Staff Perspective: Stepping into Insomnia Treatment - How to Find the Best Fit

The least intensive treatment option is via self-help. This can be unguided, such as via reading books and attempting to track your own sleep and implement the strategies described. Examples of this approach include the “Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain” workbook by Colleen Carney, Ph.D. and Rachel Manber, Ph.D., recognized experts in the field, or “The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need” by Stephanie Silberman, Ph.D. and Charles Morin, Ph.D., also well-known sleep psychologists. Both books cost between $20-25. Self-help can also be guided such as via apps that provide feedback on your sleep inputs and suggested changes. Some examples of this include the Insomnia Coach app developed by the VA (https://mobile.va.gov/app/insomnia-coach) and the Path to Better Sleep website hosted by the VA (https://www.veterantraining.va.gov/sleep/index.asp) that offers four modules, including a self-check, psychoeducation, and a walkthrough of Cognitive Behavioral Therapy of Insomnia (CBT-I) for self-implementation.

Some apps even offer a sort of coaching model, where you may receive occasional contact from a person who reviews your app data (usually this is someone without advanced training in behavioral health or sleep medicine). Outcome data suggest self-help approaches can indeed be helpful, but may fit better for those who approach them already motivated and committed to adhering to the guidance they learn, and may not be as long lasting as more intensive options (Gao et al, 2022).

This category includes treatment with a provider who may or may not have specialized training in behavioral sleep medicine, but is following an evidence-based protocol, with individuals who are expected to largely independently implement changes with only some guidance. For example, CBT-I in a group setting is guided and has a relatively short time commitment. CBT-I group usually ranges from four to six appointments lasting 60 to 90 minutes each, for a total in-person range of four to six hours. Group sizes are usually up to about seven people, allowing individuals to get to know each other and receive support in making changes, with a cost less than that of specialty individual care at the next level up.

Another low-time commitment option is Brief Behavioral Treatment of Insomnia, or BBTI, typically offered individually. BBTI can be implemented by a paraprofessional or nurse, or by a therapist such as a clinical social worker or psychologist. While BBTI does require active effort to make changes in sleep-related behavior, it can be offered in easily accessible locations, such as a primary care or other medical clinic, and involves five contacts lasting an average of 30 minutes each, for a total in-person commitment of only two to three hours. The cost can vary, but would typically be at one’s usual medical visit copay or is covered for those receiving BBTI in DoD military treatment facilities. Full disclaimer, I both offer and train other providers in BBTI including ongoing consultation and I believe it is a helpful treatment to the majority of those who adhere to the plan, although some may have unhelpful sleep-relevant beliefs that need to be addressed outside of the protocol or may require additional appointments. Outcome data suggests both of these options not only last longer than self-help options, but result in more noticeable improvement (Koffel, Koffel, & Gehrman, 2015; Gao et al, 2022).

Clinician-guided treatment at this next step up above self-help may fit better for those who would like to improve their sleep and are willing to develop their own plan but prefer scheduled access to an identified provider who gives information, encouragement and support for problem-solving any questions that may arise.

At the highest level of stepped care would be full implementation of the gold standard treatment, individual CBT-I. Clinicians who provide CBT-I may range from those who have initial training in the basics of the CBT-I protocol and offer straightforward implementation with some appropriate adaptations as needed, all the way to experienced clinicians who specialize in behavioral sleep medicine and offer treatments not only for insomnia but for nightmares, circadian rhythm disorders, adjunctive obstructive sleep apnea and narcolepsy support and more. While CBT-I training is open to providers of many backgrounds (see https://cbti.directory/ for a list of self-identified CBT-I trained clinicians), a Diplomat in Behavioral Sleep Medicine is the board credential denoting expertise available for this specialty area (see https://www.bsmcredential.org/index.php/bsm-diplomates for the roster).

The gold standard for a reason, CBT-I interventions are specifically tailored to address each individual’s unique relevant contributors and any comorbid mental or medical health concerns with a detailed plan and flexible appointment range, resulting in long lasting outcomes even in more complex situations (Gao et al, 2022). While this kind of approach would benefit anyone with insomnia, those who are not yet sure about making changes around their sleep, those who want to more collaboratively develop a plan or have more ongoing face to face support, and those who want a provider who can simultaneously weave in factors such as decreased mood, anxiety and trauma would do well at this step.