Acceptability and feasibility of training to integrate digital CBT for insomnia into routine psychotherapy: A focus group study

Abstract

Objective:

Routine psychotherapy for mental health problems does not adequately address insomnia. Integrating cognitive behavior therapy for insomnia (CBTi) into routine psychotherapy could both extend the reach of CBTi and enhance sleep and mental health outcomes. Digital CBTi (dCBTi) is a promising and scalable option for integration that requires little prior training and session time. This study aimed to understand the perspectives of licensed mental health therapists on the acceptability and feasibility of this strategy of integrated dCBTi.

Method:

Six one-hour focus groups were conducted with 52 licensed therapists (21 PhD/PsyD, 11 LCSW, 10 MFT, 9 LPC, 2 MD). Each group included 6–11 participants. Inductive thematic analysis was used.

Results:

Therapists identified general advantages of dCBTi, benefits to integration, and concerns about integration. They described the knowledge and resources needed both for training and in session. They expressed that a 4-hour workshop and spending 5–10 minutes in session supporting patient use of dCBTi would be feasible.

Conclusion:

Data offer preliminary evidence in support of the perceived value, acceptability, and feasibility of integrating dCBTi in routine psychotherapy from a therapist perspective. Therapists are open to receiving training in integrated dCBTi and see its potential value in improving outcomes for their patients.

Introduction

One-third of adult patients who enter treatment for mental health problems experience insomnia symptoms (Seow et al., 2018). When left untreated, insomnia symptoms may hinder response to treatment for other mental health problems (Smith et al., 2005). However, routine psychotherapy for depression and anxiety insufficiently addresses insomnia symptoms (Carney et al., 2007; Franzen & Buysse, 2008; Kraepelien et al., 2022; Zayfert & De Viva, 2004). Fortunately, insomnia disorder can be effectively treated among individuals with mental health problems using cognitive behavior therapy for insomnia (CBTi) (Hertenstein et al., 2022).

The vast majority of psychotherapists are not trained to deliver evidence-based insomnia therapy (Gumport et al., 2023; Meltzer et al., 2009; Zhou et al., 2020), which limits access to therapist-led CBTi. A survey study of doctoral programs in clinical psychology in the United States found that 41% of programs offer no training—no courses, lectures, or training cases—in treating sleep problems (Meltzer et al., 2009). Results from a national survey of clinical psychologists in the United States found that 95% of clinical psychologists receive no training in behavioral sleep medicine (Zhou et al., 2020). Therefore, while concerning, the shortage of behavioral sleep medicine providers in the United States and worldwide is unsurprising (Thomas et al., 2016). This provider shortage greatly limits access to CBTi.

Digital CBTi (dCBTi) is a promising and scalable option for treating insomnia disorder. Automated dCBTi programs that utilize built-in algorithms to customize sleep recommendations based on user self-report data are effective at improving insomnia, including among people with comorbid depression and anxiety (Cheng et al., 2020; Luik et al., 2017; Stott et al., 2021; Ye et al., 2015). Consequently, the United Kingdom recently updated health guidelines for treating insomnia to recommend dCBTi over sleep medications (Wise, 2022). However, when users are left to complete dCBTi independently, rates of dropout tend to be high (around 35%), which is higher than in therapist-led CBTi (Soh et al., 2020). In general, continued use of mental health digital programs is low (Baumel et al., 2019).

Evidence indicates that adding human support to dCBTi increases engagement with, completion of, and adherence to dCBTi (Kaldo et al., 2015; Meaklim et al., 2019; Straten & Lancee, 2020). Therapists are well-situated to provide such support because they can leverage their existing therapeutic relationships and integrate dCBTi into their routine psychotherapy. Integration of dCBTi into routine psychotherapy (integrated dCBTi) could increase access to insomnia care and improve sleep, anxiety, and depression outcomes (Lancee et al., 2013).

As a preliminary step to rolling out integrated dCBTi, the goal of this study was to understand the perspectives of licensed mental health therapists on the acceptability and feasibility of this strategy. To this end, the study sought to address three primary questions. First, what do general psychotherapists identify as potential benefits of and concerns about integrating dCBTi into treatment for their patients? Second, what do general psychotherapists believe they need to know in order to be able to integrate dCBTi? Third, what do general psychotherapists need in order to make the training in the integration of dCBTi pragmatically feasible?

Methods

Participants and procedure

Participants were eligible if they: (a) were licensed mental health therapists, (b) had a clinical care model that included seeing patients weekly or biweekly, (c) provided therapy in English, and (d) were available at a scheduled focus group day/time. Requests for participation were sent to the mailing lists of the following professional organizations: Northern California CBT Network, South Bay Mental Health Professionals Networking Group, Association for Behavioral and Cognitive Therapies, San Francisco Association for Contextual Behavioral Sciences, and the Dialectical Behavior Therapy Listserv. Requests for participation were posted to therapist groups on Facebook. Requests for participation were also posted to LinkedIn and sent to therapists via contact information pulled from Psychology Today and by word of mouth by the authors to colleagues who practice psychotherapy.

All procedures were conducted virtually. First, consented eligible participants were asked to complete a brief questionnaire describing their demographics and work setting. Second, participants attended a one-hour virtual (Zoom) focus group at a predetermined date and time in October or November 2023. Focus groups began with a 5-minute presentation describing the rationale for integrating dCBTi into routine psychotherapy, as well as an outline of integrated dCBTi, including duration of training and structure of in-session support for patients. This outline is provided in Table 1. Next, therapists participated in a moderated discussion in which they were asked open ended questions about their views of the idea of the outlined integrated dCBTi. Participants received a $50 gift card for their participation in the focus group. All procedures were approved by the Stanford University Institutional Review Board.

Table 1.

Expected Elements of Integrated dCBTi

Stage of integration	Features
Therapist training	• A short virtual training (4-hour) • Opportunity to participate in monthly virtual consultation group
Implementation with patients	• Step 1: Introduce integrated dCBTi to patients in-session  ○ Approximately 10 minutes • Step 2: Provide support for patient engagement in the dCBTi program  ○ Approximately 5 additional sessions  ○ Approximately 5 – 10 minutes per session  ○ Cheerlead and promote ongoing use  ○ Troubleshoot difficulties with adherence

A total of 57 participants completed the consent process. Three were ineligible because they could not confirm they were practicing psychotherapy and two participants were unable to attend the scheduled focus group times. Thus, 52 participants were included in the analyses. Participant characteristics are presented in Table 2.

Table 2.

Therapist Characteristics

Characteristic	Mean or N	SD or %
Gender 1
Man	8	15.69
Woman	41	78.85
Other2	2	3.92
Race 3
American Indian/Alaska Native	1	1.92
Asian	7	13.46
Native Hawaii or Other Pacific Islander	0	0.0
Black or African American	2	3.85
White/Caucasian – European	33	63.46
White/Caucasian – North African	9	17.31
Other	2	3.85
Unknown/Decline to Share	1	1.92
License
Psychologist	21	40.39
Psychiatrist	2	3.85
Marriage and family therapist	10	19.23
Social worker	11	21.15
Licensed professional counselor	8	15.39
Number of states licensed in 4	1.46	1.13
Clinical experience (years)	10.01	7.30
Primary theoretical orientation
Cognitive, behavioral, or cognitive behavioral	42	80.77
Other5	10	19.23
Primary location of clinical work
Private or group practice	33	63.46
Community mental health clinic	4	7.69
Medical school or hospital	8	15.39
Academic department	2	3.85
Other6	5	9.62
Clinical problems or disorders treated 3
Anxiety disorders	51	98.08
Depression	50	96.15
Bipolar disorder	13	25.0
Schizophrenia and other psychotic disorders	5	9.62
Substance abuse problems	12	23.08
Developmental disorders	8	15.39
Obsessive compulsive disorder and related disorders	23	44.23
Trauma and stressor related disorders	45	86.54
Feeding and eating disorders	10	19.23
Personality disorders	21	40.39
Sleep problems	20	38.46
Learning and attention problems	20	38.46
Other	5	9.62

Note. Sample N = 52.

¹N = 51.

²Participants also stated they identified as genderfluid and nonbinary.

³Total exceeds sample size as participants were allowed to select multiple responses.

⁴States of licensure were Alabama, California, District of Columbia, Florida, Hawaii, Illinois, Iowa, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Texas, Utah, Virginia, Washington, West Virginia, and Wisconsin.

⁵Other primary theoretical orientations identified were Psychodynamic, Family-Systems, Acceptance-Commitment Focused, Integrative, and Solution-Focused.

⁶Other primary locations of clinical work identified were a college counseling center, juvenile detention center, mental health technology company, primary care setting, and Veterans Affairs medical center.

Measures

Demographics questionnaire

A questionnaire was given to all participants before attending the focus group. It assessed gender, race/ethnicity, education background, U.S. states of clinical licensure, theoretical orientation, setting of clinical work, and clinical problems treated.

Focus group interview

Focus group question probes were developed for the specific study aims by the study team. The questions are presented in Table 3. Questions were asked verbatim across the different groups. During each of the six the live focus groups, one study team member moderated the discussion (first author NG) and another team member (co-author IT) took detailed notes describing participants’ responses to the questions, including verbatim quotes.

Table 3.

Focus Group Questions

Domain	Discussion Prompt or Question
Acceptability	What do you think about integrating dCBTi into your routine provision of clinical care (assuming you receive sufficient training to do so)?  What are your concerns?  What are you excited about?
Acceptability	In what ways would an integrated app treatment focused on sleep be helpful to your patients?
Acceptability	How would you prioritize training in integrating dCBTi?
Feasibility	How feasible would a 4-hour long live (virtual) training be to learn how to integrate dCBTi?
Feasibility	How feasible will it be for your to implement integrated dCBTi with your patients:  How feasible will it be to spend 15 minutes of session time to first introduce the dCBTi program?  How feasible will it be to spend 5–10 minutes of subsequent session time supporting adherence to and engagement with dCBTi?
Miscellaneous	What pieces do you think you would need the most support with around integrating dCBTi into treatment as usual?
Miscellaneous	What elements would you want to see in this training?
Miscellaneous	Any additional thoughts you have about incorporating digital CBTi in routine provision of care?

Note. dCBTi = digital cognitive behavior therapy for insomnia.

Data coding

Notes from each of the focus groups were coded using an inductive method. Inductive coding allows for a deep reading of data and creation of meaning from the open-ended qualitative data (Braun & Clarke, 2006; Hsieh & Shannon, 2005). Using an inductive thematic analysis approach, the first author drafted a list of themes and a coding manual. Themes were confirmed and expanded on by two coders (co-authors IT and NC) who met to establish a consensus code for each idea identified in the focus group notes. Prior work has demonstrated that thematic saturation can be reached at five focus groups (Guest et al., 2017; Hennink et al., 2019).

Analytic method

Qualitative thematic analysis was used to synthesize, review, and finalize themes, and to describe patterns.

Results

Focus Groups

Views About the Benefits of and Concerns with the Integration of dCBTi (Aim 1)

Identified domains and themes are presented alongside example quotes in Table 4.

Table 4.

Summary of Domains and Themes Focused on Views of Integrated dCBTi

Theme	Description	Example Quotes
Perspectives on dCBTi Apps
Therapist dashboard	Ability to see what patients are doing is a feature therapists would like in an app they integrate	• “Is there a way beyond client self-report where therapist can check in on the client’s engagement in the app outside of session? It would be helpful to be able to check in on what the patient is actually doing on the app. Can it be shared? Can we see patient data?” (Group 1) • “Could be useful if we can figure out how therapist can get access to data as well.” (Group 3)
Advantages of dCBTi apps
Important tool to give to patients	dCBTi as another helpful tool/skill to give to patients	• “Sleep is so important; any added resource that could help is a great idea. it’s not going to be perfect for everybody, but I want this as an option, a tool.” (Group 4) • “I could send them the same sleep hygiene sheet I always send them, but app like this could emphasize importance and really translate to lived experience more.” (Group 5) • “I think it’s a great idea, sleep is a huge complaint of patients.” (Group 3)
Patients like data	Patient enthusiasm for looking at data	• “An interactive tool where they can see charts and graphs that show their practice so that they don’t just say it doesn’t work.” (Group 2) • “I think patients respond really well to data. Having a weekly summary report is helpful/impactful.” (Group 6)
Apps helpful for tracking	Apps provide an interactive method for tracking sleep-related behaviors and treatment progress	• “Ease of use. Able to prompt patients to use it. We aren’t necessarily good reporters of our sleep behaviors so maybe having app help track it” (Group 6) • “Just getting patients to do sleep logs, if there is an app that lets them streamline and adhere to tracking, this would be a big benefit.” (Group 6)
Promoting self-efficacy	Use of self-guided treatment may promote self-efficacy	• “The feeling of autonomy can be really good.” (Group 1) • “It will increase confidence if they can take independent initiative, especially if eager to try and decrease suffering.” (Group 5)
Makes homework easier	Nothing extra to carry and remember to bring to/from treatment makes doing homework easier	• “People are asking about app options. Patients are more and more reluctant to take papers with them, complete and bring them back. Apps for homework are good.” (Group 2) • “can be an attractive tool because they don’t have to remember how to do it, can just go to app and get instructions.” (Group 4)
Advantages of dCBTi integration
Important tool to give to patients	dCBTi as another helpful tool/skill to give to patients	• “Sleep is so important; any added resource that could help is a great idea. it’s not going to be perfect for everybody, but I want this as an option, a tool.” (Group 4) • “I could send them the same sleep hygiene sheet I always send them, but app like this could emphasize importance and really translate to lived experience more.” (Group 5) • “I think it’s a great idea, sleep is a huge complaint of patients.” (Group 3)
Keeps sleep a priority	Integration helps keep sleep on the menu of items addressed in a session	• “Full support, sleep issues come up a lot. feasibility-wise, if it isn’t a central part of the treatment, it can quickly drop off radar of patient importance.” (Group 5)
Increased accountability	Having the therapist help provide accountability to self-guided app as well as having the app provide reminders when patient is at home	• If they have support of app but also have accountability and ability to troubleshoot/get some support would be great.” (Group 3) • “Could help implementing momentum and consistency.” (Group 4)
Improves customization	Integrated dCBTi approach directly addresses patient/provider concerns about the lack of customization with digital apps without losing the perks that come with digital interventions.	• “It can do preliminary work. Probably less expensive, could be provided to wider audience, fewer clinical hours, better source of control, wider audience, but also kind of limited so having a coach with resource sounds like a best of both words.” (Group 1) • “Clinician can be an effective troubleshooting tool” (Group 3)
Comorbid conditions	Can benefit overall mental health, not just sleep	• “Could be helpful if it reinforced the importance of sleep and how sleep can help them with depression/anxiety, and how it impacts mental health as the whole.” (Group 2) • “So many have issues with sleep that exacerbate symptoms of depression/anxiety. Seems like so many would benefit.” (Group 1)Why not use an app? If a client is finding that work around insomnia hasn’t provided traction, they probably want to try. Low risk, high reward.” (Group 1)
Little use of session time	Do not need to devote much session time to sleep, can be done outside of session, and swill not detract from main focus of treatment	• “Could be a way of streamlining some of CBTi that could otherwise take up more session time.” (Group 6) • “For complex clients ... a good adjunct.” (Group 6) • “Sessions seem so full; I don’t have time to talk about somewhat peripheral things or things I’m not super trained in. Would be nice to say do this outside session while talking about impact/meaning.” (Group 1) • “something I would be open to, work with adolescents and young adults, sleep issues and insomnia is almost universal. But there also isn’t time in session to provide education and do comprehensive CBTi in session, so something they can do on their own is helpful adjunct to treatment.” (Group 2)
Low risk-high reward	Potential risks/negatives are low stakes, whereas the payoff of improved sleep could be of huge benefit	• “Why not use an app? If a client is finding that work around insomnia hasn’t provided traction, they probably want to try. Low risk, high reward.” (Group 1) • “Seems mostly upside, low downside. If easily accessible, low/free cost, with a bit of training they can maximize the use. Without maximizing use people stop using.” (Group 1)
Concerns with dCBTi integration
Costs to patients	Concerns about additional costs to patients	• “Would be curious about additional price of using the app for the client since they’re doing it with a therapist.” (Group 6) • “Would be important that app could be free since there are so many apps that are subscription-based now. Think about cost to patient.” (Group 2) • “If apps cost anything, it can be a huge barrier. Is it covered by insurance or reimbursable?” (Group 4)
Reliable internet	Concerns about patients’ access to reliable internet to access dCBTi program	• “Work with low SES so I wonder how feasible it would be for telehealth or stuff. Do they have reliable internet access?” (Group 4) • “Access to service. There are a lot of very rural areas around me, people don’t have phones or internet in some areas.” (Group 4)
Data security and privacy concerns	Concerns around data security and privacy	• “Pro-digital, but generally concerned about data security. are patients really given the opportunity for informed consent, do we really know where their data is going?” (Group 6) • “Discussion around data collection and privacy for the app. A concern for some patients. How do we accurately convey all of this to patients?” (Group 5) • “How is the data going to be used? Many clients are sensitive to inputting data, how is it being tracked? This would come up with clients.” (Group 3)
Predicting need for therapist providing technology support	Therapists do not want to spend precious session time serving as tech support	• “Making sure that therapists aren’t having to spend time troubleshooting technology” (Group 6) • “I want FAQs and where to send clients who need technical support” (Group 1) • “And I don’t want to be doing tech troubleshoot, so are there decent resources that they can access without me? What can we do to help people get over the initial “how do we use this app” (Group 2) • “There would need to be live tech support that somebody could call on a telephone and be walked through. don’t want to be taking tech calls at random hours.” (Group 2)
Limits in ability to support	Therapist limited in scope to supporting dCBTi	• “Therapist does not necessarily need to be trained to CBTi...On the one hand good for accessibility. On the other hand, what if the client is struggling and therapist is limited in follow-through capacity to support?” (Group 6)
Uncertainty about fit	Concerns about if integration of dCBTi fits into routine clinical practice	• “How much will I have to veer from traditional clinical practice to implement this?” (Group 2) • “There is also an issue where the fee schedule of where I work gets in the way of integrating technology.” (Group 4)

Note. dCBTi = digital cognitive behavior therapy for insomnia.

Perspectives on dCBTi.

Therapists identified six general advantages of dCBTi apps. They believed that (1) dCBTi programs are a helpful resource they can offer to patients with insomnia, (2) patients tend to enjoy seeing data collected and summarized by apps, (3) apps facilitate behavior tracking, (4) self-guided treatment via an app promotes self-efficacy, and (5) apps can make following between-session recommendations easier, for example, by scheduling automated reminders. Therapists also reported that (6) having a dashboard on which they can see the patient’s use of dCBTi and their progress would be helpful.

Benefits of the Integration of dCBTi.

A total of six themes highlighting perceived advantages of integrated dCBTi were identified. Therapists believed that (1) the integration of dCBTi could help keep insomnia a treatment priority, because checking in on patients’ sleep becomes part of the session agenda. Therapists thought that (2) their guidance could provide accountability as patients engage with this primarily self-guided treatment and (3) allow for further customization of treatment recommendations. Therapists expressed that (4) integrated dCBTi has the potential to improve daytime function and symptoms of other mental health issues. Many believed that (5) integrated dCBTi would not detract from the main (i.e., non-sleep) focus of treatment. Therapists also opined that (6) the ratio of potential risk to reward for integrated dCBTi is ideal; risks of integrating dCBTi into routine psychotherapy are minimal while potential benefits to patients’ sleep and daytime functioning are large.

Concerns about the Integration of dCBTi.

Six themes highlighting therapist concerns about integrated dCBTi were identified. Therapists raised concerns about (1) added financial cost to patients and (2) access challenges for patients without reliable internet service. They also wondered about (3) communicating about data security and privacy with patients and (4) the potential need to spend precious session time providing technology support to patients who are not tech-savvy. Therapists expressed concerns about (5) the scope of the support they could provide in integrated dCBTi without receiving comprehensive CBTi training. They also questioned (6) if integrated dCBTi fits into their or their employer’s existing clinical care model, such as employer fee schedules.

Knowledge and Resources Needed for the Integration of dCBTi (Aim 2)

Identified domains and themes are described with example quotes in Table 5. Participating therapists described 11 components that they desire to be included in a training on integrated dCBTi. Seven themes related to content that can be covered during an initial workshop: (1) an explanation of basic theoretical CBTi principles, (2) guidance on how to identify appropriate patients with whom to use integrated dCBTi, (3) information on how to introduce dCBTi to a patient, (4) recommendations for how to incorporate dCBTi support into a session agenda, (5) strategies to address challenges with dCBTi among special populations, (6) opportunities to practice integration techniques covered in the workshop, and (7) information on how to select a specific dCBTi program. Two themes related to post-workshop resources that would assist therapists’ ability to integrate dCBTi: (8) access to ongoing consultation and (9) a resource repository that they could turn to independently, as needed. Lastly, participating therapists described a need (10) to trust information about the evidence base for a specific dCBTi program and (11) to have exposure to the program before they would be willing to recommend it to patients.

Table 5.

Therapist-Identified Knowledge Needs for Integrating dCBTi

Theme	Description	Example Quotes
CBTi principles	Knowledge about CBTi content and rationale	• “Maybe some basic CBTI training so we don’t undermine our own competence if clients ask us about things.” (Group 1) • “I think important to have a good concept of CBTi. give a general outline of what CBTi looks like. You should be able to engage in conversation about the why for the strategies/recommendations” (Group 6) • “Foundation-level explanation of CBTi, regardless of pre-existing training. You should be able to explain the rationale for the different treatment components to your clients” (Group 6)
Identifying ideal candidate patients	Learn whom to use the dCBTi app with	• “Big question: who should this be used with?” (Group 6) • “Helpful to understand who should get this and when.” (Group 1) • “It would be a challenge to know which clients would benefit— as in, who should proactively be directed. Ideal vs. non-ideal candidate.” (Group 1) • “are there any contraindications? any safety caveats?” (Group 5) • “When to use this for and who, when and who not to use this with” (Group 3) • “Helpful sleep assessment tools— what is a good cut off for people who could benefit from the app.” (Group 2)
How to introduce dCBTi to patients	Knowledge of how to introduce dCBTi to patients in the first session of integration	• “Would be helpful to learn about presentation strategies for presenting app to different types of clients” (Group 1) • “Want to know how to talk to clients about what sets this app apart from other things they’ve tried in the past.” (Group 1) • “Motivational interviewing around using the app and training on how to sell the app could be useful.” (Group 3)
How to integrate into session agenda	Knowledge of how to weave in dCBTi integration when addressing other primary problem	• “But I would want support on how to integrate it if I’m doing another EBT that is the focus of the session. How do I weave in the sleep component?” (Group 5) • “Would want more advice on how to integrate this into the rest of session, how sleep affects relationships, mental health, how to make it feel really relevant to patient experiences and fit into the rest of the treatment plan.” (Group 1)
Addressing challenges in special populations	Support around addressing challenges in dCBTi integration for special populations	• “How would you do this with a difficult patient? With teenagers who are gaming? People who are overachieving and don’t value sleep? How much will we talk about the cultural component? How do we deal with behaviors within specific populations and those who don’t really value sleep?” (Group 6) • “Where there is a chaotic home situation (sleeping on couch, with four roommates), are there ways to tweak basic tools to make them more accessible to people across socioeconomic spectrum?” (Group 2)
Live practice	Opportunity to practice dCBTi integration strategies	• “Also opportunity to practice would be key, not just listening.” (Group 2) • “It would be great to really have hands-on practice.” (Group 6)
How to select a dCBTi app	Knowledge of how to choose a dCBTi app	• “There are a million apps and the thought of choosing one seems daunting. Would want to really understand which recommended app to use.” (Group 1) • “Barrier is knowing what the good apps out there are, what’s credible, what do I want to put word behind.” (Group 2) • “Differentiating why a specific app is the one to choose.” (Group 3)
Consultation groups	Access to ongoing consultation and troubleshooting	• “After the 4-hour meeting do we have access to monthly consultation?” (Group 1) • “Some consultation resources could be really good” (Group 1) • “Troubleshooting would also be super helpful for me. Can we check in with a group?” (Group 6) • “I want to engage with other clinicians using this” (Group 6)
Support resources	Access to materials to look up how to best provide support for specific problems	• “Having an FAQ resource.” (Group 2) • “Would like to have a variety of troubleshooting options— basically having a resource “book” so that you can work on troubleshooting yourself and not rely on calling someone else.” (Group 6)
Evidence base for the dCBTi program	Knowledge about efficacy of the dCBTi app for patients they treat	• “Who has this been used on? What other groups/populations, etc has this been used on? Are there populations it really hasn’t been assessed in? Give us more context on the evidence base for different populations and has this actually worked” (Group 4) • “Evidence and research behind the apps would be important to me. Would love to see some RCTs and research support for the particular app being developed so I feel comfortable handing it to my clients” (Group 6)
Exposure to dCBTi app	An opportunity to become familiar with dCBTi before giving it to patients	• “Would feel important to see app before giving it to patients.” (Group 1) • “I need to be able to speak knowledgeably about the app, I need to understand what the client experience will be.” (Group 2) • “Does the therapist have a version they can access to prep before session.” (Group 5)
Motivators to receiving training in integrated dCBTi
Continuing education credits	Receipt of continuing education credits	• “If there were continuing education training credits offered, this would be a great incentive to go through the training piece of it” (Group 6) • “Having CEUs would be motivating” (Group 2) • “Are there CEs? CEs would be motivating” (Group 4) • “CE training program would be a nice platform to offer it through. CEs make it more enticing for folks” (Group 3)
Convenience	Training occurring in a place or at a time or a format that is very convenient to the therapist	• “Nice if a workshop attached to conference, easier to attend workshop” (Group 2) • “Accessibility would be big for me.” (Group 6)

Note. dCBTi = digital cognitive behavior therapy for insomnia

Motivators to receive training in the Integration of dCBTi.

Two themes were identified regarding the motivation to receive training in integrated dCBTi. Therapists wanted (1) to receive continuing education credits for time spent in training, and (2) training to occur at a place and time that can fit their already busy schedules.

Therapist Needs for Making the Integration of dCBTi Training Feasible (Aim 3)

Identified domains and themes are described with example quotes in Table 6.

Table 6.

Therapist-Identified Needs to Make Integrated dCBTi Training Feasible

Theme	Description	Example Quotes
Feasibility of 4-hour training
Distribution of training time	Preferences for if the training take a 4 hour block of time or several shorter blocks of time
All at once		Advantages • “One block of time could work instead of breaking it down. depends on if we will have time to practice and stuff. I think I prefer one block (if it’s just four hours). If longer, maybe break it up.” (Group 5) • “Maybe it is easier to do it all in one go.” (Group 1) Disadvantages • “Getting that big of a block with private practice is difficult without losing money.” (Group 2) • “Four hours is a no thank you, two-hours seems more reasonable.” (Group 6) • “I find more than 2 hours of telehealth to be challenging/exhausting. More likely to do a 4-hour training in person. Maybe if chunked up or with breakout rooms and stuff I would feel better. Just need to stay active in the training and mix things up.” (Group 5)
Multiple blocks		• “Would be more feasible if broken into two, two-hour sessions.” (Group 2) • “Two, two-hour blocks would be easier” (Group 3) • “depends on when? all at once or split up? I could see it being broken into two 2-hour sessions.” (Group 6)
Synchronous vs. asynchronous	Preferences for if the training be synchronous vs asynchronous	• “Doing a live 4-hour training would be hard (as a parent juggling many responsibilities, non-synchronous/go-at-your-own-pace/participate on a forum would be easier)” (Group 6) • “Would the training be synchronous or asynchronous. Asynchronous absolutely makes it easier.” (Group 1) • “Is the training self-led or is it a set time? If set time, likely to be a greater adherence and a commitment. I do like self-paced things, but also understand that that this gets set to the side. overall, would prefer a set time and instructor to hold me accountable.” (Group 5) • “I like self-paced and speeding things up.” (Group 5)
Flexible scheduling options	Need for flexibility around when live training scheduled	• “Just lots of flexibility ” (Group 3) • “Timing would be important. I see kids in the afternoons after school, so best timing for me would be morning/early afternoon so that it doesn’t get in the way of meeting clinical targets.” (Group 3) • “If we assume live, there would need to be a lot of scheduling/time flexibility.” (Group 6)
Need for advance notice	Advance notice in order to be able to schedule	• “Feasible as long as there is significant advanced notice” (Group 2) • “Would need three months notice to protect the time” (Group 2)
Costs of therapist training	Time and money to get trained in integrated dCBTi	• “Initial time and money on the clinician’s side can be a barrier to receiving the training.” (Group 6) • “Also cost is a big deal.” (Group 6)
Feasibility of providing 5–10 min of support within session
Reasonable	Does the integration seem feasible	• “Yep, seems realistic, particularly if trained. Ten minutes is reasonable. Doesn’t seem like clients would be opposed to it.” (Group 1) • “Pretty seamless, and coming back to it every/every other session would be reasonable. would be easy to incorporate in intakes as an intervention that I offer if individuals indicate having sleep challenges” (Group 3) • “Pretty easy for such an important target, seems like a reasonable amount of time” (Group 4) • “Yes, feasible, not that hard to incorporate it. clients we would be using this with are clients who would be struggling with sleep, this would just be a more focused way of addressing sleep, we’d talk about sleep in a less structured way anyways” (Group 4) • “Very feasible. it’s a small amount of time to add to session” (Group 5) • “Yeah, seems pretty feasible to me” (Group 6) • “I agree, seems feasible. It’s almost that I already spend more time talking about sleep now than that commitment would be” (Group 6)
Feasibility concerns	Concerns about feasibility including needing to spend time monitoring sleep data outside of scheduled treatment time, billing/reimbursement, and having a packed treatment to integrate dCBTi alongside	• “How do I protect time outside of session to monitor their data?” (Group 2) • “Setting matters. I work in primary care, so sessions are compact and back-to-back and I often only have time for the manualized treatments that we are given (Group 3) • “The biggest barrier is billing code or what to do if I were to go over time in terms of insurance” (Group 5) • “If it’s a set protocol treatment, really difficult to integrate dCBTi.” (Group 5)

Note. dCBTi = digital cognitive behavior therapy for insomnia.

Attending a 4-hour training.

Therapists expressed a preference for asynchronous training versus a live workshop. Therapists’ preference for a single 4-hour session versus multiple shorter training sessions was divided; they identified advantages and disadvantages of each option, largely informed by personal scheduling constraints. If the training were to be synchronous, participants stated they would require flexible scheduling options and advance notice to fit the training into their schedules. Participants also expressed concerns that the cost of training could be prohibitive or a barrier.

Providing 5–10 minutes of support within a session.

Overall, therapists thought that it would be feasible to use 5–10 minutes of therapy session time for supporting the use of dCBTi, particularly when working with patients who are motivated to improve sleep. The few concerns raised pertained to integration within certain manualized treatments for which the session agenda is already packed (e.g., Cognitive Processing Therapy), and within settings when session duration is short (e.g., limited session duration in primary care). They also voiced a wish for billing codes for their time spent supporting their patients’ use of dCBTi.

Discussion

The present study examined the preliminary feasibility and acceptability of a proposed model of integrated dCBTi. Potential benefits and concerns with this strategy described by participating therapists largely fell within two domains: (1) the clinical utility of integrating targeted, evidence-based insomnia treatment into routine clinical care and (2) online programs increasing their tools for patients. Views on the clinical utility of integrated dCBTi were generally positive, with many therapists showing enthusiasm about the potential to significantly reduce sleep difficulties, which may in turn improve other psychiatric symptoms. This is consistent with literature documenting that improving sleep can improve a range of mental health symptoms (e.g., Freeman et al., 2017; Taylor & Pruiksma, 2014). They viewed the ability to offer patients accountability and to help personalize dCBTi treatment recommendations as two benefits of integration, thus addressing a well-documented weakness of dCBTi (Lancee et al., 2013; Ramos et al., 2024). However, therapists also articulated a need for training to enable them to provide the appropriate amount of guidance and to support engagement and use of dCBTi. This suggests that a dedicated training on integrated dCBTi is an important step in rolling out this strategy among therapists. For feasibility, the training will need to be brief (e.g., one 4-hour workshop or two 2-hour workshops), offered at flexible times, and offer continuing education credits. Asynchronous training was also highlighted as an option for increasing feasibility. Asynchronous training decreases the ability of learners to ask a live trainer questions, and as highlighted in the focus groups, allows for multi-tasking during the training, an unfortunate reality of many busy clinicians. Future training, synchronous or asynchronous, should consider methods to enhance engagement and minimize multitasking, including discussions and experiential work.

Therapists also believed that integrated dCBTi would benefit their clinical practice by providing them with tools that they can offer to patients reporting insomnia symptoms, without substantially diverting session time away from other treatment targets. Given high rates of comorbidity between mental health problems and insomnia (Seow et al., 2018), this time- and cost-effective approach to integrating dCBTi into routine clinical care has the potential to expand the reach of high-quality, first-line insomnia treatment to patients who may otherwise not have known to seek out or been able to access an evidence-based insomnia treatment. Health insurance considerations, such as limited options for in-network providers, variable reimbursement for out-of-network treatment costs, and session/time caps for behavioral health treatment coverage, underscore the value of integrating dCBTi into existing models of routine clinical care for mental health problems. This area is actively evolving; the Centers for Medicare and Medicaid Services (CMS) 2025 reimbursement took an important step by including the option for psychotherapists to bill for their time spent prescribing and supporting digital apps with patients.

In the present study, therapists identified several advantages of using an online program to help with sleep. For example, they perceived that a well-designed digital interface and scheduled reminders/alerts can make behavior tracking easier, promote self-efficacy, increase homework compliance, and allow patients to visualize their data, something they perceive that their patients enjoy. These findings are consistent with the results of a study evaluating patient use of a CBTi mobile app designed for use alongside therapist-led treatment, which reported that therapists believed the app increased homework compliance and patient engagement with treatment (Miller et al., 2019).

Participating therapists expressed confidence that spending 5–10 minutes of a typical session integrating dCBTi would be feasible, with one therapist even noting, “I already spend more time talking about sleep now than that commitment would be.” Only limited feasibility concerns were identified; these centered on time needed to monitor patients’ sleep outside of scheduled therapy sessions and potentially having a packed agenda at certain sessions. Such concerns can be addressed in training via discussions of how to best monitor sleep in the context of integrated dCBTi, how to determine which treatment protocols are best suited for integrated dCBTi, and, most importantly, how to prioritize integrated dCBTi.

Therapists also identified several challenges their patients may have when trying to use dCBTi, including out of pocket cost to patients, not trusting the privacy of an online program, ease of program download and navigation for patients with variable tech literacy, and reliability of internet access. Notably, many of these concerns can be mitigated. For instance, free, evidence-based dCBTi programs exist (e.g., Insomnia Coach [Kuhn et al., 2021]), and costs can be minimized as there are efforts to get dCBTi programs covered by insurance (Mohr et al., 2023). Progress has been made in that area in that as of January 2025, Medicare reimbursement is available and it is likely that this will expand to other insurers. While internet access remains limited in some areas, the majority of adults have access to WiFi (Gelles-Watnick, 2024). Therapists can also consider a quick assessment of patients’ tech savviness to determine if the patient is an appropriate fit for integrated dCBTi or if it will demand too much of the session time to provide technological support, although this type of assessment may require additional training. Approaches to addressing these pragmatic concerns can be covered efficiently during an integrated dCBTi training workshop, including directing patients to spaces where free internet is offered, such as public libraries and discussing the different available programs, including those which are free, which are FDA cleared etc.

Examination of focus group feedback elucidated three domains of need among therapists interested in providing integrated dCBTi to their patients in a competent manner: a training workshop, continued access to post-workshop resources, and having the opportunity to try out an dCBTi program so they are familiar with its flow and can answer patients’ questions. Therapists expressed that information on how to identify patients who could safely benefit from dCBTi (and those for whom dCBTi would be contraindicated) and how to introduce integrated dCBTi to them in a manner that will increase their likelihood of engaging with it. They also opined that general training on CBTi principles during the workshop would help them to accurately answer patient questions without undermining dCBTi treatment recommendations. Providing this foundational information will be important for therapists to learn about sleep and dCBTi contraindications. They thought that opportunities for hands-on experience (e.g., live role-play) to practice workshop strategies would facilitate skill acquisition. For ongoing resources after the workshop, therapists suggested that a written summary be made available, indicating that it would improve their confidence using integrated dCBTi with a variety of patients. For example, this might include a list of suggestions for how to address common barriers to patient adherence and ways to adapt treatment recommendations for special populations. Many highlighted that ongoing consultation would also support their continued use of integrated dCBTi. This is consistent with prior findings indicating that post-workshop consultations often lead to better patient outcomes (Frank et al., 2020). Within workshops and in post-workshop consultation, it may also be helpful to include referral sources for patients who are non-responders to dCBTi.

This study had limitations. First, the sample was mostly White, identified CBT as their theoretical orientation, and included few physicians, which may limit the generalizability of our findings. Second, there may be additional barriers to patients accepting and using dCBTi that were not identified in the focus groups in the present study, which was focused on therapist acceptance and feasibility of use, such as patient age, language, and culture. Third, the themes identified may be specific to therapists who had not received training on or utilized integrated dCBTi within their routine clinical practice. Future studies evaluating the feasibility and acceptability of integrated dCBTi to therapists after they receive training and try this approach in their routine practice might reveal themes that were not identified in this study.

Overall, this study offers evidence that therapists perceive integration of dCBTi into their ongoing psychotherapy as valuable, acceptable, and feasible. Therapists are open to receiving training in integrated dCBTi and see its potential value in improving outcomes for their patients. This is encouraging given the insufficient number of behavioral sleep medicine providers and the potential scalability of integrated dCBTi to increase access to evidence-based insomnia care.