You may remember from chapter 3 that what you do in response to poor sleep can greatly influence whether your sleep problems become chronic. One common response to unreliable sleep is to spend more and more time “trying” to sleep. You may stay in bed longer and longer. Or maybe there are more hours between your initial bedtime and final rise time, with stretches in the middle during which you are out of bed. Or perhaps you take naps during the day. You may be chasing more sleep every night of the week, or just on weekends. As you spend more time trying to sleep, your sleep thins out to cover the wider territory you set aside for it. You may experience this as light, fitful, or nonrestorative sleep, or as multiple awakenings throughout the night. For example, if you are regularly getting six hours of sleep, you may say, “Yeah, but they’re not even six good hours!”
In sleep restriction therapy (SRT) we limit your sleep window (the hours you set aside for sleep) to match the amount of sleep your body currently is getting. The result? Your sleep is likely to consolidate: it will knit back together and you will have fewer interruptions; your sleep will be deeper and more restful. At first you may still have all the daytime consequences of insomnia (such as fatigue or “foggy” thinking) because you still will not be getting enough sleep. However, once you have a stable base of consolidated sleep, we will build on that to get you back to a healthy amount of sleep.
As we said in chapter 5, both sleep restriction and stimulus control are likely to work for you, so we often suggest picking the one you are most willing to do fully. Having said that, we would recommend SRT over SCT if any of the following are true:
We suggest you start with SCT instead of SRT if:
Sleep Restriction Therapy: Basic Recipe
Now let’s look closely at each step. Though the steps may seem simple in concept, clients usually have quite a few questions once they start to think about actually doing the program.
Your sleep efficiency is the proportion of time in bed that you are asleep. Most people do spend some time (ten to twenty minutes) awake before dropping off to sleep in the beginning of the night. It also is completely normal to have one or two brief awakenings (depending on your age and other factors). Thus, we don’t expect 100% efficiency. A good target is 90% for youth and adults, and 85% for older adults, since people do have more awakenings with age (Williams, Karacan & Hursch, 1974).
There are times to use SRT even if your average SE is over 90%. For example, if your SE was high only on nights you used sleep aids, this will pull up your average. You can calculate your average total sleep time using only the nights on which you did not use sleep aids. This then forms the basis for your initial SRT prescription. Also, if your technical SE is over 90% because you do not stay in bed when you are not asleep, but you are asleep less than 90% of the time between your initial bedtime and final rise time, SRT can certainly work well.
Remember, it is best to use ten to fourteen nights of sleep log data to determine your current average TST. If you are currently averaging over five hours of sleep, you will set your TIB equal to your average TST. Otherwise, you will set your TIB to five hours. The developers of this treatment started with a lower limit of four hours and thirty minutes prescribed TIB, but increased this to five hours because less than five hours was creating too much sleep deprivation in the beginning of treatment, without enough added benefit to outweigh this cost (Spielman, Chien-Ming & Glovinsky, 2011).
Once you figure out how many hours you will be in bed, how do you choose which hours? There are different philosophies about this. We tend to share the view of the people who developed SRT: we suggest setting your sleep window during the stretch of night that is most likely to contain your best sleep (Spielman, Chien-Ming & Glovinsky, 2011). For example, if you fall asleep easily and get several hours of solid sleep before waking up, start your sleep window at your desired bedtime. If, on the other hand, the early part of the night is hardest, and you finally drop into a deep sleep at 3 a.m., then set your sleep window for the latter part of the night, waking up at your desired rise time. If it is the middle stretch that brings the most tranquil sleep, shave off time in bed at both ends. If there is no predictable pattern or your sleep is equally fitful throughout the night, consider what schedule will be easiest for you. Is it easier to imagine staying up later, or getting out of bed earlier?
If, after considering all of this, you still are not sure, our default is to have you go to bed later and rise at your desired wake time. We say this because (1) a majority of our clients say that it is easier to force themselves to stay awake later than it is to force themselves out of bed before sunrise; and (2) having a fixed wake time is one of the best anchors for your internal clock, and you will not have to adjust your wake time during the treatment program if you start with it at your desired rise time.
By “desired bedtime” we mean the time you hope to go to bed once your sleep has regulated. If you would normally shoot for 10:30 p.m.–6 a.m., but have been getting in bed at 9 p.m. because you’re so exhausted, start your sleep window no earlier than 10:30 p.m. By “desired rise time,” we do not mean in your ideal world, but rather the earliest you have to be up to meet your obligations (child care, work, school) or participate in desired activities (worship services, running group). So if twice a week you need to be up by 6:30, have your rise time be no later than 6:30. Having a consistent sleep-wake schedule—not just a restricted one—is an essential component of SRT.
Even short naps will lower your sleep drive. We are not sure, but even tiny “nod offs” close to bed may make a big difference in some people’s sleep drive. A stronger sleep drive will help you fall asleep quickly and stay asleep throughout the night.
It is essential that you continue to keep your sleep log as you do SRT. Not only will this help you honestly evaluate how closely you are sticking with the program, it also will provide the information you need to know when it is time to increase (or decrease) your time in bed. Notice in this instruction that you are changing your TIB based on a full week of data, not just one night. This (1) allows you to build the solid base of consolidated sleep we are seeking, (2) protects against “kneejerk” reactions to one unusually “good” or “bad” night, and (3) may keep you from putting too much pressure on yourself to sleep on any one particular night.
By a “one-week period” we mean any consecutive seven days, not necessarily a calendar week. You are welcome to calculate your averages just once a week, or you can do it more frequently using the previous seven nights’ data. For example, say your SE is 88% in the first week of treatment (leading you to keep your TIB the same), and was clearly better the last four nights than the first three. Instead of waiting another seven nights, you may want to see if your SE has reached the 90% threshold after three more days on the program. If your seven-day average SE is now 90%, you can increase your TIB after ten nights, instead of waiting a full two weeks.
Very rarely do our clients have to reduce their TIB if their initial prescription was set at their current average TST. It is theoretically possible that your sleep will become even less efficient during the program, and your SE will fall in the range that suggests you decrease TIB. However, we have only had this happen with clients who started with a more gentle restriction, and therefore could not really expect to sleep 85% of the time they were in bed.
Think of your target as the amount of sleep that allows you to feel rested and perform well during the day. There is no one ideal for everyone. In fact, your own sleep needs are likely to change over time.
You may discover through this program that you need less sleep than you thought. For example, right now you may think that you do best with eight hours. Let’s say in the first six weeks of treatment you are hitting the 90% SE mark and you add fifteen minutes TIB each week. Now, in week 7, you increase TIB to seven and a half hours and your sleep breaks apart some, yielding an SE of less than 85%. You decide to return to seven and a quarter hours TIB, and realize that you are feeling rested and there are no negative daytime consequences. We would celebrate this as a success. The goal of treatment is not to get to some predetermined amount of sleep that you think you need, but to get the sleep that you actually do need. We want to help you sleep to live, not live to sleep. Focusing on how you feel during the day—instead of how much sleep you are getting at night—is a big part of this.
“You want me to RESTRICT my sleep, when I’m already getting too little? No way!”
We cannot tell you how many times we have witnessed people convert from “no way” to true believers. This treatment works! It may help to realize that although the treatment is called sleep restriction, we are restricting your time in bed more than your actual sleep. A better, less alarming name might be “sleep consolidation therapy.”
Realistically, though, you probably will get less sleep at first. You will be in bed for the amount of time you currently are sleeping, and we expect you to sleep about 90% of the time you are in bed, which means you may get 10% less sleep than your current average. For example, if you are averaging six hours of TST, you will get closer to five and a half hours of sleep if your SE is 90%. Now, if you follow the program strictly, you may be so tired that your SE is well over 90% and you may not lose sleep. Also, even if you get less sleep, your sleep may quickly become deeper and more restorative, leading you to feel better instead of worse. Even if you do feel worse at first, we are confident that this will pay off in the long term.
Some clinicians do suggest an initial prescription of thirty minutes more than your average TST. This extra padding makes it more likely that you will not initially lose sleep, making the program more palatable or acceptable to some people. You can certainly try this more lenient approach. We suggest the more aggressive approach because we have seen this work better for more people.
“Can I do a more mild version of the treatment?”
Perhaps you are currently sleeping an average of six hours a night, are in bed nine hours, and want to know if you can limit TIB to seven hours instead of six. Remember, you do not “have” to do anything we suggest! In our experience, a smaller “dose” of the treatment does sometimes work. And sometimes it doesn’t. Ask yourself: do you prefer to be aggressive, so that you are more likely to get quicker results? Or do you prefer to be a bit more gentle, perhaps to have less anxiety about the treatment or to feel more confident that you can handle your daytime obligations?
Most of our clients who start with a more gentle prescription end up reducing their TIB more before they get the results they are looking for. Interestingly, there is a treatment called “sleep compression” that has you gradually decrease your TIB until it matches your TST. In the example above, you would start by restricting TIB to seven and a half hours, which is halfway between your average TST and TIB. The following week you would reduce to six and three-quarters hours, and then the next week to six hours. We suggest SRT instead of sleep compression if you are willing to be more aggressive, because it works more quickly.
“My baseline sleep logs show an average TST of four hours. Can I restrict my TIB below five hours, to be even more aggressive?”
We suggest that you start with five hours of TIB. If you do not make significant progress and are safely tolerating the sleep deprivation, then you may decide to restrict your TIB further. If you are going to restrict TIB below five hours, we recommend that you be in bed for at least thirty minutes more than your current TST since you are unlikely to sleep the entire time you are in bed, and you are getting so little sleep already. In this example, then, you would set TIB to four and a half hours.
“Once in a while I have to get up earlier than usual, but I really don’t want this to be my regular rise time. What should I do?”
Although having a consistent sleep-wake schedule is important, remember our emphasis on finding the sweet spot: be as consistent as you can be so the program has the best chance of working, but flexible enough to tailor the program to your own needs. Let’s say you usually need to rise at 7 a.m. but once every two weeks you have to be up at 6:15. If 7 a.m. is a much more appealing rise time, you may decide to have an inconsistent sleep schedule once every two weeks, rather than an undesirable rise time every morning.
“My prescribed sleep window starts really late. What should I do until bedtime?”
Whatever you want! You can stay out later socializing, reading at a coffee shop, or grocery shopping. You can get house chores or work done. You can engage in your favorite hobbies. You can do something indulgent that you ordinarily don’t take the time to do. We do suggest a wind-down period (see chapter 9). It is just that this buffer between your day and your sleep may be at 1 a.m. instead of 10 p.m.
Some people do struggle to stay awake. You may feel too tired to safely be out of your home, and may not have the energy or focus for chores, work, or your hobbies. You may doze off with a less demanding activity like watching television. First, consider recruiting someone to spend time with you (even if by telephone). Do you have any “night owls” in your life, or people who live in a different time zone so that they will be awake when you are struggling? Do you have a housemate who would be happy to stay up late with you? Second, spend some time brainstorming activities that are possible with your level of energy, provide enough stimulation to keep you awake, and won’t disturb others in your household. This is different for everyone. Maybe reading feels impossible, but you can listen to an audio book. Maybe you are too unfocused to manage your finances, but you can sort and file papers that have been screaming for organization. Other ideas from some of our clients: prepare tomorrow’s meals; fold or iron laundry; clean or organize; play games like Sudoku or solitaire; organize photographs; write (letters, stories, journals); stretch or do a nighttime yoga routine; take a bath; watch television or movies; plan an upcoming vacation; or do crafts like knitting, sewing, scrapbooking, or wood whittling.
We do encourage you to make these hours rewarding. The last thing we want is for you to view this treatment program as extending the hours of drudgery in each day. If all the time you have been spending trying to sleep has gotten you behind, and you are getting more and more overwhelmed with life’s chores, then maybe it will be more rewarding to get stuff done. On the other hand, if you have been pushing through everything you “have to” or “should” do, with little time or energy left for simple pleasures, then we suggest that you do something more relaxing or indulgent.
“My prescribed sleep window suggests that I get up really early. I’m afraid I won’t be able to.”
This can take some significant problem-solving, and the solutions available depend on your living environment. If you have a housemate who rises early, see if he or she will help you. We have had some clients whose spouse or parents woke them with a cup of coffee in hand! Or perhaps someone not in the house would be willing to call you. Or maybe, based on the guidelines above, you initially set your sleep window to a 4 a.m. wakeup and your bed partner rises at 4:45. You may decide to set your rise time in sync with your partner’s in order to make it easier for you to comply.
If you need to depend on an alarm but sleep through even the loudest, you may benefit from a bed-shaking alarm or a timer that turns on your lights. If you are prone to turning off the alarm and falling promptly back to sleep, you may need multiple alarms, including one or more that is out of reach of the bed. There are alarm clocks that move around the room so that you have to chase after them. There are smartphone applications that make you do an alerting task—like swipe a particular pattern or scan a medication bottle—to turn off the alarm. We had a client set multiple alarms in a path from bed to bathroom. Once in the bathroom, he got in the shower to keep from getting back in bed. Other clients put something on the bed to create an obstacle to climbing back in—one dumped a basket of laundry, while another scattered some marbles (ouch!).
“My prescribed sleep window suggests I get up really early. What should I do in the wee hours of the morning?”
On the one hand, we do not want you to train your brain to expect to start your day so early if your ultimate goal is to sleep later. On the other hand, we want you to recapture some of the time you have lost to insomnia, and we want you to experience these early morning hours as rewarding so that it is easier to stick with the program.
You may decide to simply start your day earlier, doing precisely what you would have done in the first hour after a more traditional wake time. Or you may decide to use these hours for pleasurable or self-care activities, such as exercise, reading, or watching movies. Or perhaps you want to get caught up on household tasks like cleaning or finances. Most of the information we provided above about what to do late at night applies here. Do you have a friend or relative who is a “morning lark” and would be interested in meeting for a walk or an early breakfast? Is there an exercise class you are interested in? It’s amazing how much of the world is awake even at 5 a.m.!
If your ultimate goal is to be sleeping later, be careful not to make any long-term commitments that will not fit with your desired sleep schedule. For example, it is fine to go to a 5:15 a.m. exercise class this week if your prescribed wake time is 4:30. However, do not prepay for a three-month class at 5:15 a.m. if you hope to sleep until 6 a.m. later in the program.
“If I follow this program, I won’t be going to bed with my bed partner. This is upsetting to me and/or to him or her.”
First, if it is your partner you are worried about, check with him or her before you jump to conclusions. Explain what you are planning to do, why, and the fact that this will likely be a short-term change. (We say “likely” because your natural rhythm may be different than your partner’s. Trying to go to sleep too early or too late may be part of your problem. If so, you may maintain a different sleep schedule even after the program.) We have been surprised how often our clients have expected their partners to be hurt or angry when they turned out to be supportive.
If you do not want to miss out on the connection you and your partner have at bedtime, you can climb in bed with your partner and then get out of bed when he or she falls asleep. This has worked really well for a couple of our clients!
“What’s wrong with napping? Entire cultures revolve around a midday siesta!”
We are not asking you to give up naps forever. This program relies on your having a strong and consistent sleep drive at bedtime each night. Daytime naps will lower your sleep drive.
“My SE is over 90%. Can’t I increase my TIB by more than a piddly fifteen minutes?”
You can, but we generally do not recommend it. The developers of the treatment suggest increasing TIB in fifteen- or thirty-minute increments (Spielman, Chien-Ming & Glovinsky, 2011). We suggest fifteen minutes because when our clients have tried to take bigger steps, more often than not their sleep has broken apart more. Sometimes it was then hard for them to recapture their initial improvements.
“Can’t I increase my TIB more frequently if my SE is high?”
Again, you can, but we do not recommend it. There is nothing magical about seven nights, so we can’t argue that you should absolutely wait seven instead of adjusting after five nights, for example. And there are not any research studies comparing different versions of SRT. But just like with the amount of time you add at each step, our experience suggests that “the slower you go, the faster you get there.”
Our experience also supports flexibility. If there is a compelling reason to increase your TIB after five or six nights, we would certainly support you in trying this.
“My average SE for the past week is 90%, but the past two nights haven’t been so great. Should I increase my TIB tonight?”
If you are willing to be patient and take it slow, we recommend continuing with your current TIB until your sleep is again more consolidated. You need not wait another week. If you sleep more solidly tonight, you may decide to increase TIB as soon as tomorrow night given your high weekly average SE.
“I set my sleep window to the part of the night when I sleep best, as you suggested. I am sleeping well during that time, but I can’t seem to sleep more now that I’ve increased my TIB.”
Remember how we said that there are different philosophies? You may want to use the competing philosophy: schedule your sleep window for the part of the night that contains your worst or least reliable sleep. The hope is that this will force you to sleep during the most difficult hours. It will then be easier to expand your sleep into the part of the night that contains your best sleep.
For example, if you sleep well in the beginning of the night, you will now stay awake during these hours. When you finally go to sleep for the last part of your target sleep window, your sleep drive will be so high that you will be more likely to sleep. When it is time to increase your TIB, you will do so by going to bed earlier. This likely will not be a problem because you will be going to bed at a time of night when you tend to sleep better.
“I’m fighting off a cold or flu. What should I do?”
Our bodies do need more rest when we are sick or getting sick. If you are actually able to sleep deeply, you may decide to suspend treatment and let your body get the sleep it needs. However, if you are resting more than you are sleeping, or if your sleep is fitful or broken, we encourage you to give your body the rest it needs while keeping the SRT principles in place. That is, outside of your prescribed sleep window, rest on a couch or chair, preferably without nodding off. Rest in bed during your prescribed window.
“I want to start SRT now, but I’m in the middle of tapering off of a benzodiazepine. What do I need to know?”
We have had plenty of clients do SRT at the same time they are coming off of a benzodiazepine medication (generally prescribed for sleep or anxiety) because they are tapering very slowly and do not want to delay SRT for weeks or months. The main thing to avoid is changing your medication dose and your TIB at the same time. We generally recommend five days between changes (though this is not based on research because we are unaware of any data on this). For example, if your SE is 90%, but you just decreased your medication dose, hold steady your TIB for another five nights. Then add fifteen minutes, but only if your SE is still 90% or more. Similarly, if you just increased your TIB, wait at least five nights before decreasing your medication dose.
The idea is to let your body adjust to the change you just made (decreased medication or increased TIB) before introducing another change. If this advice is counter to a schedule your physician gave you for coming off of your medications, please consult with your physician.
“I’m going to be traveling across time zones. How should I handle this?”
If it works to keep your sleep window the same based on your home time zone, this is least disruptive and we would default to this. However, you may need to be awake at different hours (if, for example, you are traveling east and have early morning commitments). There is not one right way to shift your sleep window. We mostly want you to think it through ahead of time, and pick a plan in which you have confidence. Some people slowly shift their sleep window before they travel. Others slowly shift it once they arrive at their destination. Others shift all at once instead of slowly. And some shift their sleep window to hours somewhere between their home and travel time zones.
“Daylight Savings Time is starting (or ending). How should I handle this?”
The same principles apply here as with travel. If you don’t need to adjust your hours, don’t. If you do need to, you can do it all at once, or incrementally. Let’s say your target sleep window is 10 p.m.–6 a.m. If your current sleep window is 11 p.m.–4 a.m., then you can continue to sleep at the same “sun time” when the clocks change. Shifting one hour in either direction keeps you in your target range. Similarly, you can stay on the same sleep schedule if your current sleep window is 1 a.m.–6 a.m. and the clocks are moving back, though the clock will now read 12 midnight to 5 a.m. If you do this, then you will need to add TIB to both ends of the sleep window over the course of treatment, rather than just moving your bedtime earlier.
If, however, your current sleep window is 1 a.m.–6 a.m., and the clocks are moving forward, then you will need to adjust your sleep window in order to stay within your target sleep window. On the Saturday night of the time change, you can go to bed and get up an hour earlier if you have been very sleepy in the hour before your current bedtime and are confident that you will fall asleep easily. Otherwise, you may want to shift your sleep window earlier in increments of fifteen to thirty minutes. (You can also use some of your extra time out of bed to lobby your congressional representatives to do away with Daylight Savings Time!)
“I just don’t want to [spend less time in bed, give up even more sleep]!”
You don’t have to want to do a particular thing in order to do it. Try this: think of all the things you have done even though you did not want to. Have you paid taxes or bills that you did not want to pay? Waited in a line when you would have liked to walk right up to the register? Sat squished in the middle seat on an airplane? Scrubbed a toilet or done other housework that you hate doing? Attended a family function you wanted to skip? Completed a class you did not like? Chances are you have done thousands of things that you have not wanted to do.
Sometimes when we want to get somewhere, we do not enjoy every part of the journey. This may be true of your journey to better sleep. If you do not want to do this treatment fully, we urge you to take a few moments to think about your goals. Why are you reading this book? What do you want to change? How might your life be better if SRT works for you? Now, carefully consider: are you willing to spend less time in bed—and possibly sleep a little less—in the service of these goals?
If you simply are not willing to follow the SRT guidelines, then you can consider stimulus control. If this is not an option (based on your work in chapter 5, or because you are not willing to do that either), then you can start with cognitive strategies, especially working with the thoughts that are interfering with your willingness to do the behavioral programs.
“I have bipolar disorder [or a seizure disorder]. Are you sure I can’t do this program?”
No! We have had success using SRT with clients who have bipolar disorder or other conditions that are sensitive to decreased sleep. However, because of the increased risk of negative consequences (such as increased mood instability), we strongly suggest that you work with a knowledgeable clinician who can help you decide whether and when to use the program, modify the program as needed, and monitor your symptoms.
You may be wondering how long it will take for this treatment to work. Your sleep may improve almost immediately: by giving yourself less time in bed, your sleep may quickly consolidate, leading you to feel more rested even with less sleep. Or, even if your sleep isn’t more refreshing, you may feel a lot better because you have recaptured hours of your life that you had given over to insomnia. One client came in after the first week of SRT amazed at how good it felt to go to his office. In response to his insomnia he had been working from home so that he could cater to his erratic sleep schedule and take breaks when he needed to. He hadn’t realized how isolated he felt, nor how guilty he felt about “taking advantage” of a flexible manager. With his SRT prescription, he knew he had to be out of bed for many more hours, and decided that it would actually be easier to stick to the program if he was at the office instead of near a bed. As his daytime quality of life improved, so too did his ability to sleep at night.
Many people, though, feel worse before they feel better. As acknowledged above, you may get about 10% less sleep than your pretreatment average since you are unlikely to sleep 100% of the time that you are in bed. And if you have some nights that are better than others, you will be giving up the extra sleep you were getting on the best nights by restricting yourself to only an average night’s sleep. Plus, if you feel anxious about restricting your sleep window, anxious arousal may make you sleep worse than usual.
If you do feel worse at first, please know that this does not mean that the treatment isn’t working! In fact, this may even work in your favor. Lost sleep tonight can ramp up your sleep drive, improving your sleep on subsequent nights. If you stick with SRT, we have very high confidence that the program will work, and you will soon be feeling better.
Finally, at some point during the program you may feel more groggy when you wake up, and you may conclude that you are even more sleep deprived than before. Believe it or not, this can be an encouraging sign: we feel more groggy when we are pulled out of deeper stages of sleep, so your grogginess may mean you are getting more deep sleep, which is exactly what we are hoping for!
You may be worn down from months or years or even decades of insomnia. We know that this can make it incredibly hard to risk getting even less sleep or feeling even more tired. We would not ask you to do this hard work if we had not witnessed the dramatic improvements our clients have had using this treatment. Nor would we ask you to do this hard work if we knew of an easier and more comfortable way.
Whether you improve quickly or it takes weeks, your improvement may not be linear. You may make progress and then suffer a setback. Most often a setback will come when you have just increased your TIB. With time, your sleep is likely to consolidate again. If it does not consolidate during the week, and your SE has dipped below the 85% threshold, you will decrease your TIB. We know this can be discouraging, but don’t give up! If you stick with the program, it is likely to work. Sometimes our bodies need to hang out at a new plateau before more change is possible. Weight loss is a good example. If you want to lose twenty pounds and you change your eating and exercise habits to accomplish this, the first five pounds may come off quickly. Then the scale may stop moving. If you are accepting of this and are willing to stay at this weight while you continue to eat and exercise for weight loss, your body will eventually adjust to its new weight and you will again start to lose. If, on the other hand, you become discouraged and return to your old eating and exercise habits, you will regain the five pounds (and maybe more). Similarly, if you were getting an average of five hours of sleep before this program and now the needle is stuck at six, we encourage you to keep with the program. Six reliable hours of sleep at the same time each night really is a significant improvement, and we are confident you can build on this, even if it is going slower than you would like.
How long can you expect to be doing the SRT program? You can calculate the shortest amount of time it will take you to reach your target: take the difference between your goal TST and your starting prescribed TST, and divide by 15 if you are using minutes, or multiply by 4 if you are using hours; this is the number of weeks the treatment will take if you are able to increase TIB by 15 minutes each week. For example: if you desire 7½ hours of sleep and start with 5¾ hours in bed, the difference is 105 minutes (or 1.75 hours). 105/15 = 7 (or 1.75 × 4 = 7), so the program will take at least seven weeks to complete. In our experience people usually spend a little more time on the program.
However, if you are aggressive (starting with TIB equal to TST, and really sticking to the program each night) you likely will feel significantly better within three to five weeks of starting the program. The last few weeks on the program will be relatively easy because you will be getting consistent, predictable, good-quality sleep, which you haven’t had in a long time. Plus, even though you will not yet be at your goal, you will be getting more sleep than before treatment. So do not get too discouraged when you calculate how long the program will take you. You likely will get significant relief in less time!
Use worksheet 7.1 to develop your personalized SRT plan. Really think about each part of the plan. (How will you stay awake? How will you wake up? Why are you willing to do this?) Ask yourself if you are willing to commit to the treatment plan you just devised. You do not have to know for how long you are willing to commit. It is enough to be fully committed today. You can recommit tomorrow.
Sleep Restriction Therapy: Basic Recipe
My Prescription: My pretreatment average total sleep time = hours.
| Start Date | TIB (hrs) | Bedtime | Rise Time | Start Date | TIB (hrs) | Bedtime | Rise Time |
|---|---|---|---|---|---|---|---|
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1. |
5. |
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2. |
6. |
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3. |
7. |
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8. |
Strategies for staying awake until my prescribed bedtime:
Strategies for getting up at my prescribed wake time:
Activities I can do in the extra time I’m spending out of bed:
What I will have to give up (for example, “sleeping in on weekends,” “falling asleep for one last stretch right around my wake time”):
What discomfort I may experience (for example, “I may be even more tired at first,” “loneliness being up alone late at night or early in the morning”):
Why I’m willing to give these things up (for now) and experience these discomforts (for now):
Once you have started your SRT program, you can start to work on other strategies that are part of your treatment plan (refer to worksheet 5.1). However, be sure to stay focused on your SRT program. Remember, SRT and SCT are really the backbone of CBT-I and we would rather you do one treatment component fully than do several parts of the treatments in watered-down fashion.
Continue to track your sleep with the sleep log. Be as accurate and honest as you can be about what time you got into bed and what time you got out. This will help you evaluate how closely you are following the program. To help you decide when to change your TIB, you need to calculate your average total sleep time, time in bed, and sleep efficiency at the end of each week. Also record your weekly averages on your Sleep Log Summary (worksheet 5.2 or 5.3), and use this worksheet to track when you start SRT and other parts of your treatment program.
In chapter 13 we will help you thoroughly evaluate your treatment program after six or eight weeks. But you also will be tracking your progress each week by calculating your sleep efficiency. What should you do if you are not sleeping for 90% of your sleep window?
First, look closely at your logs and at the SRT instructions and ask yourself how closely you are following the program. Did you start with a longer sleep window than your average TST? If so, are you willing and able to reduce your TIB to be more aggressive with the treatment? Or did you increase TIB before your SE reached 90%? Did you fail to decrease your TIB, even though your SE was under 85% and your TIB was over five hours? Finally, how closely are you sticking to your current TIB? Are you nodding off earlier than your bedtime, or sleeping through the alarm, or choosing to “sleep in, just this once”?
We have been surprised how often people say they did the treatment when their sleep logs show that they did not follow the guidelines very closely. If there is any room at all for improvement, the first thing we recommend is that you do the program even more fully. Are you willing to recommit to this treatment program? What would help you do so? If it is hard to do on your own, you may want to seek out a professional trained in CBT-I.
If you are doing the program fully and have had some clear improvement (you were able to add some TIB and your sleep is more consolidated) but have stalled out, we encourage you to continue. Remember, your body may need to hang out at a new plateau before it makes even more improvement.
If you have been doing the program fully for at least four weeks and are not improving at all, it may be time to switch to or add stimulus control.
Ready to set off on this leg of your adventure? Good luck!