Louise Berger, OT: OT in Sleep Medicine

In this post, we will learn from Louise Berger, OT. Louise is a qualified Occupational Therapist, who has been specializing in sleep medicine for over a decade. She established the Insomnia Service at the Royal Surrey County Hospital Sleep Clinic (NHS) in 2012, and under her leadership, it has grown in reputation and size, now treating hundreds of patients every year. The Insomnia Service was honored to receive the hospital’s award for Clinical Team of the Year, in 2018. Louise has a background in psychology and coaching and has a passion for seeing lives change for the better.  She loves to use her understanding of the science of behavior change and natural inclination for out of the box thinking, to create novel ways of delivering behavioral sleep treatment and enhancing CBT for Insomnia. Alongside her NHS role, Louise provides sleep coaching to clients across the globe and is also working for a TechBio company, contributing to the development of digital therapeutics, which include a sleep product. Louise is committed to raising the profile of sleep treatment and increasing access for those who need it.

Q & A with Louise:

Please tell us a little about yourself and a few of your favorite occupations.

I consider myself a lover of life. I find joy in many things, especially being with my family, spending time with friends, being out in nature, walking, food! If I get the chance, I love adventurous activities like sailing, rock climbing, gorge walking, diving, theme parks and anything else that requires adrenaline! I naturally have a restless and creative mind that is constantly wanting to learn and innovate, which leads me to spending a lot of time doing self-directed study When I haven't got any energy for anything else I love a gritty thriller on Netflix!

What motivated you to contribute to this podcast series?

You invited me and I can't help but push a door open when one is presented to me! More importantly though, I am passionate about my role and promoting sleep as a clinical area that needs addressing in everyday practice. I believe that OTs are well equipped and positioned to lead the way in supporting clients with their sleep.

Please describe the UncommonOT work that you do and the setting in which you work, the population you serve, and the needs that you address.

I have several jobs, but the one I'm going to talk about today is my role within an NHS hospital sleep clinic, where I established and lead the Insomnia Service. While there are around 150-200 NHS Sleep clinics in the UK, I'm not aware of any that employ OTs, other than ours. Furthermore, including ours, I am only aware of two other sleep clinics that provide insomnia treatment. We are based in a hospital, but our patients (as we refer to them) are all outpatients. We are an adult service so our minimum age tends to be 16 years and our oldest patients are in their 80s. Most will have been referred by their GP, after complaining of difficulties sleeping. While we are theoretically an insomnia service, due to the lack of understanding of sleep disorders and the ubiquitous use of the word 'insomnia' to describe any sleep dissatisfaction, we end up also seeing patients with a full range of sleep disorders, including obstructive sleep apnoea, periodic limb movements, slow wave sleep disorders, REM behaviour disorder, hypersomnia, etc. We are one of the few services in the UK that people suffering from insomnia can be referred to. This is obviously a ridiculous scenario given that insomnia is the most common sleep disorder. Furthermore the gold standard insomnia treatment is non-pharmacological. Given the very strict regulations around prescription medication in the UK, this is a huge relief and the only solution to many people, who would otherwise be forced to suffer with their sleep problem or resort to other substances like alcohol or illegal cannabis.

What inspired you or drew you to this type of OT work?

I was invited to set up the insomnia service about 12 years ago, while I was working as an OT in A and E. I can't resist pushing doors that are in front of me, so I keenly agreed! Essentially, the Sleep service at the hospital had been providing a sleep disordered breathing service only for around 10 years. The manager had identified a need to expand the service, given the high number of patients with no apnoea or mild apnoea and insomnia, for whom they currently had no treatment. Having decided that an Occupational Therapist would be a good person for the job she approached the hospital OT department and I was nominated. Sleep wasn't something I had much experience of, other than what happened to me at night, so I had a very steep learning curve. After not very long, I realised that sleep was a fascinating area, a hugely unmet need and somewhere where treatment is literally life changing, so I'm now here for the long haul!

How did you get there? Can you describe your path?

I'm not sure there's any set path to go into sleep. For every profession even doctors, neurologist, psychologists, sleep tends to be outside the scope of professional training and further training is necessary. Personally I had a strong background in physical health and rehab, as well as mental health and trauma. That's also the case for the other 2 OTs in my service. Sleep is in many ways fun and challenging, because it is influenced so much by physical and mental health working in the field draws strongly on the knowledge base of both.

Please describe a typical day or OT session in your uncommon setting? What OT skills do you utilize?

Every day is patient clinics. Most of these are remote as space within the hospital is limited and many of our patients come from a long way away (due to their being so few services in the UK), so prefer remote appointments. All pt contact is 1:1 and I'd usually have two new patients for assessment and around 5 patients for shorter, 30 minute follow up appointments every day. A first assessment would be a conversation to gather a detailed history about sleep related symptoms, as well as broader info about physical and mental health, medication, social situation, occupations and the many other factors that influence sleep. I'd be looking to determine what the presenting disorder is (e.g. is it insomnia or another disorder), what further assessments need to be carried out, whether the person is open to and has capacity to engage in behavioural treatment and explain what treatment involves. Even for parasomnias such as sleep terrors or sleep walking, behavioural interventions can be helpful. We also know from experience and research, that most of the approaches we use for treating insomnia, can be hugely helpful to people living with Obstructive sleep apnoea. So even when it turns out that someone's assumed insomnia is another sleep disorder, we can often help them at least to some extent. When following up patients, we are obviously reviewing progress, reviewing sleep diaries and providing further education and advice to improve their sleep. The primary intervention we use is CBT for Insomnia, which is a multicomponent approach delivered over a number of weeks. Some of our patients will require sleep studies, in which case we will invite them in to set up home sleep studies. When sleep studies show mild to moderate sleep apnoea, we will set the patient up with a CPAP machine to treat this. Any remaining time in the day is generally spent in meetings and doing admin. OT skills wise, I think we use loads, at every stage of the journey we are evaluating the bio/psycho/social context of the individual, as well as their occupations, and how this is impacting their ability to sleep but also participate in daily activities. We are evaluating motivation to change, empathising, problem solving and pitching solutions and support according to a person's motivation and capability to move in the direction of their values.

Can you talk about some recent highs (successes) and lows (challenges) of your current role?

The biggest high is undoubtedly the way treatment of sleep disorders changes people's lives. The written and verbal feedback we receive is absolutely amazing. People frequently say things like, "This has literally changed my life" or refer to our input as "life changing". The lows usually relate to frustrations of working within a very rigid healthcare system (NHS) in a country where every public service is cracking under pressure. Many of our patients have fallen through the gaps because the social and healthcare system cannot give them what they need. Elderly patients for example who are hugely isolated and have no support or patients with severe mental health issues, who are not getting have wait months and months for assessment then get nothing like the support they need to recover. Patients with ADHD who are chaotic and struggle to engage with any services. In some cases, these patients need far more than secondary care input for their sleep. In fact, I think that a few are referred to us on the assumption that surely something is better than nothing, whereas we are not really what they need.

How do you continue to learn in order to stay on top of things within your role?

I am an avid learner. I read textbooks and journals, attend courses and conferences, engage in supervision, collaborate with other professionals. Listen to podcasts. I can't find enough time to keep on top of it all!

Can you share a little bit about salary and compensation in this setting?  How do OT or the services you provide get funded?

Within the NHS, our salary is determined by the banding of the role. It's meant to be an equal and fair system amongst all non-medics, meaning that certain criteria, produce a certain job banding. Whether the individual has years of experience or higher qualifications does not factor in. Equally, frustratingly, if a person excels at their job and goes beyond their remit or plods through the day doing the bare minimum also has no impact on pay. Having been in my role for many years, I am now at the top of band 7 so will never get a pay rise! That's around £48000 a year I think. I work part time in this job, so it is pro ratered.

Any career advice for our followers and listeners on how to get started on this path?

Learn more about sleep. It's important to understand some of the science behind it, the key sleep disorders and insomnia treatment techniques. A good training course in CBT for Insomnia will provide this. Psychiatrist and Sleep Expert Nishi Bhopal provides some good free You Tube videos on addressing sleep with your patients. I'd also suggest thinking about opportunities to join a sleep clinic. OTs are well placed to expand into this area, I just don't think the rest of the world has woken up to this. Alternatively, there may be an opportunity for you to become a specialist in sleep within your existing service. Ideally I'd still recommend collaborating with other experts too. Sleep can get complicated and misdiagnosing insomnia, when there is another sleep disorder present, can be unhelpful for you and your patient. if you think your patient needs a sleep study you'll want to know where to refer them.

What’s a common myth or misconception about your job/role you’d like to call out or demystify?

That it doesn't exist!! When I talk to strangers, maybe at a party, about my role, they're always surprised. So many people are aware of child sleep specialists but not that there is anything for adults. Many, many people respond with, "oh my sleep is terrible, but I didn't realise there was anything I could do about it or a place that my GP could refer me" We also have patients frequently reporting that the only way they got referred by their GP, was by showing them our web page! Up until that point, the GP had insisted there was nowhere they could be seen for their insomnia!

Please list any resources you would like to include with your Show Notes (courses, articles, assessments, tools, etc.)

LinkedIn: https://www.linkedin.com/in/louise-berger-12246a155/?originalSubdomain=uk

Email: louiseberger@gmail.com

This is a free 30-minute talk I created, providing powerful insights and science-backed techniques for overcoming stress-related sleep disturbance or longer-term insomnia. https://www.royalsurrey.nhs.uk/saygoodnight

As always, I welcome any feedback & ideas from all of you or if you are interested in being a guest on future episodes, please do not hesitate to contact Patricia Motus at transitionsot@gmail.com or DM via Instagram @transitionsot

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