Transdiagnostic CBT

1. Introduction

Version followed: TranS-C (Transdiagnostic Intervention for Sleep and Circadian Dysfunction) as manualised in Harvey & Buysse (2017), Treating Sleep Problems: A Transdiagnostic Approach, and delivered as "Standard TranS-C" in the adult community serious-mental-illness RCT (8 weekly 50-minute individual sessions alongside usual care; Harvey et al., 2021). Differences in the youth version (6 sessions; Harvey et al., 2018) and in "Adapted TranS-C" (4 × 20-minute sessions; NCT04154631 protocol, v1 Dec 2022) are flagged where they matter. The manual itself (module scripts, 17 handouts) is not drawn on here. Module names, the problem each optional module targets and the module-selection rule are drawn from trial papers, protocols and Sarfan et al. (2023); the RISE-UP wake-up routine is verified as Harvey's (Kaplan et al., 2018, via a university handout); "energy-generating activities" is not found in any source. No source gives the manual's step-by-step procedures, so step-level procedures remain [synthesis] or [uncertain].

This approach joins two things. (a) The transdiagnostic process model of Harvey, Watkins, Mansell and Shafran (2004, Cognitive Behavioural Processes across Psychological Disorders, OUP) is a framework, not a manualised therapy: it argues that the cognitive and behavioural processes that maintain disorders are largely shared across diagnoses, so assessment and treatment can target processes rather than diagnostic labels [source: OUP book page; chapter content not drawn on, so details of the framework are from general knowledge and marked [uncertain]]. (b) TranS-C is the clinical protocol from Harvey's later work that applies this logic to one process, sleep and circadian dysfunction, across psychiatric (and medical) conditions [source: Harvey et al., 2021; div12 workshop page; AACBT workshop page].

Core idea of change: sleep and circadian problems in people with mental disorders are kept going by psychosocial, behavioural and cognitive processes; TranS-C aims to "reverse" these maintaining processes [source: Harvey et al., 2018, JAACAP] and so improve sleep health across six dimensions (regularity, satisfaction, alertness, timing, efficiency, duration; Buysse's sleep health framework, abbreviated RU-SATED) rather than treating one sleep diagnosis [source: Harvey et al., 2021; NCT02469233 protocol; Bagary, 2018 review]. Better sleep health is expected to improve psychiatric symptoms and functioning. It integrates CBT for insomnia (CBT-I), Interpersonal and Social Rhythm Therapy (IPSRT), chronotherapy and motivational interviewing/enhancement [source: Harvey et al., 2021; Harvey et al., 2018].

2. Framework

Architecture: 4 cross-cutting + 4 core + 7 optional modules [source: Harvey et al., 2021; Trials 2016 protocol Table 2; NCT02469233; NCT01828320; Guilford book page]

Dose and format

• Standard adult TranS-C: individual, weekly, 50 minutes; default 8 sessions, up to 4 more (maximum 12), rarely needed; delivered alongside usual care [source: Harvey et al., 2021; NCT02469233].
• Book reviewer's summary of the manual: 4–10 sessions usually suffice depending on complexity and number of modules [source: Bagary, 2018].
• Youth (10–18, evening chronotype): 6 weekly 50-minute individual sessions in the school year; 18% needed one double session [source: NCT01828320; Harvey et al., 2018].
• Adapted TranS-C for community mental health: 4 weekly 20-minute sessions; core content split into five modules (irregular sleep-wake times; winding down; waking up; daytime impairment; maintenance); only one optional module kept (sleep-related worry), integrated as needed [source: NCT04154631].

Phases (the sources describe modules, not named phases; the phase grouping below is [synthesis] built on the sourced sequencing rule)

1. Assessment and engagement (pre-treatment and session 1). Sleep assessment (book chapter 2), a daily sleep diary, screening for other sleep disorders (suspected apnoea or limb-movement disorder → medical evaluation, not exclusion) [source: Guilford TOC; NCT02469233; NCT01828320]. Goal: a shared picture of which sleep-health dimensions are impaired.
2. Foundation (sessions 1–3). Introduce all four cross-cutting modules: build the formulation, educate, elicit motivation, set goals [source: Trials 2016 Table 2; Bagary, 2018]. In practice Core 1 (regular times, wind-down, wake-up) usually starts here; it was delivered to 100% of coded cases [source: Harvey et al., 2021 fidelity data].
3. Targeted change (middle sessions). Remaining core modules plus any optional modules selected by "clinical presentation, treatment goals, and provider case conceptualization" [source: NCT04154631]. Cross-cutting work continues every session.
4. Maintenance (final session or two). Core 4: consolidate and plan for keeping changes [source: module name, all trial sources; placement at the end is [synthesis], as sources say modules can be given in any order].

Criteria for moving on: not specified in any source [uncertain]. Practical rule [synthesis]: move from foundation to targeted work once the client is completing the diary, has a written goal and has agreed one behavioural experiment; add an optional module only when the diary and formulation show a problem that core work has not shifted after 1–2 weeks; start maintenance when goals are met or 1–2 sessions remain, whichever comes first.

Module-selection rule: every session includes the four cross-cutting modules; optional modules are chosen through "case conceptualization, patient goals, and provider judgment". Each optional module is matched to a problem: Optional 1 poor sleep efficiency (insomnia); Optional 2 too much time in bed (hypersomnia); Optional 3 delayed or advanced phase; Optional 4 sleep-related worry; Optional 5 CPAP compliance; Optional 6 disruptive environments; Optional 7 nightmares. The developers' worked example: a client with hypersomnia and a delayed phase gets the core modules plus Reducing Time in Bed and Delayed or Advanced Phase [source: Sarfan et al., 2023].

Therapist qualifications and training: master's- or doctoral-level clinicians; one-day workshop (6–8 h, or two 3-h blocks), manual, weekly supervision; certification in implementation work required three supervised cases; competence rated with the Cognitive Therapy Rating Scale (score of 40 or more treated as competent) plus a TranS-C element checklist [source: Harvey et al., 2021; NCT02469233; NCT04154631].

3. Guiding principles

1. Target sleep health, not a single sleep disorder. Assess and aim for change across regularity, satisfaction, alertness, timing, efficiency and duration; one client may have insomnia, oversleeping and a delayed clock all at once [source: Harvey et al., 2021; AACBT page; Bagary, 2018].
2. Transdiagnostic: the process, not the diagnosis, decides treatment. Use the same protocol whatever the psychiatric diagnosis; let the formulation, not the label, choose modules [source: Harvey et al., 2021; process-model rationale from Harvey et al., 2004 [uncertain: book chapters]].
3. Modular and formulation-driven. Deliver cross-cutting modules every session, most core modules, and optional modules only when indicated; order is flexible [source: Harvey et al., 2021; NCT04154631].
4. Behaviour change, not information. The active ingredient is the therapist actively promoting change; in fidelity coding, TranS-C sessions had 88 behaviour-change actions to psychoeducation's 0. Every session should end with a concrete change to try [source: Harvey et al., 2018].
5. Motivation throughout. Use motivational interviewing/enhancement in every session, not only at the start; practically, elicit the client's own reasons before prescribing [source: Bagary, 2018; Harvey et al., 2021 (motivational enhancement delivered to all coded cases)].
6. Regularity first. Regular sleep-wake times with wind-down and wake-up routines form Core 1 and were delivered in every coded case; practically, stabilise timing before fine-tuning anything else [source: Harvey et al., 2021; regularity-first emphasis is [synthesis]].
7. Gradual shifts. Move bedtime earlier by about 20–30 minutes per week, slower than traditional chronotherapy; practically, small steps the client can sustain [source: NCT01828320].
8. Avoid unnecessary sleep deprivation. Stimulus control and sleep restriction were made optional because they can cause partial sleep deprivation, a safety concern in serious mental illness; practically, use them only when indicated and with monitoring [source: Harvey et al., 2021].
9. Use light and social rhythms as levers. Morning natural light, dim evening light, youth-chosen electronic curfew (no light boxes in the youth protocol), and regular meals, social contact and exercise from IPSRT; practically, change the day to change the night [source: NCT01828320].
10. Client choice and autonomy. Youth pick their own electronic curfew; practically, the client chooses the specific behaviour and time [source: NCT01828320; generalisation to adults is [synthesis]].
11. Developmental fit. The manual includes developmental adaptations for adolescents; practically, adjust language, parent involvement and school schedules for youth [source: Guilford book page; specifics [uncertain]].
12. Structured CBT stance. Competence is rated on a general cognitive therapy scale; practically, use agenda-setting, collaboration, guided discovery, feedback and homework review each session [source: Harvey et al., 2021 (use of CTRS); listing of CBT skills is [synthesis]].
13. Work alongside usual care. TranS-C is added to existing treatment, not a replacement; practically, coordinate with the prescriber and care team [source: Harvey et al., 2021].
14. Look for other sleep disorders. Suspected apnoea or limb movements get a medical evaluation; CPAP adherence is a treatment module of its own [source: NCT02469233; module list].

4. Intervention inventory

Sourcing note: the following are verified: module names and groupings, the problem each optional module targets, the specific parameters cited (20–30-minute weekly bedtime shifts, morning light and dim evening light, youth-chosen electronic curfew, IPSRT social rhythms, daily diary for planning and sleep restriction, imagery rehearsal for nightmares, chronotherapy and timed light for delayed phase, exposure for CPAP claustrophobia), the RISE-UP morning routine and the youth text-message boosters [source: Harvey et al., 2021; NCT01828320; NCT04154631; Bagary, 2018; Sarfan et al., 2023; Dolsen et al., 2023; Kaplan et al., 2018 via University of Melbourne handout]. The manual's own step-by-step scripts and handouts are not drawn on (trial papers and protocols name modules but do not describe steps). The steps below are written from standard CBT-I, IPSRT, chronotherapy and MI practice to fit each verified module, and are marked [synthesis]. Check them against Harvey & Buysse (2017) chapters 3–5 before relying on detail. All example language is illustrative.

4.1 Sleep assessment and daily sleep diary (assessment tool used throughout)

• Purpose: get a week-by-week picture of bed time, sleep-onset time, night waking, wake time, rise time, naps and daytime alertness; drives formulation, goal setting and any sleep-restriction calculation. Youth in the TranS-C trial completed their own diary each morning "mainly for treatment planning and sleep restriction" [source: NCT01828320].
• Steps [synthesis]: (1) In session 1, give a one-page diary and fill in last night together. (2) Agree a cue for completing it each morning (with breakfast, phone alarm). (3) Start every session by reviewing it together: compute average time in bed, estimated total sleep, rise-time variability across the week and weekday-weekend difference. (4) Pick out the one or two patterns the session will target. (5) Screen for other sleep disorders (loud snoring or witnessed breathing pauses, leg discomfort at night, sudden sleep attacks) and refer for medical evaluation when suspected [source for referral rule: NCT02469233].
• Example language (illustrative): "Let's look at your week together. What jumps out at you?"
• Watch for: diaries filled in all at once from memory; clients who find the diary itself raises sleep anxiety (shorten it to bed, rise and a 1–5 quality rating) [synthesis]. Working: diary returned most days and used by the client to explain their own week.

4.2 Cross-cutting 1: Case formulation (functional analysis)

• Purpose: identify the behavioural, cognitive, psychosocial and circadian processes keeping this person's sleep problem going, and use them to choose modules [source: module named "case formulation"/"functional analysis", Harvey et al., 2021; Trials 2016].
• Steps [synthesis]: (1) Map the 24 hours: when the client gets light, eats, moves, socialises, uses screens, uses caffeine/alcohol/substances, naps, goes to bed and gets up. (2) For each problem dimension (e.g. irregular timing, long time in bed, daytime sleepiness), ask what happens just before, what the client does in response, and what that does to sleep next night (e.g. sleeps in after a bad night → less sleep drive and later body clock → harder to fall asleep). (3) Draw the loop on paper with the client. (4) Link it to the psychiatric picture (low mood → staying in bed → irregular rhythm → worse mood). (5) Mark the leverage points and translate each into a module (e.g. sleeping in → Core 1; worry in bed → Optional 4). (6) Revisit the map each session as new information arrives.
• Example language (illustrative): "So after a rough night you stay in bed until noon, which makes sense, and then the next night your body isn't ready for sleep until 3 a.m. Does that loop sound familiar?"
• Watch for: formulation that only lists sleep-hygiene "rules" rather than personal loops. Working: the client can describe their own loop and predict what a change would do.

4.3 Cross-cutting 2: Sleep and circadian education

• Purpose: give the client a working model of sleep so recommendations make sense [source: module named in all trial sources].
• Steps [synthesis]: (1) Explain two drivers of sleep: sleep drive that builds the longer one is awake (and is spent by naps and long lie-ins) and the body clock that sets timing and is reset mainly by light, especially morning light, plus regular meals, activity and social contact. (2) Introduce the six sleep-health dimensions and ask which matter most to the client. (3) Tailor to the client: e.g. why evening light and screens push the clock later; why staying in bed longer often makes sleep lighter; how alcohol and caffeine affect sleep. (4) Keep each piece short and tied to the client's diary, then ask the client to explain it back. (5) Return to education each session as each module comes up.
• Example language (illustrative): "Think of sleep as needing two things to line up: enough tiredness built up, and your body clock saying it's night."
• Watch for: lecturing; overload in clients with cognitive impairment (one idea per session, written down) [synthesis]. Working: client links their own behaviour to the model unprompted.

4.4 Cross-cutting 3: Behaviour change and motivation

• Purpose: build and sustain motivation to change long-standing sleep habits; motivational interviewing/enhancement is used throughout and was delivered to all coded cases [source: Harvey et al., 2021; Bagary, 2018; div12 page citing Miller & Rollnick, 2012].
• Steps (MI elements from Miller & Rollnick; how TranS-C sequences them is [uncertain]): (1) Ask open questions about what the client wants from better sleep, then reflect and summarise. (2) Elicit the client's own reasons for change (desire, ability, reasons, need) and selectively reflect them. (3) Use 0–10 importance and confidence rulers: "Why a 5 and not a 2? What would move it to a 6?" (4) Explore pros and cons of the current pattern and of changing, without arguing. (5) Ask permission before giving information or advice; offer a menu of options rather than one prescription. (6) Turn intent into a specific plan [synthesis: implementation intentions and cueing from behaviour-change practice]: what, when, where, cue, and what to do if it goes wrong. (7) Plan small rewards and track wins [synthesis].
• Example language (illustrative): "On a scale of 0 to 10, how important is it to you to be up by 9 most days? … What makes it a 6 rather than a 3?"
• Watch for: sustain talk ("I'm just a night person"), which signals a need for more evocation, not more advice. Working: the client proposes their own next step and change talk increases across sessions.

4.5 Cross-cutting 4: Goal setting

• Purpose: define what the client wants to change in sleep and in daytime life, so modules have a target [source: module named in all trial sources].
• Steps [synthesis]: (1) Ask about life goals first (work, study, relationships, mood) and how sleep links to them. (2) Translate into 1–3 sleep-health goals on the six dimensions (e.g. "same rise time within 1 hour, 6 days a week"). (3) Make them specific, measurable on the diary and achievable in weeks. (4) Write them on a shared sheet; review progress at each session and revise.
• Example language (illustrative): "If sleep were going better, what would you be doing during the day that you're not doing now?"
• Watch for: goals set by others (family, clinic) that the client does not own; goals about hours of sleep only. Working: goals referenced by the client in review.

4.6 Process-model formulation (Harvey, Watkins, Mansell and Shafran, 2004) [uncertain]

• Status: the 2004 book is a research and treatment framework, not a manualised protocol; its chapters are not drawn on here. Commonly summarised processes include selective attention, memory biases, reasoning biases, recurrent negative thinking and behaviours such as avoidance and safety behaviours [uncertain: from general knowledge]. Using it clinically below is [synthesis].
• Steps [synthesis]: (1) For any presenting problem, ask which of these processes keep it going (e.g. monitoring for threat, worry/rumination, avoidance or safety behaviours). (2) Pick processes shared across the client's comorbid problems. (3) Choose standard CBT methods that target the process (attention shifting, behavioural experiments, dropping safety behaviours, stimulus-cued worry postponement). In TranS-C the same logic is applied to sleep: e.g. monitoring the clock and the body for signs of poor sleep is treated in Optional 4.

4.7 Core 1a: Establishing regular sleep-wake times

• Purpose: stabilise the body clock and sleep drive by keeping rise time (and then bedtime) consistent across weekdays and weekends; delivered to 100% of coded cases in the adult trial [source: Harvey et al., 2021]. Youth trial reduced weeknight-weekend variability [source: Harvey et al., 2018].
• Steps: (1) From the diary, show the spread of rise and bed times and the weekday-weekend gap [synthesis]. (2) Agree an anchor rise time the client can keep 7 days a week, set near their current weekday rise time [synthesis]. (3) If bedtime needs to move earlier, shift it gradually, about 20–30 minutes per week [source: NCT01828320]. (4) Add social-rhythm anchors from IPSRT: regular meal times, social contact and exercise at similar times daily [source: NCT01828320]; build them into a simple daily schedule [synthesis]. (5) Add light timing: natural light soon after waking and dimmer light in the evening [source: NCT01828320]. (6) Problem-solve barriers (weekends, no fixed daytime commitments, shared households) and set a fallback (e.g. on weekends no more than about an hour later) [synthesis]. (7) Review the diary each week and adjust.
• Example language (illustrative): "Rather than trying to fall asleep earlier, which is hard to force, let's start with the part you control: getting up at the same time every day."
• Watch for: all-or-nothing reactions to one missed morning; clients without daytime structure (unemployment, disability), where IPSRT anchors matter most [source for IPSRT use in unstructured schedules: Bagary, 2018]. Working: rise-time variability shrinks on the diary within 2–3 weeks [synthesis].

4.8 Core 1b: Learning a wind-down routine

• Purpose: create a buffer between an activating day and bed so the client is ready for sleep at the planned time [source: module named in all trial sources].
• Steps [synthesis unless tagged]: (1) Ask what the client does in the hour before bed and how activating each activity is. (2) Agree a wind-down period before the planned bedtime (commonly 30–60 minutes in CBT-I practice [uncertain: manual's recommended length not verified]). (3) List calming, low-light activities the client actually enjoys (reading paper books, music, bath, stretching, a hobby, prayer) and choose 2–3. (4) Set an electronic curfew time chosen by the client [source: youth-selected electronic curfews, NCT01828320]; agree what to do with the phone (charge outside bedroom, alarm clock instead). (5) Dim lights during wind-down [source: dim evening light, NCT01828320]. (6) Run it as an experiment for a week and record on the diary how long it took to fall asleep.
• Example language (illustrative): "What could your last 45 minutes look like if it were designed to land you gently in bed?"
• Watch for: wind-down activities that are themselves arousing (gaming, intense social media, work emails); clients who treat wind-down as a test of whether they will sleep. Working: shorter time to fall asleep, client reports looking forward to it.

4.9 Core 1c: Learning a wake-up routine

• Purpose: overcome sleep inertia and make the anchor rise time achievable [source: module named in all trial sources].
• Steps [synthesis unless tagged]: (1) Ask what happens between the alarm and getting up (snoozing, phone in bed). (2) Build a short sequence of actions for straight after the alarm. Harvey's lab developed the RISE-UP morning routine for this: Refrain from snoozing; Increase activity in the first hour; Shower (or wash face and hands with cold water); Expose yourself to sunlight; Upbeat music; Phone a friend [source: University of Melbourne sleep handout, which credits Harvey and cites Kaplan et al., 2018; letters also listed in an Asset Health blog]. Kaplan et al. (2018) tested it as a treatment experiment to reduce subjective sleep inertia in insomnia and bipolar disorder; the handout reports it reduced the severity and duration of sleep inertia and increased morning activity [source: handout]. Whether the TranS-C manual presents it under this name is not verified [uncertain]. (3) Let the client choose which elements fit; not all six are needed [synthesis; the blog says the same]. (4) Place the alarm across the room; open curtains or go outside soon after waking [source for morning light: NCT01828320]. (5) Plan something rewarding or social early in the day. (6) Track on the diary whether the rise time was met.
• Example language (illustrative): "The first 10 minutes after the alarm are the hardest. Let's plan exactly what you'll do in them so you don't have to decide when you're groggy."
• Watch for: sedating medicines that make mornings very hard (coordinate with the prescriber; never adjust medication yourself). Working: fewer snoozes, rise time met most days.

4.10 Core 2: Improving daytime functioning

• Purpose: reduce daytime sleepiness, fatigue and impairment, which often maintain the night-time problem through napping, inactivity and lying down [source: module named; "reducing daytime impairment" in NCT04154631; youth trial reduced daytime sleepiness, Harvey et al., 2018]. Delivered in 68% of coded adult cases [source: Harvey et al., 2021].
• Steps [synthesis]: (1) Use the diary to see when energy dips and what the client does then (naps, lying down, more caffeine, cancelling plans). (2) Distinguish sleepiness (falling asleep) from fatigue (tired but cannot sleep). (3) Experiment with activity during dips rather than rest: a short walk outside, talking with someone, a change of task, daylight. (4) If naps are needed, keep them short and earlier in the day, and plan them rather than drifting off. (5) Plan the day's schedule so demanding tasks fall at higher-alertness times. (6) Safety: if the client is very sleepy, advise against driving or operating machinery while drowsy.
• Example language (illustrative): "When you hit that 3 p.m. slump, what would happen if, instead of lying down, you stepped outside for 10 minutes? Shall we test it?"
• Watch for: daytime sleepiness that persists despite better night sleep (consider undiagnosed sleep disorders or medication effects and refer). Working: fewer unplanned naps, client-rated daytime energy improves.

4.11 Core 3: Correcting unhelpful sleep-related beliefs

• Purpose: change beliefs that drive unhelpful sleep behaviour (e.g. that one must stay in bed to rest, that a bad night will ruin the next day) [source: module named; delivered in 58% of coded adult cases, Harvey et al., 2021].
• Steps [synthesis]: (1) Identify beliefs from the formulation, or with a validated beliefs questionnaire such as Morin's Dysfunctional Beliefs and Attitudes about Sleep scale (licensed; use items as prompts in session without copying them). (2) Rate how strongly the client holds each belief (0–100%). (3) Use guided discovery: what evidence supports it, what else fits, what happened on past nights. (4) Design a behavioural experiment: state the prediction, agree a test (e.g. compare days after getting up at the anchor time versus sleeping in, rating mood and energy), record results. (5) Re-rate belief strength and write the new conclusion.
• Example language (illustrative): "You're predicting that if you get up at 8 after a bad night you'll feel worse all day. Shall we test that this week and see what actually happens?"
• Watch for: intellectual agreement without behaviour change; beliefs embedded in psychiatric symptoms (e.g. delusional content about sleep), which need the treating team. Working: belief ratings drop and avoided behaviours are tried.

4.12 Core 4: Maintenance of behaviour change

• Purpose: consolidate gains and prepare for setbacks; delivered in 100% of coded adult cases [source: Harvey et al., 2021; NCT04154631 "maintaining changes made during treatment"].
• Steps [synthesis]: (1) Review the diary from the start of treatment to now with the client. (2) Ask what changes made the most difference and write them as the client's own plan. (3) Identify high-risk situations (illness, travel, holidays, relapse of mood or psychotic symptoms, medication changes, shift in daily structure). (4) Plan an early-warning sign (e.g. rise time slipping for 3+ days) and a first response (return to anchor rise time, wind-down, morning light). (5) Distinguish a lapse from a relapse and plan who to tell. (6) Agree a brief self-check schedule after treatment ends.
• Example language (illustrative): "If six months from now your sleep starts slipping, what's the first thing on this list you'd go back to?"
• Watch for: the client crediting change to luck or the therapist. Working: client can state their plan without the sheet.

Booster option from the youth trial: for 6–12 months after treatment, an arm of the trial received 24 weekly text messages, sent manually between 4 and 9 p.m. "Push" messages repeated a treatment point; "pull" messages prompted recall (e.g. "What do you do to wind down before bed?"). The messages were short and written at a low reading level [source: Dolsen et al., 2023]. Clinicians can draft a few such messages from the client's own Core 4 plan [synthesis].

4.13 Optional 1: Improving sleep efficiency (stimulus control and sleep restriction)

• Purpose: for clients who spend long periods awake in bed, strengthen the bed-sleep association and consolidate sleep. The module uses stimulus control and sleep restriction from CBT-I [source: NCT04154631; Harvey et al., 2021], kept optional because both can cause partial sleep deprivation, a safety concern in serious mental illness [source: Harvey et al., 2021].
• Contraindications and safety [synthesis from standard CBT-I practice]: use caution or avoid with bipolar disorder (sleep loss can trigger hypomania/mania), seizure disorders, untreated sleep apnoea, high fall risk, and jobs or driving where drowsiness is dangerous; agree with the prescriber and team before starting; warn about increased daytime sleepiness in the first weeks.
• Steps, stimulus control [synthesis]: (1) Go to bed only when sleepy, not just tired. (2) Use the bed only for sleep (and sex). (3) If unable to sleep after what feels like about 15–20 minutes, get up, go to another dim room, do a calm activity and return when sleepy. (4) Same rise time every day. (5) Avoid daytime napping or keep it short.
• Steps, sleep restriction [synthesis]: (1) From 1–2 weeks of diary, calculate average total sleep and sleep efficiency (time asleep ÷ time in bed). (2) Set a time-in-bed window close to average sleep time, with a floor that protects safety (standard CBT-I protocols do not go below about 5–6 hours; use a more conservative floor in serious mental illness [uncertain: TranS-C's own floor not verified]). (3) Fix the rise time; bedtime follows from the window. (4) Each week, widen the window by about 15–30 minutes if efficiency is high, keep it if moderate, narrow it if low. (5) Monitor mood and sleepiness each session.
• Example language (illustrative): "We're going to make your time in bed a bit shorter for a while so that the time you do spend there is mostly sleep. It may feel harder for a week or two before it gets easier."
• Watch for: rising mood or energy, reduced need for sleep or racing thoughts (stop and review with the team); excessive daytime sleepiness. Working: efficiency rises and the window can be widened.

4.14 Optional 2: Reducing time in bed

• Purpose: for clients who spend too much time in bed, i.e. hypersomnia presentations, which are common with depression, negative symptoms or sedation; the aim is to reduce time in bed to restore sleep drive and daytime activity. Optional 1, by contrast, targets poor sleep efficiency (insomnia). In the adult trial this module went to all 4 cases with hypersomnia and no comorbid sleep problem [source: Sarfan et al., 2023]. The manual's procedure is not drawn on; the steps below are [synthesis].
• Steps [synthesis]: (1) Use the diary to show total hours in bed, including daytime lying down. (2) Explore what time in bed does for the client (escape, rest, avoidance of people or symptoms) without judgement. (3) Agree gradual reductions (e.g. getting up 15–30 minutes earlier per week) rather than a sudden cut. (4) Plan what the client will do with the reclaimed time, using activity scheduling and the social-rhythm anchors. (5) Coordinate with the prescriber where sedation is a factor.
• Example language (illustrative): "Bed has become the place you go when things are hard. What would make the first hour out of bed worth it?"
• Watch for: low mood worsening with sudden reductions; avoidance functions that need direct work. Working: fewer hours in bed with stable or better mood.

4.15 Optional 3: Dealing with delayed or advanced phase

• Purpose: shift a body clock that runs too late (common in adolescents and "night owls") or too early. Techniques come from behavioural treatment of delayed sleep phase, including chronotherapy and timed light exposure [source: Bagary, 2018]; in the youth protocol bedtimes moved earlier by about 20–30 minutes per week with morning natural light, evening dim light and electronic curfews, and no light boxes [source: NCT01828320]. In the youth trial, TranS-C reduced evening preference and moved circadian phase earlier [source: Harvey et al., 2018].
• Steps for delayed phase [source: NCT01828320 for the shift size, light and curfew; rest is [synthesis]]: (1) Confirm the pattern on the diary (late but normal-length sleep when free to choose; difficulty only when forced to get up early). (2) Set the current natural sleep window as the starting point. (3) Move rise time and bedtime earlier by about 20–30 minutes per week. (4) Get outdoor light soon after waking; dim light and stop screens in the evening. (5) Keep weekends within the same window. (6) Strengthen with morning activity, regular meals and social contact.
• Steps for advanced phase [synthesis]: reverse the logic: later evening light and activity, avoid very early bright morning light, and shift bedtime later gradually.
• Example language (illustrative): "Your clock isn't broken; it's set late. We'll nudge it earlier by about 20 minutes a week, mostly using light."
• Watch for: large weekend lie-ins undoing the week's gains; school or work pressure to shift too fast. Working: earlier sleep onset on the diary with less weekday-weekend gap.

4.16 Optional 4: Reducing sleep-related worry and vigilance

• Purpose: reduce worry, rumination and monitoring (of the clock, the body, signs of poor sleep) that keep the client aroused in bed [source: module name; the only optional module kept in Adapted TranS-C, NCT04154631]. Procedures unknown [uncertain].
• Steps [synthesis]: (1) Identify the content and timing of worry and any monitoring behaviours (clock-watching, checking the phone, scanning for tiredness). (2) Schedule a "worry time" or write a to-do and worry list earlier in the evening, before wind-down, with a next step for each item. (3) If worry arises in bed, note it briefly and postpone it to the next day's slot. (4) Turn the clock away and remove the phone. (5) Run a behavioural experiment comparing nights with and without clock-watching. (6) If worry is part of a primary anxiety or mood disorder, coordinate with the main treatment.
• Example language (illustrative): "Let's give the worries a proper appointment at 7 p.m. so they don't need to show up at 2 a.m."
• Watch for: postponement turning into suppression. Working: shorter time awake in bed and less clock-checking.

4.17 Optional 5: Promoting CPAP adherence / exposure for CPAP claustrophobia

• Purpose: help clients with diagnosed obstructive sleep apnoea use CPAP; includes exposure therapy for claustrophobic reactions to the mask [source: module name, all trial sources; CPAP adherence methods named in Bagary, 2018].
• Consent and safety [synthesis]: only with a medical diagnosis and prescribed device; coordinate with the sleep physician on mask fit and settings (never adjust pressure yourself); explain exposure, obtain informed consent, agree the client controls the pace and can stop.
• Steps [synthesis]: (1) Use MI to explore reasons for and against using CPAP. (2) Solve practical barriers with the sleep clinic (mask fit, dryness, noise). (3) For claustrophobia, build a graded hierarchy: hold the mask, put it to the face without straps, wear it with air on while awake watching TV, wear it lying down in the day, then at night for part and then all of the night. (4) Stay at each step until anxiety falls noticeably, without escape or distraction; repeat daily. (5) Track nightly hours of use (device data or diary).
• Example language (illustrative): "We'll start with something you rate a 2 out of 10, like just holding the mask while you watch TV, and only move on when that feels easy."
• Watch for: panic history, trauma linked to suffocation or restraint (go more slowly, consider trauma-focused care first). Working: rising hours of use and lower anxiety ratings.

4.18 Optional 6: Negotiating sleep in a complicated environment

• Purpose: improve sleep where the setting is hard to control, e.g. noise or streetlight [source: NCT04154631]; relevant to shared housing, shelters and supported accommodation [synthesis].
• Steps [synthesis]: (1) List what disrupts sleep in the room and home (noise, light, temperature, bed-sharing, pets, others' schedules, safety concerns). (2) Separate what the client can change, can negotiate, or must cope with. (3) Low-cost fixes: earplugs, eye mask, white-noise source, blackout material, fan. (4) Rehearse requests to housemates, family or staff (assertiveness role play). (5) Where safety at night is a concern, address that first and link with case management.
• Example language (illustrative): "Let's practise exactly what you'd say to your roommate about the TV at 1 a.m."
• Watch for: real danger in the environment; do not treat a safety problem as a sleep problem. Working: fewer environment-related awakenings on the diary.

4.19 Optional 7: Reducing nightmares (imagery rehearsal)

• Purpose: reduce frequency and distress of recurrent nightmares, using imagery rehearsal therapy [source: module name; imagery rehearsal named in Bagary, 2018]. TranS-C's specific procedure unknown [uncertain].
• Steps [synthesis from standard imagery rehearsal practice]: (1) Explain that nightmares can behave like a learned habit that can be changed while awake. (2) Choose a nightmare, starting with a less distressing one; in PTSD avoid detailed trauma recall unless trauma-focused treatment is in place. (3) Ask the client to change the dream in any way they choose, then write or tell the new version briefly. (4) Rehearse the new version in imagery for a few minutes daily, while awake. (5) Track nightmare frequency and distress on the diary.
• Example language (illustrative): "You're the author now. Change the dream however you like; it doesn't need to be realistic."
• Watch for: high distress during imagery, dissociation (pause, ground, go more slowly); nightmares as part of active PTSD or suicidal risk (see section 5). Working: fewer or less distressing nightmares within weeks.

5. Handling problems

The sources say little about troubleshooting; most guidance below is [synthesis] and is labelled as such. Sourced points are tagged.

• Severely impaired clients and incomplete module delivery. In the adult trial, core-module fidelity was "lower than expected" (only 37% received all four core modules); the authors suggest providers focused on basic sleep health because of participants' level of impairment [source: Harvey et al., 2021]. Response: prioritise Core 1 (regular times, wind-down, wake-up) and maintenance, which reached every coded case; add other modules only when the basics are in place [synthesis]. Where time is short, the Adapted TranS-C format (4 × 20 minutes; regular times, wind-down, waking up, daytime impairment, maintenance, plus worry if needed) is a tested simplification [source: NCT04154631].
• Stuck: diary shows no change after 2–3 weeks [synthesis]. Check whether the agreed behaviour was actually done; if not, treat as a motivation or barrier problem (below). If it was done, revisit the formulation: is there an undiagnosed sleep disorder, a medication effect, substance use, a delayed clock mistaken for insomnia, or an environmental cause? Refer for medical evaluation when apnoea or limb movements are suspected [source for referral: NCT02469233].
• Ambivalence and "resistance" (e.g. "I'm a night person", "nights are the only time I have to myself") [synthesis drawing on MI, which TranS-C uses throughout]. Do not argue; reflect both sides, explore what late nights give the client, and look for a change that keeps that value (e.g. protected "me time" earlier in the evening). Lower the step size rather than pushing harder.
• Non-adherence to diary or homework [synthesis]. Shorten the diary; complete it in session from memory as a fallback; link it to an existing morning cue; ask what got in the way without blame; agree one behaviour per week rather than a list; use phone reminders where appropriate.
• Overwhelm and cognitive difficulty [synthesis]. One idea and one change per session; write everything down; give a single summary card; involve a supporter or case manager with consent; repeat key messages across sessions. Adapted TranS-C's shorter sessions are an option [source: NCT04154631].
• Mood elevation or hypomania risk [synthesis]. Sleep loss can trigger mania in bipolar disorder; avoid or carefully limit sleep restriction and fast schedule shifts, watch for reduced need for sleep, increased energy or racing thoughts, and alert the prescriber and team. The developers made sleep restriction and stimulus control optional for safety reasons in serious mental illness [source: Harvey et al., 2021].
• Worsening depression with reduced time in bed [synthesis]. Slow the pace, pair each reduction with a valued activity, and coordinate with the depression treatment.
• Psychotic symptoms affecting sleep (e.g. voices louder at night, fear of the bedroom) [synthesis]. Coordinate with the treating team; adapt the environment and wind-down plan; do not challenge delusional content as a "sleep belief".
• Suicide and self-harm risk [synthesis following standard practice]. Insomnia and nightmares are recognised warning signs; ask directly about suicidal thoughts when sleep or nightmares worsen, follow your service's risk-assessment and safety-planning procedures, and include lethal-means counselling (safe storage or removal, e.g. of stockpiled sleep medication). Clients with active serious suicide risk were excluded from the adult trial [source: NCT02469233], so TranS-C's use in that state is untested.
• Medication questions [synthesis]. Clients often ask about sleeping pills or sedating medication; record what they take and when, and refer all dosing and change decisions to the prescriber.
• Shift workers [uncertain]. Night-shift work on more than 2 nights a week was an exclusion in the adult trial [source: NCT02469233], so adaptation for shift workers is not covered by the sources; any work with them is [synthesis].
• Adolescents and families [synthesis]. Expect school-day pressure for early rising and weekend catch-up sleep; the youth protocol used gradual bedtime shifts and youth-chosen electronic curfews [source: NCT01828320]. Involve parents in environment and schedule changes while keeping the young person's choice central.
• Ruptures [synthesis]. Ruptures often arise when the client feels lectured or judged about "bad habits". Name it, take responsibility for pushing too fast, ask what would be more useful, and return to the client's goals.
• Distress in exposure or imagery work (CPAP exposure, nightmare rescripting) [synthesis]. Agree a stop signal, step down the hierarchy, use grounding, and reschedule rather than forcing completion.

Optional modules not matched to the presentation (verified). In the adult trial, modules were often not given as intended. Only 4 of 9 clients with insomnia and no comorbid sleep problem received Improving Sleep Efficiency, and only 24.8% of all insomnia cases did. Sleep-related worry was the most-used optional module for both insomnia (52.5%) and subdiagnostic hypersomnia (57.4%). The authors recommend supervision that uses goal setting, focuses on delivering optional modules, and matches presenting problems to modules systematically [source: Sarfan et al., 2023]. Response: after formulating, check each sleep problem against the optional-module targets in section 2. Write down why the matching module is or is not being given, and review this in supervision [synthesis].

Sources

Sources:

• A Randomized Controlled Trial of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) to Improve Serious Mental Illness Outcomes in a Community Setting (eScholarship record) and full-text PDF. Harvey AG, Dong L, Hein K, et al. (2021), DOI 10.1037/ccp0000650. Cited as Harvey et al., 2021.
• Modifying the Impact of Eveningness Chronotype ("Night-Owls") in Youth: A Randomized Controlled Trial (eScholarship) and PDF. Harvey AG et al. (2018), JAACAP 57(10):742–754. Cited as Harvey et al., 2018.
• Trials 2016 study protocol, Table 2: TranS-C modules. Harvey AG et al. (2016), "A transdiagnostic sleep and circadian treatment to improve severe mental illness outcomes in a community setting: study protocol for a randomized controlled trial", Trials. Cited as Trials 2016.
• ClinicalTrials.gov protocol NCT02469233 (adult community TranS-C RCT).
• ClinicalTrials.gov protocol NCT01828320 (youth TranS-C RCT, amendment 10, 2019).
• ClinicalTrials.gov protocol NCT04154631 (Standard vs Adapted TranS-C implementation trial, v1 Dec 2022).
• Guilford Press: Treating Sleep Problems: A Transdiagnostic Approach (table of contents and description).
• Bagary M. (2018) Review of Treating Sleep Problems, British Journal of Psychiatry 213(4):620. Cited as Bagary, 2018.
• SCP Division 12: A Transdiagnostic Approach to Treating Sleep Problems in Clinical Practice: Basics & Beyond.
• AACBT workshop: CBT for Transdiagnostic Sleep Problems (Harvey, 2018).
• Oxford Academic: Cognitive Behavioural Processes across Psychological Disorders and Chapter 7, Conclusions (metadata only).

Further sources:

• The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) in Community Mental Health: Comorbidity and Use of Modules Under the Microscope (eScholarship record) and full-text PDF. Sarfan LD, Hilmoe HE, Gumport NB, Harvey AG (2023), Cognitive and Behavioral Practice 30(4):692–706. Cited as Sarfan et al., 2023.
• Transdiagnostic Sleep and Circadian Intervention for Adolescents Plus Text Messaging: Randomized Controlled Trial 12-month Follow-up (eScholarship PDF). Dolsen EA, Dong L, Harvey AG (2023), Journal of Clinical Child & Adolescent Psychology 52(6):750–762. Cited as Dolsen et al., 2023.
• Why don't I wake up feeling refreshed? (University of Melbourne, John Trinder Sleep Laboratory handout). Credits RISE-UP to Harvey and cites Kaplan et al., 2018.
• Get Better Sleep With the RISE-UP Method (Asset Health blog). Secondary source, used only for the list of letters; its credit to a Stanford team conflicts with the handout and is not followed.
• Triple Vulnerability? protocol and SAP, NCT01828320 (PDF). Names the modules only, with no RISE-UP or step-level detail.

Further reading (not drawn on): Kaplan KA et al. (2018), "Rise and shine: A treatment experiment testing a morning routine to decrease subjective sleep inertia in insomnia and bipolar disorder", Behaviour Research and Therapy (ScienceDirect blocked).

Further reading (not drawn on beyond publisher pages):

• Harvey AG, Buysse DJ (2017). Treating Sleep Problems: A Transdiagnostic Approach. Guilford Press. The TranS-C manual.
• Harvey AG, Watkins E, Mansell W, Shafran R (2004). Cognitive Behavioural Processes across Psychological Disorders: A Transdiagnostic Approach to Research and Treatment. Oxford University Press.
• Miller WR, Rollnick S (2012). Motivational Interviewing: Helping People Change (3rd ed.). Guilford Press. Cited by the developers as the MI source.
• Frank E (2005). Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy. Guilford Press. Cited by the developers as the IPSRT source.

Further reading (not drawn on): the PubMed Central copies of the Trials 2016 protocol, of the youth-intervention papers (including the 6-month follow-up), and of Harvey AG (2016), "A Transdiagnostic Intervention for Youth Sleep and Circadian Problems", Cognitive and Behavioral Practice 23:341–355, which is the most likely open description of module procedures; ScienceDirect pages; the manual's chapters and handouts.