What is Stimulus Control Therapy for Insomnia?
Cognitive behavioural therapy for insomnia (CBT-i) is the primary treatment recommended for insomnia. This article will take a closer look at one of the methods used during CBT-i: stimulus control therapy. We’ll cover all you need to know about the method, along with how to access CBT-i.
What is CBT-i?
CBT-i is a psychological therapy based on the connection between your thoughts and your actions. The therapy is structured in a very specific way to help you address thoughts and behaviours which are contributing to your insomnia. Through sessions of CBT-i you’ll learn to replace these negative patterns with positive thoughts and behaviours to help you overcome your insomnia and get the restful sleep you need.
The National Sleep Foundation explains: “Thoughts and feelings about sleep are examined and tested to see if they’re accurate, while behaviours are examined to determine if they promote sleep. A provider will then clarify or reframe misconceptions and challenges in a way that is more conducive to restful sleep.”
CBT-i achieves this vital change by using a number of methods, stimulus control therapy being one of them. Each method is important in its own way: they are brought together to get the best results for patients. CBT-i is evidence-based, meaning that it has been proven to work. Once you’ve completed a course of CBT-i, you will have gained the tools you need to continue sleeping restfully. The aim is to give you these skills so that even if you face a setback, you know how to cope with it. Therefore, CBT-i produces long term results.
The theory of stimulus control therapy
The Stimulus Control Model
A stimulus is anything, either internal or in your external environment, which causes a response within you. Stimulus control therapy is based on the Stimulus Control Model of sleep, which suggests that insomnia is caused by stimuli within our environment. The model was developed by a scientist called Richard R. Bootzin in 1972.
Essentially, the model shows that stimuli we experience within a specific environment, such as in our bedroom, can create an association in our mind between that environment and either a state of wakefulness or a state of relaxation and sleep. Therefore, stimuli which evoke an ‘awake’ response in the bedroom contribute to insomnia. By controlling the stimuli in our bedroom environment we can create a relaxed state, tackling insomnia and allowing us to sleep peacefully in the long term.
The stimulus control model is similar to classical conditioning. Classical conditioning is a proven theory developed by a scientist called Ivan Pavlov in 1927. He made his discovery during an experiment about dogs and how they react when they are being served food. During his experiment, the dogs began to salivate when they saw food because they knew they were going to be fed. Pavlov then figured out he could create the same response using other stimuli to indicate that they were going to be fed. For example, he taught (or ‘conditioned’) them to associate feeding time with a random sound or an object and they would salivate in the same way.
Of course, we’re not dogs! However, the theory has been proven to apply in humans too. Classical conditioning shows that we can learn to associate anything with a particular trigger and our body will respond accordingly. This is also known as a conditioned response. Insomnia itself can become a conditioned response.
If we’ve learnt to associate turning the light off in the bedroom (the trigger) on the way to bed with an ‘awake’ state for example, then our body will respond to that trigger by keeping us awake (the conditioned response). The same applies to other ‘wakeful’ stimuli like us lying awake in bed tossing and turning instead of sleeping. This document states: “The process of going to bed has developed into an automatic trigger for negative emotions. This is conditioned insomnia. Many insomniacs report feeling very tired before bed but then becoming alert when they go to bed. This is a sign that conditioned insomnia is present.”
There are many stimuli which can create that ‘awake’ association between the bedroom and sleep. For example, regularly watching the TV or listening to loud, high energy music in the bedroom can make you feel more awake. Likewise working, studying, or exercising in your bedroom builds the association that your brain and body should be active, awake, and alert when you’re in the bedroom. If you have stressful conversations or arguments in your bedroom regularly, this could have the same effect.
This document on stimulus control therapy by Richard R. Bootzin explains, “Cues, both external and internal to the individual, that are associated with the onset of sleep become discriminative stimuli for the occurrence of reinforcement. Consequently, difficulty in falling asleep may be due to inadequate stimulus control.”
However, it’s not just these more obvious active stimuli which can create that association. If your insomnia has stemmed from another cause (such as losing a loved one, going through a loss, or experiencing a time of high stress) sometimes even after these events have passed your insomnia continues. This is because your brain has learnt that you stay awake when you’re in the bedroom.
Stress and anxiety around bedtime can create the same response. We’ve all been there. If you have a few nights of restless sleep, it’s really common to start feeling worried and frustrated. You might start anticipating not being able to sleep, for example thinking ‘I’m never going to be able to sleep tonight’ or ‘tonight will be the same as last night’. Sleep deprivation can also impact your mood negatively which only adds to this sense of foreboding. Unfortunately, this causes anxiety around bedtime which actually makes you feel more awake when you head to bed and makes you less likely to sleep.
Similarly, it’s common to find lying awake at night very frustrating. You might start clock watching and thinking ‘if I go to sleep now I’ll only get 4 hours of sleep’ and so on. You may think about all you have to do the next day and worry about how your fatigue is going to affect your performance. You may start having very negative thoughts and become increasingly frustrated and restless.
Understandably, all of this stress at bedtime only makes you less likely to sleep. It actually reinforces to your brain that you ‘should’ be awake in bed. When you go to bed from then on, your bedtime routine will become cues which trigger your brain to feel more awake, rather than to get you ready for sleep. You might feel tired and ready to sleep before you head to bed, but once you get into bed start to feel wide awake. This is because your insomnia has become conditioned. This report on the topic states: “The bed, bedroom, turning the lights out and attempting to go to sleep has become the stimulus that triggers negative emotions such as frustration and worry that will increase wakefulness and delay sleep. The process of going to bed has developed into an automatic trigger for negative emotions. This is conditioned insomnia.”
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. You’ll 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, you’ll 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. You’ll also be more likely to sleep through the night. If you do wake up during the night, you’ll 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 sleep–wake schedule to help maintain improvement.”
Steps of stimulus control therapy
There are a few steps which are used during stimulus control therapy to create and strengthen that all-important association between the bedroom and sleep. Each step is important. It’s vital that during CBT-i you put your all into the therapy and carry out the steps required when you’re at home. Stick to these steps consistently for a number of weeks to start getting the results you need.
A regular wakeup time
Our circadian rhythm is our internal body clock. It uses cues like daylight and darkness to assess and regulate when we should be awake and when we should be asleep. Many people with insomnia begin to stay in bed later in the morning to try to catch up on sleep. Unfortunately, this can throw off your circadian rhythm. Having a consistent ‘wakeup time’ each morning helps to regulate your circadian rhythm. This document explains that, “a consistent schedule helps both strengthen cues for sleep and reduce daytime problems associated with sleep disturbance.”
It’s crucial to set an alarm and get up around the same time each morning, regardless of how much (or little) sleep you’ve had the night before. It can also be very helpful to get out into the daylight as much as possible during the day. You can choose a wakeup time which is realistic for you and fits in with your lifestyle to help you maintain consistency.
Keeping the bedroom a sanctuary for sleep
To ensure you maintain the association between the bedroom and sleep, it’s imperative you keep your bedroom for sleep, relaxation, and sex only. Avoid any actions in the bedroom which are going to make you feel more awake, such as watching TV; working; using your phone; having stressful conversations; exercising; eating; or playing games.
It’s also really important that you don’t sleep anywhere other than in your bed to keep this association strong. For example, don’t doze off on the sofa as it gets close to bedtime: instead, ensure you head to bed when you’re feeling tired. This article emphasises this: “This becomes a problem because when you sleep in a place other than the bed, you are creating an association between sleep and non-sleeping environments.”
Only going to bed when tired
We often go to bed based on how much sleep we think we need before we need to get up in the morning. This seems completely logical, but if you’re struggling with insomnia, this only adds pressure. Instead, this step of the therapy teaches you to start listening to your internal cues to figure out when to go to bed.
It’s really important that you only go to bed when you really feel drowsy and ready for sleep, even if this is later at night. You shouldn’t go to bed before you feel really tired, because this will cause you to be awake in bed and weaken the association the therapy is aiming for. Going to bed when you feel tired increases the chances that you will fall asleep quickly.
This article from Stanford Medicine explains that it’s vital to understand the difference between fatigue (often caused by your insomnia) and sleepiness: “Fatigue is a state of low energy, physical or mental. Sleepiness is a state of having to struggle to stay awake. Dozing off while watching TV or as a passenger in a car involves sleepiness. People with insomnia often feel tired but “wired” (i.e. not sleepy) at bedtime.” Understanding this difference and learning to recognise the signs of true tiredness within yourself will help you to go to bed at the appropriate time.
Getting up when you can’t sleep
If you go to bed and find that you can’t sleep after 15 to 20 minutes, you should get up and move to another room. You should also do this if you wake up during the night and can’t get back to sleep. Lying awake in bed for longer than this can lead to frustration and restlessness, as well as weakening the association between the bed and sleep that you’re trying to build.
When you go to another room, ensure you do something relaxing rather than something which is going to wake you up more. You could read a book; listen to an audiobook; or listen to relaxing music for example. It’s a good idea to keep the lights dimmed and any volume turned low. You should focus on relaxation and try not to worry about sleep. When you start to feel sleepy again, you can go back to bed and see if you drift off. You can do this as many times as you need to ensure you aren’t lying awake in bed for too long.
Although short naps during the day are proven to boost energy and concentration, it’s important that you don’t nap during stimulus control therapy. This applies even if you have not slept much the night before. Avoiding naps during the day will help you to fall asleep more easily at bedtime.
How will I feel during stimulus control therapy?
You might be wondering what the experience of following all of these steps will actually be like. For the first week or even two, you are likely to find that you are still unable to sleep so you will need to get up and move into another room following the steps provided. You might need to do this a few times in one night. Since you will still be getting up at the same time each morning even when you haven’t slept well, you will find that you are feeling more sleepy than usual during this time.
This doesn’t mean the therapy isn’t working so don’t lose heart. It simply takes some time to begin seeing results. It’s vital you don’t stop the therapy or skip steps if you find this is the case: focus on the end goal. It can be helpful to know that this is normal. When you keep following the steps, this build-up of sleepiness will actually help you to start falling asleep more quickly. As this happens, things will begin to click into place. The more times you fall asleep after turning the light off and climbing into bed, the more your mind will build that association you’re working towards.
As your mind begins to connect the bedroom and your bedtime routine with falling asleep, you’ll gradually find that you are sleeping more restfully. It will take fewer times getting out of bed and moving rooms for you to fall asleep. You’ll start getting more hours of restful sleep. With this, you will begin feeling more refreshed in the morning and more energized throughout the day. You might even start looking forward to bedtime rather than worrying about it.
The therapy will help to get your sleeping patterns back on track. Even as you start feeling more confident about your sleeping habits, it’s important you stick to the steps exactly until the therapy is complete. As your course of CBT-i comes to an end, you’ll be taught how to maintain the positive habits you’ve built moving forward, even when you are more flexible with your sleeping habits or if you have setbacks. This will allow you to gain long term results and keep sleeping peacefully even after the therapy is over.
How to access CBT-i
Now that we’ve 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 it’s important to remember that this can be a costly option. You can find a private sleep therapist by searching online. It’s 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.
Take your time to choose the right option for you depending on what’s available in your area; your financial resources; and which way of accessing therapy fits in best with your lifestyle. However you get the therapy you need, if you have long term insomnia make sure you do reach out. You don’t have to struggle through sleepless nights. With the right treatment, you can start sleeping peacefully again!
Rob Newsom, (2020), “Cognitive Behavioral Therapy for Insomnia (CBT-I)”. National Sleep Foundation.
Drug and Alcohol Services South Australia, (2017), “Insomnia Management Kit: Stimulus Control Therapy”.
Richard R. Bootzin, Michael L. Perlis, (2011), “Stimulus Control Therapy”. BSM Treatment Protocols for Insomnia, Chapter 2: Behavioral Treatments for Sleep Disorders, Elsevier Inc.
Martin Reed, MEd, (2019), “Stimulus Control Therapy for Insomnia”. Insomnia Coach.
Stanford Health Care, (2020), “Stimulus Control and CBTI”.