Discussion of findings in relation to previous research
Readiness for change can be an important step toward change [
41]. In this study, patients started treatment with a desire for change, and this desire may have influenced their engagement in the treatment and their ability to achieve improvements [
42,
43]. Patients described how they felt “strange,” “weird,” and “lonely” in a world of “good sleepers.” Such feelings of isolation and alienation have been described previously by people living with insomnia [
8]. In the current study, important motivators for engaging in behavioral change were feeling that you were not alone in your problems and that you had the support of other group members who shared the experience of living with insomnia. These findings echo those of previous studies of patients’ experiences of mindfulness-based group treatment for insomnia [
16] and of group treatment for health problems other than insomnia (obesity and diabetes) [
44,
45]. Moreover, in our study, patients found that the engagement and understanding of the group leader motivated them to try new behaviors. The importance of a trustful relationship with care providers for behavioral change and health outcomes is well known, both from qualitative [
16,
18] and quantitative studies [
46,
47].
Our finding that the group format was important to behavioral change is in line with the findings of previous studies [
48,
49]. A set of therapeutic or curative factors common to group therapy seem to be the main mechanisms behind such change [
50], and many of these factors are recognizable in our findings. They include being in a safe and secure environment in which people can both listen and be heard; feelings of involvement, trust, and validation; recognizing that one’s own experiences are similar to those of others; becoming more optimistic about one’s own chances of success after witnessing the success of others; learning by observing the journeys of other group members; gaining knowledge from the group members and leader; gaining insight through the feedback of others; and gaining insight into what lies behind one’s own feelings and behaviors [
50].
Educational theory posits that lived experience is crucial to learning [
51] and that learners move from gaining fact-based knowledge through experience and reflection to deeper understanding and the ability to broadly apply what they have learned [
52]. Consistent with educational theory, patients in our study experienced knowledge as essential to behavioral change. They described how repeated information and discussion, shared experiences, keeping a sleep diary, and bodily experience that came from practicing techniques facilitated a deeper understanding of sleep and their own behaviors. Previous studies of group treatment [
45] and of individual treatment [
18] have also found that such deeper understanding facilitates behavioral change. Like our findings and in keeping with educational theory, the findings of a previous study of sleep restriction underscore the role that bodily experience plays in deeper understanding [
17]. Similar to the patients in our study, patients in that study found that sleep restriction led to bodily experiences congruent with what they had learned about sleep and noticed the quality of their sleep was better.
In the present study, patients’ deeper understanding of sleep and of their own behaviors made them feel competent. Feelings of competence helped patients relax and let go of sleep performance and worry, develop more regular sleep habits, and reduce the time they spent in bed. These findings are clinically important because worry—especially worry about sleep—perpetuates insomnia by inducing maladaptive sleep behaviors aimed at achieving sleep and avoiding sleeplessness, such as spending extra time in bed [
34].
Our findings that feelings of involvement, trust, and competence were important to motivation and to patients’ success in changing their behaviors are consistent with behavioral theory [
53,
54]. These feelings are similar to those of autonomy, relatedness, and competence described in self-determination theory as crucial to the intrinsic motivation that allows people to take action and persist in behavioral change [
54]. Moreover, according to the theory of self-efficacy, feelings of competence are important to motivation, and self-efficacy is crucial to how people choose to act and how they cope with challenges [
53].
In addition to feeling involved, trustful, and competent, patients could also struggle with feelings of vulnerability and failure. Some vulnerabilities may have been related to insomnia. When they choose to seek help for insomnia in primary care, people have typically passed a certain threshold of symptomatology. Specifically, problems with fatigue and psychological distress are often the experiences that prompt people to seek help [
9]. Some patients in the present study felt distressed because they thought they might get too little sleep. Obtaining a good night’s sleep is often a major concern for people with insomnia, and this concern helps maintain the disorder [
55].
People’s confidence in their coping abilities affects their emotional reactions to difficult situations [
53]. In the current study, some patients lacked confidence that the techniques would work for them or that they would be able to use what they learned; these patients expressed feelings of helplessness and failure. Patients with poor confidence in their coping ability might also feel less motivated to try to change their behaviors and to persist in behavioral change [
54].
Sleep restriction is one of the most potent techniques in CBT-I [
56]. In the present study, patients were mostly positive toward sleep restriction, but it could pose challenges. For instance, the limited sleep that came with the technique caused mental and physical tiredness, side effects that have been described previously [
17,
57]. Like our study, an earlier study found that challenges to practicing sleep restriction also included experiences of negative impact on functioning, difficulties managing sleepiness prior to bedtime, boredom during extra hours awake, and changes in appetite/hunger [
17]. In addition to these challenges, we found that sleep restriction could affect patients’ social life because of its inflexibility.
Patients used the techniques that felt right for them and adapted these techniques as needed. Like the findings of the current study, the findings of a qualitative meta-analysis of patients’ experiences of psychotherapy highlighted how important it was for patients to feel free to adjust techniques to their individual needs [
18]. In our study, group leaders’ adaptation of sleep restriction to patients’ needs helped patients overcome barriers posed by this challenging technique. Patients who perceive fewer barriers to sleep restriction are more likely to continue practicing it [
58].
Finally, the importance of adjusting techniques to the individual underscores the value of person-centered care. In person-centered care, one of the core competencies in nursing, the patient is viewed as an expert on her or his own experiences and everyday life [
59]. Person-centered care can empower patients [
60] by helping them feel able to make autonomous decisions about their self-management [
61].
Clinical implications
This study suggests ways in which the group treatment program for insomnia might be refined to better suit primary health care patients. Our findings indicate that certain aspects of the treatment program helped patients feel motivated and helped them achieve improvements. These included a group of people that shared the experience of insomnia, an involved and engaged leader, meeting at a convenient and trusted location, educational components, the sleep diary, regular meetings, and stepwise introduction and practice of techniques. Certain techniques seemed to be particularly helpful; for instance, sleep restriction, the relaxation exercise, power naps, reduction of hypnotic drugs, and techniques related to worry (worry time and identifying and arguing against negative thoughts).
Our findings also indicate that participation might be facilitated by fewer weekly treatment sessions. However, patients’ worries about future relapse suggest that follow-up sessions might be a helpful addition to the program.
Finally, the study provides insight into challenges related to treatment. Many of the challenges experienced by patients may be inevitable because they are related to insomnia itself (e.g., worry about sleep, tiredness, and a lack of confidence in the ability to sleep), and confronting them is a part of treatment. Other challenges are inherent in the techniques but can be minimized by adjusting the techniques to the individual. Still other challenges may arise from the group format. For instance, group leaders should keep in mind that comparing oneself to others is not always helpful. Whereas some people in the group may feel encouraged by such comparison, others can feel they have failed and even blame themselves for their perceived failure.
Methodological discussion
A number of aspects of the study affected its trustworthiness. The atmosphere in the focus groups was relaxed, and it was clear that the patients felt familiar with each other. The participation of three to four patients in each focus group enabled each person to contribute to the discussion. However, larger focus groups might have offered more opportunities for active group interaction [
62].
In qualitative analysis, data saturation is reached when new data no longer add novel information, but there is no consensus on how to determine when saturation has been achieved [
63,
64]. In the current study, repeated interviews [
65] were not carried out; we interviewed all the groups that were ongoing at the time of the study. However, the study had a relatively narrow aim, and sample specificity was high: all participants had experiences of the explored phenomenon. Moreover, we judge the dialogues to have been strong and data to have been rich within and across groups. Patients expressed a variety of experiences, characterized by both similarities and differences. We thus judge the study to have an adequate sample size in relation to information power [
64]. Study findings were not presented to the study participants for validation [
66].
In two of the five groups, the researcher who conducted the interview was also the group leader and had guided the participants through group treatment. This may be a limitation if patients felt they had to be particularly polite or focus on positive experiences. On the other hand, it may have helped patients feel secure because they knew the interviewer had followed their treatment process.
The prior understanding of two of the researchers was high, as they had previously led insomnia groups. Such prior understanding may have limited the analyses by affecting the interpretation of the data [
67]. However, it may also have strengthened the study by conferring a deeper understanding of the explored context. To reduce the analytical limitations caused by prior understanding, all four authors participated actively in the analytical process, which involved ongoing discussion and reflection until consensus was reached. One of the authors of this study (KK) is bilingual; English is her native language. The others, like the patients, are native speakers of Swedish. KK and CS continuously discussed the coding with each other and collaborated to translate the condensed meaning units, quotations, codes, categories, subthemes, and themes. This increased the trustworthiness of the findings.
All interview participants were women, in part because of the distribution of insomnia in the general population [
5] and in part because the majority of patients in the trial from which participants came were women (73%) [
25]. It is possible that men would have experienced the group treatment differently or expressed their experiences in a different way.
The patients who were interviewed had participated voluntarily in and completed the group treatment. Many had waited for this treatment for more than 3 months, and none who had waited dropped out once they started. They were thus a selected and highly motivated group. Readers should take this into account when judging the transferability of the results. However, previous studies of treatments that encourage behavioral change have found experiences that are reflected in our findings. Thus, the findings of the current study may be relevant to other, similar treatment contexts.