many advantages in the treatment of insomnia, and its benefits seem to extend beyond its initial impact on sleep parameters. Although no controlled study has of yet evaluated its unique contribution to overall insomnia treatment outcome, preliminary evidence suggests that cognitive therapy plays an important function in mediating and maintaining long-term therapeutic outcome (Edinger et al., 2001b; Morin et al., 2002). More specifically, cognitive therapy may play an important role as a consolidator of behavioral changes and foster the development of adaptive strategies to cope with residual sleep difficulties, thus helping to prevent future episodes of insomnia or reducing their duration and severity. Clinical evidence also suggests that cognitive therapy is particularly useful to distinguish normal, age-related sleep changes from pathological insomnia and to reduce the emotional distress that quite often accompanies insomnia. Cognitive therapy is also instrumental to facilitate hypnotic discontinuation by reducing excessive apprehensions about withdrawal symptoms and by helping patients to discriminate between those symptoms and the consequences of insomnia. Despite the increasing use of cognitive therapy in the management of insomnia, research evidence documenting its unique contribution to outcome is scarce. Whether dysfunctional cognitions would change with the use of behavioral strategies alone remains an open question. Of course, this raises another more basic, yet still unanswered, question of whether behavioral change follows or precedes cognitive change. Addressing dysfunctional beliefs has also been hypothesized to facilitate implementation and compliance with behavioral interventions, hence contributing to overall CBT efficacy. Future research exploring the effects of cognitive therapy alone, and its relative contribution to CBT outcome, would be informative. Additional research evaluating the contributions of cognitive therapy in the context of secondary insomnia would also be helpful, especially where its efficacy in treating the primary condition has already been documented (e.g., depression, anxiety disorders). Such studies would be informative because insomnia sometimes outlasts the primary condition when sleep is not specifically addressed in treatment. Such clinical research would enhance not only our understanding of treatment mechanisms, but also our knowledge of insomnia etiology. ACKNOWLEDGMENT Preparation of this article was supported, in part, by grants from the National Institute of Mental Health (MH60413) and the Canadian Institutes of Health Research (MT42504).

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