Table 2.

Strategies for managing adherence issues

Adherence Issue	General Strategy
Concerns about restricting sleep schedule	Patients often express dissatisfaction with their usual amount of sleep and are therefore inclined to spend extra time in bed to get any more sleep or at least to rest. Help them see that this strategy hasn’t been working for them and that it is only likely exacerbating the problem. Explain to them that by learning that they can sleep solidly, their anxieties about sleep will reduce, and their shedule will begin to repair itself. Also, remind them that as they begin to sleep solidly, they will be able to gradually increase their time in bed and maintain efficiency, so this restriction is short-term and not a lifetime sentence.
Difficulty getting out of bed at the prescribed rise time	It is important to encourage patients to set an alarm even if they normally do not. They should also inform their bed partner of their required wake time and solicit their assistance in helping them to get out of bed. Other useful strategies include having participants place the alarm clock at a distance from them, so they are forced to get out of bed to turn it off and scheduling morning activities with other people. It is also important to reiterate the rationale for consistent wake times to regulate the circadian clock.
Falling asleep before their prescribed bedtime	Often the prescribed bedtime is later than the patient’s habitual bedtime, and they may spend the last few hours before bed alone and engaged in a quiet activity, making them vulnerable to falling asleep. The patient should be encouraged to schedule social activities, both inside and outside the house, and to spend later evening hours doing something active rather than passive. You can reassure the patient that getting too “wound up” is less problematic than falling asleep before their prescribed bedtime.
Failure to observe the 15–20 minute “rule”	Patients often instinctively want to remain in bed to stay under the warmth of their covers, to avoid “waking themselves up,” or at least “to rest.” Getting up may also represent failure or cause worry that it could disturb others. Encourage them to expect to be up and so to make a specific plan about what they will do (e.g., leave the heat and light on in the living room, set out a book). The more specific the plan, the greater the likelihood the patient will follow through during the night.
Napping during the daytime	Patients may nap during the daytime or after work to deal with the daytime sleepiness associated with restricting their sleep. It is important to reiterate the rationale for avoiding daytime napping by framing it in terms of building the drive for sleep and not spending or depleting that drive at any time other than at night when they want to sleep. It is also helpful to schedule alternative activities during that time to avoid the urge to nap. They should also view daytime sleepiness as an indication that the behavioral strategies are successfully increasing their sleep drive.
Lapsing from the assigned schedule, especially on weekends	Patients should be encouraged to avoid exceptions to their sleep schedule during treatment. Reiterate the rationale for regularity and consistency and emphasize that it will shorten their treatment if they are consistent. Help them to generate morning activities to get them out of bed at the appropriate time. It can be emphasized that to fall asleep earlier, or sleep in later, will spend down sleep drive thus, making the next several nights more prone to problems.
Desire to make rapid adjustments to the restricted sleep schedule	Patients will often ask to make significant increases to TIB early in the therapy, especially if they notice increases in their SE early on. Empathize with this desire but emphasize that it takes time to restore the biological clock to a consistent rhythm. It can also be useful to draw a distinction between how long they have had insomnia and how quickly they have made positive changes to highlight that this is a longstanding issue that requires changing, which is likely to take some time. Note that adjustments are permissible when the patient meets the SE≥85% criterion.

Note. Adopted from Perlis et al. [28] – Cognitive behavioral treatment of insomnia: A session-by-session guide.