A conversation about CBT-I with sleep physician Daniel Erichsen (#5)

Transcript

Martin Reed: Welcome to The Insomnia Coach Podcast. My name is Martin Reed. I believe that nobody needs to live with chronic insomnia and that cognitive behavioral therapy for insomnia (CBT-I) techniques can help you enjoy better sleep for the rest of your life.

Martin Reed: All right, so Daniel, thank you for being here with me today.

Daniel Erichsen: Thank you, I’m just so excited to be here, really.

Martin Reed: It’s great to have you. So first of all, can you tell us a bit more about how you got into sleep, and a bit more about your day-to-day work with your sleep patients?

Daniel Erichsen: Absolutely, so I’ll start quickly from way in the beginning, my dad’s a doctor, my mom’s a nurse, so I just kind of fall in that medical footsteps, and eventually found myself doing pediatrics actually, in the Bronx, New York. I was doing well, but I knew I wanted to do some kind of sub-specialty, some kind of fellowship, and I didn’t really know what to do. I initially thought I was going to do something really intense, like pediatric-intensive care, but I realized that was not for me. And it was really a friend of mine just said, “Oh Daniel, do you know that there’s a fellowship in sleep medicine?” That made me really curious, because I always liked higher functions, like what it… I was really curious about like, what is the purpose of sleep, why do we sleep? And so that’s how I applied and got into sleep fellowship.

Daniel Erichsen: And what happened was, I was really fortunate because my fellowship director was, he taught us CBT, very basic, but they taught us CBT. So I thought it was interesting, started practicing, and then I realized that A, it works, it helps people, but B, it’s like, nobody’s heard about it. And then I got more and more interested in really working with insomnia, but that’s how I got into sleep and insomnia.

Martin Reed: Mm-hmm (affirmative). And so CBT, which we know is cognitive-behavioral therapy, and it’s slightly modified for insomnia, like specifically for people with insomnia. Do you practice CBT-I techniques like, on a daily basis with people that you see in-clinic?

Daniel Erichsen: Yeah, it’s rarely that a day goes by without me doing some CBT. I work in a sleep clinic, a pretty typical sleep clinic, meaning the bulk of what we see is sleep apnea, I would say, probably 70 to 80% of patients are referred to us because they have sleep apnea. That said, there’s a good… The other 30%, a lot of people are insomnia, but out of those people that were referred because they have sleep apnea, when we get a history, a lot of them really have insomnia. So I say definitely between one to four patients a day is like, straight-up CT, yeah.

Martin Reed: And so, when you learned about CBT-I, what was it about it that resonated with you, like, before you’ve actually started to implement it yourself? What made you think, “Ah, this is the way forward?”

Daniel Erichsen: That’s a really good question. I have to say that what we learned was… Really what I remember is the three core techniques, which is like, bedtime restriction, you know, spending less time in bed to be able to sleep drive, and then stimulus control, and leaving the bed when you can’t sleep to re-associate, et cetera. When I really started, like when I learned about it, it wasn’t really that it spoke to me from the beginning, I just thought it was interesting and it was something a little bit different, and I understood the logic behind it. When it really started to speak to me if you will, was when I was actually… I was done with training, I started practicing, and I realized how big of a problem it was. And then it kind of started growing on me how important it was, something to that effect, yeah.

Martin Reed: Mm-hmm (affirmative). So why do you think that the CBT-I technique is just so effective for people with chronic insomnia?

Daniel Erichsen: I think because… Well, it’s two aspects to it I think. One is like looking at it from a pure sleep physiology perspective, and what I talk a lot about with clients and patients… When I say clients, by the way, I mean like people I interact with on the YouTube channel, and patients in-clinic. The pure physiology aspect of it is like, the only thing that can produce sleep is you being awake and producing a strong sleep drive, and then it makes logic sense to have more awakefulness and less time in bed. It works, it works from a pure sleep physiology standpoint, that’s one thing. And the other thing is that CBT-I… And this is the part that I think is often overlooked, and a lot of people don’t get this part of the CBT-I, which is so important, is that CBT-I untangles a lot of those beliefs that people innately start to develop as hey have insomnia.

Daniel Erichsen: As you know Martin, some people, you treat some people that have had insomnia for a couple weeks and they have some beliefs, and some people have had it for years, and they’re really entrenched, all types of behaviors and beliefs that are just so unhelpful. So CBT-I, just un-entangling people, that’s the other part why I think it’s so effective.

Martin Reed: Yeah, absolutely, I couldn’t agree with you more, all right. So based on that, you’re also working on an app called BedTyme, for the iPhone I believe it is. Can you tell us a bit more about this app? What gave you the idea to develop it, how does it work and how do you see it helping people with insomnia?

Daniel Erichsen: I had practiced sleep medicine for maybe six, seven years, and I was getting to this point where I was like, “I’m just saying the same thing over and over to people,” like talking about the basic CBT stuff. I was shocked, I was like, “How could it be that there are millions of people out there with insomnia,” literally. I’ve done some math on this, by the way Martin, and I figured like, if 50% of everybody in the Western world had insomnia there would be something like 150 million people with chronic insomnia, which is so many people with insomnia.

Daniel Erichsen: And then we know that CBT-I works, and literally not a single patient I saw in-clinic had heard about it and understood it. I was like, getting really… I couldn’t understand it, so that was in the back of my mind. And then, I was at the Sleep Conference 2017 in Boston, and then it kind of just came to me, it was just like a sudden thing. I was like, “I know how this could work.” I was like, “Bedtime restriction, which is fairly straightforward, could basically just be… It could be comprised into an algorithm, like you ask people, “How much sleep do you need, what time do you want to wake up,” and it just tells you, “Do this.” And then it can titrate it, and stuff like that. I was like, “This could be really helpful.” I didn’t think that it would be the solution to insomnia, but I think this could be helpful.

Daniel Erichsen: So that’s where it came from, but then after launching it and after speaking more about insomnia, starting a YouTube channel, talking to you Martin, one thing I really realized is that you cannot solve somebody’s insomnia without that cognitive portion, this understanding. So what I’m working on now is adding, so everybody who downloads the app is going to have a coach from day one that can help them. So that’s where I’m going with that.

Martin Reed: That’s awesome. I think the cognitive side of it is often overlooked, like we tend to just focus on the behavioral side of things with CBT-I. You know, when you see the advice online, a lot of it tends to be, “Well spend less time in bed, get out of bed when you can’t sleep.” But apart from that it’s kind of like, “Trust me,” right?

Daniel Erichsen: Exactly.

Martin Reed: And these techniques are hard, especially in the short-term, and so you really need to have a really good understanding of the logic behind them to change…

Daniel Erichsen: Exactly.

Martin Reed: … the way you think about them, and that’s really critical. I tend to find that when I talk to people that say they’ve tried CBT-I but it didn’t work for them, there’s so many ways you can kind of pick that apart. It’s like, “Well how long did you try, how consistent were you, was it even CBT-I or was it just sleep hygiene?”

Daniel Erichsen: Exactly.

Martin Reed: And then sometimes you can kind of drill down to it, and it’s just, “Well, you were told about the behavioral side of things, but no explanation was given as to why this is important.” I feel without that understanding, you’re almost kind of doomed to failure unless you’re just a naturally really trustworthy person.

Daniel Erichsen: I’m just going to echo what you said in a little, slightly different way, so people can… Sometimes that helps, is like what my wife told me, or something very similar, if you’re asking somebody to change their behavior, well, they can’t… They’re not going to do that unless they understand why they’re supposed to change it, you know?

Martin Reed: Mm-hmm (affirmative).

Daniel Erichsen: So just going to echo that.

Martin Reed: Yeah, absolutely. So you’re so prolific in the field of sleep, so you’ve done two books as well, your newest one, which is, “Why We Don’t Sleep,” which I just read a couple of days ago actually. I just want to share, rather than me trying to describe what the book’s about, I think you wrote an excellent forward at the start of the book. So I just want to read that, and then I’m going to lead into a question, okay?

Daniel Erichsen: Sure.

Martin Reed: All right, so this is the forward to the book, which is called, “Why We Don’t Sleep, how the wellness industry unintentionally created an insomnia epidemic, and how academia, media, the medical community, non-profits and a large governmental body keep feeding it.” And this is the forward. “What if I told you that nothing you’ve heard about how insomnia, or insufficient sleep affects your health, was true? What if I told you that sleeping four hours per night did nothing more than make you feel terrible, and that sleep deprivation does not cause brain damage, heart problems, or early death? Would that make you sleep better? Would that make you share the good news with others, helping them sleep better as well? I sure hope so, because that is the purpose of this book.” Now, I thought that was a really powerful opening statement, just because we both work with people with insomnia every single day, right?

Martin Reed: So we recognize that so much of the anxiety and the worry about sleep is based on, “What’s going to happen to me? How is this going to impact my health? I’m going to die earlier, I’m going to get Alzheimer’s, I’m going to get cancer,” and this kind of feeds into it. And your first words in this book are, “None of this is true,” so-

Daniel Erichsen: Exactly.

Martin Reed: So here’s a couple of questions for you, I’ll start with one.

Daniel Erichsen: Sure.

Martin Reed: Let me start with one. We’re all told that we need eight hours of sleep, right? So how does this match up with you telling us that, “All right, if you get four nights you might feel kind of lousy the next day, but it’s not going to affect your health.” How does this match up with what we’re told?

Daniel Erichsen: Yeah, I know that it’s a good question. I wish everybody always asked me that question, because I’m trying to give people an answer, but nobody’s asking that question, but yeah. First of all, I want to say that eight hour number, I’ve done quite a lot of digging to figure out like, “Where does that eight hour number come from?” And there’s absolutely no shred of science studies that supports that eight hour number. But, it’s been around for… There are 300 year old references, like, people have been thinking that eight hours is a magic number for a long time. But, here’s the interesting thing, and I’m sure you know this literature as well Martin. But, there are big studies where people look at at least thousands of people, and multiples-

Daniel Erichsen: I’m sure like, tens of thousands of people have been studied, where you check how much people estimate sleeping, and how much they actually objectively sleep, and it’s very, very consistent. People that are healthy adults that don’t have any sleep issues typically will say, “I sleep about seven hours.” Now, when you objectively test those same people, either with actigraphy or EG, like brain activity measuring, people sleep about six hours. So people tend to overestimate about an hour, so in reality people sleep about six hours. I think that’s super-important to know, and by the way, last… And last thing I’m going to say is that, not only is this true here in the US where we are now, or in the western world, but people have done studies in pre-industrial societies where there isn’t even artificial light, like in Tanzania, Bolivia and Namibia.

Daniel Erichsen: And guess how much people sleep there, objectively tested? Six hours, exactly the amount here. So I do not know where that eight hour number comes from, and in terms of health consequences there are also very, very big studies showing that short sleep is… Particularly insomnia has no link to shortened lifespan, or hasn’t been shown to cause any health consequences. Short sleep and long sleep also have not been shown to cause any health consequences, we can talk more about that if you want to, but I’ll leave that there.

Martin Reed: Yeah, it’s like you’re reading my mind. I completely agree with you, and I think a lot of this, the perpetuation with this whole idea that we need say, eight hours, I’ll just say that because that’s the most common number you see bandied around. I think also it’s because people with insomnia tend to compare their sleep with that of others, so if you are someone who doesn’t struggle with sleep, how much sleep do you get? They don’t know because they don’t think about it, so they’ll just say, “Eight hours,” because that’s what they read in the media.

Daniel Erichsen: That’s right, exactly.

Martin Reed: … a good amount of sleep, right? So they don’t think about it, so they’ll just say, “Oh, I don’t know, eight hours.” And so then it gets the person with insomnia even more worried, they’re like, “Everyone I know says eight hours. What are you talking about Daniel? You’re saying that everyone sleeps six, when all my friends are telling me eight?” Well I think they probably are only getting like, six hours of sleep, but they’re not thinking about it so they’re just defaulting to eight hours.

Daniel Erichsen: 100%, I think that’s 100% correct. And I want to sneak one thing in, like when I started developing this app, I talked about part of it is, it asks the user how much are you sleeping? And when I asked friends to test it, the most common complaint was, they were like, “How am I supposed to know that? Can’t the app just calculate that for me?” And I realized, they have no clue how much they sleep, just as you say.

Martin Reed: Yeah, exactly. And I think when we don’t struggle with sleep, we just assume that from the moment we get into bed-

Daniel Erichsen: Exactly.

Martin Reed: … to when we get out of bed we’re asleep, right?

Daniel Erichsen: Exactly.

Martin Reed: For example, I think last night I went to bed at like, midnight, and I woke up at like, 8:00.

Martin Reed: That’s not going to mean I got eight hours of sleep, I was probably lying there for an hour before I fell asleep, I probably woke during the night and was awake for a little bit during the night, and I probably took… I probably woke up like, half an hour before 8:00 you know? So there’s all these chunks of missing time, but because I don’t think about them, it probably does come into between six and seven hours. It’s not that eight hours.

Daniel Erichsen: Yeah, exactly. I talked about this, pretty recently I thought a lot about this, and I came up with this term I call, “Sleep envy,” you know?

Martin Reed: Mm-hmm (affirmative).

Daniel Erichsen: A lot of us almost have sleep envy, but the truth is that that other person is not sleeping as much as you think they do, so no reason to have sleep envy.

Martin Reed: Yeah, absolutely. And it’s just not constructive, because we all have our own sleep needs you know? We can compare it to like, shoe sizes, you know?

Daniel Erichsen: Yeah, right.

Martin Reed: We don’t get mad because our friend wears a size six shoe, and we want to… We wear a size four shoe, right?

Daniel Erichsen: Yeah, that’s good, yeah.

Martin Reed: Why do we get just as concerned when it comes to sleep, because we’re all different.

Daniel Erichsen: 100%.

Martin Reed: All right, so moving on from that, on a similar kind of vein, what do you think is the worst habit, or the worst trait that you tend to see among people with insomnia that really feeds into their sleep issues?

Daniel Erichsen: Yeah, right, I saw… You sent me some potential questions, and I thought a little bit about that one. Well, in fact I will say, as soon as I saw that question initially, intuitively I thought self-monitoring, and I know you know this Martin, but what I feel like so many other people I work with are doing is, they’re self-monitoring, they’re checking exactly how much they slept, how many times they woke up, they count the minutes they woke up, clock watching’s a big part of that. But that introspectiveness, that trying… Really, really looking at how you’re sleep… Like how much you’re sleeping to the minute, is really, really destructive. And the reason it is, and I’m segwaying a little bit from that, the goal with CBT-I, and this is the kind of recent… Which has recently really dawned upon me recently.

Daniel Erichsen: The goal has to be that you should be happy and live a happy life, and be… Feel good, and not… The goal cannot be, “I need to get seven hours.” Because having that hour goal, it leads to more self-monitoring, more introspective, more clock-watching, more obsession, more insomnia, versus like, “I want to feel good and have a happy…” That leads away from that, it takes your attention away from hours and self-monitoring, and towards sleeping better. So I think that self-monitoring is one of the really big ones.

Martin Reed: Yeah, absolutely, I couldn’t agree more. I mean, it’s easier said than done though, right? I mean, I tend to, when I start getting towards the end of working with clients, so often the biggest thing they tell me is, “My biggest takeaway was, don’t think about sleep, don’t worry about sleep. If you have a bad night, don’t worry about it.'” But it’s so easy to just say that to someone, right? “Don’t worry about your sleep, and then it will be fine.” So how do you get through this? So if someone’s listening to this now and they’re thinking, “Oh, yeah, it’s all well and good you’re telling me not to worry about my sleep. But how do I actually not worry about my sleep?” What would your answer be to them?

Daniel Erichsen: You know, I think about that all the time, because that’s one of the crucial things, how do you do that? This is the best I’ve come so far, is, I usually tell people like, “If I tell you not to think of a pink elephant, guess what? You think of a pink elephant, of course,” right? So that doesn’t work, you can’t just decide not to worry. And what I feel is the best way is distraction, it is, you have to find something that you enjoy doing, whether that’s spending time with family, with friends, a hobby, an interest that you have. You have to find something that consumes your time, and let that become where your attention goes, I think that’s the best one. And by the way, I want to sneak a little thing in here, which I think was really funny. I had this person that emailed me from the YouTube channel who said he had started having insomnia, and then what happened is he started having these GA symptoms like acid reflux and something.

Daniel Erichsen: He became really worried about that, and guess what? His insomnia got better. It just shows you how, even if you’re distracted, your attention goes to something that’s not necessarily good, any attention that’s taken away from insomnia is good.

Martin Reed: Yeah, I agree. And I think that’s one reason why it’s so important to try not to modify your life, or your routine, or your schedule in response to a bad night of sleep. I think one of the worst things you can do is call in sick for work, or cancel plans with friends, because then all you’re doing is thinking about the insomnia, thinking about the sleep, and you’re guaranteeing the sleep has a bad impact on your life.

Daniel Erichsen: Absolutely. Another way of saying the same thing is like, when you modify something or when you cancel an event because you had insomnia, you ascribe… You’re giving the insomnia power, you’re acknowledging that it has a lot of impact on your life. So yeah, definitely stay away from that.

Martin Reed: Yeah, I mean, I’ve got a little story to share with you about that. I mean, I had a client that… He was able to identify the trigger of his insomnia, it was he hated his job, it was a stressful job and he didn’t like it. He did something about it, he quit and he found a new job. But the new job didn’t start for, I think it was a four week gap, so he was like, “All right, during this period I’m going to get my sleep back on track.” I was working with him, and he was implementing all the behavioral techniques, making some progress, pretty slow though. So I asked him, “Well, tell me what you’re doing during the days?” Pretty much nothing, he would just stay indoors, maybe watch some TV. He would rarely even get out of the house. So we talked about, “Okay, what are some activities you used to enjoy doing during the day, before you struggled with sleep?”

Martin Reed: He gave me a list of like a dozen things he loves to do. So it was like, “Well how about you just… Every single day you pick one thing on that list, and you just do it. Sometimes it might be easy, sometimes it might be a struggle, but just force yourself to do one every day.” I left him with that task for a week, come back in a week. I’m not going to say he was magically cured, but the progress he had made, it was incredible. He was finding it much easier to fall asleep, he was less worried when he woke during the day… Sorry, when he woke during the night, and he just had a better outlook and the quality of his day got better. So he was thinking about sleep less, worrying about sleep less, and that in itself drove the improvements in his sleep.

Daniel Erichsen: 100%, yeah.

Martin Reed: All right, here’s a good question for you. How do you help people who seem to be getting back on track, whether it’s going through a really structured course of CBT-I, or one or two techniques. They’re doing well, maybe for a few weeks, and then all of a sudden their insomnia just comes back. They have maybe one bad night, they’re not too worried, then it’s two, then three, and then all of a sudden they fear, their insomnia comes back, they’re never going to be able to fall asleep again. What’s the next step for these people?

Daniel Erichsen: Yeah, good question, and that happens all the time. I know exactly what I’m going to answer you, so, and it goes along with what we said before, but when that happens, when you’re kind of like, “You have been doing a bit better, and then you have this…” Some people call it like a setback, or the insomnia comes back, then… And this is really hard, but the best thing to do is not react to it. Basically, don’t try to change anything, don’t do anything. In fact, it’s the most important time at all to be non-reactive, and because, again, if you start changing things, then you’re back to where it’s like, “Oh, I changed this,” now wait and see how that’s going to work. Oh, now they’re getting even less sleep, now they change another thing, and you’re chasing your tail again and things are spinning out of control.

Daniel Erichsen: So it’s really important, and this is so paradoxical, but it’s really important to do as little as possible. I know you’ve heard this one, but I think the perfect… Really good analogy, and credit to Sasha Stevens, I read it in her book Bedtime Stories. But imagine that you getting better is like you hiking up to a mountain top, and at the mountain top there’s a place where like, you’re happy, you’re sleeping well, everything’s going well for you. And you have done that, you have been hiking up, but suddenly you stumble on a rock, and if you then stop and you examine the rock, you look at it like, “Why did I fall upon this, how should I change my stride, how can I keep this from happening again,” you’re never going to get there, you have to just be forward-looking and, and then another little thing, and focused on the good. Like, imagine you have been doing so much progress, focus on that and just keep moving forward.

Martin Reed: Mm-hmm (affirmative), I think you… That’s great. I think you had another little anecdote, and it was something to do with when you’re trying to raise a child, and if you ignore their behavior then they can suddenly come back with a vengeance and really be kicking and screaming, and then you have this doubt. “Do I keep going, is this not working?” Can you tell me a bit more about that one?

Daniel Erichsen: Oh yeah, that was yesterday. Oh, that was like… You know, it’s funny.

Martin Reed: Yeah, I do. I stalk you Daniel, I know everything.

Daniel Erichsen: I know right? Yeah honestly, Martin, it’s so fun interacting with you, because you too… I think we’re kind of semi-obsessed, and we always think about these things. But I was in the shower, so what happened was, there was this one person I’m interacting with now, she sent me an email, her name is Natasha. She had the same thing, was doing better for a couple of days, then things just came crashing down. And another guy, in fact I don’t know if this is a woman or a man, but Zimi, same thing. The title of that email was like, “10 steps backward.” And then it dawned upon me, that this is what’s called an extinction burst. It’s like when you’re trying, your child is always acting up and you’re kind of pacifying that child by saying like, “Stop doing that, stop doing that, stop, stop,” and you can kind of semi-keep it under control.

Daniel Erichsen: But then you realize that that child just wants your attention, and you’re like, “What I have to do to finally kind of eliminate this behavior,” I was like, “I’m not going to give this child any attention,” but guess what? Before that starts working, that child is going to want your attention like nothing else. They’re going to be screaming and kicking, and holding you. They really want your attention now. And so that’s why you have this kind of setback, it’s actually a good sign, it’s a sign that you pulling away tension, this child is trying to fight, but if you just keep going, don’t give it that attention, it will go. That behavior will go away, potentially forever. So yeah, my insight was like, “That is a good sign, it’s a good sign when you have that initial quote unquote, ‘Setback,'” you know?

Martin Reed: Yeah. I think that will resonate with anyone who is a parent, I think any parent can identify with that one.

Daniel Erichsen: Right.

Martin Reed: I wanted to make sure that we did, we discussed that. That’s great.

Daniel Erichsen: Oh hey, and now I’m going to sneak another one in there, because thinking about child and having kids and everything, and this is one of your… Something I got from you Martin, you taught me how you can hold your breath for only so long right? Eventually you have to start breathing, it’s kind of like… And I thought about that, like, you cannot hold your breath up to a point where you actually harm your body. It’s just simply impossible, same thing with sleep, you can have insomnia, you can sleep very little, but it cannot harm you. And then thinking about children, you know how kids have these breath-holding spells? Have you heard of those?

Martin Reed: Right, yeah. Mm-hmm (affirmative), yeah.

Daniel Erichsen: They want something badly, and then they just hold their breath until they literally turn blue, and sometimes they even pass out. But that’s the point, they can turn blue, but they can’t harm themselves. Breathing comes back, sleep comes back.

Martin Reed: Yeah. It’s like insomnia’s a little child right, and it just demands all of our attention, and the best way of dealing with that is to just kind of ignore it, right?

Daniel Erichsen: 100%.

Martin Reed: All right, so let’s move on and talk about success. I know, you know, everyone that’s kind of involved in cognitive behavioral therapy for insomnia knows that it really works. It can be hard to implement, but it works. Have you got any success stories that you can share with us? Like, is there someone who maybe seemed to struggle with the techniques, or they struggled with insomnia for so long and thought they were beyond help? Maybe they relapsed, but they ultimately got their sleep back on track. Are there any kind of success stories like that you can share?

Daniel Erichsen: Yeah, when we first talked Martin, you said your podcast was going to focus on success. I was like, “That’s brilliant, because we so need that.” And I think this is good for everyone hearing this, that, imagine that if one single person has gotten past their insomnia using CBT-I, that means you can too, and I think the success stories are so important. As we talked here, I remember we saying like, “Maybe something from clinic, from that world,” since I’m a sleep doctor. Actually yesterday I was like, “This is the perfect one, I’m going to talk about this one.” So I saw this patient, the first time I believe maybe six months ago, something in that time frame. At that time, she was referred because of sleep apnea, that’s what it said in the referral. It turns out when I saw her that she’d had a sleep study, had very mild sleep apnea.

Daniel Erichsen: Was using CPAP faithfully, but wasn’t really feeling any better. The interesting thing was that the main… The chief complaint was that she was just so tired and sleepy, to a point where she had been treated with stimulant medications that you use for like, narcolepsy, and felt like… Didn’t really feel any better, had even gone though this multiple sleep links testing, which is really involved testing for narcolepsy where you check how many time… You get like, five opportunities to nap, and you see how long it takes to fall asleep, and had fallen asleep on average 12 minutes per nap, which is a long time. Meaning like, this is not objective… This actually isn’t narcolepsy, but just was not feeling any better. So the first thing I did was, I couldn’t really figure it out, because she would got to bed like 9:30, get out of bed like 6:00, and like, that’s plenty of time to sleep so you’re not insufficient sleep.

Daniel Erichsen: Sleep apnea is well-treated, it’s not sleep apnea. And I was like, “Do you feel depressed?” And she said, “I have a history of depression, but it feels well-treated now. I just…” I was like, “You know what? How about try bright light therapy?” It’s usually not a dramatic effect, but some people feel like it’s helpful. So I was like, “Maybe get a bright light therapy, exposure yourself to bright light and see how you feel.” Came back not feeling any better, still really sleepy, tired. I referred to a psychiatrist, but at some point during that encounter I was like, I saw in the med list that she had been prescribed Ambien. I was like, “That’s really odd, because you’re really asleep and tired, and you’ve been prescribed Ambien. So how are you sleeping?” She was like, “Well not that great.”

Daniel Erichsen: I was like, “Oh, now I’m interested.” I’m like, “So tell me more.” She says, “I go to bed at 9:30, bu I wake up two hours later, and then I stay awake for some time, and then I have a fitful sleep, a fragmented sleep, and I get…” And I was like, “You have insomnia.” I was like, “And it’s a little bit unusual presentation,” but I was like, “You’ve got insomnia.” I was like, “Let’s try CBT.” And then I said, “From now, I know this sounds weird but… I know you’re tired and sleepy, but I want you to go to bed later and get up earlier, spend less time in bed.” And she was like, “Okay,” willing to try, was kind of in the desperate mode. Like, “I want to try everything.” Came back and was like, “I’m feeling better. I’m feeling a little bit less tired, I’m sleeping a little bit better.

Daniel Erichsen: “And my counselor, who I was going to see for…” Who she was going to see for the depression, also noticed the CBT, so I was encouraged. By the way, at that time she was not employed, and then just recently saw her back, and it was like one of those, it’s a new person. Happy, smiling, sleeping good from you know, most of the time. Sleeping pretty well from 11:00 to 6:00 or something like that, but most importantly looking for a job again. It was dramatic, and that was a true success story I think.

Martin Reed: Yeah, that’s amazing isn’t it? Can you just clarify, what was it that made you think, “Oh, this is insomnia.” Was it because the awakenings during the night, it took…. Did it take her a long time to fall back to sleep when she woke during the night, or…

Daniel Erichsen: Yeah, that was a big one. Well, let me in fact phrase it another way, the reason I didn’t even think of insomnia was the main complaint was feeling tired and sleepy, and then I was down the sleep apnea track. But it was like, when I realized that she was going to bed really early in an attempt to get more sleep, typical insomnia, like she wanted more sleep. And then it wasn’t the sleep apnea where you wake up, fall asleep, wake up, fall asleep, it was the long awakening. So that was the clue, like, “Oh, this is insomnia.”

Martin Reed: Yeah, absolutely. I mean, I tend to work with… I work with some people that have treated sleep apnea, they’re already on the machines or they have really mild apnea, so they just have the dental appliance. So I’m always really careful to make sure that they do have insomnia, it’s not just there’s something not right in terms of their current treatment for the apnea. I think one of the key giveaways is if you’re waking during the night and you immediately have worry, and it takes you a long time to fall back to sleep, that’s a hallmark of insomnia right?

Daniel Erichsen: Yeah, absolutely.

Martin Reed: If you’re just waking up, if you regularly wake up during the night and fall straight back to sleep, or you feel like you don’t really have a problem with sleep, but you wake up in the morning, you just feel lousy because you didn’t sleep, and then more of the symptoms of apnea. Would you agree with that?

Daniel Erichsen: Yeah, absolutely. I think the key is as you said, the short, the brief, multiple awakenings. And then it’s also like, this is just something I thought about as we were speaking right now, it’s like the external… Kind of external versus internal reason that you wake up, meaning, sleep apnea’s also, “Internal,” it’s the tongue falling back that wakes you up. But it’s not an emotional, if you will, state that wakes you up. So you wake up and it can be frightening, but people wake up because they’re choking, literally. But they’re not emotionally affected, they’re like, “I wake up, choking, that was terrible,” and then they fall asleep. It’s in a way an external awakening versus insomnia, where it’s like your emotional state wakes up and then you’re aroused, you’re worried, you’re anxious and you can’t fall back to sleep, absolutely.

Martin Reed: That’s great. You have a YouTube channel as well, it’s called Insomnia Insight. I’m sure that, well, I know because I watch it, but you have a lot of involvement in people, they email you with their sleep concerns, and you try and address them in daily videos, kind of daily videos. Have you got any success stories from the YouTube channel that spring to mind, where someone has kind of struggled, thought, “Nope, this isn’t going to work, I’m beyond help,” and they’ve actually started to see some improvement in their sleep?

Daniel Erichsen: Yeah, there’s several. And before I forget this by the way, yesterday I… Because I’m inspired by your success stories and everything Martin, I decided that I wanted to write another book, which is really going to be going over kind of the basic techniques, but also picking people from the YouTube channel that have done well, and mostly people that have done well, some other good examples. And what I realized as I was going through my email list was that everybody who I’d had a kind of longer conversation with, actually did well. It was those people that sent the email to me, and I sent them kind of a long reply, and they just said, “Okay, thank you.” I don’t know, but I have a feeling that they may have not done well because they didn’t commit. But anyway, that’s just a side note. I think there was this one, a lady, she’s from…

Daniel Erichsen: Is she from Canada? Yeah, I think she’s from the Canadian west coast, named Suzanne. She’s retired, maybe in her 60s, but she randomly stumbled across my YouTube channel and we started communicating via that. She didn’t have a long, it was like, maybe six to nine months, but pretty classic, a lot of worry, tried a lot of supplements, and again, since I can’t read it, I can’t remember all the details, but it was also not easy at all. Like, the first four to six weeks, a lot of these setbacks, struggling, trying again and then finally kind of, she was doing a little bit better, and about three months into our interaction she was doing pretty well, and then kind of what finally got her to a point where I consider her completely recovered was in fact that she was traveling to India, she was going to leave for four weeks, and she was a little bit worried about it.

Daniel Erichsen: But I told her, “I think that could be really good for you, change of environment and everything.” And when she came back she emailed me, said, “I had a great time, I haven’t thought about sleep at all, I sleep great,” and even now, like a couple of months into it, she’s doing fantastic. That’s one of a number of other success stories from the channel there.

Martin Reed: Yeah, you know, I think what’s really important just listening to you there was the fact that it took months, it took a few months of effort. CBT-I, I think it is pretty much a miracle cure, but it doesn’t work overnight you know? It takes a lot of effort, and it can be really hard, and some people respond to it within just a couple of weeks, but some people, they need months of consistent implementation before they get to that breakthrough moment where they don’t even think about sleep anymore.

Daniel Erichsen: Yeah, it can be really different. You have a couple of people who interact with that, literally, they just need a little bit of bedtime restriction, and they’re fine. But I also, just the other day, I got an email from another person named Juan, who I’ve been interacting with a lot. He started having trouble sleeping about two years ago, started doing self-directed CBT. When I connected with him six months ago he was doing a little better, but, now he’s doing really good, but him was the classical week to week progress, week to week, like a little bit better all the time, so yeah. It’s very different, but again, I think honestly, we talked about this before, I’m starting really to think of CBT-I as, it’s like diet and exercise for weight loss. Meaning, if you do it, it will work. It’s hard to commit to it, but if you do it it will work.

Martin Reed: Yeah, absolutely, I completely agree with you. Just to comment on the week-to-week thing that you just mentioned, it’s also important to bear in mind that you’re not going to make positive improvements every single week.

Daniel Erichsen: Sure, absolutely.

Martin Reed: There’s going to be setbacks, almost everyone has setbacks. It’s very rare that I work with someone for like eight weeks, and every single week is constant improvement.

Daniel Erichsen: 100%, yeah.

Martin Reed: And so that’s really important to just bear in mind, because a lot of people kind of lose motivation, especially if they’ve had like, three, four, maybe five weeks’ consistent improvement, and then they have a bad week, and then start to think, “Oh, this isn’t working. What am I going to do next? This isn’t working, I need to look and try something else.” I mean, it is working because five of those six weeks were good, one week was bad, so they’ve worked for five weeks and it’s like, “Hey,” just like you said, it’s, “Keep going, don’t think about it, don’t examine it.”

Daniel Erichsen: Yeah, 100%. I know, again, like Sasha Stevens, I read a couple of her books. Maybe she’s taking it a little too far, I don’t know, but what she says is like, “You should really play up the positive,” and she’s like, “You should obsess about the positive. Tell people to write it down,” things like that, which may be a little bit too much. But in essence I agree with it, like, really focus on the positive and see the setback as, it’s a hiccup, it’s a little stumble, and then just keep going, yeah.

Martin Reed: Yeah. It’s so easy to dwell on the negatives though right?

Daniel Erichsen: Yeah.

Martin Reed: Because the brain sees it as this danger to us, so it wants to protect us, so it wants to dwell on it and examine it. It doesn’t care about the good nights, because they’re not a perceived threat, so it just completely ignores them. So it’s important not to feel bad with yourself for thinking negatively about the bad nights, because that’s what we’re hardwired to do. But it’s just a case of recognizing that, and making yourself think about, or focus on the good side, on the positive side, because your brain by default isn’t going to do that for you.

Daniel Erichsen: 100%, it’s interesting you mentioned that. I’ve meant to, thought about it for a long time, to do a video on self-compassion, you know, don’t be hard on yourself, and I think that’s super-important.

Martin Reed: Yeah, absolutely. I had this down as a question, but you know what? I think we’ve already covered it, but I’ll ask it anyway. If you could get someone who’s really kind of skeptical about CBT-I, and you just wanted them… But they were willing to do like one technique as an experiment, one CBT-I technique. What technique would that be, that you would encourage them to try?

Daniel Erichsen: Right, yeah, I think it would be bedtime restriction. For most people that’s known as sleep restriction, and by the way, another little side note here, I was biking yesterday, I was thinking about this, this is terrible. As we talked about it all the time, sleep restriction sounds so terrible. Why not call it sleep expansion, you know? Because, you can motivate that because you’re expanding the time in bed that you sleep, so anyway. But I think that bedtime restriction, whatever you want to call it, I think is that… If you choose one, I would choose that one, because it has the element, the other… If you’d asked me not even the technique, if you asked me like, “Choose this one single thing to do,” I would have said, “Get out of bed the same time every morning.” That’s like, if you choose just one single thing I would choose that.

Daniel Erichsen: But if I can get to choose a technique, it would be bedtime restriction, because it includes that. You know, get up every single time every morning, but then don’t spend more than typically six hours in bed, which is really effective.

Martin Reed: I agree with you on this morning anchor, you know, the getting out of bed by the same time every single day, is just so important. But a lot of people say to me, “Well, why do I need to do that? Everyone I know, they take lie-ins on the weekend, or if they have a day off work they’ll stay in bed. Why can’t I do that?” Can you just walk us through why it’s so important to get out of bed at the same time every day?

Daniel Erichsen: Yeah. I think I’ll start off with this, saying that that friend of yours who’s sleeping in, they don’t have insomnia. Literally, they can do whatever they want, it’s fine, totally fine for them. But the difference is, you do have insomnia, so you can’t be as lenient at this time. But, and this is also important, that’s where you want to get. You want to get to a point where you’re not worrying at all about sleep, you’re not trying anything to sleep, and you can do whatever you want. That’s where you want to go. But why is that so important? I think really this is how I would phrase it, we often… We think about sleep, we often think it starts when we go to bed and it kind of ends when we wake up right?

Martin Reed: Mm-hmm (affirmative).

Daniel Erichsen: But really, it’s the opposite. It all starts when we get up, and I think the best way to understand that or think about it is like, there was something called the 18 hour rule, or 17 hour rule. Let’s say you need seven hours of sleep in 24 hours of the day, then 24 minus seven is 17. And so that means, what this means is that it will take 17 hours of wakefulness for you to be ready to sleep. When you think about it that way you realize, “Okay, it really all starts with the wake up time.” For example, if you wake up… Now this is going to be the hard part with Matthew, but if you wake up at 6:00 AM then you’re going to be ready to sleep 17 hours after that, which is going to be, so let’s do it, six plus seven… Oh, what’s that? Help me Martin. 11, right? Yeah, exactly, 11. If you wake up at 6:00 AM, you’re going to be ready to sleep somewhere around 11:00.

Daniel Erichsen: Now, if you wake up four hours after that, let’s say three hours. Let’s say three hours after that, let’s say you wake up at 9:00 AM, or you get out of it at 9:00 AM, that means 17 hours after that you’re not going to be ready to sleep until 2:00 AM. When you start thinking of it this way you realize, “Okay, it really all is about that wake-up time.”

Martin Reed: Yeah, that’s really important to bear in mind, and I love the fact that you say, “You know, these people, they can take morning lie-ins because they don’t have insomnia.” It’s kind of like saying, “Well, I have diabetes, I can’t eat that cupcake. But why can all these other people eat cupcakes, who don’t have diabetes? So that’s really important to bear in mind, that’s why some people don’t need to worry about getting out of bed at the same time every day. But if you’ve got insomnia, it’s really important to… It’s just so important to get out of bed at the same time. Your body really needs that morning anchor, just as you’ve described.

Daniel Erichsen: 100%. And just kind of jumping to another thing, what I think is another… It’s funny, because we talk about how people don’t understand they can do really whatever they want in terms of… People often ask me like, classic, I’m sure you get this all the time. Especially social occasions when people hear you speak, they’re like, “So what do you think of melatonin? What do you think about this supplement? Well I think that… My reply is like, “Well, if you don’t have any problems sleeping, it’s fine. You can do whatever you want. But if you have trouble sleeping, then things are different, then you should probably really not do it.” By the way, I’m getting… This is a whole different discussion, but we can save it up for another time.

Martin Reed: No, it’s funny that you mentioned melatonin, because all my friends kind of make fun of me because they know that I’m quite against it as a treatment in-

Daniel Erichsen: Quote unquote.

Martin Reed: Yeah, for insomnia. So any time we go out and hang out with them they’re like, “Oh, did you bring the Martin?” Because they know that it always gets me going, you know? But the reason why, just for people listening that don’t understand, is that we find that so many people with chronic insomnia take melatonin supplements to bring on sleepiness and help them sleep. But the fact is there’s absolutely no evidence that it helps when it comes to chronic insomnia. There’s some kind of patchy evidence that says it might help for other sleep disorders, like circadian rhythm. But when it comes to chronic insomnia, I mean, I’ve not come across any, and there’s, even when they do reviews on insomnia treatments, it’s never a recommended treatment for chronic insomnia because there’s just insufficient evidence for it.

Daniel Erichsen: Yeah, and it’s just one as you know, of like a thousand supplements that you can try, and the reason, if you have insomnia it’s not good for you to go down that route, is because if it… Quote unquote, if you find that the melatonin doesn’t help you, that’s not good because then you feel like, “Oh, this is another thing that doesn’t help me. Something must be really wrong with me,” and you become more anxious, you have more insomnia. If you find it quote unquote, “Helps you,” then you start believing that there’s an external thing that can make you sleep, and you start losing your sleep confidence, you start believing that you can’t sleep by yourself. And then when that melatonin no longer is quote unquote, “Working,” you’re in a more desperate situation. So yeah, really, really not good for insomnia.

Martin Reed: What do you say to people… Because I get this quite a lot, what do you say to people that were taking melatonin, they’re going through a course of CBT-I, they’re starting to feel as though they’re sleeping better. So then they start to come off the melatonin, they decided they’re going to stop taking it, or reduce it, and then their sleep gets worse. So they automatically say, “Well, this proves that the melatonin was working. Does this mean I need to take melatonin forever? Am I going to be reliant on it forever?” How do you help address that conflict? Because we’re here saying that melatonin isn’t an effective treatment for chronic insomnia, but then when people are trying to come off it they see that their sleep’s getting worse.

Daniel Erichsen: Yeah, that’s a good question. I think there are a couple of options there. One, if somebody is really into sleep physiology, then you can… I tell them that the only thing that makes you sleep and sleep is your natural sleep drive, your need for sleep, and I think a good analogy is eating. I always tell people, the only thing that can make you hungry and eat is fasting, staying awake. And then if people believe that, like they see that, and yeah, I understand, the only thing that actually can make me sleepy is my sleep drive, then they can be more willing to explore the fact that melatonin has nothing to do with it. What I feel a lot of people tell me is that this medication, or melatonin, it works sometimes and sometimes it does not work, and that’s a really good way to explore, why doesn’t it work all the time?

Daniel Erichsen: And then, “I don’t know,” and then I’m like, “Well, it’s because it actually doesn’t work. It’s just you weren’t sleepy enough that time.” But to describe the scenario you have, probably one option is to just say, “Well, as long as you’re doing well, then it’s fine, you can continue taking it. But when you start having more sleep confidence as time goes by, and maybe that one time you forgot to take it and you still slept good, and you know, things like that happen, you start questioning it, then when you’re ready you can start tapering off.

Martin Reed: Yeah, that’s good. One thing I know with a lot of people when they come off the melatonin… We’ve kind of gone down a rabbit hole of melatonin here.

Daniel Erichsen: Right.

Martin Reed: But one thing that I find is at first they might find that sleep becomes a little bit more difficult, just because they’re kind of taking away that mental crutch. But they feel so much better in the morning, like when they first wake up they tend to find that a lot of people who take quite a lot of melatonin in the morning, they have this real sleep inertia, this real strong lethargy and morning grogginess, which they tend to have always associated with their insomnia. But once they start taking less melatonin, I’m… So I always kind of start to wonder is, is so much of this morning fatigue associated with people who have insomnia, and they’re taking melatonin more to do with the melatonin than the poor night of sleep? Is that anything you’ve thought about or come across?

Daniel Erichsen: That’s interesting. I never really thought about that, but I will say this, I always thought of melatonin as like, it’s naturally produced in our brains, you take some extra. How much is that really going to affect you? And as a lot of people feel like, “I took melatonin, it did nothing for me.” And I am not surprised when I hear that, but I also have a lot of people that say, “I took melatonin, and I felt so tired and hungover, and I’m always surprised, but I feel like I’ve heard it so many times that there might be something to it.” So yeah, that’s… Pretty much were my thoughts on that. I thought there was one more thing I want to add, but I forgot.

Martin Reed: I was just curious, because I mean, it’s only observational right, and there’s just something that I’ve observed, there’s so much… When someone takes melatonin they tend to be the people that have more of this morning fatigue, morning grogginess. And as soon as they stop taking it, they notice such an improvement, and it’s weird. It may not be connected, but it’s just an observational thing that I’ve noticed working with people.

Daniel Erichsen: Yeah, that might be… There absolutely might be some truth in it, and now I remember what I was going to bring up, which I just… Another thing I just talked about the other day, which was, when people… People with insomnia typically are tired, you know?

Martin Reed: Mm-hmm (affirmative).

Daniel Erichsen: Foggy, fatigued, as you know. And I always have ascribed to the fact that they have poor quality sleep, fragmented sleep and that causes that. But now, just the other day, I’m curious to hear what you think about this, I was thinking, maybe it’s not the fragmented sleep that is the culprit. Maybe it’s the hyper-arousal, maybe your brain is running at 150 miles an hour all day, and part of the night, maybe that’s why you’re so tired?

Martin Reed: Yeah, that makes sense to me. I mean, because if you think about it, just think back to when we were at school, if it was college or high school, whatever, it doesn’t matter. And you’re studying for an exam, it’s a really high-pressure period where you’re really using your brain, it’s exhausting right?

Daniel Erichsen: It is, yeah.

Martin Reed: So that definitely makes sense, especially if you have really entrenched, chronic insomnia where you just spend all this brainpower thinking about sleep, worrying about sleep. It’s exhausting, right?

Daniel Erichsen: Yeah.

Martin Reed: So yeah, that makes sense to me. I think that could easily be a primary driver of fatigue, that we tend to blame on the insufficient sleep.

Daniel Erichsen: Exactly.

Martin Reed: It’s probably more to do with just the brain working, running a mile a minute.

Daniel Erichsen: 100% there’s something there.

Martin Reed: Yeah, absolutely. All right, so, let’s wrap up, let’s wrap this conversation up, it’s been great. I just want to ask you one final question, all right?

Daniel Erichsen: Sure.

Martin Reed: So if someone is listening to this, they’ve had insomnia for years, maybe even decades, they think they’ve tried everything, they think they’re beyond help, there’s nothing they can do to improve their sleep, they just feel completely defeated, what would you tell them?

Daniel Erichsen: I would tell them a couple of things, but I think one thing is, a lot of people tend to feel lonely and isolated, but know that a lot of people are struggling with insomnia, and that’s of course not a good thing. But there’s nothing wrong with you, like, it’s not like you’re sleep… Something’s wrong with your immune system or your digestive system or your… It’s just like, you’ve developed insomnia, like you have these behaviors and thought processes that is… That is all there is, there’s nothing else. And then I want to say, there’s always hope. I have yet to come across… As I mentioned before, I’ve yet to come across somebody who committed to CBT, who didn’t give up, who kept working with me, that has not gone on to do better. Literally, everyone does better, that is committed and tries.

Daniel Erichsen: And a final thing here, so many people say that, “I’ve tried everything,” and the irony is that almost everyone has tried… They’ve tried everything, except what actually works, which is CBT. So people have tried everything except what they should try from day one, the thing that really works. So there’s always hope.

Martin Reed: That’s great. Thank you so much. So yeah, I think that that’s… We’ve covered quite a lot of ground today, and I’m sure that everyone listening is going to get a lot of value out of this. So thank you so much for your time Daniel, I’m going to put links to your YouTube channel and to your app and to your books in the show notes. Apart from that, if someone wanted to reach out to you, what’s the best way for them to find you, or to get in touch with you?

Daniel Erichsen: Yeah, absolutely, all those things are good. I’m on Twitter, Daniel Erichsen, I’m on Instagram as well, and the YouTube channel. Any avenue there, you’ll find me.

Martin Reed: All right, great, I’ll make sure that we put links to them all in the show notes. Thank you again so much for your time Daniel.

Daniel Erichsen: Any time, it’s been a pleasure Martin.

Martin Reed: Take care.

Martin Reed: Thanks for listening to The Insomnia Coach Podcast. If you’re ready to implement cognitive behavioral therapy for insomnia, CBT-I techniques to improve your sleep but think you might need some additional support and guidance, I would love to help. There are two ways we can work together. First, you can get my online coaching course. This is the most popular option. My course combines sleep education with unlimited support and guidance and is guaranteed to improve your sleep. I will teach you and help you implement new CBT-I techniques over a period of eight weeks. This gives you time to build sleep confidence and notice results without feeling overwhelmed. You can get the course and start right now at insomniacoach.com/online.

Martin Reed: I also offer a phone coaching package where we start with a one hour call. This can be voice only or video, your choice. And we come up with an initial two week plan that will have you implementing CBT-I techniques that will lead to long term improvements in your sleep. You get unlimited email based support and guidance for two weeks after the call along with a half hour follow up call at the end of the two weeks. You can book the phone coaching package at insomniacoach.com/phone.

Martin Reed: I hope you enjoyed this episode of the Insomnia Coach Podcast. I’m Martin Reed, and as always, I’d like to leave you with this important reminder. You can sleep.