Intervention
sleep-related
The add-on sleep intervention comprised four sessions over six weeks and is based on CBT-I principles. The sleep intervention was added to the regular rehabilitation program, which varied between individuals based on their rehabilitation goals. Thus, the add-on sleep intervention is a short variant of CBT-I which is in addition to the rehabilitation treatment as usual. All therapists were trained in CBT-I. Furthermore, individual supervision by an experienced CBT-I therapist was available during the study. During the COVID-19 pandemic lockdown in 2020, treatment sessions were delivered online through video calls and assessments were sent by post.The first session started with the baseline assessment. During a structured interview, participants were asked to address their sleep-related problems. Subsequently, a daily homework assignment was given to the participants that involved completing a sleep-wake diary for one week. This sleep-wake diary provided information about several (sleep) parameters, including sleep duration, time spent in bed, wake time, sleep quality, nighttime activities, caffeinated drinks and alcohol consumption.The second session (one week later) consisted of psychoeducation about sleep and recommendations were made to change sleep behaviour. Psychoeducation and recommendations were somewhat personalized based on information gathered from the sleep assessment (interview, questionnaires and sleep diary). Behavioural techniques consisted of discussing sleep hygiene, such as caffeine intake and activities before bedtime, stimulus control and sleep restriction. Stimulus control aims to improve the association between bed and sleep-behaviour by solely using the bed for sleeping (and not for other activities such as reading or watching TV). In addition, an adapted form of sleep restriction was used in which participants were instructed to shorten the time spent in bed to a maximum of 7 hours in order to consolidate sleep. It is important to note that regular CBT-I treatments instruct participants to spent only 5 hours in bed. Since research demonstrated that individuals with ABI need more sleep as compared to individuals without ABI (After two weeks, the third session took place in which the adjustments in sleep behaviour and its effect on sleep quality were evaluated and, if necessary, extended or adapted. Possible additional elements contained relaxation exercises, strategies to cope with worrying (e.g., ‘worry postponement’) or increasing physical activities during daytime. Participants were instructed to maintain their changes in sleep behaviour for another two weeks.During the final session, which took place two weeks after the third session, changes in sleep behaviour and its impact on sleep were evaluated. Furthermore, the therapist and participant jointly developed a relapse prevention plan which also included an overview of the most important sleep recommendations. The session ended with the post-treatment assessment (T6: PSQI, HADS, DMFS, DBAS-16). Throughout the treatment, participants were encouraged to follow the program strictly to develop a regular sleep pattern. A summary of the content of the sleep intervention is presented in Summary of the short add-on sleep therapy