Treatment of insomnia in an outpatient OT Clinic

Two years ago, if you had asked me (Amy, first author) whether an occupational therapy practitioner (OTP) could provide cognitive behavioral therapy for insomnia (CBT-I), I would have said no. Traditionally, psychologists have been the primary providers of cognitive behavioral therapy. However, research shows that well-trained OTPs can effectively use CBT-I as part of an occupation-based sleep intervention (Eakman et al., 2022; Leland et al., 2014). My learning journey has led me to discover a new opportunity for the occupational therapy community.

I have been an occupational therapist for 20 years, and I currently work in a hospital-based outpatient clinic as a leader and clinical provider. My curiosity about sleep was sparked by complaints over the years about sleep disruption from my clients with orthopedic injuries. Through research and networking, I discovered that although many people experience sleep dysfunction, there are not enough providers addressing this issue. I am excited to share details about how I developed a specialty practice that integrates CBT-I into occupational therapy sleep intervention in an outpatient setting.

The Literature on Sleep and Sleep Dysfunction

Getting enough quality sleep is a concern in the U.S. and globally. Lack of sleep can impact clients’ healing times, energy levels, and rehabilitative performance (Goorman et al., 2019; Gorski, 2019). One of the most common sleep conditions is insomnia, which affects 25% of people across the lifespan (Koffel et al., 2018), but particularly impacting older adults (Leland et al., 2014). Insomnia is a subjective sleep disorder that impacts the quality and quantity of sleep and creates daytime fatigue.

Getting diagnosed and finding effective treatment can be challenging for people with insomnia. According to Koffel and colleagues (2018), there are several barriers to timely, effective sleep intervention.

• Many primary care physicians lack training in sleep conditions or lack the time to assess sleep.
• Clients may not be aware of CBT-I or its effectiveness in treating insomnia.
• Finding a local CBT-I provider can be difficult due to a shortage of professionals.

According to the Occupational Therapy Practice Framework: Domain and Process, fourth edition (American Occupational Therapy Association, 2020), sleep and rest are under the self-care domain, and interventions include activities that prepare the individual and the environment for sleep. Common occupational therapy interventions to address sleep dysfunction include:

• providing sleep education,
• addressing sleep habits such as routines and sleep environments,
• teaching stress management and relaxation techniques, and
• promoting healthy daytime activities.

Defining Sleep and Insomnia

A fundamental way to describe sleep is a state of rest or unconsciousness vital to living (Suni, 2021). Many sleep experts have recommended that adults receive 7 to 9 hours of uninterrupted sleep each day (Suni, 2021). Some functions of sleep include tissue growth and restoration, memory consolidation, immune system and central nervous system regulation, and removal of BETA-amyloid and other waste in the central nervous system (American Academy of Sleep Medicine, 2022; Suni, 2021).

Chronic insomnia is a disorder that is characterized by the inability to sleep properly (i.e., sleeping poorly, difficulty falling asleep, difficulty remaining asleep) and can impact daily activities. According to Perlis and colleagues (2008), there is often a triggering event that precipitates sleep loss. However, sleep challenges may linger beyond the initiating factor. People struggling with insomnia often experience difficulties falling asleep or remaining asleep, and daytime fatigue impacts daily performance. Most people experience acute insomnia at some point in their lives. When sleep challenges occur for 3 months, it is classified as chronic insomnia (Perlis et al., 2008).

CBT-I and Training

There is strong evidence for the effectiveness of CBT, and CBT-I is considered a first-line treatment for people with insomnia (Tester & Foss, 2018). CBT-I is a multi-component treatment consisting of stimulus control, sleep restriction, sleep hygiene, cognitive therapy, and relaxation strategies (Climent-Sanz et al., 2022). OTPs interested in becoming a CBT-I provider need to pursue continuing education, including:

• taking a continuing education course in CBT-I to learn the treatment protocol (typically 8 to 16 hours of learning),
• observing sessions (1 to 3 cases), and
• receiving consultation and/or supervision from a qualified CBT-I provider (until competency is reached).

Developing a New OT Program for People With Insomnia

As part of my Post-Professional OTD Innovation Project (capstone) at the MGH Institute of Health Professions, I developed an occupational therapy–led sleep program that integrates traditional occupational therapy strategies with CBT-I interventions. I started by completing a 16-hour CBT-I course taught by OTPs at Colorado State University (Eakman & Rolle, 2023). See Figure 1 for other steps I took to create this new outpatient service. This project was reviewed by the Mass General Brigham IRB and determined to be a quality improvement project consistent with non-human subject research (NHSR).

Evaluation Process

A comprehensive occupational therapy evaluation for clients with insomnia helps obtain a clear picture of how insomnia is impacting their lives, identify the contributing factors, and rule out contraindications. This evaluation involves an interview, client-rated outcome measures, a sleep diary, and a thorough sleep history. There are many available screening and assessment tools to help gather data, including the Consensus Sleep Diary (Carney et al., 2012), Epworth Sleepiness Scale (Johns, 1991), Insomnia Severity Index (Bastien et al., 2001), and Sleep Disorders Symptoms Checklist-25 (Klingman et al., 2017). Other assessments include screens for mental health, sleep environment, quality of life, daily activity performance, and tools to rule out other sleep disorders. The purpose of the interview is to identify:

Case Example

AF is a composite client based on real cases from my practice. AF is a 55-year-old female with a diagnosis of chronic insomnia. Initially, AF was screened to determine if she meet the criteria for the sleep program. This screening included a basic sleep history, ruling out contraindications such as a seizure disorder, and ensuring the ability to complete an 8-week program. Next, she was asked to complete a Consensus Sleep Diary (n.d.) for 2 weeks to obtain baseline sleep information. See Table 2 for details. AF’s initial evaluation revealed that she had a 10-year history of poor sleep, possibly triggered by hormonal changes. She reported sleeping poorly 3 out of 7 days per week, including difficulty falling asleep and remaining asleep. AF stated that due to low energy and daytime fatigue, she was no longer taking walks, having dinner with friends, or painting. Table 2 highlights the baseline details from AF’s consensus sleep diary.

Table 1. AF’s Baseline Information From the Consensus Sleep Diary

Interventions

The interventions provided are based on evaluation findings and are individualized for each client. I typically see clients for eight visits lasting 30 to 60 minutes each, following a 2-week baseline data collection. During these sessions, I provide education about the circadian system, homeostatic sleep driver system, arousal system, sleep hygiene, stress management, emotional regulation, and theories to demonstrate how insomnia occurs. In addition to CBT-I interventions, I provide tips and strategies for schedule management, balancing daily occupations, establishing a bedtime routine, engaging in meaningful tasks, exercising, and participating in social activities.

Interventions for AF included a structured sleep schedule; her sleep time was restricted to 5.5 hours (1:30 am to 7:00 am). She was also given stimulus control goals of getting out of bed after 20 minutes if she could not sleep and avoiding other activities in bed such as online shopping and watching television. As AF improved, she was given an earlier bedtime, which continued to increase throughout the program. Figure 2 demonstrates how AF improved her sleep efficiency by reducing the time awake in bed during 8 weeks of treatment.

Outcomes

Clients often demonstrate an improved quality of sleep after receiving CBT-I and other OT interventions for insomnia. Figure 2 demonstrates how AF improved her sleep efficiency by reducing the time she spent awake while in bed during 8 weeks of treatment. Other benefits reported by clients completing the sleep program include less daytime fatigue, increased social and physical activities, a reduction in client-rated anxiety scores, and an improvement in concentration. Many clients also express improved confidence in managing their sleep and the ability to handle other challenges in their lives. For AF, as her sleep quality improved, she had the energy to re-engage with valued occupations, including walking several times a week, painting, and socializing in the evenings.

Conclusion

Sleep dysfunction is a growing problem in the U.S., and OTPs have an opportunity to add a new intervention to their practice. CBT-I is well-studied and has been proven effective in the treatment of insomnia. Additionally, research shows that well-trained OTPs can effectively use CBT-I as an intervention to help clients experiencing sleep dysfunction.

References

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American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

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Carney, C. E., Buysse, D. J., Ancoli-Israel, S., Edinger, J. D., Krystal, A. D., Lichstein, K. L., & Morin, C. M. (2012). The Consensus Sleep Diary: Standardizing prospective sleep self-monitoring. Sleep, 35, 287–302. https://doi.org/10.5665/sleep.1642

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Consensus Sleep Diary. (n.d.) Get a better night's rest. https://consensussleepdiary.com/

Eakman, A. M., & Rolle, N. R. (2023). Cognitive behavioral therapy for insomnia for occupational therapy [Live recorded continuing education]. https://colostate.instructure.com/courses/163116/pages/start-here?module_item_id=5017626

Eakman, A. M., Schmid, A. A., Rolle, N. R., Kinney, A. R., & Henry, K. L. (2022). Follow-up analyses from a wait-list controlled trial of occupational therapist–delivered cognitive–behavioral therapy for insomnia among veterans with chronic insomnia. American Journal of Occupational Therapy, 76, 7602205110. https://doi.org/10.5014/ajot.2022.045682

Goorman, A. M., Dawson, S., Schneck, C., & Pierce, D. (2019). Association of sleep and hand function in people with carpal tunnel syndrome. American Journal of Occupational Therapy, 73, 7306205050. https://doi.org/10.5014/ajot.2019.034157

Gorski, J. M. (2019). Evaluation of sleep position for possible nightly aggravation and delay of healing in tennis elbow. Journal of the American Academy of Orthopaedic Surgeons, 3(8), 1–5. https://doi.org/10.5435/JAAOSGlobal-D-19-00082

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Koffel, E., Bramoweth, A. D., & Ulmer, C. S. (2018). Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): A narrative review. Journal of General Internal Medicine, 33, 955–962. https://doi.org/10.1007/s11606-018-4390-1

Leland, N. E., Marcione, N., Niemiec, S. L. S., Kelkar, K., & Fogelberg, D. (2014). What is occupational therapy’s role in addressing sleep problems among older adults? Occupation, Participation and Health, 34(3), 141–149. https://doi.org/10.3928/15394492-20140513-01

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Suni, E. (2021, December 2). Stages of sleep: What happens in a sleep cycle. Sleep Foundation. https://www.sleepfoundation.org/stages-of-sleep

Tester, N. J., & Foss, J. J. (2018). Sleep as an occupational need. American Journal of Occupational Therapy, 72, 7201347010. https://doi.org/10.5014/ajot.2018.020651

Amy Harper, OTR/L, CHT, is a Supervisor of Rehabilitation Services at Phelps Hospital Northwell Health in Westchester, NY. Amy recently completed her PP-OTD at MGH Institute for Health Professionals. Her experience includes working with clients who have orthopedic, developmental, musculoskeletal, neuromuscular, and neurological conditions. Recently, Amy has started a program to add sleep as an area of practice in the outpatient setting.

Sunny R. Winstead, EdD, OTR/L, is a faculty member in the Department of Occupational Therapy at the MGH Institute of Health Professions in Boston. Sunny holds a BA in English Literature and Rhetoric, an MS in Occupational Therapy, and an EdD in Educational Leadership. Her professional background includes adult inpatient, outpatient, and community-based practice, management and supervision, program development and consultation, private practice, and academia.