Specialising in Sleep: What psychologists and therapists need to know with Dr Dave Lee

TRANSCRIPT

SPEAKERS

Rosie Gilderthorp, Dave Lee

Welcome to the business of psychology podcast, the show that helps you to reach more people, help more people and build the life you want to live by doing more than therapy. Before we get started today, I've got a bit of a favour to ask you. So we're planning some summer workshops at the moment for members of the Do More Than Therapy wider community, so everybody listening to this podcast, and I'm trying to work out what's going to be most useful for you guys. So there's two workshops that we're thinking of running over the summer. And they're both going to be completely free and open to everybody. So the first one is a repeat of our find your specialism training, because we get such great feedback from that, and lots of people contacted me last time saying they've missed it, and they really wanted to attend. So I thought we might run that one again. And the other one that we're thinking of running is the 50 minute business plan, which is a new training where I'll take you through the key components for useful business plan, and help you to start to create or update yours in 50 minutes. But I'm not sure what you guys want, so I've put a poll on the Do More Than Therapy page on Facebook, and if you could just hop over there and tap which option would suit you best, that would really help me make a decision, because I'm kind of trapped in uncertainty at the moment. So I'd really appreciate it if you could just vote in that poll. And let me know which training is going to be most useful for you this summer. I'll probably put it on over a couple of different dates in July and August to try and catch everybody in between summer holidays. And it's just something we're doing really because we're aware that the next round of Psychology Business School isn't starting until September, and there are lots of people who will be wanting to launch their private practice or give their private practice a bit more attention in September and might be really wanting to get started. So yes, please do, after you finish listening to this episode of course, hop on over to the Do More Than Therapy page, and just let me know your preferences in that poll. Or if you've got a better idea, I'll leave the option open so that you can add your idea into the poll as well. Because I'd love to know what you guys would benefit the most from. Okay, so let's get on with today's show.

Today I'm talking to Dr. Dave Lee about his specialism, a topic that's central to all of our lives, but rarely gets the therapeutic attention that it deserves; sleep. So I'm really excited to talk to Dave today because I think his career and what he achieves through his practice, show the value of specialising for both our clients and our own fulfilment. So I'm going to start by asking Dave some questions about how he developed his business to the point that it's at now. And then we're going to get into his specialist subjects, how we should deal with sleep difficulties when we recognise them in our clients. So welcome to the podcast Dave.

Thanks, Rosie. Nice to be here. Thanks for inviting me in.

So can you say a little bit about who you are and who you help.

So I'm Dave Lee, I'm clinical director at Sleep Unlimited, we're a team of around 15 health professionals and a bit of office support staff as well. We take a multidisciplinary approach to managing sleep problems. So we have psych... a lot of psychologists, assistant psychologists, clinical psychologists, and physiologists as well, dealing with the whole range of sleep problems across the lifespan. So we'll, we'll work with newborns, parents, children, teenagers, adults, older adults. My particular clinical specialism is working with people who've had brain injury. So we do a lot of medicolegal work with about 65% adults mostly who've had road traffic accidents or falls, and about 35% paediatric clients who maybe have experienced birth trauma and sometimes accidents as well. So that's so that's where I specialise but but our broader team will work with anybody who's got a sleep problem and liaise with other health professionals who might be working with them as well.

So where did your passion for helping people with sleep come from?

All way more by luck than judgement. I would say as life goes, we fall into things. I started out as an engineer and hated it and quit my engineering degree because I wanted to do something more fulfilling and rewarding and then helping other people out. I found the engineering quite faceless. My first real interest in sleep was piqued when I was about nine years old. I went to play with a friend down the road and he brought me into his house and stuck on Jaws, the er the shark film. I was a bit too young to probably see that and there's a couple of sort of key moments in it and one one, I don't know if you remember the film but I'm sure some of the some of your listeners will, there's there's a scene with a submerged boat and hatch op... falls open and this, this dismembered head floats out of this hatch and ah it's so scary. And I was traumatised by this and then I experienced bad dreams about it, reliving that for a couple of weeks. And we see that a lot with trauma that nightmare's a core diagnostic feature of PTSD. So I was getting up, sleepwalking, agitated, I was getting into the bath and turning the taps on in my pyjamas. So there was something going on with water and relating to the film, and sure that was all linked up. And my mom would find with dad find me in the bathroom agitated in the bath, water running, still asleep. And my mom started getting me to count from one to ten and that calmed me down, and she'd dry me off, put me back to bed. That worked for a few nights and it stopped working. And I was still agitated, and nightmare walking sleepwalking. So she then started getting me counting backwards from ten to one and that worked for a few nights. And then that stopped working. And then she got me counting from one to ten in French. And that worked for a few nights.

You were a clever nine year old.

Well, I did, I was doing numbers in French at school. And I'll come back to that point, it's a really interesting point though. And then that stopped working. And then she got me counting backwards in French from ten to one. And then after about two weeks of going through that process the the nightmares abated. I'd obviously processed the trauma, and no more sleepwalking, no more nightmares. And I always found that fascinating as I was growing up and still do, that actually what I was doing was a really quite cognitively demanding task whilst asleep. And I've gotten, I had no memory of this in the mornings. And that's a real feature of the parasomnias generally, and nightmares are very common parasomnias, everyone's had a bad dream, that we're amnestic often for what we've been doing whilst we've been sleepwalking, sleep talking, we don't remember. Oh d'you remember talking about the Taj Mahal and your dreams last night? Nah, I don't remember that. So So amnesia for that, for that is very common. And and I find that fascinating that I was not consciously aware, I have no memory. I didn't encode that in any way. I couldn't recall that in the morning. Yet, I was doing a really cognitively demanding task whilst asleep. And I still find that a fascinating thing. And that's still interests and excites me 35 years later. So that's so I think, where my interest was piqued, and I was lucky because I messed up my engineering degree at Loughborough University, but Loughborough had a an internationally renowned sleep research centre attached to it. And then when I went back, and I paid my way through my human biology degree, when I decided that I wanted to go back and retrain. I was in the human sciences department, human biology was very linked with psychology, I did quite a lot of psychological modules on my undergrad biology degree. And that then opened the door for me to do a PhD in the sleep research centre there. So that's what brought me in to that. And it was, as I say, more by luck than judgement, right place, right time, interested, ended up being qualified enough to get on and do that. And then did a, embarked on a five year clinical sleep psychology PhD, which has brought me into the world of psychology and although I trained as a biologist, I'm now a chartered psychologist and chartered scientist, and I work very much in the psychological domain now, even though sleep's are very biological thing, too. It's a really interesting phenomenon that crosses biology, psychology, sociology, economics, it touches across all the whole range of our of our experience, not just personally, but as a society as well.

Absolutely. And I'm sure we'll come more on to this because I was thinking, as you were speaking, you know, everything that we work with increasingly the more that we understand it, the more it seems ridiculous to separate the mind from the body. And we, we know that we can't separate people from their context. So I yeah, I'm interested in sort of the pattern of difficulties with sleep over the past few years, you know, are you seeing a rise at the moment?

Yeah, yeah. And there's been some survey data that came out in the autumn last year. So looking at sleep issues in the in the within the first lockdown period since since March the 23rd last year, we've seen a doubling of sleep problems in in the UK. Across the developed world, we'd normally ex.. prior to March last year, we would have, we'd expect to see one in four people experiencing some sort of sleep problem at that at a clinical level. And we've seen that double in the last year, because of increased anxiety, obviously, and anxious people tend not to sleep well. And we've seen a lot more anxiety around for obvious reasons, changed routines, routines that people may well have been in for decades, getting up at the same time going to work the same route all of a sudden that changed overnight, and that's a stressor as well. We've seen people struggling more with striking the work/life balance, because they've had to bring work home and work from home, which they might not have had to done before. And they and some of them even working in their bedrooms. So now the bed and the bedroom is not necessarily just a place to sleep, it's also worrying about work and stuff as well. And the fourth factor is 25% of people have admitted to drinking more alcohol during the lockdowns, and we'd expect that number to be higher, because if you ask people how much they drink, they tend to not be the truth. So we'd expect that to be higher than that. So because of those four reasons, we've now seen a doubling of sleep problems in a very short space of time, the stress is ongoing, we've got a lot of people now who maybe are not working as much as they were before, redundancies, being furloughed, struggling to get back to work, certain industry sectors like hospitality really struggling. And we've also got a large cohort of people now who are living with symptoms of long COVID. And that is an interesting new-ish area. We've had post viral syndrome forever. And you get you get the flus, a proportion of people who get the flu will experience post viral syndrome afterwards. And I said, essentially, that's what long COVID is, it's post viral syndrome. And fatigue is your number one symptom of post viral syndrome and long COVID. Same thing. So we're going, because so many people have had this nasty virus, we're we're going to see a large number of people living with post viral syndrome, long COVID. And I think there's definitely things that we can do behaviour really and psychologically around sleep that will improve those symptoms for people. I've got some ideas about that, because there's there's some links between our immune system, our sleep, exposure to bright light, these sorts of things. So I could talk about that if people are interested, if you if you want to dig into that. But I think there's definitely something that we need to be doing more of, focusing on sleep, especially now because of the doubling. And also managing the longer term stress and post-viral long COVID symptoms. There's a lot I think that's the sleep world can offer there, if you can find someone to deliver it.

And that seems to be the issue. So we're definitely come on to that because I'm expecting by the end of this podcast, a lot of us are going to be going off and wanting to get trained. But I'll leave that for a bit further on if that's okay. And because I'm just really interested in whether you ever had any reticence about specialising in such a tight area, because it sounds like you know, you go from being doing quite broad undergraduate degree to specialising at doctorate level really quite early on. How did that feel at the time?

I just think that's such a great example, because I run this workshop, and kind of every three months or so, we aim to do it three times a year, which is it's a free workshop that helps people to figure out what their specialism should be because I'm really big believer that, especially if you're in independent practice, you've got to develop a specialism, or you'll kind of go nuts. Because we want that level of being on top of the literature, we want to be diving deep, and making sure that we're providing the best that we can for our clients. And I just don't believe that you can do that, that you can sustain that quality across a huge range of difficulties. But what I'm hearing from you, and this is, you know what I've heard from lots of people that I've interviewed on this podcast, who've got a specialism is that yeah, you have your special subject, but you're not limited to one client group. And that changes and evolves and you find new people to help with your expertise as your career progresses.

Yeah, yeah, absolutely. I'm much broader now than I was before. But also in terms of building the team, it's recruiting people with, with that... their own expertise. So we've got five clinical psychologists who work work on our team, and one specialises in pain, once a neuro psych that works with me on the on the medicolegal brain injured client group that we work with, we've another one who specialises in children, or general adult as well. So it's having that that breadth of experience, because you can't know everything about everything. So to have a specialism and then being able to drill in and say, well, so you're the go to person for that particular issue with that particular client group. That would be that would be great for people to be able to do that more, but also we need to network and know about each other. Oh, Rosie knows about this. Well, you you're, you're that person you talk to Rosie. Dave knows about this, you're that person talk to Dave. And so we need to know about each other as well, in order to make that work I think.

I completely agree. And it's part of the reason the Do More Than Therapy group exists. Because you know, if we know about your book, for example, if you plug that we've got a thread where you can plug things like books and online courses and training and that kind of thing that people won't be able to see the video but I will link to the book.

It's called teaching the world to sleep. It's on Amazon.

Yes. And we'll all be reading it I think. But if people know about that, that's like a business card that sticks in your head. So then that's how we build up those networks. In our minds, I think of you know who's the right person to refer to, because we can't develop every specialism and we can't, we can't become experts in everything. There'll be some of us where, you know, our focus is so tight on something like EMDR, for example, that it wouldn't make sense to add sleep interventions into our toolkit. But if we know somebody who's got those skills, then the client can still get the best experience so I couldn't agree more.

Aha, interesting you mentioned that because EMDR is massively linked to sleep.

Yes, yeah, I was gonna ask you about that. I wasn't sure if I was gonna ask you on or off air but I'll ask you on air now. Can you talk a little bit about the link?

Right so EMDR, essentially the process bilateral stimulation hold in mind the traumatic event. You don't forget the event but your emotional attachment to it de-potentiates by bilaterally stimulating whilst holding in mind the traumatic event and you can bilaterally stimulate with eye movement or touch or sound. Now, when we're in REM sleep, at certain stages sleep or rapid eye movement sleep, and most I'm sure you've all heard of that. Our amygdala or limbic system is highly activated in REM. So if you wake up from REM during the middle of the night, it's quite normal to be particularly wound up, worried anxious about stuff, because your limbicly activated. And our REM dreams are highly emotional because of that limbic activation. So I can be really passionate, violent, expressive, in my REM dreams, way more than I would be in my waking life. And we think that's about emotional reprocessing and venting, I can safely scream in my boss's face, in my dreams. But I'm not going to do that when I'm awake, because I get fired. So, and what's happening in in REM, we're holding in mind the traumatic event, the nightmare maybe, and our eyes are flicking left and right, we're bilaterally stimulating ourselves. So are we not doing EMDR on ourselves every night, to process the stress of life, because life is stressful. We get cut up on the motorway, we have a pandemic to deal with, we worry about our kids and our finances, though day to day stress is part of life, and REM we think is a natural EMDR process that we do, as we've evolved to do, to process the trauma of the day before so that we wake up the next day having de-potentiated that trauma so we now can approach Tuesday in a functional way. So I think there's a huge link between EMDR and and... And if our trauma is too great during the day, we've experienced too much insult from whatever that might be, then maybe REM sleep is not enough for us. So actually, we can do a top that up. And what this is what we think EMDR is, this is like a waking REM proxy that we do on ourselves. So you can you can do this, you can get a little bit of extra REM, if you like by going and seeing an EMDR therapist.

That is very much the way our clients talk about it as well. You know, I think how many times as an EMDR therapist, do you hear god, I slept 14 hours last night, and that's never happened to me before in my life.

You hear that a lot in recovery, people know that I need more sleep now to process all of that.

All the time, all the time.

Yeah. And also the other thing that's quite interesting with EMDR is quite often during the process, odd things will just pop up out of left field in people that are where's that come from? Which is very dreamlike. Your dreams can be quite random and old things can just pop up, so it really does feel like they're very similar processes going on with REM and with EMDR. Yeah.

It's just fascinating. And I'm sure all the EMDR therapists listening are like talk more about this. For anyone who doesn't do EMDR, I will move on. But we can we can maybe dive into this at another time. It's very, very interesting. So you know, thinking it, we've touched on this sleep, it touches every client group that we work with. And, and yet, I think a lot of the time, and I don't think this is just me, I think this is true, hopefully for a lot of people. But we kind of take this kind of I'll work with the rest of the difficulties, I'll work with the low mood and the anxiety and just kind of hope that that will have an impact on sleep. And actually it often does. But but why do we spend so little time do you think training and learning about how to intervene with sleep directly?

I suppose a couple of things to say about this. Number one who owns a sleep problem? Is it a nurse job or an OT job or a physio or psychology or a GP? You know, if you've got a sleep problem, who do you see? Who gets trained in it, it's not a core feature of any undergrad degree course. A medical, five year medical degree in training, though, those students will probably spend five or six hours on sleep and that's all the neurobiological bit, not how to fix it when it goes wrong. Yet most people with a sleep problem will present to their GP and they have very little training in how to deal with and deliver nice recommended evidence based behavioural sleep medicine, which is cognitive behavioural therapy for insomnia CBTI. That's what we should be doing, but they're not trained in it and they don't know anyone else is trained in it, because no one discipline has said yes, we'll own that, we'll stick that on there as a core module on the undergrad OT course, so now you've got a sleep problem, OTs are trained in dealing with that, go and see them for CBTI. We haven't got to that point yet. So no one owns a sleep problem it from a healthcare professionals perspective. So that leaves the punter in the street with the sleep problems scrabbling around to know where to go, or the GP scrabbling around knowing where to refer them to. So they end up with second line treatment approaches which is the tablets which we have got a huge range of issues in terms of tolerance, hangover effects, dependency, and also cognitive impairment and confusion, befuddlement because we're still doped up, because of long half lives the next day. So the sleeping tablets are very, very ineffective, they cause more problems than they they're worth and you can take them for 25 years, as soon as you stop taking them, you sleep problem comes back. They don't work, they don't actually deal with the underlying issues, but CBTI does. So that's what we should be doing. We've just got an extreme paucity of train people to deliver that. So so I think that's the big obstacle really. And that's the, that's sort of my my focus now is trying to spread the word about this and impress on the disciplines to train undergraduates in this in health in how to manage this, because it doesn't really matter, CBTI isn't particularly complicated, any nurse, physio, OT, GP, psychologists could deliver this stuff, it's not that difficult. We just need to raise awareness and get people trained in it.

It's really interesting, because I think I mentioned before we started recording that I did do a CBT, I guess, probably CBTI informed group, in training for a group with chronic pain, who were also struggling with sleep. And I think that the difficulty for us is to trainees who are kind of tasked with, you know, take this book, read it and deliver this programme will be familiar to many listeners, that the problem was engagement and getting people to believe that it would work. You know, I heard time and time again, I can never come off these tablets, I never want to, I don't want to try...

Scared of trying?

Because yeah, because the I guess it's maybe because the medical model is so entrenched. Or maybe it's to do with the beliefs that were brought up with around around sleep. What do you think is at the heart of that, you know, people's reluctance, perhaps to engage?

It's, it's twofold. We have a reactive health system in the West, we don't go to see a doctor until we're ill. And then we ask them to fix us. And we want them to type into their computer our symptoms, get a diagnosis out and then take a get a bottle of pills to deal with that, go home, eat the pills, and problem goes away, That we like that, we're used to that that's the medical, Western medical model. It's reactive. It's not like the eastern medical model. In China, you pay your doctor all the time, and then when you get ill, you stop paying them, because they failed you, and they had it's their responsibility to put you right, so they're much more proactive. And we're seeing that coming into our Western health system. Now we have exercise for obesity and nutrition classes, smoking cessation classes, all this sort of stuff is becoming much more proactive because we worked out finally the penny's dropped, that actually saves a lot more money if you keep people well and stop them getting ill in the first place. But it doesn't fit with the traditional model. So Marjorie's got a sleep problems, she goes to see the doctor, she gets the tablets, she eats the tablets, they absolutely do what they say on the tin. If I give you 15-20 milligrammes of diazepam, right now you will be asleep in the next 15 minutes, it's highly effective medication, but it doesn't give you good quality sleep. And the underlying issue for the insomnia is still there, the trauma, the drinking too much caffeine, staring at telly all day and not going outside and getting any natural daylight, those behaviours are still going on, because we haven't addressed them. So I think we've got that reactive medical model on the one hand, and then we've got this weird new thing called CBTI, which isn't new, it's been around for 45 years in various forms, it's evolved, but nobody really knows about it. And it's oh it's all psychobabble mumbo jumbo this, so what you want to talk to me and that's going to sort is it? A lot of you know, a lot of psychologists will meet that resistance all the time. But I think actually when you look at the data, and you see that CBT for insomnia, and there's a whole massive, there's hundreds and hundreds of research studies demonstrating its efficacy across a whole range of client groups, at about 70%. So seven out of 10 people who engage with CBTI will see benefit from it. So if you can go to people and say, look, these tablets are toxic, they're not really actually solving the problem for you, and you're going to be taking these for the rest of your life, and you want to mix them with alcohol and antihistamines, then you're going to be knackering your liver and your kidneys at the same time, maybe. And look, here's this other thing, which is 70%, effective, non toxic, and will last you for the rest of your life. It's a no brainer. So I think it's about education. It's about challenging the traditional approach. And the only way we'll do that is by teaching more people about this stuff. Health professionals, and the general public as well. So raising awareness that there is a very, very effective intervention for this, which is non toxic, and it's 70% effective is awesome. And a good drug will hit 30% of people, 30% of people it won't do very much for them. And 30% of people who consume that drug will will have some negative side effects. The fact that CBTI hits 70% of people is fantastic. And the work that I've been doing and trying to tweak it and improve it and make it better, we're increasing that up into the 80s, which is brilliant, you know, so only 20% of people are not going to benefit from it. Well, why not? Well, they've got specific issues, they're the ones who need more help, they might have, say, sleep apnea, where they're not breathing well at night, that is easily treatable, if we know how to identify it. And it's really easy to identify, but nobody knows how to do it. So again, it's raising awareness, it's training. Or they may be particularly traumatised, in which case they need psychological help, in conjunction with, and we work multi disciplinary, disciplinarily, is that a word?

I don't know, probably.

So that we can, you know, so I will work with you and your client, and you work with the trauma, and we do some sleep stuff, or we train you to do the sleep stuff so you can do both at the same time. And that will enhance your practice. So we're in training with we're told, we're taught, you don't work with someone if they come into your clinic, and they're drunk, or they're high on drugs, because they're not going to be in the room with you. They need to be sober or straight before you can do that work. And it's exactly the same with with sleep. A full night of sleep deprivation is a bit pop psychology this, but it's been, it's been bandied around that it's equivalent to about 8 pints of beer.

Oh, I believe it. I believe it. I once, my son didn't sleep, I think I mentioned before we started recording, he didn't sleep for a year. And my daughter was also a baby, so I was up all night. If he slept for a minute or two, I'd be grateful. And I remember having to drive to the hospital because he was also you know, poorly in lots of ways. And I couldn't figure out how to turn the car engine off. I should not have been driving.

Oh, absolutely not, yes.

So bloomin dangerous. And yes, I so I fully believe that.

It's frightening to look back on that now, yeah yeah.

Really frightening.

And it is incredibly detrimental to our performance, y'know reaction time, concentration, attention, memory, all hugely impacted by sleep deprivation. So if Marjorie hasn't slept for three nights, well, you can't really do anything with her. You need to get her... we need people to be stable, to work with them effectively. So it's sobriety, it's not high on drugs, but it's also having had some sleep and and that's why we always impress upon people to do sleep work, to help give people the energy and the resources and the motivation to work with you on the on the harder stuff later. You can't bring Marjorie in, and she's not slept for three nights, and then just go straight in and dig up her 30 year abuse history. That's actually not ethical. And she's gonna go away and oh that hurt, I didn't like that. And then she disappears, and she comes out of services, whereas if you do CBTI stuff with her and get her sleeping a bit better, which is straightforward stuff, so two things then happen. She's she's got the energy and the motivation and the resource and the memory capacity to engage with you effectively in therapy. But also, she loves you, because you've sorted asleep out which she's been struggling with for 30 years, and what a fantastic way to build rapport and get that therapeutic alliance going on. So that's why we always argue, do the sleep stuff early. Empower your client with more energy and motivation, but also use that as a process to build that therapeutic alliance, which is absolutely critical.

And so often we spend a long time as trauma therapists resourcing clients, and actually what better resource can you give a client than better sleep? And help them to deal with what's going to come next. Sounds really, really important. And it just blows my mind a little bit that we don't think about it more.

We're not good at owning stuff, though. Because I'm thinking, you know, listening to you speak, I'm thinking you know, I bet and obviously can tell me if I'm wrong, but I bet that clients, if you ran a group programme, I bet clients would show up to it. And I was thinking they would show up for Dave's group. They didn't show up for mine, what would be the difference? And I think it's about that ownership and that confidence that comes with really being an expert in this subject, and because you obviously own it.

Yeah, it's become my, my little corner of the world. And I like it. And I don't have much competition, because there's not many of me around there. So I'll hang on to it because it's my patch, I quite like that. But I'm do, I'm also very passionate about sharing it. And actually, I don't think it does need me, I think that you could go and you could say, look, you can motivate people to engage with it by explaining how bad the drugs are, and how good CBTI is; 70% effective last year for the rest of your life. This is teach a man to fish, whereas the tablet is give a man a fish, and you just keep doing that every night, and it's disempowering, and it's toxic and side effects, and they don't really improve people's sleep, and the underlying issues are still there. So I think that you have to be a salesman a bit, you've got to sell it to your clients. And if you can do a good job at that, then then they would engage more.

And I think that is the heart of the struggle for many of us. It's difficult to take that stance, because there's actually there's not many things that we've got that sort of robust evidence about. And so often, I think we can be a bit more tentative in the way that we describe things, but actually, possibly when they've been prescribed medication that's not being done in a tentative way. So sometimes, if we're trying to offset that medical model, that I think there's a strong argument for yes, getting out your research statistics, and saying, look, we've got this RCT, they show 70%, actually over here, they're getting 80%. I think, if we were confident to do that, that would probably make a really big difference to how people engage with this stuff.

So that's what I was gonna ask you actually, because I know that there's a whole range of sleep disorders that people can be diagnosed with. And is it, do you take the same approach to all of them? Can you talk a bit actually about what they are, and what sorts of approaches you might take?

Awful.

Bizarrely we feel awful, tired. And I think sleep's unique in the sense that too much of it, hypersomnia, brings the same symptoms as not enough of it. So if you're pinching sleep for life during the week, you're insomniac and you feel awful. And then you oversleep at the weekend to pay it back and you're hypersomniac and you feel awful, you know, you have to get the right amount for you all the time to feel right. And there are certain conditions that are associated with hypersomnia, MS, ME, chronic fatigue syndrome, fibromyalgia, long COVID. Actually, maybe a lot of them, and fatigue is a core diagnostic feature of all of those conditions. And actually that fatigue may be being driven by hypersomnia, not the condition itself.

That so interesting. So would that be our kind of perceived wisdom about you know that you just feel like oh, you're not feeling very well go to bed, that actually maybe that's really not helping some people?

The received wisdom commonly advice commonly given as well if you're feeling tired, sleep as much as you can, and actually no, and with me, we work with people with MS, ME, they're in their 60s and they're sleeping for 14 hours a day. Well, 14 hours a day Marjorie is appropriate for you if you're three months old, or if you're you know you shouldn't be sleeping for that long. You're almost certainly experiencing hypersomnia there. And then you've got a whole range of parasomnias we talked about nightmares, sleepwalking, sleep talking, they're really common. But we also have sleep eating, sleep driving, sexsomnia where people engage in sexual activity in their sleep, sleep homicide.

What?

Yeah, therein lies the years of therapy.

There's the clinical skills for you. So so that was quite a long answer Rosie to it too. But just a quick summary then there's a lot of different insomnias, and that is the skill of us is to identify what the issues are, and then that tells us how we intervene. Terry is waking up in the night, he's struggling to get off to sleep because he's drinking 15 pints of coffee a day. It's a behavioural thing. Marjorie's got a 30 year abuse history, she's living with long COVID, she's got a broken hip and is in chronic pain. She's just been bereaved, she's going to need a very different approach. She's going to need a lot of time, a lot of effort. Terry just needs a quick slap, nicely, stop taking the coffee. Oh, is it a stimulant? I didn't realise that. Yes, it is Terry, leave it alone after lunch and you'll probably sleep better. Two minutes. Marjorie needs 22 weeks or two years, you know of therapy to to get through what what she's been through. So it's about, and this is the departure that we've made in our work, taking the 70% effectiveness up to 80 is by doing a much more detailed assessment formulation process at the front, so we know what the issues are for that client and then we cherry pick and give them what they need and not what they don't need.

So that that was that answers actually what my next question was going to be. So is it kind of like CBTI has a framework and you kind of use your formulation to navigate the person through that framework?

So conventional CBTI is a six week programme, come across six week programmes anywhere else? All over the national hectic service is six week programmes. Exercise, smoking cessation classes, blah, blah, blah. Where does this magic number six come from? Dunno?

No idea.

No idea. All right, old school CBT therapists back in the 70s Aaron Beck and CBTI is massively dominant IAPT psychological well being practitioners, all CBT. Loads of other types of psychotherapy out there, which are great, but CBTI at the moment seems to be massively dominant. Sorry. CBT. Massively dominant. Why? Because Beck measured it. Pearls didn't measure Gestalt like Beck did with a BAI and the BDI. So Beck could demonstrate improvement. And I think that was his genius. And then original CBT was not time limited, then some bright spark in the 70s-80s said, oh look, we're getting most of the change in 12 weeks. So in the 80s, early 90s CBT was a 12 week programme. And then in the 90s, some bright spark came along with oh, look, we're getting most of the change in six weeks. And I think that's where your six comes from. I think that six week session programme is something the NHS understand. And that's why all these other models now fit into a six week model. And now we've got CBTI, conventional CBTI is a six week model. It's not very C, it's mostly BT.

That's how I remember it, yes.

Yeah, very, very much. So it's weak on the cognitive side. And it's a six week model. And it was designed that way to sell it to health services, because health services understand the three letters CBT more than they understand psychodynamic psychotherapy or other things like that. And they understand the number six. So how do we effectively sell this into health services? We make it a six session model, because the NHS understands the number six, and we'll call it CBT for insomnia because the NHS understands those three letters, but it's not that C, it's more BT, and Marjorie with a 30 year abuse history needs way more than six sessions. Terry, who drinks too much coffee needs five minutes. So what we're doing is we're making a service, it's a service centred approach to try and fit it in logistically within the health service. It's not a patient centred approach. And that I think's the issue, the big issue with conventional CBTI, it's week on the C, it's six weeks, why? Does that help Terry or Marjorie? Or does it help the managers in the NHS? Yeah. And there's no real decent assessment at the beginning, Terry and Marjorie both present with insomnia, well you get six weeks of CBTI. Well I'm sorry, that's not appropriate for either of them. So this is what we've been trying to do, and this is how we push 70 up to 80. We throw in the six sessions out of the window. We we if Marjorie needs more C, then we give that to her, but we formulate and find out what the hell's going on first, and then we give Terry what he needs, not what he doesn't. And we give Marjorie what she needs and not she doesn't, which makes us more efficient as therapists, we get a better experience delivering it, the clients we work with get a more bespoke, formulated approach, which means they're more likely to comply with it, because it's for them, and compliance is everything. And now we push up into the 80s by doing it in a more sophisticated, patient centred way. So that's, that's the journey that I've been on over the last 10 years is to take this fantan... I'm a big fan of CBTI think it's great, but it's a bit crap, how do we make it better? And that's why I've been thinking about and that's what we've, we've we've got a second generation CBTI programme, which we call our REST programme, we get away from CBT because it's not. It's about routine, it's about environmental stuff, it's about stimulation control, that kind of stuff we do in behavioural sense. And it's about psychology, how we think and feel that psychology, RESP doesn't sound quite as good as REST. So we call it we've got the T we call it Thinking to get our funky acronym in there. So that's really what the book was about was about looking at the effective intervention that CBTI is and smashing it apart, and how do we make it better, and detailing the assessment process in that, so that we can then formulate and then design bespoke interventions for clients, which improves their motivation and we get better results.

I mean, it just makes so much sense, doesn't it? It's such a shame. I think, a lot of people, you know, myself included, when you've been forced into that six session CBT model, when like I was saying, you know, you've been forced to do a six week group for lots of people that really have complex issues and needed something different from that, then it starts to get a bit of a bad reputation. And you start to think well it's not effective.

It gets a bad reputation with the client, but it gets a bad reputation with the health practitioner as well.

Oh, absolutely.

So how could we, so somebody comes to me, and they're presenting with a whole range of difficulties, and sleep is one of those, what would be the signs that we should be intervening with sleep first, before we get all the other stuff?

Well, pretty much everybody you see has got a sleep problem, so you're going to be intervening with sleep with all of them, really, in an ideal world. But if you're not trained to do that, you then think well, I don't know how to do that. And I don't know anyone else who does that. So what we'll do is we'll we'll forget about that, because I can't do anything with that, and we'll just focus on other things. Now, that happens everywhere all the time. So if you've got the skills to deal with the sleep stuff, then you can then that is going to enhance your practice. So it's get skilled up in that stuff. Because you cannot find anybody with any sort of enduring physical or mental health problem, who doesn't also have a sleep problem. So anything that you can do to improve someone's sleep is going to improve their life, at least a little bit. And if you do that, they'll love you for it, and then they're more likely to engage with the rest of the stuff like we're talking about earlier. So so I would absolutely front end it. And, and, you know, we do have the technology, there's information out there on how to do this, you talked about Colin Espie's overcoming insomnia book, you know, go and read this as a trainee, and then set up a clinic and go and deliver it, and you struggle to get people on, maybe you lacked a bit of confidence in marketing it or you didn't, weren't supported very well in that. And that was, that's great, and that's conventional CBTI back when Colin was doing his work later 80s through the 90s. But it's better now we can be more sophisticated with it. And, and it's not particularly complex. So you could train yourself up, you know, buy a more up to date book on the subject, and train yourself, or come on some, some training courses, and, and that's, that's really what I want to be doing is training as many people as possible so that we can get this out as far and as wide because it's so ubiquitous.

Absolutely. So would there be times then when you'd really recommend that instead of trying to do it yourself, even if you've had a bit of training, but it's not, it's not your specialist area, when when would you recommend that we refer on to you know, somewhere like Sleep Unlimited yourself?

So we're going to talk about this a lot in in, in our training, we do a two part training process, the first day is a foundation day about the science of sleep and the different types of insomnia and how we might, an introduction to CBTI. And the second day is CBTI all the way through, how you assess and treat using that as a model. When we go through our second generation REST programme in that. We talk about where it's contra indicated, and where you would refer on for other things. And we talk about a stepped care approach. whereby at the bottom of the pyramid, you've got a large number of people with a low level of a problem. And the next level up you've got a smaller population who are a bit more complicated. And after those, the two training days for health professionals, if you're trained, trained health professional, you should be able to deal with those two levels, but also be able to identify the people who are more complicated, less of them, further up the pyramid, and be able to then say, right, actually, these people are going to need more of a multidisciplinary approach. And that's out with my level of expertise as a nurse or an OT, I'm going to then refer on. So the idea is that we're delivering the training around to a lot of health professionals, so they can deal with most people who are fairly straightforward, but also identify the ones that do need more help and knock up. Now the NHS do like a step care approach, you know, giving people what they need, not what they don't need, but being able to triage them into the right level of care. So, so yeah, absolutely. I mean, if you're, if you're not confident, and you think it's out with your comfort zone, or your level of expertise or training, then, you know, pick up the phones, Dave, I've got this client, they look like this, what do you think? Are they, they probably will try that, you'll probably be right, or whoa, whoa, stop, stop, that person needs to go and see a psychiatrist, because they're acutely unweld, stop. But most people would be able to do that anyway, which we're trained to identify and manage risk, aren't we? So.

Yeah, I mean, one of the things I was thinking, you mentioned sleep apnea earlier.

Yeah.

And obviously, that's, you know, an area which is totally out of psychologists, expertise.

Yeah. And that's, that's a contraindication. So if we identify someone with sleep apnea, they just get referred into a completely different treatment pathway, you know, that's respiratory medicine, that's something else. You know, that's when we identify those people, I send them over to our physiologists to deal with that, because that's what they're trained to deal with. So they get oximetry and we identify how much they desaturate and how much of an issue it is, and then then informed the treatment process from that. And that's not CBTI at all. It they still struggle with their sleep after their apnea is managed, then it's CBTI, but you do the apnea first.

A client coming in saying, you know, I never feel rested from my sleep, and maybe they're also, you know, quite anxious or they struggle with low mood or something, it can be quite difficult for a lay person like me to recognise ah, this could be sleep apnea, and I need to refer. Is there anything I could look out for? That so interesting.

Yeah, yeah, absolutely. So so the STOP-Bang questionnaire S T O P B A N G you get a point for each of the eight questions. So snore, do you snore? Tired, are you tired? Observed has someone observed you stop breathing in your sleep? P is high blood pressure, B is BMI over 30. A is age over 50, N is a fat neck so larger than 16 inches around or 42 centimetres around, and G is gender being male. So if you're scoring naught one or two, you're low risk. If you're scoring three, four or five, you're moderate risk. And if you're scoring six, seven or eight, you're high risk, and you need referral to respiratory medicine right now, and you should not be driving your car. And if you've got apnea, you need to tell the DVLA and you can't drive until your symptoms have been managed for three months, and you have to have your treatment reviewed every three years to maintain your driving licence. At the moment, we've got 330,000 people diagnosed with apnea in the UK, we think it's one and a half million, because loads of people have it and they're unaware they've got it. So it's very, it's a massive issue. I we do quite a bit of work in the logistics industry. Lorry drivers 99.9% men, Loughborough University did some research a couple of years ago, 84% of them are overweight, average age is 53, over 50, 30% have high blood pressure. So already they're, most of them are in the risky range. So we think 42% are at moderate risk. 16% of lorry drivers in the UK are at high risk. Just a few weeks ago, I did some work with the rail industry, and they found 15% at high risk using the same process. So it drive drivers are really risk, professional drivers on the rail or on the road 15-16% there's no difference there really, because they're highly at risk because they're men, overweight, they've got high blood pressure, they're getting older, and you're already taking a lot of boxes there. So your listeners you will know someone who has this condition. And it's very easy to identify, it is very easy to treat. So look out for the STOP-Bang questionnaire. It's on t'internet. It's on our website, people can download it, go out, you've got six out of eight, seven out of eight, right get to the GP or come to us, we can we can get that. So that STOP-Bang is a screen. And then we use a device called an oximeter, which is a small wrist worn device with a finger cuff that that fits over the end of your finger to measure your blood oxygen levels, and you wear that for one night, and it's definitive, you've either got apnea or you haven't, if you haven't great, and if you have right now we get you treated for it. So very easy to identify and treat. It's just raising awareness. It's just ignorance about this condition.

Oh, absolutely. Absolutely. And I think because I work with a lot of parents and paediatric sleep apnea, is, I think it's slightly different in its cause, or that's my understanding.

Yeah, so there are two types of apnea. There's obstructive and there's central. So central sleep apnea is is brainstem controlled. So your respiratory centres in your brain stem are very close to your sleep centres. And we don't really understand that the underlying aetiology mechanisms of how this works, but but something happens when we go into different stages of sleep which just knocks the respiratory centre off, and then people just stop breathing, that's central sleep apnea. The only treatment for that is continuous positive airway pressure CPAP, the mask. Now that's much more common in your paediatric population. Your lorry drivers, big fat overweight men with large necks, obstructive sleep apnea, and then we can deal with that in a whole range of other different ways. You know, losing weight, having your tonsils taken out, having your tongue trimmed, ovulo rhinoplasty procedures to open up your oropharyngeal volume. Yeah, these are getting more invasive. One of the least invasive is the is the MAD the mandibular advancement device, which is like a double gumshield, which you sleep with, you put it in your mouth, and it brings your chin forward to open the airway up. And of course, you can use CPAP as well, for for obstructive. So again, we'd be diagnosing that in the STOP-Bang would identify whether someone has apnea or not. The oximetry and the embletter testing will look for, will then differentially diagnose between obstructive or central. And that then informs the treatment pathway after that.

Yes, and one thing, my GP told me this to look out for with paediatric sleep apnea is, you know, if you're seeing a lot of behavioural problems that you think as a parent are linked to tiredness, you know, how you get that gut feeling or just knackered all the time, but they're sleeping, they seem to be sleeping, but not not maybe being rested, then I just think, you know, often we see parents who are at their wits end, they've tried everything, but maybe that's the thing they've not been to the GP about yet.

Absolutely. It needs screening, it needs it needs assessing, investigating, and if it's there, then we can deal with it. But yes, you do, you do see people who've been struggling to get the right, right attention, should we say?

Absolutely. And there's so much ignorance around this. I mean, honestly, I stumbled across that because of, you know, some issues that I had with my daughter, never would have crossed my mind. Not in a million years. I just think, I think you're right, we need to raise much more awareness about this stuff.

Yeah. And one of the things that I particularly concerns me in the paediatric domain is sleep requirement. A lot of people have heard the eight hour thing that you need to get eight hours of sleep and you do meet parents who think that eight hours is enough for their six year old and it is not, kids need more sleep. And if you can take a bunch of healthy happy children, deprive them of their sleep, and then they start to show you behavioural stuff, tiredness, problems with memory, concentration, attention, overtired, children can become quite hyperactive. So actually, all of those are core diagnostic criteria for ADHD. Now, I think there's an awful lot of kids out there who have a diagnosis of ADHD, who are just tired, because I can take a bunch of kids who are not who don't have ADHD, make them tired, and they start to look like that. You can also take kids with ADHD and get them sleeping better, and all those symptoms start to alleviate. So ADHD is a thing, but I think we're misdiagnosing an awful lot of kids with this. We stigmatise them. We give them toxic medication, Ritalin, what kind of medication is Ritalin? It's a stimulant. Hello, stimulants don't get on so well with sleep by the way. So we're managing a tired child, we misdiagnose them with ADHD, we're giving them a stimulant drug, which makes them more tired. And we stigmatise that person. So I, I do a little bit of forensic sleep work. And I've been involved in five sexsomnia cases of sexsomnia being a parasomnia where people can engage in sexual activity in their sleep, and if they're asleep when they're doing it, they're not culpable because it's an insane automatism, as we talked about earlier with sleep homicide, so I was asked to go and be an expert witness on a case of a chap who was on remand for sexually assaulting a woman. And he was saying that he was sexomniac and I was called in as the expert to go and assess and, and in that process I spoke to his mum because you remember Kenneth Parkes who he had 22 blood relatives who also had and we and and childhood sleep problems. So we needed to know what his childhood sleep was like. So I interviewed mum. She was single mum, she was struggling in a fairly low socio economic area, low level of education didn't, first child was struggling like everybody does bringing up a child. He was difficult. She let him stay up late playing computer games in his bedroom. He was sleep deprived. He was at school, he was mucking about, he was getting in trouble, he wasn't performing, he got a diagnosis of ADHD. He took medication for it, he was stigmatised. Don't bother with me. I've got ADHD, he got expelled. He left school. He got in trouble with the law. He sexually assaulted a woman. The witness statements. He wasn't a sleepwalker as a child, so he didn't have much parasomnia stuff, he just didn't sleep well. And he's he was he did not have sleep apnea, he was behaving in quite a complicated, sophisticated way at the point at which the crimes were committed against this woman. And I informed the court that I didn't think that he had sexomnia, he's now in prison, and so he should be. But there's a whole life gone wrong. If we got to mum, and gave her some support, and got him sleeping well, he would have been, he could be a High Court Judge right now. I'm not saying that's any better. And that'd he be you know, he'd be a tax he's costing us I don't know how much does it costs to keep a guy in a secure prison? 100 grand a year? A tax payer and he could be out here being a tax payer. And there's a woman out there who has not been raped. There's a whole life gone wrong, because we fail to identify and deal with this stuff at the right time because of a lack of awareness. Now, that's tragic. That's where I don't want to be in 30 years time. This we... if we could have got to her and helped her back then he could go be a High Court Judge right now. So that's just an example of how we can get things a bit wrong, and then how it could just spiral out of control.

Yeah, and I think so many of us who do work with parents in that early stage, you know, we're hearing this desperation around sleep all the time. And so I imagine there's gonna be a lot of people listening to this or thinking, I've got to get skilled up, I want to get skilled up as fast as possible. So what's the best way to do that, then?

It depends what you're looking for in terms of how much skill you want to you want to get and if you just want to sort of bedtime reading, pardon the pun, then you know that there are books out there, but I would look for books that have been written by people who have experience. There's a lot there's a lot of there's a lot of so called sleep experts out there, and we trained loads of them, they come on a two day course. And then they go and build themselves a website and say, well, I'm a sleep expert now because we're an unregulated industry right? So there's loads of those people out there so I would just look for someone who's got some credentials you know, like Colin Espie and others around but, but you're looking for CBTI because that's, that's what's recommended by NICE, it doesn't recommend anything else. You've got a sleep problem at the moment, It's CBTI or tablets and that's it. So don't believe the hype. There's a lot of other stuff out there a lot of aggressive marketing for pills and potions and gizmos and bedding, which is based in zero facts, zero science attached to loads of this stuff, just lots of shiny aggressive marketing so so I suppose at a low level, you know, get buy buy a book by say, say Colin Espie, one of his more up to date books, or our our book Teaching the World to Sleep. That's the evidence base. It's fully referenced that you know, so don't believe it if you don't want to, go into the reference list, and you can find out for yourself. So this is not me, this is what the science is telling us at the moment, which is I've just pulled it together. Or if people are interested, we know we do open courses, we do about six a year. We used to do them in in person in Bristol, London, Birmingham, Manchester, Edinburgh, Newcastle. And we haven't been for a year so they've all been online and they've been working very well actually online, you do lose a bit but at the same time, you don't have to fraddle around with loads of travel and accommodation and extra costs attached. So we've been able to keep pricing down by doing them online. So in future what we're going to do is we're going to do four or five online courses a year and one or two in person. So I think we're going to Manchester in in October this year? And then next year, we'll go somewhere we'll go Bristol or London and we'll just dot around the place to do the in person in house stuff if people want that. But the online stuffs actually working so well we will stick with that. And then with that so that's the general today open course but we do other stuff. We do training days on brain injury, neuro rehab populations, paediatric populations, working with parents and young children. So we got, we got other training that we do specifically for different health professionals or direct to user, we do a lot of training in organisations direct to employees, shift workers, drivers, white, blue collar workers, as well as the health professional. So there's a lot of stuff. It's all on our website if people want to come and see the range of offerings that we've got. Or if you're not sure, just pick up the phone, give us a ring and talk about what your interests, concerns, worries might be and we can say, well, maybe you want to go in that direction, or read that book, or come on that course, something like that. And so so yeah, more than happy to talk to people about what they might feel that they need.

Brilliant, and I'll link up to all of your contact details in the show notes of this episode.

www.sleepunlimited all one word .co.uk.

Yeah, brilliant. I'm sure loads of people are gonna go over there and check you out. And like I said, all of your contact details will be in the show notes. So you can come over there and have a look. I've taken up so much of your time. And I'm aware I promised you it'd be shorter than this.

I could talk about this all day and all night. I love it. So no more than happy to and if you want to talk about this again, or more, or dig into different stuff, just yeah, give me a shout anytime.

Fantastic. Thank you so much for coming on today.

Thanks, Rosie. Nice talking to you. Thanks very much.

Before you go, I really need your help with something. So over the summer, I'm planning to run some free workshops for you guys, so that anyone thinking of starting or growing their practice in September, can get a bit of a jumpstart on it because we're not running any Psychology Business School courses over the summer. So at the moment, I'm thinking of running two sessions, a repeat of our find your specialism training, which has got such amazing feedback. And I know that lots of people want us to do that one again. And the session called the 50 minute business plan, where I take you through the key components of a useful business plan and help you to start or create or update yours in 50 minutes. I've put a poll on the Do More Than Therapy page on Facebook and if you could just hop over there and just tap which option would suit you best, that would be really, really helpful. Or you can always add another option in if you prefer, it's not set in stone yet. I just really like your feedback on the training that's going to be the most useful to you guys over the summer. So thank you so much in advance, and I'll see you next week.

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