When conducting our two-day workshops on Cognitive Behavioral Therapy for Insomnia (CBT-I), participants often note that a high percentage of their patients experience or report having sleep difficulties. Participants also note that patients seeking help have often been struggling with these problems for years. As a result, patients can enter into treatment feeling both helpless and hopeless about the possibility of their sleep functioning improving. Due to the chronic nature of this problem, patients have often tried a variety of things to improve their sleep (e.g., over the counter sleep aids, medication, sleep hygiene techniques) without success. With the global sleep economy continuing to rapidly expand and projected to be worth 551 billion dollars in 2023 (Statista, 2022), patients may also have tried a variety of novel products that promise relief from sleep problems.
It can be difficult for providers to keep up on all of the latest trends. CDP recently conducted a webinar entitled “Debunking Misperceptions about Sleep Interventions” to talk about some of these issues and how to develop a framework for examining claims by various products or interventions (https://deploymentpsych.org/Sleep-Misperceptions-Archive). However, it is important to note that despite chronic nature of patient’s sleep difficulties, various comorbidities patients may have, or new products promising relief, we have a very robust evidence based treatment for insomnia: CBT-I.
In a recent publication, Miller et al., (2022) conducted a systematic review of the literature to examine how adherence was measured, what predicted adherence, and how adherence to CBT-I treatment was related to outcomes for adults with insomnia. The authors examined published literature from 1992-2021 with 102 studies meeting their inclusion criteria. The results from their study revealed that lower dysfunctional beliefs about sleep at baseline of treatment, greater psychosocial support and self-efficacy were associated with greater treatment adherence generally and with specific components of CBT-I (i.e., stimulus control, sleep restriction, relaxation, and cognitive therapy). Let’s take a look at each of these components separately.
1) Dysfunctional Beliefs about Sleep
A) Given that military culture can often reinforce negative attitudes or beliefs related to sleep, it can be important to assess for potential dysfunctional beliefs pertaining to sleep.
Recommendation: Use the Dysfunctional Beliefs About Sleep (DBAS) scale to assess for strongly held beliefs that may interfere with treatment. This is typically given during session 1 or 2 of CBT-I, and again later in treatment when starting to teach cognitive skills as part of CBT-I. Readministering the DBAS later in treatment can help assess whether there has been any changes to strongly held beliefs about sleep. You can click on the link below for a copy of the DBAS-16. https://deploymentpsych.org/system/files/member_resource/DBAS%2016%20Fillable%20autoscore_0.pdf
B) Dysfunctional beliefs can be a result of faulty information.
Recommendation: Start with good psychoeducation. CBT-I involves providing patients with psychoeducation about why we sleep or why it is important, how sleep is regulated, how our sleep needs change over time, and a conceptualization of how predisposing, precipitating, and perpetuating factors (3P model) contribute to the risk, onset, and maintenance of insomnia. In addition to psychoeducation, we can also target problematic thinking through teaching patients cognitive restructuring, using problem solving skills, conducting behavioral experiments, or practicing more mindfulness based techniques. CDP has videos that demonstrate providers providing psychoeducation on the 3P Model and other CBT-I interventions.
2) Psychosocial Support
A) It can be difficult to get patients to make changes to their sleep related behavior such as practicing stimulus control and or sleep restriction. One barrier that can come up is the perceived lack of support or willingness of a bed partner to accommodate proposed changes.
Recommendation: It can be helpful to have a bed partner attend a session where psychoeducation is provided (i.e., session 2 of CBT-I), or as needed to help brainstorm solutions to help improve implementation of stimulus control (e.g., not watching tv in bed) and or sleep restriction (e.g., going to bed at different times). Have a patient sign a release of information, and the bed partner can attend in person, or participate via phone or video conferencing.
3) Self-Efficacy about Implementation of CBT-I
A) A lack of clarity in terms of directions or recommendations can create confusion for a patient and undermine confidence.
Recommendation: It is important that patients have a clear idea of what they are being asked to do and why. Providing clear instructions and rationale helps to focus treatment and allows the patient to ask relevant questions.
B) Not having a plan can also reduce confidence in a patient’s ability to adhere to treatment recommendations.
Recommendation: A patient should leave the session with a clear idea of what the plan is or how they will be implementing treatment recommendations. CDP has a tool we call a patient’s sleep plan that you can use with patients when doing CBT-I. This tool can help keep track of the prescribed sleep window (bedtime and waketime) and how patients will address potential barriers regarding adhering to their wake-up time, bedtime, and getting out of bed if they are awake. It is available on our Providers Portal (https://deploymentpsych.org/system/files/member_resource/Patient_New_Sleep_Plan.docx). It is also important to allow for time in session to discuss how patients will address potential barriers to practicing stimulus control and sleep restriction. This provides an opportunity to collaboratively work with the patient to increase their chances of being successful with implementing treatment recommendations.
Overall, it is good to recall that patients have plenty of reasons to abandon ship and not stay the course with evidence based treatments (e.g., chronic nature of their sleep problems, frustration with results of previous efforts) for insomnia such as CBT-I. As providers, we should expect and anticipate push back from our patients. We also need to be careful about not abandoning the ship to focus on other interventions promising relief with little to no empirical support. This blog focused on highlighting recent research that indicated we can promote treatment adherence to CBT-I by focusing on addressing dysfunctional beliefs about sleep, enhancing social support and patient’s self-efficacy about implementing CBT-I interventions.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland Texas.
Miller, A., Kavaliotis, E., Mascaro, L., & Drummond, S. P. (2022). Approaches to the assessment of adherence to CBT-I, predictors of adherence, and the association of adherence to outcomes: A systematic review. Sleep Medicine Reviews, 63, 101620.
Statista (July, 2022) Size of the sleep economy worldwide from 2019 to 2024. Retrieved October 31, 2022, from https://www.statista.com/statistics/1119471/size-of-the-sleep-economywor.... .