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Paradoxical intention vs stimulus control in the treatment of severe insomia
PARADOXICAL INTENTION VS STIMULUS CONTROL TREATMENT OF SEVERE INSOMNIA ROBERT
LADOUCEUR
IN THE
and YVES GROS-LOUIS
Univsrsit6
Lnval
Summary-This study compared the effectiveness of paradovlcal intention. stimulus control. informatwn and a control group on severe sleep onset insomma. Results showd that paradoxical intention and stimulus control were equally effective but sigificantly better than ths information and control groups. It 1s suggested that treatment be adapted for each individual according to data collected from the intensive behavioral nnalyGs of rach c;lw
problems related to insomnia and (d) not for insomnia. Selfbeing in psychotherapy monitoring of sleep onset latency was recorded during 2 weeks (baseline).
Many behavioral methods have been used in the treatment of insomnia such as relaxation, systematic desensitization, mental imagery, biofeedback training, electrosleep. paradoxical intention, stimulus control etc. (see Killen and Coates, 1951; Ladouceur and Gros-Louis, 19S4). Recent researches and clinical endeavours have focused their attention on the therapeutic efficacy of paradoxical intention and stimulus control (Espie and Lindslay, 19S5; Lacks et al.. 19S3). Although both methods have yielded positive results, it is not clear which one is more effective and what the respective mechanisms involved are. The present study evaluates the relative efficacy of paradoxical intention and stimulus control in the treatment of severe insomnia.
Treatmetlt
Subjects were treated in groups of 3 and -l and were randomly assigned to one of the four following groups. (a) Parudo.rical intmtion (N = 7). This treatment was delivered according to the procedure described by Ascher and Turner (1979). Individuals were instructed to stay awake as in order to analyze and long as possible understand their sleeping patterns. (b) Stirnul~~s control (,\l’ = 6). Following Bootzin’s instructions (Bootzin and Nicassio, 197S), insomniacs were asked (1) to go to sleep only when tired, (2) not to use the bed for anything except sleep and sexual activities, (3) if unable to fall asleep, to get up, to go to another room and to come back only when sleepy, (1) to wake up every morning at the same time and (5) to eliminate naps during the day.
METHOD Subjects
Twenty-seven individuals (9 males and 1s females) recruited via radio and newspaper advertisements participated in the study. Their average age was 41.S years and they had a mean duration of insomnia of 9.5 years. Selection criteria were (a) a 60-min sleep onset latency, (b) reported insomnia for more than 6 months, (c) no evident physiological Requests for reprints should be addrrsscd to: Robert Psychologir. Pav. F2lix-Antoine Suvard. 121s. QuCbw,
(c) Sleep ir$ornzutim (N = 6). Basic informations on sleep habits were provided and Ladouceur. Univcrsitc Canada GIK 7P-I.
267
Laval.
Cltt!
Univrrsitaire.
Ecoie
de
203
ROBERT
misconceptions
about
their
LADOLCELR
sleep
were
cor-
i-tXtd. (cl) Cotlrrol group (.\~ = 6). These individuals self-monitored their sleep onset latenq during baseline and treatment phases. Trliatment was given during four consecutive \veekj. each session lasting betueen 2 and 3 hr. In order to increase methodological rigor. counterdemand instructionr were given during the first three therapeutic sessions. as suggested by Steinmark 2nd Borkovec (1971). Tkvo months after the end of treatment. follow up data were collected during 1 ~veck.
Self-monitoring of sleep onset latency ~~2s used as the main dependent variable. When possible, the spouse also recorded the sleep latenq of the subject. Finally. treatment credibility and espectations were assessed according to Borkovec and Nau‘s questionnaire (1973) at the cirst and third ~.eeks of the treatment phase.
RESULTS
AKD DISCUSSION
Analyses of variance performed on age, duration of insc,mnia and sleep onset latency revealed no significant difference5 arnon~ groups (F < 1). Trcatmcnt credibility and expectations w t‘r e also equivalent among groups (F < 1) except for the Information c’roup. who showed less motivation to continue c’ therapy at the end of treatment. Sleep onset latency data analyzed with ;I 4 (groups) x 6 (weeks) analysis of variance with repeated measures revealed that the time factor \vx significant at the post test (E‘(5,15) = 2.67, p < 0.01) and the group x time interaction was marginally significant (F( IS.1 15) = 1.61. p < O.(N). No significant differences \vere found between the third and fourth weeks. showing that severe insomniacs Lvere not responsive to therapeutic expectancies (11 > 0.05). The Duncan post hoc test and simple main effect test confirmed that paradoxical intention and
stimulus control group5 were equully effa3iL.e but significantly superior to information and control groups (p < O.IJ5). At follo~v-up. only the two experimental groups we‘re s~yificantl\~ improved (p < 0.05). Finall!.. the spouse<’ informations confirmed the subjscts‘ data and both mzasures Lvt’rc‘ hishI! correlated (r = 0.90, p < (1.(M~l). The data confirm& the efficacy clt’ t\vc) behavioral methods in the treatment of insomnia. Paradoxical intentIon and stimulus control bvere equally 2ffectiL.e but superior to placebos or control groups. Kendall and Norton-Ford (I%?) and Escher. Ro\+ers and Schotte (19SS) have pointed to some limitations to the uw of counterdemand instructic)ns. Indeed, such demands ma>’ be perceived ~1s II pnrndosical intention element ~~~~r.TP. Despite this possible cumulative effect. twtti interventions had stronger therapeutic effects than vxrc found in the placebo and contrc>l groups. If inteniive beh:lGoral analysis had ken conducted in each individual cat and the treatment method chosen according to the patients’ complaints. therapeutic efficac>, might have been increased (SW Wolpe. 1973, Ic)Sh).
PARADOXICAL INTENTION AND STIMULUS CONTROL Killen J. and Coates T. J. (1984) The complaint of insomnia: what is it and how do we treat it? In Franks C. M. (ed.), New Developments in Behavior Therapy: From Research to Clinical Application, pp. 377-408. Haworth, New York. Lacks P., Bertelson Ad. D., Gans L. and Kundel J. (1983) The effectiveness of three behavioral treatments for different degrees of sleep onset insomnia. Behav. Ther. 14, 593-605. Ladouceur R. and Gros-Louis Y. (1984) Traitement comportemental de l'insomnie. Presses de l'Universite du Quebec, Montreal.
269
Steinmark S. W. and Borkovec T. D. (1974) Active and placebo treatment effects on moderate insomnia under counterdemand and positive demand instructions. 1. Abnorm. Psychol. 83, 157-163. Wolpe J. (1973) The Practice of Behavior Therapy. Pergamon, New York. Wolpe J. (1986) Individualization: the categorical imperative of behavior therapy practice. J. Behav. Ther. & Exp. Psychiat. 17, 145-153.
LADOUCEUR
IN THE
and YVES GROS-LOUIS
Univsrsit6
Lnval
Summary-This study compared the effectiveness of paradovlcal intention. stimulus control. informatwn and a control group on severe sleep onset insomma. Results showd that paradoxical intention and stimulus control were equally effective but sigificantly better than ths information and control groups. It 1s suggested that treatment be adapted for each individual according to data collected from the intensive behavioral nnalyGs of rach c;lw
problems related to insomnia and (d) not for insomnia. Selfbeing in psychotherapy monitoring of sleep onset latency was recorded during 2 weeks (baseline).
Many behavioral methods have been used in the treatment of insomnia such as relaxation, systematic desensitization, mental imagery, biofeedback training, electrosleep. paradoxical intention, stimulus control etc. (see Killen and Coates, 1951; Ladouceur and Gros-Louis, 19S4). Recent researches and clinical endeavours have focused their attention on the therapeutic efficacy of paradoxical intention and stimulus control (Espie and Lindslay, 19S5; Lacks et al.. 19S3). Although both methods have yielded positive results, it is not clear which one is more effective and what the respective mechanisms involved are. The present study evaluates the relative efficacy of paradoxical intention and stimulus control in the treatment of severe insomnia.
Treatmetlt
Subjects were treated in groups of 3 and -l and were randomly assigned to one of the four following groups. (a) Parudo.rical intmtion (N = 7). This treatment was delivered according to the procedure described by Ascher and Turner (1979). Individuals were instructed to stay awake as in order to analyze and long as possible understand their sleeping patterns. (b) Stirnul~~s control (,\l’ = 6). Following Bootzin’s instructions (Bootzin and Nicassio, 197S), insomniacs were asked (1) to go to sleep only when tired, (2) not to use the bed for anything except sleep and sexual activities, (3) if unable to fall asleep, to get up, to go to another room and to come back only when sleepy, (1) to wake up every morning at the same time and (5) to eliminate naps during the day.
METHOD Subjects
Twenty-seven individuals (9 males and 1s females) recruited via radio and newspaper advertisements participated in the study. Their average age was 41.S years and they had a mean duration of insomnia of 9.5 years. Selection criteria were (a) a 60-min sleep onset latency, (b) reported insomnia for more than 6 months, (c) no evident physiological Requests for reprints should be addrrsscd to: Robert Psychologir. Pav. F2lix-Antoine Suvard. 121s. QuCbw,
(c) Sleep ir$ornzutim (N = 6). Basic informations on sleep habits were provided and Ladouceur. Univcrsitc Canada GIK 7P-I.
267
Laval.
Cltt!
Univrrsitaire.
Ecoie
de
203
ROBERT
misconceptions
about
their
LADOLCELR
sleep
were
cor-
i-tXtd. (cl) Cotlrrol group (.\~ = 6). These individuals self-monitored their sleep onset latenq during baseline and treatment phases. Trliatment was given during four consecutive \veekj. each session lasting betueen 2 and 3 hr. In order to increase methodological rigor. counterdemand instructionr were given during the first three therapeutic sessions. as suggested by Steinmark 2nd Borkovec (1971). Tkvo months after the end of treatment. follow up data were collected during 1 ~veck.
Self-monitoring of sleep onset latency ~~2s used as the main dependent variable. When possible, the spouse also recorded the sleep latenq of the subject. Finally. treatment credibility and espectations were assessed according to Borkovec and Nau‘s questionnaire (1973) at the cirst and third ~.eeks of the treatment phase.
RESULTS
AKD DISCUSSION
Analyses of variance performed on age, duration of insc,mnia and sleep onset latency revealed no significant difference5 arnon~ groups (F < 1). Trcatmcnt credibility and expectations w t‘r e also equivalent among groups (F < 1) except for the Information c’roup. who showed less motivation to continue c’ therapy at the end of treatment. Sleep onset latency data analyzed with ;I 4 (groups) x 6 (weeks) analysis of variance with repeated measures revealed that the time factor \vx significant at the post test (E‘(5,15) = 2.67, p < 0.01) and the group x time interaction was marginally significant (F( IS.1 15) = 1.61. p < O.(N). No significant differences \vere found between the third and fourth weeks. showing that severe insomniacs Lvere not responsive to therapeutic expectancies (11 > 0.05). The Duncan post hoc test and simple main effect test confirmed that paradoxical intention and
stimulus control group5 were equully effa3iL.e but significantly superior to information and control groups (p < O.IJ5). At follo~v-up. only the two experimental groups we‘re s~yificantl\~ improved (p < 0.05). Finall!.. the spouse<’ informations confirmed the subjscts‘ data and both mzasures Lvt’rc‘ hishI! correlated (r = 0.90, p < (1.(M~l). The data confirm& the efficacy clt’ t\vc) behavioral methods in the treatment of insomnia. Paradoxical intentIon and stimulus control bvere equally 2ffectiL.e but superior to placebos or control groups. Kendall and Norton-Ford (I%?) and Escher. Ro\+ers and Schotte (19SS) have pointed to some limitations to the uw of counterdemand instructic)ns. Indeed, such demands ma>’ be perceived ~1s II pnrndosical intention element ~~~~r.TP. Despite this possible cumulative effect. twtti interventions had stronger therapeutic effects than vxrc found in the placebo and contrc>l groups. If inteniive beh:lGoral analysis had ken conducted in each individual cat and the treatment method chosen according to the patients’ complaints. therapeutic efficac>, might have been increased (SW Wolpe. 1973, Ic)Sh).
PARADOXICAL INTENTION AND STIMULUS CONTROL Killen J. and Coates T. J. (1984) The complaint of insomnia: what is it and how do we treat it? In Franks C. M. (ed.), New Developments in Behavior Therapy: From Research to Clinical Application, pp. 377-408. Haworth, New York. Lacks P., Bertelson Ad. D., Gans L. and Kundel J. (1983) The effectiveness of three behavioral treatments for different degrees of sleep onset insomnia. Behav. Ther. 14, 593-605. Ladouceur R. and Gros-Louis Y. (1984) Traitement comportemental de l'insomnie. Presses de l'Universite du Quebec, Montreal.
269
Steinmark S. W. and Borkovec T. D. (1974) Active and placebo treatment effects on moderate insomnia under counterdemand and positive demand instructions. 1. Abnorm. Psychol. 83, 157-163. Wolpe J. (1973) The Practice of Behavior Therapy. Pergamon, New York. Wolpe J. (1986) Individualization: the categorical imperative of behavior therapy practice. J. Behav. Ther. & Exp. Psychiat. 17, 145-153.