Sleep restriction (SR) is a technique used in cognitive behavioral therapy for insomnia (CBT-I or CBTI). It’s intended to increase the drive to sleep.
Sleep restriction works by limiting the time spent in bed thereby inducing mild sleep deprivation. Two things hopefully happen in the process:
Many people with insomnia spend too much time in bed unsuccessfully trying to sleep. Sleep restriction works by shortening the sleep window, allowing only a few hours of sleep during the night at first. Then, over time, the sleep window is gradually increased until a more normal night's sleep is achieved. By severely limiting the time spent in bed, the therapy basically forces you to sleep.
For example: if you are limiting your initial sleep time to four hours in bed and the desired-wake up time is 6:00am, you must not go to bed until 2am. Once in bed, if you do not fall asleep within 15-20 minutes, you must get out of bed and go to another room and only return to the bed again if you are sleepy. This is repeated as many times as necessary throughout the night until you fall asleep. Naps are forbidden during the day and you must not close your eyes and sleep until the 2am bedtime rolls around again.
Once sleep is achieved, you gradually open up the sleep window, usually in 15-minute increments.
Cognitive behavioral therapy for insomnia (CBT-I) is pretty much considered the gold standard for the treatment of insomnia. Research suggests it’s up to 80% effective in various populations. (I question this success rate, especially for the long-term.) Sleep restriction is just one component of CBT-I.
It’s an attractive option because it’s drug-free, makes perfect sense on paper, and for all intents and purposes, should normalize sleep patterns.
Except for when it doesn’t.
I experienced my first run with sleep restriction in my mid 30’s while I was seeing a psychiatrist who specialized in sleep disorders. Like most insomniacs, I was desperate for sleep. Thinking my brain was completely broken, I would have done anything anyone with a credential behind their name told me to do.
The doctor described the sleep restriction process as a sort of “boot camp” for sleep. (If there's anything worthy of a boot camp designation, it's sleep restriction.) This doctor was speaking my language... A professional ballet dancer into early adulthood, “no pain, no gain” were words I lived by for most of my existence.
He figured out a plan, and in my sleep deprived haze, I enthusiastically agreed to give it my all.
Little did I know...
Sleep restriction seriously backfired on me as it does for many with chronic insomnia. It was brutal for my brain and made insomnia way worse. In my opinion, these are the 5 key reasons sleep restriction doesn’t work for everyone:
(First of all, is it ever a good idea to put the words sleep + restriction together? For an insomniac?!)
1. it increases hyperarousal. Call me crazy but approaching a stressed-out nervous system with a stressful treatment just doesn’t seem like a good idea. Sleep is about safety and surrender. It’s about calming the mind and body so sleep naturally follows. In spite of best intentions, all sleep restriction did for me was create an even GREATER level of anxiety and arousal in my brain. It was like sleep hygiene on steroids.
The added pressure of trying to cram my sleep into a severely reduced window felt absolutely UNREAL to me.
Strict rules around when and how I could sleep created a firestorm in my brain and it went into HIGH ALERT. With the added level of arousal, it’s no wonder I slept even less.
2. It increases feelings of guilt and failure. Before starting sleep restriction, my doctor asked me (repeatedly), “Are you committed to sleeping better?” “You MUST be ready to commit.”
What in the Sam Hill... of COURSE I was ready to commit, insomnia was ruining my life! How else could I explain it? Plus, I was a perfectionist since birth, so I positively lived for die-hard programs like this. Sign. Me. UP!
Things didn't go exactly as planned...
I slept even less and failed miserably from the get-go. My drive to succeed at the boot-camp (not to mention the massive amount of hope I had riding on the therapy), caused me to exceed any safe level of sleep deprivation.
I became a walking zombie.
My doctors reply, after torturing myself and sharing concern for my overall safety during the sleep restriction gig: “You must not be ready to commit.”
3. It punishes sleep when it should be celebrated: Sleep restriction enforces a strict sleep window. For people that don’t sleep during most of the window (due to heightened arousal) yet seem to fall asleep right before the alarm goes off, it requires an almost superhuman effort to make yourself get up. I am talking Hercules here, people. Especially if there’s no real need to get up.
I’ve worked an odd schedule with various start times my whole life. Often, I don't start work until the afternoon. So, after something like 45 minutes of sleep during the night, I just could not make myself get up when the alarm went off. And because I had nowhere to be at that hour anyway, getting up to stare vacantly at the wall seemed pointless. So, on occasion, I would continue to sleep for 2 or 3 more delicious hours until I woke up feeling human again.
But here’s the thing…
Instead of feeling grateful and encouraged by the wonderful sleep I achieved, I felt disappointment and failure because my sleep window was exceeded, I was "non-compliant," and now I was facing the grave possibility that I wouldn't sleep again that night. (Here comes the PRESSURE.)
So, something that should be celebrated, no matter how it's achieved, becomes sabotaging.
4. It contributes to anxiousness and hopelessness about the situation. I had so much hope riding on sleep restriction therapy. I thought for sure it was going to work. After all the things I tried (which was pretty much everything) I thought this was going to be the thing that finally got me past insomnia. Plus, the payoff for such a crazy amount of suffering had to be good, right?
My inability to stick with the schedule and improve my sleep created a profound sense of hopelessness about my situation. If the gold standard didn’t even work, how would anything else? I felt defeated, crushed, and terrified that insomnia was never going to go away.
5. Sleep restriction becomes a crutch. Perhaps the biggest downside to sleep restriction is the propensity to believe that something outside yourself is responsible for sleep. (If you're one of the lucky ones that gets results, that is.)
Many people experience success with sleep restriction, but how do we know it’s the therapy itself or the belief in the therapy? When we hand our power over, and put our confidence in something outside ourselves, we lose faith in our own ability to sleep. Without faith in our own ability to sleep, we're always dependent on “something else” or something “out there” with no real understanding or confidence in our own sleep physiology.
If insomnia comes back, we again must implement sleep restriction or whatever thing the mind believes is responsible for sleep to actually happen.
Ultimately, it is our own thoughts, beliefs, and responses that create insomnia, and until you go to the root level of that structure, you are always at risk of insomnia returning.
To be clear, I am not a certified CBTI therapist, and as previously mentioned, there are other components of CBTI that work in conjunction with sleep restriction. I do think that SR has a valuable place in the treatment of insomnia, and it can be a powerful tool for getting people back on track with their sleep.
I believe it's imperative, however, to make sure the nervous system is in a good place before implementing sleep restriction therapy. For some people, the mere thought of further restricting the opportunity for sleep is going to create additional fear about not sleeping. A good CBTI coach will be able to gauge the status of the nervous system, present sleep restriction in a way that it doesn't pose a threat to the individual, and guide a sleeping schedule accordingly.
Even though my previous experiences with sleep restriction weren't great, I think currently, I would be a perfect candidate! My sleeping times have been a bit chaotic, so I think implementing a sleep window would get my sleep back on track quite nicely. My nervous system is in a good place and I no longer have a fear of losing sleep. A sleep window would provide a bit of relief and structure for my brain.
Remember, the beautifully intrinsic process of sleep happens naturally, in the absence of effort. Your body knows how to sleep and that's never going to change.
You can find a more recent blog on some of the most FAQ's about Cognitive Behavioral Therapy for Insomnia (CBT-I) here.
Love + sleep,
Beth Kendall MA, FNTP
Holistic Sleep Coach
Health Disclaimer: The information and other content provided in this blog, or in any linked materials, are not intended and should not be construed as medical advice, nor is the information a substitute for professional medical expertise or treatment.
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