Feel Well Again Blog

Insomnia is a major challenge for a lot of Americans. Up to one-third of the adult population reports suffering from insomnia, and the prevalence of sleep problems among women and older adults is even higher.

Despite the high economic costs in terms of lost productivity and the danger of accidents resulting from a lack of sleep, the vast majority (85%) of people with insomnia remain untreated. This is largely because they are unaware of the treatment options.

Two types of treatment for insomnia have received the most attention and research support: hypnotic medications (i.e., sleeping pills) and cognitive behavioral interventions. In this article, I focus on one type of cognitive behavioral therapy for insomnia (CBT-i) called stimulus control treatment.  

What Is Insomnia And Why Cognitive Behavioral Therapy (CBT)?

Before reviewing the groundbreaking 1972 paper that continues to shape the way clinicians treat insomnia, let’s look at a definition of this sleep disorder and why cognitive behavioral therapy is a promising treatment.

Insomnia is a general clinical term that refers to a difficulty in initiating or maintaining sleep. It also happens to be the most common sleep disorder (for an overview of other sleep disorders, check out this blog article). You may have primary insomnia, which is an independent medical condition, or your insomnia may be related to another medical or psychiatric condition, which we call secondary insomnia.

If you have trouble falling asleep, staying asleep or wake up with a feeling that your sleep wasn’t restful on at least three nights a week for at least a month, then you have insomnia. Insomnia can also result from or be worsened by learned bedtime behavior patterns such as racing thoughts and ruminations.

While sleeping pills can help insomnia, they won’t work if the source of your insomnia is from poor sleep habits (erratic sleep/wake times, late night caffeine consumption, and late night electronic use, to name a few). 

They also can carry potential side effects depending on the drug and dosage used, such as weight gain, constipation, sleep walking, confusion, and grogginess during the daytime. Because of this, our clinic is a fan of behavior interventions including relaxation training, sleep hygiene, and stimulus control therapy. Such treatments are efficacious, relatively cost-effective, and yield reliable long-term benefits without the risk of side effects from potentially unnecessary medication.

Let’s now turn to the 1972 paper that introduced stimulus control therapy to the world and has been cited over 600 times since.

Stimulus Control Therapy for Insomnia

The principle behind stimulus control therapy is rather straightforward, and has been brought to bear on several theories about human habit development. 

The idea is this: When you associate your bed with sleep, you’re more likely to fall asleep when you get into bed. When you associate your bed with wakefulness (like when watching TV), worrying thoughts, or hyperarousal, you’re less likely to fall asleep when you get into bed.

The goal of stimulus control therapy, then, is to “bring sleeping under the stimulus control of [the] bed or bedroom.” In other words, if you use your bed only for sleeping, then your bed becomes a cue for your brain to fall asleep. Having a healthy bedtime routine can help facilitate a healthy circadian rhythm.

The Method

This method was first developed by Dr. Richard R. Bootzin, who was an internationally recognized pioneer of psychosocial treatments for insomnia, and one of the world’s leading figures on sleep disorders and their treatments. Bootzin first tested the idea of stimulus control treatment for insomnia on one of his students, who requested his help for treating his insomnia.

Here are the instructions Bootzin gave to his student:

1. Lie down intending to go to sleep only when you are sleepy.
2. Do not read or watch television in the bedroom (today, we would add: do not look at your phone).
3. If you find yourself unable to fall asleep, get up and go into another room. Stay up as long as you wish and then return to the bedroom to sleep.
4. If you still cannot sleep, repeat Step 3. Do this as often as necessary throughout the night.

These rules were intended to be the basis for developing permanent sleeping habits, so the patient was instructed to continue following them even after his insomnia was under control.

The Results

Stimulus control treatment was effective at controlling the patient’s insomnia within two weeks. At the beginning, he had to get out of bed and leave the room four or five times each night. By the end of the two-week trial, about half of the nights passed without him needing to get up at all. By the end of the follow up period, he was getting up once during the night less than once per week.

Of course, this was not a controlled research study, so it doesn’t have the scientific rigor of subsequent research studies (such as this one, for example) testing the effectiveness of stimulus control. Still, it is Bootzin’s seminal paper, and it was a scientific breakthrough that left a lasting impact on the practice and science of sleep medicine. Today, stimulus control is considered an essential treatment component in cognitive behavioral therapy for insomnia (CBT-i).

If you are suffering from insomnia, contact us to discuss whether stimulus control therapy or an alternative treatment option could help give you the sleep you deserve.