Let’s take a typical person who is sleeping really well. Say she averages eight hours of sleep each night, and likes to read in bed until her eyes become so heavy she cannot read anymore, usually about thirty minutes. She turns out the lights and falls asleep quickly; she sleeps through the night with no awakenings, except perhaps getting up for a minute to go to the bathroom. She is in bed eight and a half hours, and sleeps for eight, which means she is sleeping 94% of the time that she is in bed. Because of this, her brain very strongly associates the bed with sleep. She can afford to do something else in bed (read) without disturbing her sleep, because over 90% of the time she is in bed, she is sleeping. At an unconscious level, her brain knows: bed = sleep. When she gets into bed at night, her brain starts to prepare for sleep. What else would it do? The bed is for sleep, right?
Now let’s say this same woman has some stressful life changes and no longer falls asleep quickly when she turns out the lights. Instead, her mind gets busy: Will I do okay in this new job position? What if they decide it was a mistake to promote me? How will Tom and the kids handle the fact that I’m working more hours? Melissa is really starting to struggle in school. How will I stay on top of that when I’m working more? Am I being a bad mom? I am a bad mom. Like yesterday—why did I yell at Ryan? He wasn’t really doing anything so wrong… . And on and on her mind chatters as she tries to fall asleep. Now she is only sleeping about six hours each night. By nighttime she is exhausted, so she starts to go to bed earlier, hoping to catch more sleep. Instead of being in bed for eight and a half hours, she is in bed nine, and then, as time goes on, nine and a half hours. She does get a little more sleep, but still only about six and a half hours. Now she is only sleeping 68%, or two-thirds, of the time that she is in bed. And not only does she read and sleep in bed, she also worries and lies awake in bed. Bed no longer equals sleep. Bed = sleep or reading or worrying or lying awake. When she gets into bed at night, her brain does not automatically prepare for sleep. Why should it? It may be time to read or worry or just lie there, rather than sleep. Over time, her sleep problems may get even worse. When she wakes in the middle of the night to go to the bathroom, her mind may get activated when she climbs back into bed. Now she not only has trouble falling asleep in the beginning of the night, but also has long awakenings in the middle of the night.
Stimulus control therapy (SCT) is a program that can help you retrain your brain to strongly pair bed with sleep. To do this, we want to minimize the link between bed and everything else, including other activities (such as reading or watching television) and internal states of arousal (such as frustration, stress, fear, or worry). You want to give your brain and body a smaller menu of options when you hit the bed. We also want to weaken the association between sleep and everywhere other than bed. That is, you will use your bed only for sleep and sex, and you will sleep only in bed. SCT was the first behavioral program developed to treat insomnia (Bootzin & Perlis, 2011), and we know both from our clinical experience and from well-controlled research studies that it works (Morin et al., 2006).
As we said in chapter 5, both stimulus control and sleep restriction are likely to work for you, so we usually suggest picking the one you are most willing to do fully. However, sometimes one treatment is a better fit, based on your sleep pattern. Here are some clues that SCT is likely to work well for you:
We suggest you start with sleep restriction instead of SCT if:
Stimulus Control Therapy: Basic Recipe
Let’s take a much closer look at each step. Many times we meet people who think they have done SCT, but upon further questioning we learn they missed some of the nuances. In our experience, these nuances are important, so we want to hold your hand as much as possible to ensure that you have the best chance of benefiting from your SCT program!
Remember, we want the bed to cue your brain to sleep, and only sleep. Take stock—what else do you do in your bed or bedroom? Do you watch TV? Use a smartphone, tablet, or computer? Read? Talk with your bed partner? Do work or pay bills? Do you lie in bed and ruminate (think about the past again, and again, and again), worry, plan, problem-solve, or fantasize?
If you answered yes to any of these, take some time to figure out where you can do these activities other than your bedroom. Designate a new “home” for your electronic devices. Pick a spot in another room where you can read, work, or pay bills. Use “designated worry time” (chapter 11) to move your thinking to another time and place. Why is sex allowed but nothing else? Bootzin and Perlis (2011, 24) explain that most of us are “just not very creative about where we have sex”!
This is a little more complicated than it sounds. We want you to go to bed when you are sleepy so that it is more likely that you will fall asleep quickly (remember, we’re shooting for bed = sleep). However, a consistent bedtime does help. Therefore, we encourage you to pick a target bedtime, and set yourself up to be sleepy by that time each night: start to wind down about sixty minutes earlier and complete your bedtime routine (such as personal hygiene and changing into pajamas) as if you are going to get into bed at your target time. If you are sleepy, get into bed and turn out the lights. If you are not, stay out of the bedroom and do something that is likely to help you get sleepy, and go to bed once you are sleepy.
There is an exception to this guideline: some people do not feel sleepy until they lie down in a dark room. If this sounds like you, you can experiment by going to bed at your target bedtime each night, regardless of how sleepy you are. If you don’t fall asleep within about twenty minutes, you will get up (see step 3).
The original instructions for SCT state that you should leave the bed if you are awake for ten minutes (Bootzin & Perlis, 2011). We suggest that you leave the bedroom after twenty minutes to try to strike a balance. On the one hand, we want to limit the amount of time you are in bed awake. On the other hand, it is completely normal for it to take up to twenty minutes to fall asleep, and we don’t want to set up unrealistic expectations. Given our primary goal of retraining your brain, you can absolutely get up sooner if you are so alert, annoyed, or anxious that you know sleep isn’t coming anytime soon.
Here are a few additional pointers. Worksheet 6.1 guides you in establishing a specific plan for where you will go and what you will do if you are not sleeping.
There is no designated amount of time to stay out of bed. You may feel sleepy and return to bed after just a few minutes, or it may take hours, or it may not happen at all before your wake time. As soon as you notice yourself feeling sleepy, return to bed and give yourself up to twenty minutes to fall asleep.
Just like going to bed in the beginning of the night, there is one exception. If you know that you do not get sleepy until you lie down in a dark room, then you may want to return to bed after a set amount of time, such as twenty minutes.
Remember, part of strengthening the connection between bed and sleep is to sleep only in bed. Therefore, even if moving to the bedroom gets you more alert, in the long term SCT will work better if you don’t fall asleep elsewhere.
On any given night, you may get up and go back to bed multiple times, once, or not at all.
We often say that if you are only willing to do one thing to help your sleep, have a consistent wake time. The importance of this step cannot be overstated!
Fixing your wake time will help you establish a regular sleep-wake rhythm, which supports healthy sleep and leads to less daytime sleepiness (Manber et al., 1996). Also, if you stay in bed later some mornings, fewer hours will have passed and your sleep drive will be lower at your target bedtime the next night, possibly making it harder to fall asleep quickly.
The standard SCT instructions do say that you can “sleep in” up to one hour later on non-work days (Bootzin & Perlis, 2011). We generally encourage you not to do this, so you can harness the full power of a consistent sleep-wake schedule. We are most likely to support a later rising time on non-work days if you (1) have to wake up earlier than your natural rhythm on work days, and (2) are getting significantly less sleep than you need (as opposed to cobbling together the right amount of sleep, but in disjointed fashion). In these cases, the extra hour of sleep two mornings a week can make you less tired, while your overall “sleep debt” will help you fall asleep at your target bedtime even after having slept in. If you try to sleep later on non-work days and notice that you sleep worse the next night, we encourage you to have a consistent wake time every day.
In setting your target bedtime and consistent wake time, we encourage you to choose times that give you a “sleep window” of no more than the total amount of sleep you think you need each night. For example, if you need eight hours of sleep, choose 10:30 p.m.–6:30 a.m., not 9:30 p.m.–7 a.m. Because you have come to expect to be awake in the middle of the night, it is natural to give yourself a larger sleep window. However, this tends to backfire, as you will see if you read about sleep restriction or the combination of SCT and SRT.
Naps deprive you of the opportunity to harness the power of sleep deprivation to help you fall asleep quickly and to stay asleep at night. Also, sleeping during the day may weaken the association between nighttime and sleep, which you want to strengthen. Finally, often when people nap during the day they do not do it in their beds. Remember, to strengthen the link between bed and sleep, you should sleep only in bed.
“But I’ve always read in bed and I love it! Do I really have to give it up forever?”
First, you don’t have to do anything. And telling yourself that you “have to” can actually get in the way. But you may choose to follow this guideline because you have hope that this method will work!
And, no, it does not have to be forever. We encourage people to think of it as “working a program.” Right now you are doing stimulus control, and we encourage you to do it fully to give it the best chance of working. Once you are sleeping better, you may choose to go back to reading in bed. If you keep sleeping well, great! If your sleep starts to get worse, you probably will decide it is worth it to do your reading elsewhere. A lot of the people we have worked with have been surprised how easy it is to read or watch television (or do whatever they were doing in bed) somewhere else, and then move to the bed when it is time to sleep. You do not have to stop doing what you currently do right before bed. We are just suggesting you do it somewhere other than the bedroom.
“What’s wrong with napping? Entire cultures revolve around a midday siesta!”
Just like the instruction to not read or do anything else in bed, we aren’t asking you to give up naps forever. But napping during the day may weaken the connection between sleep and night. So while you are working a stimulus control program to treat your nighttime insomnia, we want you to sleep only at night. Also, you may remember from chapter 2 that your sleep drive will increase the longer you are awake, and will be partially discharged by any sleep you get; we want your sleep drive to be as high as possible at your target bedtime to facilitate falling asleep quickly.
“I have no place other than my bedroom.”
We have worked with people who live in studio apartments and people who are trying to stick to stimulus control while staying at hotels. Although you will ideally use your bedroom only for sleep and sex, you can still do stimulus control even in the tightest of quarters. For example, one woman we worked with used one side of her queen-sized bed for reading and the other for sleeping! Others have gotten creative by setting up a cozy spot on the floor with some large pillows. One man who often travels got in the habit of looking for a chair on his floor of the hotel (he usually found one by the elevators); if he needed to leave his bed, he retreated to the chair with his book (and room key!). Another client padded the bathtub with blankets and pillows and read in there while her family slept in their shared hotel room on vacation.
“Even when I’m sleeping well it takes me thirty minutes to fall asleep. Should I still get up after twenty minutes?”
Most clinicians would suggest that you still get up within twenty minutes, thinking that any longer than that gives you too much time to associate bed with wakefulness. We have mixed feelings about this because we want to support your natural sleep rhythms and don’t want to overpathologize it if you take thirty minutes to fall asleep. We generally suggest that people do an experiment and see what works. If you can be in bed for thirty minutes and not feel frustrated or anxious about the fact that you are not yet sleeping, then it may be reasonable to do this in the beginning of the night, but to give yourself less time to fall asleep if you wake in the middle of the night. On the other hand, we suggest you get up sooner if you are starting to get frustrated or anxious.
“I never really feel sleepy. When should I go (or return) to bed?” (Or: “Paying attention to whether I’m sleepy enough to return to bed is getting me more amped up. What should I do?”)
If “sleepy” is a foreign concept to you, go to bed at your target bedtime in the beginning of the night. First, though, think carefully about whether that target bedtime is realistic given your natural sleep-wake (circadian) rhythm. If you know that you are a “night owl,” we would suggest setting your bedtime after 10 p.m. even if you have to get up early for daytime obligations. If you start to sleep the entire time you are in bed but are not getting enough sleep, you can start to move your bedtime earlier in small increments, to see if you can adjust your clock (see appendix A for more information on shifting your clock).
Regarding when to return to bed after leaving it if you don’t tend to feel sleepy or if you get anxious scanning your body for signs of sleepiness, consider using twenty minutes as a rule of thumb. You’ll get out of bed again if it becomes clear that you are not going to fall asleep quickly.
“I’m exhausted all the time. What do you mean when you say I should go to bed when sleepy?”
Being tired or exhausted is different than being sleepy. By “sleepy” we mean that you feel as if you could fall asleep. Additional signs of sleepiness include yawning, heavy or droopy eyes, or head-nodding.
“Given how sleep deprived I am, shouldn’t I rest in bed? Even if I’m not fully asleep, at least I’m not fully awake and alert either!”
If you rest in bed when not sleeping, you may feel better the next day, but this is a very short-term benefit, with the risk of feeding the insomnia spiral in the long term. Plus, most people we have worked with don’t actually feel much better resting in bed; their minds just tell them that surely they will feel worse if they are spending less time in bed! You can use the fatigue ratings on your sleep log to look at the data and see if you do feel significantly better when you rest in bed. (However, see below for some information on why you may, indeed, feel worse when you first start SCT.)
“I’m fighting off a cold or flu. What should I do?”
Our bodies do need more rest when we are sick or getting sick. Try to give your body that rest while keeping the basic principles in place: rest on a couch or chair; sleep in bed. If you are sleeping a lot, you will be in bed a lot. If you need a lot of rest but can’t sleep, you will be on the couch a lot.
“I don’t look at the clock when I wake up in the middle of the night because it makes me anxious or alert. How will I know if I’ve been awake for twenty minutes?”
Although you can use your instinctive sense of how much time has passed, most people are not very accurate. We suggest having a stopwatch at the ready. When you awaken, reach out (ideally with eyes still closed) and start it. You can check it to see how much time has elapsed (without seeing the time) when you think it is time to leave the bed.
“I’m really enjoying spending less time in bed, and more time [reading, listening to podcasts, watching movies, being productive …]. Is this a problem?”
It depends. If you are simply recapturing time when it is normal for you to be awake, celebrate your freedom from the tyranny of insomnia! Even if you are not yet sleeping better, at least you are giving up less for insomnia; it is having less control over your life. This is a wonderful thing! However, if you are really enjoying having a two-hour stretch in the middle of the night to have the house to yourself, do something relaxing, or get stuff done, then you may be training your brain to be awake during hours you want it to be asleep.
“I tend to eat if I’m up in the middle of the night. Is that okay?”
It is best not to train your body to expect food during your sleep period. Do your best to consume enough calories during the day that your body is not needing fuel overnight. This may mean having a small snack before bed (see chapter 9 for more about this). If you occasionally are too hungry to sleep, it will help to have a snack. However, try not to make this a habit.
“I just don’t want to [give up other activities in bed; get out of bed if not sleeping]!”
You don’t have to want to do a particular thing in order to do it. Try this exercise: say three times “I don’t want to raise my arm.” On the second time, start to raise your arm; have it fully in the air by the time you are done with the third round. Were you able to raise your arm even though your mind told you that you didn’t want to? This may seem silly, but we encourage you to practice this throughout the day: say “I don’t want to open the door” as you open it, or “I don’t want to turn off the light” as you turn it off. (Similarly, if you think I can’t get out of bed, do the same exercises saying “I can’t raise my arm” and “I can’t open the door.”) Get practice doing things regardless of what your mind says about wanting or being able to do them. If you simply are not willing to follow the SCT guidelines, then you can consider sleep restriction. If this is not an option (based on the exercises in the last chapter, or because you aren’t willing to do that either), then you can start with cognitive strategies, especially working with the thoughts that are interfering with your willingness to do the behavioral programs.
“I’m really worried that I’ll be too tired to do what I have to do, or that getting less rest is dangerous to my health.”
You may (or may not) feel worse before you feel better (see below). We encourage you to consider this possibility in your planning, both in terms of timing and for safety. For example, if you have a really important deadline or event next week, you may decide to wait to start this program until you are on the other side of it. If you are worried about whether it will be safe for you to drive, consider asking other people for rides, taking public transportation, or walking. If you work as a bus driver or a long-distance truck driver (for example), you may decide to start the program during a week off, to see if you are more sleepy and assess whether or not it is safe to work while doing the program.
“I’m trying to do the program, but sometimes I fall asleep on the couch [in the morning after my wake time, at midday, in the early evening]. I’m just so tired!”
We understand. Here are some things that have helped some of our clients stay awake when they aren’t supposed to be sleeping: sit rather than reclining or lying down; hold a glass full of ice—you will get pretty quick feedback if you start to fall asleep; enlist the help of a housemate if someone else is up with you; if your eyes start to close, get up and leave the house (walk around the block, visit a friend) or do some jumping jacks or go up and down a flight of stairs.
You may be wondering how long it will take for this treatment to work. Your sleep may improve almost immediately: just knowing that there is a plan and that you won’t be lying awake in bed for hours may give you tremendous relief, and with this relief will come decreased physical arousal and increased ability to sleep. Just having the plan is so powerful for some people that they rarely have to leave their bed. Or you may experience quick improvement simply because you have recaptured hours of your life that you had given over to insomnia. Even if you are not sleeping more, by being out of bed and spending more time doing enjoyable activities, you may feel a lot better.
For most people, though, improvement takes more time. The process of retraining your brain may take several weeks. The first few nights you will be adjusting to a new way of doing things, and you may even feel a little anxious about the treatment, so you may sleep even worse than usual. It is at this point that people often call us seeking some reassurance. Our general response is that it is normal to be anxious or worried, and we have very high confidence that the program will work if you do it fully and stick with it. We want to encourage you in this way, too.
You also may feel worse initially because you may actually get less sleep at first. Let’s say you get out of bed because you are not sleeping and you return to bed thirty minutes later. It is possible that you would have fallen asleep in just five minutes if you had stayed in bed, in which case doing SCT cost you twenty-five minutes of sleep. Are you feeling anxious just reading this? We know it can be hard to risk precious minutes of sleep when you are struggling with chronic insomnia. Remember that you are reading this book because what you are currently doing is not working. Are you willing to experience more short-term pain for long-term gain? We don’t say this flippantly. We know how hard it can be. We are asking you to do this hard work because we have seen people who have suffered the discomfort of insomnia for years or even decades have dramatic improvement when they were willing to feel even worse at first.
Whether you improve quickly or it takes weeks, your improvement may not be linear. You may “take two steps forward and one step back.” Try this exercise: stand up, and pick a destination about ten feet from you. Take two steps toward your destination, then one step back toward where you started. If you keep doing this, where do you end up? It may not be as quick, and it may take more effort compared with constant forward motion, but you will still get to your destination if you persist.
How you respond to a setback can make all the difference in where you end up. If you respond with fear or extreme frustration, you will trigger more physical arousal and have a harder time getting back to sleep that night or getting to sleep the next night. You also may give up on the treatment program all together. This reaction to what could have been a temporary setback can get you stuck right back where you started. On the other hand, if you can practice acceptance and surrender to whatever this night brings (chapter 4) and stick with the program, there is a good chance the backward step will be followed by another two forward.
Use worksheet 6.1 to develop your personalized SCT plan. Really think about each part of the plan. (Where will you go? What will you do?) Set yourself up for success by making the necessary preparations. After you complete the worksheet, ask yourself if you are willing to commit to the plan you just made. You need not commit for weeks. Are you willing to commit to your SCT plan for the next twenty-four hours?
Stimulus Control: Basic Recipe
Where in my home I will go:
Activities I will engage in (be specific!):
Preparations to make ahead of time (for example, put low-watt bulb in table lamp, select book):
My target bedtime: My consistent wake time:
Strategies for avoiding naps or nodding off:
What I will have to give up (for example, “the comfort of going to sleep to the sound of the TV,” “the solitude I get from spending time in my room,” “sleeping in on weekends”):
What discomfort I may experience (for example, “I may be even more tired at first,” “I may be really sleepy without my afternoon nap or sleeping in on weekends,” “Guilt for disturbing my bed partner”):
Why I’m willing to give these things up (for now) and experience these discomforts (for now):
Once your SCT program is under way, you may want to start working on the other treatment elements that you selected on worksheet 5.1. But don’t let that distract you from your SCT program: remember, we would rather you do one treatment component fully than do several parts of the treatment in watered-down fashion.
Continue to track your sleep by completing the sleep log each night. As instructed, use arrows to track when you get in and out of bed. This will help you evaluate how closely you are following the program. At the end of each week, calculate your average total sleep time, time in bed, and sleep efficiency. Also record your weekly averages on your Sleep Log Summary (worksheet 5.2 or 5.3), and use this worksheet to track when you start SCT and other parts of your treatment program.
In chapter 13 we will help you thoroughly evaluate your treatment program after six to eight weeks. But you probably will want some feedback before then. Each week, take a few minutes to look at the data you are collecting. Is your total sleep time going up even a little bit compared with the weeks before you started the program? Is your sleep less fitful (are there more solid and fewer squiggly lines on your sleep log)? Are you falling asleep more quickly? Are you spending less time awake in the middle of the night? How are you feeling during the day?
We encourage you to stick with SCT for several weeks even if you are not seeing any obvious improvements. It can take some time for your brain to more readily pair bed and sleep. After all, it probably has had months or years of associating bed with insomnia! Research studies usually test a six-week treatment program, so do not give up too early. Also, you may get better results when you add to SCT other parts of your treatment program, such as cognitive strategies.
We also encourage you to look each week at how closely you are following the SCT instructions. Review the instructions and look closely at your sleep logs. Are there stretches of greater than twenty minutes when you are in bed awake? Do you have some notes indicating that you slept on the couch? Is your wake time consistent, or do you have days of sleeping in or going back to bed after your designated wake time? Are you engaging in activities that are stimulating and keeping you awake? We have been surprised how often people think they are doing the treatment when they actually are not following the guidelines very closely.
If your sleep is not improving, or not improving as quickly as you would like, the first thing we recommend is that you do the program even more fully, if there is any room at all for improvement. Are you willing to recommit to your SCT program?
If you follow SCT fully for three to four weeks and are seeing no benefit at all, then it may be time to switch to or add sleep restriction therapy. You also can consider switching to SRT if you are not willing to do SCT fully. If SRT is not a safe option for you, or if you also are unwilling to do that treatment, then you can turn your attention to cognitive strategies. Or this may be a good time to seek the support of a professional trained in CBT-I.
Are you ready to jump in? Good luck with this part of your adventure!