Improving Your Sleep With Behavioral Strategies

Are you having trouble falling or staying asleep? You’re not alone. According to the Cleveland Clinic, 70 million Americans struggle with insomnia.
Improving Your Sleep With Behavioral Strategies
Ashleigh Golden, PsyD

Dr. Ashleigh Golden is a licensed psychologist and an expert in cognitive-behavioral treatments for anxiety, depression, obsessive-compulsive disorders, and sleep disorders. Dr. Golden completed a 2-year sub-specialized postdoctoral fellowship at the Center for OCD and Anxiety-Related Disorders at the Saint Louis Behavioral Medicine Institute. Dr. Golden has supervised teams of clinicians across the country in intensive outpatient and partial hospital settings. She has a special interest for working with people who are ambivalent about accessing or participating in evidence-based therapy.

What is insomnia?

Are you having trouble falling or staying asleep? You’re not alone. According to the Cleveland Clinic, 70 million Americans struggle with insomnia, a common sleep disorder which involves having trouble falling asleep, staying asleep, or waking up too early. Insomnia can negatively impact mood, energy, health, work performance, and quality of life

What can I do about insomnia?

In a previous blog, we noted that Cognitive-Behavioral Therapy for Insomnia (CBT-i) is an evidence-based, effective treatment for insomnia, and covered the cognitive component of the treatment (how changing your thinking can improve your sleep). In this post, we’ll cover the behavioral part of the treatment — that is, how changing your behavior can have a positive impact on the quality of your sleep.

How do I change my sleep habits?

Scheduling and stimulus control are core components of CBT-i with strong research support, according to the Society of Clinical Psychology. Sleep scheduling is all about establishing consistent schedules that allow for sufficient sleep, including setting times for when you go to bed, when you get out of bed, and how much time you spend in bed to bolster your sleep system.

The main goal of stimulus control is to lower the “conditioned arousal” (anxiety) that people feel when trying to go to bed, with the intention of reassociating the bed and bedroom with sleep (rather than wakefulness) and re-establishing a consistent sleep schedule. The idea is that by making the bed a stronger cue for sleep, you will fall asleep and stay asleep more easily. 

Stimulus control is essentially a set of guidelines that include: 

  1. Going to bed only when you are sleepy;
  2. Getting out of bed when you are unable to sleep;
  3. Using the bed/bedroom only for sex and sleep (so no reading, watching TV, or working);
  4. Getting up at the same time each morning, even on weekends; and
  5. Avoiding napping as much as possible.

So how do I actually do stimulus control?

Now that you are familiar with stimulus control’s basic recommendations, let us take a deeper dive into how to implement them. Here are some guidelines from the University of Massachusetts School of Medicine that you can follow:

  1. Get out of bed at the same time every morning, including weekends, no matter how poor your sleep was the night before. A consistent get-out-of bed time is necessary to establish a consistent sleep rhythm. Sleeping in on weekends or after a poor night’s sleep is the equivalent of changing your clocks for Daylight Savings Time in the spring, weakening your sleep system and making it tough to sleep the next night. 
  1. Determine the maximum amount of time you should set aside for sleep by matching the time you go to bed and the time you get up to your average weekly sleep time. This typically involves tracking your average weekly sleep duration for the week and adding one hour. So, if you are averaging 6 hours of sleep, you should not set aside more than 7 hours for sleep. However, if your average is fewer than 5 hours, you should not set aside fewer than 5.5 hours for sleep. Decreasing the amount of time that you set aside for sleep so that it closely matches your average sleep duration can help your bed serve as a cue for sleep. As your average sleep duration increases over time, you can gradually increase the time you set aside for sleep.
  1. Figure out your earliest allowable bedtime by subtracting your maximum allowable time set aside for sleep from your get-out-of-bed time. So, if you have figured out that your get-out-of-bed time is 7 a.m., and your maximum time set asleep is 7 hours, you should not turn off your lights to go to sleep before midnight. If you find it tough to stay up until your earliest allowable bedtime, get your body moving. If you are watching TV or reading, walk around every tenth page of your book or every time a commercial comes on. The time you set aside for bed will increase as your average sleep duration increases over the next several weeks, and, in turn, your earliest allowable bedtime will change.
  1. If you cannot avoid napping, limit your naps to fewer than 45 minutes and your naptime to no later than 3 p.m. Naps past this time and longer than 45 minutes can make it more difficult to fall asleep later that night. You can unintentionally end up weakening your sleep system by ‘borrowing’ deep sleep from the upcoming night during a nap. Naps consisting of 45 minutes or fewer and that take place before 3 p.m. will help you feel more energized and awake, and will not disrupt your sleep later on. 

How do I actually do stimulus control?

The University of Massachusetts School of Medicine recommends a 4-step process:

  1. Use your bed and bedroom only for sleep and sexual activity, since you want to associate your bed with sleep, not being awake. Do not use your bed and bedroom for working, studying, phone or Zoom calls, or watching TV.
  1. Limit the time you spend awake in bed to a half-hour before you turn the lights out and a half hour after you awaken in the morning. 
  1. When you turn off the lights to go to bed, make sure that you actually feel drowsy or sleepy. Stanford Health Care highlights the difference between sleepiness and fatigue. Fatigue is a state of low energy, while sleepiness is a state of struggling to stay awake. Going to bed only when you feel sleepy boosts the chance that you will fall asleep quickly. Rely on internal cues of sleepiness or drowsiness, such as your head nodding or your eyes closing, rather than external cues, like a clock or what time your partner goes to bed. If you are going to bed based on external cues, you may not be feeling drowsy, and may be more likely to lie awake thinking or worrying.
  1. Do not lie in bed tossing and turning. If sleep does not come to you within 20-30 minutes of going to bed, or if you wake up during the night and do not fall back asleep within 20-30 minutes, go to another room and do a relaxing, quiet activity, like reading a book or doing a puzzle. Engage in this activity until you feel sleepy, then go to bed again. Repeat this process until you fall asleep. While it might feel like you will be more successful lying in bed and trying to sleep, this is not the case. The longer you lie in bed tossing and turning, the more you associate your bed with being awake. 

If you have tried sleep scheduling and stimulus control as well cognitive strategies and are still struggling with falling asleep, staying asleep, or waking up too early, talk to your doctor. If you have not given these techniques a shot, what do you have to lose by giving them a try? While some of them might feel challenging to start, they can go a long way towards improving your sleep quality, which can in turn make a big difference in your mood and energy levels, as well as your health, work performance, and overall quality of life.