Staff Perspective: In Support of Group Cognitive Behavioral Therapy for Insomnia (Part 2): Now What?
We reviewed some evidence for the effectiveness of group cognitive behavioral therapy for insomnia (CBTI) in Part 1 of this article, and began to discuss how clinicians can structure a group, such as components, number of sessions, and session length. Today, let’s follow-up to share some logistics about how to set your CBTI group up for success. Specifically, you’ll want to consider who sends patients to your group, which patients sent are the best fit for your group, group sizing and composition, and how to document your group’s progress, including outcome measurement.
To begin, you will want to consider from where your patients will be referred. Will this be a self-referral group, advertised base- or post-wide? Will your patients come from a formal referral via their primary care provider or sleep medicine physician? Or will your fellow mental health providers send their active patients to you when insomnia is a clear co-morbidity? Whichever your source, I encourage you to clearly market your group, both verbally and on flyers or referral information sheets to be given to the patients. Words like “insomnia”, “sleep quality”, and “behavioral strategies” set the expectation that your group is specifically designed for those with insomnia disorder as opposed to other sleep disturbances, as well as the expectation that the focus is on behavior change to promote more refreshing sleep as opposed to taking medications in an effort to get more sleep time.
Marketing your group is not only important in helping your patients get ready to begin, it also helps referring providers more appropriately recommend participation. Imagine how frustrating it must be as a patient to take time off to show up for an appointment, physically get to your office, wait to be seen, and then be told this group is not for them! I like to chat with all those providers who might refer to the group about the intent, set-up, and criteria that make patients more likely to match well (e.g those who meet the criteria for insomnia disorder, even if other co-morbidities exist). I also clarify that the referring provider will remain the patient’s primary provider. A word of advice: it never hurts to bring cookies or treats to boost your street credibility when trying to get referrals for your CBTI group.
Consider building in a screening step between the referral and formal group enrollment, to ensure patients are a good fit, as well as to ensure and support motivation to attend the group appointments. One of the biggest challenges we hear about in setting up a CBTI group is attendance; apparently, if you build it, the patients may or may not come. My personal thought on this is that it is one thing to get a flyer from a table or from your provider, but quite another to have someone personally speak to you, get to know you, encourage you to consider a treatment, and help you officially set up an appointment with a plan to fill your referring provider in on the details. Whether in person or by phone, a brief 10-20 minute screening can bridge that gap between referral and starting the group.
What exactly is the intent of the screening? Well, the primary idea is to ensure that patients referred to your group do in fact meet criteria for insomnia disorder. Referrals that turn out to be other sleep conditions, such as a circadian rhythm sleep-wake disorder, shift work disorder, or even sleep deprivation due to “social jet lag” (a.k.a. staying up late to hang-out, despite excessive sleepiness), will not respond as well to treatment as CBTI is designed to target insomnia. This does not mean you cannot choose to include patients with co-morbidities, simply that at least one of the patient’s diagnoses should be insomnia. Thus, your screening can be brief and simply focus on the diagnostic criteria for insomnia disorder. You will also want to briefly screen for other relevant co-morbid conditions, particularly sleep disorders, such as obstructive sleep apnea and nightmares, as well as mood and anxiety disorders such as PTSD (unless you know the referring provider already did so). Again, these can be concurrently treated during group participation, but do warrant an appropriate referral for further evaluation if the patient is not already being treated. While there are relatively few exclusion criteria, active suicidal or homicidal risk necessitates termination of the screening and immediate focus. I like to end the screening with feedback to the patient on likely contributors to their poor sleep, sharing a plan to target these during group with individualized recommendations, and assisting the patient in formally scheduling the first group appointment.
Choosing brief instruments in conjunction with your clinical questions can enhance the efficiency of your screening. Instruments widely used in the literature include the Insomnia Severity Index (ISI), Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS), and Epworth Sleepiness Scale (ESS), which are all available if you have attended one of our evidence-based workshops on our CDP provider portal. Other possibilities depending on your population include the Short-Form 12 (SF-12) and brief measures of mood or other symptoms. Fewer screeners make sense in a group context, and allow for a faster screening, so I recommend a limit of two measures.
Screening for your group does not have to result in a go or no-go outcome; instead, think of group CBTI as part of a stepped-care model. Some patients may benefit from simply a self-help intervention or sleep hygiene class, others may fit group well, and still others may need referral to an individual course of treatment due to complexity or previously failed treatment trials.
Once you have a screened pool of patients, you need to decide where to send them. Will you have just one group, with all comers welcome? Will you have a group for those with co-morbid chronic health conditions as opposed to those without? Will you have a group specifically for those who also have nightmares? In a military setting, you may also want to consider aspects such as rank and status (e.g. active vs. retired, active vs dependent). Of course, you may not have sufficient numbers of patients to have multiple groups. In my experience, groups that had no limitations on characteristics did well, but each situation may differ. Whichever you decide, a group size of 3-7 will probably best balance the availability of social interaction with your ability to focus attention on each patient’s plan at every session.
Other than the patient’s plan for their specific sleep schedule, group CBTI notes in the medical record are largely identical for each group member. This means group facilitators can save time by having a template for each group session, perhaps even having a technician or assistant ready the template while the group is running. However, the patient’s ‘prescribed’ sleep schedule, sleep log summary data, mental status, and any assessment scores will need to be individually entered.
Speaking of assessment scores, let me take a moment to recommend outcome measures to track your group’s response to treatment. If you used any assessments in the screening process or at the first session, selecting one of those as an outcome measure allows for handy baseline data to compare across sessions and consistency. Of course, you will also have sleep log data every session after you introduce the baseline sleep log that also represents outcome measurement. Because patients will need to arrive early to have their sleep logs scored prior to group, you may want to limit additional assessment to one brief measure. At the last group session, I share with my patients their changes in scores, on both the measure and sleep log.
Some of you may have further questions about facilitating a CBTI group or unique situations. I enjoy hearing case stories, so please post your questions and thoughts below. In the meantime, let us share some examples from our case repertoire to illustrate some real-life experiences.
SGT Smith was a mid-20s, single, African-American male active-duty Service member who was initially reluctant to consider a group treatment, but wanted to minimize use of sleep medications. His sleeping difficulties developed after deployment, when he returned from an active billet with a fast pace to his usual personnel position at a windowless desk for hours on end completing paperwork. His baseline log showed “typical” insomnia; that is, he got in bed earlier than he needed to and most nights took over an hour to fall asleep, with multiple awakenings. He did fall back asleep until his alarm, largely because his alarm went off so early (0500) to allow him PT prior to the duty day. He was again reluctant to engage in sleep restriction and stimulus control, but agreed to do so. By the next session, his sleep had improved, but he did not appear enthusiastic and instead was quiet as other group members reinforced his progress. At the end of group, his sleep had largely normalized, and although he was still quiet, he commented that he appreciated the group and felt better about his sleep. Some months later, I called an office on post for work reasons, and to my surprise it happened to be SGT Smith who answered, and who not only remembered me, but sounded pleased to hear me, reiterated multiple times how much better he felt, and very kindly offered to assist me over and above the level of service I expected. I hung up feeling reinforced about the positive impact of group CBTI.
CMSgt Kinney was an early-to-mid-50s, married, Caucasian male recently retired Service member who presented with high expectations for both himself and his sleep. He had a “can-do”, motivated attitude, and indicated he had put off medical care for several aspects of his health, including sleep, until retirement so that he could focus on his mission. His initial sleep efficiency was in the low-50s, and his total sleep time on his baseline was so low that I told him I did not want to reduce his time in bed to below 5 hours regardless; he insisted he had operated with this little amount of sleep for years. He returned to the next session having followed all of his sleep “prescription” thoroughly to a T, and even notated in various colors other behaviors and relevant information on his sleep log. However, his sleep efficiency had “only” improved to the mid-70s. I spent a bit of time reinforcing and supporting him, as while he focused on the fact that he was not at a normal sleep efficiency of 90% or more, he had improved 25% in one week after years of insomnia! We agreed to continue his sleep plan with no changes for one more week. Not surprisingly, he stuck with it, and not surprisingly, he improved again. By the end of group, he was vocal about his gains and attempting to pump up all the other group members, especially the junior enlisted, about the importance of adherence to treatment.
1st Lieutenant Paul was a late-30s, single, mixed-ethnicity female active-duty Service member. She had significant chronic pain and depression, for which she was concurrently treated, and often walked slowly to group sessions, trailing behind other group members. She dutifully completed her assessments and baseline sleep log, but did not appear to engage fully. She often reframed information as not relevant given her co-morbidities, and used her background as a nurse to attempt to distract the group from discussing maladaptive behaviors she engaged in, such as resting in bed and not adhering to stimulus control and sleep restriction. After repeatedly referring to the group facilitator as a “mean provider” she relented and agreed to implement stimulus control and rest when tired or in pain outside of her bedroom. As her sleep habits and sleep quality began to improve, her mood improved as well, likely due in part both to improved sleep and less time in bed in general. She reported at the final group session that her therapy provider had noticed her better mood and reinforced group CBTI participation. Although her sleep efficiency did not improve past 85% over the course of the group, she had a clear gain from treatment despite her co-morbidities, and agreed to continue her new sleep habits under the monitoring of her therapist.
Diana C. Dolan, Ph.D., CBSM is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and presents trainings on a variety of EBPs and deployment-related topics, and provides consultation services.
We reviewed some evidence for the effectiveness of group cognitive behavioral therapy for insomnia (CBTI) in Part 1 of this article, and began to discuss how clinicians can structure a group, such as components, number of sessions, and session length. Today, let’s follow-up to share some logistics about how to set your CBTI group up for success. Specifically, you’ll want to consider who sends patients to your group, which patients sent are the best fit for your group, group sizing and composition, and how to document your group’s progress, including outcome measurement.
To begin, you will want to consider from where your patients will be referred. Will this be a self-referral group, advertised base- or post-wide? Will your patients come from a formal referral via their primary care provider or sleep medicine physician? Or will your fellow mental health providers send their active patients to you when insomnia is a clear co-morbidity? Whichever your source, I encourage you to clearly market your group, both verbally and on flyers or referral information sheets to be given to the patients. Words like “insomnia”, “sleep quality”, and “behavioral strategies” set the expectation that your group is specifically designed for those with insomnia disorder as opposed to other sleep disturbances, as well as the expectation that the focus is on behavior change to promote more refreshing sleep as opposed to taking medications in an effort to get more sleep time.
Marketing your group is not only important in helping your patients get ready to begin, it also helps referring providers more appropriately recommend participation. Imagine how frustrating it must be as a patient to take time off to show up for an appointment, physically get to your office, wait to be seen, and then be told this group is not for them! I like to chat with all those providers who might refer to the group about the intent, set-up, and criteria that make patients more likely to match well (e.g those who meet the criteria for insomnia disorder, even if other co-morbidities exist). I also clarify that the referring provider will remain the patient’s primary provider. A word of advice: it never hurts to bring cookies or treats to boost your street credibility when trying to get referrals for your CBTI group.
Consider building in a screening step between the referral and formal group enrollment, to ensure patients are a good fit, as well as to ensure and support motivation to attend the group appointments. One of the biggest challenges we hear about in setting up a CBTI group is attendance; apparently, if you build it, the patients may or may not come. My personal thought on this is that it is one thing to get a flyer from a table or from your provider, but quite another to have someone personally speak to you, get to know you, encourage you to consider a treatment, and help you officially set up an appointment with a plan to fill your referring provider in on the details. Whether in person or by phone, a brief 10-20 minute screening can bridge that gap between referral and starting the group.
What exactly is the intent of the screening? Well, the primary idea is to ensure that patients referred to your group do in fact meet criteria for insomnia disorder. Referrals that turn out to be other sleep conditions, such as a circadian rhythm sleep-wake disorder, shift work disorder, or even sleep deprivation due to “social jet lag” (a.k.a. staying up late to hang-out, despite excessive sleepiness), will not respond as well to treatment as CBTI is designed to target insomnia. This does not mean you cannot choose to include patients with co-morbidities, simply that at least one of the patient’s diagnoses should be insomnia. Thus, your screening can be brief and simply focus on the diagnostic criteria for insomnia disorder. You will also want to briefly screen for other relevant co-morbid conditions, particularly sleep disorders, such as obstructive sleep apnea and nightmares, as well as mood and anxiety disorders such as PTSD (unless you know the referring provider already did so). Again, these can be concurrently treated during group participation, but do warrant an appropriate referral for further evaluation if the patient is not already being treated. While there are relatively few exclusion criteria, active suicidal or homicidal risk necessitates termination of the screening and immediate focus. I like to end the screening with feedback to the patient on likely contributors to their poor sleep, sharing a plan to target these during group with individualized recommendations, and assisting the patient in formally scheduling the first group appointment.
Choosing brief instruments in conjunction with your clinical questions can enhance the efficiency of your screening. Instruments widely used in the literature include the Insomnia Severity Index (ISI), Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS), and Epworth Sleepiness Scale (ESS), which are all available if you have attended one of our evidence-based workshops on our CDP provider portal. Other possibilities depending on your population include the Short-Form 12 (SF-12) and brief measures of mood or other symptoms. Fewer screeners make sense in a group context, and allow for a faster screening, so I recommend a limit of two measures.
Screening for your group does not have to result in a go or no-go outcome; instead, think of group CBTI as part of a stepped-care model. Some patients may benefit from simply a self-help intervention or sleep hygiene class, others may fit group well, and still others may need referral to an individual course of treatment due to complexity or previously failed treatment trials.
Once you have a screened pool of patients, you need to decide where to send them. Will you have just one group, with all comers welcome? Will you have a group for those with co-morbid chronic health conditions as opposed to those without? Will you have a group specifically for those who also have nightmares? In a military setting, you may also want to consider aspects such as rank and status (e.g. active vs. retired, active vs dependent). Of course, you may not have sufficient numbers of patients to have multiple groups. In my experience, groups that had no limitations on characteristics did well, but each situation may differ. Whichever you decide, a group size of 3-7 will probably best balance the availability of social interaction with your ability to focus attention on each patient’s plan at every session.
Other than the patient’s plan for their specific sleep schedule, group CBTI notes in the medical record are largely identical for each group member. This means group facilitators can save time by having a template for each group session, perhaps even having a technician or assistant ready the template while the group is running. However, the patient’s ‘prescribed’ sleep schedule, sleep log summary data, mental status, and any assessment scores will need to be individually entered.
Speaking of assessment scores, let me take a moment to recommend outcome measures to track your group’s response to treatment. If you used any assessments in the screening process or at the first session, selecting one of those as an outcome measure allows for handy baseline data to compare across sessions and consistency. Of course, you will also have sleep log data every session after you introduce the baseline sleep log that also represents outcome measurement. Because patients will need to arrive early to have their sleep logs scored prior to group, you may want to limit additional assessment to one brief measure. At the last group session, I share with my patients their changes in scores, on both the measure and sleep log.
Some of you may have further questions about facilitating a CBTI group or unique situations. I enjoy hearing case stories, so please post your questions and thoughts below. In the meantime, let us share some examples from our case repertoire to illustrate some real-life experiences.
SGT Smith was a mid-20s, single, African-American male active-duty Service member who was initially reluctant to consider a group treatment, but wanted to minimize use of sleep medications. His sleeping difficulties developed after deployment, when he returned from an active billet with a fast pace to his usual personnel position at a windowless desk for hours on end completing paperwork. His baseline log showed “typical” insomnia; that is, he got in bed earlier than he needed to and most nights took over an hour to fall asleep, with multiple awakenings. He did fall back asleep until his alarm, largely because his alarm went off so early (0500) to allow him PT prior to the duty day. He was again reluctant to engage in sleep restriction and stimulus control, but agreed to do so. By the next session, his sleep had improved, but he did not appear enthusiastic and instead was quiet as other group members reinforced his progress. At the end of group, his sleep had largely normalized, and although he was still quiet, he commented that he appreciated the group and felt better about his sleep. Some months later, I called an office on post for work reasons, and to my surprise it happened to be SGT Smith who answered, and who not only remembered me, but sounded pleased to hear me, reiterated multiple times how much better he felt, and very kindly offered to assist me over and above the level of service I expected. I hung up feeling reinforced about the positive impact of group CBTI.
CMSgt Kinney was an early-to-mid-50s, married, Caucasian male recently retired Service member who presented with high expectations for both himself and his sleep. He had a “can-do”, motivated attitude, and indicated he had put off medical care for several aspects of his health, including sleep, until retirement so that he could focus on his mission. His initial sleep efficiency was in the low-50s, and his total sleep time on his baseline was so low that I told him I did not want to reduce his time in bed to below 5 hours regardless; he insisted he had operated with this little amount of sleep for years. He returned to the next session having followed all of his sleep “prescription” thoroughly to a T, and even notated in various colors other behaviors and relevant information on his sleep log. However, his sleep efficiency had “only” improved to the mid-70s. I spent a bit of time reinforcing and supporting him, as while he focused on the fact that he was not at a normal sleep efficiency of 90% or more, he had improved 25% in one week after years of insomnia! We agreed to continue his sleep plan with no changes for one more week. Not surprisingly, he stuck with it, and not surprisingly, he improved again. By the end of group, he was vocal about his gains and attempting to pump up all the other group members, especially the junior enlisted, about the importance of adherence to treatment.
1st Lieutenant Paul was a late-30s, single, mixed-ethnicity female active-duty Service member. She had significant chronic pain and depression, for which she was concurrently treated, and often walked slowly to group sessions, trailing behind other group members. She dutifully completed her assessments and baseline sleep log, but did not appear to engage fully. She often reframed information as not relevant given her co-morbidities, and used her background as a nurse to attempt to distract the group from discussing maladaptive behaviors she engaged in, such as resting in bed and not adhering to stimulus control and sleep restriction. After repeatedly referring to the group facilitator as a “mean provider” she relented and agreed to implement stimulus control and rest when tired or in pain outside of her bedroom. As her sleep habits and sleep quality began to improve, her mood improved as well, likely due in part both to improved sleep and less time in bed in general. She reported at the final group session that her therapy provider had noticed her better mood and reinforced group CBTI participation. Although her sleep efficiency did not improve past 85% over the course of the group, she had a clear gain from treatment despite her co-morbidities, and agreed to continue her new sleep habits under the monitoring of her therapist.
Diana C. Dolan, Ph.D., CBSM is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and presents trainings on a variety of EBPs and deployment-related topics, and provides consultation services.