Better Sleep: How psychology can help you beat insomnia

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Hello, and welcome to Instant Genius, a bite-sized masterclass in podcast form. Every Monday and Friday, you'll hear world-leading scientists and experts talking about the most fascinating ideas in science and technology today. I'm Jason Goodger, Commissioning Editor at BBC Science Focus. Over the past several decades, it's become abundantly clear that getting a good night's sleep is essential for our health and well-being.

However, currently around one in three of us often struggle to get enough shut-eye, thanks to the stress and anxiety caused by our hectic lifestyles. Thankfully, help is out there in the form of Cognitive Behavioural Therapy, or CBT. In this episode, we speak to the founder of the Insomnia Clinic, Catherine Pinker. She tells us exactly what a good night's sleep looks like, how developing a healthy sleep appetite is vital if we want to wake up feeling fresh and renewed in the morning,

and share some psychological techniques we can use to help us sleep more restfully. So welcome to the podcast. Thanks very much for joining us. Thanks for having me.

So today we're talking all about insomnia. So lots of people have issues with sleep. But first off, is there a strict scientific definition for what exactly insomnia is? Yeah, so insomnia is classified. As somebody who has difficulty falling asleep, difficulty staying asleep, waking up too early and feeling as though their daytime functioning has been impaired. And if this has been going on...

longer than three months, more than three nights per week, then they would fall under the category of somebody with insomnia. I would say the people that I work with, often there are people who think, oh, it's not insomnia because...

People think that insomnia is I don't get any sleep at all, but actually that's not the case. It can be. It just takes me too long to fall asleep or every night I'm awake at 3 a.m. for two hours. That's still insomnia and therefore treatable. So often people have insomnia, but they don't think they do because it's not as bad. as they've been led to believe. So how common is insomnia then? So recent statistics look

about one in three people have problems with sleeping. So it was one in 10 people struggled to get really good sleep. One in three are struggling with what we would call insomnia. I would say that it certainly seems as though it has risen in the last few years and since COVID.

COVID was really the perfect storm. The pandemic was, you know, if we'd have asked for a situation that could ruin everybody's sleep, it would have been that one. So, you know, can't go outside, can't exercise as much, don't socialise, loads of anxiety, treating your bedroom like an office, all of those things together. As I say, it was a perfect storm. So certainly sleep problems are on the rise at the moment. So what are some of the causes of this then?

Anything can trigger a bad night. So it can be something really obvious and really big, like a bereavement, a divorce. and you know a period of exam stress so something that obvious where you go to bed stuff on your mind and you can't get to sleep or you don't stay asleep you're awake in the morning and you you know you're aware that your mind's racing

So it can be something really obvious. It could be something really minor, like one night there was noise outside and you didn't get back to sleep afterwards, or you had a bit of a cough and cold or hay fever or something, or it's too hot. Or it could be that you don't know it was just a slow burn.

The most important thing about sleep problems is it doesn't really matter what triggered them. What matters is how we responded to the fact we didn't sleep very well. Because if we didn't think about it, we didn't care about it, it would go back to normal.

The problem is most of us are very intolerant to not sleeping well. You know, we feel the impact really quickly. The next day you don't look as good. You can't perform as well. You feel more irritated. So what happens is if we don't sleep well for a specific reason. But we add pressure to getting back on track. So we start becoming more vigilant. We're trying too hard. We're changing our bedtimes. We're changing what we do during the day. We're thinking a lot about it.

That pressure is the thing that creates insomnia. So the good news there is that... For people who are struggling to work out why it happened, or even for those people who go, well, I know why I've got it, therefore I can't fix it because it was because of this event. Actually, that's not the case. It doesn't matter how we get there. What we look at moving forward is...

What is maintaining it? What's keeping the problem going? And how can we break that cycle? So the trigger is not that important. Anything can trigger it. So how does poor sleep affect her health then?

So it impacts upon our mental health and our physical health. So from a physical health perspective, our immune system can be compromised if we're not getting enough sleep. If you think of it sort of like a...

a pyramid when you're asleep that your body's got certain jobs that it needs to get done and some of them are more important than others so that's why you know your skin and you know your bags under your eyes those kind of things happen when you haven't had enough sleep because i guess they're not they're not top of the pyramid you know And so our immunity can be compromised. So we're more likely to get coughs and colds.

ongoing problems from that perspective also in terms of chronic longer-term disease there is correlations between heart disease obesity type 2 diabetes and from a mental health point of view the two very much come hand in hand it's really difficult even if you're doing everything right it's really difficult to be positive not have any anxiety if you're not sleeping well so we know that people with insomnia are more likely to then suffer with depression and anxiety

And people with depression, anxiety are more likely to develop insomnia. So it's very much a cyclical relationship between the two. And if we can improve one of those things, then the other one can improve as well. So you mentioned that the sort of pressure that we can put on ourselves.

So what does a good night's sleep look like? You know, say, is it okay if I wake up a couple of times during the night? Yeah, it's a really good question because it's this sort of like... chasing good sleep because the sleep is so it's in the media so much at the minute isn't it and the pressure around all the impacts of bad sleep and how unhealthy it is for us so people are chasing that

eight hours of sleep for example no in answer to your question we all wake up during the night so we sleep in 90 minute cycles and at the end of that 90 minute cycles you're in a lighter sleep and most of us will stir we will

perhaps wake up, have a sip of water, turn over, but we're not aware of it. We don't remember it the next day because we go straight back into the next sleep cycle. If you are somebody who struggles with sleep, what will happen is you'll wake during that period and not be able to get back to sleep.

Waking in the night is not a problem. Waking up to use the toilet is not a problem. It's if we can't get back to sleep. That's when the quality of the sleep is compromised. So for me, a good night's sleep is do you fall asleep pretty quickly when you get into bed most of the time?

The majority of the time, can you sleep through the night? And when you wake, do you get back to sleep again? And during the day, do you feel like you could fall asleep at any moment? Are you falling asleep on your commute? Are you falling asleep on the sofa? Those would be signs that you're not getting enough sleep.

outside of that actually that is a good night's sleep falling asleep quickly being able to get back to sleep when you wake up and not feeling like you need to catch up on that debt during the day that's a good night's sleep so the hours are not so important for me. I focus on quality, not quantity. Let's make sure the quality is really good because that's what makes us feel better. Eight hours of broken sleep will make us feel worse than six hours of really good quality sleep.

So let's have a look at some of the things that we can do then. So you work with something called CBT, Cognitive Behavioural Therapy. So what is that and how can we use that to help us get better sleep? So CBT for insomnia has been around for a long time and it's a specific program focusing on what is maintaining insomnia. So the cognitive part of it is we are looking at the...

the thoughts and usually the catastrophic thoughts, the pressure, the way that our body is interpreting not sleeping as a threat and therefore developing adrenaline. So we look at the cognitive side of it. How do we change how we respond to those thoughts?

And then the behavioral side of it is that once we've developed insomnia, our body clock is out of sync. So our body clock no longer falls asleep at, let's say, 10.30 anymore, or it's always awake at 3 a.m. So our body clock has taken on this new pattern. And it's an unhealthy pattern that we don't want. So the behavioral part of it is around actually from a biological perspective, how can we get our body back into a...

pattern where it understands what we want it to do so that you can get the best quality of sleep. So CBTAI is focusing on the cognitions behind insomnia and the behaviours that are keeping it going. So what are some of the techniques that you'd employ?

to help people sleep better? So one of the first things that we would get people to do is, if I talk about the three things which control how well we sleep, and then I think that will really help listeners to understand why they're in that cycle.

The first thing that we need to sleep well is a really healthy sleep appetite. So this appetite for sleep is a build-up that we build up during the day. So we wake up in the morning, we start to build this appetite and the ideal scenario is that when we get into bed at night...

We would fall asleep quickly because our appetite was high. We would go to a nice deep sleep. And then when we'd run out and we'd taken everything we needed, we'd wake up at the other end. So the drive is really, really important. And that works in conjunction with our body clock. So most people have heard of a circadian rhythm, but it's not just controlling wake and sleep. It's also controlling when we use the toilet.

when we're hungry, when we're thirsty, our temperature, all of those things have a place within that 24-hour cycle. So when we're sleeping poorly, what happens is your body clock will just adapt to the new pattern. So if I go to bed at 10,

and I wake up at two and I'm awake for two hours, if I do that enough, my body clock will just now adapt to that. It will now just think that that's a period of time where I want to be awake for and I'm going to have something to eat or I'm going to worry or ruminate for a couple of hours and then go back to sleep.

So our body clock needs to understand what it is we want it to do, and it gets out of sync when we have insomnia. So our drive has to be high. Our body clock has to understand what it is that we actually want it to do. And the third thing that controls how well we sleep is our connection with our bed. So it sounds obvious, but actually if you spend 50% of the time that you're in bed feeling anxious, frustrated.

angry, sad. It could be that you have a health condition, so you're in pain. It could be that you've had some PTSD and you're in bed for that reason, or you just had insomnia for so long that you're frustrated at night. If that happens, then the connection with your bed is not about sleep. It's about wakefulness.

And that explains why people can be exhausted all day, they know they're sleep deprived, they're probably falling asleep on the sofa, but the second their head hits the pillow, they're wide awake and their brain's racing. And that's because your body and your mind now associates that place with threat.

So it doesn't do the job that we want it to do. So we keep going there every night. We go back into battle because it's not like being scared of a spider. I'm scared of a spider. Technically, I could just spend my whole life trying to avoid spiders. But sleep is something every 24 hours we need to try and do again. So those are the things that control our sleep. So our sleep drive, our body clock and the connection with our bed.

So in CBT for insomnia, we would be looking at those three areas. So one of the quickest ways to increase that sleep drive, meaning that we fall asleep quicker and we sleep for longer, is very simply to spend less time in bed.

So it's the opposite of what we would naturally do. If I'm not sleeping well, I want to go to bed earlier. I want to set my alarm a bit later and I want to give myself that opportunity. But actually when I increase the opportunity, what actually happens is my body clock doesn't really understand.

what I'm doing because I don't normally go to bed at this time. I've got hours and hours in bed building that horrible, weak, catastrophic connection with my bed. So actually, if I shorten my time in bed, what happens then is my appetite is higher. If I go to bed later, my melatonin has been developed for longer. I've got more of a natural...

appetite to actually get to sleep. So if I go to bed later and if I set my alarm earlier, what happens is after a few days I'm building up a bit of a momentum. for this sleep so my body is going to be hungrier for it meaning that it's more likely to happen so it's the opposite of of what people would naturally do but it is one of the first things that we would say in the program to make some of the biggest changes and the most impactful changes for people

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How about things like breathing techniques? I mean, do they work? So, yeah, we would incorporate things like breathing techniques. On its own, it's not enough. Because if you have developed a weak connection with your bed, if you're...

Body clock thinks that three o'clock is the right time to wake and your appetite is very weak. The breathing exercises are great for relaxation. So there's definitely a place for them. It's going to make you feel better about the situation. It's going to make you have more energy the next day if you keep your body calm.

So it's part of the program. So the way that I would bring in breathing techniques is during the day, I would be saying to people, okay, we need to understand why your brain is adding so much pressure to sleep. So asking questions around.

What is the worry here? What if you don't sleep? What do you think is going to happen? And people would answer, you know, well, I'll be tired tomorrow, but we need to dig a bit deeper. So what would being tired tomorrow mean? Why does that matter? Well, what if I make a mistake at work? okay what if you make a mistake at work well I could lose my job okay so really now we understand that the reason you're worrying about your sleep is because it's directly related to losing your job

So we ask these questions to help people get to the core of what it is they're actually worrying about. And then we can do a bit of reframing or we can challenge those thoughts and just check, are they real? And when we do that, we shift that sort of... energy away from thought because we can say okay normally I don't get enough sleep but I don't

I haven't made any mistakes at work before. I always get stuff done, even though I'm tired. So really the worst case scenario is I'm not going to enjoy tomorrow, which is still not great. We're not pretending it is, but it's not catastrophic. I'm not going to lose my job tomorrow.

Then we can incorporate breathing techniques because once we've dug a little deeper, we've done a bit of investigation and so on, then breathing is really useful because the breathing exercise can then teach your body, actually, I'm okay. In this moment, I'm safe.

And so in the middle of the night, doing a breathing technique to try and get back to sleep can be really useful. But for me, it's only useful if we've also gone and understood why the pressure was on in the first place. Why am I panicking in the middle of the night?

I love things like breathing techniques and mindfulness. I think they're brilliant on their own. They're not enough to fix an insomnia problem, but they are part of the program. Absolutely. How about things like these sprays, these fragrances? Do they have a role to play?

So for me, anything like that is a placebo more than anything else. So if you love the smell of lavender and you slept really well as a child and your room always spelt like lavender, then lavender could be a really positive cue for you to fall asleep. But the reality is we don't need anything to fall asleep. If our drive is high, if our body clock is set correctly, and if I believe that I'll sleep because my connection with my bed is good, I can sleep.

Things like bedtime yoga or having a caramel tea or having a bath, those kind of things. If you enjoy them and you believe they're going to work, then they can work because placebo is really powerful. The problem with those things comes when you believe that they work and then one night they don't, and then you need to add to that list.

When we work with a poor sleeper, they tend to have loads of things that they do in order to sleep well. So they have to have a certain routine. They never drink caffeine after X time or... They can't sleep anywhere other than their own bed. So they've created a very strict sort of set of rules around sleep.

the reality is a lot of those things aren't true and we don't need them but they feel protected by them but then when they stop working which inevitably they will because they're not really doing so much when they don't work you're in an even more anxious position then so

I have nothing against the sprays and the teas and those kinds of things. But if you are having a sleepy tea and you're spraying your pillow and you're still not falling asleep, those things have become part of the problem. They're actually connected to not sleeping. So you can just get rid of them all. So only do stuff in your bedtime routine. that you enjoy so bedtime routines don't need to be long mine is you know i clean my teeth put my pajamas on and read my kindle for 10 minutes

That's it. I don't have to do anything more than that because I relate those things to falling asleep, just like with a baby, you know, bath, bottle, bed. So a long wind down routine is not necessary and actually becomes part of the problem because it's too much pressure. So how about supplements then? So I've heard magnesium for example can help us sleep. I mean do they have a part to play?

Anyone who's deficient in magnesium, it can certainly hinder sleep. Generally, if someone has an insomnia problem, just taking magnesium... in for me is unlikely to fix the entire problem because of these reasons because actually you've got this bad connection or your body's used to waking up so that's not to say you shouldn't take the magnesium if you're deficient in it take the magnesium but you may need to do some of the cbt tools

as well so and i can talk you through a few more of those tips as well but the going to bed later waking up earlier in addition to the magnesium so it's very rare that you can take something that can fix all of those things because it's not tackling the root it's just tackling the deficiency And I always advise people, see if you can get a test first, because a lot of people are taking tons of stuff to try and sleep, like lots of different supplements. And again, it adds that pressure.

There are things that can aid relaxation like magnesium. And if we're deficient in it, your sleep could be interfered with. Is it going to be a complete fix if you have a severe insomnia problem? Probably not, but it could be part of the puzzle.

So what are some of these? You mentioned that some further sort of CBT techniques. Can you talk us through some of those, please? Yes, absolutely. So the second thing that we always ask people to do is when we wake up in the middle of the night. the first thing that we all do is check the time. So we look at the clock, we see that it's 3am.

And then we can't get back to sleep. And everybody does it because we sort of we want to see how much time we've got left. We sort of want to gauge how bad the situation is. The problem with checking the time is twofold. So firstly, your body is a clock. So if you check the time.

what happens is you are setting that internal alarm clock to go off again tomorrow night because we're confirming, yep, it's 3 a.m. That's why you might find that you literally wake up at like 2.28. every night 2 28 2 28 and it's because your body is set to wake at that time so by checking the time we confirm it secondly for the majority of people who aren't sleeping well

that time is not going to make you feel better because either you didn't get enough sleep or you haven't got enough time left. So it immediately triggers a panic in your body. Our body and our brain is really clever in that when we sense threat, our adrenaline kicks in and that fight or flight is activated.

The problem is that we only have one fight or flight system. So the same thing kicks off whether we're about to get hit by a car as to whether or not we just simply can't get back to sleep and we're worried about being tired tomorrow. The same system kicks in.

So the problem here is that when that system has kicked in, it's designed to keep us awake. That's the point of the adrenaline response. So your body would never allow you to fall into a deep eight hour sleep if it felt that there was a lion around the corner. So we have to be.

alert therefore you won't get any sleep after that. So if you can avoid checking the time you avoid that trigger so I would advise people to set your alarm before bed always set an alarm so you're going to wake up nice and early and you're going to get out of bed because that way we keep that momentum really strong.

So set your alarm for the morning. If you can go back to sort of an old style alarm clock, even better. You know, we all know that phones in your room and those kind of things are bad for us for a variety of reasons. So if you can put your phone over the way or turn it over. And when you wake in the night, avoid checking and just notice that maybe you want to check. So it's okay to want to check and feel uncomfortable about not, but just ride it out.

And actually that in itself just stops that pattern from becoming so concrete that we wake at the same time and we have this pattern of ruminating. So it's a really useful technique. So don't check the time when you wake, go to bed later, wake up earlier. And then during the daytime, so sleep is this 24 hour cycle. It's not just the bedtime part of it. So when we're awake at 3am ruminating and we can't calm our mind down.

That's because at three, four o'clock in the morning, your brain is nowhere near as rational as it would be at three o'clock in the afternoon. So something that isn't that big a deal feels a really big deal at three. And we've all been there, you know, that sort of like.

really panicking thinking oh my god this is you know the worst thing i ever said 10 years ago comes back to you and you know the dread of a future that hasn't anywhere near unfolded is there so 3am is a terrible time to be doing that thinking the problem is that most of us don't make time to process what's in our minds. So we live in this sort of 24 hour society. There's always something to distract yourself with. So if I'm worried about something.

What I can do is I can ignore it. I can distract myself from it. I can tell myself to stop being silly and I can just go on my phone for a bit longer or I could go the other way and I could Google it and I could start really engaging in the worry and going down that spiral. So what I would encourage...

anyone to do not just if you've got sleep problems but anyone who struggles with any kind of stress or anxiety is make time every day to listen to your mind and and hear what it is that it's trying to get you to pay attention to at three o'clock in the morning and the way you do this is pen and paper so No phones or tablets or anything. Pen and paper.

And you just write down what's on your mind. So sit quietly for a moment. Whatever comes up, write it down. Now, there's nothing too silly. It doesn't need to be rational. It can be the really irrational thought. In fact, that's the one we want because that's the trigger.

So write down what am I actually worried about and dig deep. So whenever you write it down, so what? So what? What does that mean? If I'm tired tomorrow, what does that mean? What's the worst outcome? And what you're doing by doing this process is really therapeutic because it will make you see that.

Firstly, you don't have loads of problems. You've probably got three or four and they're probably the same theme and therefore you kind of know what you're looking at. So it gets things into perspective a little bit. And then what you can do is you can look at that list and split it into hypothetical or real. So as I said before, this threat response is really clever because it can kick in with a hypothetical worry in the same way that it can if it's real. So if I've lost my job.

I'd feel a certain way. I can feel just as bad worrying about losing my job. You know, my brain is clever. It protects me either way. When we look at this list and we have real or hypothetical, the real ones are things that have happened. So I have lost my job or I am poorly. I am ill.

Those things give us a certain element of control. There's something we can do about those. So make a plan. What can you do? Who can you call? Dialize all of it. When am I going to do it? How long is it going to take? Make a plan. For the hypothetical ones.

Stop being really kind to yourself. You just acknowledge you're worried about it. We're all made up of lots of different belief systems and experiences over our life. And for whatever reason, not sleeping is making you feel out of control. So you be kind to yourself about that. But you also accept...

This hasn't yet happened. Yes, it's happened in the past and maybe it would happen again, but right now it isn't happening. So it's a hypothetical. And all you have to do is accept that you're worried about it. Maybe you need to just feel worried for a minute. So in that... 20 minute slot. We're going to notice what's worrying us and we're going to feel it properly. Allow your body that space because then at three o'clock in the morning, it's much easier to...

let these things go because you know you made your plan. You've already felt the fear of what if I lose my job? Okay, well, let's sit with it. What if you lose your job? Realistically, what would you do? Let's make a plan. So it's just a way of being a little bit more proactive with worry because

As I say, the society we live in, in the old days, like for my dad, he worked in a factory and if he had a tea break, he had nothing to do but have a cup of tea and ponder. Now we would all just sit on our phones for the entire tea break.

We don't naturally listen to what it is our brain is telling us. So get into that habit. You don't have to do anything with it. We're just going to listen. And at nighttime, you'll find it's much easier to push those thoughts, to let them drift away rather than engaging and ruminating.

So how about another thing that's very common now? It's the sleep tracking devices. I mean, are they useful at all? So for me with sleep tracking, it depends on the purpose of them. If you are somebody who sleeps really well. and you are interested to know more about your sleep because maybe fitness, then I can see that there is a place for them then. For the majority of people that certainly that I would be working with is...

There's no point in a sleep tracker telling you that you slept badly because you were there. You know you slept badly. We don't, you know, you don't need someone to tell you that. And we don't really know how accurate they are. People tend to sort of... overestimate how bad their sleep was.

And for me, what happens is you have somebody who goes to bed, sleeps poorly. They wake up. The first thing they do is check their score and it tells them that they've got like 20 out of 100 and therefore they should adapt their day accordingly. So now they're...

They're frustrated. They're in a bad mood. They're going to cancel a social plan. They're going to not go to the gym because they're too tired. They're going to cancel something at work that they should have just gone ahead and done. And then they're going to go to bed early because they're going to try and fix it that way.

I would love to see an experiment where we gave people a false positive. So we told them they slept really well and see how they feel. Like what impact does that have on your mood if someone tells you, actually, you got a great night's sleep last night? Because for me, the buildup of anxiety that comes from sleep trackers.

is useless all you've done is add even more pressure you knew you knew you slept badly anyway so if you are somebody with sleep anxiety then don't track your sleep the other thing about trackers is they are totally lacking in good advice at the end telling someone they sleep badly and that they shouldn't go about their daily daily exercise but not telling them how to improve their sleep is pointless so

The trackers and if you were to Google poor sleep, what you'll get is some very generic sleep hygiene advice. So sleep hygiene is reduce caffeine, reduce alcohol, go to bed early, make sure your routine is good. you know, do some bedtime yoga, for example, blackout blinds, earplugs. As I've been talking about through this podcast, none of that stuff is going to fix the problem, but it is going to add a lot more pressure to it.

So until we're in a position where sleep trackers offer the evidence-based advice, you know, a CBT-led advice program at the end, I don't see the point in telling people that they're not sleeping well. Does that make sense?

What's the point? How are we helping them by telling them that? Absolutely. So sort of by way of closing, what kind of final message would you like to get across to the listeners? That insomnia is... absolutely curable so however long you've had it whatever triggered it even if you're in menopause and you can see it's directly related to hot flushes the reason we can

fix the problem is because we learned to have it in the first place so it was only how we felt about it and what we did to try and fix it that got us there and that's you know i'm not judging people on that we all do the same thing when we don't sleep well but

Be reassured. There are things that you can do that will improve your sleep. You can unlearn the pattern. So I think that, like I say, we're very limited in the options that people have when they go to the doctor. It's sort of sleeping pills or sleep hygiene advice. But actually, CBT for insomnia is... incredibly effective program there's just not a ton of access to it so look for cbt for insomnia and be reassured you can improve your sleep however long it's been going on for

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