Stimulus control and sleep restriction are well-proven strategies to treat chronic insomnia, and they are thought to work by slightly different mechanisms. Stimulus control therapy (SCT) retrains your brain to more strongly associate bed with sleep (Bootzin & Perlis, 2011). Sleep restriction therapy (SRT) consolidates your sleep, making it less fragmented and more restorative, by giving your brain a shorter sleep window (Spielman, Chien-Ming & Glovinsky, 2011). It stands to reason that combining these two approaches will pack an even more powerful punch, as you simultaneously retrain your brain and consolidate your sleep.
Another reason to combine SCT and SRT is that there is some significant overlap in these two treatments. When you do SRT, you are in bed less and you are asleep for more of the time that you are in bed. This is right in line with the goal of SCT! Similarly, when you do SCT, you restrict your time in bed because you leave the bed when you are not sleeping. So these two treatments really complement each other.
Unfortunately, we are not aware of any research studies comparing SCT, SRT, and their combination. Therefore, we do not really know if the combination is more likely to give you better or quicker results. However, based on our experience, we encourage you to use the combined approach if you are:
By “able” we mean that exercise 5.2 led you to conclude that both SCT and SRT are safe for you, and both are possible with your sleep pattern. You already know what we mean by “willing to do it fully”! We do not suggest that you do two watered-down treatments. If you start with combined SCT-SRT and then feel that you have taken on too much, then choose either SCT or SRT and do it fully instead.
Why do we suggest the combined approach if you are willing and able to use it? In our experience, SRT often works more quickly than SCT. We often think of it as more powerful. However, SCT gives you a tool to use in the future, when you have just an occasional night of poor sleep. Imagine that treatment has gone well and you are getting fairly reliable, consolidated sleep. Then one night you have trouble falling asleep. What should you do? With SRT, there is no clear way to respond. Your sleep efficiency over the course of the week is still high, so restricting your time in bed is not necessary. It is perfectly okay to not respond to one lone night of disrupted sleep, if you can practice acceptance and not trigger an insomnia spiral. However, people who use SCT tell us that they love knowing what to do when they cannot sleep. They say that it works better for them to get out of bed than to toss and turn and allow frustration or worry to build. So combining SCT and SRT may give you the best of both worlds: a quicker response, and a tool to maintain it!
Combined SCT and SRT: Basic Recipe
As you can see, in this combined SCT-SRT program you limit your sleep window to the number of hours you are currently sleeping, and you leave your bedroom if you are awake for more than twenty minutes. Let’s say you currently get six hours of sleep on average, and you pick a sleep schedule of 12 midnight to 6 a.m. Before midnight, you will be out of your room as much as possible, using it only to prepare for bed or put laundry away, for example. You will climb into bed at midnight and give yourself up to twenty minutes to fall asleep. You will also give yourself up to twenty minutes to fall back to sleep if you wake in the middle of the night. If, at any point, you are awake for longer than twenty minutes, or if you become anxious or frustrated, you will leave the bedroom and go to a predetermined place and do something that is boring or relaxing. You will return to bed when you are sleepy. You will once again leave your bed if you are not asleep within twenty minutes. Regardless of how much or how little you have slept, you will get out of bed at 6 a.m. and will, once again, spend as little waking time as possible in your bedroom. You will not nap during the day. As your sleep knits together and you start to sleep an average of 90% of your sleep window, you will add fifteen minutes to your time in bed, up to once per week.
Notice that in this program we suggest you calculate sleep efficiency (SE) using your sleep window rather than your actual time in bed, which will be different if you get out of bed during your sleep window because of the stimulus control part of the treatment. Think of your sleep window as the time between lights out and your final rise time. In the example above, if you stick to your prescription and go to bed at midnight and get out of bed for the final time at 6 a.m. each day, then your average sleep window will be six hours. If you cannot sleep and you get up and read for an hour, you will still use six hours instead of using five hours of TIB to calculate your sleep efficiency that night. This is because we want you sleeping at least 90% of your prescribed sleep window before you increase your time in bed. If you are prescribed six hours, are out of bed for two hours, and sleep close to four hours, your SE calculated the traditional way will be over 90%, but it doesn’t actually make sense to add time in bed when you are only sleeping for two-thirds of your prescribed time!
This different way of calculating your SE is really the only thing that is different from the instructions for doing either SCT and SRT alone. Rather than repeat all of these instructions here, we would like you to read chapters 6 and 7 (if you have not already done so) before starting a combined SCT-SRT program. In those chapters you will find detailed instructions for all of the steps in this combined approach (for example, what are some activities you can do if you cannot sleep and you leave your bed during your sleep window? How should you choose your bedtime and rise time?). You will also find answers to the most common questions and challenges our clients bring to us.
Now that you have reviewed chapters 6 and 7, complete worksheet 8.1 to develop your personalized combined SCT-SRT program. Take your time and carefully consider each part of the plan. (How will you keep yourself awake for so long? Where will you go and what will you do if you cannot sleep during your sleep window?) If you need to make any preparations—such as gathering reading material or asking someone to help you get up at your rise time—do this ahead of time.
Before you start, check in with yourself. How willing are you to start this program? Can you fully commit to the plan you just developed? If you can commit to it tonight, that is enough. You can commit again tomorrow, and the day after, and the day after that.
Combined SCT and SRT: Basic Recipe
My Prescription: My pretreatment average total sleep time = hours.
| Start Date | TIB (hrs) | Bedtime | Rise Time | Start Date | TIB (hrs) | Bedtime | Rise Time |
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1. |
5. |
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2. |
6. |
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3. |
7. |
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4. |
8. |
Strategies for staying awake until my prescribed bedtime:
Strategies for getting up at my prescribed wake time:
Activities I can do in the extra time I’m spending out of bed:
If I leave my bed because I’m not sleeping during my sleep window…
This is where in my home I will go:
These are activities I will engage in (be specific!):
Preparations to make ahead of time (for example, set multiple alarms, put low-watt bulb in lamp):
Strategies for avoiding naps or nodding off:
What I will have to give up (for example, “sleeping in on weekends,” “falling asleep for one last stretch right around my wake time,” “the comfort of going to sleep to the TV”):
What discomfort I may experience (for example, “I may be even more tired at first,” “Loneliness being up alone late at night or early in the morning,” “Guilt for disturbing my partner”):
Why I’m willing to give these things up (for now) and experience these discomforts (for now):
Once your combined SCT-SRT program is under way, you are welcome to start working on sleep hygiene or the cognitive strategies that are part of your personalized treatment plan (worksheet 5.1).
Make sure you continue to track your sleep with the sleep log. Mark when you get into and out of bed (in the beginning, middle, and end of the night). Each morning, estimate the total number of hours you slept. This will help you evaluate how closely you are following the program, and also will help you determine when you should increase (or decrease) the amount of time you spend in bed.
At the end of each week, calculate your averages and use your Sleep Log Summary form to help you track your sleep and your treatments. Use the information in the preceding two chapters and in chapter 13 to help you decide what to do if your sleep is not improving.
You have taken on an ambitious treatment program. If you do it fully, you may be really tired at first, but there is an excellent chance that your sleep will improve and you will soon feel much better. Good luck!