How to Use Stimulus Control Therapy for Insomnia

So often we look for psychological or physical causes for insomnia, but we should always consider the habitual element.

Do you know about Yuri Ivanovich Pavlov? Ring any bells?

Sorry, that’s an old one! Of course, the Russian physiologist is mainly remembered for his work on classical conditioning.

Pavlov found that if you continually feed a dog at the same time as sounding a bell, after a while simply sounding the bell will cause them to salivate – even in the absence of food. He had conditioned their response.

Mind you, it’s not just our canine friends who can be conditioned. I worked with a cancer survivor once who told me she would feel nauseous, and sometimes even vomit, every time she went back to the hospital where she’d received chemotherapy. The association between the environment (the stimulus) and the feeling of nausea (the response) had been conditioned, so that now it happened even in the absence of chemotherapy.

But this kind of pattern matching happens all the time in less obvious ways, and certainly when it comes to sleep – or lack thereof.

Association and habit maintain insomnia.

Insomnia is a real blight, not just on the individual¹ but on society² as a whole. We often, quite rightly, look for psychological³ or hormonal⁴ causes for insomnia.

But I want to address here the conditioned response or habitual element to sleeplessness. Associations are powerful, and so is expectation. If you’ve come to expect a pill to help soothe your headache, then even a placebo pill may do the trick.⁵

Certainly we need to deal with our clients’ worries, ensure their sleep hygiene is sound, and maybe even use sleep restriction therapy. Stimulants such as internet surfing should be kept to a minimum before bed, and the bedroom itself should be used only for sleep and sex, not for work or TV watching.

So how can we start to diminish the arousal our insomniac clients might experience when going to and beingin bed?

How to help heal insomnia

When seeking to unhook negative sleep associations, we need to first ascertain whether they actually exist to any significant degree.

Recently I worked with a client called Rob. When I asked him how he felt when he imagined getting ready for bed and going into his bedroom for the night, he closed his eyes and looked pained.

“I feel tense just thinking about it! My bed in the room… everything makes me feel a little sick!”

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Now that was an extreme reaction, but we had usefully ascertained that, yes, Rob had definitely built up a major emotional response to both the act of going to bed and the environment in which sleep was supposed to happen. Strong emotionality is to sleep what cement is to drinking water. We had to change the association back to one of calm and rest, not fear and disquiet.

Now, many of your insomnia clients won’t necessarily have such a strong emotional reaction when they merely imagine going to bed. But you might be surprised how many people don’t feel good at all when they think about their bedroom.

Stimulus control therapy simply entails helping change the association between the trigger and the response. We can do this by changing the environmental trigger itself, calming down your client’s reaction to the environmental trigger, or both.

Step one: Assess the association.

Just as I did for Rob, have your client describe how they feel just visualizing their bedroom and imagining going to bed. Do they have a positive sense of their bedroom, or not? Do they feel any tension? Do they start feeling anxious in the minutes or even hours before they go to bed? This can amount to a kind of performance anxiety and dread.

We can use scaling or grading questions to ascertain to what extent your client has formed a conditioned negative association. I asked Rob: “On a scale of 1 to 10, 1 being the most relaxed and 10 being the most stressed, what number are you when you think about getting ready for and going to bed?” He told me glumly that he was a 10!

It was time to move on to the second step.

Step two: Calm the association.

I taught Rob to relax deeply and feel calm and peaceful. Then I had him imagine observing himself from the outside looking calm and sleepy, then going to bed. We did this repeatedly to override the old association. I also hypnotically rehearsed with Rob the hours before going to bed. In the end, he reported feeling relaxed and calm now when thinking about going to and being in bed.

“What number would you put yourself at now?” I asked.

“Hardly any number at all… maybe a 1.”

This was proof that we were directly changing the association, like Pavlov’s dog finally being able to hear a bell without salivating. We had made progress! But there was something else we could do for good measure.

Step three: Change the environment.

No matter what you’re working on with your client, it’s always worth asking exception questions. Here’s what I asked Rob:

“When hasn’t the problem occurred when you might have expected it to?”

Rob told me something interesting. When his sister had come to stay, he had suggested that she sleep in his room and he in the smaller guest bedroom. “It was really weird, Mark,” he recalled. “That night I slept like a baby!”

To me it wasn’t weird at all. The association of feeling tense and horribly alert hadn’t been built up in the guest bedroom – so he had slept. Similarly, if Pavlov had started clapping his hands instead of ringing the bells, his dogs wouldn’t have salivated, because there was no association between eating and hand clapping. Conditioning is quite specific. Sometimes clients will tell you that they sleep better away from home. Again, this would be because the conditioned associations are not there.

Fortunately, there are ways to break down these associations without having to sleep away from home! I have suggested clients move their bed to a different position. One couple even redecorated their rooms completely! In so doing, they disrupted the old associative conditioning and made room for new, better associations.

Stimulus control therapy, along with paradoxical intervention (such as requesting the client sleep less) and progressive relaxation training, has been found to be effective for insomnia.⁶ I used it as a part of an overall approach with Rob, but for him it really did seem to be the active ingredient in curing his insomnia.

When Rob started sleeping again, he told me, “Going to bed used to be an ordeal but now I look forward to the deep rest and calm it brings. Sleep is the source of my power!”

A bell rang somewhere in my mind as I remembered Pavlov.

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About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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