Why do we use such an unfair name for a component of CBT-I?

By Sree Roy

Cognitive behavioral therapy is the most powerful technique that sleep specialists have for insomnia. Yet, the component that matches a person’s time in bed to their actual sleep time is marred by a threatening, inaccurate, and unfair name. Can we all agree that the phrase “sleep restriction therapy” needs to be eliminated from the medical lexicon?

“Patients are coming for help with their sleep, and the language we have is essentially ‘we’re going to take more sleep away from you,’” says sleep psychologist Anne Germain, PhD.

The irony is that the protocol of “sleep restriction” does the opposite: it restricts the location of wake. “We’re preserving sleep and just adding a little bit of time for normal wakefulness at night,” notes Germain, a member of the American Academy of Sleep Medicine and the Sleep Research Society. “Ultimately, the effect is to restrict wakefulness at night.” In COAST, the insomnia software platform Germain developed as founder and CEO of NOCTEM Health, the tool is presented to providers as “wake restriction.”

But, is “wake restriction” the consensus? Hardly. But agreeing on the replacement may not be a problem—as long as “sleep restriction” is dropped.

Behavioral sleep medicine specialist Andrew Colsky, LPC, LMHC, calls it “sleep recalibration” or “sleep optimization.” Tracy Chisholm, PsyD, DBSM, a psychologist at the Portland VA Medical Center, prefers “sleep efficiency training” and other phrases that emphasize the end goal.

“Bed restriction therapy” emerges as a lead contender, if the field ultimately opts to select a singular replacement. It is accurate—though its connotation is not ideal. “Now you’re not threatening somebody in the same way,” says sleep coach Barry Krakow, MD. “It’s still a threat. But it’s different because people think, ‘You want me to spend less time in bed? OK. But you’re not telling me to get less sleep.’”

Krakow, who accepts referrals to coach patients with insomnia at barrykrakowmd.com, also stresses that engagement hinges on shifting patients away from an hours-focused mindset and toward the concept of sleep quality. “Do you want more bad hours of sleep, or are you going to consider an idea with perhaps more hours, or less hours, but higher quality sleep?” he posits to patients.

Colsky, the owner and founder of National Sleep Center and sleepsciencetoday.com, reframes “sleep restriction” and stimulus control techniques, noting that how they are presented determines whether patients feel empowered or judged. Instructions like “don’t lie awake in bed” can make patients fear doing something wrong, says the Society of Behavioral Sleep Medicine (SBSM) member, whereas emphasizing an active benefit—getting out of bed—invites patients to see themselves as partners.

In short, terminology shapes how patients interpret what they are being asked to do. “I’ve run into patients who almost rejected engaging in treatment with me because they already tried ‘CBT-I’ in an app and they didn’t benefit,” says Chisholm, an SBSM member. “Names and labels have power, and even using the acronym ‘CBT-I’ can be confusing for patients who don’t understand that there’s not equivalency between CBT-I (the app) and CBT-I with a highly trained clinician.”

Landing on a single replacement for “sleep restriction” may not be necessary. After all, clinicians may benefit from tailoring terminology to individual patients. But establishing a clear, fair vocabulary would give patients with insomnia a sturdier foundation for the work ahead.