Wellness: Don’t Hit Snooze on Clients’ Sleep Struggles
By Catlin Denis, LCSW, RYT
Social Work Today
Vol. 23 No. 2 P. 6

Social Work and Insomnia Treatment in the Digital Age

When it comes to sleep issues, clinicians commonly defer, delay, or even forget to address treatment options with clients. But social workers can immediately leverage digital modalities to bolster efforts to ameliorate clients’ sleep disturbances, thereby improving their overall mental health outcomes.

In 1943, Maslow published A Theory of Human Motivation,1 creating what’s now known as Maslow’s Hierarchy of Needs. His work established the precedent that priority should be given to human physiological concerns before addressing additional presenting needs such as for belonging, love, security, and self-actualization. Many social workers focus on the physiological elements of food, water, shelter, and temperature, but we tend to hit snooze on the significance of sleep, which is another basic human need.

Technology may interrupt sleep, but it also offers resources for improving it. For better and worse, the COVID-19 outbreak in 2019 and its continued longevity have resulted in more frequent use of technology, especially in social work practice. A positive outcome has been a robust influx of digital mediums, interventions, and opportunities for social workers to help clients achieve their goals and their (literal) dreams. As a profession, we must continue to rise to greet technology, advocate for better access to it, improve overall digital literacy, and keep our eyes wide open to the permeating influence it has, and will increasingly have, in our work and in our clients’ lives. Digital access and literacy will undoubtedly increase resources for our clients and energize best practice efforts.

The Need for Zzzzs
Can you recall the last time you slept poorly? How did that feel physically, emotionally, or cognitively the following day? Did you have to work? Did your family, friends, or coworkers notice? Did you skip evening activities? You are not alone in this experience. According to the Cleveland Clinic,2 sleep disorders affect as many as 70 million people in the United States alone each year, with insomnia symptoms occurring in 33% to 50% of adults and chronic insomnia estimated to occur in 10% to 15%.

Social work is a unique profession in that tethered to our conceptual lens is systems theory, and we understand that sleep is tied to all other elements of being alive. Furthermore, Espie and colleagues3 reflect that we can counter the belief that sleep issues are solely nighttime issues; the nighttime experience of insomnia dominos into our more active waking hours. Sleep issues affect our physical, mental, and behavioral health. According to the National Institute of Health, chronic long-term inadequate sleep can influence the risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. Sleep issues can lead to mood disorders, increased stress, fatigue, and reduced brain performance (ie, concentration and decision-making).

Consideration should be given to rule out medical origins, such as sleep apnea or thyroid issues; this can be achieved by encouraging patients to discuss these problems with their primary medical providers, which may lead to blood tests, sleep studies, and other assessments.

Technology and Digital Treatment for Insomnia
Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment.4 Several studies show that mobile, online, and self-guided CBT-I treatment can be effective in mild insomnia.5,6 Web-based and telehealth CBT-I have also been effective in chronic insomnia.7 Beun and colleagues explain that there are effective strategies within some mobile technology applications for insomnia treatment.8 Cheng and colleagues explore how it reduces insomnia and depression severity and can be delivered digitally and how tech-mediated treatment can increase access to it.9 CBT-I can also be enhanced through wearable or passive technology.10,11 For example, smart watches and Amazon Halo Rise can provide valuable data to inform sleep behaviors and immediately support the adjustment of the environment.

What Social Workers Can Do
Imagine you are a general mental health social worker in an outpatient agency. Patty is a new client presenting today with primary concerns of anxiety and relationship problems. To the one sleep-oriented intake question, “In the past 30 days, about how many days did you have issues with sleep?” she responds, “about 20.” Upon completion of intake, the treatment plan is to provide eight sessions of CBT for anxiety and refer your client for couple’s counseling.

With knowledge about digital technology, you can provide Patty with self-guided sleep resources that can also help with anxiety. The free CBT-i Coach smartphone application is a digital resource you recommend. It’s the outcome of a collaboration between the VA’s National Center for PTSD, Stanford School of Medicine, and Department of Defense’s National Center for Telehealth and Technology. You schedule your first follow-up with Patty at your next appointment in two weeks.

Patty returns home and downloads CBT-i Coach. She explores the “Learn” section and quickly identifies one perpetuating factor of her sleep issues—caffeine. Patty often relaxes after dinner with a cup of coffee. She knows that caffeine is a stimulant, but she didn’t realize its effects last for several hours. As recommended in the app, she used the “Tools” section to set a daily reminder for caffeine intake. Patty also tries the “Schedule Worry Time” and “Breathing Tool.”

At your next appointment, Patty reports an improvement in her ability to fall asleep much faster and feel sleepier at bedtime (likely due to less caffeine remaining in her body). A bonus is exposure to anxiety management tools. The CBT-I app’s digital resources, in general, often have tools that help with other problem areas.

Resistance and Barriers
Clients may be tired of navigating technology alone or may have limited digital literacy. When recommending apps, therapists should assess clients’ positive and negative feelings about apps, available resources and support, and inquire about how technology currently interplays in their lives, including their comfort level with it. Self-guided treatment is effective long term, online, and across the age continuum and improves daytime and nighttime aspects of insomnia symptoms. In addition, general mental health symptoms such as depression and anxiety are indirectly improved by digital CBT-I.3,12-16 Social workers can help clients understand these positive aspects and assess whether digital tools are a good fit for them.

Professional Collaboration Network for Treating Sleep Issues
Social workers are never really alone in the digital age. We can use technology to connect with others in our profession and with experts outside our physical proximity. Social media platforms such as Twitter, Facebook, and Tik-Tok allow us better access to tailored audiences. To connect with experts on Twitter for sleep issues, social workers can explore hashtags such as #CBTi and #SleepPeeps. The Cognitive Behavioral Therapy for Insomnia (CBT-I) public group on Facebook has more than 10,000 members. Melanie Sage, PhD, MSW, and her team illustrate how digital professional collaboration networks offer a tool to social workers that can establish and enhance engagement with multidisciplinary experts and colleagues with similar interests, thereby helping them stay up to date with the latest technology and clinical practice.17 Although social workers are sometimes reluctant to use it, technology has continued to expand and permeate our practice, our lives, and our patients’ lives, increasing our need to connect and enhance our digital literacy.

Final Thoughts
We do not have to hit snooze on our clients’ sleep struggles. We do not have to sleep on digital resources. We can wake up to the possibilities that evidence-based digital tools offer our clients resources that increasingly demonstrate good research outcomes. We can better guide our clients by asking them to specify whether their sleep issues are related to falling asleep, staying asleep, or early awakenings. Doing this empowers our clients to learn more about their sleep disturbances and find the right kinds of interventions. A caution is that current digital resources are not meant to completely replace insomnia treatment but instead provide an opportunity to reduce sleep disturbances’ harmful effects on physical, mental, and behavioral health. We can provide available resources to clients in need of direction and encourage them to work on their sleep in addition to their presenting problems. Although it’s smart for social workers to have some basic knowledge of sleep issues, we cannot be experts in everything; the good news is that we don’t have to be. Evidence-based digital tools can support our interventions with ease.

— Catlin Denis, LCSW, RYT, lives in Houston, and is a clinical social worker at the VA. He is a DSW student at the University at Buffalo, SUNY, and moonlights as a yoga and cycle instructor. His broad and varied research interests include barriers to adjunctive therapies, the intersection of addiction and insomnia, and technology in social work practice.

Acknowledgments: Thanks to Melanie Sage, PhD, MSW; Patricia Huber-Villano, LCSW; and Denise Link, LCSW, for their review and input.

Digital Resources
CBT-i Coach Mobile App: https://mobile.va.gov/app/cbt-i-coach

Self-Directed Internet Course: www.thiswayup.org.au/programs/insomnia-program

VA Self-Led Internet Course: www.veterantraining.va.gov/insomnia

Amazon: Halo Rise sleep tracker

Meta Quest 2 Application: TRIPP Drift

Audiobook: Why We Sleep by Matthew Walker

Netflix: Headspace Guide to Sleep

References
1. Maslow AH. A theory of human motivation. Psychol Rev. 1943;50(4):370-396.

2. Common sleep disorders. Cleveland Clinic website. https://my.clevelandclinic.org/health/diseases/12119-insomnia. Updated December 23, 2020.

3. Espie CA, Emsley R, Kyle SD, et al. Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life: a randomized clinical trial. JAMA Psychiatry. 2019;76(1):21-30.

4. 9th annual Insomnia Awareness Night to highlight symptoms, treatment for chronic insomnia. American Academy of Sleep Medicine website. https://aasm.org/9th-annual-insomnia-awareness-night-to-highlight-symptoms-treatment-for-chronic-insomnia. Published June 21, 2022.

5. Horsch CH, Lancee J, Griffioen-Both F, et al. Mobile phone-delivered cognitive behavioral therapy for insomnia: a randomized waitlist controlled trial. J Med Internet Res. 2017;19(4):e70-e70.

6. Bogdan V, Szentagotai A, David D. Internet-administered cognitive-behavioral therapy for insomnia. J Cogn Behav Psychother. 2013;13(1A):225.

7. Holmqvist M, Vincent N, Walsh K. Web vs telehealth-based delivery of cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep Med. 2013;15(2):187-195.

8. Beun R. (2013). Persuasive strategies in mobile insomnia therapy: alignment, adaptation and motivational support. Pers Ubiquitous Comput. 2013;17(6):1187-1195.

9. Cheng P, Luik AI, Fellman-Couture C, et al. Efficacy of digital CBT for insomnia to reduce depression across demographic groups: a randomized trial. Psychol Med. 2019;49(3):491-500.

10. Gordon C, Aji M, Glozier N, et al. O028 Effectiveness of digital brief behavioral therapy for insomnia with wearable technology: pilot randomized controlled trial. Sleep Advances. 2021;2(Supplement_1):A13-A13.

11. Wilhelm H. Amazon introduces Halo Rise, a no-contact sleep tracker, but also so much more. Amazon News website. https://www.aboutamazon.com/news/devices/amazon-halo-rise. Published September 29, 2022.

12. Fitrianie S, Horsch CH, Beun RJ, Griffioen-Both F, Brinkman W. Factors affecting user’s behavioral intention and use of a mobile-phone-delivered cognitive behavioral therapy for insomnia: a small-scale UTAUT analysis. J Med Syst. 2021;45(12):110-110.

13. Horsch C, Lancee J, Beun R, Neerincx M, Brinkman WP. Adherence to technology-mediated insomnia treatment: a meta-analysis, interviews, and focus groups. J Med Internet Res. 2015;17(9):e214-e214.

14. Maguen S, Gloria R, Huggins J, et al. Brief behavioral treatment for insomnia improves psychosocial functioning in veterans: results from a randomized controlled trial. Sleep. 2021;44(3):zsaa205.

15. Zetterqvist V, Lundén C, Herrmann A, et al. Internet-delivered cognitive behaviour therapy for adolescents with insomnia comorbid to psychiatric conditions: a non-randomised trial. Clin Child Psychol Psychiatry. 2021;26(2):475-489.

16. Van der Zweerde T, Van Straten A, Effting M, Kyle SD, Lancee J. Does online insomnia treatment reduce depressive symptoms? A randomized controlled trial in individuals with both insomnia and depressive symptoms. Psychol Med. 2018;49(3):501-509.

17. Sage M, Hitchcock LI, Bakk L, et al. Professional collaboration networks as a social work research practice innovation: preparing DSW students for knowledge dissemination roles in a digital society. Res Soc Work Pract. 2021;31(1):42-52.