Since various forms of psychopathology (e.g., mood disorders, anxiety disorders) are commonly associated with sleep disturbance, insomnia was long considered a symptom of such conditions. As such, it was generally assumed that psychotherapeutic interventions which effectively treat the primary psychiatric condition would be needed to alleviate the associated insomnia symptoms. Many of the early insomnia interventions proposed entailed complex and time consuming psychotherapies (e.g., psychoanalysis) that were of limited availability due to the special training and expertise they required. Moreover, the usefulness of these approaches for insomnia management remained questionable, due to the general lack of properly controlled studies to demonstrate their efficacy [1].

The emergence of behavioral therapies in the 1950s represented a shift in this orientation, not only for the treatment of psychopathology in general, but also for the treatment of insomnia. Indeed, the behavior therapies are designed to directly correct presenting problems, instead of exploring and understanding their psychological origins (e.g., psychological conflicts) [2]. Admittedly, one of the main features distinguishing behavioral therapy from other forms of psychotherapy is that it defines problems in terms of identifiable behavioral excesses and deficits¹. Therefore, compared to prior psychotherapeutic approaches, this goal-oriented form of psychotherapy treatment takes a more hands-on, practical approach to problem-solving. As a consequence, behavior therapy is much quicker and less costly. Furthermore, and of utmost importance, a strong scientific orientation is a hallmark of behavior therapy. These distinctive features have contributed to its success through the years, leading in the development of empirically validated behavioral treatment approaches for a variety of conditions including chronic insomnia. In fact, the behavior therapy movement has produced the majority of the empirically validated non-drug treatments for insomnia currently available to clinicians.

The evolution of behavioral insomnia therapies was aided by both empirical and clinical identification of physiological, emotional, and behavioral factors that serve to perpetuate sleep disturbance. One such factor that received early attention in this evolution was that of somatic arousal. In an early study comparing good and poor sleepers, Monroe [3] noted that poor sleepers showed greater autonomic arousal (i.e., higher body temperature and faster heart rate) prior to and during sleep than did good sleepers. This observation led to the early speculation that a heightened state of somatic arousal prior to and during sleep might serve to sustain insomnia. This speculation, in turn, led to the supposition that treatments designed to reduce this somatic arousal would be effective for ameliorating insomnia.

Early insomnia treatments designed to target sleep disruptive somatic arousal have their roots in the work of Edmund Jacobson, who was the first to propose a formal structured behavioral therapy for reducing such arousal. In the 1930s Jacobson first proposed the use of a structured exercise involving the alternate tensing and relaxing of major skeletal muscle groups so as to promote a reduction in generalized somatic arousal [4]. Applications of this sort of approach to insomnia management first appeared in the form of single case and case-series studies in the 1950s and 1960s [5, 6]. Perhaps among the more notable of these early studies was a case series study by Kahn et al. [7] who used an imagery-based variant of relaxation training called autogenic training to treat a series of 16 college students complaining of insomnia. In another early study, Geer et al. [8] used a variant of desensitization therapy in which a patient was instructed in relaxation and then instructed to visualize being at home in bed falling asleep while being relaxed. Although wrought with methodological limitations, such early studies provided encouraging results in regard to the potential efficacy of relaxation approaches for insomnia management.

It was not until the 1970s when behavioral treatments for insomnia gained popularity and researchers began conducting more well-controlled and convincing insomnia treatment studies. The first series of controlled studies tested a host of relaxation procedures whose focus was mainly on reducing bedtime physiological arousal presumed to maintain the sleep difficulties. These therapies included progressive muscle relaxation training, autogenic training, imagery training, and hypnosis [9, 10]. Of these, progressive relaxation was probably the most thoroughly tested [11]. However, researchers also tested alternate approaches, such as frontalis electromyograph (EMG) biofeedback [12, 13], in the belief that achieving frontalis muscle relaxation will generalize to other muscle groups, resulting in a global relaxation effect that would facilitate sleep. Although individuals participating in these early tests of relaxation and biofeedback did improve their sleep, findings of these studies did not produce convincing evidence that elevated arousal was a major factor in insomnia. Indeed, a study by Borkovec et al. [9] reported that reduction in arousal during therapy was unrelated to sleep outcome measures. In the same vein, Hauri [13] showed the amount of EMG reduction achieved during treatment did not correlate with improvement in sleep. Furthermore, this author noted that not all the insomnia sufferers are necessarily tense. Collectively these various findings suggested that procedures aimed at reducing somatic arousal at bedtime may be essential for some but not all insomnia sufferers.

A closer look at the findings of the studies cited above raised the possibility that a process other than the reduction of somatic arousal could explain the sleep improvements observed in the insomnia sufferers studied. Borkovec et al. [9] believed that the self-generated monotonous stimulation inherent in relaxation training may be the crucial variable. Indeed, it had been noted that a frequent complaint in insomnia sufferers was excessive cognitive activity after retiring [8], that is, they complain of “racing thoughts”. In a classic study by Lichstein et al. [14] the authors asked a series of 296 insomnia sufferers whether cognitive or somatic arousal was the main determinant of their insomnia . The largest number of subjects (55 %) perceived cognitive arousal to be the cause of their sleep problems, whereas another 35 % claimed that their insomnia was caused by both somatic and cognitive arousal. Thus, 90 % of these individuals implicated cognitive arousal in their insomnia. Such findings suggest that instruction and training in a method of attention focusing that is incompatible with that cognitive activity may serve to facilitate sleep.

Based on this assumption, a number of investigators started testing interventions designed to reduce cognitive arousal so as to improve the sleep of insomnia sufferers. With the goal of teaching patients to concentrate on non-arousing thoughts, some of the earlier cognitive interventions consisted of a number of attention focusing techniques, such as meditation [15] and guided imagery [16]. Although limited in number, these early studies yielded favorable results, pointing out that reducing cognitive arousal, per se, is an important component for the overall management of insomnia [11].

As the focus on cognitive arousal grew, the importance of the exact nature, content, and focus of insomnia sufferers’ pre-sleep cognitions became increasingly apparent [17]. In this regard, it was commonly observed that individuals complaining of sleep onset difficulties go to bed preoccupied with getting to sleep quickly and that, in fact, exacerbates their problem by this heightened intention to directly control their sleep processes. Therefore, it was hypothesized that this pre-sleep concern might be an important therapy target for those with sleep-onset insomnia. To address this sleep-defeating mentation, Turner et al. [18] developed a creative treatment for insomnia named paradoxical intention. They argued that performance anxiety over sleep could be reduced if patients were encouraged to focus upon trying not to fall asleep. Therefore, if the patient complies and genuinely tries to remain awake in bed, performance anxiety over not sleeping is alleviated and sleep becomes less difficult to initiate. In their classical study, Turner et al. [18] found good success rates for paradoxical intention, equivalent to that achieved with other promising first generation interventions. However, results have been less consistent across subsequent studies [19], with several suggesting an exacerbation of sleep problems in some patients following this therapy [20].

Paralleling the early proliferation of studies devoted to relaxation interventions for insomnia was a growing recognition that bedtime arousal and associated sleep difficulties is often, if not usually, sustained by sleep-disruptive habits. This recognition, in turn, led to the development of a variety of insomnia therapies designed to improve sleep primarily by eliminating patients’ sleep-disruptive practices. Among these therapies, stimulus control therapy (SCT) has been the most studied and proven technique. SCT, developed by Bootzin in 1972 [21], is based on the observation that, for many insomnia sufferers, the bed and bedroom are not cues for drowsiness and the onset of sleep. Instead, they become strong signals or discriminative stimuli for alertness, sleeplessness, and frustration through their repeated association with unsuccessful sleep attempts. The resulting conditioned arousal at bedtime, thus, serves to sustain insomnia. Therefore, SCT’s main goal is to teach the patient to reassociate the bed and the bedroom with rapid and successful sleep onset. This is done by instructing the insomnia sufferer to curtail all sleep-incompatible behaviors in the bedroom that serve as cues for staying awake (e.g., watching TV, talking on the phone). In addition, the patient is explicitly asked to go to bed only when sleepy and to get out of bed when lying in bed awake for an extended period unable to fall asleep. The conditioning theory from which this technique derives implies that, by following these recommendations, the individual will learn again to associate the bed and the bedroom with the rapid onset of sleepiness [22]. However, it should be noted that SCT also includes such recommendations as adhering to a standard rise time and avoiding daytime napping. These additional recommendations may also have sleep promoting effects by eliminating habits that respectively disrupt the circadian timing of sleep and reduce sleep drive at bedtime. Hence, this therapy actually addresses several putative mechanisms that serve to perpetuate insomnia over time. This fact likely explains the relative efficacy and consequent popularity of SCT when compared to other first generation treatments [23]. Indeed this treatment has arguably proven among the more efficacious first-generation behavioral insomnia therapies [24], and as will be discussed later, earned a role in the more current-day insomnia treatments [25].

A few years after the emergence of SCT, Hauri [26] proposed another approach for the management of insomnia called sleep hygiene therapy (SHT). In contrast to SCT, SHT generally targets global lifestyle and environmental factors that serve as sleep inhibitors. SHT is basically an educational intervention, which includes general guidelines about health-related practices, such as exercise, substance use, etc., and environmental factors, such as light, noise, and uncomfortable temperatures, which may affect sleep. Although the success of this approach to treat insomnia, when used in isolation, has not been strongly documented [24, 27], this primarily “educational” intervention has remained an important and fundamental part of overall insomnia management [25].

Following the emergence of SCT and SHT, Spielman et al. [28] introduced sleep restriction therapy (SRT) , a form of therapy that addressed one of the factors that they believed commonly perpetuated insomnia, namely excessive time in bed (TIB). SRT, thus, involved restricting available sleep time and making changes in TIB contingent upon the patient’s clinical response. It was thought that this approach would help to restore normal (homeostatic) sleep drive that was markedly reduced by the practice of spending excessive time in bed each night. Like SCT, SRT proved to be relatively effective for insomnia management and thus has enjoyed wide popularity through the years since it was first proposed [24, 29].

Despite their proven efficacy, each of the first-generation behavioral therapies had their limitations. Indeed, none of these interventions in itself addressed all mechanisms thought to perpetuate insomnia . Whereas relaxation approaches target bedtime arousal and sleep-related anxiety, they largely ignore other mechanisms commonly involved in insomnia, such as circadian, homeostatic, and sleep-inhibitory (i.e., conditioned arousal) factors. In contrast, these latter factors were addressed more directly by SCT and SRT, yet these therapies did not deal with cognitive factors sustaining many sleep-disruptive attitudes and beliefs seen in insomnia sufferers. On the other hand, whereas SHT directly addresses some inhibitory mechanisms (e.g., use of caffeine, nicotine) and indirectly may alter some dysfunctional sleep-related beliefs, this educational intervention, when used alone, seemed to have little impact on sleep outcome.

It should also be mentioned that much of the early research with the first generation therapies was rather limited in focus. In fact, the majority of studies testing the efficacy of these interventions focused on correcting sleep-onset insomnia [30]. Studies examining the efficacy of these interventions for sleep-maintenance insomnia were rare and often less promising. This lack of attention given to sleep-maintenance insomnia was particularly surprising, particularly when one considers that it is a more common complaint than sleep-onset insomnia, especially in middle-aged and older populations. Due to the limitations of these first-generation approaches, a more omnibus multi-component approach for the management of insomnia started to gain popularity by the end of the 1980s.

In an effort to overcome the limitations of the narrowly targeted first-generation insomnia therapies, and especially their shortcomings for the treatment of sleep-maintenance insomnia, researchers turned their attention to the use of behavioral treatment packages. It was assumed that a better treatment response would be attained if the range of insomnia perpetuating mechanisms could be addressed during the course of therapy.

In a collection of three case studies published in 1981, Thoresen et al. [31] reported on the use of a behavioral treatment package consisting of relaxation training, cognitive restructuring, and problem solving to address both sleep-onset and sleep-maintenance insomnia. A few years later, Hoelscher et al. [30], based on the assumption that sleep-maintenance insomnia may be more refractory to behavioral treatments than sleep-onset insomnia, developed a more “aggressive” form of behavioral treatment, comprising three components: sleep period reduction (i.e., SRT) , sleep education, and stimulus control, and tested this “package” with four chronic insomnia sufferers. Their findings, although preliminary, were encouraging and called for further controlled evaluations of the efficacy of a behavioral treatment package addressing behavioral and cognitive targets for sleep-maintenance insomnia.

Over the following decade, the 1990s, various renditions of a multi-component approach for the management of insomnia were described and tested [32]. Although the core behavioral components, SCT and SRT , have been included in the majority of the so-called CBT treatments, the cognitive arm has varied across studies. To correct common dysfunctional attitudes and beliefs about sleep, some interventions have used formal cognitive restructuring [33] whereas others have employed a standardized sleep education package [34].