Managing Insomnia

Lesson 2
Managing Sleep-Interfering Thoughts and
Behaviours - Part 1
Welcome and Lesson Overview
This summary reviews the key points discussed in Lesson 2 and includes tasks for you to work
on. In this lesson you learn strategies to reduce arousal at bed time, thereby making it easier to
fall asleep.

Topics Covered In This Summary & Action Plan

Here is a list of the topics we will cover in this Summary. Tick these off as you go:

1. Stimulus Control Therapy – Five Behavioural Changes You Can Make to Reduce
Arousal in Bed (page 3)

2. Quieting the Mind With “Worry Time” (page 8)

3. Creating a Wind-Down Routine Before Bed (page 9)

4. Reducing Sleep Worry and Effort (page 10)

5. Summary (page 12)

6. Action Plan (page 12)

But first, let’s quickly review Lesson 1…

In Lesson 1, you learned about normal sleep and the three key factors that
regulate sleep. You also did a self-assessment to learn about the main
behaviours and thinking patterns that maintain your insomnia.

Next, you learned about sleep hygiene to improve basic sleep habits. You
also learned about sleep medications and set goals for treatment. We hope
you have been keeping your sleep diary each morning.

Quick Recap Quiz

A. Write down the three factors that regulate sleep:
1.
2.
3.

B. What keeps insomnia going? (finish the sentence below)

Unhelpful _________________ & __________________

C. Name two things you can you do to improve your sleep?

1.
2.

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Answers to recap quiz. A) Sleep drive, Circadian Rhythm, Arousal. B) Thoughts & Behaviours. C) This is
individual to you but ideas include no napping, reduce caffiene intake, exercise.

In today’s lesson, you will learn essential strategies for reducing arousal in bed and retraining
your brain to associate the bed with sleep.

1. Stimulus Control Therapy

Many people who have sleep difficulties have developed Conditioned Insomnia. This is where
going to bed and being in the bedroom triggers worry and frustration about sleep, causing you
to become alert, thereby making it harder to sleep. Going to bed is now an automatic cue for
unpleasant feelings. But the good news is that this association can be unlearned. You can make
some changes so that the bed becomes a trigger for sleep and relaxation by following some
simple steps.

This technique is called Stimulus Control and there are 5 key steps:

STIMULUS CONTROL THERAPY

Step 1: Keep the bed for sleep and sexual intimacy only
Step 2: Wake up at the same time each day
Step 3: Go to bed only when sleepy
Step 4: If you don’t fall asleep within 15-20 minutes, get out of bed
Step 5: No napping

Step 1: Keep the bed for sleep and sexual intimacy only
− Don’t use the bed or bedroom for any other activities such as watching TV, using your
laptop or mobile phone, playing games, eating, working, talking on the phone, worrying, or
“processing” the day’s events.
− Remember that the idea is to learn to associate the bed with sleep again.
− When you do other activities in bed, your brain gets mixed signals because sometimes the
bed is for sleep but sometimes it is for doing other, arousing activities.
− Keep it clear – Bed = Sleep
− The only exception to this, if you really need to, is reading or listening to a podcast or
audio book, as long as these are not too exciting.
 These exceptions are permitted because they are relaxing and often help to quiet an
active mind without being too stimulating to keep you awake. Also, reading is often a
cue for sleep for many people.

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Step 2: Wake up at the same time each day
− This includes weekends as well as after nights when you went to bed later than usual, or
when you didn’t sleep well during the night.
− It’s tempting to want to make up for lost sleep on the weekend or to have a lie in when
you have had a poor night’s sleep, but keeping a regular wake up time is essential to
synchronising your circadian rhythm.
− When you are not consistent in your wake times, it is like you are giving yourself jet lag
(like when travelling between time zones, which we know really disrupts your sleep).
− Many people find this step particularly challenging to stick to but remember that this
course is like “boot camp” for your sleep. There is likely to be some short-term pain for
longer-term gain.
 Remember also that a little sleep deprivation will only enhance your sleep on the
following night.
 If you are reluctant to implement this step, perhaps consider the next week as a little
experiment – Try it out for one week only and if it doesn’t help you, then you haven’t
lost much. But, if it does help, you might consider sticking to this step consistently.
− Choose a time that best suits your lifestyle (make sure it’s achievable with work and social
demands) and stick to it every day.

Step 3: Go to bed only when sleepy

− Many people with insomnia go to bed too early in an attempt to give themselves more
opportunity to sleep. The problem with this is that it means you are going to bed before
your body is ready to sleep. This only leaves you awake for long periods in bed, leaving you
frustrated, meaning that the bed is again associated with wakefulness rather than sleep.

More time in bed does not equal more time asleep.

− What was your sleep like before you had insomnia?
 What time did you go to sleep/wake up? Sleep time: _______ Wake time:_______
 Do you notice that your previous bedtime is very different to your current bedtime?
If yes, this might be another good indication that you are perhaps going to bed too
early.

− Go to bed when you feel sleepy not just when you feel fatigued. Sleepiness is feeling
drowsy, so that you have to work to stay alert, whereas fatigue is associated with a lack of
energy or motivation and a feeling of weariness.

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Step 3 Trouble shooting:
Q: I don’t really feel tired before bed. What should I do?
A: Sometimes people who experience excessive arousal or anxiety may not feel sleepy despite high sleep
drive. That is, the anxiety is masking sleepiness. If this applies to you, we recommend using the
techniques in the second half of today’s lesson to assist you in reducing anxiety before bed.

Other people may not feel very tired before bed but are able to fall asleep quite quickly when they finally
get into bed. If this applies to you, you may be better off setting a regular bedtime that isn’t too early
rather than waiting until you feel sleepy.

Step 4: If you don’t fall asleep within 15-20 minutes, get out of bed
− Remember that we want to pair the bed with sleep. So, if after turning out the lights, you
can’t sleep within 15-20 minutes, get up, go to another room and do something relaxing.
− Lying in bed when you can’t sleep only increases frustration and arousal making it harder
to sleep.
− Although many people with insomnia are reluctant to try this step at first, over several
nights of trying this step, your conditioned arousal in bed will reduce as your brain again
learns to associate the bed with sleep. Once this happens, your sleep will improve.
− When you implement this step, you are giving yourself “permission” not to sleep right
now. This really does take the pressure off having to fall asleep immediately, allowing
sleep to naturally come to you.
− If, due to a medical condition, it is unsafe for you to get out of bed in the night or you are
feeling too anxious about implementing this step, we suggest that instead of getting out of
bed, you mentally give yourself permission to engage in a relaxing activity (e.g., turn the
light back on and read), rather than trying to force yourself to sleep. The idea here is that
you are no longer trying to sleep – so you are unlearning the association between bed and
frustration.

Step 4 Trouble shooting:

Q: I’m warm and comfortable in bed. Isn’t it better to at least rest there rather than get out of bed
which might wake me up more?
A: Lying in bed awake means that your brain gets mixed signals about the bed. Sometimes it’s for sleep
and other times it’s for wake. This step (and Stimulus Control in general) helps you to learn to
reassociate the bed with sleep only. We know it isn’t always enticing to get out of bed, particularly if it is
cold. In this case, it’s a good idea to prepare in advance and leave out a blanket and some warmer
clothes for when you get out of bed.

Q: What if I don’t get back to sleep after getting out of bed?

A: Stimulus Control is a long-term strategy. You can’t unlearn the association between bed and arousal in
just one night. Getting out of bed isn’t necessarily about helping you to get more sleep that night.
Rather, it’s about relearning the association between bed and sleep for in the long term. If you get out of
bed, you may find you do end up getting back to sleep faster that night as you take the pressure off
trying to sleep but if you don’t, remember that this simply means that you are building up your sleep
pressure so that you sleep better the next night.

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Q: How do I decide whether or not to get out of bed?
A: Remember not to use the clock as a cue as to whether to get out of bed or not. Rather, just use your
felt sense. If you have been lying in bed a while unable to sleep or are feeling frustrated in bed, that’s a
good sign that you are better off getting up.

Q: What should I do when I get out of bed?

A: Just stick to relaxing activities in dim light and try to avoid anything too stimulating which may disguise
tiredness. Some activities might include – reading, listening to a podcast/audiobook, light TV, a craft task
that isn’t too engaging. Ideally, aim to do fairly boring tasks and ensure that anything you read,
watch, or listen to isn’t too suspenseful or exciting.

Q: I’m worried about disturbing my partner if I get out of bed. What do you suggest?
A: We suggest that you discuss your concerns with your partner and explain the rationale behind
Stimulus Control. You may find that your partner will not be too disturbed by you getting out of bed and
indeed, this may be preferable to you staying in bed tossing and turning.

Q: Sometimes when I get out of bed in the middle of the night, I fall asleep on the couch or in the spare
room. Is that OK?
A: Remember that the idea is for you to learn to reassociate your bed and bedroom with sleep. You do
this through consistently falling asleep in your own bed. When you fall asleep on the couch or in another
bedroom, you don’t learn to reassociate your own bed with sleep. For this reason, we encourage you to
go back to your own bed when you start to feel sleepy so that you can have more experiences of falling
asleep faster there.

Step 5: No napping
− As we’ve discussed, napping weakens your sleep drive, making it harder to fall asleep at
night time. It can also result in lighter, more fragmented sleep.
− Try to engage in energy-generating activities during the day to reduce the chances of
napping. Examples include going for a walk or doing something social.
− Of course, if you are going to engage in an activity where it would be dangerous for you to
be very sleepy, safety naps are appropriate. Safety should always be the number one
priority.
− If you are going to nap, naps 20 minutes or less and further away from your bedtime, are
least likely to interrupt your nighttime sleep.

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 Remember, it takes a little time to retrain your brain to associate the bed with
relaxation and sleep, so it’s normal for your sleep to get a bit worse before it gets
better as you go through this process. It will likely take several attempts at getting up and going
back to bed until you fall asleep quickly. Over time, your bed and bedroom will become a
stronger cue for sleep. A lot of sleep comes down to habit and habits take time to get solidified.

Let’s hear what others had to say about using Stimulus Control…

“I was really anxious at first about doing the Stimulus Control steps. Even though my sleep
was bad on weeknights, at least I managed to get a little sleep on weekends so I really didn’t
like the idea of giving up my sleep ins on the weekend. But, I tried it for a couple of weeks and
it didn’t take long for my sleep to improve. It wasn’t perfect just yet but I was definitely
getting more sleep after following these steps.” Mary, 35

“I found it very hard to get out of bed in the middle of the night when I wasn’t sleeping. So, for
the first week I did all the other steps but stayed in bed when I couldn’t sleep. My sleep didn’t
improve so the next week, I tried harder to stick to all of the steps. It actually made a huge
difference getting out of bed when I couldn’t sleep. I was worried that getting up when I
couldn’t sleep would make me feel more awake but in fact it was the opposite - I stopped
being so frustrated when I couldn’t sleep and that made me feel calmer. It was like I was
telling myself that it was OK not to be asleep and that really took the pressure off. I think
that made me more relaxed and meant that I was then able to fall back asleep after a little
while, when I started to feel more sleepy.” Isaac, 51

“I couldn’t get through the day without napping before. But I ended up in this bad pattern of
sleeping badly at night, compensating with a long afternoon nap, which then meant I slept
poorly again the next night. Once I started this program, instead of napping, I decided to go
for a walk around the block at the same time as I would normally nap. That was enough to
give me a little more energy so that I could skip the nap. After a few weeks, my sleep became
less disrupted at night which meant it was easier to forgo my afternoon nap.” Raj, 58

Which of the 5 steps of Stimulus Control will you work on this week? Tick off all that
apply:

 Keep the bed for sleep and sexual intimacy only

 Wake up at the same time each day
 Go to bed only when sleepy
 If you don’t fall asleep within 15-20 minutes, get out of bed
 No napping

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2. Quieting the Mind with “Worry Time”
Many people find that their first opportunity to process the day’s
events is when their head hits the pillow. Your mind can start
churning… “I shouldn’t have yelled at the kids today”… “I’ve got
so much on tomorrow”… “Should we get a new car?”… “I really
need to get to sleep”… No wonder it is hard to shut off a racing
mind!
Here are some recommendations to manage this:

1. “Worry Time” and Journaling

Many people find it helpful to designate some time earlier in the day for
thinking, worry, or reflection.
The idea here is that you have the opportunity for a “brain dump” so
that instead of having lots of thoughts and worry “floating” around in
your head, you give yourself the opportunity to put them on a page.
Some people find it helpful to keep a daily journal to this end.
Or, you may simply decide to designate a time (say, 6pm) to spend 10 minutes focussing on any
worries that you have. If worries come up outside of this designated time (e.g., when you are
going to sleep), you can simply tell yourself that you will postpone those worries until ‘Worry
Time’ the next day. During Worry Time, try to make an effort to think about the things that tend
to run through your head when you are trying to sleep. Worry time is a useful technique for
gaining control over your worry and rumination.

The main thing is that you give yourself an opportunity each day to process that
day’s events, well before bedtime.

Some people also find it helpful to keep a pen and paper by the bed so that they can jot down
any thoughts that pop into their head while trying to sleep. That way, you have written it down
but can wait until the morning to actually work through the thought or concern.
Sometimes, if you set yourself a specific time to worry and make an effort throughout the day to
postpone worrying until then, you might find that by the time your “worry time” arrives, you’re
in fact no longer bothered by a particular worry!

2. Make a plan for the next day before you leave the office/at the end of the day
It can also be helpful to write a list of what you need to do the next day before you
leave the office or at the end of your day. This gives you an opportunity to plan or
problem solve the next day ahead well before you want to sleep.
When will I do my thinking time? ______

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How will I remember to do my thinking time earlier in the evening? (e.g., ask my partner
to remind me; set a reminder in my phone; put a post-it note on the fridge)
_______________________________________________________________________
_______________________________________________________________________

3. Savouring
Some people find it helpful to spend a few minutes in bed recalling and actively
appreciating their positive experiences from the day. To do this, simply try to bring to
mind any positive aspects of your day.
It can be small things like appreciating a beautiful scene or location, a hug with your
child, or being grateful for the friendly interaction you had with the coffee barista, or
you may think of something you achieved during the day, or reminisce about a
previous holiday, or think ahead to a pleasant event in the future.

3. Creating a Wind-Down Routine Before Bed

Another way of managing arousal is to create a wind-down period before bed. The idea here is
to engage in relaxing activities that are not activating. This is not about hurrying sleep onset
directly but rather about reducing hyperarousal that can interfere with sleep.
Here are some ideas. Tick off the ones that you might like to try:
 Read
 Do a craft project (e.g., knitting, building model airplanes)
 Have a bath or shower
 Take out your clothes for the next day
 Make lunch for tomorrow
 Do some prep for tomorrow night’s dinner
 Meditate
 Watch TV (only light programs)
 Stretching or Yoga
 Listen to music
 Give yourself a manicure or facial
 Iron or mend clothing
 Organise your photos
 Other:
________________________________________________________________________
 Other:
________________________________________________________________________
 Other:
________________________________________________________________________
(List adapted from Manber & Carney, 2015)

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 A word of warning… There’s no need to have fixed rules around this or be too obsessive
because it’s not helpful to have to do certain behaviours in order to sleep.

That is, we don’t want you to increase sleep effort. Having fixed protocols and rules around
going to sleep can raise your stress about sleep and constrain other aspects of your life. So, take
a relaxed and flexible approach and see what works best for you.
Consider:

 Not doing any work or checking emails after a certain time (e.g., 8pm) and at the very
least, not doing any work or checking emails in the hour before bed.
− Ideally, leave your work at work.
 Not using your computer in the 30-60 minutes before bed.
 Not playing on your phone in the 30-60 minutes before bed.

Remember, melatonin rises in the night time and makes you sleepy.
Light from electronic devices can be enough to suppress your melatonin. So, try
to limit exposure to light before bed and during the night.

You could also try using a blue-light filter on any electronic devices in the evening. Blue light is
particularly powerful in suppressing melatonin so it is helpful to use tools that limit blue light
exposure in the night time. If you have an iPhone, you can use the “Night shift” mode to reduce
blue light exposure from your phone. Alternatively, the “Twilight” app, which also includes a
blue light filter, is available on both iPhone and Android.

4. Reducing Sleep Worry and Effort

We saw that when Leo couldn’t sleep, both at the start of the night and in the middle of the
night, he tended to catastrophise about his next day functioning.

Sleep Worry = Worry about the consequences of not getting adequate sleep.

Sleep worry is very common in people with insomnia. When you worry about
your sleep, you may get pretty frustrated, start to feel tense, and notice that
you are feeling really awake.
This is a tricky situation because it makes sense that you feel frustrated about not sleeping but
at the same time, this frustration only increases your arousal making it harder to sleep.
When you are frustrated about not sleeping, it’s common to increase your sleep effort. That is,
you may find yourself actively trying to sleep either by willing yourself to sleep or by doing
things to try to bring on sleep (e.g., fixed rituals, trying not to think).

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 Sleep Effort = Actively trying to sleep.

This struggle with sleep is similar to the Finger Trap toy. With the toy trap that
you put on your fingers, your task is to get the trap off. One’s natural
inclination is to pull your fingers apart and when that doesn’t work, to pull
even harder. The problem with this approach is that it only makes the trap
tighter, making it more difficult to get off. The solution is in fact to do the
opposite to your natural inclination and to push your fingers closer together.
This loosens the weave in the trap, allowing it to come off easily.

The struggle with sleep is like the finger trap toy. The more you struggle, the worse it gets.
Another way of thinking of this is to think of it like being in a tug of war with sleep. You pull and
then sleep pulls harder. There is another solution – you can choose to drop the rope.

Fighting sleep is futile.

So what can you do instead of getting frustrated about not sleeping and increasing your sleep
effort?
You do the opposite and just go with it or accept it.
You do that by shifting your mindset about not sleeping and
coaching yourself through it.

This is supported by getting out of bed when you can’t sleep,

like we discussed with the Stimulus Control strategies.

You cannot make yourself fall asleep.

Instead of saying…
− “I’ll never get back to sleep” or “It’s going to be a disaster if I don’t get more sleep”

You could say…

 It’s OK that I’m awake now. Sleep will come when it’s ready.
 I’ll just take my mind off my worries and focus on something else.
 The odd night of poor sleep won’t hurt me.
 Even if I don’t get back to sleep, that will just increase my sleep drive
so that I sleep better tomorrow night.

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  I’ve survived sleeping badly many times. It’s not pleasant but I can cope.
 Even if I don’t get much sleep, I know I’ve functioned fine on little sleep before.
 I can handle this.
 It’s normal to wake up in the night time.
 I’ve worried about not getting enough sleep before and have been just fine.
 I’m learning skills to improve my sleep in the longer term. Even if I don’t sleep
well tonight, my sleep will improve over time.
 You can’t fight not sleeping.
 I’m better off shifting my attention to something else, like a podcast or reading.
 Worrying about my sleep only makes it worse.
 Even “good sleepers” have the odd night of poor sleep.
 Other: _____________________________________________________________

*Tick off the ones that resonate most with you. You might want to keep those ones on a note
next to your bed.

5. Summary
Congratulations on completing Lesson 2! In this week’s Lesson we covered:
− Stimulus Control – Five behavioural changes you can make to reduce arousal in bed.
− Quieting the mind with “worry time”, to-do lists at the end of the work day, savouring, and
journaling.
− Creating a wind-down routine before bed.
− Reducing sleep worry and sleep effort.

6. Your Action Plan

Your tasks to do following this lesson are:
 Review Lesson 2 slides again.
 Print out, complete, and re-read this lesson summary.
 Start working on 5-step Stimulus Control.
 Try out using worry time, journaling, savouring, or making a plan at the end of your
day (but well before bedtime).
 Create a wind-down routine and try it out tonight.
 Choose some helpful things from the list in section 6 that you can say to yourself to
help reduce your frustration about not sleeping.
 Fill out your sleep diary every morning.

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 Quick Sleep Reflection
Take a moment to reflect on your sleep over the last week…

A. What have you noticed about your sleep and sleep routine?

________________________________________________________________________________
________________________________________________________________________________

B. Write down some ways you have changed your sleep routine over the previous week.

________________________________________________________________________________
________________________________________________________________________________

C. What did you find easy/difficult about changing your sleep routine?

________________________________________________________________________________
________________________________________________________________________________

Please schedule a time to complete Lesson 3 in your diary. It will become available in 5 days. It
is important that you read this lesson summary and complete the homework tasks before you
go onto Lesson 3.

In the next Lesson, we will cover another important behavioural approach to

improve your sleep as well as strategies to manage thoughts that keep you
up at night. Good luck!

The Team from This Way Up.

www.thiswayup.org.au

Bibliography
Drug and Alcohol Services South Australia. Insomnia Management Kit: Instructions for GPs. ‘Sleep Problems’ -
www.sahealth.sa.gov.au

Kaplan, K.A. & Harvey, A.G. (2013). Treatment of sleep disturbance. In D. Barlow (Ed), Clinical Handbook of
Psychological Disorders, 5th Edition. New York: Guilford Press.

Manber, R., & Carney, C. E. (2015). Treatment Plans and Interventions for Insomnia: A Case Formulation Approach.
Guilford Publications.

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 Sleep Diary - Complete This Every Morning Week: ______
(or use the electronic version on your dashboard when you log in to your course)
Example

In the morning, fill out the information Night Tuesday _______ _______ ______ _______ _______ _______ _______
for the prior night. Date 25/03 / / / / / / /

1. Yesterday, I napped from ___ to ___ 1:50pm to

(Note the times of all naps) 2:30pm

2. What time did you go to bed last night? 10:45pm

3. What time did you try to go to sleep/turn off the lights? 11:15pm

4. How many minutes did it take for you to fall asleep after turning
40 min.
out the lights?
5. How many times was your sleep interrupted last night, not
2
counting your final awakening?
6. In total, how long did these awakenings last? 60 min.

7. How many times did you leave your bed last night? 1

8. What was the time of your final awakening? 6:15am

9. What time had you planned to wake up at? 6:30am

10. What time did you get out of bed for the day? 6:45am

11. Did you take any over-the-counter or prescription medication(s) Medication:

to help you sleep last night? Relaxo, 5mg

12. What was the quality of your sleep?

3
(1 = Very poor, 2 = Poor, 3 = Fair, 4 = Good , 5 = Very Good).
Comments (if applicable)
I have a cold

Time in bed 8hr

Total sleep time 5hr,20min.

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