Can Sleep Restriction Therapy Do More Harm Than Good?
Sleep restriction therapy is often described as one of the most effective components of cognitive behavioural therapy for insomnia (CBT-I). The idea is simple. By reducing the amount of time someone spends in bed to match the amount of sleep they are actually getting, sleep drive increases, making it more likely that they will fall asleep quickly and stay asleep. As sleep improves, time in bed is gradually extended.
From a physiological perspective, it's an elegant approach. But early in my career, I began to notice that it didn't work for everyone.
For many of the clients I was seeing, particularly those living with anxiety, reducing their time in bed had an unintended consequence. The moment they realised they only had five or six hours in which to sleep, the pressure increased. Thoughts such as, "If I've only got five hours, I definitely won't sleep," were incredibly common. As anxiety rose, alertness increased, and sleep became even harder to access.
I also noticed that many people struggled to stick with the programme. Staying up while partners or family members went to bed often increased feelings of isolation, while the growing sleepiness left people feeling mentally and emotionally fragile. For some, the daytime consequences also raised genuine concerns, particularly when driving or carrying out safety critical work.
What saddened me most, however, was the sense of failure people carried when they couldn't follow the programme. Many believed they had "failed CBT-I" or simply hadn't been disciplined enough. But I wasn't convinced that was the whole story. Sleep restriction, when applied rigidly, doesn't always take into account the person sitting in front of you. Someone managing anxiety, depression, chronic pain, a young family, illness, or significant life stress may need something very different.
Over the years, this led me to question whether there was a gentler way to apply the same understanding of sleep physiology. Rather than strictly restricting time in bed, I began working with clients to establish a realistic and supportive sleep window. Sometimes this involved a small reduction in time in bed, particularly where people had extended it in an attempt to catch more sleep. But the emphasis was different. It wasn't about forcing sleep through restriction. It was about creating the conditions in which sleep could return naturally, while helping people learn that rest still has value, even on wakeful nights.
This doesn't mean sleep restriction is wrong. For some people it can be extremely effective. But after working with thousands of people with chronic insomnia, I've come to believe that flexibility and compassion are just as important as physiology.
Because for many people, the problem isn't that they haven't tried hard enough. It's that they've been trying too hard for too long. Sometimes the way forward isn't to push the system harder. It's to meet it with a little more understanding, flexibility, and care.
