Study • Health · Sleep
A randomized, placebo-controlled, trial of online Cognitive Behavioral Therapy for chronic Insomnia Disorder delivered via an automated media-rich web application.
Espie, C.A., Kyle, S.D, Williams, C., Ong, J.C., Douglas, N.J., Hames, P., Brown, J.S.L. (2012). A randomized, placebo-controlled, trial of online Cognitive Behavioral Therapy for chronic Insomnia Disorder delivered via an automated media-rich web application. SLEEP 35, 769-781.
Abstract
STUDY OBJECTIVES:
The internet provides a pervasive milieu for healthcare delivery. The purpose of this study was to determine the effectiveness of a novel web-based cognitive behavioral therapy (CBT) course delivered by an automated virtual therapist, when compared with a credible placebo; an approach required because web products may be intrinsically engaging, and vulnerable to placebo response.
DESIGN:
Randomized, placebo-controlled trial comprising 3 arms: CBT, imagery relief therapy (IRT: placebo), treatment as usual (TAU).
SETTING:
Online community of participants in the UK.
PARTICIPANTS:
One hundred sixty-four adults (120 F: [mean age 49y (18-78y)] meeting proposed DSM-5 criteria for Insomnia Disorder, randomly assigned to CBT (n = 55; 40 F), IRT placebo (n = 55; 42 F) or TAU (n = 54; 38 F).
INTERVENTIONS:
CBT and IRT each comprised 6 online sessions delivered by an animated personal therapist, with automated web and email support. Participants also had access to a video library/back catalogue of session content and Wikipedia style articles. Online CBT users had access to a moderated social network/community of users. TAU comprised no restrictions on usual care and access to an online sleep diary.
MEASUREMENTS AND RESULTS:
Major assessments at baseline, post-treatment, and at follow-up 8-weeks post-treatment; outcomes appraised by online sleep diaries and clinical status. On the primary endpoint of sleep efficiency (SE; total time asleep expressed as a percentage of the total time spent in bed), online CBT was associated with sustained improvement at post-treatment (+20%) relative to both TAU (+6%; d = 0.95) and IRT (+6%: d = 1.06), and at 8 weeks (+20%) relative to IRT (+7%: d = 1.00) and TAU (+9%: d = 0.69) These findings were mirrored across a range of sleep diary measures. Clinical benefits of CBT were evidenced by modest superiority over placebo on daytime outcomes (d = 0.23-0.37) and by substantial improved sleep-wake functioning on the Sleep Condition Indicator (range of d = 0.77-1.20). Three-quarters of CBT participants (76% [CBT] vs. 29% [IRT] and 18% [TAU]) completed treatment with SE > 80%, more than half (55% [CBT] vs. 17% [IRT] and 8% [TAU]) with SE > 85%, and over one-third (38% [CBT] vs. 6% [IRT] and 0% [TAU]) with SE > 90%; these improvements were largely maintained during follow-up.
CONCLUSION:
CBT delivered using a media-rich web application with automated support and a community forum is effective in improving the sleep and associated daytime functioning of adults with insomnia disorder.
Tactics used

TACTICS
Behavior Substitution
Behavior substitution refers to attempting to eliminate a problematic behavior by replacing it with another one. Often, the substituted behaviors are intended to have similar sensory qualities (e.g. drink flavored sparkling water instead of soda). The goal is typically to disassociate the original behavior from its cue, enabling the more positive behavior to be triggered automatically.

TACTICS
Checklists
Checklists are an age-old tactic for remembering to do certain tasks. Checklists are sometimes used to measure behaviors that should take place with a certain frequency, e.g. every day or X times per week, and other times, to ensure certain steps are followed every time a person does a complex behavior.For behavior designers, the challenges of checklists often entail choosing the right behaviors, breaking them down to the correct level of granularity for a given population, and serving them up in the proper context or sometimes with personalization. They are likely underutilized and consistently improve the performance of even experts, like pilots and surgeons.

TACTICS
Coaching or Counselling
Coaching or counselling here refers to having a trained person provide guidance to someone attempting a behavior. Many mental health and lifestyle programs utilize coaching in various forms, including phone calls, video chat, text messaging, or in-person sessions. Some programs have replaced some or all of these traditionally human-delivered touchpoints with AI or rules-based interactions.

TACTICS
Education or Information
Education refers to empowering a person with more knowledge or training than they had previously. While providing information alone is often a suboptimal way to drive meaningful behavior change or long-term interventions, the right message at the right time can be a powerful part of a behavior change strategy.

TACTICS
Environmental Restructuring
Environmental restructuring refers to modifying the physical environment around someone in order to influence their behavior.On the less intensive end, this could be as simple as having someone leave a pill bottle in a more obvious location or switch to using a pillbox with compartments for each day. More complex examples include carpooling potential voters to election sites to improve turnout, redesigning a workplace cafeteria layout to bias toward healthier foods, or setting up booths for influenze vaccination in offices or shopping malls.

TACTICS
Goal Setting
Goal setting simply refers to a person choosing a specific result to aim at achieving. This might include an outcome (e.g. a goal weight) or a behavior (e.g. exercise 90 minutes 3 times a week).

TACTICS
Implementation Intentions
Implementation intentions are specific details for when and how a behavior should or will be performed. These are often formulated as ""if-then"" rules, such as:- "if I crave something sweet, I'll have fruit instead of candy"- "if I am in the mood for a cigarette, I'll wait 5 minutes—then, if I still want it, I can have one"Other examples include studies where flu vaccination uptake was higher in groups of people nudged to make more specific plans (i.e. picking a specific time and date, along with a mode of transport to a specific clinic). The same general effect was observed with voting behaviors. These are a generally low-cost tool to slightly improve the gap between intention and performance of a behavior.

TACTICS
Habit Formation
Habit formation refers to approaches where a person is trained to associate a behavior or chain of behaviors with a given cue, often by introducing rewards or punishment. While traditional habit formation approaches derived largely from behaviorism and operant conditioning, many modern approaches emphasize the cognitive processes that mediate the behavioral response to cues or explore methods of modifying environments (either to reduce the frequency or salience of cues to undesired behaviors, or do the reverse for desired ones). Many habit formation programs, e.g. BJ Fogg's Tiny Habits approach, emphasize reducing the scope of the desired behavior and scaling it over time with the person's growing ability.
TACTICS
Cognitive Behavioral Therapy (CBT)
Behaviors addressed