Frustrated When Sleep Restriction Therapy Not Working? How to Problem Solve
Many people with sleep issues feel like they’ve been working on sleep for weeks.
They’re tired, they’re doing what they’re supposed to do, despite that, they’re wondering why sleep restriction therapy isn’t working.
When clients start, they’ve been struggling with insomnia symptoms, and they’re excited to have found something that research says works (CBT-I). They feel hopeful.
Then, when they’re putting all this work in, it’s hard to keep going when results aren’t immediate.
If this is you, it isn’t your fault, you’re not alone.
Sleep restriction therapy is a component of Cognitive Behavioral Therapy for Insomnia (CBT-I).
Think sleep restriction therapy is not working? Let’s look at the larger picture
As part of the larger CBT-I protocol, sleep restriction therapy is used alongside relaxation training, cognitive therapy techniques, sleep hygiene, and stimulus control to address sleep issues like chronic insomnia.
It’s effective for getting better sleep, no matter your insomnia severity. It’s known to be a first-line treatment for sleep disorders.
The process of sleep restriction therapy
Sleep restriction therapy can be a lot of work, but the benefits to most clients are worth the effort.
In this protocol, despite the name, you’re actually restricting the amount of time you spend in bed, not necessarily the amount of time you sleep.
Track your current sleep schedule
The first step is to use a sleep diary to track your sleep schedule. You use your sleep log to track your bedtime, wake-up time, hours of sleep, amount of wake time in the night, and the total amount of time that you spend in bed trying to sleep. Here’s a free version that you can use to get started.
Apply your new schedule
The next step, your therapist will use the last week of data to determine how much time you’ll spend in bed. This schedule will be based on the average amount of time you’ve been sleeping over the past week and not on the amount of time you’ve spent in bed.
So your time in bed will be restricted to the total time you have been sleeping recently. This means you will be spending less time in bed, not necessarily less time asleep.
There are other schedules that your therapist might decide are more appropriate for your unique case, but this is the most common.
While most people start sleeping more efficiently a few days into the protocol, you may realize you are not getting enough sleep.
Adjust your schedule as needed
After about a week, this schedule will be adjusted depending on how well you have been sleeping. If you’re sleeping more efficiently, your sleep window will be extended. If you’re still spending a lot of time awake in the middle of the night, your sleep window may stay the same or be shortened. Adjustments are made weekly.
Once you’re getting an adequate amount of sleep and continue to sleep efficiently, your sleep schedule will no longer need to be adjusted.
This process can be difficult, as some people experience a period where their ability to sleep gets worse before it gets better. This can be quite overwhelming if you’re already struggling with daytime sleepiness and your sleep loss feels like it’s affecting your quality of life.
Benefits of sleep restriction therapy (or how to know it’s working)
If it’s normal for insomnia to get worse before it gets better during sleep therapy, then how do you know if it’s working?
There are ways to tell if sleep restriction is an effective treatment for you. Since sleep restriction is part of CBT-I, you can see your progress in the sleep log where you’ve been sleep tracking.
Falling asleep faster
This is pretty easy to track, and you can easily tell if you are heading in the right direction, even if the rest of your sleep health isn’t improving right away.Fewer middle-of-the-night wake-ups
When you are waking up less and sleeping more soundly throughout the night, you know things are starting to improve.Better days
If you notice that you are better able to pay attention, focus, and stay awake, you know your sleep is better. Sometimes we see these changes before we see obvious changes in your sleep patterns.
Even if your sleep gets a little bit worse at first, it will quickly improve. The majority of our clients see improvement by the 4th week of treatment. Some even see improvement after the first week.
By the 8th week, most see major changes from where they started.
Signs that sleep restriction isn’t working
Now you know how to tell if sleep restriction is working, how do you decide to give it more time, or if it isn’t working for you?
Here are signs that you can use to decide if it’s not working for you.
No improvement in your sleep
One sign that sleep restriction therapy isn’t working is that there is no improvement after working on it consistently for an adequate amount of time.
If you’ve been putting in effort for a couple of weeks and still aren’t falling asleep faster or sleeping longer, this might be a sign. Make sure that your therapist tweaks your schedule a bit before you give up.
Daytime difficulties are increasing
If you’re having daytime fatigue that is getting worse, or there are safety issues that can’t be ignored, this might be a sign that it isn’t working. Some examples might be having a slower reaction time or difficulty focusing on what you are doing.
No change in the middle of the night wakefulness
If you’re still waking up off and on in the middle of the night and this hasn’t gotten any better, there is a possibility that it isn’t working for you. Once again, it is important that you give it enough time for your body to adjust to the changes to your sleep routines.
The important thing to remember is that sometimes there are temporary setbacks as our bodies adjust to the changes. For most of our clients, if you continue to be consistent with your sleep schedule, the other routines and skills you’re learning, your sleep should improve.
But as mentioned, if after 2 weeks of consistent effort and possibly some tweaking of your schedule, you’re still seeing no improvement, it might be time to problem-solve why it isn’t working.
Mistakes people make with sleep restriction
Often, when sleep restriction therapy isn’t working, it isn’t because it's not for you, this could be a sign that part of what you’re doing needs to be adjusted a bit.
Here are the most common mistakes people make:
Attempting sleep restriction by itself
This is almost always the culprit behind poor results. As mentioned before, sleep restriction therapy is not a stand-alone intervention, it’s just a small piece of an overall CBT-I treatment plan. If you are attempting sleep restriction therapy in isolation, or are only half heartedly employing other techniques like stimulus control, it will not be effective or work at all.Not tailoring your sleep window to your needs
Your sleep window needs to be specific to you and your specific sleep patterns. It's important to work with an experienced CBT-I therapist who can create your unique sleep plan based on your sleep diary and needs.Giving up too soon
Many people expect sleep restriction to start working on the first night, and when it doesn’t, or it takes a couple of days before you see improvement, it’s tempting to give up. The truth of CBT-I and sleep restriction therapy is that even though some of our clients start seeing results within the first week, it can take up to 4 weeks to see change. If you give up before then, you aren’t giving it a fair shot.Not addressing your thoughts
When you have negative beliefs/thoughts that are contributing to your insomnia, it can be hard not to give up. But first, try some of the cognitive therapy techniques (cognitive restructuring) that your therapist will teach you and see if they help you start seeing a difference.Ignoring relaxation techniques
Many people skip over this portion of CBT-I or struggle to prioritize relaxation. The truth is, you’ve been living with this level of stress for years, who’s to say it’s impacting your sleep? But as we’ve talked about before, relaxation is important to sleep, so this is a very important portion of CBT-I and shouldn’t be ignored.Not following your schedule strictly
When you are struggling with daytime sleepiness, it can be really hard to resist the call of a nap. Sometimes you might even be accidentally dozing, especially in the evenings. But following your sleep schedule and only letting yourself sleep within your approved sleep window will really make a difference in your ability to sleep. If you are struggling too much, talk to your therapist, and they will make adjustments if they are needed.
If you are going through this list and realize you don’t fit into any of these categories, then it might be time to check again if you fit into one of the categories of people that sleep restriction doesn’t work for.
Who does sleep restriction not work for
Sleep restriction therapy works well for some people, but there are certain groups that it either doesn’t work for or who should exercise caution in its use.
First and foremost, people who have certain medical conditions, like epilepsy, dementia, or who are very ill or at a high risk for falls should avoid use of sleep restriction.
Certain sleep disorders like obstructive sleep apnea, restless leg syndrome, circadian rhythm disorders, as well as certain parasomnias, can complicate treatment. If any of these diagnoses are suspected, it’s important to talk to your sleep therapist about it, and you may need to be evaluated by a medical doctor. While pregnant and postpartum women can implement this part of CBT-I, it will be important that you are under the care of a board-certified sleep therapist to make sure that you and baby stay safe.
There are also some mental health issues that your therapist needs to be aware of before starting sleep restriction therapy. The first of these is bipolar disorder, as a decrease in sleep can trigger a manic episode.
It’s also important for your therapist to know about any underlying Post Traumatic Stress Disorder so that the trauma can be addressed and your activation lowered before sleep restriction therapy is used.
Two other groups that should not utilize sleep restriction therapy are people who are on shift work or irregular schedules.
If you find that sleep restriction therapy is not recommended for you, this doesn’t mean that there is nothing you can do. Consult a sleep expert to find an alternative option.
Sleep restriction therapy tips
If you find that you are not having the success you would like with sleep restriction therapy, there are some things that you can do to help. Here are some tips that you can use to increase its effectiveness or make it more likely to help you improve your sleep quality:
Make sure that you troubleshoot with a CBT-I therapist for protocol adjustments
CBT-I is not a one-size-fits-all intervention. It needs to be adjusted to your unique situation and sleep pattern. A sleep expert who utilizes CBT-I is the place to turn to help you make those adjustments.
Get a medical evaluation
It’s important to confirm that you don’t have an underlying medical condition that is interfering with your ability to sleep.Address comorbid mental health conditions
CBT-I and sleep restriction therapy are more effective when conditions like anxiety, depression, and chronic pain are under control. Finding a sleep therapist who is well-versed in these disorders can help.Fine-tune your sleep window
Your sleep window is unique to you and your sleep cycle. If you are not already working with a therapist, they can help you to adjust that window so that it works for you.Make sure you are implementing all CBT-I components
CBT-I’s components work together and do not work as well by themselves. If you are not getting the results you seek, make sure that you are applying all of its components to your sleep.Address underlying trauma
If you suspect that something from your past is interfering with your ability to sleep, that trauma may need to be addressed so that you can sleep better. The good news is that our sleep therapists have experience with trauma and can help you make informed treatment decisions.Consider short-term sleep medication support if appropriate
In some cases, medication can help ease the transition towards sleeping better long term using CBT-I. Consult your healthcare provider if you and your therapist determine this is necessary.
A sleep therapist can help you to figure out which of these tips would be the most helpful to you. They can help you address any comorbid mental health conditions and underlying trauma.
Other options to try
If you’ve tried all of the above options and you aren’t getting the full benefit from sleep restriction therapy and CBT-I, whether it’s because of a medical condition or something else, there are other approaches to try.
For some of our clients, a modified CBT-I approach is possible, there are other insomnia treatment options that you and your therapist can explore.
If you still aren’t getting enough sleep, it’s important not to give up.
This is another place that a sleep expert therapist might be able to help.
There are a lot of options when it comes to the treatment of insomnia.
A sleep expert can help you weigh the treatment options and move forward with something that will work for you.
How to find a CBT-I Therapist for sleep restriction therapy
If sleep restriction therapy isn’t working, it isn’t a personal failure. It means that you haven’t found the treatment plan that is going to work best for you.
As you may have noticed, the best course of treatment for insomnia is to seek help from a sleep specialist.
If you would like help with problem-solving why sleep restriction therapy not working, schedule a consultation with a sleep therapist through Rhythm Wellness.
