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Dismantling CBT for Insomnia

Supplemental Materials

Comparative Efficacy of Behavior Therapy, Cognitive Therapy, and Cognitive Behavior Therapy for Chronic Insomnia: A Randomized Controlled Trial

by A. G. Harvey et al., Journal of Consulting and Clinical Psychology

Table S1

Week-By-Week Schedule for Behavior Therapy (BT), Cognitive Therapy (CT), and Cognitive Behavior Therapy (CBT)

Behavior Therapy (BT) / Cognitive Therapy (CT) / Cognitive Behavior Therapy (CBT)
Week 1
1. Set agenda and review housekeeping rules about scheduling /cancellation.
2. Treatment overview.
What does BT for insomnia involve? What to expect from this treatment?
3. Nature of self-management approach: Collaboration, stress the active role of patient in treatment.
4. Review sleep diary and reinforce self-monitoring.
5. Set treatment goals/objectives.
6. Review/summarize findings of insomnia assessment.
7. Review conceptual model of insomnia (Spielman). Relate this model to the patient’s personal sleep problem history.
8. Individual case conceptualization/functional analysis to identify behavioral factors contributing to insomnia. Introduce the behavioral model.
9. Administer the CEQ
10. Review homework assignments. / Items 1, 3, 4, 5, 6, 7, 9 and 10 are identical to BT. Differences:
a. Treatment overview. What does CT for insomnia involve?
What to expect from this treatment?
b. Individualized case conceptualization by
deriving a personalized version of the cognitive model for the night. Introduce the cognitive model.
c. Deliver intervention for: ‘Misconceptions about the cause of insomnia’ (this becomes a rolling intervention).
d. Introduce worry intervention by defining negative automatic thoughts, introducing 3 column form, introducing thinking traps handout (this becomes a rolling intervention). / Combination of BT and CT except:
i. Individualized case conceptualization by
deriving a personalized version of the cognitive model for the night and the day. Introduce the cognitive model.
Week 2
1. Set agenda.
2. Self-monitoring.
3. Review sleep diary.
4. Introduce sleep restriction procedure and rationale.
5. Return to conceptual model of insomnia – emphasize only the behavioral perpetuating factors.
6. Review homework assignments. / Items 1, 2, 3, 6 are identical to BT. Differences:
a. Individualized case conceptualization for the day. Reinforce the cognitive model.
b. Continue intervention for worry. Introduce the ‘Extended negative automatic thoughts’ form.
c. Deliver intervention for: ‘Misconceptions of insomnia consequences’ (this becomes a rolling intervention).
d. Introduce the role of other helpful and unhelpful strategies for managing unwanted thoughts.
e. Devise at least one experiment related to management of thoughts. / Combination of BT and CT except (a) was covered in Week 1.
Week 3
1. Set agenda.
2. Self-monitoring.
3. Review sleep diary.
4. Evaluate compliance with recommended sleep window and review/identify methods to enhance compliance with sleep window.
5. Set new sleep window for upcoming week.
6. Introduction of stimulus control procedures.
7. Review PSG summary from pre-treatment assessment.
8. Review basic facts about sleep and changes in sleep patterns over the lifespan.
9. Review of homework assignments. / Items 1, 2, 3, 7, 8, 9 are identical to BT. Differences:
a. Review ‘Extended negative automatic thoughts’ form.
b. Review experiment.
c. Draft individualized summary on the ‘Management of unwanted thought’ handout.
d. Continue intervention for unhelpful beliefs. Give a rationale for the Survey Experiment. Devise survey together and plan for administering the survey. / Combination of BT and CT.
Week 4
1. Set agenda.
2. Self-monitoring.
3. Review sleep diary.
4. Evaluate compliance with recommended sleep window and review/identify methods to enhance compliance with sleep window.
5. Set new sleep window for upcoming week.
6. Review of stimulus control procedures.
7. Review of homework assignments. / Items 1, 2, 3, 7 are identical to BT. Differences:
a. Continue worry intervention. Review ‘Extended negative automatic thoughts’ form. Refine individualized summary on the ‘Management of unwanted thought’ handout.
b. Continue intervention for unhelpful beliefs. Summarize progress on Survey Experiment.
c. Begin intervention for: ‘Unrealistic sleep needs and daytime functioning’ (this becomes a rolling intervention).
d. Introduce handout entitled “CBT handout on beliefs and attitudes about sleep”.
e. Begin the intervention for monitoring. Define monitoring.
Identify the different types of monitoring/attentional bias engaged in. Assist your patient to develop an awareness of the presence of monitoring and how it can function to maintain insomnia by triggering negative automatic thoughts, negative emotion and safety behaviors. Assist your patient to experience the effects of droping monitoring via an experiment.
Note. Add several questions about daytime energy levels and functioning to the sleep diary for the coming week in order to prepare for the daytime focus in Session 5. / Combination of BT and CT.
Week 5
1. Set agenda.
2. Self-monitoring.
3. Review sleep diary.
4. Chart progress and check on initial goal attainment. Provide feedback regarding progress and compliance with treatment. Emphasize specific problem areas that need more attention. Revise initial treatment goals as needed.
5. Review of home practice and problems with all behavioral procedures.
6. Review methods to enhance compliance with homework assignments.
7. Set new sleep window for upcoming week.
8. Give Sleep Hygiene handout.
9. Review homework assignments. / Items 1, 2, 3, 4, 8, 9 are identical to BT. Differences:
a. Finish Survey Experiment and continue progress on intervention for ‘Unrealistic sleep needs and daytime functioning’ (this becomes a rolling intervention).
b. Begin the intervention for the daytime including devising the Energy Generating Experiment.
Review the diary of sleep and energy during the day. Devise and complete the Generating Energy Experiment. Begin deriving a table that lists ‘Actions that can be taken during the day to increase the adverse effects of poor sleep’ and ‘Actions that can be taken during the day to decrease the adverse effects of poor sleep’. / Combination of BT and CT.
Week 6
1. Set agenda.
2. Self-monitoring.
3. Review sleep diary.
4. Review of home practice and problems with all behavioral procedures.
5. Review methods to enhance compliance with homework assignments.
6. Set new sleep window for upcoming week.
7. Review conceptual models of insomnia and individual case conceptualization.
8. Review homework assignments. / Items 1, 2, 3, 8 are identical to BT. Differences:
a. Review the results of the Energy Generating
b. Take the opportunity to reinforce previous work on ‘Misperception of insomnia consequences’
c. Setup Fear of Poor Sleep Experiment.
d. Start the intervention for safety behaviors.
e. Begin to target ‘Misconceptions about sleep-promoting practices’ theme. / Combination of BT and CT.
Week 7
1. Set agenda.
2. Self-monitoring.
3. Review sleep diary.
4. Set new sleep window. Start increasing time in bed (above sleep time) so that it gradually gets closer to 6.5 to 7 hours per night.
5. Start focus on maintaining treatment gains and relapse prevention.
6. Review of homework assignments. / Items 1, 2, 3, 5, 6 are identical to BT. Differences:
a. Review the results of the Fear of Poor Sleep Experiment.
b. Continue deriving a table that lists ‘Actions that can be taken during the day to increase the adverse effects of poor sleep’ and ‘Actions that can be taken during the day to decrease the adverse effects of poor sleep’
c. Address misperception of sleep. / Combination of BT and CT.
Week 8
1. Set agenda.
2. Self-monitoring.
3. Review sleep diary.
4. Adjust sleep window for upcoming weeks.
5. Continue focus on maintaining treatment gains and relapse prevention.
6. Review of homework assignments.
7. Closure. / Items 1, 2, 3, 5, 6 are identical to BT. Differences:
a. Final progress on rolling interventions. / Combination of BT and CT.