#38 - Sex In The Bed
You’ve probably heard the following:
Go to bed when you feel sleepy
If you don’t fall asleep within 20 min, get up, and go to another room.
When you feel sleepy again, go back to bed and try again.
If you don’t fall asleep within 20 min … well, go back to Step 2.
As you can see at this point, there’s a lot of getting up and down and trying to fall asleep .. but eventually you’ll break this pattern and fall asleep in < 20 min. But …
5. Get up at the same time every morning
6. Avoid napping
And then the one that shows us sleep scientists ain’t nerds …
7. Only use the bed for sleeping (and sex)
These instructions form what’s known as Stimulus Control Therapy (or SCT). SCT for insomnia was invented by Richard Bootzin (who preferred to be called ‘Dick’) in the early 1970s.
Over the decades it has withstood the tests of science and come out as an effective behavioural treatment for insomnia. As a behavioural treatment, you’ll often see SCT imbedded within cognitive-behaviour therapy for insomnia.
How many of us can say that we’ve invented something that has improved the quality of life for millions of people?
Well, Dick did.
The Evolution of Dick
For those of us who knew Dick (yes, unfortunately he passed away in 2014), he was an incredibly humble man. He tempered compliments for inventing SCT by saying “Well I just saw that people working in the alcohol field were using it, so I just adapted to insomnia”.
He was grounded. He was sharp. A gentleman. A scientist. A mentor. But nevertheless, a curious soul.
Dick visited Flinders University in Australia several times over the years to visit his colleague and friend Leon Lack (my mentor).
In 2007, Dick stayed at Flinders for a month after the Worldsleep07 conference in Cairns, and we benefitted from his wisdom.
He was working on a radical adaptation of SCT with Leon Lack and Helen Wright, as Leon had inadvertently developed a laboratory protocol to measure people’s body clock - but he and Helen saw the potential of it as a therapy.
So imagine these instructions are given to you for your insomnia:
It’s Friday night. You’re lying in bed. You’ve got 30 min to fall asleep
If you do fall asleep, you’re woken up after 1.5 minutes.
This happens every 30 min - over the entire weekend.
You can imagine what happens, right? By only getting 1.5 min of sleep every half hour, you start to become very sleepy. So sleepy that you fall asleep soon after your head hits the pillow …
And there’s the classic line!
Unlearning Insomnia
One of the most common statements a person with insomnia will say is “My head hits the pillow and I’m awake!”
Both SCT, and the radical Leon-Helen-Dick version (first named Flinders Accelerated Sleep Training [aka, FAST]), make a person eventually feel so sleepy that their head hits the pillow and they fall asleep.
In this way they are ‘unlearning’ insomnia.
One of the drawbacks of SCT is that people don’t like to do it. And really, who can blame them! Having to get up and down - move from the bedroom to the lounge room and back again - repeatedly - night after night.
It’s been said that the unlearning of insomnia takes weeks of SCT.
But FAST was intended to do its namesake - SCT in a weekend.
Fortunately, funding was received to compare FAST against SCT - and guess what?
FAST produced quicker changes in the time taken to fall asleep
FAST produced a quicker increase in sleep duration
But - the combination of FAST + SCT produced the largest benefits to sleep for people with insomnia
During the initial publication process, the anonymous reviewers didn’t care for having the name ‘Flinders’ in the title of a new insomnia therapy. That’s because no other insomnia treatment was labelled with a university name.
So FAST turned into ISR (Intensive Sleep Retraining*).
(*Sounds pretty unsexy for people recommending sex in the bed)
But ISR ran into its own problems.
It was done in a sleep lab, with expensive sleep-recording equipment and expensive 24/7 staffing.
How was it going to shift from the lab and into people’s homes? Well … that’s a story for another blog. Let’s get back to SCT …
Pushing the Envelope
I recall once when Dick visited my office and we got into a chat about whether you could modify SCT.
See, the name of SCT describes how it works.
It’s about controlling the response to a stimulus. In the case of insomnia, the stimulus is inferred to mean the bed…
…. by the way, I hope you’re not feeling tired right now from reading this blog? I know people often yawn when I’m presenting at workshops about sleep. Are you OK to go on? …
So, the point is that there can be a number of stimuli in the bedroom that can be associated with insomnia:
The bedroom itself
The bed
The pillow
Turning off the light (or these days, turning off the phone)
Heck, some people have told me their insomnia gets triggered by the sun going down
So I asked Dick:
“Can there be a modification to the SCT instructions, given there are so many stimuli in the bedroom. Do you have to go to another room? So many people with insomnia say they hate getting up in the cold and the dark and going to another room. Can you get up, but stay in the bedroom?”
He answered:
“Sure. You can get out of bed and sit on a chair next to the bed”.
This was great news to me. At that time I was working in an insomnia clinic and treating adults week-after-week. They hated getting up, which meant a back-and-forth discussion took place for 5-10 min. And to be honest, I didn’t like repeating this debate week-in week-out.
But this was a win.
I could tell my patients they didn’t have to go to another room.
Nevertheless, I was looking for another win - so I kept questioning Dick. And these questions were based on observations from doing my PhD …
But this is where the story stops. See, I love writing these blogs and making them available to everyone.
At the same time, our subscriber list is growing - and to honour them, I give them an added nugget.
In this case, they get to hear the rest of my conversation with Dick Bootzin, and the further adaptations for SCT that I’ve learned - and my patients love my version.
If you missed out on subscribing this time, look down at the bottom of the page. Don’t miss out next time…
Prof Mike Gradisar