Académique Documents
Professionnel Documents
Culture Documents
P
eople with chronic insomnia now have more treatment options.
The emergence of mindfulness-based therapy for insomnia
(MBTI) and other programs that use mindfulness meditation
provide an integrative approach, a unique set of tools, and
a different way to think about the problem of insomnia. If
mindfulness-based approaches can be considered a viable
treatment option, how do they fit into the existing landscape of
treatments? Should MBTI be a first-line treatment, or should
people with insomnia first try to use sleep medication or cog-
nitive behavior therapy for insomnia (CBT-I)? Are insurance
companies going to pay for their patients to receive MBTI?
In this chapter, I provide my perspective on some issues and
areas of controversy related to the implementation of MBTI
into real-world health care systems. The chapter concludes
with some resources for readers who wish to continue their
journey into mindfulness meditation and behavioral sleep
medicine.
http://dx.doi.org/10.1037/14952-011
Mindfulness-Based Therapy for Insomnia, by J.C. Ong
Copyright 2017 by the American Psychological Association. All rights
reserved.
179
180 M i n d f u l n e ss - B as e d T h e r ap y f o r I n som n ia
Patient Considerations
Given that there is no evidence yet to provide guidance one way or the
other, a prudent approach might be to allow patients to participate in
MBTI who are on a stable dose and who still experience symptoms of
insomnia because the medication has not sufficiently resolved the insom-
nia symptoms. However, if patients are just beginning to take sleep medi-
cation, or if their sleep is improved with sleep medication, then it might
make more sense to have them first monitor the impact of the medication
on their insomnia symptoms before deciding whether MBTI is appropri-
Copyright American Psychological Association. Not for further distribution.
himself that was not apparent to him in previous MBSR classes in which
the participants were more diverse with regard to presenting complaints.
He felt that this led to a polarization between group members and himself,
which was completely unexpected for both him and me. We have since
attempted to increase the heterogeneity of our groups by trying to have a
range of patients of different ages, backgrounds, and other demographic
characteristics whenever possible. Other ways to increase heterogeneity
might be to include those with comorbid insomnia or those who are tak-
ing sleep medication, as discussed earlier.
Provider Considerations
This book is meant to be a starting point for those who are interested
in delivering MBTI or teaching mindfulness meditation as a means of
reducing symptoms of insomnia. As I have stated throughout this book,
my position is that those who are considering using mindfulness medita-
tion in a medical or psychiatric practice or teaching MBTI as part of an
educational setting should be committed to practicing the principles of
mindfulness. This begins by having a personal meditation practice and
embodying the principles of mindfulness as a way of living. Those who
do not have any experience with meditation might start by taking an
MBSR class (or similar mindfulness-based program) to gain firsthand
experience as a participant. Those who have an established meditation
practice should consider attending a meditation retreat, which allows
one to deepen the connection with mindfulness principles while also
connecting with a community of other meditation practitioners. Moving
forward, it is recommended that MBTI instructors continue to reinforce
their meditation practice with regular attendance at a meditation retreat
or meditation group. While there is no minimum competency for medi-
tation practice, these suggestions are designed to foster a commitment to
practicing mindfulness principles and enable MBTI instructors to bring
mindfulness into their work with patients.
The professional competency needed to deliver MBTI is an area that
is potentially controversial. Recall from earlier chapters that MBTI should
184 M i n d f u l n e ss - B as e d T h e r ap y f o r I n som n ia
ter a medical or psychiatric issue. Thus, MBTI is best suited for licensed,
doctoral-level clinicians, such as clinical psychologists or physicians who
are familiar with behavioral medicine and have some experience work-
ing with patients who have sleep disorders. These clinicians would likely
require additional training in teaching mindfulness meditation or train-
ing in working with insomnia patients. Masters-level providers, such as
nurses, clinical social workers, psychologists, and licensed marriage and
family therapists, can also deliver MBTI. However, they might require
more training than doctoral-level providers or need more experience
working with insomnia patients.
This level of competency might seem restrictive, as some MBSR
instructors are not licensed clinicians and yet could still be very effective
at delivering MBTI. Furthermore, some would argue that an established
personal meditation practice should be the primary determinant of com-
petency to deliver a mindfulness-based therapy. Although these are valid
arguments, the potential risks of working with people who have insomnia
warrant a conservative approach at this time. It is possible that changes
in health care regulation could reclassify mindfulness-based therapies as
an educational class under integrative medicine as opposed to a form of
psychotherapy. Perhaps future research on health service and provider
competency could open up opportunities to reevaluate this standard.
Although there are no formal certifications for delivering MBTI, there
are certifications and formal training for instructors who wish to deliver
other types of mindfulness-based therapies. The Center for Mindfulness
at the University of Massachusetts offers certification as an MBSR teacher
(see Exhibit 10.1). There are also several training opportunities for teach-
ing MBCT, including online training and 5-day professional training
institutes offered at the University of California, San Diego; University of
Toronto; and Oxford University.
In addition to training on mindfulness, training in behavioral sleep
medicine (BSM) is important in the delivery of MBTI. The American
Board of Sleep Medicine offers a Certification in Behavioral Sleep Medicine
that covers the broad practice of BSM. As noted earlier, the American
Psychological Association (APA) recently approved sleep psychology as
a recognized specialty, and efforts are underway to develop an examina-
tion and certification for sleep psychology under the American Board of
Professional Psychology. Although not required to deliver MBTI, obtain-
Delivering MBTI in the Real World 185
EXHIBIT 10.1
Delivery of MBTI
ance to pay for a mindfulness behavior therapy (MBT), if they are able
to receive a letter of medical necessity from their health care provider.
Unfortunately, these financial considerations might present barriers to
those in a lower socioeconomic status who cannot afford to pay out
of pocket or who do not have a flexible spending account established.
Hopefully, health care reforms, such as the Affordable Care Act, will
provide greater opportunity for everyone to have a fair chance to access
mindfulness-based therapies.
Copyright American Psychological Association. Not for further distribution.
There are now more empirically supported treatment options for individ-
uals who suffer from insomnia. Pharmacological approaches are becom-
ing safer and more targeted in their pharmacodynamics. The z-drugs,
melatonin agonists, and more recent orexin antagonists are more specific
when compared with the older generation of pharmacological approaches
to insomnia, which included barbiturates and benzodiazepines. Similarly,
advances in nonpharmacological approaches have increased the range
of treatment targets to address different symptoms of insomnia. CBT-I
188 M i n d f u l n e ss - B as e d T h e r ap y f o r I n som n ia