How Stimulus Control Therapy Works
The good news is that just as your mind can become conditioned to associate the bedroom with being awake, so you can retrain it to associate the bedroom with sleep. Stimulus control therapy teaches you to control the stimuli in your environment and use it to help you sleep. This part of CBT-i helps you to gradually reduce and stop the cues which have caused the conditioned awake response, actively breaking this association along the way. Youll also be guided through replacing those behaviours with new cues which make the bedroom and being in bed a trigger for sleep.
As you work through the therapy, youll find that as you start preparing for bed at night you begin to feel tired. As you head into the bedroom and settle down for sleep, your mind and body will be prepared for sleep. You will find it much more relaxing and start to drift off far more easily. Youll also be more likely to sleep through the night. If you do wake up during the night, youll be able to cope more effectively and get back to sleep far quicker.
The document from Richard R Bootzin states: Stimulus control therapy was designed to help individuals suffering from insomnia to strengthen the bed and bedroom as cues for sleep, to weaken the bed and bedroom as cues for arousal, and to develop a consistent sleepwake schedule to help maintain improvement.
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Go To Bed Only When You Feel Sleepy
The first step makes logical sense. Why would you go to bed if you dont feel sleepy? But yet so many of us do. We like our routines, and for most of us, that means a set bed time.
Recent research has shown that how sleepy we feel actually changes from day to day. So you could go to sleep at the same time, get the same amount of sleep, and get up at the same time each day, and on different days you will feel different levels of sleepiness at night.
Instead of having a set bed time, go to bed when you feel sleepy. Have what I call a soft bed time, a time period of around 60 minutes when you aim to go to bed. Within that time period, be aware of how sleepy you feel and go to bed only when you feel sleepy enough to fall asleep.
Cognitive Behavioral Therapy For Insomnia : Stimulus Control
This set of instructions addresses conditioned arousal. It was developed by Richard Bootzin. They are designed to strengthen the bed as a cue for sleep and weaken it as a cue for wakefulness. The key instructions are:
- Establish a regular morning rise time. This will help strengthen the circadian clock regulating sleep and wakefulness. Ideally, bedtime should also be regular, but for people with insomnia it is impossible to actually fall asleep around the same time nightly. When insomnia resolves, regular bedtime can further strengthen the circadian rhythm.
- Go to bed only when sleepy. This will increase the probability that you will fall asleep quickly. It is important to distinguish between fatigue and sleepiness. Fatigue is a state of low energy, physical or mental. Sleepiness is a state of having to struggle to stay awake. Dosing off while watching TV or as a passenger in a car involve sleepiness. People with insomnia often feel tired but “wired” at bedtime.
- If unable to fall asleep, either at the beginning or in the middle of the night, get out of bed and return to bed only when sleepy again.
- Avoid excessive napping during the day. A brief nap , taken approximately 7 to 9 hours after rise time, can be refreshing and is not likely to disturb nocturnal sleep.
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The Role Of Conditioning In Therapy For Insomnia
Stimulus control therapy was created by psychologists in response to the growing habit of people seeing their bedroom as a place of fear.
If insomnia has pushed you to a point where just placing your head on your pillow makes you feel nervous and overwhelmed, then stimulus control therapy can help.
This insomnia therapy reduces the amount of time you spend awake in your bed, to correct the link between bed and slumber.
To better understand how stimulus therapy for insomnia can work, lets take a look at the Pavlov experiment.
This experiment might ring a bell for you if youve ever explored basic psychology before. Pavlov was the father of the classical conditioning concept in psychology.
The Russian scientist discovered that if you constantly feed a dog at the same time as you ring a bell, the sound of the bell will eventually cause the dog to anticipate food and salivate.
Even in the absence of food, Pavlovs dogs still salivated when the bell rang, demonstrating a conditioned response.
The same concept can apply to advanced sleep therapy.
If you teach your brain that your bed is only used for sleep, then it will eventually start to release the melatonin and other hormones required for sleep as soon as your head hits the pillow.
To support this conditioning, you need to do a few things:
Who Benefits From Cbt
The American College of Physicians recommends CBT-I as the first-line treatment for individuals whose insomnia is considered primary, secondary, or comorbid when clear psychological, cognitive, or behavioral factors are causing or worsening to the sleep problem. CBT-I is designed to treat negative psychological conditioning, hyperarousal, problematic sleep schedules, lifestyle factors, stress, problematic coping responses, poor sleep hygiene, and problematic sleep-related thoughts and beliefs.
Many of these factors, especially negative psychological conditioning and problematic sleep-related behaviors, occurs in most cases of chronic insomnia. So, insomnia should be considered as occurring with, rather than caused by, other medical or mental health problems. Because of this, CBT-I is appropriate and is recommended in most cases of chronic insomnia, even when it occurs with other medical or mental health problems.
CBT-I is beneficial in both older and younger adults. It is also beneficial for people using prescription or over-the-counter sleep medication for short or extended periods of time. CBT-I supports maintenance of satisfactory sleep during systematic tapered discontinuation of sleep medications.
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Sleep Restriction And Compression
People with insomnia often spend too much time lying in bed awake. Sleep restriction limits time spent in bed in order to reestablish a consistent sleep schedule.
This technique is intended to increase the drive to sleep and can temporarily increase daytime fatigue. It is not recommended for people with certain medical conditions that can be made worse by losing sleep, such as bipolar disorder and seizures.
Sleep restriction begins by calculating the total time spent asleep on a typical night using a sleep diary. Time in bed is then adjusted to reflect this amount, plus 30 minutes.
For example, if a person is trying to sleep 8 hours a night but only getting 5 hours, they start by adjusting their bedtime to spend 5 hours and 30 minutes in bed. Once a person spends the majority of their time in bed sleeping, they can begin gradually increasing their time in bed.
Sleep compression is a slightly different, and more gentle approach, often used with older people. Instead of immediately reducing time in bed to the amount of sleep they get on a typical night, time in bed is gradually reduced until it is reasonably close to the time they spend actually sleeping.
Does Stimulus Control Therapy Work
If this advanced sleep therapy sounds pretty straightforward thats because it is.
There are no complex guidelines to follow with stimulus control therapy.
All you need to do is commit to changing the way that you use your bed. If you stick to the guidelines above correctly, then youll begin to change your relationship with your bedroom.
Importantly, like any therapy for insomnia, its unlikely that stimulus control will automatically transform your sleep the first time that you try it.
The more time youve spent struggling with insomnia, and the more anxiety youve developed about sleep, the longer it will take for you to change your conditioning.
Remember, learned associations can be challenging to overcome.
However, with persistence, most people without underlying sleep disorder issues find that control therapy allows them to improve their sleep quality within a matter of weeks.
If youre a particularly complicated case, then your doctor might recommend working with a specialist on your stimulus control therapy too.
You can combine this process with other kinds of CBT for insomnia to accelerate your cure.
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Appendix: Guidelines For Sleeping Better At Night
The best way to treat insomnia is to identify and remedy the cause: medical, psychiatric, or other. This should be done wherever possible. It is also important, and helpful, to implement behavioral measures these are described below. None of the suggestions here is an absolute requirement however, most are based on good scientific evidence and are, therefore, best adhered to. Importantly, the guidelines need to be tailored to individual contexts what is appropriate for one patient may not be suitable for another.
During the Day
Do not nap during the day unless you have good reason to believe that doing so improves the quality of your life. If you do nap during the day, you must recognize that your nighttime sleep requirement will be correspondingly shortened.
Note. Some persons function with better efficiency if they take a short afternoon nap and one or more short daytime naps may even be desirable in elderly persons.
Exercise moderately during the day so that you are physically tired out at night.
Note. Moderate physical fatigue can be relaxing excessive physical fatigue can be counterproductive because it could result in aches and pains that interfere with sleep. Exercise too late in the evening could result in arousal that persists and prevents sleep at night.
Note. Sexual activity is an exception to the rule because its culmination results in physical and mental relaxation.
Take measures to minimize pests such as mosquitoes.
How Does Stimulus Control Work
Stimulus control therapy for insomnia is evidence-based. This means that clinical studies have confirmed that the technique works.
Stimulus control works because of the power of association. Have you heard of classical conditioning? If not, perhaps youve heard of Pavlovs experiments with dogs? Heres a good overview of those experiments:
Pavlovs dogs began to salivate as soon as they saw food because they learned that they were about to get fed. Next, the dogs began to salivate when they heard a sound that they learned to associate with getting fed. Pavlov soon learned that he could condition the dogs to produce saliva by teaching them to associate getting fed with a range of different sounds and objects.
Of course, we are not dogs but the theory is still sound!
When you were a child and you heard the ice-cream truck jingle, what happened? Your heart rate probably increased in anticipation of ice-cream. As an adult, if you get a speeding ticket you will probably notice your heart rate increase the next time you pass a police car on the road.
In other words, your body responds whenever you see or think about something that has triggered a body response in the past.
Heres a good video about this:
When it comes to sleep, if you often spend a lot of time in bed awake, your body learns that the bed is a place to be awake. If you spend a lot of time in bed tossing, turning, and worrying, then your body learns that the bed is a place for tossing, turning, and worrying.
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The Rules Of Insomnia Therapy: Using Your Bed Properly
If your doctor finds no medical reasons for your insomnia after a sleep study, stimulus control therapy will be one of the first things that they recommend.
You dont need to stay in a doctors office to use stimulus control for sleep. Instead, you just need to commit to a series of important rules.
How To Access Cbt
Now that weve discussed how stimulus control therapy works and how helpful it can be, you might be wondering how you can access it. There are a few ways you can get access to CBT-i:
- Through your doctorYou could choose to go and see your GP. You can discuss your symptoms and ask about being referred for CBT-i. You may need to advocate for yourself, which you can do by being informed, calm, and persistent. Being referred by your doctor might involve seeing a sleep specialist or attending another clinic for therapy. You may be put on a waiting list depending on where you live. In some places, you may be able to self-refer for CBT-i: this is something you can find out through your doctor. If CBT-i is not offered in your area, there are other ways you can access therapy.
- PrivatelyYou could choose to seek private CBT-i, but its important to remember that this can be a costly option. You can find a private sleep therapist by searching online. Its vital you ensure they have the proper qualifications and licences, so be sure to do your research. If your resources allow, private therapy can enable you to access CBT-i without waiting.
- OnlineYou could choose to use online CBT-i, which allows you to access insomnia treatment immediately in your own home. This tends to be a more cost-effective option, allowing you to work through therapy sessions on your smartphone, tablet, or computer at your own pace.
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Now that was an extreme reaction, but we had usefully ascertained that, yes, Rob had definitely built up a major emotional response to both the act of going to bed and the environment in which sleep was supposed to happen. Strong emotionality is to sleep what cement is to drinking water. We had to change the association back to one of calm and rest, not fear and disquiet.
Now, many of your insomnia clients wont necessarily have such a strong emotional reaction when they merely imagine going to bed. But you might be surprised how many people dont feel good at all when they think about their bedroom.
Stimulus control therapy simply entails helping change the association between the trigger and the response. We can do this by changing the environmental trigger itself, calming down your clients reaction to the environmental trigger, or both.
Treating Insomnia With Stimulus Control Conditioning
Insomnia can be difficult to deal with, and not everyone wants to take sleeping pills, so what are the other options? Difficulty falling or staying asleep can be overcome with behavioral treatment options, including something called stimulus control therapy. What is stimulus control therapy? How does it relate to general guidelines to improve sleep habits called sleep hygiene and to psychological conditioning?
To answer these questions, lets review an excerpt from UpToDatea trusted electronic medical reference used by healthcare providers and patients alike. Then, read on for additional information about what all of this means for you.
- You should spend no more than 20 minutes lying in bed trying to fall asleep.
- If you cannot fall asleep within 20 minutes, get up, go to another room and read or find another relaxing activity until you feel sleepy again. Activities such as eating, balancing your checkbook, doing housework, watching TV, or studying for a test, which “reward” you for staying awake, should be avoided.
- When you start to feel sleepy, you can return to bed. If you cannot fall asleep in another 20 minutes, repeat the process.
- Set an alarm clock and get up at the same time every day, including weekends.
- Do not take a nap during the day.
“You may not sleep much on the first night. However, sleep is more likely on succeeding nights because naps are not allowed.”
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Sleep Education And Hygiene
Sleep education involves providing information that lays a foundation for the active treatment recommendations made in SCT, SRT, CT, and RT. Education focuses on issues such as sleep architecture, sleep regulation, how insomnia develops, and ineffective sleep behaviors.
Sleep hygiene includes practices such as avoiding alcohol near bedtime and caffeine after noon, and not watching the clock when awake during the night. Older adults with difficulty staying awake in the evening before an appropriate bedtime and a wake-up time earlier than desired may benefit from evening exercise or exposure to bright light to help improve sleep quality and strengthen their circadian rhythm.
While education and hygiene are important and necessary for enhancing a patient’s understanding about the rationale behind and effectiveness of CBT-I, they are generally insufficient as a treatment on their own. Some resources for patients are shown below in Table 2.
|Table 2. Resources for Patients Who Have Insomnia|
Control And Limit Stimulation Before Going To Bed
- Complete your evening meal three hours before bedtime, particularly for those people prone to heartburn or indigestion
- Avoid caffeinated or alcoholic beverages before sleeping
- Avoid smoking for at least three hours before going to bed
- Unless your physician has directed otherwise, choose to take your medications far in advance of sleeping times, because most medications can disrupt or delay sleep
- Dont engage in physical exercise within four hours of going to sleep
- Avoid napping too close to bedtime and
- Try to avoid stressful situations before going to bed.
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