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Table 5 Qualitative insights for satisfaction, views, and experiences with intervention elements (RE-AIM effectiveness dimension)

From: Applying therapist-guided digital cognitive behavioral therapy for insomnia in psychiatry: a mixed-methods process evaluation

i-Sleep session and corresponding intervention elements

 

Participants experiences and quotes (n = 36) with MHC subgroups: pre-clinical (n = 11), general MHC (n = 13), specialized MHC (n = 12)

 

Therapists’ experiences

and quotes (n = 9)

Session 1

     

Bedroom surroundings, evening ritual and

lifestyle adjustments

 

Many participants were already familiar with and were practicing key sleep hygiene tips prior to the intervention. There was a consensus among participants that sleep hygiene is a “good start” of the intervention: “I think it’s a good foundation. I also feel that I had already tried many of these things.”– participant 3 (general MHC group). For some participants, ingrained lifestyle habits, such as smoking/smart phone use, proved to be especially challenging to address.

 

Therapists recognized sleep hygiene as fundamental, noting it serves as an essential starting point. However, they stated that additional guidance beyond the initial introduction between therapist and participant may not be necessary. One therapist remarked: “Sleep hygiene is often a bit of an open door. The extra addition of guidance is good for initial introduction and such, but intensive steering is usually not needed.” - therapist 1.

 

Session 2

     

Fixed bedtimes and sleep restriction

 

Many participants found sleep restriction to be highly beneficial. As one participant summarized, “The most valuable and also the most challenging.”– participant 4 (general MHC group). Remarkably, nearly all participants were unfamiliar with this approach prior to the intervention. Most participants reported significant tiredness as a side effect. One participant noted, “It made me tired, yes. I also encountered problems with planning, which started to hinder my functioning. At that moment, it became practically impossible for me to manage.”– participant 5 (specialized MHC group). Another participant described their experience as, “I was utterly exhausted.”– participant 6 (specialized MHC group).

 

Therapists highlighted their perceived effectiveness of sleep restriction, noting that “I think it’s the most important component of i-Sleep because it works.”– therapist 2.

Therapists also emphasized the value of guidance: “With sleep restriction, guidance is particularly valuable. It helps you assist someone more effectively and challenge them to spend less time in bed, as people often opt for the easiest solution. Therefore, guidance is essential in this context.”– therapist 1.

 

Session 3

    

Relaxation exercises and rumination (time and other)

 

For most participants, the relaxation exercises proved useful and effective. There were some criticisms on the style of the audio fragments used in these exercises. Within the specialized MHC groups, some participants reported that the relaxation exercises had an adverse effect. One participant remarked, "I really couldn’t manage that, because, you see, I also have traumas, and consciously engaging with relaxation and being in tune with my body that way actually triggered a lot of anxiety for me. So, it made that session very challenging for me, and it’s actually one of the reasons why I ultimately didn’t complete the entire module. Because I noticed it brings up a lot of things that I can’t handle right now.”– participant 7 (specialized MHC group).

 

Therapists noted that creating detailed plans with participants, outlining specific yet simple activities designed to promote relaxation, was generally well-received by participants. However, some therapists expressed that not all participants fully engaged with or understood the importance of these activities. As one therapist observed, “Some don’t understand the importance of taking time for themselves to relax.” – Therapist 5.

Session 4

     

Alternative thoughts

 

Participants reported increased awareness of their negative thought patterns and their impact on sleep. Yet many found it challenging to consistently alter these thoughts. As one participant explained, “Yes, I found that quite difficult. I remember there were a few thoughts that I could reframe, but I often struggled to come up with alternative thoughts for certain ideas. It was challenging for me to handle that.”– participant 8 (specialized MHC group). The relevance of addressing negative thoughts varied among participants. Some found the intervention element highly beneficial, while others perceived it as less applicable, particularly if they did not experience any significant negative thoughts about sleep.

 

Therapists noted diverse responses to cognitive restructuring and stressed that a single session may not be adequate for some participants: “if people have more severe [mental health] problems, addressing the cognitive aspect in just one session isn’t really sufficient. Often, they not only struggle with sleep but also with other issues, making it feel somewhat awkward to tackle it that way. In such cases, I think face-to-face treatment would be preferable. For certain target groups, you could use this approach, but in a limited way.“- therapist 3.

Therapist also noticed that: “For topics like cognitive challenges, some people may easily overlook them when filling out the session. They might just provide a random thought or claim they don’t have any problems, indicating they haven’t fully understood the assignment. I’ve noticed that without our presence, they might not even engage with these aspects.” - therapist 3

 

Session 5

     

Future plan

 

Participants appreciated the opportunity to review and focus on the strategies that were effective for them, noting, “It’s helpful to review and maintain the points that worked.”– participant 2 (pre-clinical group). They also recognized that the future-plan session serves an important role, as expressed by another participant: “The real work starts after finishing the program, [the future plan] is a prompt to keep applying what you’ve learned and not revert to old patterns.”– participant 9 (pre-clinical group). Some participants suggested that the future plan session could be more compact and presented in a bullet-point style for easier reference.

 

No remarks.

 
  1. Of note. Bedroom surroundings refer to modifications in the sleep environment to promote better sleep quality, such as reducing, noise and light, temperature. Evening ritual involves establishing a calming pre-sleep routine, including activities like relaxation exercises. Lifestyle adjustments are changes aimed at improving sleep, such as limiting caffeine intake and ensuring regular physical activity. Fixed bedtimes refer to maintaining consistent sleep and wake times throughout the week to regulate the sleep cycle. Sleep restriction involves limiting time in bed to match the participant’s average total sleep time (TST), with gradual increases based on sleep efficiency (SE). Relaxation exercises include techniques like guided meditation and deep breathing to reduce arousal and facilitate sleep onset. Rumination (time) designates a specific period (e.g., 15 min) to process worries before bedtime, helping to reduce intrusive thoughts. Rumination (other) involve cognitive strategies aimed at managing unhelpful thoughts, such as focusing on staying awake or blocking repetitive thoughts. Alternative thoughts focus on challenging and modifying unhelpful thoughts related to sleep, replacing them with more adaptive and realistic perspectives. Future plan entails developing a personalized plan to prevent relapse into insomnia, summarizing the key strategies learned throughout the intervention
  2. Abbreviations. MHC: mental health care