A conversation about the challenges of CBT-I (and how to get through them) with clinical psychologist Steve Orma (#10)

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, Steve, so thank you so much for being on the podcast with us today.

Steve Orma: Yeah, absolutely, it’s great to be here, Martin. Thanks for having me on.

Martin Reed: Let’s get started right at the beginning. How did you get interested in the field of sleep and insomnia in particular?

Steve Orma: Yeah, so the way that I got into it is I had insomnia myself, probably like about six years ago now. I had been a psychologist already for several years and my specialty was anxiety and stress. I knew very little about sleep or insomnia because psychologists receive no training. I received zero training in sleep in my six years of graduate training and everything, which is also pretty common for medical doctors. It’s kind of crazy and ridiculous.

Steve Orma: I got this insomnia and it wasn’t going away and it was pretty bad. I was suffering and I needed to solve this problem and because I didn’t know anything about it, I just started researching it on my own. I read a lot of different books that were out there and just read everything and just looked for the best treatment. I was already familiar with CBT because that was the primary treatment that I used for anxiety was CBT. When I found there was actually a specific treatment for insomnia that used CBT, I was intrigued because I know it’s a really powerful form of therapy.

Steve Orma: I found really a book that I thought was really good and I modeled it after that book because it had a pretty good way to follow. I just put myself through the treatment. I mean, I did it all on my own. It’s kind of like me. If I have a problem, I’m very motivated and I’ll do it. It was hard. I mean, it’s hard to go through the treatment. It was three weeks before I got any improvement at all and I was getting four to five hours of sleep a night maybe for six days a week, so it was pretty bad. Then, I started getting improvement and it ultimately… then it started getting better at that point and I started getting hopeful, but it took about eight weeks full… about eight weeks and then I was totally cured. Then, I was like, “Wow.”

Steve Orma: I saw so many clients dealing with anxiety and also seeing a lot of depression. So many clients dealing with sleep problems, but it just never gets addressed. It’s like a side issue and I saw there’s probably people could helped with this. Actually, that’s when I wrote my book because I found there was some problems with some of the books that I read. Like, they were just overwritten or they had a lot of scientific jargon.

Martin Reed: Right.

Steve Orma: I wanted to pare it down to this is what you need to do. You don’t need to know all this other stuff. I wrote that and then I started working with my clients specifically with insomnia and that’s how I got into it.

Martin Reed: Wow. Yeah, I thought it was really interesting how you said you’re a psychologist for I think you said six years and you received no formal sleep training or sleep education. That does resonate with what I’ve heard from medical doctors, too. They’ve told me… Daniel Erichsen, who’s now a sleep physician, he told me during his MD studies, he got one and a half hours of education and training related to sleep and I find that just absolutely incredible, especially today, there’s so much emphasis on sleep as an important pillar of health and yet, we’re giving doctors maybe less than two hours of training in the field of sleep. It’s incredible.

Steve Orma: I think it’s incredible and it baffles my mind because sleep obviously is a fundamental foundational thing that we have to do. I mean, everybody sleeps. You know?

Martin Reed: Right.

Steve Orma: We sleep not just for an hour or two, most of us sleep for several hours because we need it for like… it effects every system in your body and we know when we’re not getting enough sleep how we feel. It doesn’t feel good. It is amazing that the doctors and psychologists and therapists just don’t get that training.

Martin Reed: Yeah, absolutely. You mentioned when you were struggling with sleep and insomnia yourself that you turned to a book. Do you remember what book that was?

Steve Orma: Yeah, it’s Say Goodnight to Insomnia by Gregg Jacobs, which is a pretty… I think it’s a pretty popular book and he’s a Harvard researcher and clinician for many years and studies… I think he had like 10,000 patients or something that he used CBT on and had great success. That’s who I learned it from.

Martin Reed: Yeah. I’ve had a few people that have worked through that book and I think it can be really helpful in terms of it’s like a really structured approach. Right? It kind of-

Steve Orma: Yes.

Martin Reed: … it leaves very little room for doubt. It’s very kind of regimented, so some people respond really well to that and some people struggle with it, but I kind of feel it’s like a 50/50. It really just depends more to do with your personality. If you’re that kind of person that knows you respond well to just having everything laid out for you, then that book can be really helpful for people, but then I’ve heard from other people who are like, “I don’t know about this, I don’t really understand the logic behind this, can we be a little bit more flexible here?” Then, they kind of start to doubt whether they can implement the techniques and they struggle that way.

Steve Orma: I think it’s hard to do it on your own. You know?

Martin Reed: Mm-hmm (affirmative).

Steve Orma: I mean, I was able to do it, but I also had been a psychologist for several years, I knew a lot about anxiety, I knew a lot about just treatments, so I had an advantage and I’m also very disciplined. Not everyone is that disciplined, which is fine. It is hard to do on your own as well, like just from a book. Yeah, I mean, one of the reasons I wrote my book was because that I found his approach really helpful, but there was so much detail, particularly with diaries and calculations and I tried to create a little bit more of a simpler easier way to do it, so it doesn’t create so much stress.

Martin Reed: Mm-hmm (affirmative).

Steve Orma: Yeah.

Martin Reed: Yeah, I think that’s… You made a really important point there. I think that because you are already familiar with, let’s just say CBT, cognitive behavioral therapy, just in general, so you are more confident even just from the outset that there was something behind this, that it could be effective for you and I think if you don’t have that background, it’s really important to either if you’re reading it from a book or if you’re working with a coach or a therapist, to get that full understanding of the rationale. Understanding why these techniques work because when you first hear them, they can just be so counterintuitive. Right?

Martin Reed: For example, how can allotting less time for sleep give me more sleep? How can getting out of bed when I’m struggling, help me sleep? It’s really important to have that understanding and sometimes if you don’t have this preexisting confidence in the techniques because you’re already familiar with the logic behind them, then it’s just so important to fully understand the rationale behind what you’re doing.

Steve Orma: Yeah, it’s a very paradoxical treatment and I think because… or counterintuitive, because just the idea of getting out of bed when you’re exhausted and you have a limited amount of time to sleep and the bed’s really comfortable, it goes against your logic even. It’s like, why would I get out of the bed if I want to sleep? Wouldn’t that wake me up more? Isn’t that going to waste my time? Paradoxically, when you get out of bed, which is one of the techniques, you end up, most of the time you’ll get back to sleep faster if you do that than if you stay in the bed.

Martin Reed: Mm-hmm (affirmative).

Steve Orma: You have to help clients wrap their head around that because otherwise it might be hard for them to comply to that detail because it’s hard to do.

Martin Reed: Absolutely. I really want to kind of get into this, the more challenging side and how we help guide people through that as we talk a little bit more. First, I just want to talk a little bit more about your insomnia, because I find it really interesting. You have this insomnia history, as I do, and that’s really how we both got interested in sleep and insomnia and discovered these really effective CBT-I techniques. Do you remember what initially triggered that sleep disruption that manifested itself into insomnia?

Steve Orma: I don’t know exactly, but I know that previous to that in 2010 maybe, so maybe five or six years before that, I had a small bout of it and what caused it was on the night I had to take two licensing exams to become a psychologist and on the night before both of them, I was so worried about not getting enough sleep because I had to go take these exams that paradoxically, I didn’t sleep that well. I only got like three or four hours of sleep, I felt like crap in the morning. Luckily, I was able to go and still pass the exams, but I did not feel good. It was because I was worried about not getting enough sleep and being able to function. That became one of my key worries, which I think is also a very, very common worry with insomnia. Then, paradoxically, you’re worried about it and you get anxious and then that keeps you up because you’re anxious now and then you don’t sleep. Then, you get more anxious and you’re watching the clock.

Steve Orma: It’s just like this downward cycle just starting from that one worry. I think that was my main worry and I think that was probably… there wasn’t any major stressors going on in my life, which sometimes is a trigger. I think it was more my worry about… and I was seeing a lot of clients then. I had a practice with, I was seeing 10 clients a day sometimes, which was really too many-

Martin Reed: Yeah.

Steve Orma: … for me to see, but I was seeing a lot and I think then I was like, really there was this pressure for me, I need to get enough sleep so I can go and perform well. I think, I just, I got anxious about it. Then, that led to… I think that led to the developing of the insomnia and I probably engage… I don’t remember, but I’m sure I engaged in then some of the poor sleep behaviors that you shouldn’t engage in, but that you do to try to improve your sleep, which then makes your sleep worse.

Martin Reed: Mm-hmm (affirmative).

Steve Orma: Then, it just turned into full blown insomnia.

Martin Reed: Yeah. The reason I like to ask people about how their insomnia developed is because I think pretty much everyone listening can identify with the story because insomnia is quite predictable. It follows this quite well-trodden path in terms of there’s often this identifiable factor or issue, this life stress or a one-off event that just triggers this short-time sleep disruption, what would normally be short-time sleep disruption. That’s quite normal, but the problem can then be is when that issue’s no longer relevant, the sleep issues can stick around. Often, it’s related to things like worrying about sleep. We suddenly start to worry and think about sleep when it was something we never used to think about or give any attention to and that just kicks the arousal system in and just immediately makes sleep more difficult.

Martin Reed: This can then prompt us to do all these behaviors to try and control sleep and improve sleep, like going to bed earlier, staying in bed longer, napping during the day, trying to conserve energy, all these sleep efforts and that further compounds the problem. That’s when you end up just with this chronic problem, which perhaps might have only been an issue for one or two days, but quite naturally we’ve attempted to get our sleep back on track. It’s our actual efforts themselves that have perpetuated the problem.

Steve Orma: Yeah. I mean, it’s really like… I mean, insomnia in one sense is you taught yourself or trained yourself to not be able to sleep, but the thing is, people aren’t doing that deliberately, obviously. They’re not sleeping well, they have that initial trigger, like you were saying, and that could be a lot of different things. Then, in response to that, and it might have just been normal to have a few bad nights of sleep because of that trigger, but then in response to that, the reaction is, oh my god, I’m not sleeping. There’s something wrong here.

Steve Orma: There’s an anxious reaction to the fact that you’re not sleeping and then, the thought is I need to do something. Then, you mentioned some of the behaviors, like sleeping in or maybe I’m going to take a medication or I’m going to take naps during the day. Then, that makes the sleep worse, which then raises the anxiety and then they want to do more to try to help the sleep. It’s like they’re trying to help improve the sleep and being so focused on the sleep is what messes the sleep up. When they were sleeping okay, like when we’re sleeping fine, we’re not really thinking about sleep.

Martin Reed: Yeah.

Steve Orma: It’s just like, it’s time to go to bed, you get in, and you go to sleep because you’re just… there’s an assurance that you’re going to sleep.

Martin Reed: Yeah, and I think you made a really important point there. It’s so important that we don’t blame ourselves for implementing these behaviors and put an effort into sleep because it’s quite natural. Just from our own experience in life, we’ve learned that, generally speaking, the more effort we put into something, the more likely we are to get the outcome we’re looking for. If we study harder, we’re more likely to get that degree. If we work harder at work and meet our deadlines and take on extra work, then we’re more likely to get that promotion. It’s quite natural that as soon as we struggle with sleep, we want to put more effort into fixing that issue and put in more effort into sleep, but with sleep, it completely backfires. Right? As soon as we put that effort in, it actually make sleep more difficult and this can really become a problem then because we’re so used to expending effort to get a desired outcome that when it doesn’t work, it just leads to even more worry that something is seriously wrong with us and our sleep.

Steve Orma: Yeah, and I think that’s the frustrating thing about insomnia for people is like they’re trying to do all these things to help their sleep. It’s not that they’re trying to mess their sleep up, but they’re trying to improve it and then, the more they try to improve it, the worse it gets because usually the things they’re trying are the wrong things. I don’t blame them because they don’t know what to do, just like I didn’t know what to do, and then you go online and you talk to your doctors, and they’re giving you… and you get bad advice there and you try that out. That doesn’t work and then you get more frustrated and you get hopeless. It just gets you into this really bad state. I have a lot of empathy for people that are going through that.

Martin Reed: 100%, and I think that that is often one of the big problems I have with sleep hygiene as well is that’s often the first thing the people with insomnia are told about, but we know the sleep hygiene is an effective treatment for chronic insomnia. People in research studies, they put the control group or the no intervention group, they give them sleep hygiene because we know it doesn’t work, but yet, so often people with chronic insomnia are given sleep hygiene advice. Then, when it doesn’t work, which is to be expected, it just leads to more worry that something is really, seriously wrong.

Steve Orma: Yeah. Right, sleep hygiene, no matter what, you go online and you Google overcome insomnia and there’ll be just a zillion articles, most of them on some form of sleep hygiene.

Martin Reed: Yeah.

Steve Orma: I’ve even been on sleep doctors, like physicians who specialize in sleep, and on their site is just, here’s ways that you can improve your sleep and it will be the sleep hygiene. That baffles me because it doesn’t really… if you have insomnia, it doesn’t work, it’s not enough by that time. Yeah.

Martin Reed: Exactly. Your key word was by that time. I think that was the key phrase there-

Steve Orma: Yes.

Martin Reed: … because sleep hygiene can be helpful as a preventative measure, so for example, if you’re already sleeping pretty well, maybe you could just follow these guidelines. Kind of like, I always use this analogy, I got it from Michael Schwartz, who I had on the podcast, I think it was one of the earlier episodes, three or four, and he kind of likens it to dental hygiene. It’s like brushing your teeth. We brush our teeth, so we don’t get a cavity, just like we can implement sleep hygiene, so that it minimizes sleep disruption. Well, once we get that cavity, no amount of brushing our teeth is going to get rid of that cavity. Likewise, as soon as we developed chronic insomnia, no amount of sleep hygiene is going to get to the root of that problem. That’s when we need to look elsewhere and really, the best thing to do is to implement these cognitive behavioral therapy for insomnia, CBT-I techniques.

Steve Orma: Yeah, I mean, I think it’s a good analogy, the dental hygiene. It’s like, the sleep hygiene is actually part of CBT-I, but it’s kind of like the least important.

Martin Reed: Right.

Steve Orma: Last thing that you do as just like… this is like extra things you can do just to make your sleep more solid. It’s not the core of it, it’s just one tiny piece that’s the least important, but it’s stuff that’s important to do. I mean, it’s stuff that is good to do and it will help, but it won’t… once the insomnia has set in, it’s not on its own going to be effective.

Martin Reed: Yeah. I completely agree. I just want to step back a little bit, something you mentioned earlier when we were talking about all the things that we do when we have insomnia in a bid to improve our sleep can actually make the problem worse. I touched on a couple of them. What kind of things, in your experience, do you find the biggest problems or the things that people are more likely to do in a bid to improve their sleep, but actually can end up making the insomnia worse?

Steve Orma: Yeah, I mean, I think you mentioned a bunch of them earlier. Sleeping in, which is pretty common for a lot of people, usually on the weekends because usually people can’t… If you have a job, it’s hard to sleep in during the week, so then people will binge sleep on the weekend and the reason that’s a problem is then when it comes to Sunday night, you have a hard time falling asleep. The reason for that is you haven’t been awake long enough, like there’s a concept in CBT-I called prior wakefulness, which is the longer you’re awake, the more pressure builds to sleep because there’s a neurotransmitter called adenosine that’s released the longer you’re awake. The later you wake up, the less pressure there is when you go to sleep at night, so if you get up later on the weekends, then come Sunday night when you go to bed to get up to work Monday morning, you’re not going to be tired when you get into bed at your normal time. You would need to wait another two, three hours because you’ve pushed your body clock ahead.

Steve Orma: Then, so things like that, I think taking naps, because again, it’s taking away that pressure. I mean, naps sometimes can be okay done in a certain way, in a certain context, but usually, those things are going to take pressure away as well, so then it’s going to be hard to sleep at night. I think medication is a big one. I mean, not everyone takes medication and I include in this not just prescription medication, over the counter, herbals, any of those things are going to mess with your sleep. Number one, particular the medication, alcohol’s another one that people use for sleep, is they mess with your sleep cycle, so they’re going to mess with your sleep quality, they’re going to block REM sleep or deep sleep. Then, I think another huge factor with those is the psychological dependence outside of the physical, is a belief that I have to take something to sleep and that I don’t have the power within me to sleep. Then, what that does, is it raises anxiety around sleep and that is something that can make insomnia or set insomnia in, is that sleep worry or sleep anxiety.

Martin Reed: Yeah, and that can be a real problem with… I see it a lot. I’m sure you do, too, especially with supplements and all these over the counter, so-called, remedies. Any time that we think that something external is generating sleep for us, any time we have that belief, it’s a problem because we just missed that opportunity to regain confidence in our own natural ability to sleep. Any time we sleep, we can just easily believe that it was because of that pill or that supplement. I find it quite ironic because you see people that take a pill or a supplement, and then they sleep. They say, “Oh, I only slept because of that pill,” and then if they take the pill or the supplement and they don’t sleep, they blame themselves for it. They don’t recognize that it’s evidence the pill or the supplement isn’t working. You’re just trapped in this cycle of looking for something that’s going to work to generate sleep instead of focusing attention on implementing techniques that can help you actually regain trust in your own natural ability to sleep.

Steve Orma: Yeah. What I’ll tell clients sometimes is that overcoming insomnia is basically learning how to become confident that you’re going to be able to sleep or trusting that you’re going to sleep and that you don’t need anything external and that you have the ability within you. It’s built into your system to be able to sleep and it’s more that your sleep’s just been pushed off track and what we need to do is just get it back on track. We can do that naturally and we can do that gradually. Then, you’ll be able to sleep like you were able to sleep before.

Martin Reed: Yeah. I completely agree with you and I get so many clients when I finish working with them, and that’s their kind of big revelation at the end is just having that trust back. I think it can be a long road to regain that confidence and your confidence is naturally going to be quite fragile, so it’s quite typical that in the future if you have that bad night, you can immediately worry that somehow your insomnia’s returning. Then, it’s important to take a step back and just see was there an identifiable external cause? Maybe I got some bad news, had an argument with my spouse, or was there something that could explain why my sleep was disrupted that night. Often there is and just recognizing that and seeing that as the cause of that temporary sleep disruption, rather than just immediately worrying that your insomnia’s returned, can be really helpful.

Steve Orma: Yeah. There’s a part of the CBT-I treatment called relapse prevention, which is preparing yourself in advance for when you have a poor night of sleep in the future because you’re going to. Everybody does. Right?

Martin Reed: Right.

Steve Orma: I mean, no one… because there are things that are out of your control. I mean, there could be noises, there could be your partner is tossing and turning and you’re having trouble. It could be something you’re excited about, I mean, it could be a positive thing and you can’t sleep because you’re so excited. Because of that, sometimes our sleep is going to be disturbed and we’re not going to have a great night of sleep and that’s fine. In learning how to react to that mentally, knowing how to respond in your thinking to when you have a poor night of sleep is one key factor in overcoming the insomnia.

Martin Reed: Yep. Completely agree. Here, let me ask you this because this is something I get asked quite a lot is if our ultimate goal here is to eliminate all the effort that we’re putting into sleep, how does implementing all these CBT-I techniques, which require effort, how is that helpful at improving our sleep?

Steve Orma: That’s a great question because that’s another counterintuitive thing about… right? Well, I think that on the track of sort of the analogy I was saying earlier, it’s like, when you have insomnia your sleep is on a wrong track. It’s like a train is going down and then it gets pushed off the track. It’s on this other track that’s kind of wobbly and not too good and the thing is, is that, at that point you can’t just not do anything. Right? You can’t just go on in automatic pilot because your system has been thrown off and you have to get it back on the track. The way to get it back on the track is through this CBT-I technique.

Steve Orma: Then, once it’s back on track, then the sleep goes again without effort and all you need to do is maintain the behaviors. The thing is, I think the reason that CBT-I works so well is it’s a totally natural treatment that just works with the way your body sleeps. When you’re sleeping well, you’re kind of practicing the CBT-I techniques in a certain way. Meaning, you’re generally going to bed when you’re tired and you’re waking up a certain time, you’re not getting anxious about your sleep. Most of the time you’re in bed, you’re sleeping not perfectly, because once your sleep system is really strong, you can be more flexible and break the rules a little bit, so CBT-I is a way to get your sleep system back on track and working normally. Once that’s going, then you don’t have to put that effort in anymore.

Martin Reed: That’s a really good explanation. I like to say to people that we really just kind of… it’s natural that you’re going to want to put effort into fixing the problem, but what CBT-I is all about is directing that effort in a constructive way. Instead of looking to directly put effort into sleep, which is not constructive, we’re looking to put effort into helping you set the stage for sleep, to give sleep the best chance possible, so we’re putting effort into building sleep drive by reducing the amount of time you allot for sleep. We’re putting effort into relearning that the bed is a place for sleep and relaxation, making the bed a strong trigger for sleep and we do that by putting some effort into getting out of bed when we feel wide awake and wired and anxious. I think there is still definitely effort involved, but with CBT-I, it’s about just directing it in a constructive way to get you back to that point where you’re not putting any effort into sleep whatsoever.

Steve Orma: Yeah. I think that’s a really good way to put it as well. I think, yeah, what I’ll say to clients is, they’ll say, “Well, if I can’t control my sleep. How do I improve my sleep?” You’re not trying to control your sleep either with CBT-I, you’re trying to control the conditions that set up sleep, so you focus on what conditions do I need to set up in my behaviors, in my thinking, that will automatically lead to sleep without any effort? The sleep comes as like sleep, you think of sleep as like a result. Good sleep is a result that comes from doing certain things and when you do those things, sleep will come automatically, easily, effortlessly on most nights. CBT-I is a way to set those conditions.

Martin Reed: I really like the way that you say sleep comes as a result because, as I’m sure you know, these CBT-I techniques, although they’re quite straightforward, they can be really challenging to implement and it can take time for you to see the results. You said yourself when you implemented it, you didn’t really notice anything for three weeks, but then by eight weeks, you know things were significantly better. It can become really easy to make the focus of your attention over the short-term, looking for results, so you can look, like from day one, every night from then on. I’m still only getting four, I only got four hours last night and the next night you’re worried, I only got three hours, then the next night, only five hours. You make all of your attention on the results whereas, if you make your focus of your attention on the implementation of the techniques, the results will come naturally by themselves and often a lot quicker because you’re not specifically and explicitly looking for them. Would you agree with that?

Steve Orma: A hundred percent and I think that the biggest challenge is helping clients trust that process because, like we’re saying, it’s hard to go through it usually for most people, and it’s hard to go and apply the techniques. Especially when you’re seeing like, well, my sleep is getting better, I’m going through all this pain, and I’m putting in all this effort, and my sleep isn’t even improving. Maybe your sleep even gets worse for a little bit, which could happen. It’s like, why am I not getting these results and you have to help them trust that even though that’s happening, it’s going to improve if they continue sticking with it. I think that’s why the support is so important with it. It’s hard to do it on your own is like just the compliance and helping clients just stick with it when they’re doubting themselves because once they get over a certain hump and all of a sudden, they’re like, “Oh, my God.” They’re sleeping better and the numbers are improving and they can see that. That’s when they start getting hopeful and building their confidence.

Martin Reed: Yep. Completely agree and that’s exactly what I see as well with clients is that, obviously, everyone’s different. Some people respond really quickly, others take longer, but often it’s that you get to that period that you almost experience this mini breakthrough and that’s different for everyone. Some people would describe it as just feeling sleepy again before going to bed and that’s their breakthrough. For other people, the breakthrough is sleeping almost entirely through the night for two or three nights in a row. It’s different for everyone, but as soon as they get that breakthrough, as soon as you get that recognition that all that effort you’re putting into the CBT-I techniques is actually paying dividends, that kind of really helps you push on and see it through and just get those long-term results that you’re looking for.

Steve Orma: Yeah, a hundred percent. I mean, I think like the same thing happens in let’s say you’re trying to lose weight and let’s say you’re 50 pounds overweight, and it’s hard to start exercising. You have to get up and you have to go to the gym and you’re lifting weights. It’s hard, it’s painful, it’s uncomfortable. You’re working really hard and two weeks later, you’re not seeing any results or maybe you’ve lost a pound and you get discouraged, but I think the expectation is the key here with CBT-I. I don’t even know if it’s part of a normal CBT-I, the treatment is setting expectations. There definitely is a module on just your thoughts and busting myths and things like that, but just in terms of like what you’re going to go through, what you can expect, that way, I think it could prevent them from getting discouraged because we talked about already, oh, this is going to be hard or you’re going to experience this at this point. I think that’s one of the most important keys is just people being able to stick with it all the way through.

Martin Reed: Yeah, I completely agree with you. It is important, as well, to recognize that although, I think I said this earlier, although the techniques are quite straightforward, they can be challenging to implement, so it’s important to recognize that before you get started that it’s going to be difficult. There’s no two ways about it. It does take a lot of effort to stick to the CBT-I techniques and it’s also important to recognize that… not the CBT-I techniques, like anything, can’t guarantee you X number of hours of sleep. If you’re already going into it thinking that your goal is to get, let’s say eight hours of sleep, that can be an unrealistic goal as well just because very few of us need eight hours of sleep. Everyone has their own individual sleep requirement, so if you’re always kind of trying to push to reach this goal that could be completely unattainable for you, that could make progress difficult too.

Steve Orma: Yeah, I think that’s part of the expectation and I think if… I talk about this in the first session when we talk about the eight-hour… because a lot of people, like, I should be getting eight hours and maybe they should, but maybe they shouldn’t because it’s different for each person. What I say is that, “Obviously, you’re not getting enough sleep because you’re tired and you have all these symptoms and you’re struggling and you’re anxious and all these things, so you know you’re not sleeping enough, but we don’t know at this point, what is the exact… what’s the right amount of sleep for you? Once we get your sleep back on track, without you even thinking about it or worrying about it, again, you’re just going through and doing the conditions and you’re doing the things that you need to do to set yourself up for good sleep. Then, once that pattern gets normalized and consistent, you will figure out what your normal sleep is because you’re setting up the conditions for it and you’ll get a sense of, oh, I generally am sleeping consistently seven hours or seven and a half or whatever it is.”

Martin Reed: I think you touched on a really important point, too, where you talked about how people are feeling during the day. Ultimately, I think that’s the best way of evaluating your sleep in a way is just if you feel that you’ve got sufficient energy to get through the day, and you’re feeling good during the day generally speaking, then that’s often a far better reflection of how well you’re sleeping than X number of hours.

Steve Orma: Yeah, I think that’s true. I mean, and then some people actually can get eight hours of sleep. I’ve had clients, they’re getting eight hours of sleep, and they don’t feel rested the next day. That’s because sometimes the quality of the sleep isn’t that good, they’re waking up a lot, but also sometimes something else completely different is going on that has nothing to do with the sleep. That’s another thing that could be happening, too, is sometimes people put all the pressure on their sleep to feel good the next day and how you feel is determined by a lot of different things, not just your sleep. Now, sleep is obviously critically important, but it can be affected by other things as well. I think generally I agree with you that when you’re getting enough consistent sleep, you feel that, you wake up in the morning and you feel like you had a good… especially when you know, when you haven’t slept well, like when you slept four or five hours, it feels very different than when you get a really good night’s sleep. You feel radically different energy wise, like your mood feels better, you feel lighter, and I think that’s the best… definitely one of the best indicators.

Martin Reed: Yeah. I think that one thing that we also look to address through these CBT-I techniques, which you just touched upon as well, is that sleep doesn’t have as strong an influence on the quality of our day as we often think. Especially when we’ve been struggling with insomnia for so long, it’s so easy to attribute anything negative that happens during the day to your sleep and then that further compounds the problem because then you have more sleep related worrying. Probably put more effort into sleep.

Martin Reed: For example, if you notice yourself making mistakes at work, you could just immediately blame that on a bad night of sleep, where it could be the cause, but it might not be. If you miss a deadline, you might blame that on a poor night of sleep. It just becomes so easy to blame everything negative that happens during the day on sleep and just attribute anything negative with sleep. That can be an issue, too, that I think the CBT-I helps address.

Steve Orma: Yeah, and part of CBT-I is even, deals with what are called negative sleep thoughts, which is just negative thoughts about your sleep or anxious thoughts and worries about your sleep. Also, negative sleep thoughts about after you have a poor night of sleep, how are you responding to that? Obviously, it sucks to have a poor night of sleep, it’s an unpleasant experience, but then how you think about it after you wake up will greatly affect how you feel that day. If you wake up and you think, “Oh, man, I only got four hours of sleep. I’m just going to feel like shit today, I’m not going to be able to get anything done. It’s going to be horrible,” you’re much more likely to not feel good and for your day to be like that than if you wake up and you say, “Yeah, I didn’t sleep well. I’m definitely probably going to be tired today, but I’ve been through this before, I know I can function fine. I’m going to do my best and I know I’ll get through the day.”

Steve Orma: You’re not like… you’re not sugar-coating it and denying you had a poor night of sleep, so you’re not saying, “I’m going to feel wonderful.” It has to be something that’s true, but it can be something that just shifting it to something more positive and that you’re going to be okay can definitely help you feel better and get through that day. It helps you just cope better with the insomnia.

Martin Reed: Yeah. Just to use that as an example, sometimes it can be helpful if you have had a bad night of sleep to just recognize that your sleep drive is going to be stronger, so it makes the chance that you’ll get a better night sleep the following night a lot better. Of course, you’re not going to be aware of this unless you’re learning more about sleep, which is one of these core… like the sleep education side of it is just one of these core components of the CBT-I technique, so you can take comfort in the fact that after a night of very little sleep, your sleep drive is going to be really strong. That means that it’s far more likely that you’re going to get a better night on the next night, better night of sleep the following night.

Steve Orma: Yeah, that actually was really helpful for me when I was going through insomnia is when I had a poor night of sleep, yeah, it was rougher to get through the day for sure, but I would just keep telling myself, “Just get through the day,” because I know that I’m going to be so exhausted tonight that I’m much more likely to sleep better. A lot of times I did. I slept better, I slept longer, I slept deeper because I was just really, really exhausted.

Martin Reed: Yeah, and I think it’s also important, too, to recognize that we do a lot more self-monitoring after a bad night of sleep as well. If we have a really bad night, we actually look for the effects of that bad night of sleep. Sometimes even just on the subconscious level. You can notice like these little niggles, these neck pains, these back pains or you’re just always looking for almost like supportive evidence to support the fact that you had a bad night of sleep and that all these negative effects are happening. How do we move away from that?

Steve Orma: I think that, yeah, and I think that’s related to the intense focus on the sleep, which is part of insomnia. We were just saying earlier, when you’re sleeping fine, you’re not thinking about your sleep. Paradoxically, with insomnia, you become somewhat obsessed, maybe not totally obsessed, but you can become very focused. Sometimes you can be obsessed where you’re just thinking and worrying about your sleep a lot that then you focus a lot more on the effects when you don’t have a good night sleep. Like, how your body feels or like you were saying, you become very vigilant about that.

Martin Reed: Mm-hmm (affirmative).

Steve Orma: How do you move away from that? I mean, that’s part of learning how to shift your focus and shift your mind, which is part of the treatment. One thing that we do in the CBT-I is we track your negative sleep thoughts. Actually, you write them down because you want to just instead of having them just swirl around in your head, you take them out and you write those down and you capture them because now you can respond to them and you can say, “Okay, how can I think about this differently?” Then, you think of something that is a positive sleep thought. Again, something you can believe, that’s something that just shifts and makes you feel better. It’s learning, partly learning how to shift your mind and think about your sleep. What you really need to do is like… what I’ll tell clients is you have to kind of become at peace with the fact that you’re not sleeping. Again, it’s a paradoxical thing. If you’re not sleeping and you’re tossing and turning, the more you try to sleep and the more upset you get, the worse your sleep is going to get even though you’re not sleeping.

Steve Orma: What you have to do is give into it. It’s kind of like a Zen thing where you have to say, “I’m not sleeping. It’s a fact. I accept it. I need to then follow the protocol,” or whatever it is. Get out of bed and then be okay with that, come to peace with that because it’s the fighting against that or the obsessing about it or the worrying about it that makes it worse. It’s learning that, and the only way to… like, the first step is just to be, it’s okay, I’ll be fine even though maybe I’ll only get four hours of sleep, it’s the middle of the night, it’s dark, everyone else is asleep, I’m the only one on earth awake. In fact, that’s what it feels like, but I’m going to be okay. I’m going to read this book, I’m going to enjoy the night, I’m going to relax, and then what happens is it starts becoming something that’s not as much of a threat. It becomes something that is like, I can deal with this, I’m okay.

Steve Orma: Then, once you start adopting that kind of, let’s say relationship with it, your sleep usually starts improving because, again, it’s paradoxical because now you’re more relaxed. Now you’re not afraid of this, so you’re not getting anxious. Then you’re more relaxed and therefore, you’re better able to go to sleep. It’s kind of a strange thing, so it’s kind of learning to be able to not worry and think so much about your sleep and being okay with the fact that you’re not sleeping, but knowing that you’re doing something that will improve the sleep.

Martin Reed: Yeah. It’s so easy to worry and dwell upon the worst possible outcome whenever we’re struggling with sleep. It’s so easy, too, to just ignore any potential positive outcomes or just different ways of looking at the thought or the situation. For example, before we go to bed, we might just immediately worry that we’re going to be up all night and then we just stop and we just dwell on that without actually thinking that maybe there are some alternative outcomes. In your book, you actually have a really good technique for this. You suggest drawing a pie chart with all these potential outcomes. Can you talk us through this a little bit more?

Steve Orma: Yeah. The pie chart is like when it comes to, let’s say, insomnia, a lot of times we think the worst. It’s called catastrophic thinking. Right? Holy crap, what if I don’t sleep at all tonight? What if I can’t sleep anymore? What if I’ve lost the ability to sleep? Of course, those thoughts generate anxiety, so those are the fuel for anxiety. The bigger the worry, the bigger the anxiety, but if we’re used to going to the worst-case scenario, probably what you’d find if you think about it, that rarely happens or even when it does happen, it’s not as bad as you think. A lot of times it doesn’t happen and other things happen, so the pie chart exercise, it’s very simple, an easy one to do.

Steve Orma: If you think of a pie, you just draw a circle and then you draw one little triangle inside the circle. That’s like one little piece of pie, and you say, okay, one possibility is my worst-case scenario. I won’t sleep at all tonight. Okay, that’s a possibility that maybe if that’s happened before that that could happen. What else could happen tonight? Then, you draw another little triangle. Okay, well I could also maybe sleep four hours. I’ve done that many times, so let me write that. You write down, I could sleep four hours. Okay, that’s better than no sleep at all. Right? Or I could sleep six hours and you write that down. Or I could sleep, maybe I have… occasionally I do sleep seven or eight hours, so maybe that’s a possibility. Basically, it’s like you’re giving your mind alternatives for what could happen. Yes, it’s possible, you’re not denying that you might not sleep at all, but you’re saying there’s all these other possibilities.

Martin Reed: Yeah.

Steve Orma: Then, what that does is it just takes a little bit of the pressure off because you know that it’s like, it might not be as bad as you think.

Martin Reed: I think it’s a great technique because you’re making that conscious effort to explore alternatives because it’s so easy. The brain just naturally wants to dwell on what the biggest potential problem might be because it wants to problem solve for you. Unless you take a step back and actually make that conscious effort to think about alternatives or to evaluate that thought that’s generating so much worry and anxiety, your brain will just focus on the worst possible outcome and, as you said, this just leads to more worry and makes sleep more difficult. I really like that pie chart just because it makes you implement a conscious effort to just explore alternatives and when you do that, it can just take all that power away from that thought that’s triggering the worry and anxiety that you’re having.

Steve Orma: Yeah, and I like it because it’s a very simple exercise. You’re not trying to convince yourself that your worry isn’t true, which usually doesn’t work. It’s just, it’s a gentle technique and very easy to do where you’re just giving yourself alternatives and you’re saying, “Well, this could happen, too.” That alone then takes the pressure off of just this one possibility and then will lower the anxiety.

Martin Reed: Mm-hmm (affirmative). We touched upon this earlier on when we were talking that it’s just so easy to give up prematurely when we’re implementing these CBT-I techniques. They take a lot of effort. Sometimes it takes a while for you to get results. There are often… in fact, I would say, there are usually and it’s to be expected there are setbacks along the way, too. When you’re working with clients and they experience setbacks, how do you help them get through that and, I mean, do you have any good examples that you can share with us of perhaps a client that was really struggling with the techniques, maybe experienced a number of setbacks, but they got through it and now they’re sleeping a lot better?

Steve Orma: Yeah. Now, I just finished with a client that I think would be a good example and she’s late 30s. She’s a physician, two young kids, and her insomnia was triggered by the birth of her second child, which messes up a lot of a mother’s sleep.

Martin Reed: Yeah, mm-hmm (affirmative).

Steve Orma: She had had this insomnia for two years. With her, she was someone who maybe was sleeping a little over five hours a night on average. It took us, we had gotten to like the six-week mark, and her sleep hadn’t improved that much. She had other, like three or four weeks in, she was losing hope, kind of what we talked about earlier. I’m doing all these techniques, my sleep isn’t getting better, I don’t know how long I can stand this anymore. She was really kind of like losing hope and wanting to give up and wanting to take a medication and going that route. To get her through that, and this was all through email because I give, in between sessions, I provide email support for my clients when they start freaking out like that-

Martin Reed: Right, yeah.

Steve Orma: … because it’s hard to do it on your own and you’re all alone. She was sending me all these emails and I basically just… part of it was part pep talk and just saying like, “Trust me, these skills are… the techniques are going to work. I know it’s hard, I’ve been through it myself, so I can use my own experience. I empathize with you, but…” I think one thing I said to her was you’ve given birth twice, that’s nothing compared to… or getting over this is nothing compared to raising two kids. Basically, just putting into perspective and helping her see she’s been suffering for this for two years, and the treatment, even though it’s hard, it’s generally six to eight weeks. It’s like, yes, it’s hard and you could go through this challenging period, but if you can get through it, your insomnia can go away and then you can keep it away for indefinitely if you just maintain your sleep.

Steve Orma: I just try to put it in perspective and reassure them that it’s going to work. Part of it is they just want to feel confident; they want you to make them feel like this is going to work and that they’re not different. Sometimes people think well, I just… maybe it works for other people, but it’s not going to work for me.

Martin Reed: Right.

Steve Orma: Something wrong with me, so we worked through it and she was like a star client. She stuck with the skills really, really well and then, at around week six, we started seeing some really good improvement. Then, from there forward, it just kept getting better and better and she just emailed me from… I think it’s where it’s like we had finished our treatment, but I still track it and she’s still applying the techniques. She’s doing really well, so I think she’s a good example because hers took I think nearly six weeks before she saw any significant improvement and that’s hard.

Martin Reed: Yeah, it is. I have similar stories like that where a client hasn’t noticed any significant improvements until like seven weeks.

Steve Orma: Yes.

Martin Reed: It’s just, I think the people that implement these techniques for seven weeks without getting the results, but then get that breakthrough, they’re kind of astonishing. You know? They’re superstars because they put all that effort in and if they’d have given up at five weeks or six weeks, which would be completely understandable, right, because they’re putting themselves through all this short-term challenge, they would never have got the results that they’re looking for, but because they stuck with it, because they stay committed, I just find it quite inspirational. When I see clients transforming this way and they want to credit me with the transformation, I’m just the guide. They’re the person that put all the effort in and they’re responsible for that transformation.

Martin Reed: I just find it really incredible when people just stay committed because really, like what you just described, that’s really all it takes is just this commitment to the techniques and just trusting they’re going to work. As soon as you start to get that, like that mini breakthrough, as soon as you start to notice those improvements, it can really just turn everything on its head and just turn that vicious cycle that we often associate with insomnia, that more worry leading to more disruptive sleep, leading to more worry, and it reduces that worry, which leads to better sleep, which leads to less worry, which leads to better sleep, but it all just stems from waiting patiently for that mini breakthrough to come.

Steve Orma: Yeah, and I think the key is to be able to keep them applying the techniques consistently and be able to get through that challenging or rough period even though they’re working hard and they’re getting out of bed and they’re doing all this stuff and they’re seeing my sleep isn’t improving. Why isn’t my sleep improving? Just communicating that’s normal, like that’s part… because your body’s been sleeping a certain way for a long time and you’re training it to sleep the way it used to. Right? It’s almost like you’re setting a new habit and it takes a little time for it to set in. There’s like a delay between the application of the techniques and your body responding to it, so they have to stick with it with a little bit of faith. They’re trusting, they’re trusting me and they’re trusting themselves to do it as well. Then, when they get that breakthrough, when they start seeing those improvements, that’s like you said, then they start getting that positive feedback and things to start improving on themselves. That’s actually a lot of times when the shift in the thinking happens because they’re seeing now, oh, my sleep is improving.

Martin Reed: Yeah, I think it’s important to recognize, too, that just like it took time for insomnia to develop and just become this really entrenched problem, it’s going to take time to unpick it. It’s kind of, on reflection, it’s quite unreasonable for us to think that we’ve been living, let’s say, with insomnia for three years and within a week or two, we’re suddenly going to be back to how we were three years ago. It does take time to unpick it and just recognizing that can help, can just help you… what’s the right phrase? Just help you recognize the importance of being patient and that it is normal that it’s going to take time to get your sleep back on track.

Steve Orma: Yeah. It makes sense if you think about it, that it would take some time because any behavior or thought pattern that has become a habit, which is what happens with insomnia, and it gets to set in just like any other habit. There’s different components to that habit, so it takes time to interfere with that habit and then set a new habit and make that the new one. It’s normal that it takes time for your body to adjust to that, just like it takes you a little while to learn how to drive a car or learn anything, it’s not immediate. You have to go in knowing that and knowing that it’s not going to be instant, but respectively, it’s pretty fast if you’ve been suffering with insomnia for a year, five years, 10, some people 30-40 years-

Martin Reed: Yep.

Steve Orma: … and you can get over that thing in a matter of a couple months, it’s worth that effort to sustain that effort.

Martin Reed: Yeah. It’s quite incredible really when you put it into perspective like that because I’ve worked with a client that had insomnia for 30 year, three, zero, 30 years, but after eight weeks, sleep is no longer an issue. That’s just incredible that 30 years of struggle and just believing that this is something that perhaps I’m going to have to live with forever, eight weeks of commitment and maybe eight weeks of struggle and challenge, but after those eight weeks, now insomnia is no longer an issue is quite incredible.

Steve Orma: Yeah. Yeah, it’s a phenomenal treatment and I think we just have to get the word out.

Martin Reed: Yeah.

Steve Orma: I think just like a lot of education and just letting people be aware that this treatment exists because I think a lot of people would be interested in it if they knew about it. A lot of people don’t even want to take medication or anything like that.

Martin Reed: Yeah, I completely agree with you and tell me if you would agree with this. One of the reasons why I love CBT-I techniques so much and I could just talk about them all day, is just because ultimately, they’re skills based. It’s something we learn about, so anytime sleep becomes an issue again in the future, let’s say 10 years down the line something happens to trigger short-term sleep disruption and we struggle to get through it, we just implement the techniques again. We’re already familiar with them, we know they work, we know all about them, we’ve learned about them, we just go back and we implement them again and our sleep gets back on track. It’s just like this thing that is the ultimate long-term answer because it lasts forever, it’s with us forever. It’s not like now we have to get a new prescription or look for a new supplement or a new pill or put our efforts into all these things we doubt that they’re going to work. We’ve got this skill set that’s with us for life, and anytime we need it, we can just implement the techniques.

Steve Orma: Yeah. I think that’s one of the most powerful things about the treatment is not only will it get rid of your insomnia, but then now you have the knowledge and the skills and the tools to maintain your sleep for the rest of your life and if you run into another bout of poor sleep, you know exactly what to do to prevent it from becoming a problem, a bigger problem, and you’d be able to get it back on track. You don’t need anyone’s help at that point because you’ve gone through it and you know how to do it yourself. That’s pretty powerful.

Martin Reed: Yeah, absolutely. All right, Steve, I’ve got one last question for you. I’ve taken a lot of your time and I really appreciate it, so there’s this one question I like to ask at the end of every episode. If someone with chronic insomnia is listening and feels as though that they’ve tried everything, that they’re beyond help, and they can’t do anything to improve their sleep, what would you tell them?

Steve Orma: The first thing I would ask them is have you tried CBT-I because I hear people over and over again say, “I tried everything,” and they’ll go through a whole list of drugs they’ve tried or herbals or meditation or sleep hygiene and they don’t say CBT-I. I don’t blame them for that. Again, as we were saying, these people don’t know about it, so that would be the first thing because it’s really the only actual treatment. I don’t even consider medication a treatment. It’s like a Band-Aid and it’s highly effective, so that would be the first thing that I would ask is have you been through that and have you really gone through the whole thing and stuck with it because I think most people that do that will… they’ll get some improvement in their sleep, if not full improvement.

Martin Reed: Yeah. Yeah, I completely agree. On that note, do you ever get people that have confused sleep hygiene with CBT-I? Often I get people that say they’ve tried CBT-I and then when they talk through the techniques they’ve been implementing, I don’t hear sleep restriction, I don’t hear stimulus control, but I do hear things like blackout curtains, white noise machines, things like that.

Steve Orma: Yeah, I do hear that because I think sometimes when you read about it online, the way that the publication presents CBT-I is like as just a sleep hygiene or sometimes they’ll just mention getting out of bed if you’re not sleeping. They’ll take bits and pieces of CBT-I and then people will read that and think, “Oh, yeah, I’ve tried all that, so I’ve done CBT-I,” because they don’t know that it’s this whole treatment that you go through. Yeah, I have seen that. Yeah.

Martin Reed: All right. Well, Steve, thanks again. I think we’ve kind of run over our time a little bit, so I really appreciate you taking the time out of your day to talk to me about insomnia and about CBT-I. I think that everyone listening will find it really helpful, especially because you come from that perspective of someone that’s gone through it. You’ve walked the walk, you’ve implemented the techniques yourself, you know exactly how challenging they can be over the short-term, but you know they work because they’ve worked for you and they’ve worked for your clients. Just as I know it works because it worked for me and it works for my clients.

Martin Reed: Really, I just want to leave people with this message, that these CBT-I techniques are overwhelmingly effective for chronic insomnia and if someone’s listening and they haven’t tried them, I encourage them to try them. If someone’s perhaps tried it in the past, but not been successful, just maybe see if you can find someone to work with to give the techniques a try again, because I really do believe that everyone can be successful to some extent. Most people get great results, but everyone gets some kind of results if they implement these CBT-I techniques.

Steve Orma: Yeah, I agree a hundred percent.

Martin Reed: All right, thanks again for your time, Steve. I really appreciate it.

Steve Orma: Yeah, absolutely, Martin. Thanks a lot. It’s been fun.

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.