Running head: MOTIVATIONAL INTERVIEWING 1

Motivational Interviewing: A Single Subject Review of an Adult with Insomnia

Kelly Rossi

The University of North Carolina at Pembroke

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Abstract

Insomnia is a highly common sleep disturbance which 30 to 50 percent of adults will experience

at some point during their lifetime (Taylor & Dietch, 2018). It is associated with an increased

risk of other health complications like heart disease, decreased immune functioning, mood

disorder, substance use and suicidality (Taylor & Dietch, 2018). Various interventions are used

to treat insomnia. This paper will review existing literature regarding interventions for insomnia.

A single subject research study of an adult presenting with insomnia using the intervention of

motivational interviewing will be highlighted.

Keywords: Insomnia, Motivational Interviewing, Single Subject Research

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Motivational Interviewing: A Single Subject Review of an Adult with Insomnia

Literature Review

In 2009 roughly 63.2 billion dollars were lost in workplace productivity due to Insomnia

(Qaseem, 2016). The DSMIV defines Insomnia as a difficulty initiating and maintaining of sleep

at least three times per week for a period of at least three months. Insomnia as defined by the

DSMIV also affects a person's daytime functioning or causes them distress (American

Psychiatric Association & American Psychiatric Association, 2011). While it is estimated that 5

to 15 percent of adults would meet the criteria for diagnosis, roughly 30 to 50 percent of adults

will experience insomnia at some point during their lifetime (Taylor & Dietch, 2018). Women,

those who are elderly, persons undergoing chemotherapy and those with a mood disorder

diagnosis (major depression, anxiety, PTSD) are those most likely to experience clinical

insomnia (Qaseem, 2016). Insomnia is still vastly underreported, the five percent of patients who

do seek help, are most likely to do so with their general practice or primary care doctor (Taylor &

Dietch, 2018). Several interventions exist to address Insomnia, however, general practitioners

lack awareness of these interventions and typically use pharmaceutical interventions which are

not considered as the best treatment. Typical interventions include Cognitive Behavioral

Therapy, Psychoeducation, and hypnotic medications. Let’s examine each of these interventions

in a bit more detail.

Effective Interventions

More than fifty studies on insomnia have shown the effectiveness of Cognitive Behavior

Therapy (CBT) (Sharma, 2012). CBT has the greatest long-term impact on insomnia. It uses a

multifaceted approach typically combining relaxation therapy, stimulus control therapy,

psychoeducation, and sleep restriction therapy. While each of these techniques can be useful as a
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single approach, using them in combination greatly increases the effectiveness and produces

better outcomes in clients (Sharma, 2012). CBT is also considered the primary treatment

approach because it is unlikely to cause harm to clients. Other interventions may work but have

potential side effects. However, there is a need for more helping professionals trained in CBT

(Taylor & Dietch, 2018). Access to CBT may be limited in rural areas or waiting list may be

long in other regions. This may be a contributing factor in why CBT is still under-utilized in the

treatment of insomnia. Alternative platforms like web-based CBT interventions and group CBT

interventions still need future research but preliminary studies show these approaches also affect

change in clients living with insomnia (Sharma, 2012).

Sleep Hygiene is often utilized by general practitioners because it is a very simple

intervention and they confuse it with stimulus control therapy (Taylor & Dietich, 2018). Sleep

Hygiene therapy is a psychoeducation approach where a professional teaches the client about

healthy sleep habits and practices which contribute to restful sleep (Sharma, 2012). Subjects

included would be diet, exercise, substance use, environmental factors (such as light,

temperature, bedding) would be discussed with the client. These factors may contribute to

insomnia but are rarely the cause of it (Sharma, 2012). This makes Sleep Hygiene highly

ineffective as a single intervention. It must instead be paired with other interventions like CBT.

Stimulus control therapy is thought to be the most effective single intervention taking its roots

from learning theory. It seeks to change the client’s previous association with the bed/room as a

place of insomnia to one of restful sleep (Sharma, 2012). Stimulus control therapy does look at

environmental stimuli which can contribute to sleep or lead to wakefulness. This may be why

general practitioners confuse it with sleep hygiene (Taylor & Dietch, 2018). Stimulus therapy is

a more involved technique which lends it to be better used by those trained in behavioral therapy.
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Hypnotic medications are often prescribed as a treatment for insomnia. They can be

useful in acute or sudden onset insomnia (Taylor & Dietch, 2018). However, clinicians agree

they are not a practical long-term solution. They often do not create a lasting change but instead

only manage symptoms (Sharma, 2012). Hypnotic medications can also have dangerous side

effects, especially if used for longer periods. Side effects can include sleepwalking/driving,

accidents, dementia, tolerance and abuse (Taylor & Dietch, 2018). Patients are often more

accepting of CBT or other therapies versus relying on medications. Some populations may be

opposed to using medications due to religious or cultural beliefs. While medication may be

effective short-term, or in conjunction with other interventions like CBT it should not be thought

of as good long-term intervention for insomnia.

Motivational Interviewing was first developed in 1983 by William R. Miller as a client-

centered approach to working with those with substance use (University of Massachusetts

Amherst). It is a goal-oriented approach which helps a client find their own motivation to

overcome reluctance to create positive change. Though it is rooted in substance use disorder it is

now often used to help clients create a lifestyle change for the management of diabetes, heart

disease, asthma, food addiction or almost any situation where a client may be unsure about

creating change (University of Massachusetts Amherst). This intervention is not all that helpful

if the client is already highly motivated to create change, but it can be effectively paired with

other interventions like CBT. Motivational Interviewing is generally a brief behavioral therapy

accomplished in one to two sessions unless paired with other interventions. This single subject

design examined whether motivational interviewing could have a positive impact on an adult

client with mild insomnia.

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Methodology

The single subject design is useful for demonstrating whether a change has occurred for a

client. It is a more accessible form of research for clinicians versus group experimental designs

which generally involve more time and resources. In single-subject design the client acts as the

control (Byiers, Reichle, & Symons, 2012). It can take on various designs, but this case will be

looking at pre-experimental or an AB design. This design is flexible and easy to implement into

practice, along with being an important first step in research. However, it is not considered

experimental as it does not control for outside variables. It can show a correlation between an

intervention and change in a client but will not necessarily prove causation. Other designs would

be more useful for proving causation (Byiers, Reichle, & Symons, 2012). In this pre-

experimental (AB) single-subject design study a baseline (A) period will be measured for a

period of fourteen days. After gathering of baseline data, a motivational interview (B) will take

place and measurements will again be taken for fourteen days to determine if any noticeable

change occurred post-intervention.

Sampling

The client, a 33-year-old Caucasian male self-presented with a complaint of mild

insomnia. This would be an example of non-random, convenience sampling. A psycho-social

assessment was performed in his home and instructions were given on how to keep a sleep log.

This sleep log will serve as the baseline data or phase A of the single-subject design. The

recorded log of the client’s bedtimes shows the dependent variable. The independent variable

will be the intervention or motivational interview. Therefore, one would look for a correlation of

the motivational interview (the independent variable) affecting the dependent variable of the
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client's bedtimes. In this case, the client expressed a desire to try to fall asleep before 11 pm

eastern standard time. His baseline data showed typical bedtimes of nearly midnight or later.

Study Design and Procedures

For this study data was collected using a Samsung Smart Watch which was linked to the

S Health app for Android. These tools logged the client's bedtimes daily both prior to and post-

intervention. A baseline measure of fourteen days prior to the motivational interview was

gathered. Similarly, fourteen days of post-intervention data were gathered after the motivational

interview session. By using the assistance of technology to record the client’s bedtime there is

likely less risk to the validity of the data gathered as far as the client’s possible manipulation of

data (either consciously or unconsciously).

Graphical Presentation

Baseline Data – A Post Intervention Data - B

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Assessing Change

Looking at the graph one is left with some impressions. The over-all data trend tends to

be slightly inconsistent which would not be unexpected in a client experiencing insomnia. The

average bed-time during the baseline phase was 11:53 PM Eastern Standard Time. Following

intervention there was an hour and six-minute average drop in bedtimes, showing that the client

was successful in getting to bed at earlier times which reflects his stated goal. The average

bedtime post-intervention was 10:47 PM EST. His stated goal was to develop a habit of going to

bed prior to 11 pm EST. Post-intervention data was fairly consistent with outliers falling

predominantly on weekend dates. Outliers falling only on weekend dates versus weekdays did

lead the researcher to wonder if outside factors may be influencing the behavior and therefore the

data a bit.

Strengths and Limitations

While pre-experimental studies are easy to implement into practice, they do have some

limitations. They can help measure change within a client and help a clinician determine if a

change has occurred. Proving change has occurred can be very important to clients, clinicians,

and agencies because it shows progress. However, the pre-experiential design does not control

for outside influences, so it is hard to know if it was the intervention itself which was effective or

if other factors contributed to changes seen. During this study, the client had a significant job

change. He went from a less demanding job where he was very burnout and unhappy to a much

higher responsibility job where he reported feeling “needed”. It is hard to determine whether the

motivational interview increased his desire to get to bed earlier or if the new job that he

anticipated getting up early for brought about the changes in his behavior. Outside influences
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can cause major threats to the validity of a study. While it is possible to determine that change

did occur, it is hard to say that change was the result of the intervention when outside influences

could be the cause of change. AB single subject designs are good for their practicality for real-

life scenarios, however, it is tough if not impossible to draw conclusions which could be applied

to larger populations.

Conclusion

This pre-experimental design study showed some positive correlation between

motivational interviewing and a client living with mild insomnia. Due to the outside influence of

a job change, it was difficult to determine if the motivational interview was the cause of the

positive change in behavior. This study could inform practice in that a clinician may be more

willing to try a motivational interview in other patients with insomnia or pair it with a CBT

approach. If positive results were seen in other cases it might guide or develop further research

into the effects of motivational interviewing as an intervention for insomnia. There has been a

hypothesis that psychoeducation and CBT could be done proactively in at-risk populations or for

clients experiencing stress which could help mitigate the risk of them experiencing insomnia. A

direction of research could be exploring whether proactive motivational interviewing could be

useful for clients at risk of insomnia (like soldiers in a pre-deployment state, or patients about to

start chemotherapy).
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References

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statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American

Psychiatric Association.

Byiers, B. J., Reichle, J., & Symons, F. J. (2012). Single-Subject Experimental Design for

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doi:10.1044/1058-0360(2012/11-0036)

Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management

of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the

American College of Physicians. Annals of Internal Medicine, 165(2), 125.

doi:10.7326/m15-2175

Sharma, M. (2012). Behavioral interventions for insomnia: Theory and practice. Indian Journal

of Psychiatry, 54(4), 359. doi:10.4103/0019-5545.104825

Taylor, D. J., & Dietch, J. R. (2018). Integration of cognitive behavioral therapy for

insomnia. Journal of Psychotherapy Integration, 28(3), 269-274.

doi:10.1037/int0000133

University of Massachusetts Amherst. (n.d.). A Definition of Motivational Interviewing.

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https://www.umass.edu/studentlife/sites/default/files/documents/pdf/Motivational_Interv

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