# A mixed-method process evaluation of guided online cognitive behavioral therapy for insomnia in patients with borderline personality disorder

## TL;DR

This study evaluated how guided online therapy for insomnia works in patients with borderline personality disorder, finding that personalized guidance and behavioral strategies are key to success.

## Contribution

The study provides new insights into the implementation processes and effectiveness of guided iCBT-I for BPD patients with insomnia.

## Key findings

- Patients valued responsive therapist guidance and behavioral strategies like fixed bedtimes.
- Introspective techniques were perceived as challenging by participants.
- Integration of insomnia treatment into regular BPD care is desired for better outcomes.

## Abstract

Borderline personality disorder (BPD) is often associated with insomnia, which may contribute to a vicious cycle of reciprocal exacerbation of sleep disturbance and BPD symptoms. Online cognitive behavioral therapy for insomnia (iCBT-I) has shown promise for treating insomnia in BPD patients. This study evaluated the key determinants, underlying processes, and change mechanisms of successful implementation of guided iCBT-I in BPD patients.

In the context of our clinical trial, we conducted this mixed-method process evaluation in 30 patients with BPD and comorbid insomnia complaints (mean age 29.5 years ± 8.72) that received guided iCBT-I. Our process evaluation was guided by four dimensions of the theoretical RE-AIM framework: Reach (e.g., reason participation), Effectiveness (e.g., perceived symptom reduction), Implementation (e.g., treatment delivery), Maintenance (e.g., sustained adherence). We combined insights from quantitative patient-reported evaluation of treatment satisfaction and adherence and therapist log data, with qualitative exploration of patient experiences through in-depth interviews in a subsample of five patients.

21 patients (70%) completed the intervention. Patients appreciated the online modality and emphasized the importance of responsive and personalized (videocall) therapist guidance and active reminders. Patients found behavioral strategies, such as fixed bedtimes and an evening winding-down routine particularly helpful, while more introspective and cognitive techniques were often perceived as challenging. Qualitative effectiveness evaluations aligned with clinical trial outcomes on BPD, insomnia and arousal-related symptoms. Finally, patients expressed a strong desire for more and well-integrated sleep treatment into regular BPD care trajectories.

Guided iCBT-I proved a feasible and promising intervention for patients with BPD, with successful implementation contingent upon personalized guidance, focus on behavioral strategies tailored to individual needs, and solid integration into BPD care.

The online version contains supplementary material available at 10.1186/s12888-026-07859-8.