Dissemination of CBTI to the Non-Sleep Specialist: Protocol Development and Training Issues

Abstract

Strong evidence supports the effi cacy of cognitive behavioral therapy for insomnia (CBTI). A signifi cant barrier to wide dissemination of CBTI is the lack of qualifi ed practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and fl exibility of the treatment protocol. We developed a case conceptualizationdriven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These "real-life" constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination.

Impact of Brief Cognitive Behavioral Treatment for Insomnia on Health Care Utilization and Costs

“…[25][26][27] However, Manber and colleagues have described the successful training of mental health clinicians without sleep specialization to deliver CBTi in the VA healthcare system. 28 In response to this, shortened protocols (i.e., ≤ 4 sessions) have been developed, and research has shown them to be efficacious and effective in treating insomnia in adults of all ages (see McCrae, 29 Buysse,30 or Edinger and Sampson, 31 for review). For example, Edinger and Sampson demonstrated that four sessions of CBTi resulted in clinically significant improvements in wake after sleep onset, total wake time, and sleep efficiency compared to sleep hygiene recommendations alone.…”

Treatment of sleep disturbances in posttraumatic stress disorder: A review

“…The first is with patients who are undergoing or ready to engage in trauma-focused CBT for PTSD (either PE or CPT). This is because traumafocused CBT is demanding and intensive and adding another therapy that requires behavioral changes may hinder adherence (Manber et al [75]). Also, research reviewed here indicates that there is a reasonable chance that trauma-focused CBT will improve sleep.…”

“…The CBTI protocol being disseminated takes into account the possibility that PTSD symptoms such as nocturnal hyperarousal and perceived need for vigilance may complicate standard application of CBTI (DeViva et al [44]) and necessitate special adaptation of the standard CBTI protocol. The protocol is anchored in case conceptualization (e.g., Persons [76]), taking into account factors that contribute to each patient's unique presentation (Manber et al [75]). Special considerations for the application of CBTI for patients with PTSD-related sleep problems include, among other things, cognitive therapy techniques such as cost-benefit analysis for addressing fear of going to sleep and presleep perimeter checks, methods for addressing hyperarousal, and interventions to decrease such maladaptive behavior following nightmare arousals as staying awake trying to figure out the meaning of a nightmare (Manber et al [75]).…”

“…The protocol is anchored in case conceptualization (e.g., Persons [76]), taking into account factors that contribute to each patient's unique presentation (Manber et al [75]). Special considerations for the application of CBTI for patients with PTSD-related sleep problems include, among other things, cognitive therapy techniques such as cost-benefit analysis for addressing fear of going to sleep and presleep perimeter checks, methods for addressing hyperarousal, and interventions to decrease such maladaptive behavior following nightmare arousals as staying awake trying to figure out the meaning of a nightmare (Manber et al [75]). The CBTI protocol adapted by the VA CBTI rollout did not include training in IR, in part because of limited evidence base for its use for the treatment of nightmares in combat-related PTSD and in part because complete training in CBT for insomnia that is comorbid with medical and psychiatric disorders is intensive and left little time for inclusion of treatment modules for other sleep disorders, including nightmare disorder.…”

Nurse Practitioners (NPs) as Cognitive Behavioral Treatment for Insomnia (CBT-I) Providers: An Underutilized Resource

“…Finally, the success of the Veterans Administration (VA) CBT-I training program has much to teach us. The question moving forward is how to export this level of dissemination from a self contained system like the VA to the open access Health care system that exists throughout the U.S [17].…”