Cognitive Behavioural Therapy for Insomnia (CBT-I) is the gold-standard treatment for chronic insomnia disorder. Despite well-established efficacy, treatment response varies considerably in clinical practice. Some individuals struggle to implement behavioural recommendations; others follow them precisely yet experience increased distress, unstable improvement, or relapse once structure is relaxed. Existing models of insomnia provide strong accounts of how sleep disturbance develops and is maintained, but offer limited guidance on the psychological conditions determining when behavioural interventions are most effectively received or sustained. This suggests a clinically significant sequencing gap between the introduction of behavioural techniques and the individual's readiness to integrate them. This paper introduces the Handler Sleep Formulation Model (ARISE Framework), a clinically derived sequencing framework designed to identify the psychological conditions under which behavioural insomnia treatment becomes effective and remains stable over time. The framework was developed through theoretical integration of established cognitive-behavioural models of insomnia, principally Espie's Attention-Intention-Effort pathway and Harvey's cognitive model, with iterative clinical observation of treatment response across psychotherapy and behavioural sleep practice. Processes were identified through repeated clinical examination of adherence patterns, tolerability, and relapse. The model is illustrated through three anonymised clinical case examples representing a range of insomnia presentations. ARISE conceptualises chronic insomnia not as a failure of sleep capacity but as a pattern of sustained engagement with wakefulness. Four interacting client processes are identified: Arousal/Monitoring (attention directed toward detecting sleep, expressed as clock-watching, bodily scanning, and night reconstruction); Regulation (effortful attempts to produce sleep through corrective strategies, rituals, and aids); Interpretation (meaning assigned to wakefulness and its anticipated consequences, including catastrophic beliefs and identity-linked significance); and Sequencing (the individual's readiness to tolerate and sustain behavioural change). A fifth element, Evaluation, describes the clinician's continuous formulation process, identifying the dominant maintaining system at each stage and adjusting intervention timing accordingly. The model proposes specific readiness indicators to signal when CBT-I components are likely to function effectively rather than inadvertently intensify monitoring or effort. The ARISE framework offers a formulation-based approach to sequencing behavioural insomnia interventions, directly addressing the gap between protocol-driven treatment and individual psychological readiness. It does not delay behavioural intervention but determines when it can work. The framework is intended for clinicians across modalities and functions as both a sequencing guide for CBT-I trained practitioners and a structured formulation tool for those working with insomnia within broader psychotherapeutic practice. ARISE is presented as a hypothesis-generating model that complements, rather than replaces, CBT-I. Empirical investigation is required to determine whether ARISE-informed sequencing improves treatment adherence, tolerability, and long-term outcomes in insomnia treatment.
Zehavah Sarah Handler (Tue,) studied this question.