Lessons Learned from theNational Dissemination ofCognitive Behavioral Therapyfor Insomnia in the VeteransHealth AdministrationImpact of Training on Therapists’Self-Efficacy and Attitudes

Rachel Manber, PhDa,*, Mickey Trockel, MD, PhDa,Wendy Batdorf, PhDb,c, Allison T. Siebern, PhDd,C. Barr Taylor, MDa, Julia Gimeno, BAa, Bradley E. Karlin, PhDb,e

KEYWORDS

� Cognitive behavioral therapy for insomnia - CBT-I � Insomnia � Dissemination training� Veterans Health Administration - VHA

KEY POINTS

� Chronic insomnia, common among veterans, is associated with negative physical health, and, if un-treated, can impact the severity of comorbid medical and psychiatric conditions.

� Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective and well-established treat-ment, but patient access is limited because few clinicians are trained to deliver the therapy.

� This article describes the training methods and the impact of training on therapists’ use of CBT-Iand on their self-efficacy to deliver and attitudes toward CBT-I.

INTRODUCTION

Chronic insomnia is a common sleep disorder,1–3

particularly among Veterans,4,5 and it is associatedwith negative physical health (eg, myocardial in-farction, congestive heart failure, diabetesmellitus)and mental health (eg, depression).6,7 Untreatedinsomnia can impact the severity of comorbid

a Psychiatry & Behavioral Sciences, 401 Quarry Road, StaDepartment of Veterans Affairs Central Office, 810 Vermc Department of Veterans Affairs, 6200 Aurora Avenue,ford Center for Sleep Sciences and Medicine, 450 Broe Department of Mental Health, Bloomberg School oBroadway, 8th Floor, Baltimore, MD 21205, USA* Corresponding author.E-mail address: rmanber@stanford.edu

Sleep Med Clin 8 (2013) 399–405http://dx.doi.org/10.1016/j.jsmc.2013.05.0031556-407X/13/$ – see front matter � 2013 Elsevier Inc. A

medical and psychiatric conditions and can hindertreatment of the coexisting disorder.1,8,9 Insomniais also associated with increased health care useand economic burden in the workplace, withan estimated annual cost of $100 billion.10,11

Poor sleep, common among individuals withmental disorders, is often unresolved with generalpsychotherapy.12

nford, CA 94305, USA; b Mental Health Services, U.S.ont Avenue, Northwest Washington, DC 20420, USA;636A6/MHM6 Urbandale, IA 50322, USA; d The Stan-adway, Redwood City, California 94063-5730, USA;f Public Health, Johns Hopkins University, 624 N.

ll rights reserved. sleep.theclinics.com

Manber et al400

Cognitive behavioral therapy for insomnia (CBT-I)is an empirically supported, nonpharmacologictreatment for insomnia. The National Institutes ofHealth (NIH) Consensus Statement and the BritishAssociationofPsychopharmacologyhavebothclas-sified CBT-I as a first-line treatment for insomnia.3,13

Randomized trials comparing CBT-I with sleepmedication (zolpidem, zopiclone, and temazepam)found that CBT-I has comparable efficacy short-term, and better long-termmaintenance of gains af-ter treatments are discontinued.14–16 Moreover,CBT-I is effective, even when insomnia is comorbidwithotherdisorders, suchaschronic pain conditionsand major depressive disorder.17,18 However, pa-tient access toCBT-I is not always possible becauseof the limited number of clinicians trained to deliverthis therapy.19,20 Accordingly, training in anddissemination of CBT-I are greatly needed.The Veterans Health Administration (VHA) is

disseminating CBT-I nationally as part of its ef-forts to make evidence-based psychotherapieswidely available to veterans.21 Seeking to provideaccess to CBT-I to veterans with insomnia acrossthe nation, the VHA has implemented a national,competency-based CBT-I Training Program totrain licensed mental health clinicians from a vari-ety of disciplines (psychiatrists, psychologists,social workers, nurses, licensed professionalmental health counselors, and marriage and fam-ily therapists) working in a multitude of settingsacross the system. In a previous article, theauthors described the decisions that have shapedthe development of the Department of VeteransAffairs (VA) CBT-I Training Program.22 Initial pro-gram evaluation results indicate that the imple-mentation of CBT-I by newly trained therapistsis associated with an overall large reduction ininsomnia severity and improvements in depres-sion and quality of life among veterans.23

This article describes the training process,including steps taken to support long-term use ofCBT-I; reports on therapist outcomes in terms ofsuccessful completion of the training programand continued use of CBT-I after completion;and describes the effects of the training on partic-ipants’ self-efficacy to deliver and attitudes towardCBT-I. The data analysis focused on the following2 questions: (1) To what extent do therapists con-tinue to provide CBT-I after completing training?(2) Do self-efficacy and attitudes toward providingCBT-I improve during training? Key lessonslearned from the initiative are also shared.

THE VA CBT-I TRAINING PROGRAM

Using a competency-based training model, the VACBT-I training program provides a 4-month case-

based consultation period, during which trainingparticipants receive corrective feedback on theimplementation of CBT-I with veterans from ex-perts in CBI-I. The consultation period comple-ments an education component (experientialworkshop and reading materials). Both the work-shop and consultation components are described.

Workshop

The training begins with a 3-day workshop de-signed to provide a foundation for CBT-I. Theworkshop includes modeling of specific CBT-Iskills and opportunities for experiential learning.The workshop is led by a behavioral sleep medi-cine expert and includes a discussion of sleepregulation (Borbely’s 2-process model24), pro-vides an overview of sleep architecture, describesthe theories of insomnia, and outlines the compo-nents of CBT-I (sleep education, stimulus control,sleep restriction therapy, cognitive therapy strate-gies, and methods for reducing cognitive andsomatic arousal). The workshop provides trainingin comprehensive assessment and case concep-tualization and presents a flexible, case-formulation based, 6-session CBT-I protocol.The workshop also addresses adherence chal-lenges and adaptations of the CBT-I protocol forinsomnia occurring comorbid to other disorderscommon in the veteran population, including post-traumatic stress disorder (PTSD) (avoidance ofbed because of fear of nightmares or checking be-haviors), major depressive disorder (hopelessnessof sleep improving, low motivation, and using thebed as an escape from emotional pain), chronicpain (using bed as escape from physical pain),and mild traumatic brain injury (cognitive impair-ment). Extensive modeling in therapeutic tech-nique delivery takes place with demonstrationvideos by CBT-I experts, and experiential learningtakes place with small and large group discus-sions and role-play exercises. Immediate correc-tive feedback from expert CBT-I trainingconsultants is provided and valued by trainingparticipants.Learning is facilitated by materials that support

the administration of treatment. These include (1)a comprehensive treatment manual that providesin-depth explanation about what is learned in theworkshop and additional reference materials tobe used as resources, (2) patient handouts, (3)session-by-session checklists, (4) an intake form,(5) a case conceptualization form, (6) 2 publishedbooks,25,26 and (7) an excel spreadsheet to facili-tate calculation of variables, derived from sleep di-ary data, which are essential for administeringsleep restriction therapy.

Dissemination of Cognitive Behavioral Therapy for Insomnia 401

Consultation Phase

After the training workshop, training participantsparticipate in 4 months of weekly telephoneconsultation sessions in small groups (4 trainingparticipants (consultees) per group), led by CBT-Iexperts serving as training consultants. Duringthe consultation phase, training participantsprovide individual CBT-I to veterans who haveconsented to be a training case and to be audio-taped. Training participants send 6 taped sessionsto the CBT-I experts (training consultants) for themto review and rate for competency. A competencyrating scale was developed by the CBT-I trainingprogram development team.22 Training consul-tants (CBT-I experts) listen to full audiotapedsessions and rate the training participant’s admin-istration of CBT-I–specific components and moregeneral psychotherapy skills. Minimum compe-tency standards are part of the criteria for suc-cessful completion of the training program.22

The 90-minute consultation calls are heldweekly and provide a forum for constructive feed-back, based on tape review. The calls also provideopportunities for questions to be answered, furtherlearning about sleep and sleep disorders, role-playpractice of CBT-I skills, and discussions of clinicalissues that emerge in the course of treatmentimplementation.

STEPS TO SUPPORT IMPLEMENTATION OFCBT-I AND SUSTAINABILITY

To support the implementation of CBT-I duringand after the training, the training program hasdeveloped a Web-based SharePoint site that pro-vides central access to training materials andongoing access to VA CBT-I consultants viamonthly conference calls (“virtual office hours”).Each of these conference calls is moderated bya CBT-I expert and provides training participantswho have competed the training program an op-portunity to ask questions about issues and chal-lenges that have emerged in the context ofdelivering CBT-I. This consultation support is de-signed to promote sustained implementation ofCBT-I and help with challenging cases and imple-mentation issues after completion of the trainingprogram.

To further promote internal sustainability oftraining in CBT-I, significant focus has beenplaced on training new consultants, selectedfrom the pool of participants who completed thetraining program. Given the limited number oftrained CBT-I providers, the initial group oftraining consultants was a mix of VA-affiliatedand external CBT-I experts, many of whom had

certification in behavioral sleep medicine. Existingtraining consultants may recommend consulteesto apply to become consultants through a struc-tured recommendation and application process.Accepted applicants then receive training in howto serve as a training consultant, which includesparticipation in a workshop. A substantial pro-portion of this workshop is dedicated to educa-tion about sleep medicine topics, includingsleep-related breathing disorders, restless legsyndrome, periodic limb movement disorder,parasomnias, and circadian rhythm disorders.This aspect of training is designed to help thesefuture training consultants guide their future con-sultees in selecting cases for CBT-I training andin making appropriate referrals for further assess-ment and treatment of sleep disorders other thaninsomnia. The training consultant workshop alsoprovides a review of program logistics and theconsultation process, and guidelines about con-ducting the consultation calls and providing feed-back based on review of taped CBT-I sessions. Asubstantial amount of time during the consultanttraining workshop is spent on familiarizing thefuture training consultants with the CBT-I-Competency Rating Scale (CBT-I-CRS), which isused by training consultants to rate consultees’taped sessions. During the consultant trainingworkshop, future training consultants rate tapedsessions, discuss their ratings, and receivecorrective feedback from the trainer. Ratings areultimately calibrated across the future trainingconsultants. After this initial training, futuretraining consultants attend a second therapisttraining workshop. During their 4-month consulta-tion period with their first cohort of training partic-ipants, the newly trained training consultantsattend weekly group consultation calls with aconsultant trainer. These weekly calls provide op-portunities for asking questions and discussingemerging sleep and consultation process issues.

PROGRAM EVALUATION

Program evaluation is a central component of thetraining program and includes evaluation ofpatient- and therapist-level variables. This articlereports on therapist training outcomes, specif-ically the impact of training on therapist attitudestoward and self-efficacy to deliver CBT-I. TheInstitutional Review Board at Stanford Universitydetermined that using de-identified data obtainedin the course of this program evaluation is exemptfrom further review. At the time of writing,6-month posttraining de-identified data wereavailable from the first 6 cohorts of trainingparticipants.

Manber et al402

TRAINING PARTICIPANTS

Training participants come from every region, orVeterans Integrated Service Network, of VHA,including sites in Puerto Rico and Guam, andwork in a variety of clinical settings. Treatment set-tings include outpatient mental health clinics,primary care clinics, and residential treatment pro-grams (including programs for PTSD and sub-stance use disorders) within VA medical centersand in community-based outpatient clinics. Thera-pists are selected to participate in this training pro-gram through a structured application process. Tobe eligible for the training program, therapists hadto (1) be licensed mental health staff in VA; (2)deliver individual psychotherapy services on a reg-ular basis; (3) work in settings where insomnia is apresenting issue and CBT-I can be implemented;(4) have committed to participating in a 4-monthconsultation period after the workshop; (5) expressa commitment to provide CBT-I after completionof the training program; and (6) indicate willingnessto recruit at least 1 to 2 patients with insomnia forthe consultation process.

MEASURESCBT-I Self-Efficacy Scale

The 32-item CBT-I Self-Efficacy Scale was devel-oped for this initiative by behavioral sleepmedicine experts who were involved in the devel-opment of the training program. Similar to theCBT-I-CRS, the scale includes items assessingconfidence in using both specific CBT-I skills (eg,“Address cognitions that interfere with sleep”)and general psychotherapy skills (eg, “Display abalance of warmth, concern, confidence, genuine-ness, and professionalism during therapy ses-sions”). Response options are on a 6-point Likertscale and range from not at all confident tocompletely confident.

Attitudes Toward CBT-I Scale

The 6-item Attitudes Toward CBT-I Scale includes3 items assessing positive attitude toward CBT-I(eg, “CBT-I is an effective treatment for patientswith insomnia”) and 3 items assessing negative at-titudes toward CBT-I (eg, “Therapists’ adherenceto a CBT-I protocol decreases their job satisfac-tion”). Response options are arranged on a 5-pointLikert scale, ranging from strongly disagree tostrongly agree.The CBT-I Self-Efficacy and Attitudes Toward

CBT-I Scales were completed at the following 4time points: before the training workshop, immedi-ately after the training workshop, at the end of theconsultation period, and approximately 6 months

after the consultation period ended. At the6-month follow-up assessment, therapists wereasked to report the number of patients they treatedfor insomnia during the prior month and thepercent of those treated with individual CBT-I.From this information, the authors derived thenumber of patients therapists treated with individ-ual CBT-I in the past month.

RESULTS

To date, the VA CBT-I training program providedtraining to 12 cohorts of clinicians betweenSeptember 2010 and September 2012. At thetime of writing, de-identified data were availablefrom the first 6 cohorts.Of the 207 therapists in the first 6 training co-

horts, 141 were women and 66 were men; 135were psychologists, 50 were clinical socialworkers, 11 were nurses, 10 were psychiatrists,and 1 did not indicate discipline. All but 14 of the207 successfully completed training (8 droppedout of training and 6 did not meet minimum com-petency criteria for successful completion). Ofthe 193 who successfully completed the program,171 also responded to the 6-month follow-upsurvey consultation. Approximately 74% (136)reported having provided CBT-I during the previ-ous month. Of the 988 patients with insomniaseen during the month before the survey, themean number of patients therapists reported treat-ing with individual CBT-I was 3.4 (standard devia-tion [SD], 5.3), with a median of 2 (range, 0–52;interquartile range, 0–4). The most common chal-lenges to continued use of CBT-I identified bytraining participants were (1) competing profes-sional time demands, cited by 35 training partici-pants, and (2) issues related to patients (eg,no-shows and patients’ distance form clinic), citedby 14 training participants.Principle components analysis with direct obli-

min rotation of CBT-I Self-Efficacy Scale itemsdemonstrated 2 components: 1 for CBT-I skills–specific self-efficacy, consisting of 22 items(eigenvalue 5 16.7; a 5 0.98), and 1 for generalpsychotherapy skills self-efficacy, consisting of10 items (eigenvalue 5 5.0; a 5 0.93). These 2components explained 68% of baseline variancein the self-efficacy item set. All other possiblecomponents had eigenvalues less than 1 andwere not retained. Principle components analysisof the Attitudes Toward CBT-I Scale, with directoblimin rotation, identified a single component,which explained 46% of variance (a 5 0.77).No significant change was seen in general psy-

chotherapy self-efficacy from pre-workshop topost-workshop assessment. However, average

Dissemination of Cognitive Behavioral Therapy for Insomnia 403

item score on therapists’ general psychotherapyskills self-efficacy did increase from post-workshop to post-consultation assessment4 months later (from 4.9 [SD 5 0.59] to 5.3[SD 5 0.54]; difference 5 0.46 [95% CI, 0.36–0.56]; t161 5 9.3; P<.001; Cohen’s d 5 0.77).

From pre-workshop to post-workshop assess-ment, average item score on therapists’ CBT-Iskills–specific self-efficacy subscale increased from3.6 (SD 5 1.1) to 4.3 (SD 5 0.67) (difference 5 0.70[95% CI, 0.56–0.85]; t186 5 9.5; P<.001; d 5 0.65).From post-workshop to post-consultation assess-ment, CBT-I skills–specific self-efficacy increasedfurther, from 4.3 (SD 5 0.65) to 5.1 (SD 5 0.66)(difference 5 0.82 [95% CI, 0.71–0.93]; t160 5 15;P<.001; d 5 1.3).

The average item score on the Attitudes TowardCBT-I scale increased from pre-workshop to post-workshop assessment, from 4.0 (SD5 0.54) to 4.4(SD 5 0.50) (difference 5 0.45 [95% CI, 0.38–0.52]; t188 5 12; P<.001; d 5 0.83). No significantchange was seen from post-workshop to post-consultation in this scale.

DISCUSSION

Within 2 years of its initiation, the VA CBT-I trainingprogram provided training to 12 cohorts of clini-cians. The first 6 cohorts involved 207 trainingparticipants, with 93% meeting process and com-petency requirements for completion of training.Approximately three-quarters of these clinicianscontinued to provide individual CBT-I during themonth preceding the 6-month follow-up assess-ment (6 months after the consultation periodended). With the typical 6 weekly sessions, a ther-apist who continues to provide CBT-I to theaverage of 3.4 patients per month for the samplewill provide a course of 6 individual CBT-I sessionsto at least 27 patients per 48 work weeks per year,which, with 196 therapists, translates to 5292 vet-erans treated with individual CBT for insomniaeach year. Data are not available on the numberof patients treated with group CBT-I. The authorsanticipate at least comparable uptake among sub-sequent VA CBT-I training cohorts. As word aboutthe availability and effectiveness of CBT-I withveterans spreads, and an increasing number oftherapists are trained in CBT-I, the number of pa-tients receiving CBT-I in the VHA should continueto grow.

The authors found that the CBT-I skills–specificself-efficacy increased from pre-workshop topost-workshop, with further increase from post-workshop to the end of the consultation period (ef-fect sizes of d 5 0.65 and 1.3, respectively). Thislarge additional increase in CBT-I skills–specific

self-efficacy between post-workshop and post-consultation provides further support for theimportant role of consultation in the training oftherapists in evidence-based psychotherapies,such as CBT-I.27 Moreover, Bandura’s28 work onself-efficacy suggests that increasing therapists’self-efficacy in CBT-I will lead to increased initialadoption and long-term implementation of CBT-I.

Although the workshop training alone did notimpact self-efficacy in general therapy skills, theexperience in providing CBT-I during the 4-monthconsultation period did lead to improved self-efficacy in general psychotherapy skills. Thisfinding is not surprising given that the process ofconsultation includes discussion and feedbackon general psychotherapy skills that are a part ofCBT-I and are rated on the CBT-I-CRS. Thus, thefindings indicate that the consultation yields bene-fits broader than enhanced CBT-I skills andprovides greater confidence in more general psy-chotherapy skills, even among licensed indepen-dent mental health professionals. Moreover, it ispossible that the additional increase in CBT-Iskills–specific self-efficacy from post-workshopto the end of the 4-month consultation periodgeneralized to self-efficacy regarding nonspecifictherapeutic skills. Perhaps the experience of suc-cessfully improving the sleep of their patients pro-vided the CBT-I trainees positive reinforcementabout their skills as therapists in general.

Although the authors found a large effect sizefor the increase of positive attitudes towardCBT-I from pre-workshop to post-workshopparticipation, positive attitudes toward CBT-I didnot increase significantly from post-workshop topost-consultation, possibly because of a ceilingeffect.

The most common obstacle to long-term use ofCBT-I has been competing time demands. GroupCBT-I may improve therapists’ ability to treatmore patients. It is effective29 and increases ac-cess to treatment by reaching a greater numberof patients simultaneously. However, groupadministration of CBT-I is more difficult and re-quires additional skills, particularly in the contextof comorbidities. Over time, as therapists gainexperience in administering individual CBT-I,they will, with some additional training, be able toincreasingly provide group CBT-I effectively. Sup-plemental training resources are being developedby the CBT-I training program to extend individualCBT-I skills and competencies to groups.

The current data have limitations that should beconsidered. First, the therapist-level measures(ie, Attitudes Toward CBT-I Scale and CBT-ISelf-Efficacy Scale) have not been previously vali-dated. However, as part of the development of the

Manber et al404

scales, behavioral sleep medicine experts re-viewed the items of each and approved theirface validity. In addition, results of principle com-ponents analyses and Chronbach’s a estimatesreported herein suggest good convergent validityfor items comprising these scales. An additionallimitation of this evaluation is the lack of a compar-ison group. Additional research is needed toconfirm the current findings.

SUMMARY

Of the therapists who enrolled in the VA CBT-Itraining program, 93% successfully completedthe process and competency-based requirementsof the training, and 6 months after completion,three-quarters continued to deliver individualCBT-I consistent with the training. Training wasassociated with improved CBT-I skills–specificself-efficacy and attitudes toward CBT-I. The4-month consultation period was associated withenhanced self-efficacy beyond the improvementspost-workshop, which is likely attributable toreceiving feedback that is based on observedwork sample and improving patients’ insomnia.Patients served by clinical care delivery systemsoutside of the VHA may benefit from similar CBT-Idissemination efforts.

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