People may believe sleep to be simply a static state that is the direct opposite of wakefulness; however, this is not the case. Rather, it is a complex and dynamic process, and throughout sleep we progress through multiple stages that can be measured discretely across behavioural, physiological, and cognitive domains. This chapter describes the differences and features of these different stages and how they can be measured. Also described is the fact that sleep and wakefulness are not mutually exclusive, and that there are times when the lines between sleep and wake can be blurred, and this is notably true in insomnia. Finally, the chapter explains how sleep is regulated through interacting homeostatic and circadian processes, and the neuroscientific underpinnings of the sleep and circadian system.

Although sleep is measurable, the assessment of insomnia does not typically rely on using objective measurements. Nevertheless, there may be circumstances where objective assessment is warranted. This chapter describes the role of and place for objective estimates of sleep such as polysomnography, actigraphy, commercially available personal devices, and physiological assays, and weighs up the evidence for these.

Many patients will have received sleep hygiene, or at least be aware of it. Although it is minimally effective as a stand-alone treatment for insomnia, along with sleep education, it is an important part of multicomponent CBT. They both help contextualise other key therapeutics within CBT (e.g., sleep restriction therapy, stimulus control therapy, or the evening wind-down routine). The chapter covers the key lifestyle and bedroom factors that comprise sleep hygiene, and how to communicate these to patients. Next, this chapter introduces the ‘5 principles’ of good sleep health, which describe the importance of (1) valuing, (2) prioritising, (3) personalising, (4) trusting, and (5) protecting sleep as a framework for supporting good sleep.

Whereas the previous chapters of this book focused on how to deliver evidence-based CBTx at the patient level, this chapter seeks to consider and challenge readers on how to design, deliver, and implement CBTx for insomnia scale. It outlines the strengths of different delivery methods of CBT (e.g., individual, group, telehealth, books, and digital) and puts forth the case that digital therapeutics (DTx) can serve as a means of fulfilling clinical guideline care for insomnia at scale. Next, the chapter focuses on how guideline-recommended treatment can be delivered in an efficient manner through a stepped care approach that utilises the variety of delivery methods available. The chapter proceeds to outline a care-delivery model at the ecosystem level to treat the widest possible population, taking into account treatment guidelines and real-world examples such as the role of medication and different care pathways. It goes on to describe how to provide a specialised insomnia service within different clinical services and concludes by highlighting key partnerships and alliances for the future of insomnia CBTx.

Many patients with insomnia report difficulties with downregulating or de-arousing. Relaxation techniques have been an established component of CBT for many decades and may be a suitable option for some patients with insomnia. In this chapter a historical and scientific background to relaxation therapeutics is provided. The chapter next describes how to introduce relaxation to patients, and how to frame it as a value proposition. It goes on to provide instruction to clinicians in how to introduce, contextualise, and deliver relaxation therapeutics, namely establishing an evening wind-down routine, progressive muscle relaxation, and autogenic training.

A variety of standardised and validated tools and measures can provide a wealth of information to further understand a patient’s complaints, to evaluate the impact of insomnia on their life, and to screen for other disorders. This chapter provides a detailed overview of measures that a clinician can incorporate into their assessment to confirm the presence of insomnia, aid in differential and/or comorbid diagnosis, and understand broader impacts of their sleep complaint. The chapter then proceeds to describe the value of the sleep diary in an initial assessment. Finally, it encourages the reader to consider outcomes that are measurable, clinically meaningful, and matter to the patient.

The role and importance of cognitive factors in the development and maintenance of insomnia have been well recognised for some time. Indeed, insomnia is characterised by several types of challenging thoughts, and these, coupled with hyperarousal, lead to difficulties sleeping. This chapter describes the role of cognitive factors in insomnia and describes in depth a range of cognitive techniques, their background, and the evidence for them. A number of cognitive techniques are described, including cognitive control, paradoxical intention, articulatory suppression, imagery-training, mindfulness, cognitive restructuring, and problem-solving. For each therapeutic, the reader is provided with specific instructions and narratives to follow to aid in their implementation when working with a patient.

Whereas diagnosis helps you understand what is going on, formulation allows you to understand why that problem is happening and how to address it. This chapter provides instruction on key CBTx skills relating to case formulation and treatment implementation, guided by a scientist-practitioner approach. It provides practical tools, rubrics, and metaphors that can assist in formulation, and discusses treatment readiness as a key construct to treatment implementation. Finally, the chapter outlines how to use the book to help readers develop personalised treatment plans for patients.

Sleep is vital to our existence; it underpins a myriad of brain and bodily functions, and supports optimal functioning across a variety of different domains including cognitive functioning, emotional regulation, tissue repair and growth, and our immune system, among others. It is not surprising, therefore, that when sleep disturbance is experienced it can lead to impairments in performance and functioning. In addition, when sleep and circadian disruption are experienced regularly, such as in the context of insomnia, individuals can be at increased risk of developing a range of physical and mental health disorders including cardiovascular disease, depression, and anxiety. Such findings reinforce the need to address sleep disturbance and also highlight that it is not only sleep duration that is important but also timing and regularity of sleep–wake patterns.

Early encounters with patients provide a valuable opportunity to understand their presenting complaints and needs. In order to do this effectively, it is important to have a structured approach to evaluating their symptoms. Using a step-by-step approach, this chapter instructs you how to understand a patient’s initial presenting complaints and assess their needs in an initial assessment. This includes setting the scene with the patient, evaluating their insomnia using a structured sleep interview, and using observation to obtain helpful and pertinent clinical information in collaboration with your patient.