• Eduard Jan de Bruin and Anne Marie Meijer.
• Research Institute of Child Development and Education, University of Amsterdam, The Netherlands. Electronic address: E.J.deBruin@UvA.nl.
• Sleep Med. 2017 Jan 1; 29: 68-75.

BackgroundGuided Internet cognitive behavioral therapy for insomnia (CBTI) offers an effective treatment for adolescents, but little is known about the active ingredients of therapeutic feedback on outcomes.ObjectiveThis study aims to identify which factors can be distinguished in written therapeutic feedback in Internet CBTI, and examine whether these factors and participation in a chat session contribute to sleep outcomes.MethodsInternet CBTI was applied to 57 adolescents (mean age 15.43 years, SD 1.74, 82.5% girls). Symptoms of insomnia and chronic sleep reduction, and total sleep time, time in bed, and sleep efficiency from seven day sleep logs were measured at baseline, post-treatment, and at two month follow-up. With a coding instrument developed for this study, two independent researchers coded transcripts of the written therapeutic feedback of the Internet CBTI sessions with an event sampling method.ResultsPrincipal component analysis of the initial 17 items from the coding instrument yielded four distinct factors of therapeutic feedback, of which only Sleep expertise seemed to contribute to improvements after Internet CBTI. The other factors, indicating forms of encouragement, and participation in a chat session seemed counterproductive.ConclusionsThis first longitudinal study into effects of therapeutic feedback in adolescent Internet CBTI indicated that emphasizing knowledge about sleep might contribute to insomnia improvement. The structured nature of the preprogrammed treatment content, delay of therapeutic feedback due to standardized timing, and unintentional reinforcement of undesirable behavior by giving attention to failures might explain the negative results of encouraging behavior. Further research to identify effective therapeutic factors in Internet therapy is warranted.Copyright © 2016 Elsevier B.V. All rights reserved.

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