Trauma-Informed Cognitive Behavioral Therapy for Insomnia in Women Veterans: An Intervention Development Study

Carlson GC, Kelly MR, Erickson AJ, Saldana K, Gomez G, Carlson KJ, Lee D, Pigeon WR, McCarthy E, DeViva JC, McGowan SK, Josephson KR, Alessi CA, Yano EM, Martin JL, Hamilton AB. Trauma-Informed Cognitive Behavioral Therapy for Insomnia in Women Veterans: An Intervention Development Study. Cognitive and behavioral practice. 2026 May 1; 33(2):417-430, DOI: 10.1016/j.cbpra.2025.03.002.

Related HSR&D Project(s)

• RCS 21-135 – Research Career Scientist Award
• RCS 20-191 – Research Career Scientist Award
• CDA 20-227 – Increasing PTSD Treatment Engagement in Women Veterans: Role of CBT for Insomnia
• RCS 05-195 – Research Career Scientist Award

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Abstract:

This paper describes the methodology and outcomes of the development of a trauma-informed protocol for cognitive behavioral therapy for insomnia (CBT-I). Methods included (a) convening an expert panel of U.S. Department of Veterans Affairs providers (n = 4) to identify trauma-related symptoms that may interfere with standard CBT-I delivery and to assess trauma-informed adaptations to an existing CBT-I protocol, (b) presenting adapted protocol materials to veteran engagement groups for feedback, and (c) sequentially delivering the trauma-informed CBT-I protocol to women veterans (n = 5) with iterative refinement of the intervention materials and evaluation of clinical improvement (Insomnia Severity Index and Pittsburgh Sleep Quality Index total scores and sleep diaries). Trauma-informed adaptations to CBT-I included posttraumatic stress disorder (PTSD) diagnosis psychoeducation, nighttime hyperarousal reduction strategies, nightmare/sleep avoidance psychoeducation, behavior tracking to challenge avoidance, psychoeducation about trauma-related thoughts, and orientation to PTSD treatments. Veteran engagement group consensus supported expert feedback. Women who completed trauma-informed CBT-I reported improved sleep outcomes from baseline to 3-month follow-up and high perceived acceptability and clarity regarding trauma-informed adaptations. This efficient, multistep approach resulted in an acceptable, efficacious protocol for use in a randomized clinical trial. These methods can be applied to other protocols to systematically adapt other psychotherapies for patients with PTSD.