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How have you been sleeping?

by Layla Niemann, LICSW, PIP




If there is one health metric I LOVE to get nerdy about, it is sleep! I became interested in this treatment area while working in long-term care environments in which chronic Insomnia was a frequent concern. I wanted to help my clients become better sleepers so I went on a deep dive into Cognitive Behavioral Therapy for Insomnia or CBT-I. Come with me down this little rabbit hole, and I hope to illustrate how becoming a better sleep detective can enhance your practice, fast-track other treatment interventions, and could even save lives!


Poor sleep is a common concern with multiple etiologies and consequences. Insomnia is a precursor for suicide, depression, and PTSD. (1) Veterans tend to experience Insomnia at a much higher rate than the general population, with as many as two-thirds meeting diagnostic criteria for Insomnia following deployment. (2) Other sleep disorders such as sleep apnea and circadian rhythm disorder may shorten the lifespan via cardiovascular and metabolic distress (3).

As clinicians, we routinely recommend bloodwork or other follow up with a physician during our assessment of anxiety and mood disorders because of the intrinsic link between mind and body. Recommending further medical follow-up is just as important when addressing sleep difficulty.


Mental health professionals are uniquely positioned to identify problems that physicians may not always have time to detect. The average length of face-to-face time during a routine doctor’s appointment is approximately 15 minutes (7), whereas mental health clinicians spend up to an hour a week with some clients. We have the gift of time, and we can explore problems from all angles, giving us insight into a wide range of symptoms and possible antecedents. Clients who present with symptoms indicative of sleep disorders such as daytime sleepiness, brain fog, obesity, or fatigue should be referred to a physician qualified in Sleep Medicine as soon as these symptoms are mentioned in an assessment or manifest in ongoing treatment.

Mental health clinicians can serve as essential team members treating clients in conjunction with sleep specialists. Insomnia is the most common sleep disorder and the one we can do the most to remedy. Insomnia impacts around half of the adults in the United States (4) and is easily treatable; unfortunately, there is a wide gap between patients in need of treatment and trained clinicians.


The current gold standard for insomnia treatment is Cognitive Behavioral Therapy for Insomnia (CBT-I). This brief intervention is a fantastic little powerhouse that yields fast and lasting results! CBT-I combines the Behavioral Model of Insomnia developed by Art Speilman in 1987 and the Stimulus Control Model pioneered by Richard Bootzin. The two primary components of the modality, stimulus control therapy (SCT) and sleep restriction therapy (SRT), reacclimate the mind and body back to healthy sleep rhythms. CBT-I also contains some traditional CBT elements, including behavioral changes, correcting cognitive distortions related to sleep, and psychoeducation. Therapy is typically supplemented with relaxation training, progressive muscle relaxation, and Imagery Rehearsal Therapy if nightmares are of concern. CBT-I is the only approved treatment for Insomnia besides hypnotic medications. The American Academy of Sleep Medicine and the American College of Physicians recommend CBT-I as the first-line treatment for Insomnia (6).


If you would like to learn more about CBT-I, I have attached several resources and training opportunities. CBT-I is a modality that requires formal training but does not currently require certification to administer. As a provider who frequently uses this modality, I highly recommend as much education as possible before utilizing it as several contraindications require treatment modifications. These include bipolar disorder, seizure disorders, and narcolepsy. Treatment modification must also be made when treating individuals whose professions require a high concentration for public safety. So if you love graduating happy, healthy, well-rested clients within weeks, I urge you to add CBT-I to your Continuing Education wishlist!


If you need more convincing that CBT-I is the coolest sleep hack you will ever learn, here are the top 5 reasons I love providing this therapy:


  1. This is an EASY treatment modality because it is time-limited and follows specific session plans.

  2. Treating Insomnia decreases symptoms of other disorders, but especially Depression, Anxiety, and PTSD!

  3. CBT-I can be provided in a group format.

  4. CBT-I can be provided as an adjunct therapy with treatment plan collaboration.

  5. CBT-I involves data collection and math, so engineers really love it! I 💓 HSV


Links and References:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218784/

  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5930488/

  3. https://www.hopkinsmedicine.org/endoscopic-weight-loss-program/conditions/obstructive_sleep_apnea.html#:~:text=Studies%20have%20shown%20that%20sleep,accidents%20due%20to%20decreased%20attention.

  4. https://www.ajmc.com/view/insomnia-overview-epidemiology-pathophysiology-diagnosis-and-monitoring-and-nonpharmacologic-therapy

  5. https://catalog.pesi.com/sales/bh_c_001249_cbti_041718_organic-85242

  6. Sleep Health. 2015 March; 1(1): 11-12. doi:10.1016/j.sheh.2014.12.011

  7. https://journals.stfm.org/familymedicine/2018/february/young-2017-0121/


Book:

Cognitive Behavioral Treatment of Insomnia; A Session by Session Guide, Perlis, Jungquist, Smith, and Posner


App:

CBT-I Coach - Free App developed by the Veterans Administration


Trainings:

https://www.med.upenn.edu/cbti/cont_ed.html

https://cbtiweb.org/

https://catalog.pesi.com/sales/bh_c_001249_cbti_041718_organic-85242




Layla Niemann, LICSW, PIP

Cornerstone Counseling Center

256-519-9000

lniemann@cornerstone-hsv.org

www.cornerstone-hsv.com

www.walkandtalkhsv.com




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