RESTore TM Insomnia and Sleep Disorders Clinician Manual for Single User A step by step manual to help you guide your clients through the program Version 10 July, 2016
Table of Contents Introduction... 3 RESTORE TM CBT... 3 Benefits of RESTORETM... 3 How to Use this Manual... 3 Role of Clinician Support... 3 Features Common to All Modules... 4 Program Structure... 4 Resource Room... 5 Sleep Diary... 5 Progress Graph... 6 Homework... 7 Module 1... 9 1. Greet the client... 9 2. Start Module 1... 9 3. Clinician Support Session (when client has finished module)... 10 3.1. Review of Homework Activities... 11 3.2. Plan for completing Homework... 11 3.3. Confirm when the client will complete their next computer session.... 11 Module 2... 12 1. Greet the client... 12 2. Start Module 2... 12 3. Clinician Support Session (when client has finished module)... 14 3.1. Review of Homework Activities... 14 3.2. Plan for completing Homework... 14 3.3. Confirm when the client will complete their next computer session.... 14 Module 3... 15 1. Greet the client... 15 2. Start Module 3... 15 The RESTORE Sleep Calculator:... 17 1
3. Clinician Support Session (when client has finished module)... 17 3.1. Review of Homework Activities... 17 3.2. Plan for completing Homework... 18 3.3. Confirm when the client will complete their next computer session.... 19 Module 4... 20 1. Greet the client... 20 2. Start Module 4... 20 3. Clinician Support Session (when client has finished module)... 21 3.1. Review of Homework Activities... 21 3.2. Plan for completing Homework... 21 3.3. Confirm when the client will complete their next computer session.... 21 Module 5... 22 1. Greet the client... 22 2. Start Module 5... 22 3. Clinician Support Session (when client finishes module)... 22 3.1. Review of Homework Activities... 22 3.2. Plan for completing Homework... 23 3.3. Confirm when the client will complete their next computer session.... 23 Module 6... 24 1. Greet the client... 24 2. Start Module 6... 24 3. Clinician Support Session (when client finishes module)... 24 3.1. Review of Homework Activities... 25 3.2. Plan for completing Homework... 25 3.3. Confirm when the client will complete their next computer session.... 25 2
Introduction RESTORE TM CBT Welcome to the RESTORE cognitive behavioral therapy (CBT) program for sleep and insomnia. RESTORE is a web based, interactive cognitive behavioral therapy (CBT) program for insomnia and sleep disturbances. It is designed to help clients identify and change unhelpful ways of thinking and behaving while also teaching them more effective problem solving techniques. The program helps clients understand the causes and symptoms of insomnia and provides exercises to allow them to work on their specific problems. Benefits of RESTORETM RESTORE will help your clients sleep better and therefore feel better. The RESTORE program provides ease of use to the client, an alternative to medication (and thus no side effects), has long term efficacy and teaches skills that are useful for a lifetime. How to Use this Manual This manual has been designed to give you step by step instructions on how to help maximize the benefit of the RESTORE program for the client. Following the general program overview, the manual provides a detailed module by module guide to help you understand what the client will experience each week and suggestions about your role in supporting the client s use of the program. Role of Clinician Support The clinician does not have to be trained in CBT. The clinician s role is to support clients in completing RESTORE and encourage commitment to the program. They assist in clarifying any problems or concerns the client has about treatment, monitor the client s progress and encourage commitment to program completion. Clinicians should encourage the client to complete one computer module per week and to work on the homework and exercises between sessions. The clinician can set up a schedule to meet with the client throughout they program as they determine best based on individual goals and circumstances. In addition, clinicians can use the Enterprise client management system provided with RESTORE to keep track of their clients and view their progress. 3
Features Common to All Modules Program Structure The RESTORE program is six weeks long. The client completes one module each week and is prevented from starting the next module until a week has passed. The program is designed this way to allow as much accumulation of sleep data from the client as possible and enable the client to put into practice what they have learned each week. The program keeps track of which modules have been completed and, once a module has been completed, clients can go back and repeat it as often as they wish. The modules vary in length from 20 to 50 minutes. Each module follows the same structure: Welcome Segment Brief survey about prior week experiences Narrated multimedia segments on current week's topic Three Question Survey Each online module contains the same elements but various new program support materials and tools are introduced throughout the program. Online Module Elements Video / Audio Graphics Exercises Questionnaires Resource Room Program Support Elements Sleep Diary Homework Sleep Calculator Progress Graphs Supplemental Materials Between modules, clients will be asked to: 1. Track their sleep daily using the Sleep Diary 2. Complete homework 3. Work on exercises There are four repeating elements in each module: the Resource Room, the Sleep Diary, the progress graphs and homework. 4
Resource Room The client will end each module in the Resource Room, which will be the Home Screen for the program once they are logged in. Once a module has been completed all supplemental material, homework, additional information and exercises can be accessed at any time from the Resource Room. Example of the Resource Room home screen: Sleep Diary Clients are requested to regularly make entries into their Sleep Diary to track their progress through the program. 5
Progress Graph Following completion of a Sleep Diary entry, the client can see graphs of their progress over time based on these entries compared with the goals they set for themselves at the beginning of the program. 6
Homework Cognitive Behavioral Therapy includes take-home activities (or homework ) for clients to complete between modules. RESTORE will assign several self-monitoring tasks and exercises for clients to complete as homework at the conclusion of each module. For example, clients will be asked to make regular entries into their Sleep Diary and practice relaxation exercises. Homework completed during the previous week is built upon in subsequent weeks of treatment. Thus it is essential that clients 7
complete their homework each week if they are to maximize their benefits from the RESTORE program. At the end of each module, the key points from the module and the homework are available on the module summary sheet. They can be downloaded and/or printed. Example of Module Summary: 8
Module 1 1. Greet the client In a Clinic Setting Greet the client briefly and take them to the computer. Limit your interaction with the client to non-specific topics. Make sure the client understands how to use the computer and navigate through the program. Leave the client to work through the Module on their own, but let them know where you will be in case they need assistance. Client working at Home During your initial meeting with the client ensure they understand how to start the program and work through it on the computer. Ask if they have any questions or concerns. You may wish to show them the preview video at www.restorecbt.com 2. Start Module 1 After the introductory video (2 minutes) the client is asked to complete a 22 question survey to help customize the program. Module 1 covers the following: The importance of realistic sleep expectations Identification of sleep goals 9
Explanation that the more work put into the program the better the outcome Identification of any cognitive distortions regarding sleep of others and themselves Discussion of the psychological and medical causes of insomnia Discussion of the importance of tracking their sleep on a daily bases using the Sleep Diary Identification of any cognitive distortions regarding sleep of others and themselves Scheduling time to work on the program If the client has not made a sleep diary entry for several days, they will receive a message when they log in asking them to do so before they can continue with the program. 3. Clinician Support Session (when client has finished module) In a Clinic Setting Client working at Home 10
Spend a few minutes face to face with the client to ensure they understand the homework activities and their plans for completing the homework. Remind them to make an entry in their Sleep Diary every day. Following completion of Module 1, ensure the client understands how to make entries in their Sleep Diary and understand the importance of monitoring their sleep. Let them know you are available to answer any questions they have by phone or email. 3.1. Review of Homework Activities Between Module 1 and 2, the client has been asked to monitor their sleep using the Sleep Diary. In particular, the client has been asked to monitor how regular their bed time is, how long it takes them to fall asleep, how many times they awaken during the night and what time they wake up. They have been asked to track their sleep without using a clock. Some individuals find this difficult at first, but you should provide encouragement for them to stick with it. 3.2. Plan for completing Homework The client should plan on spending at least 15 minutes on homework this week. They can access the Sleep Diary and the information from Module 1 via the Resource Room at any time during the week. Encourage your client to fill in the Sleep Diary every day when it is easiest to remember rather than at the end of the week just before the next module. Encourage your client to fill in the Sleep Diary every day when it is easiest to remember rather than at the end of the week just before the next module. 3.3. Confirm when the client will complete their next computer session. 11
Module 2 1. Greet the client In a Clinic Setting Greet the client briefly when they arrive for their appointment and take them to the computer for their session. Leave the client to work through Module 2 on their own, but let them know where you will be in case they need assistance. Client working at Home Not applicable 2. Start Module 2 When the client logs into RESTORE they will be taken to the Resource Room where they can choose to review Module 1, their Sleep Diary or begin Module 2. Module 2 covers the following: Review of homework from the previous week (including a short three question survey regarding how much of their homework plan they were able to complete) A question regarding how often they were able to avoid looking at the clock at night. This question is followed by an appropriate response to congratulate them on good progress or remind them that although it is hard, not looking at the clock is an important part of the RESTORE program. Imagery Induced Relaxation (the idea that imagining a relaxing scene leads us to feel more relaxed, breathe more slowly, and feel more calm) 12
Self-Hypnosis (referred to in the video but only available in the Resource Room ) Progressive Deep Muscle Relaxation Paced Breathing Following completion of Module 2, clients can view progress graphs based on the entries in their Sleep Diary. This can be accessed via the Resource Room (see section 3.1 below). 13
3. Clinician Support Session (when client has finished module) In a Clinic Setting Spend a few minutes face to face with the client to ensure they understand the homework activities and their plans for completing the homework. Client working at Home The next time you meet with the client ensure that they understand the Applied Relaxation techniques and remind them to fill out their sleep diary. 3.1. Review of Homework Activities Between Module 2 and 3, the client should continue to: Monitor their sleep using the Sleep Diary Practice the Applied Relaxation techniques; Paced Breathing, Progressive or Deep Muscle Relaxation, Imagery Induced Relaxation and Self Hypnosis. Ideally, the client should practice one or more of the relaxation techniques on a daily basis. Audio files are available in the Resource Room following completion of Module 2 to assist in going through the Applied Relaxation exercises. 3.2. Plan for completing Homework The client should plan to practice these exercises at a time when they will not be interrupted by the telephone or electronic device or by other commitments. Remind the client to fill out their Sleep Diary every day. 3.3. Confirm when the client will complete their next computer session. 14
Module 3 1. Greet the client In a Clinic Setting Greet the client briefly when they arrive for their appointment and take them to the computer for their session. Leave the client to work through Module 3 on their own, but let them know where you will be in case they need assistance. Client working at Home Not applicable 2. Start Module 3 When the client logs into RESTORE they will be taken to the Resource Room where they can choose to review previous Modules, update their Sleep Diary or begin Module 3. Module 3 covers the following: Review of homework from the previous week (including a short three question survey regarding how much of their homework plan they were able to complete) Specific questions on how many times they practiced each of the Applied Relaxation techniques. Following the submission of the answers, an appropriate response is given. If the client did not practice the exercises at all or only 1 or 2 times, some tips are offered for 15
ways to more successfully complete the exercises. Stimulus Control - Certain cues or stimuli can produce wakefulness when you are in your bedroom whereas other cues or stimuli can promote sleep Cues which prompt sleepiness Medications and substances that may cause insomnia Drugs used to treat insomnia Based on the client s entries, at the conclusion of Module 3, RESTORE will make a recommendation on what technique to focus on (sleep restriction, stimulus control or both) Sleep Restriction / Sleep Calculator clients will be introduced to a sleep calculator to help them calculate their optimal sleep window (example below) 16
The RESTORE Sleep Calculator: 3. Clinician Support Session (when client has finished module) In a Clinic Setting Spend a few minutes face to face with the client to ensure they understand the homework activities and their plans for completing the homework. Reassure client regarding Sleep Restriction (see below). Client working at Home The next time you meet with the client, make sure they are continuing to fill out their Sleep Diary and review with them the tips for Sleep Restriction. Provide appropriate guidance on tapering off their sleep medication, if appropriate. 3.1. Review of Homework Activities Between Module 3 and 4, the client should continue to: Monitor their sleep using the Sleep Diary Practice restricting their sleep Establish good stimulus control and, 17
Meet with their clinician to discuss tapering off their sleep medications if they choose. Sleep Restriction reassurance for client: Sleep window will not be restricted to less than 4 hours The client will only be doing this for a short while Remind client to keep making entries in their Sleep Diary. 3.2. Plan for completing Homework In order to find their ideal sleep window, the client should plan to practice sleep restriction based on at least three days of entries in the Sleep Calculator and should keep their new bedtime for at least three days. The client can log into the Sleep Calculator via the Resource Room at any time to recalculate their sleep window. 18
3.3. Confirm when the client will complete their next computer session. 19
Module 4 1. Greet the client In a Clinic Setting Greet the client briefly when they arrive for their appointment and take them to the computer for their session. Leave the client to work through Module 4 on their own, but let them know where you will be in case they need assistance. Client working at Home Not applicable 2. Start Module 4 When the client logs into RESTORE they will be taken to the Resource Room where they can choose to review previous Modules, update their Sleep Diary, review their Sleep Calculator or begin Module 4. Module 4 covers the following: Review of homework from the previous week (including a short three question survey regarding how much of their homework plan they were able to complete) How thoughts about sleep can actually impact our sleep Automatic Thoughts Identification of unhelpful automatic thoughts about sleep Examination and challenge of the validity of unhelpful thoughts about sleep How to replace unhelpful thoughts with more helpful ones. The client will complete an exercise where they are asked to enter their own Automatic Thoughts and helpful thoughts (Coping Thoughts). The So What If technique Management of anxiety through setting aside Worry Time. More tips for a better night s sleep 20
3. Clinician Support Session (when client has finished module) In a Clinic Setting Spend a few minutes face to face with the client to ensure they understand the homework activities and their plans for completing the homework. Client working at Home The next time you meet with the client, confirm they are continuing to fill out their Sleep Diary and cover any questions they have regarding identification of Automatic Thoughts and generating their list of Coping Thoughts. 3.1. Review of Homework Activities Between Module 4 and 5, the client should continue to: Monitor their sleep using the Sleep Diary Work on identifying Automatic Thoughts Generate a list of Coping Thoughts Schedule a worry time Use the So What If technique Attempt to talk to themselves in a more reassuring way about sleeplessness. 3.2. Plan for completing Homework The client should plan to spend some time each day working on generating their list of Automatic Thoughts and Coping Thoughts, using their scheduled Worry Time and practicing the So What If technique. Remind them to continue filling in their Sleep Diary. 3.3. Confirm when the client will complete their next computer session. 21
Module 5 1. Greet the client In a Clinic Setting Greet the client briefly when they arrive for their appointment and take them to the computer for their session. Leave the client to work through Module 5 on their own, but let them know where you will be in case they need assistance. Client working at Home Not applicable 2. Start Module 5 When the client logs into RESTORE they will be taken to the Resource Room where they can choose to review previous Modules, update their Sleep Diary or begin Module 5. Module 5 covers the following: Review of homework from the previous week (including a short three question survey regarding how much of their homework plan they were able to complete) Sleep Hygiene refers to factors that promote or prevent sleep. Some habits impacting sleep: Light in Bedroom Eating Exercise Alcohol Napping Smoking Caffeine Temperature Sleeping with a noisy bed partner or pet The clients are asked to choose a few factors to work on during the next week s homework by clicking the icons shown below. 22
3. Clinician Support Session (when client finishes module) In a Clinic Setting Spend a few minutes face to face with the client to ensure they understand the homework activities and their plans for completing the homework. Client working at Home The next time you meet with the client, confirm they are continuing to fill out their Sleep Diary and cover any questions they have about Sleep Hygiene. 3.1. Review of Homework Activities Between Module 5 and 6, the client should continue to monitor their sleep using the Sleep Diary and work on improving their sleep hygiene, including AVOIDING the following: Sleeping with a noisy bed partner (i.e., one who snores, is restless, has pauses in breathing during the night) Eating within 2-3 hours of bedtime or snacking during the night Drinking caffeinated beverages (e.g., coffee, tea, soft drinks, hot cocoa) during the day or evening (for some people one drink in the morning can affect sleep the next night) Becoming too warm/cool at night when sleeping due to room temperature or inappropriate number of blankets Smoking Drinking alcohol within two hours of bedtime Napping for more than 20 minutes and after 3pm Exercising within 2 hours of bedtime (unless you are in good shape) Sleeping in a room that is not completely darkened 22
3.2. Plan for completing Homework The client should focus on correcting identified personal sleep hygiene factors affecting their sleep. 3.3. Confirm when the client will complete their next computer session. 23
Module 6 1. Greet the client In a Clinic Setting Greet the client briefly when they arrive for their appointment and take them to the computer for their session. Leave the client to work through Module 6 on their own, but let them know where you will be in case they need assistance. Client working at Home Not applicable 2. Start Module 6 When the client logs into RESTORE they will be taken to the Resource Room where they can choose to review previous Modules, update their Sleep Diary or begin Module 6. Module 6 covers the following: Review of homework from the previous week (including a short three question survey regarding how much of their homework plan they were able to complete) Introduction to Mindfulness which focuses on the present moment as opposed to concerns about the future or regrets from the past Mindful Observing Mindful Listening 3. Clinician Support Session (when client finishes module) In a Clinic Setting Spend a few minutes face to face with the client to ensure they understand the homework activities and their plans for completing the homework. Client working at Home The next time you meet with the client, confirm they are continuing to fill out their Sleep Diary and practicing Mindfulness Activities. 24
3.1. Review of Homework Activities Between Module 6 and 7, the client should continue to: Monitor their sleep using the Sleep Diary Practice Mindfulness activities for 20 minutes each day Continue to practice good sleep hygiene 3.2. Plan for completing Homework Discuss with the client when they will complete the homework exercises and how they will try to remove distractions to ensure a period of uninterrupted time. 3.3. Confirm when the client will complete their next computer session. 25
Module 7 1. Greet the client In a Clinic Setting Greet the client briefly when they arrive for their appointment and take them to the computer for their session. Leave the client to work through Module 6 on their own, but let them know where you will be in case they need assistance. Client working at Home Not applicable 2. Start Module 7 When the client logs into RESTORE they will be taken to the Resource Room where they can choose to review previous Modules, update their Sleep Diary or begin Module 7. Module 7 covers the following: Review of initial goals and sleep graphs Review and understanding of progress made during the program Alternate options outside of the program Conclusion of program 26