Barriers and Facilitators of Sleep Restriction Therapy in Internet-Delivered CBT-I: A Qualitative Content Analysis and the Development of a Treatment Path Model.

Sleep Restriction Therapy (SRT) is a core component of cognitive behavioural therapy for insomnia (CBT-I). Yet, adherence to SRT can be a major challenge for patients. As this challenge is evident in conventional face-to-face therapy, it raises the question of adherence to SRT in internet-delivered therapy. This qualitative study investigates adherence to SRT in internet-delivered CBT-I and aims to identify candidate variables that can guide treatment decisions. Participants diagnosed with insomnia who participated in an internet-delivered CBT-I as part of a stepped-care model were interviewed. Data from interviews with 23 participants were included in this study. A qualitative content analysis was employed. Hindering and facilitating individual, intervention-related, and e-coaching-related factors were examined. Moreover, the consequences of SRT (e.g., negative effects and attrition) were examined. Eleven participants consistently implemented SRT, two rejected it from the beginning, eight discontinued, and two showed inconsistent adherence. Docility, low levels of frustration tolerance, and previous negative experiences with SRT emerged as hindering individual factors. In contrast, a high level of insomnia-related burden, social support, perceived individual fit with the program, and being satisfied with the therapeutic guidance appeared to foster adherence. Based on the results of this study, a treatment path model is introduced, postulating candidate predictors for the indication for SRT within internet-delivered CBT-I (e.g., docility and previous negative experiences with SRT), candidate predictors for engagement (e.g., level of commitment and social support), and potential variables for process monitoring (e.g., negative effects and satisfaction with and need for therapeutic guidance).