When Counting Sheep is Not Enough:

Cancer Chat Canada Pilots A CBT Group for “Sleeping Well With Cancer And Beyond”

Heather Rennie, M.A., M.Sc. Clinical Coordinator, Provincial Psychosocial Oncology Program Lead- Cancer Chat

Presentation Outline

• Introduce Cancer Chat Canada • Cancer and Insomnia • Sleeping Well with Cancer and Beyond • Alberta Pilot • Preliminary Results • Next steps, Referral Information • Insomnia Resources

Introduction to Cancer Chat Canada

A Pan-Canadian Online Initiative

• CancerChatCanada.ca (CCC)- a collaborative, national, internet-based psychosocial service that meets the standards of professional practice offered in center-based programs.

• The program offers live chat Online Support Groups (OSG’s) for patients, survivors, and family caregivers.

• Now for the first time CCC offers Online Educational Groups (OEG’s).

• CCC’s mission: To serve Canadians affected by cancer, who face difficulty accessing face-to-face professional support.

National Partnerships

http://cancerchatcanada.ca/

Chat Room

Who Joins an Online Support Group?

• Socio-demographics – Age (Mean = 50 years; Min = 19 and Max 78 years) – Gender (Female = 90%; Male = 10%) – Participant Type (Patients = 40%; Survivors = 37%; Caregivers = 23%)

• Underserved, burdened population

– 53% lived in rural or small-to-medium sized towns – 32% with metastatic diagnosis – 24% of patients were restricted in their physical activity and

unable to perform any work, or not capable of self-care – 52% of caregivers were caring for a loved one who was unable

to perform any work or self-care – 84% had limited or no previous counseling for cancer-

related distress – 32% reported having no access to other support groups.

Cancer and Insomnia

Cancer and Insomnia

• Insomnia is a widespread complaint, effecting 10% of the North American adult population on a chronic basis

• With cancer, the estimates are much higher (30-50%) • BC Cancer Agency screens new patients, sleep

is in the top three complaints • Sleep quality impacts quality of life, daily functioning and so on

Cancer and Insomnia

• Psychological impact of cancer diagnosis • Medical treatments (chemotherapy, steroid

medications, hormonal therapies) • Cancer-related fatigue • Pain • Disruption of normal routine • Worry about recurrence

Sleeping Well with Cancer and Beyond

Sleeping Well with Cancer

Session 1: Introduction Session 2: Biology of Sleep Sleep and Cancer Sleep Restriction Session 3: Stimulus Control Session 4: Relaxation/ Imagery Session 5: Cognitive Restructuring Session 6: Problem Solving and Ending

Eligibility Criteria

• Subjective complaints of poor sleep. • Difficulties in initiating and/or maintaining sleep

– > 30 min to fall asleep – > 30 min awake during the night; – sleep efficiency is lower than 85%

• Sleep difficulties are present 3 or more nights per week. • Duration of insomnia is longer than 6 months. • The sleep disturbance causes significant

impairment in social/occupational functioning or mood disturbances

Exclusion Criteria

• Participant recently diagnosed with cancer or their illness prevents them from engaging in the group

• Insomnia is a result of acute illness and will resolve with cancer remission

• Participant is very near to end of life (<3 months)

Self Management

• Active approach to improving sleep • Setting goals • Tracking their sleep in a daily sleep diary. • Completing weekly readings on topics such as

stimulus control, sleep restriction, relaxation imagery.

• Attending sessions to discuss goals, setbacks and gains.

• Adapting sleeping habits according to facilitator recommendations.

Manual

I-CAN SLEEP: Cognitive-Behavioral Therapy for Individuals with Insomnia and Cancer Self-help materials developed by Drs. Shawn Currie (Addiction and Mental Health, Alberta Health Services) and Sheila Garland (University of Pennsylvania)

Self-help book based on this program:

Currie, S.R., & Wilson, K.G. (2002). 60 Second Sleep Ease: Quick Tips to Get a Good Night’s Rest. New Horizon Press: New Jersey.

Sleep Diary

Sleep Parameters

Key Components of the Sleeping Well Program

Sleep Education

• Biology of sleep, function of sleep

• Sleep hygiene – factors that influence sleep quality

Behavioral Components

• Sleep Restriction – curtails the amount of time spent in bed (bringing it initially as close as possible to the estimated time you actually sleep)

• Rationale – people with insomnia tend to spend more time in bed to achieve the same sleep duration

• Goal is to increase sleep efficiency • Prescribe a “sleep window” and adjust as sleep

efficiency improves and is maintained

Stimulus Control

• Stimulus control is based on the assumption that insomnia is the result of faulty conditioning – conditioning the bed and bedroom with “worrying” or “not sleeping”, instead of sleeping

• Goal is to re-establish or strengthen the association between sleep and the stimulus conditions that support sleep

• Go to sleep when sleepy, and get out of bed if you can’t sleep for more than 20 minutes

Relaxation and Imagery

• Relaxation is good for sleep • Physiological response – heart rate, blood pressure and muscle activity decreases • Body temperature increases slightly • Using relaxation is like giving your body a

“push start” into a state of sleepiness • Refocusing your thoughts, distraction from “mind

chatter”; induces positive emotions

Cognitive Components

• Negative self-talk, automatic thoughts and sleep problems

• Bed becomes a place to problem-solve and worry

• Coping strategies for managing stress-related thoughts and feelings at bed time

Problem Solving

The “SOLVE” Technique:

State your problem Outline your response List your alternatives View the consequences Evaluate your results

Alberta Pilot Study

Partnership with Alberta

• Tom Baker Cancer Centre has been running face-to-face “Sleeping Well” groups

• Dr. Michael Speca, a psychologist, has facilitated these groups

• He is also a facilitator with CCC • Jurisdictional issues – can only facilitate

Alberta groups right now

Pilot Planning

• We met several times with Michael to plan this group

• The challenge was how to offer an educational group in an online, text only environment

Sleeping Well with Cancer & Beyond

• Online Educational Group for Cancer Patients/Survivors with Insomnia

• 8 participants, facilitated by a health professional (90 minute sessions; 6 sessions)

• Based on the principles of cognitive behavioral therapy/ self management approach

• Participants develop an individualized sleep program with facilitator guidance

• Share experience of coping with insomnia – share knowledge, receive understanding and support from others

What Does our Research Tell Us?

Group Demographics

• All Alberta cancer patients • Age (Mean:60 Range:55-65)

Attendance

• All participants completed the group • Overall attendance was excellent (94%) • Overall sleep diary completion (95%)

Outcomes for Patients (N=8)

54 Minutes

20 Minutes

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How long did it take to fall asleep ?

Pre-Group

Post-Group

167 Minutes

46 Minutes

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How long were you awake during the night?

Pre-Group

Post-Group

Outcomes for Patients (N=8)

Achieved Benefits

After the Group…

• 88% said they gained practical advice and

information/resources • 75% said they felt more confident about their

ability to cope with cancer and insomnia • 75% said they gained perspective on what

they’re going through

Participant Feedback

• Improving Sleep Quality “It has been an amazing week. Had a good sleep every night

without waking up.” • Increasing Quality of Life “I am so excited! Slept all night… first time in 2 years.” • Continuing Self- Management “I hope to maintain my sleep efficiency… I am prepared to

work through the program again on my own if I need to.”

• Setting Goals “I’ve been very pleased with the progress to date, and

look forward to eliminating that sleep deficiency I’ve built up over the years.”

• Achieving Results “My sleep efficiency went from 68% to 93% in six

weeks and that to me was amazing!”

Participant Feedback

What it all means

• Text-only communication has unique and unexpected benefits:

- Accessibility - Time - Easier

• Educational, therapist-led online discussions can increase knowledge, improve self management, and reduce sleep difficulties.

• All of the participants increased their Sleep Efficiency and improved their Quality of Sleep!

Insomnia Resources

Health Care Professionals

Morin, Charles M. (1993). Insomnia: Psychological Assessment and Management. New York: The Guilford Press.

The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need. (2009). Stephanie Silberman CBT work book, forward by Charles M. Morin

Self- Help Books

Goodnight mind: turn off your noisy thoughts and get a good night's sleep. (2013) Colleen E Carney & Rachel Manber Quiet your mind and get to sleep: solutions to insomnia for those with depression, anxiety, or chronic pain. (2009) Colleen E Carney & Rachel Manber Sink into sleep: a step-by-step workbook for reversing insomnia. (2013). Judith Davidson

Upcoming Groups

• Sleeping Well with Cancer and Beyond – 1st group starts January, 22, 2015 – next group starts February, 26, 2015 • Family Caregiver Group • Mixed Diagnoses Patient Group • Advanced Cancer Patient Group • Metastatic Breast Cancer Young Women Group • Ovarian Cancer Support Group • Post-treatment Cancer Survivor Group

How do I make a referral?

We take referrals throughout the year and have new groups starting every month

If you have a referral you can: • e-mail cancerchatcanada@bccancer.bc.ca, • call our coordinator toll free at 1-877-547-3777 ext. 645234

• direct patients to the www.cancerchatcanada.ca registration form to

self-register

Closing Reflections

Questions?

Thank you so much for attending!