A conversation with Michael Schwartz about CBT-I and intensive sleep retraining (#3)

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. I’m here with Michael Schwartz. He’s the founder of MicroSleep, LLC, and the program director for the Clinical Sleep Health Program at the Oregon Institute of Technology. Michael has over 30 years or experience in sleep. He’s a registered and licensed sleep technologist, and he’s certified in clinical sleep health.

Martin Reed: First of all, you do have a lot of experience in the field of sleep. How did you get involved in sleep?

Michael Schwartz: Let’s see. I came out of college with a degree in psychology, and I do remember them talking a little bit about sleep in a couple psychology classes. Which I think is interesting, because we always hear in medical school that they don’t really talk much about sleep. I remembered a little bit of it, and thought it was really interesting, and then didn’t think much of it after that.

Michael Schwartz: Then I got out of college and was doing odd jobs in the summer, and I was actually painting a house. The person whose house I was painting was the best friend of a manager of a local sleep lab. The lady stuck her head out the window and said, “Hey, Mike, are you a night person?” I said, “What do you mean?” She said, “There’s a job as a sleep technician down the road. Are you interested?”

Michael Schwartz: One thing led to another, and I was hired on to work nights in a sleep lab. Then I was running the big stainless steel polygraph machine with the Z-fold paper. Then that was in the mid to late ’80s, and started off down in Southern California, and then just went on from there.

Martin Reed: Great. Now you do a lot of work, especially … You still do a lot of the sleep apnea work, but you also do a lot of work with insomnia, as well, right? How did you branch out from doing this sleep lab work into insomnia?

Michael Schwartz: With a background in psychology, I was familiar with some of the aspects of insomnia. It was just always a bit of an interest of mine. When I eventually made my way up to Oregon in the 1990s, there was a medical director of the sleep lab where I was in who was a pulmonologist, and was actually quite interested in chronic insomnia. We started talking, and one thing led to another, and he worked it out where I could educate patients. I would provide sleep education.

Michael Schwartz: That’s really how I started working with patients in a hospital setting who had, primarily, chronic insomnia. A large number of them had comorbid sleep apnea, so it was a combination type patient that I was educating. It was mostly sleep hygiene, but there was some of the other components that are a little more helpful for chronic insomnia that I was allowed to phrase in my own way with the support of the medical director.

Michael Schwartz: I felt very fortunate. It was a very interesting way to get into the field, for me.

Martin Reed: On a typical week now, roughly how many people with insomnia are you seeing, are you working with?

Michael Schwartz: I probably start with about four or five new clinical patients with chronic insomnia. I often see them over the course of a month about three different times. Then in my online work, I might just see a couple a month. It’s a side thing that I do. Primarily in a clinical setting where I see patients with sleep disorders, including chronic insomnia.

Martin Reed: Like me, you are a true believer in cognitive behavioral therapy for insomnia, (CBT-I) techniques. How did you progress from sleep hygiene on to CBT-I in particular? Why is it that you think CBT-I is so effective for chronic insomnia?

Michael Schwartz: It really gets down to, what is hygiene? Hygiene is something you do to prevent something. If someone is in front of you and they are struggling with chronic insomnia, sleep hygiene, it doesn’t work, not in and of itself. As we all know who are in the field, that when we look at a study on insomnia, sleep hygiene is the control group. It’s not expected to really help much at all, but it does provide a way to keep insomnia at bay, if you will.

Michael Schwartz: In the ’90s when I started working with patients, I quickly realized that. I was also researching on the side, and working with the medical director, as well. We realized, “We got to go beyond this hygiene thing to really help these people.” A primary focus was to get them off of sleeping medications. Ambien was becoming very popular at the time, and quickly we discovered that there were some problems.

Martin Reed: That’s actually a really good comparison between sleep hygiene and the CBT-I. I completely agree with you, that sleep hygiene is good, perhaps as a preventative measure, but once you’re already down that rabbit hole and your experiencing chronic insomnia, it’s probably not going to help that much. All the studies confirm that.

Martin Reed: Which is unfortunate, because, for a lot of people, it’s the first advice they get with chronic insomnia. Then when it doesn’t work, because that’s not its intention, we become really worried that we’re beyond help. A lot of people I’ve talked to, I’m sure you’ve experienced this as well, is they think that CBT-I is the same thing as sleep hygiene. They immediately discount it if they’re lucky enough to even come across it in the first place.

Michael Schwartz: Probably like you, one of the first things I often hear is, “I don’t do this. I don’t do that. I do do this. I do do that.” They’re basically going down a list of sleep hygiene, probably because it was on a handout they got from their doctor.

Martin Reed: Yeah. Absolutely.

Michael Schwartz: Maybe their neighbor shared a website with them, or something like that. Yeah, like you said, they are often frustrated in part because they got those instructions right off the bat. They thought, “If I just do these, my sleep will improve.” They do them, and their sleep doesn’t really get affected. They’ve taken out some of the things they like to do. They like to have a cup of coffee in the afternoon with their friends, or they like to do a casual social thing, but they withdraw, and all that just makes the insomnia worse.

Martin Reed: That’s good. That’s something that I’d never really considered before. I did recently record a video just to remind people that it’s okay to drink coffee if you have insomnia. Now you’ve just mentioned that. Sleep hygiene really is all about controlling your life in more of a way that CBT-I does. I think CBT-I controls your life at night, but sleep hygiene controls your life in the day. This has just occurred to me, just talking to you now.

Michael Schwartz: Yeah. That’s true. I do think it’s important … Caffeine is a strong, potent chemical. I don’t like to dismiss it. It will make your sleep, I believe, a little less deep if you have moderate to large amounts in your system while you’re sleeping. That’s something I do remind patients. Some people do fall asleep with caffeine, but I don’t think their deep sleep percentage might be what it would be if they didn’t have so much caffeine.

Michael Schwartz: I do like to make sure it’s reasonable. I think I’ve heard you say, “No pot of coffee after dinner,” or something like that, absolutely. But clearly it’s not something to be scared about, especially if it’s involved with social things, because social things are important for people to be engaged.

Martin Reed: Yeah. Absolutely. When I have clients fill out a sleep diary, I actually have a section in there for caffeine consumption. I’ve never had one client where I’ve looked at their sleep diary and been, “It’s obviously the caffeine that’s the cause of their insomnia.” Most people drink moderate amounts, and they’re done by noon. But I’ll still have people concerned. They’ll say, “I drank one cup of coffee at 9:00 in the morning. Do I have to give this up?” I don’t know what your opinion is on this, but I feel like if you’re just drinking one or two cups a day-

Michael Schwartz: Yeah, and everyone’s a little different. If someone knows that they get pretty jittery with a little bit of caffeine, they’re very sensitive to it, yeah, maybe the last one at lunch is not a bad idea. But for someone who, it’s just something they like to do, I’d say just make sure you’re not having a couple of big cups after dinner. Wrap up your last one before dinner, and then call that good. That always seemed to be reasonable for me.

Martin Reed: Yeah, absolutely.

Martin Reed: Let’s get back on the CBT-I track. Why is CBT-I so effective? Why do you think it works so well for people with chronic insomnia?

Michael Schwartz: First of all, it’s not a medication, which failed. All the medications will ultimately fail. They’re not designed to be long term. CBT-I, on the other hand, is basically behavioral, with a little, I like to say, a dose of psychology thrown in. It is very prescriptive, and it gets really right to the root causes of the insomnia. It looks at that whole issue of effort to sleep, which I think is at the core of, probably, 90% of chronic insomnia, is people making willful efforts to initiate or re-initiate sleep, and those willful efforts start to cause anxiety, which is feeding the flames of insomnia. Then it just gets worse and worse.

Michael Schwartz: CBT-I directly addresses that. It restricts time in bed. It breaks that association between the bed and wakefulness, and replaces it with the bed being associated with sleep. That’s why I think it’s so effective. It’s really very focused, very specific to chronic insomnia.

Martin Reed: Yeah. I would agree with you. The techniques themselves are pretty straightforward, but they’re tough to implement. I think that’s what a lot of people struggle with, but I think that’s why it works, because it is quite prescriptive in the short term. You’re given a sleep window that normally involves allotting less time for sleep than you’re used to. Then you’re told to implement techniques which seem counterintuitive, like, “Spend less time in bed.” “Get out of bed when you can’t sleep.” I think it is really important that any course of CBT-I includes a lot of education, just so people can understand why these techniques are important, and the rationale behind them.

Martin Reed: When I talk to people that have tried some of these things in the past, they didn’t really understand why they were doing it. They knew it was the thing that they were supposed to do, but they didn’t fully understand, or they hadn’t fully bought in to the “why”. I think that’s essential if you’re going to keep going, or want to keep going.

Michael Schwartz: Right. That’s why it’s also … It’s important to really be able to communicate with people well. I think that’s why a lot of doctors don’t do it, is because they don’t have all that great at bedside manner. They went to medical school, saving lives, and so they’re looking at charts of organics, organ systems in the body, and trying to make sure they’re going to live.

Michael Schwartz: CBT-I is not that. You have to develop a rapport with the client or patient, because you’re going to ask them to do something that’s, like you just said, it’s counterintuitive. It’s physically demanding. It’s a challenge. If you’re not relating with them, they might just say, “I’ll try that, yeah, okay,” and then they don’t.

Michael Schwartz: You have to show them through your own experience, through experience of other clients you’ve worked with, that you understand what you’re talking about, and that you can really make them feel confident enough to really give it a go. Because, like you said, it is counterintuitive. Less time in bed. Ultimately more sleep, but not right away. It’s going to take a little work. That’s a touch message sometimes.

Martin Reed: Yeah, it is. I think that that buy in is essential if you’re going to be consistent. Here, I’ll ask you a question. Have you ever seen someone be successful when they just implement the CBT-I techniques just every now and then? They’ll do the stimulus control, which is getting in and out of bed when you can’t sleep. They’ll do it for a couple of nights, but then be like, “It’s too hard. I’ll stay in bed this night.” Or they’ll not pay attention to the sleep window so much, and they’re just not very consistent. Have you ever seen someone be successful?

Michael Schwartz: No. I can’t think of anyone. Maybe one name is escaping me, but in 30 years, no, I can’t recall anyone that clearly has done that. It just doesn’t really go away. You have to make some changes for it to subside. A person might be predisposed, so they might have flareups more often than another person, perhaps, but it doesn’t just resolve, just magically go away. You have to address the issues that perpetuate it.

Martin Reed: Yeah. I agree. My experience, too. I find that clients can be successful if they’re not as consistent, but, boy, it takes a lot longer.

Michael Schwartz: Yeah, it really does. Then it leads … You probably do the same thing. I start asking questions, like, “What’s keeping you from being consistent? What are your obstacles?” Because people have … I like to say “life throws curve balls”. Someone’s got stuff going on, and I’ve had patients in the lab … I’ve had patients that live at the top of the hill in a mansion and patients that sleep in their car, and everything in between. You got to know where they’re coming from to know how to help them tailor the CBT-I techniques.

Michael Schwartz: I know that’s what you do, as well. Anyone who does this realizes that. You can’t just say the same thing to every single person, you have to be aware that they’re coming from different places, and they have different situations. Bed partner, no bed partner. Work, no work. Whatever it is, there’s things going on that a good sleep coach like yourself really can help guide a patient through so they can implement the CBT-I techniques.

Martin Reed: Yeah. Absolutely. You made a really good point there, that we’re all different. Life does get in the the way. You know what? Life should get in the way sometimes. Sometimes someone might be really upset that they went out with friends one night, and they couldn’t make it home for the start of their sleep window. I say, “That’s good. You’re out having fun with friends. That’s life.”

Michael Schwartz: Right. Because maybe they’re a person who had been previously not going out and doing social things with friends. It’s like, what’s worse? One night of not doing your sleep window versus being out with your friends that you haven’t done in six months? I would probably argue it’s the being out with friends that you haven’t done for six months that’s probably a more helpful thing that particular night. In long term, you want to make sure they’re back doing their sleep window and getting their sleep consistency up.

Martin Reed: Yeah, absolutely. One hundred percent. The consistency is key, but it’s also important to recognize that you want to be living your life, too. Like you said, if you haven’t been out with your friends for six months, but now you feel like you’re recognizing that it’s important to do this and not let your insomnia control your life … If you go to bed late one night but in return you’ve had all that fun, and been out with your friends, and lived your life, then it’s worth it. As long as you’re not doing it every single night. You can’t expect to see improvements if you’re doing it every night, you’re not coming home until 3:00 in the morning.

Michael Schwartz: And you’re not throwing a baseball through your sleep window, sleeping until noon the next day, things like that. It’s all within reason.

Michael Schwartz: If a client or a patient told me something like that, I would probably ask, “When was the last time you were out with friends? That could be a really good sign. Maybe you’re starting to feel a little better, more confident in yourself, that you can allow yourself to do these things. Maybe you feel like you’re presenting yourself as a better friend. More understanding, you’re listening better, you’re more interested in other people.” These are all things that are clearly worth pointing out to someone who’s been struggling with insomnia for maybe 20 years, or something like that.

Martin Reed: Yeah. Absolutely. Leading on from this, because I know the sleep window is something that some people struggle with, what other CBT-I techniques do you find that people tend to … There’d either be more resistance, or it just takes a lot more effort to be consistent with?

Michael Schwartz: The big one, of course, is leaving the bed when you’re awake at night. That’s probably the biggest “effort” aspect. Also, some people like to lie around a bit in the afternoon if they don’t work, or something like that, and asking them to be on their feet for a while instead. I always say napping is okay if it’s really short, minimal, quick little power nap in the early afternoon. It’s not going to do anything to your sleep at night. If it makes you feel a little better to get through the afternoon, then it might be worth it, but you don’t want to lie around all afternoon. Sometimes that can be effort.

Michael Schwartz: I have some patients that … You can’t fall asleep on your feet very easily, so if you’re on your feet, you’re probably not going to be lying around. You’re not going to suddenly wake up on the couch, realizing you’ve been there for an hour and a half with the TV on. I think that’s a bit of an effort as well.

Michael Schwartz: Other efforts, besides just the “get up at the same time every morning pretty consistently”, I like to say within an hour at the most of variance. So what works for them, say, obligatory time of maybe 6:00 for work, or something, then I say, “What about the non-work days?” If they say 9:00 or 10:00, I might say, “You know what? How about let’s go for 7:00?” You give them an hour of lie-in in the morning on their non-work days. That does, obviously, take effort.

Michael Schwartz: Getting out of bed in the middle of the night, getting up at the same time every morning, clearly the two big ones, I think. Most people are fine if you tell them to try to get up and walk a little more, get a little exercise during the day. Get outside in the light. The sunlight is such a great circadian setter. The getting out of bed and getting up at the same time, to me, they’re clearly the two biggest effort components with CBT-I.

Martin Reed: Yeah. Absolutely. Especially the idea of getting up at the same time every day, that can be very hard for people. Even clients that have to be up at a certain time to start work, but they, for whatever reason, they’ve decided that a sleep window that works best for them ends, say, two hours before they actually have to be up. That might just work out better for them. Then there’s that eternal struggle in the morning of, just, getting out of bed at that set time, and trying to resist that temptation to stay in.

Martin Reed: I’ve thought about this quite a lot recently, and what I’ve found is, a good motivator to get you out of bed is to create a social obligation. If you have a friend that’s a morning person, for example, arrange to meet for a coffee at the coffee shop at like 7:00 a.m. You know that you don’t want to let your friends down. You know that you have to be there to meet up with them.

Michael Schwartz: Right. Exactly.

Martin Reed: Or if you go to the gym, meet your trainer, or meet a friend at a certain time. That can really be a motivator to get out of bed at that consistent time.

Michael Schwartz: It’s that accountability you’re talking about. I have, and we’ve probably both had clients or patients that talk about, if they’re fairly depressed, they might say, “I don’t have any reason to get out of bed.” They say that in a way, like, it’s a psychological thing. It’s not just, “I haven’t scheduled something for tomorrow,” it’s, “I never have a reason to get out of bed,” because their life is really, really challenging.

Michael Schwartz: We don’t do psychotherapy with CBT-I, but we do clearly talk to people about things that could be barriers to the behavioral goal, like getting out of bed at the same time. Sometimes it is simple things, like finding out if they have a neighbor who checks in on them, or if they have an exercise thing that they could go do, like you were talking about. Around here we have a moderately sized shopping mall, and they open up their doors, I think, at 5:30 in the morning for people who want to walk on those hot summer days that we get down here. It’s a great thing. I let my patients know that.

Michael Schwartz: It’s just knowing things like that that can really give them a way to implement a behavior that’s the ultimate goal of what you want them to do. The goal isn’t to get up and walk around the mall, the goal is to get up at the same time. I don’t care what you do, I just want you out of bed at the same time. This gives them a little extra something to look forward to. Just simple things like that sometimes go a real long ways.

Martin Reed: Yeah. Something as simple, as well, as just understanding sleep drive, this sleep pressure. If we just get up instead of staying in bed for those extra hour or extra two hours, if we just get up right now, that’s more time for us to build this sleep drive, to build this sleep pressure during the day. Staying in bed might feel good at the time, but it’s that trade off. You might then struggle to fall asleep that night.

Martin Reed: Just, like you said, this psycho-education. The educational side of it is so important, too. I completely agree.

Michael Schwartz: Yeah. It is.

Martin Reed: When you’re seeing patients in your environment, is there a typical amount of time it takes for someone to see benefits in their sleep when they incorporate CBT-I? Or is it just the case that everyone is different?

Michael Schwartz: There are some people that you can pick up on, pick up some vibes early on, where you just know they’re going to really do well with CBT-I. They seem to have a great disposition, and they understand what you’re talking to them about. They’re learning the concepts. They see the logic. They understand them. They have the type of insomnia that is just anxiety driven. Those people, in my mind, tend to be the ones that can sometimes turn everything around in literally a week or two. They just really dive into it. They start to make really great progress. After two weeks, they’re just clearly going in the right direction. They understand everything you’ve told them, and they have great tools at their disposal and they know it.

Michael Schwartz: On the other hand, some people aren’t like that. They might present a strange type of sleeping pattern, or you might think there’s other things going on during sleep. They might have a little bit of sleep apnea that could be undetected at the time. Or they might be on some certain medications that really disrupt sleep. Those are clearly, I think, the ones that take longer, because maybe their gains might not be quite as robust.

Michael Schwartz: They can still definitely make gains, and I let them know that. That would be someone I would probably have to look at in a bigger picture, like, “What are our goals here? What are our expectations? What are we trying to accomplish?” Maybe it’s someone who’s in their mid to late 80s, or in their 90s, perhaps, and they have a lot of mobility issues, medication, things going on. We want to make sure we’re not trying to do herculean things, here.

Michael Schwartz: Things like that. That would be a type of a person that I might not expect to respond real robustly or quickly. It can take anywhere from two weeks all the way to … I’ve worked with people off and on. You probably have done longer than I have. Maybe three or four months, something like that. I try to get them at least going in the right direction, especially in the hospital setting where I do the education. The hospital isn’t just saying, “Have them come back as many times as they want,” it’s more restricted.

Michael Schwartz: Anyways, that’s my experience. It can be maybe a week or two at the shortest to a few months if they really are working on it.

Martin Reed: Yeah. I had to ask you that question, just because it’s a question I get a lot from clients and non-clients. They always want to compare their progress to the progress of other people, just as … I try and deflect from that, because we’re all different. It’s such a common question, I wanted to ask you just to get your viewpoint. I just tell them, “Everyone’s different. If you’re consistent, you’ll generally see some kind of improvement within a few weeks. But in terms of whatever your definition of success is, that could take many months of consistent implementation.”

Martin Reed: It’s so important not to give yourself this time plan. Like, “I need to be better within four weeks,” or, “within two months,” or, “within three months,” because you’re just putting unnecessary pressure on yourself.

Michael Schwartz: Right. Exactly. Qualifying things with, “It depends on the person.” If the person says, “How long will this take?” I say, “How much effort are you willing to put into this? Let me describe what I’m asking you to do, and then you’ll know how long, maybe, it will take, based on what you really want to do.” That’s part of the equation as well for how long it might take.

Martin Reed: Yeah. Absolutely. It’s important, too, to have realistic goals. When I have a new client enrolled, if they tell me, “My goal is to get eight hours of sleep every single night,” the first thing I have to do is explain that that would be really unusual, first of all, to get eight hours of sleep, and then to get that every single night of the week, that would be pretty incredible. Because not many people can do that.

Michael Schwartz: No. Teenagers aside, when someone starts talking eight hours of sleep, we both know it’s not what’s normal. When you get longer than eight hours, there’s some studies that show it’s not necessarily a good thing when you’re sleeping longer. That whole duration of sleep, I try to really … I don’t really get into it, because it doesn’t really matter, how long do you sleep. It doesn’t ultimately matter. All that matters is, is your sleep decent quality? Is it not elusive? If it’s elusive, that’s a problem. If it’s not good quality, like you don’t feel good when you get up in the morning or you don’t hold your energy level during the day, that’s not good either. Those are the two big things.

Michael Schwartz: I don’t care how many hours you say you slept, because, of course, reality is I don’t know, actually, how much they sleep. The trackers are not real accurate, and no one really knows, truly, night to night, how much they’re actually sleeping. It’s not something worth focusing on when you can ask yourself, “How do you feel?” That’s really the ultimate question.

Martin Reed: Yeah. I could not agree with you more. I think sleep quality is really all we should ever judge our sleep on. If we feel good during the day, we’re not feeling excessively sleepy during the day, we feel like we’re productive, then the chances are, 99% of the time, you’re going to be sleeping just fine for your individual sleep needs.

Michael Schwartz: Yeah. Long as it’s not elusive, it doesn’t feel like it takes forever to fall asleep, you don’t feel like you’re awake forever in the middle of the night. These are goals to work towards. I like to use the word “elusive”. Make sleep less elusive.

Michael Schwartz: Just make sure that falling asleep feels like it happens reasonably easy, and getting back to sleep in the middle of the night also feels reasonably easy. These are goals to work towards, because they reduce anxiety. It’s like anything. If you have more confidence in what you’re doing, you’re less anxious about it. If I was here talking about astrophysiology or something, I would probably be very nervous, because I don’t know what I’d be talking about. But I’m talking about sleep, and I have some experience, so I feel confident in it. Someone who loses confidence in their sleep, that drives worry and anxiety, which perpetuates the insomnia.

Martin Reed: Yeah. I think that’s a good tip on the sleep duration front. The only time, really, we should pay any attention to duration is, like you say, if it takes us an excessive amount of time to fall asleep, or if we’re just awake for an excessive amount of time during the night. That’s the only time, really, but that’s obvious. If you’re struggling to fall asleep at night or you’re struggling to stay asleep, you’re going to feel lousy during the day. It still just comes back to how you feel during the day as being the ultimate guide.

Michael Schwartz: It’s a very introspective thing. I encourage my clients or patients to be introspective. You’re the one who answers the question. “How do I feel? How easy is sleep? How difficult is sleep?” Trying to track it, trying to gauge it in other ways, focusing on a duration of sleep, all of that just makes things worse. Getting someone to be introspective can be, sometimes, challenging.

Martin Reed: In your work with patients with insomnia, do you have any success stories that you can think of? Was there someone that just seemed to really struggle with implementing the techniques? They maybe relapsed a few times, but they stayed committed and they managed to get their sleep back on track?

Michael Schwartz: Yes. The relapse thing, it can be a challenge. I know I have had patients who have relapsed. Maybe make some initiate gains, and then they stop doing the techniques that I’d gone over with them. Then you quickly realize that they’re not progressing because they’re not doing the techniques.

Michael Schwartz: There is one … I remember a patient I had. This was years ago, probably 15, maybe 20 years ago, that I’ll never forget. Because one of the … It was a big, strapping guy. Big, tough guy, probably a lumberjack or something. Big, tough guy. He came in, and he was really struggling with sleep. Really having trouble getting to sleep. He came in, and I’m going through the techniques with him. One of the techniques that we typically at least introduce is the idea of that worry time. That writing things down during the day to process things that might be on your mind at night, I’m a big proponent of that, because your brain physiology changes when you get drowsy. That prefrontal cortex logic stuff goes out the window, and you’re more brainstem, amygdala, emotional person.

Michael Schwartz: I was getting to that point when I was educating him, and I dismissed it. I thought, “This guy, he doesn’t have any worries. Look at him. He’s as tough as nails,” and all that. He wasn’t making, really, much progress. I started some sleep restriction, and all that. But you could tell, he just had a lot of trouble in bed. He kept talking about an active mind that started to … When I saw him the second time, I started asking him more about it. He had some real issues that he was pretty worried about that weren’t necessarily sleep related. Some of it was sleep related, and a lot of the people that you work with and I work with, the worry of sleep has reached the top of the list. Right? It’s at the top. “I’m worried about going to sleep.”

Michael Schwartz: This guy, it wasn’t at the top. He had some other things that I realized maybe could benefit from writing them down during the day, taking five or ten minutes at lunch, processing some things. Writing a few ideas, some possible solutions, and taking more of an active approach during the day when you’re thinking a little more clearly. That turned out to really help him. He commented, that was probably the big thing that really helped him with everything else with CBT-I.

Michael Schwartz: What he taught me was that you can’t assume things about your clients or your patients. As soon as you assume something, you’re going to get surprised. If you start to get into the routine of, “I know this kind of patient. I know the kind of client. I know who they are. I’ve dealt with this,” you’re going to get surprised, because sleep, it’s a whole life thing. Anything can really affect it. You have to pay attention, even with people, clients or patients, that you feel like you’ve talked to before, you feel like you’ve met this kind of person. Maybe, maybe not.

Michael Schwartz: I’ll never forget that guy. I always, with every CBT-I component, I always make sure I give it due diligence, no matter what I think of the person sitting across the table or on the other side of the screen, for me.

Martin Reed: Yeah. I think this is another reason why CBT-I is so effective, because it is a combination of techniques. It’s not just one technique. Someone might respond really well to, just, sleep restriction, which is a terrible name. Just having a shorter sleep window that more closely matches how much time they sleep. They may not even need to implement stimulus control, because just shrinking down the sleep window immediately gives them more consolidated sleep.

Michael Schwartz: Absolutely.

Martin Reed: Someone else, the sleep window may not be effective by itself, but once they combine it with the stimulus control, then it helps. Other people, they might still be struggling because their minds are just racing all night long. Reallocating that thinking time to a period during the day can be really helpful, like you said. I think this is just part of the beauty of CBT-I, because it has something for everyone in there.

Michael Schwartz: Yeah, exactly. You have to look at everything. I like to joke I have an endless wall of hats that I wear when I’m talking to someone about their sleep. Sometimes you’re their friend, their coach, the sympathetic person, the empathetic person. You have to play all the roles depending on the person and depending on their situation.

Martin Reed: Let me ask you this. When you’re working with a patient and you’re going through a course of CBT-I, do you tend to find their progress is completely linear, i.e., every single week they do a check in, or every two weeks they check in, it’s like, “Improvement, improvement, improvement”? Or, do you see some improvement, then some relapse, then some improvement, then some relapse?

Michael Schwartz: The short answer is yes, all of the above. I usually see some progress after, maybe, an initial visit, and then they come back a couple weeks later. I let every person I work with know that, initially, it’s not uncommon to go backwards. That first week can be challenging, and your worry might even go up because you know you’re doing what you were asked, but you don’t necessarily feel better right away. You’re really wondering, “Is this working?” That can cause anxiety.

Michael Schwartz: I just give them a heads up. The analogy I like to use, it’s like if someone was not physically fit and they started to go to the gymnasium to get fit. First couple times, not fun. You’re tired, you’re achy, you’re sore, someone’s barking at you to lift this, or move that way, or whatever. It’s just not necessarily all that enjoyable. But then you hang in there, and like all kinds of training, even physical training, and you start to feel a little better. Then the Holy Grail is, you then start to look forward to it.

Michael Schwartz: Sleep is kind of like that. CBT-I is kind of like that. I find the first week or two, if someone really dives into it, it can be a little bit of a dip, and then they are turning the corner by the time I see them, maybe, at a couple weeks out. The first week, I don’t even really like to check in with them too much. I might after a couple days, just to make sure they understand, they have a plan, they know they’re getting started or they’re going to get started tonight, or something like that. But then I know there’s a few days or nights where a lot of people just want to sort things out. You got the whole prescription, right there. Here’s the behavioral things to do, and just work it out. You might need to work out some things that you don’t need to necessarily talk to anyone about it.

Michael Schwartz: After a couple weeks, they’ve usually turned the corner. Then, like I said, they start to feel a little better. Then the Holy Grail, which, unfortunately, a lot of us who work with people with chronic insomnia, we don’t necessarily get to see these people at this point, where they’re doing so well on sleep, they don’t really need to talk to you. They enjoy sleep. They look forward to going to bed. They know how restorative it is, and they know that they don’t have to lie there for eight, nine, ten hours. Everything else in their life is pretty much improving. Health, psychology, whatever it is. That’s the ultimate, that’s the Holy Grail, right? But, unfortunately, we don’t often get to talk to them at that point. They’re on doing their thing, and good for them, and they should be.

Michael Schwartz: That’s the analogy I use, is like if you’re out of shape and you become fit.

Martin Reed: Yeah. I like the analogy. Here’s another reason why I like this analogy, is because, all right, you’re going to the gym to get fitter. It’s hard at first, but then as you start to recognize the gains you’re making, you feel good. But then maybe you have an injury, and then you have a bad time at the gym, just as you might have a bad night of sleep. You don’t really want to just dwell on the fact that, “All right, that one time you went to the gym you got an injury, so now we have to call it all off.” It’s really important to recognize that bad nights are still going to happen, and not to judge your progress every single morning just based on how you did last night. You want to, I always say, at least look at your sleep over at least a week, ideally at least two weeks to get a better idea of how you’re doing.

Martin Reed: Because sleep is so responsive to our daily lives, as well. If we have an argument with our partner before we go to bed, we’re probably going to struggle to sleep. If we’re on a tight deadline at work, we’re probably going to struggle to sleep. If we’ve got this really deeply entrenched insomnia that we’ve had for years if not decades, it’s going to take time to shift that. It needs this consistency with the CBT-I techniques, and the more consistent we are with them, the more consistent our sleep will become. But, there’s still going to be ups and downs along the way.

Michael Schwartz: Right. Absolutely. I like to keep things light with my clients and patients, and I might say, “You’re going to sleep every night of your life. Let’s not get hung up on just a couple nights, here.” Tomorrow night’s another chance to try something different during the day, or in the evening, or something like that that might make a big difference. You can experiment with some of the ways that you’re implementing some of the strategies to find the routine that works well for you. Like you said, it’s just like if you went to the gym and had one bad experience, it doesn’t just derail everything. You pick yourself up, you dust yourself off, you look at what happened for a moment, and you say, “Okay, maybe I just need to adjust this,” and you look forward. You don’t look back.

Michael Schwartz: It’s a huge message for people struggling with insomnia, because they do get very focused and obsessed on every single night. Often sleeping medications play into that as well, and the tortuous, “Should I take this pill at this time or not? Do I cut it in half? Should I take two of those? Or what … ” All these kinds of things, I see a lot of people like that. You have to encourage them somehow to take a big picture approach. Like you said, at least a week chunk of time.

Michael Schwartz: When they do a sleep log, maybe it’s a month-long sleep log, or something like that, I don’t even really care about the first week or two as much as, maybe, the last week. Last 10 days. What have you been doing lately? You’ve dusted off, you’ve cleared some things out in the beginning. What are you doing now? How far have you progressed? That’s where I’d like to focus, and, of course, show them if they’ve made progress the whole time. Really honing in on, “What are the successes? What are you doing that’s working lately?” Instead of them trying to remember what happened three weeks ago on a particular night, I’m like, “Don’t even worry about that. Let’s look forward, and see where we go from here.”

Martin Reed: Yeah, absolutely. It’s really important to just bear in mind that there’s always going to be ups and downs on the journey. I typically will work with someone over the course of, say, eight weeks. If I was to do a fancy line chart over the course of the eight weeks, it would be ups and downs, ups and downs. But, generally, the trend is generally positive over that period. They might start off and immediately respond and do really well, and then have two or three weeks where really struggle. Then a good week, and then maybe a bad week.

Martin Reed: It’s really important to recognize and not beat yourself up, or be hard on yourself, when you have these bad nights. You’re already doing the best thing possible, which is committing and implementing these techniques. It’s a long-term play. It’s difficult, but if you’re consistent … I always say this. If you’re consistent with the techniques, your sleep will become more consistent in return.

Michael Schwartz: Definitely. We start off as educators, and then we move into the coaching role. I always make sure that a client knows that I’m first trying to help them understand the components of CBT-I, because perhaps they’ve had some misinformation, or maybe just won’t have certain … But then once they get it, once I can tell that they get it, you become a coach. You clearly become a coach who is guiding them. They know the principles, they understand them.

Michael Schwartz: But, then, reminding them that they’re human. That’s a good thing to remind people of, now and then. What does that mean? That means that maybe you don’t do the right thing all the time. I’m not supposed to eat a lot of chocolate chip cookies. Put a plate in front of me, one of them might be missing. I just have to confess. I tell them that. Like you said, don’t beat yourself up over this. You try to do the best you can, and that’s all you can do.

Martin Reed: Yeah. Absolutely.

Martin Reed: Moving on, you have an app called Sleep On Cue. It helps people improve their sleep using a technique known as intensive sleep retraining. Can you tell us a bit more about what intensive sleep retraining is, maybe how it works in relation to your app, and how it can help people with insomnia improve their sleep?

Michael Schwartz: Yeah. It’s funny, you thought “sleep restriction” was a horrible term. “Intensive sleep retraining”. See if everyone doesn’t go running for the hills.

Michael Schwartz: It was a procedure that was, actually, first looked at maybe in the late ’70s, early ’80s for the very first time, but they didn’t really … It wasn’t really similar to what it is now, and it was called a different name. Really, was in the early 2000s that they started to look at it. By “they” I mean this research group down in South Australia, down at Flinders University. They were the ones that really done the seminal work on all of this.

Michael Schwartz: The idea is that, with CBT-I, one of the core elements is stimulus control. We’re trying to get the person to associate the bed with sleep, and nothing else, just intimacy. Basically, bed is sleep.

Michael Schwartz: With CBT-I, we instruct them, as we’ve been talking about, over night after night, “Don’t go to bed unless you’re truly sleepy. Get out of bed if you’re not sleepy. Get up at the same time every morning.” That’s what we do to try to drive … Their sleeping is stronger at night, to make their sleep more consolidated, and all that.

Michael Schwartz: The thinking by this research group was, “What if we can do something maybe that’s even more intense, possibly even more efficient than that?” Because the idea is that, with stimulus control instructions, the person is probably only getting one rapid sleep onset per night. If they lay there and they’re having trouble sleeping, they get out of bed and they go read for a little bit, they come back to bed, and maybe they lay there for a while, then they get out of bed … Eventually they fall asleep quickly. That’s the one time that night they’re going to have a rapid-initiation sleep.

Michael Schwartz: That’s the goal. The goal is to get them to fall asleep quickly, or back to sleep quickly. They said, “What if we structured this,” and said, what if they give someone a little bit of time for, maybe, 24 hours, an opportunity to fall asleep, just a short opportunity, 15, 20 minutes, something like that. Then if they do fall asleep, we’ll wake them up, get them out of bed. A few minutes later, put them back to bed and have them do it again, for 24 hours. Bedtime to bedtime.

Michael Schwartz: That’s what intensive sleep retraining is, is repeated short opportunities to fall asleep. Additionally, it’s with awareness feedback, and that’s a real important component of it. The way it works is that, starting around bedtime, the person, the way the studies were done, it was in a sleep laboratory with wires on their head, and the whole “record your sleep” thing. They gave them 20 minutes to fall asleep. If the person didn’t fall asleep in 20 minutes, they knew that because of the brainwave recordings, they went in, told the person, “You didn’t fall asleep. Get out of bed.” Or they asked them, “Do you think you did fall asleep?” And the person says, “No, I’ve just been laying here.” “Okay, You’re right. Get out of bed.” Then they came back on the half hour and did it again.

Michael Schwartz: The other scenario was, the person did fall asleep. Say they put them down for a first nap at bedtime, the person does fall asleep within the 20 minutes. They make sure they get a couple minutes of sleep recording going so they’re really sure. They go in, they wake the person up, they say, “Do you think you just fell asleep?” The person either said, “Yeah, I think so,” or, “No, I don’t think so.” Then they’re given the correct answer right then and there, because they know. They have the brainwave recordings going. That creates awareness, awareness of, what does falling asleep even feel like? Then they say, “Okay, now that you know if you’re right or wrong, get out of bed for a few minutes, come back on the half hour, do it again.”

Michael Schwartz: Those are the two scenarios. Either they fell asleep in a sleep trial, as they called it, either they fell asleep within those 20 minutes, or they didn’t fall asleep. Either way, they’re asked, “Do you think you fell asleep?” Given the correct answer, kicked out of bed for a few minutes, back to bed on the half hour. That is the intensive sleep retraining technique.

Michael Schwartz: So then after 24 hours, they say, “Okay, you’re done.” Put them in a taxi, take them home, and they sleep. They found that it was comparable to a sleep stimulus control control group, and, in fact, they found that, when you added stimulus control to intensive sleep retraining, the effects were even enhanced. You can do a 24-hour intensive sleep retraining procedure, and then, from that point forward, for a few weeks, have them do regular CBT-I. It doesn’t preclude them doing CBT-I, it’s a way you can almost start off doing CBT-I with it.

Michael Schwartz: They combined the two, and that’s what was interesting, that they found an additive effect. These people, it wasn’t just immediate improvement. It wasn’t just short term. I think they look at them six months down the road, and they had maintained their improvement in their sleep, in their insomnia. That is intensive sleep retraining.

Michael Schwartz: I first read this 2012 controlled study. They were basically calling for an at-home version, two famous insomnia school researchers, Dr. Glovinsky and Spielman, who, by the way, coined the 3P model thing of insomnia. They concluded with a review of the study, and they said, “This is really good. We need to be able to do this at home. Someone needs to come up with a way to do it at home.” I remember staring at that paragraph for about five minutes going, “Yeah, someone does need to figure out how to do this at home.” This was in 2012.

Michael Schwartz: There were smart phones around, but they weren’t necessarily as common as they are now. They’re getting pretty common. I tried different devices at first. I tried to come up with a home version of letting someone, giving them an opportunity over and over to fall asleep, and letting them know if they did fall asleep. That was what ISR is.

Michael Schwartz: I start off with gadgets. One thing was this ball that you’d hold in your hand. It had an accelerometer inside of it, and a 9-volt battery, and a wrist tether. Had some guy down at the local community college working on it for his project, and I’d be down there every other day. I’d just be scratching my head, going, “There’s got to be a way to do this.”

Michael Schwartz: Long story short, I decided to do a smart-phone app, because smart phones have accelerometers. What I decided was to use a call and response method. What the app does is it guides you through these repeated short sleep opportunities, and it sends you an audible tone to which you have to respond. The way you respond is by laying in bed, doing this short sleep opportunity, and when you hear a tone, you give the phone a slight juggle. Very slight. The accelerometer is cranked up to levels that I forget even how to describe. But, trust me, it’s very sensitive to movement. As long as you’re giving the phone a little jiggle after each tone, the app knows you’re still awake. If you stop giving the phone a little jiggle, the app says, “This person’s fallen asleep.”

Michael Schwartz: Then what it does, following the ISR protocol, is it vibrates to wake the person up. The person looks at their phone, it says, “DO you think you fell asleep, yes or no?” You tap a button, yes or no. Then it tells you the correct answer. Either, yeah, you’re right, you did fall asleep, or, no, you’re incorrect, and you didn’t fall asleep, or whatever combination it was.

Michael Schwartz: Then it says, “Now get out of bed for a few minutes.” There’s a little countdown timer. Then three minutes later they come back to bed. Just enough time to maybe use the restroom, grab a sip of water, or stretch, or something. Then you’re back to bed, and you do it again. You can stack more sleep trials per unit of time, by my app.

Michael Schwartz: The last thing that my app does that helps with doing more sleep trials during a short period of time is that it varies the sleep opportunity time. In the research, they did 20 minutes. 20-minute opportunity, that was fixed. Every trial on the half hour, that was fixed. My app, if you fall asleep during a sleep trial, the next sleep trial is slightly shorter. It keeps getting shorter as long as you keep falling asleep. If you don’t fall asleep in a sleep trial, next sleep trial is slightly longer. It adds just a little bit of time. It’s constantly varying.

Michael Schwartz: It’s a way to get a lot of sleep trials in, which is why I suggest when people get the app, maybe they only do it for 15 or 20 sleep trials starting around bedtime, which might take them into 12:00, 12:30, 1:00 in the morning, or something like that, until they’re just sick of it. When you’re sick of doing sleep trials, just put your phone down and sleep. It’s not meant to put you to sleep, because nothing will, as we all know. It’s not a gadget, it’s not a gimmick to say, “Yeah, listen to these ocean sounds and you’ll drift off to sleep,” or these binaural things, or whatever it is. It’s just sleep training. It’s really stimulus control amplified.

Michael Schwartz: I personally think it’s a great thing to do while a person is waiting for their delayed bedtime, maybe through their sleep window. If they’re instructed, maybe, to go to bed at 12:30 or 1:00, instead of sitting around watching TV where you might tend to doze on the couch or something like that and not realize it, or you’re just fidgeting, wondering what you’re going to do with your time, maybe go to bed and do some sleep training for 90 minutes, or something like that. Maybe do 10 or 12 sleep trials.

Michael Schwartz: It gives a person a way to practice falling asleep, is really the best way to describe it. At the end they get a graph. It’s a bar graph, and it shows how well they did falling asleep, and how well they did with their awareness of whether they fell asleep. It’s just a simple little bar graph. Yeah, it’s called Sleep on Cue, kind of a play on words. No one sleeps on cue.

Michael Schwartz: It’s the only way to do intensive sleep retraining with a standalone app. You don’t have to buy … There’s no wearable. There’s no extra gadget. The app just is what it is. There’s no things you got to buy. No in-app purchases, and things like that, like you buy a game and you have to buy stuff in the game. Nothing like that. There’s no advertisements. It’s just me on the phone with some programmers for the better part of a year in the middle of the night trying to explain what I’m talking about.

Michael Schwartz: Yeah, it takes some effort. People will say it’s effective. You have to be pretty focused to do it. I almost like to think of this, I’ll finish talking about the app with this analogy. I feel like I invented the hill. By that I mean, if you’re not fit, and there’s a hill, you can run up and down it as many times as you want. You’ll probably eventually get fit. I invented the hill for sleep. You have to run up the hill. You have to do the training. You can’t just look at the screen. That doesn’t do anything. In fact, you rarely look at the screen when you’re using the app. Most of the time you’re just holding it in the bedroom, and you’re waiting for the tone, which might use earbud headphones, or something like that. You’re just waiting for the tone to respond to. You’re not engaged with the app. There’s no programming things. You’re not doing stuff on it. You’re really just minimally engaged with it, with the screen.

Michael Schwartz: It takes some willpower and effort, but the studies are pretty clear with intensives sleep retraining that there’s a pretty good additive effect that could possibly enhance CBT-I in general, specifically stimulus control component.

Martin Reed: That’s really interesting. Let’s say that I decided … I’ve been struggling with insomnia for a long time. I want to give this a try. I go to the app store. I download it. Is this something that I would be doing every night for a number of weeks, or a number of months? Or is it something that I can just expect to do for a couple of nights and then I’m done with it?

Michael Schwartz: The way I answer the question is to look at the original research in intensive sleep retraining, ISR. What they did before the person came to the laboratory to do the 24-hour procedure, the night before, at home, they were sleep deprived. I think they gave them five hours of time in bed, and that was it. They showed up to the lab the next night around bedtime, already extra tired. One thing I don’t do is tell anyone who gets my app, “Sleep deprive yourself, then use my app,” because someone puts their car in a ditch, I get a call from a lawyer, and my life ends.

Michael Schwartz: What I say is, “If you happen to have a rough night,” which, someone with insomnia is saying, “Okay, got that checked off, nightly.” Okay? But if you have a particularly rough night, the next night might be a really good time to do a little bit of sleep training around bedtime. Your natural sleep drive might be a little bit stronger. That’s what they were trying to do in the research, drive up their homeostatic sleep drive to start off these sleep trials. Then if you think about it, over the 24 hours that they did them in the laboratory, not much sleep was accumulated. They only let them sleep a couple minutes when they did fall asleep in a sleep trial. Do you follow that? By bedtime the next night, they hadn’t gotten much sleep over the last 48 hours. They were pretty sleepy.

Michael Schwartz: With my app, I say, “You know what? If you have a rough night, you might try doing 15 or 20 sleep trials,” or something like that. I think it gives a person a good experience of what the app does. They start to … It’s hard to describe. It’s nonspecific. I’ve talked to other people that have told me that. I was interviewed on a different podcast a while back, and the interviewer had actually used the app. He was describing that to me.

Michael Schwartz: He said two things. One is, it takes some willpower and effort to do it. It’s the hill. You got to tell yourself to run up it. Second is that how it helps you is hard to describe. Because I said, “Did you find that it helped you more with falling asleep rather than getting back to sleep in the middle of the night?” He said, “No, actually, it was kind of equal,” which surprised me. Because the research mostly focused on trouble falling asleep, that type of sleep-onset insomnia. They didn’t really look at the “getting back to sleep in the middle of the night” thing. I think they’re going to be looking at that.

Michael Schwartz: The interviewer of the podcast interview, he described that. He said, “No, that was equally as helpful.” That was really helpful. That was uplifting for me to … I got some good, direct feedback that it even helped with that.

Michael Schwartz: I think that it’s hard to verbalize how it helps with insomnia, but I look at it as, if you really want to do something direct with your insomnia, like you just want to cut right to the chase, you want to start working on it right away, it might be the thing to try. It’s definitely an awareness thing. An awareness about getting sleepy that is maybe lost in someone who struggles with chronic insomnia. Like you said, they say, “I never get sleepy.” We’ve all heard that from people. “I never get sleepy. I don’t even know what sleep feels like. Sometimes I don’t sleep at all.” All these lack of awareness kinds of comments, it really helps with that, because you repeatedly, over and over again, get to know if what you just experienced was sleep or not.

Michael Schwartz: The app does a pretty good job with that. I should say, it was validated in a pilot study that the same Flinders group … They’re great down there, actually, in Flinders, by the way. I want to comment that … Shout out to all of them. Dr. Lack, Hannah Scott, all of them. Really great researchers. They were really helpful with me, and they did some, actually, independent research with my app.

Michael Schwartz: One thing that they did, that they studied, was, how good is the app at detecting sleep onset? That’s a core question. This thing vibrates, and then says, “Do you think you just fell asleep?” How do I know that I actually did fall asleep? Maybe the app is wrong. That’s absolutely a possibility. The correlation was in the 80s compared with PSG, brainwave, polysomnography recordings. I was really, really encouraged when I saw that number, because what it correlated with was not stage one onset. That was lower. Then you ask humans to identify stage one, and you get a lot of variability. You get stage two, the next, more stable type of sleep, starting up, humans, as well as my app, both are much better at detecting that type of sleep.

Michael Schwartz: I’ll try not to bore you here, but I went back to research from the ’60s where they were looking at audible tones and your awareness of the tone. How did you respond to the tone? What really came out of all that was, when your brain starts to generate something called a “sleep spindle”, the little squiggly waveform that we see in stage two sleep, as soon as it starts to do that, really pretty well cut off from your environment. You pretty much won’t respond to anything, not very well.

Michael Schwartz: Compared to stage one, that first light, transitional state, someone might be in it for three or four minutes. Then you’ll go and tap them on the shoulder, and you say, “Do you think you were just sleeping?” “I wasn’t sleeping, no. You just came in the room. What do you want? I’m awake.” But you look at the brainwaves, the brainwaves are saying, “That’s all stage one.” When you get to that sleep spindle stage, stage two, and the person is much more likely to say, “Yeah, I think maybe I was asleep.” They’re much more likely to not respond to an audible tone.

Michael Schwartz: I programmed the app in a way, giving it enough duration … I even drew on my own experience with polysomnography, this field I’ve been in forever, of, what is the brain doing? I was using my app, testing it out. I’m trying to picture my brain. Then I even went in the sleep lab and had someone put wires on me. I used the app. I did this two or three times, because I know what I feel like. Like, “Okay, that would’ve shown this, and that would’ve shown … ” I was almost testing it on myself.

Michael Schwartz: Lo and behold, when they did that pilot study, they found that it was a pretty strong correlation with the onset of stage two, because you want the person to know whether they fell asleep or not. You want them to be able to perceive that. That’s what … The app lets the person get to that level before it wakes them up and asks them. That’s the Sleep on Cue app.

Martin Reed: All right. Great. Correct me if I’m wrong or if there’s anything you want to add, but it sounds to me as though this app could be really helpful for people that either feel that they don’t have these cues for sleepiness anymore … If you say this statement, “I don’t get sleepy,” then your app, it sounds like it’s worth trying. Again, for more like this paradoxical insomnia, maybe, whereby you’re convinced that you haven’t been sleeping, but you’ve been told that you are actually getting some sleep, the app could be helpful there at helping you discern between sleep and wakefulness.

Michael Schwartz: Yeah. I think the key term is “awareness”. It helps you improve your awareness, which, in turn, helps you actually fall asleep with less worry. The app doesn’t connect to the internet or anything like that. You can shut everything down on your phone, and it turns into, basically, a gadget. I just needed it to do a few functions, and have an accelerometer. That was really what I was looking for. If it was something other than a phone, I would’ve used something other than a phone. But because everyone has phones, and it’s not that difficult to program things … Although this was a little challenging with some of the accelerometer features, more than I realized.

Michael Schwartz: It’s a gadget. You’re lying there, and you’re using … I should say “a tool”. I don’t like the word “gadget”. It’s a tool, helping you learn what it feels like to get sleepy or to be asleep. You train. Just like you don’t take the barbell home from the gym after you’re done to keep lifting weights throughout your rest of your day, you do it to train. That’s what the app does. It’s for training. Short term, for a little while. I think, in some people, it’s a great way to kickstart CBT-I.

Martin Reed: Great. Thanks for that. Thanks for telling us more about intensive sleep retraining, as well, and clarifying some points on that.

Martin Reed: I think we should wrap it up now, because I’ve taken a lot of your time. But let me ask you this. If there’s someone listening to this or watching this with chronic insomnia, they feel like they’ve tried everything, they’re beyond help, there’s nothing they can do to improve their sleep, what would you tell that person?

Michael Schwartz: I would tell them that they likely have not heard everything. What they have heard was possibly not described correctly. if they’re adamant that they have, that they’ve tried everything … I will even back up a step. I always make sure they’ve asked their doctor. Is there anything that could just be sabotaging all of your efforts? Do you have this huge restless legs problem where your brain is just reacting over and over again, hundreds of times every single night? CBT-I isn’t going to help that much.

Michael Schwartz: Do you have untreated sleep apnea? You snore like a freight train? You get the elbow to roll over 10, 15 times every single night? All of these really strong signs of another sleep disorder, you got to talk to your doctor about that. Same with medication — talk to your doctor. They could be sabotaging your efforts.

Michael Schwartz: But if all that’s under control, I like to tell people, “You haven’t heard it all.” You got to find someone like Martin Reed at InsomniaCoach.com, and say, “Hey, I think I’ve heard it all, but can we go over it? Can you let me know, is this what I should be doing?” Chances are very possible that they have not heard it explained correctly, not been guided correctly with CBT-I.

Michael Schwartz: My app sometimes. I might suggest they might read about it, see if it makes sense, see if they see the logic in it. Sometimes that’s maybe more than someone wants to do if they’re getting really frazzled by their whole insomnia thing, and it’s just taking over their life, and all of that. They might need, definitely, more of a coaching aspect, a real structured CBT-I program.

Michael Schwartz: I would say that’s the main thing, politely letting them know they probably haven’t heard or read everything. If they kind of have, they might not have had it explained in a way that it’s implemented properly. That’s how I’d answer that question.

Martin Reed: Yeah, I think I would agree with you. A lot of people just feel like they’ve tried everything. I’ll ask them if they’ve tried CBT-I, and they’ll say, “What’s that?”

Martin Reed: I think partly that’s the community’s fault for not spreading the word about CBT-I more. A lot of people go to their doctors, and their doctors won’t even mention CBT-I. There’s a lot of work to be done in terms of sharing these techniques, and helping people recognize that there is a solution out there that works for the overwhelming majority of people. If you go through a course of CBT-I that’s implemented correctly and implemented consistently, it would be really unusually for you not to be able to get your sleep back on track.

Michael Schwartz: I couldn’t agree more.

Martin Reed: A lot of doctors are in a hard place, because even the ones that are aware of it, they don’t have the time to go through it with their patients. Also they may not have anyone to refer them to. But, then again, at the same time, there are some doctors out there who aren’t familiar with CBT-I. They’ll encourage their patients to implement sleep hygiene. If that doesn’t work, then maybe the next step is the sleeping pills. As we know, they’re not a long-term solution.

Michael Schwartz: Right. In my opinion, if a CBT-I program doesn’t get into bedtime restriction and stimulus control early on, it’s probably not an effective program. There’s obviously education that has to be done initially. There’s got to be some basic understandings of certain things. Maybe your natural sleep drive, your circadian rhythm. Some things like that, that have to be clarified early on, but then it needs to jump into the core components quickly, I think, for someone to really realize a lot of benefit from the program.

Martin Reed: All right. Thanks for sharing your time with us, and talking to me about this today. If anyone wants to know more about you, what you do, or wants to download your app, where can they find you and where can they find your app?

Michael Schwartz: The easiest thing is just to go to my website, which is SleepOnQ, and that’s the letter Q, .com, where there’s links to everything. There’s links to the App Store, to the Google Play store, and an FAQ about the app so they can read more about it. There’s links to the intensive sleep retraining research. Then there’s a “contact me” page. I don’t really have a blog going, or anything like that. I’m on Twitter a fair amount, but everything is really … It’s focused around the website, which is SleepOnQ, the letter Q, .com. I did do, recently, a three-episode series on the app itself, so it’s actually good timing. The last three episodes I’ve done are all on the app.

Martin Reed: That’s great. All right. Thanks again for your time, Michael. It’s been a really interesting discussion. I hope it’s given people a lot of things to consider listening to this. Really, my ultimate goal is really just to give people hope that they can sleep, that there are ways to improve sleep, and that they don’t need to live with insomnia forever.

Michael Schwartz: Absolutely. You’re Insomnia Coach website has been a huge part of that. It’s immensely informative. Everything that you’re doing with CBT-I is really, really helpful. Everyone, go to Martin’s website, InsomniaCoach.com.

Michael Schwartz: I also want to make sure to recognize the research team at Flinders University in Australia who did the original research, were very supportive and helpful with my Sleep On Cue app in providing a pilot study for its validation, for recognizing sleep onset. Also to let you know that they have their own device for doing at-home intensive sleep retraining called the THIM device, T-H-I-M. You should definitely check it out. Their website is THIM.io, so if you go to THIM.io, you can read all about their device for doing at-home intensive sleep retraining.

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.