Stimulus Control is a Cognitive Behavioral Therapy (CBT) component, for the treatment of insomnia. Its main target is the deconstruction of the classical conditioning responses which lead to conditioned arousal.
Its action is double-pronged. On the one hand, it breaks up the conditioned, conscious or subconscious “pairing” of the bed and bedroom with arousal and insomnia. On the other hand, stimulus control re-establishes the link between the bed and bedtime and falling asleep quickly.
The treatment also addresses the presence of the wrong discriminative stimuli and the absence of the right ones.
Together with the other components of CBT, Stimulus Control has been scientifically proven to work for several types of insomnia.
In this article, we take a close look at this behavioral treatment method. We discuss the following:
- Stimulus Control indications.
- Contraindications.
- Step-by-step description of the procedure.
- Stimulus Control instructions. Rationale and modifications.
- Resistance to Stimulus Control.
- Evidence concerning the efficacy of Stimulus Control.
Stimulus Control Indications
Scientific research suggests that Stimulus Control is efficacious against all types of insomnia. Most studies have looked at it as a component of Cognitive Behavioral Therapy. There are a few, however, that have focused specifically on SC.
SC works for chronic insomnia, idiopathic, and paradoxical insomnia, as well as all of their subtypes. There is no evidence thus far that it works better for one type of insomnia than another.
However, by its nature, SC is at its best when dealing with sleep onset problems. This means that it might be more effective against initial insomnia than late insomnia. Still, its effects impact sleep quality as a whole. As such, it does treat late insomnia to some degree as well.
Sleep specialists have predicated Stimulus Control upon the concept that certain discriminative stimuli reinforce the occurrence of sleep-onset. It is therefore clear that insomnia is the result of inadequate stimulus control.
Pavlovian conditioning is also an integral part of SC. Stimulus control turns the bed, the bedroom, and darkness into external cues that trigger internal cues in the individual. These cues then become stimuli that trigger and reinforce sleep-onset.
In many cases of insomnia, these external cues have warped into internal cues that counteract sleep-onset. Stimulus control also takes it upon itself to deconstruct this warped stimuli-structure.
Stimulus Control Contraindications
As a Cognitive Behavioral Therapy subtype, Stimulus Control is entirely safe. It does not currently have any scientifically supported contraindications. In some cases, however, therapists may need to tweak their instruction-set.
- There may be patients who cannot leave their bed unassisted, due to poor health.
- Some patients may be bedridden because they do not possess the mechanical means to get out of bed.
- Yet another category of patients may not be able to follow instructions, due to mental issues.
Step-by-step Description of Stimulus Control Procedure
From the perspective of the therapist, SC procedure encompasses three main stages.
- The introduction of the technique to the patient is the first step.
- Detailing the instruction set is the second step.
- Drawing up concrete plans for implementing the instructions at night is the final touch.
The introduction of the Technique
Introducing Stimulus Control to patients is a simple yet essential exercise. Therapists understand that some patients may be skeptical in regards to the results such an approach can deliver.
- The therapist tells the patient about SC and that he/she should try that approach.
- The next step is to gently reveal to the patient how SC is supposed to work.
- The best way to accomplish that is to ask him/her a series of questions.
- Through the answers he/she provides, the patient usually reveals several problems with his/her sleep habits.
- The therapist then proceeds to tell the patient that he/she should be doing nothing else but sleeping in his/her bed.
- People read, work on their computers, check their phones, or even study in bed.
- The therapist recommends the cessation of all such activities.
- Patients should not spend more than 15 minutes trying to fall asleep.
- Once they grow frustrated with their inability to fall asleep, they should get out of bed and leave the bedroom.
- They should only return to bed when they feel drowsy.
- The therapist fills in the patient on the methodology and goals of SC.
Instead of the subtle question-and-answer approach, some therapists are more blunt about introducing SC to their patients. They simply sum up its gist.
- Only ever attempt to sleep when you are sleepy.
- The bed should only be the scene of sleep. Refrain from using it for any other activity.
- If you cannot sleep, get out of bed and leave the bedroom. Return only when you feel sleepy. Repeat this MO through the night, as needed.
- Set yourself a strict awakening schedule. Set the alarm if needed. You should wake up at around the same time each morning, regardless of the amount of sleep you get.
- Eliminate daytime naps.
These instructions represent the bread and butter of Stimulus Control. By adhering to them, you will rewire your brain to fall quickly asleep when you settle into bed.
Step-by-step Description of Procedure
Only go the bed when you are sleepy
Insomnia sufferers will often choose to go to bed at set times. This way, they hope to regulate their sleep/wake cycle on the one hand. On the other hand, they feel this is the only way they can get enough sleep.
By forcing this approach, they condition themselves to associate the bed with struggle and frustration.
This instruction sounds simple. But for an insomnia sufferer, it can be quite a daunting task. Therefore, its accomplishment should be viewed as a longer-term goal, to be achieved over the first few weeks of SC treatment.
The clock is not your friend when it comes to sleep. Listen to your internal clock instead.
The bed should be the scene of sleep only
This is one of the most important tenets of SC. Unlike the first instruction, patients can apply this one from the get-go.
The goal of this rule is to actively weaken the cues of wakefulness associated with the bed. At the same time, it strengthens the cues associating the bed with sound, restful sleep. The wide-spread nature of the problem it addresses amplifies its efficiency.
Most insomnia sufferers turn their beds into lairs of bustling activity. They engage in activities such as:
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- Reading.
- Watching TV.
- Playing computer games.
- Surfing the internet.
- Working.
- Using Facebook on their phones.
- Checking their social media and emails.
If you too engage in any of these activities in bed, the bad news is, you have to eliminate this habit. The good news is, you can still perform all of these activities, just not in bed.
If you apply this rule/instruction, you shall overhaul your sleep routine. The results will be immediate and significant.
Get away from the bed if you cannot sleep
This instruction is the second main component of Stimulus Control. It is the second step of associating the bed with sleep.
SC is focused on sleep onset. This instruction has a sleep-maintenance role though. By getting out of bed and engaging in some kind of activity when unable to sleep, patients will assume control over insomnia. The fact alone that they can control the condition makes it much easier to eliminate it further down the line.
Setting and sticking to an awakening schedule
Insomnia sufferers who go to bed at the same time every night to regulate their sleep rhythm are on to something. They just go about it the wrong way.
You do need to regulate your sleep rhythm as it allows you to improve the quality of your sleep. The best way to accomplish that is to awaken at the same time every morning. Going to sleep only when sleepy remains valid. Over time, you will find that you will have conditioned yourself to hit the sack around the same time every night, too.
You must stick to this schedule on workdays as well as on your days off. In addition to regulating your sleep schedule and improving your sleep quality, this approach will eliminate daytime fatigue and sleepiness. This brings us to the last Stimulus Control instruction.
Eliminate daytime naps
Much like unhealthy bedtime habits, daytime naps can grow on you. You can become conditioned to feel sleepy at a certain time every day. Interestingly, where you are at that certain time also impacts your proneness to daytime napping. Once conditioning sets in, daytime napping becomes a surprisingly difficult habit to kick.
In the context of sleep disturbance and Stimulus Control, patients should use sleep deprivation from one night, to facilitate sleep the following night. By napping during the day, this approach is rendered impossible.
Harnessing the power of sleep deprivation to facilitate proper sleep will lend patients a sense of accomplishment. This way, they will feel motivated to maintain SC compliance.
SC therapists have set certain exceptions to this rule. In the elderly, regular brief naps of around 30 minutes can be beneficial.
Stimulus Control Instruction Modifications
To accommodate a wide range of patient needs, some of the instructions of Stimulus Control need to be flexible.
Some versions of the “get out of bed if you cannot sleep” rule state that you need to leave the confines of your sheet if you cannot fall asleep within 15 minutes. Other versions of this rule emphasize leaving the bed as soon as possible. Some recommend 10-minute time-frames.
Such strict scheduling may burden patients with additional pressure. Constantly watching the clock breeds anxiety. Thus, some patients are advised to eliminate the clock from their SC program. Instead, therapists encourage them to get out of bed at the first sign of frustration about not being able to fall asleep. Proponents of this instruction modification still emphasize, however, that you should not remain awake in bed for 60 minutes, even if you are not frustrated.
Once out of bed, what activities can you perform and when exactly can you return to bed? Therapists do sometimes tweak this instruction as well.
In regards to the type of activities you can perform, try to stick to something relaxing and dim the lights. Lights impact your circadian cycles, so stay away from bright light. That includes the light emitted by your computer/phone screen. You can, however, watch TV from a distance. You can also read, with a reading light.
When should you go back to bed? As soon as you feel sleepy again. Pay attention to your internal cues concerning sleepiness. If you think you will likely fall asleep quickly if you go back to bed, you are ready to go back.
Resistance to Stimulus Control
Reluctance to get out of the comfortable bed may be a problem when practicing stimulus control. You know and understand how sleep control works, still you cannot get yourself out of bed. To address this problem:
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- Have a warm robe nearby. Wrap yourself in it as soon as you get out of bed.
- Have a place ready for your nighttime visit. Deck it out with extra pillows and make dim lights available.
- Plan an activity. Set up a heat massage device, or prepare a book/magazines you can read.
You might feel that getting out of bed will only make you more alert. Thus, you will become less likely to grow sleepy again.
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- Make sure you understand the rationale of the approach. Especially the part about pairing the bed with sleep only.
- Understand that if you sleep less tonight, you will likely sleep that much better tomorrow night.
- SC is a long-term approach. It will not make you sleep better right now. Its benefic effects are gradual.
- While awake and out of your bed at night, do something boring. Nurture acceptance over frustration.
Scientific Evidence
Stimulus control has been a scientifically accepted method to fight insomnia for quite some time.
In 1999, CM Morin, PJ Hauri, CA Espie, and others, have identified it as “the only” behavioral treatment option worthy of the highest recommendation.
A 2006 American Academy of Sleep Medicine update once again found Stimulus Control to be a treatment component of Cognitive Behavioral Therapy, that met their standard for recommendation.
Scores of researchers contributed to this update, including Timothy Morgenthaler, Milton Kramer, Cathy Alessi, and others. They represented an equally impressive number of institutions, such as the University of California and the University of North Carolina, among others.
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