One of the essential elements of cognitive behavioral therapy, or CBT-I, is stimulus control therapy. Often referred to as SCT, stimulus control therapy is part of the protocol designed to reduce negative associations regarding sleep and the sleep routine. (1)
SCT has been found in studies to be effective for all types of insomnia, including long-term insomnia lasting months or even years.
Cognitive Behavioral Therapy for InsomniaThe non-drug protocol of behavioral training and therapy designed to reduce symptoms of chronic insomnia and improve sleep efficiency.
Note: The content on Sleepopolis is meant to be informative in nature, but it shouldn’t take the place of medical advice and supervision from a trained professional. If you feel you may be suffering from any sleep disorder or medical condition, please see your healthcare provider immediately. Stimulus control therapy is best practiced in combination with the rest of the cognitive behavioral therapy protocol and under the guidance of a therapist who specializes in treatment of sleep disorders.
What Is Stimulus Control?
Stimulus control is a behavioral psychology term that refers to a predictable pattern of behavior in the presence of a certain stimulus, and another pattern in the absence of that stimulus. “Discriminative stimulus” refers to anything that can modify behavior or cause a physical or emotional response.
The concept of stimulus control is also used in training and behavioral therapy of animals. Animals and human beings learn to associate certain situations, objects, or experiences with a particular response that doesn’t occur at any other time. A person is considered to be “under the control” of a stimulus when they stop for a stoplight or feel hungry at the sight of a favorite restaurant. Stimulus control also underlies the mechanism of addiction to substances and certain behaviors. (2)
FAQQ: What's the definition of discriminative? A: That which has particular distinguishing characteristics.
Stimulus Control Therapy for Insomnia (SCT)
SCT adapts the well-known behavioral concept of stimulus control to the treatment of insomnia disorder. In the case of insomnia, “stimulus” is any behavior or thought that can activate the nervous system, cause anxiety, or serve as a cue for wakefulness. (3) A brief bout with insomnia may lead the brain to develop negative associations with the bed and bedtime routine. The attempt to sleep can cause emotions that trigger the release of stress hormones such as adrenaline and cortisol, making sleep more difficult.
Stimulus control therapy is part of the cognitive behavioral therapy protocol for sufferers of insomnia lasting three months or longer, at least three days each week. (4) CBT-I and SCT are designed to help deactivate the nervous system and retrain the brain to respond positively to sleep-related stimuli.
Other components of the therapy include:
- Sleep restriction therapy. Sleep restriction therapy limits time in bed to the average number of hours spent sleeping (5)
- Relaxation training. Relaxation training can help insomnia sufferers reduce anxiety and physical tension, allowing the nervous system to relax and making sleep more likely
- Cognitive behavioral therapy. The therapy component of the protocol addresses negative attitudes and misconceptions about sleep (6)
The CBT-I protocol has been well-studied for years, and is considered very effective as a non-pharmacological treatment for persistent insomnia.
For many people with chronic insomnia, the bed has become a place for activities such as reading or television-watching, as well as planning or worrying about upcoming events. Bed and the bedtime routine may have become psychologically linked with the inability to sleep. Stimulus control therapy is designed to strengthen associations with the bed as a place to sleep. (7)
To alleviate anxiety and negative conditioning, the following behavioral changes are recommended:
- Go to bed only when sleepy. Many people suffering from insomnia feel sleepy during the day or in the evening, but become “tired but wired” as bedtime approaches. “Sleepy” describes the feeling of being unable to stay awake, similar to the feeling of falling asleep on the couch during a movie or while reading a book
- Go to sleep and wake up at the same time every day, even on weekends. To help regulate the circadian rhythm and stem the release of the sleep-promoting hormone melatonin, expose yourself to bright light as soon as possible after you wake up. If going to bed later than usual, set an alarm for your usual wake time to help maintain your sleep schedule and prevent disruption of your body clock
- If unable to sleep after approximately ten-fifteen minutes, get up from bed and wait to feel sleepy in another room. Keep the lights dim and engage in a quiet activity such as reading. Avoid electronics, which emit stimulating blue light and may keep you awake longer. Return to bed only when you feel ready to sleep. Once in bed, get up again if you don’t fall asleep within ten minutes. Repeat as often as necessary until you sleep (8)
- Use the bed for sleep and sex only. Do not watch TV, study, use electronics, read, play video or other sorts of games, or work in bed. Talking and any other activity that might encourage wakefulness are also discouraged
- No watching the clock. Put the clock across the room and cover it if necessary. Once in bed, don’t look at it until the alarm goes off, even if you wake during the night or close to morning
- Do not nap. Naps can lower the drive to sleep at a normal time and further disrupt the circadian rhythm. Even if you didn’t get sufficient sleep the night before, avoid napping to help regulate sleep patterns
- Be patient. Like any sort of stimulus control training, stimulus control therapy for insomnia requires consistency. It takes time to change the associations the brain makes with sleep-related cues, such as showering, preparing clothes for the next day, and turning off the bedroom light
Sleep driveThe natural urge to sleep that increases gradually throughout the day, peaking in the mid-afternoon and at night.
The Effects of SCT
Stimulus control therapy may take days or a few weeks to show results. To maximize chances of success, prepare for the protocol and have realistic expectations. Know that at first, you may get even less sleep than usual for you. Have a robe available on cold nights in case you need to get out of bed and wait to feel sleepy in another room.
Though stimulus control therapy may result in short-term sleep loss, the training help to regulate the circadian rhythm and build the natural drive to sleep. Increasing the natural sleep drive will result in falling asleep more quickly, particularly when practiced in concert with sleep restriction therapy.
Falling asleep faster helps the brain develop positive associations between the bed and sleep, reinforcing a new and beneficial pattern of behavior. (9) As stimulus control continues and sleep becomes easier, sleepiness often shifts to earlier in the evening. This allows for more sleep time without lying in bed awake and anxious. More time in bed may be allowed as long as insomnia symptoms don’t return and sleep remains efficient. (10)
Most sleep specialists suggest that the protocol be continued even after insomnia symptoms subside. Occasional sleep-ins or late nights are permitted once sleep returns to normal, but in general, the protocol should be followed indefinitely to maintain progress. Extended wake periods in bed are strongly discouraged. If insomnia symptoms begin again, a return to the protocol is often recommended.
Last Word From Sleepopolis
Stimulus control therapy can help reduce the symptoms of chronic insomnia and increase sleep efficiency. It helps to alleviate the persistent anxiety and nervous system activity that can result from negative conditioning regarding sleep.
As part of the cognitive behavioral therapy for insomnia protocol, SCT can replace psychological associations that disrupt sleep with positive responses to sleep and the bedtime routine. Proven effective and long-lasting, SCT can restore healthy sleep patterns and improve insomnia symptoms for many long-term sufferers of the disorder.
- Baillargeon L, Demers M, Ladouceur R., Stimulus-control: nonpharmacologic treatment for insomnia, Canadian Family Physician, Jan. 1998
- Nader, Michael, Chapter 1 – Animal models for addiction medicine: From vulnerable phenotypes to addicted individuals, Progress in Brain Research, 2016
- Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW., Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison, Archives of Internal Medicine, Sep. 27, 2004
- Harris J, Lack L, Kemp K, Wright H, Bootzin R., A randomized controlled trial of intensive sleep retraining (ISR): a brief conditioning treatment for chronic insomnia, Sleep, Jan.1, 2012
- Maurer LF, Espie CA, Kyle SD., How does sleep restriction therapy for insomnia work? A systematic review of mechanistic evidence and the introduction of the Triple-R model, Sleep Medicine Reviews, Dec 2018
- Richard R Bootzin, Understanding and Treating Insomnia, Annual Review of Clinical Psychology, Apr. 2006
- Stimulus Control Instructions, Case Studies in Insomnia
- Zwart, Cheryl A., Analysis of stimulus control treatment of sleep-onset insomnia, Journal of Consulting and Clinical Psychology, 1979
- Miller C, Espie C, Kyle S., Cognitive behavioral therapy for the management of poor sleep in insomnia disorder, Dovepress, Aug. 29, 2014
- Reed, David, L, Measuring Sleep Efficiency: What Should the Denominator Be? JCSM, 2016