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Section 6
Behavioral Therapy for Insomnia (Part 1)

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Effectively Using Key Behavioral Interventions for Insomnia
In the last section, we discussed behavioral sleep therapy for children.  For the purpose of this course, one method of behavioral sleep therapy for children will be explained in two parts.  Behavioral sleep therapy for children consists of initial progression and subsequent progression. 

In this section, and the next track we will discuss behavioral interventions for insomnia.  As you know, insomnia can be a common sleep disorder among clients. Four behavioral interventions for insomnia that we will discuss are stimulus control therapy, sleep restriction therapy, relaxation therapies, and cognitive therapy. The focus of this track will be on the first two interventions, stimulus control therapy and sleep restriction therapy.  As you listen to this track, consider your client who has insomnia. Which behavioral intervention might benefit your client?

4 Behavioral Interventions for Insomnia (#1 & #2)

Intervention #1: Stimulus Control Therapy
First, let’s discuss stimulus control therapy.  Garrett, age 27, had insomnia.  Garrett’s complaint pertained to getting to sleep.  Garrett stated, "When I go to bed, I find myself lying there trying to go to sleep for hours.  I just can’t get to sleep right away." 

Does your client have a similar problem?  Or does your client awaken during the night and have difficulty getting back to sleep?  Perhaps he or she engages in other activities in bed.  If so, your client, like Garrett, may be a good candidate for stimulus control therapy. 

Stimulus control therapy was developed by Dr. Richard Bootzin as a way to test his theory that reducing time awake in bed could reduce a subconscious association that he believed may cause insomnia in some clients.  For example, if a client spends time awake in bed often enough, that client will begin to associate their bed with wakefulness.  Such was the case with Garrett. 

Garrett's 6-Step Stimulus Control Therapy
Step 1: "First, avoid your bed, and preferably your bedroom, for anything other than sleep or sexual activity. 
Step 2:
Second, get into your bed at your predetermined bedtime, or later if you’re not sleepy at your usual bedtime."  Garrett asked, "Are you telling me not to get into bed any sooner?"  How would you have answered Garrett?  I stated, "Yes.  With insomnia, it’s better to spend less time in bed than to lie awake." 
Step 3: Like Garrett, your client may consider allowing no more than ten or fifteen minutes to fall asleep.  I stated to Garrett, "Estimate this time.  Don’t use a clock or other time cue." 
Step 4: At a later session, Garrett stated, "Since the goal is to avoid being awake in bed, if I don’t fall asleep after ten or fifteen minutes, I get out of bed, go to another room, and do something relaxing until I feel like I can sleep."  You might consider suggesting this strategy to your clients.  Steps two through four can be repeated as many times as necessary throughout the night. 
Step 5: The next step for Garrett was to get out of bed at his predetermined rise time.  Garrett’s rise time was seven a.m.  Garrett stated, "I woke up before seven the other morning, so I got out of bed.  But I don’t let myself sleep past seven." 
Step 6: The final step in stimulus control therapy was for Garrett to avoid napping during the day.  Think of your client.  Could stimulus control therapy benefit him or her?

Intervention #2:  Sleep Restriction Therapy
Next, let’s examine sleep restriction therapy.  Like stimulus control therapy, sleep restriction therapy requires that a client limits the time he or she spends in bed.  However, there is no supposition that conditioning plays a role in insomnia.  Some clients, like Julie, age 42, may spend too much time in bed resulting in shallow sleep that is spread out over too great a time period.  The goal of sleep restriction therapy is to allow clients like Julie to get more quality than quantity out of their sleep by limiting sleep in order to increase occurrences of REM.

The first step in sleep restriction therapy for Julie was to keep a sleep log for seven to ten days.  Julie calculated her average time in bed and the average time she spent sleeping.  You might consider suggesting to your client that he or she also list the date, bedtime, how many times per night he or she wakes up, wake time, and rise time as well. 

For example, Julie was trying to get to bed each night at 10:30, but was having difficulty getting to sleep and staying asleep.  However, Julie did manage to get up consistently at 7:30, with one exception.  Julie stated, "On the fifth day of my sleep log I woke up completely exhausted.  I slept until 9:30 and was late for work." 

After ten days of keeping her sleep log, Julie found that on average she was in bed for 9 hours.  Of that time, Julie slept for about 6 and a half hours. Clearly Julie was lying awake each night for about three hours. I felt that correcting Julie’s sleep problem could best be done by her going to sleep later in the evening. However, Julie stated, "After 10:30 I really don’t have anything going on so going to sleep later would just be a waste of time. I’d rather get up earlier so I can have more time in the morning." 

Julie decided to go to bed at 11 and wake at 6:30, which provided her with seven and a half hours of sleep.  Julie was then at the starting gate for the rest of her sleep restriction therapy. 

Julie's 5-Step Sleep Restriction Therapy
Step One: First, Julie subtracted her average total nightly sleep time from her average total nightly time in bed to find the excessive amount of time she was spending in bed.
Step Two: Second, Julie eliminated the excess time she spent in bed by changing her bed time and rise time.  I have found that it can be productive to trim off time by going to bed later, but, like Julie, your client may prefer to wake earlier. 
Step Three: Third, Julie made sure that if her bed time or rise time changed, she never went to bed earlier or woke up later.
Step Four: Fourth, Julie, like Garrett, avoided naps during the day.
Step Five: Fifth, Julie began to keep another sleep log.  Julie used this second sleep log as a way to calculate her sleep efficiency.  Julie divided her total average time in bed by the total average time she slept.  I suggested she strive for at least 85% sleep efficiency.

At a later session, Julie stated, "I’m having a hard time getting that 85%.  What should I do now?"  How would you have responded to Julie?  I suggested to Julie that she continue to reduce her time in bed.  I stated, "Spend only the amount of time in bed that your sleep log shows that you are sleeping." 

For example, Julie mentioned that she was now spending seven and a half hours in bed, but sleeping only six. She cut her time in bed down to six and soon found that she was sleeping for five and a half hours each night. Clients like Julie can continue to reduce sleep time and time in bed until they approach four hours of sleep. As you already know, any less than four hours of sleep is not advisable. How many hours of sleep a night is your client getting? How much of his or her time in bed is spent awake? 

In this section, we have discussed two behavioral interventions for insomnia.  The two behavioral interventions for insomnia that we discussed are stimulus control therapy and sleep restriction therapy.

In the next section, we will discuss combined stimulus control therapy and sleep restriction therapy, as well as two additional behavioral interventions for insomnia.  The two additional behavioral interventions for insomnia are relaxation therapies and cognitive therapy. 

Peer-Reviewed Journal Article References:
Ashworth, D. K., Sletten, T. L., Junge, M., Simpson, K., Clarke, D., Cunnington, D., & Rajaratnam, S. M. W. (2015). A randomized controlled trial of cognitive behavioral therapy for insomnia: An effective treatment for comorbid insomnia and depression. Journal of Counseling Psychology, 62(2), 115–123. 

Colvonen, P. J., Drummond, S. P. A., Angkaw, A. C., & Norman, S. B. (2019). Piloting cognitive–behavioral therapy for insomnia integrated with prolonged exposure. Psychological Trauma: Theory, Research, Practice, and Policy, 11(1), 107–113. 

Dong, L., Soehner, A. M., Bélanger, L., Morin, C. M., & Harvey, A. G. (2018). Treatment agreement, adherence, and outcome in cognitive behavioral treatments for insomnia. Journal of Consulting and Clinical Psychology, 86(3), 294–299.

What are two behavioral interventions for insomnia? To select and enter your answer go to Test.

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