Recommendations to bolster adherence in cognitive behavioral therapy for insomnia: a self-efficacy approach

Abstract

This paper is aimed at clinicians who want to help their patients improve their sleep using first-line insomnia treatment. Specifically, it outlines an evidence-based and practical approach to help clinicians maximize implementation of the gold-standard treatment for chronic insomnia, cognitive behavioral therapy for insomnia (CBT-I).

Implications.

Practice: CBT-I clinicians should aim to enhance adherence to treatment protocols by bolstering patients’ self-efficacy.

Policy: Effective insomnia treatment, including CBT-I programs that are enhanced to bolster self-efficacy, should be made accessible to patients.

Research: Future research is needed to empirically test the hypothesis that a self-efficacy enhanced CBT-I protocol boosts treatment adherence and clinical outcomes compared to a typical CBT-I protocol.

CHRONIC INSOMNIA

Insomnia Disorder, which is commonly referred to as chronic insomnia, is defined as experiencing poor sleep quantity or quality, which manifests as difficulty falling asleep, maintaining sleep, or waking too early [1]. To meet DSM-5 diagnostic criteria, these difficulties must occur at least three nights per week for at least three months and result in significant distress or impairment [1]. Chronic insomnia has significant negative impacts on patients’ global functioning and is associated with psychological and medical conditions, resulting in costs to patient quality of life and the healthcare system [2]. In a nationally representative Canadian sample of adults, approximately 40% of the participants reported experiencing at least one symptom of insomnia and about 15% of the sample met full diagnostic criteria (as per an algorithm that combined the DSM-IV-TR and ICD-10 criteria) based on their responses to a telephone survey [3]. Given the burden that insomnia causes to patients, providers, the healthcare system, and society at large [2], effectively managing this widespread condition is critical.

COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA

According to medical guidelines around the world, the first-line treatment for chronic insomnia is Cognitive Behavioral Therapy for Insomnia (CBT-I) [4, 5]. CBT-I typically involves multiple components including sleep hygiene (i.e., providing psychoeducation and recommendations about factors that can facilitate better sleep, such as the sleep environment and substance use), stimulus control (i.e., getting into bed only when sleepy and leaving bed when not sleeping to strengthen the association between the bed and sleep), sleep restriction (i.e., limiting time in bed to build up sleep drive using sleep scheduling techniques), cognitive therapy (i.e., challenging unhelpful sleep-related thoughts), and relaxation training (i.e., techniques to reduce arousal such as deep breathing, ­meditation, and progressive muscle relaxation) [6]. Research has shown that CBT-I is highly efficacious in randomized control trials [6] and effective in real-world clinical settings such as primary care, as demonstrated by medium to large effect sizes and ­significant proportions of patients no longer having clinically significant insomnia after treatment [7]. It has also shown promising results when adapted to group-based [8] and self-help [9] modalities. Notably, CBT-I is superior to medications in treating insomnia, particularly in the long-term [10].

ADHERENCE CHALLENGES IN CBT-I

Adherence and attrition can be challenges in CBT-I [11]. Adherence estimates in the literature vary by setting, population comorbidity, and how the construct is measured. A recent review of adherence in CBT-I studies reported over 80% adherence in an in-person treatment program among women with breast cancer, less than 50% adherence in a group therapy program for primary insomnia, and around 60% adherence in an online therapy intervention for patients with primary or comorbid insomnia with other medical or psychological conditions [11]. Although the authors of this review theoretically defined adherence as the “persistence in the practice and maintenance of desired health behaviors [that] is the result of patient’s active participation in and agreement with treatment recommendations” (p. 453), the studies included utilized various measures of adherence, such as single- to multi-item patient, therapist, or partner reports and estimates derived from sleep diary data [11]. Despite the mixed estimates in the literature, better adherence predicts better outcomes in CBT-I [11, 12]; as such, patients and clinicians need strategies that improve adherence to treatment.

CBT-I adherence issues are most apparent within the two most potent components of treatment, stimulus control and sleep restriction, both of which require a great deal of discipline and effort to implement [13, 14]. Better at-home adherence to these two components of CBT-I predicts long-term clinical improvement [15]. As such, techniques aimed at increasing adherence have potential to bolster patients’ engagement with, and maintenance of, these critical aspects of CBT-I.

Several studies have investigated factors relating to sleep therapy adherence. Researchers have found that perceived behavioral control, social support, intention to complete the treatment program, and older age relate to better adherence [16–18]. On the other hand, difficulties incorporating the home practice (e.g., schedule changes, coming up with activities to complete when out of bed, arising at the same time each day) [19, 20] and symptoms of anxiety and depression [18] are potential barriers to adherence. In fact, patients who perceive fewer barriers (e.g., boredom, annoyance, discomfort, anxiety) to engaging in stimulus control and sleep restriction demonstrate better adherence to treatment, which in turn predicts better outcomes [21]. These findings elucidate potential targets to bolster adherence in CBT-I, but researchers have pointed to the need for more theory-based work to inform the specific strategies [11]. While there has been little research done of this kind in the field of sleep, one theory in particular—Social Cognitive Theory [22]—has been applied to promoting adherence in myriad health behaviours, offering promise for its potential utility in CBT-I.

SELF-EFFICACY, ADHERENCE, AND HEALTH BEHAVIOUR

Originating in Bandura’s Social Cognitive Theory, self-efficacy refers to one’s beliefs in their ability to effectively carry out a task to obtain a desired result [22]. Self-efficacy has been described as a mediator between knowledge and action [22]; as such, self-efficacy has been applied to the field of health behavior to help explain the disconnect between obtaining treatment recommendations and following through with them [23]. This concept can be harnessed to help fill this knowledge-action gap by ascertaining methods to bolster adherence and follow through with health behaviors.

Both expectations about outcomes (i.e., outcome expectations) and one’s ability to carry out necessary actions (i.e., efficacy expectations) are posited to be at the heart of behavior change and maintenance [23, 24]. According to Social Cognitive Theory, the most potent means of promoting self-efficacy is through performance accomplishments (i.e., personal experience) where one attains mastery [22–24]. In addition, vicarious experience (i.e., observing others complete a task), verbal persuasion (i.e., receiving encouragement), and one’s emotional arousal level and state are also posited to shape self-efficacy [22–24].

Several contextual and related factors influence self-efficacy [22]. Self-efficacy has been discussed as being associated with one’s self-regulatory abilities, which is particularly relevant in the context of health behaviors. Social support is suggested to play a role, such that congruently high self-efficacy among individuals positively influences behaviors [22]. Given that self-efficacy relates to a particular task, behavioral and cognitive controllability (i.e., the perception of, and ability to enact, control in a situation) are thought to help enhance one’s capability to take action while reducing apprehension. Taken together, each of the contributors to self-efficacy help to explain its role in connecting knowledge to action, and in turn, its link to adherence.

The role of self-efficacy in promoting health behavior has been discussed theoretically and supported empirically. Numerous meta-analyses have shown that self-efficacy is associated with positive health intentions and behaviors (e.g., exercise, condom use, smoking cessation) [25], both in correlational and experimental designs. A recent meta-analysis examined studies that randomly assigned participants to groups that experimentally manipulated self-efficacy through interventions and provided causal evidence that boosting self-efficacy leads to health behavior changes (e.g., smoking cessation, diet, exercise) [25]. Researchers have also examined self-efficacy as a mediator, or mechanism of change, in health behaviors such as stress management and nutrition [26, 27]. In conclusion, the literature demonstrates that self-efficacy is not only associated with positive health behavior change, but it in fact causes it.

METHODS OF TARGETING SELF-EFFICACY IN HEALTH INTERVENTIONS

There are several ways in which experimental health interventions have targeted self-efficacy. For example, in an exercise intervention targeting walking behavior, motivational, and volitional components of the program led to positive changes relative to a control group, and these changes were mediated by perceived behavioral control, a construct closely tied to self-efficacy [28]. More specifically, the motivational component of the intervention involved altering participants’ control beliefs by eliciting their level of confidence in their ability to complete the behavior, asking about their previous success and challenge experiences regarding personal control, factors contributing to success and challenges, and developing plans to help participants implement the behavior. The volitional component of the intervention involved specific goal setting, action plans regarding how participants will incorporate the behavior into their lives and brainstorming potential barriers and how to overcome them. Extending this work, another exercise intervention found that combining both motivational and volitional elements was most effective in promoting positive behavior change compared to either component in isolation [29]. In a nutrition intervention study promoting fruit and vegetable consumption, self-efficacy was enhanced by eliciting participants’ recall of past mastery experiences, by modeling health behavior, and by using persuasion [30]. Moreover, action planning and coping planning were bolstered by specifying how participants would meet their healthy eating goals and how to prevent and work with barriers to such behavior. Each of these strategies, which are modes to induce self-efficacy [24], helped the intervention group eat significantly more fruits and vegetables post-treatment than the active control group who received nutrition education only [30]. Additionally, the experimental group’s intention and planning to eat fruits and vegetables as well as their dietary self-efficacy increased over time. Coping planning and self-efficacy mediated the relationship between group assignment and eating behavior post-treatment, providing evidence that these were the active ingredients to promote change in the intervention.

SELF-EFFICACY AND ADHERENCE IN CBT-I

Although researchers have called for theory-driven approaches to improving treatment adherence in CBT-I, the available research addressing this issue has been scarce, predominantly examining theoretical correlates of clinical outcomes. To our knowledge, there have been no experimental studies in which self-efficacy manipulations were used to predict treatment adherence nor outcome. A 2021 systematic review briefly discussed the role of self-efficacy in CBT-I treatment adherence, highlighting the dearth of research on this topic [31]. Several researchers have found that sleep specific self-efficacy negatively relates to insomnia severity, that it improves over the course of CBT-I treatment, and that it can predict treatment adherence [32]. One set of researchers sought to specifically develop and test a measure’s ability to predict adherence to CBT-I based on Bandura’s Social Cognitive Theory concept of self-efficacy [33]. The authors measured global self-efficacy (i.e., respondents’ overall perceived ability to adhere to treatment), task-related self-efficacy (i.e., respondents’ perceptions of confidence in being able to perform stimulus control and sleep restriction tasks), and self-regulation (i.e., respondents’ ability to cope with potential treatment barriers). Global self-efficacy was more strongly related to early treatment adherence, whereas task-related self-efficacy was more strongly related to adherence later in treatment. Self-regulation was the least correlated with adherence of the three subscales. Another study found that self-efficacy was significantly lower among a student sample with insomnia compared to those without sleep problems and correlated with a greater time to sleep onset [34]. One sleep program, although not CBT-I-related, specifically aimed to enhance self-efficacy using techniques highlighted in Bandura’s theory prior to tapering patients off hypnotic medications [35]. The program effectively enhanced self-efficacy, which predicted greater dose reductions than the control group. These preliminary results provide promise for self-efficacy as a potential avenue to bolster adherence in CBT-I, specifically, through enhancing self-efficacy regarding the tasks required to complete stimulus control and sleep restriction.

PROMOTING ADHERENCE IN CBT-I THROUGH SELF-EFFICACY

As described above, researchers have yet to systematically use Social Cognitive strategies as tools to improve CBT-I adherence [36]. Drawing from research on other health behavior interventions, self-efficacy in CBT-I could be a useful means to bolster adherence to treatment. Viable approaches could include positively influencing patients’ intentions and actual behavior, especially with respect to the challenging but crucial CBT-I techniques of stimulus control and sleep restriction. Each aspect of Bandura’s model could be applied to promote CBT-I treatment adherence by shaping client’s self-efficacy through their outcome and efficacy expectations. In what follows, potential strategies to target self-efficacy in CBT-I are described. These strategies are summarized in Table A1 in the Appendix.

Outcome expectations

Setting expectations

Given that outcome expectancies relate to self-efficacy [22], gauging patients’ initial expectations and level of confidence in their ability to complete the treatment and its potential outcomes are likely important first steps to help tailor interventions and bolster CBT-I adherence. For instance, validating and normalizing any apprehension for patients who do not feel confident in themselves or the treatment may be useful before providing them with psychoeducation about the efficacy and effectiveness of CBT-I to help them form more positive treatment outcome expectations. Describing the adherence-response literature wherein patients who adhere more closely to the treatment tend to do better, in an accessible manner would also help patients understand the importance of their efforts throughout treatment. These discussions should take place within the first session to lay a solid foundation of positive outcome expectations upon which to enhance patients’ efficacy expectations, and thus their self-efficacy and adherence.

Efficacy expectations

Performance accomplishments

Building confidence.

Bandura postulated that personal experiences of mastery are the most potent promotors of self-efficacy [23]. Thus, it may be useful to draw upon patients’ past experience with another successful health behavior change. Based on the aforementioned theory and research, having patients discuss their personal experience, particularly what has been helpful to facilitate behavior in the past, can boost their expectations about their ability to carry out similar tasks [22]. Having patients specifically think of ways they could apply their past effective strategies to manage their sleep problem using the CBT-I techniques may be a key step to foster their ­self-efficacy, and in turn their adherence in treatment. For example, if a patient has found visual reminders for health behavior helpful, they may wish to display their sleep diary and a list of strategies in an accessible place in their home.

Self-monitoring.

Self-monitoring is a tool that can help patients acknowledge and reflect on personal experiences of mastery, which are key to shaping self-efficacy, and in turn fostering better treatment adherence and outcomes. It is also a key aspect of CBT-I protocol as patients track aspects of their progress (e.g., bedtime, rise time, time to fall asleep, awakenings, time out of bed, sleep quality, restedness) using a daily sleep diary. This aspect of treatment offers a critical opportunity to provide data on patients’ experiences of mastery. Therapists should encourage patients to reflect each week on their experiences, paying close attention to improvements made as a result of their actions and adherence to the treatment protocol. Patients should be encouraged to track additional details in their sleep diary, such as what specific strategies they implemented, how well they adhered to these strategies, and other outcomes such as their mood and level of functioning during the day.

Vicarious experience

Vicarious experience, or the modeling of behavior, can also contribute to increased self-efficacy. Group CBT-I offers a unique opportunity where patients can garner encouragement and confidence from others’ mastery experiences with the treatment. If directly witnessing others’ success through vicarious experience is not available in the treatment setting, reiterating the research findings and providing non-identifying and general anecdotes of patients who have adhered to the CBT-I strategies and reversed their insomnia could be useful to target this mode of shaping efficacy expectations.

Verbal persuasion

Social support and encouragement.

Verbal persuasion through social support and encouragement is also a tool that may foster self-efficacy [23]. In the context of CBT-I, both the therapist and patients’ close others can contribute. Therapists could act as patient advocates and praise them for their efforts throughout treatment. Providing a non-judgemental space for patients to share their successes and struggles will help to positively reinforce what is going well and brainstorm strategies to overcome what is more challenging. In addition, patients can inform close others in their lives (e.g., their bed partner, family members, friends) of their treatment efforts and use these supports to promote adherence. For example, a patient’s bed partner may be able to help the patient keep a consistent rise time each day or a friend may be able to engage in an evening activity with the patient to help them stay awake until their bedtime.

Emotional arousal

Action planning.

Once the specific CBT-I strategies are introduced and treatment is underway, it is important to assess and normalize any emotional arousal clients may have about the treatment tasks. To induce a sense of controllability, taking time to engage in effective action planning with patients may help to strengthen their self-efficacy and facilitate subsequent adherence to treatment. For stimulus control and sleep restriction, mapping out how these challenging strategies will look in patients’ lives may help them set up for success to adhere to them, along with garnering a sense of personal controllability to reduce their apprehension. With sleep restriction, ensuring that patients know their set bedtime and rise time for the week and planning for what activities they will do in order to stay up until their bedtime could be useful. For stimulus control, discussing with patients where they will go and what they will do when they need to leave their bed if they awaken in the night may help them to feel more confident in carrying out this strategy. To help patients envision how these behaviors will be incorporated into their routines, questions regarding the specifics of how they will carry out these tasks and having them record each of these plans may also enable effective action planning. In addition, patients might be encouraged to discuss potential activity and schedule changes with family members and close others who could be affected by, and help encourage, the behavior.

Coping planning.

CBT-I treatment can be challenging and requires motivation and discipline; as such, identifying potential barriers to adhering to treatment and how to overcome them may be a particularly useful means to reduce patients’ apprehension and in turn foster self-efficacy and adherence. Eliciting from patients what obstacles they see getting in the way of implementing the strategies properly may be a helpful way to identify potential barriers. Asking patients whether they may struggle to stay up until their bedtime, get out of bed in the night if they awaken, or get out of bed at their rise time could help them to recognize specific obstacles. Based on what they identify, brainstorming ways to overcome such barriers if/when they arise could help patients better adhere to the treatment. For example, discussing activities that they find stimulating instead of sleep-inducing to help stay awake until their bedtime (e.g., doing housework, talking to friends), finding ways to stay comfortable when they get out of bed in the night (e.g., laying out warm clothes and materials for an activity ahead of time), and planning their morning to help them stick to their rise time (e.g., prepping breakfast the night before, getting exposed to light and fresh air first thing in the morning) are potential ways to engage in coping planning with patients. Moreover, some patients may benefit from identifying some statements to help them cope and adhere to the treatment when it feels challenging, such as “short term pain for long-term gain”. In sum, planning for how to cope with barriers may be an effective means to boost patient self-efficacy and CBT-I adherence by building up their sense of behavioral and cognitive control.

FUTURE DIRECTIONS

The current paper offers a set of potential strategies for improving the current practice of CBT-I. Although the strategies proposed here are rooted in health behavior theory and empirical research in related domains, future research should seek to test out the hypothesis that a CBT-I treatment protocol that targets self-efficacy will enhance adherence and in turn result in better outcomes. This hypothesis could be tested in a randomized controlled trial comparing a typical CBT-I protocol to one that has additional components aimed at bolstering patient self-efficacy. One exciting advance in this area is highlighted by the work of Mellor and colleagues [14], who have proposed a randomized control trial comparing partner-assisted CBT-I to regular CBT-I which would target the verbal persuasion (i.e., social support and encouragement) aspect of shaping self-efficacy.

CONCLUSIONS

CBT-I is the gold-standard treatment for chronic insomnia, but adherence can be an issue due to the challenging nature of the treatment protocol. Research suggests that better adherence relates to improved outcomes. Self-efficacy offers a theoretically and empirically supported mechanism to bolster patient adherence to treatment, and in turn, their clinical outcomes. This paper provides a commentary on the practice of CBT-I with the aim of providing recommendations to foster patient self-efficacy through various means that are rooted in Social Cognitive Theory and have been studied in other health interventions. By tailoring treatment to patients and focusing on how it is delivered, not just what is delivered, therapists can shape patients’ expectations about the intervention, their ability to engage in it meaningfully and effectively, and their potential to carry forward their treatment gains with a sense of mastery and self-efficacy.

APPENDIX

Table A1 | Summary of recommended strategies to enhance self-efficacy in CBT-I treatment

Aspect of self-efficacy	Source of enhancing self-efficacy	Specific strategies to induce self-efficacy
Outcome expectations	Setting positive expectations	- Normalize and validate feeling a lack of confidence in own abilities or treatment. -Provide psychoeducation on research support for CBT-I and adherence-outcome findings in an accessible way
Efficacy expectations	Performance accomplishments	- Recall past mastery experiences with health behavior- Self-monitor during treatment with special attention paid to successes
	Vicarious experience	- Learning and gaining confidence though fellow patients’ successes (i.e., directly if in group treatment or through therapist sharing of research findings and clinical anecdotes)
	Verbal persuasion	- Social support and encouragement from therapist and close others in patients’ lives
	Emotional arousal	- Action planning (i.e., planning for how CBT-I strategies will be incorporated into patients’ lives) - Coping planning (i.e., identifying and preparing for how to overcome barriers to treatment adherence)

Funding

The author holds a Canadian Institutes of Health Research Frederick Banting and Charles Best Canada Graduate Scholarships Doctoral Award. However, the current paper is not directly affiliated with the doctoral dissertation research project of the author.

Compliance with Ethical Standards

Conflicts of Interest: The author declares that they have no conflicts of interest.

Human Rights: This article does not contain any studies with human participants.

Informed Consent: This study does not involve human participants and informed consent was therefore not required.

Welfare of Animals: This article does not contain any studies with animals.

Transparency statements not required for this article as no data were analyzed.