The Dr Louise Newson Podcast - 041 - You Are Feeling Sleeeepy - Kathryn Pinkham & Dr Louise Newson

Episode Date: March 31, 2020

In this podcast, Dr Louise Newson is joined by Kathryn Pinkham, Founder of The Insomnia Clinic, the UK’s largest insomnia service.  Kathryn, along with her team at The Insomnia Clinic, help people who suffer with poor sleep and insomnia using NHS recommended techniques. Cognitive Behavioural Therapy for insomnia is a structured programme which helps people to identify and change unhelpful behaviours and thoughts which maintain poor sleep.  In this podcast, Dr Newson and Kathryn discuss: Why sleep is important but how putting too much pressure on sleep can cause us to get even less  How sleep hygiene can make a sleep issue worse for poor sleepers  The cycle of insomnia and how to break it Tips to strengthen your sleep drive to fall asleep faster and wake less but also how to improve quality of sleep  The importance of managing anxiety in boosting energy levels  Techniques to manage anxiety    Kathryn Pinkham's Three Take Home Tips to Aid Sleep:  Shorten your time in bed - go to bed later and get up earlier. Even if it's just by half an hour. Set your alarm and then turn it over. When you wake up in the night, resist the urge to look at the clock. Spend time managing your worries and anxieties instead of focusing on your lack of sleep. If you focus on lowering your stress levels then your sleep should improve too.  https://www.instagram.com/theinsomniaclinic

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today I'm very pleased to have Catherine Pinkham with me, who is a specialist in sleep from the Insomnia Clinic in London. And we first connected several months ago when I was trying to find experts about sleep because it's something that a lot of my patients complain about having poor quality and poor duration of sleep. So welcome, Catherine.

Thank you. Nice to see you. So today, rather than talking specifically on menopause and perimenopause and the sleep, we thought we'd just do a general introduction about sleep and different ways that our sleep can be affected and simple measures that can really improve our sleep. So Catherine, before we start on that, just tell me a bit about you and your background, if you don't mind. Yeah, absolutely. So my background is in mental health in the NHS. So I originally started working for the IAP service, so the psychological service part of the NHS. And during that time, I was lucky enough to do some sleep insomnia training, which is fairly hard to come by. It's not part of the standard training for psychological practitioners. But I was looking at to do it. And straight away, I absolutely loved it. I had a couple of people in my clinic who had sleep problems and they left session one. They left. They came back session two. and it had worked. And so it really clicked for me. And I love this sort of idea that actually

it was fairly black and white. And like a lot of other stuff in mental health, it was quite black and white that actually it was working for almost everybody. And then when I was made, I was actually made redundant when I was on maternity leave. And so I decided to set up a clinic just one to one, purely sleep and just see how that went. And as you can imagine, it filled up really quickly. But I could only offer so many slots. So I started delivering them via Skype. And then it's sort of, it's grown from there really that I trained up other CBT, therapist who hadn't done the insomnia work. And so inquiries would come to me and then I could sort of distribute them across the UK to a team of therapists.

But actually more recently in the last 18 months, it became really apparent to me over the last 10, 12 years of doing this, that actually not everybody needs therapy to sleep well. CBT for insomnia, cognitive behavioral therapy for insomnia, is a step-by-step program. And actually, I recently thought I have to find a way to make this more accessible. You know, therapy sessions are expensive or that I'm trying to grow the network. work, you know, I'm a small business. The slots are, you know, hard to come by. And so recently, we have developed an online offering, so an online course delivering the same program. And my mission is absolutely that, you know, this is an NHS recommended evidence-based program of treatment.

And so my mission is, you know, how do we get as many people as possible to know what's the right stuff to do, what's the wrong stuff to do, and follow something that they can kind of rely on has been researched. That's kind of where I'm at now. So I love it. I love working with this client base. Because it's so important, isn't it? And more and more is so much about sleep and how important it is for our health. So before we talk more about your work, can I just take a stage back and ask a really silly question? So why do we need to sleep? And not of us think it's a waste of time because there's so much we could do with our lives if we weren't sleeping. So why are we designed to sleep? So yeah, I mean, sleep plays a lot of fundamental roles in both our physical and our mental

well-being. So informing pathways in our brains, consolidating memories, getting rid of waste, and making sure that our immune response is working effectively. And, you know, we know that actually people in studies who are sleep deprived for large periods of time, there is connections between heart disease, you know, even obesity and other sort of physical illnesses. So we know that sleep plays a really important role, both in physical but also mental health. People with depression are all most twice as likely to also have insomnia and sleep problems. Certainly people with anxiety almost always will have some kind of sleep problem as well. So it's almost impossible to not prioritize and not look at sleep when we're looking at how

overall we can be healthy. There's lots of information out there about how important sleep is. And I think it's good in terms of for those people who don't prioritize sleep, people who don't think it matters and who perhaps take medication for other things, they're perhaps taking medication for conditions that could be helped by sleeping more. It's important that those people learn to prioritise it. But I guess my group of people that I'm working with, they do prioritise it. They desperately want to get sleep. And so this sort of media storm around sleep and how important it is, for those people, it's quite hard. It's hard to keep hearing the devastating effects

of not being able to sleep well. Which is very difficult, isn't it? Because there's nothing worse than being really tired, going to sleep, and even starting to go to sleep. and then waking up and you know that you're going to not only feel worse, but you know there's health problems as well with not sleeping. And certainly there's a lot more now, isn't it? Like you say, sleeping helps can help reduce inflammation. It can help repair damaged cells. So we know that if people don't get adequate sleep,

there's an increased risk of diseases such as heart disease, diabetes. Even obesity, isn't it, can be related. Yeah, whilst we're asleep, we're developing certain hormones connected to appetite and our sense of feeling full. if you're tired in general, not only are those hormones affected so that you're probably eating too much or not stopping when you would be full, but also you're tired and we tend to make unhealthy lifestyle choices when we're tired. We eat more sugar, food, we don't exercise as much because we're too tired. So it's a real cycle and you can see how almost every area can be affected, you know, physical health-wise, but also mental health-wise. You know, there's the two come hand in hand. It's like you say, for most of us, we've had, you know, the odd night where you can't sleep and it's so frustrating. But if you imagine that night after night, it's impossible to. to remain upbeat and positive and embrace the day. It's hard not to be affected. Yeah, and I think it's so important because there's so much more about well-being and we're talking about diet, we're talking about exercise, we're talking about relaxation, but actually sleep is really

key for everyone, isn't it? It's so important. And it's like eating healthily, we all have to eat, but the way we eat obviously depends on our own personal choices. And to some extent, sleep is the same, we all have to sleep, although like I've said some of us don't want to sleep very much, but it's having the quality of sleep. And there are ways that we can improve, which we'll talk about. But certainly when I was a junior doctor, we had the full on call system. So I would start work if I was on call over the weekend. I'd start work on a Friday at 8 o'clock in the morning and I wouldn't finish until Monday 5 o'clock. And I can't tell you how horrible I felt by Saturday night, let's alone Sunday night. And it always reminded.

me how, you know, lack of sleep is a form of torture, isn't it? And when you're forced to stay awake, it's just the most awful feeling. You have this terrible pit in your stomach. You've got headache. You feel nausea. Like you say, you'll eat anything to try and keep awake. And it's very difficult because I was obviously forced to stay awake because of my work. But then it's very difficult. Your whole sleep cycle changes. And I think anything that changes our sleep cycle, then is very much harder to get back into that rhythm, isn't it? Yeah, absolutely. And I think the important thing to know about shift work is that when you're working through the night, it's not just a case of having to stay awake.

Actually, at a time where you are usually asleep, your body is performing all sorts of changes and temperature changes. And it's actually gearing up to be asleep. So it's just trying to stay awake is sort of an understatement. You know, you're really battling against your internal circadian rhythm. And that's why it's so, so difficult to do and why we feel so terrible afterwards, because we're fighting something that the body clock is expecting you to do. Yeah, so talk us through because I've, I mean, I've read all sorts of things about sleep, some I agree with and some I don't, but a lot of it seems to be about having a really good routine,

a bedtime routine, but also a seven-day routine. So it's not having the five days and lying in at the weekend, but I don't know whether that's true or not. So talk me through some really simple measures. So I guess it depends who we're talking to. So if you are somebody who has a decent sleep pack, pattern. Simple changes that we would call sleep hygiene. So everybody's heard of sleep hygiene. That's kind of don't drink too much coffee, don't drink too much alcohol, make sure your room's comfortable, those kind of things. And that's all quite, you know, decent advice for somebody who already

sleeps okay and just wants to be educated and healthy in as many ways they can. If you are somebody who is actually struggling to sleep well, so you can't get good quality of sleep. And it's really important to think of quality rather than quantity. So we're talking about good quality sleep, not just how many hours. If you're somebody who's struggling to do that, then actually sometimes focusing on sleep hygiene or routine and those kind of changes can actually make the problem worse. Because if you imagine that you already can't sleep well and then you don't drink any caffeine, you never go out in the evening, you have a two-hour wind-down routine involving yoga, mindfulness, sleepy teas, every single thing that you've Googled and you can buy. So a lot of the people that we see,

their sleep hygiene is perfect. They're doing absolutely everything right, but it's actually creating so much anxiety because we're trying so hard to do something that actually the more we try and do, the worse it becomes. And then it makes them feel worse in themselves. So it's more like a failure because they're not achieving what they should be with all this routine. Yeah. And they say, you know, I've tried everything. I've done everything right and I still can't sleep. And so the very first thing that I do with everyone that I work with is help them to understand the model of how we develop insomnia. Because if we can understand how sometimes what we do is maintaining that problem, it can make it a lot clearer how we need to change. And so what would have,

be helpful if I should I just talk you through that. Yeah, please do. Yeah. So the way that pool sleep develops is that for whatever reason we have a bad night, so it can be something massive and obvious like a divorce or a bereavement or a really stressful time. It can be something very minor, cough and cold, but a noise outside, or you may not even

know. For whatever reason, you just have a couple of nights where you can't sleep. Very quickly, what we started is, we're very intolerant of bad sleep. So very quickly, what we would start to do is make changes to try and improve our sleep. So, for example, if I had three nights of bad sleep. I'd certainly be thinking about it by that fourth day. And the first

thing I would do is probably go to bed earlier. So I'd think I need to get some sleep back. But actually, the problem with going to bed earlier is that one of the things that controls our sleep is our sleep drive. So if you imagine an elastic band, when you wake up in the morning, we start stretching this elastic band that's tighter and tighter as the day goes on. The ideal scenario being that this elastic band's as tight as it can possibly be, we've built up a huge appetite for sleep. And we're going to get into bed, fall asleep quickly and get a nice quality. So the first thing that we do to try and make sleep better is go to bed earlier. Straight away, what's happening is our drive is not high enough.

So we're in bed early. We're more likely to be awake because our drive wasn't quite high enough. So we're lying in bed awake. Then what happens is the more, you know, if you imagine the next week or so, we're still not sleeping well. We're now spending more and more time in bed and more and more time in bed awake. So now our bed is being associated with wakefulness rather than sleep. And the chances of you being able to remain positive and upbeat during that time. awake in bed is, you know, pretty slim. So actually this time we're now in bed feeling stressed,

frustrated, certainly anybody in menopause, hot and bothered, panicky. And we're relating our bed to that feeling. So this is how the cycle of poor sleep starts that we spend too long in bed. We go to bed too early. We perhaps get up too late. We're very anxious. We're very stressed. We're very hypervigilant about sleep. And we're connecting all of that to our bed. So in the end, it becomes sort of a Pavlov's dog style situation where actually your bed becomes a queue for anxiety. So people get into bed, they say I was absolutely chills out and relaxed on the sofa, could have fallen asleep. Second I got into bed, my mind started racing. And that's because they've learned that behaviour. They've learned to associate their bed with that problem. So in a kind of really

long-winded way, what I guess I'm saying about routine is it is important, but it needs to be the right one. If it's a routine that involves all the wrong stuff that leads up to poor sleep, then actually we're just sort of cementing the problem over and over again night after night. That's really interesting, isn't it? So what would you suggest for those people then who are trying with their routine? And like you say, because it's very common, isn't it, that you think, oh, I've had such a bad night's sleep. I'm going to go to sleep early or go to bed early and then you just lie there, feeling a failure. So what do you suggest or how do you help these people? So the first thing I would say to me, whether your problem is falling asleep or staying asleep, whatever it is, the first thing

that you need to do is increase that sleep drive. So that drive to sleep, that appetite needs to be much stronger. So what I would say is sort of work out how much sleep you're getting on. average. So if you're in bed for about eight or nine hours, but you're only getting about six hours of sleep or five hours of sleep, create a window of time in bed, which more closely matches how much sleep you can actually get. So for example, if you're going to bed at 10, you're getting out at six, but you're only getting about six hours of sleep. Instead, go to bed at midnight. So go to bed later. Set your alarm nice and early. Spend as little time in bed as you can. And what will happen is your drive is much higher. The more time out of bed, the more fresh

share daylight, those kind of things that we can do, stay out of bed, the more tired you are on this sort of genuine, sleepy tired, higher that driver is you'll fall asleep quickly, you'll get a better quality of sleep, your alarm goes off, however badly you sleep, you try and get up at that alarm, and you keep that cycle going. So what you're doing is building up a momentum of sort of sleep deprivation almost, but saying to your body clock, this is your only window of time where you can sleep. This is the only period I want you to sleep in, rather than saying, here's an eight, nine hour window, pick and choose in that when you want to sleep. That would fit in with what I've read about weekends, not having a lie in, because a lot of people think, well, I'll catch up

at the weekend. But if you're saying, I love your elastic band analogy, you're not going to have so much time to stretch it if you don't get up to later on a Saturday or Sunday morning, for example. Yeah, and I think what happens is people get into this scenario where they have two or three really, really bad nights where they don't get enough sleep. They build up a massive sleep deprivation, and then they sleep for nine hours at the weekend. And the problem with that is, if you take a nine, 10 hour night, you've lost all of that drive for the next night. So what I'm suggesting to people is, rather than getting the nights with loads, we don't get those, but we also don't get the nights with hardly any either. So what we're doing is just balancing it all out and creating

a consistent drive by spending less time in bed. So it's only one of the elements of the CBTI program, but it's the one, I guess, that usually produces the fastest impact, because actually we're just using your body's drive. And if we look at good sleepers, they don't have any rules in place. around sleep. So they don't care about the temperature of their room or the quality of their duvet or what they've eaten or drank. They don't worry about that. What they do have is a body clock that understands and is a good habit and a good pattern. They have a drive that's high. They go to sleep when they're tired and so on. So what they've done is they've managed to create a high drive, a body clock, an association with your bed that is about sleep. So the restricted window kind of deals with all of

that. It's helping your body clock to commit to a new window. It's creating a drive, but it's also so meaning that the less time you're in bed for, the less time we have spent associating bed with being awake. And, you know, that's key. If your bed is 50% associated to stress, then your body is never going to allow you to sleep well while you're in there because, you know, fundamentally we're designed to, you know, fight or flight if we're stressed. Yes. Not to sleep for eight hours. Which is so important that I am, a lot of people tell me, and certainly I know myself, when you go to bed, for me, it's usually the only time that I'm, have a bit of time on my own.

but then quite quickly you suddenly start thinking about the next day or what's going on with work, with home at the moment, with the world. You know, we're in a big crisis with COVID. And your mind can quickly race, can't it? And then when you were, like you say, very tired on the sofa downstairs, you go upstairs and suddenly you're hypervigilant and you suddenly then start thinking about all these things. And certainly, as some of you know, I do quite a lot of yoga and part of yoga, I do meditation as well. And I sort of very much visualised my thoughts. being pushed away and I really have taught myself over the years that my bed is not a time where I start to think and I'm very, but I have to do it quite, and at the moment I do it even harder because

I really don't want to have these thoughts that then become very overwhelming. Is that something that you would recommend people to do or to try and do? Yeah, I mean, probably one of the biggest, I guess, causes or the things that people come to me when they say the reason they can't sleep is a racing mind. You know, as soon as I get to bed or in the middle of the night, three o'clock in the morning, my mind is racing. So one of the techniques, that I add in alongside the sleep restriction is to advise everybody to create a time to put in place where you can think about these things. Because I think what we have now in society is that people are very busy. We don't have to ever do nothing. You know, the second we could do nothing, we would pick up our phones and do something.

So what happens is we're very, very busy all through the day. So really the only time that your brain gets to actually process something would be the time where you lay down in a dark room in the quiet. And obviously, your brain is going to come back and sabotage you in that moment and say, right, now I'm going to think about, the stuff I don't have time to think about. So what I say to people is, if we go from this learnt model that actually you've learned to do that and to associate bedtime or being in bed with thinking, instead be proactive. So every single day, a 20 minute window, especially at a time like this when everybody's feeling very stressed and unsure, a 20 minute window in the evening, perhaps after your dinner, pen and paper. And in that time, you write down everything that's on your mind. So it can be worries, it can be to-do lists, it can just be random thoughts, what ifs,

hypotheticals, whatever it is that's been sort of playing on your mind that day or plays on your mind in the middle of the night, write it all down. And in that 20-minute window, you can do various sort of cognitive behavioural techniques if you want to, so you can start challenging the thoughts or problem-solving. But really, the most therapeutic part of it is just saying to your mind, I acknowledge I've got these things on. I acknowledge that I'm worried about. I'm not going to ignore them. I'm not going to distract myself from them. I'm just going to think about them in a suitable period of time. Very therapeutic, black and white. So don't do it onto your phone. Do it in black and white. Write it all down. And at the end of your 20 minutes, you close your pad and you go and do something

else. And what then happens is that over time, if you get into this habit, your mind is less likely to keep trying to intrude and make you think about these things, because actually you've already acknowledged them. You've made some plans. You've decided what you can and can't control. And so at 3 o'clock in the morning, it's a lot easier to say, I've dealt with this. I can let it go. Whereas if we never write it down, we don't tend to do it so easy. And I love the word acknowledge because there's a lot that we can't change in our lives, but they still make us very anxious. And certainly I've learned with experience with some of my patients when I've been trying

to help them with very difficult situations and we tease back, what can you change? And often you can't change an environment, you can't change a situation, but you can change the way you deal with it. And even if just like you say, dealing with it is acknowledging it and accepting that you can't change it. It's accepting how you can change your own. behaviour towards that is really important. And I think also it's about how little things you can do to make yourself feel good about yourself because a lot of people, when they're having this

overwhelming sort of thoughts, anxieties, then it's associated with negativity. And there's a lot of negativity in the world generally, but even more so now. And then that makes people feel worse about themselves. So I think, like you say, even just being positive that you've written something down, you've acknowledged that you can't change certain things. It's going to be a good step in the right direction, isn't it? Yeah, absolutely. And what I love with that list is when you've written it down, the first thing is that if you can't fill 20 minutes worrying

when you're trying to think and worry for 20 minutes, if you can't fill that, then it's a great way of saying to stuff, so why on earth for 24 hours am I plagued by worry? Why when I'm at the cinema, am I worrying? Why when I should be listening to my daughter tell me something? I'm just distracted by a problem or a worry or a hypothetical. actually this 20 minutes is purely for that. So it's a very good way of saying, actually, I can control it.

It's just because I'm trying to ignore it the rest of the time. And my favorite thing to do in that time is allocate your worries and your thoughts into two lists, real problems and hypothetical problems. So the real ones are, you know, I have lost my job. That's a real problem. What if I lose my job is a hypothetical. And, you know, most people will be amazed at the list and how many fall in that hypothetical. And then you can say to yourself, actually, how many things on this?

list, do I have control over how is worrying about these things actually helping me and how is it hindering me? And it leads really nicely into sort of mindfulness and like we say, you know, letting go. And being able to say, I totally accept myself that I'm worried about this. It doesn't matter how silly it may be. I am worried about it. And I accept that. But I also accept that I can't control it. It's out of my control. And writing those things down really helps with that. I think visually seeing the list and seeing what you can and can't control is a great way to do that. So do you recommend that all the clients do that? Is that something that a lot of people do and a lot of people find really helpful? Yeah, I mean, I recommend everyone does it. Anyone who worries, even if your sleep is brilliant,

but you're anxious or you worry, I would recommend doing that as a first line kind of technique, you know, for a healthy mind. When things are in our mind, it feels like we have 100 things to worry about. On paper, it's always the same few things. It's always the same theme. And, you know, it gives you a real perspective when you see that. So, yeah, I'm a big fan of, I mean, like everyone, I don't always do it at the times where I should, but I know from experience with patients and clients that that in itself when it comes to sleep is just writing down that actually I don't know how well I'm going to sleep tonight or if I'm ever going to fix this problem in a way is therapeutic.

Just acknowledge that. But no one knows. None of us know how well we're going to sleep tonight. None of us know the future of our sleep. Yes. So it's really our attitude towards it that is different. And so it's something that I think everybody should do. And then what's about we know caffeine, so caffeine in drinks, but also chocolate as well and

alcohol. Different things. I mean say different things. Some people recommend that we don't have any caffeine. Other people say it's after a certain time or that you should only drink tea or decaffinated drinks. What's your recommendation regarding that? I would go from just the sort of common sense. Actually, that's where I come from it with it.

That I would say if you're drinking caffeine after maybe 4 or 5pm, that's getting close, depending on what time you go to bed, of course. I think the kind of six hours feels about right that I would say to people have tea and coffee in the morning. For a poor sleeper to say to them, actually you can't even have a cup of tea in the morning to get yourself going, seems harsh. You know, the people who are sleeping well are allowed to have a coffee in the morning. So I almost would prescribe caffeine to my clients and say,

look, if you're more likely to stick with this program by being able to get up and have a cup of tea to help you get going in the morning, then absolutely do that. But no, coffee, caffeine right before bed, no. I haven't really had much experience of chocolate and that sort of thing. I mean, same fizzy drinks. I know they have caffeine. Chocolate, I think you have to eat a lot. I think you'd have to be very sensitive for that to be the only.

only reason that you weren't sleeping. So more for me, the people that I wear with, they've already given up caffeine long ago. And that's almost become part of the problem. So common sense to me, not too close to bedtime, not late afternoon. But I think before that, absolutely fine. What about anything else in our diets? Is there anything else that you would recommend or food groups that are good to help with sleep? From the CBT for insomnia perspective that I practice from, a normal healthy diet would give you everything that you need to sleep well. if you're deficient in something, then absolutely, you know, then take supplements for that. There's not tons of evidence to say that things like magnesium can be proven to help.

People are often taking melatonin. Again, that's usually not necessary unless you have a specific circadian rhythm disorder. It's not something that we're not developing. So I say a normal healthy diet. I think that, again, focusing on food to improve your sleep will create more anxiety. Instead, focus on the evidence-based techniques rather than coming from a food or diet. I guess if you know something affects you don't eat it, don't go to bed hungry, but don't go to bed full. If you're hungry at bedtime, have a snack.

That kind of thing I think is, again, more of a common sense point of view. That's what I would say to people. The only, I guess the difference would be with alcohol, that absolutely alcohol does make your sleep quite non-restorative. So you'll feel worse after it. Yes. You're like to wake early, feeling hungover and thirsty and get a very fractured weak sleep. So going to sleep under the effects of alcohol is not a good idea. but when you do, as everybody will every now and then, if you do do that, for me, the biggest

key is actually the next day, get up, get outside, eat healthfully that day, drink plenty of water, make sure you don't go to bed too early on a Sunday night because you're trying to undo the Saturday night issue, go to bed, your normal time on Sunday night, and you'll get back to normal. So it's almost, when you do something that impacts upon your sleep negatively, don't overthink it, don't dwell on it too much the next day. Just get back into the swing of things and learn from it. I'm not sort of from this angle that should be that we all have to be perfect, no caffeine, giving everything up and taking everything on that's perfect, because I just don't think people can long term necessarily stick with that. So, you know, 80-20. Most of the time you're doing the right

stuff, then that's enough. Yeah, so like you say, not to feel guilty about it if you don't. And then what's about a lot of people who wake in the middle of the night tell me that they really can't get to sleep. So they go downstairs, they do the ironing, they'll make a cup of tea or they'll have something to eat. Is that a good thing to do? Should they be getting out of their bed when they're really really struggling to get back to sleep or should they be staying in their bed feeling worse? Combining sleep restrictions, so going to bed lids getting up early, we'll hopefully start to eliminate that problem in the night so you wouldn't wake up as much. But absolutely, if you're wide awake in the middle of the night and you are thinking, you're tossing and turning,

I always advise people to get out of bed. Sometimes people say you have to go and do something boring. But again, I think that that's sort of torturing yourself too much. Just go and watch TV, read a book, just do something that gets you out of that sort of state of mind that you're in. which is the frustrated thinking about sleep one, go and do something else. And when you feel sleepy, you go back to bed. But the important thing is you still get up at the same time, still get up early, still go to bed a bit later,

don't the next day try and compensate with the fact you had a bad night. So short term, it's quite hard because it's asking you to sort of go against what you naturally want to do, which is go to bed early, get up late, take a nap, all those different things. But actually long term, you will get that drive back and everything will start to improve. But absolutely, in the middle of the night, if you're wide, especially for men,

as a women, if you've had a hot flush, if you're wide awake, if you're feeling panicky, leave the bedroom. We don't want to associate your bed with that feeling. And I think that's really, really good advice because so many people feel that they have to stay in bed. And just listening to you now, thinking about the negative associations when you're awake in bed, how detrimental that can be for future sleep and sleep health. Yeah. And it's easy, you know, we all do it, that it's not natural for us to get out of bed because what we're doing there is we're kind of giving up. And what we're all always, whereas we want to get more sleep, we want to feel good tomorrow. So it's a hard thing to do

to get out of bed, but actually we're far more likely to fall asleep quickly if you get out of it, even just go to the toilet and then go back to bed. You kind of just cool down a little bit. You change your frame of mind. Everything changes in that time out of bed. So it's not easy because it's not natural. But actually as a short-term kind of method, it's definitely one that would recommend to anyone who has that problem waking up in the night. Excellent. Okay. No, that's really good advice. So thank you very much. And just before we finish, can you just tell me bit about the online course that's available to anyone, is this, to access? Yeah, so the online course is the step-by-step CBT for Insomnia Programme. So in the online course, it's a series of

videos that I've recorded where I'm telling people exactly what I would say in one-to-one sessions. But when you join the course, you can also join a private Facebook group. So I go on every day and I give people support and advice. So it's a great way of kind of getting support from a specialist without having to have one-to-one sessions. It's very easy to work through. It's not techie. It's not an app. It's a very simple program. I'm currently, offering it free to NHS workers because I know at the moment there's going to be a lot of anxiety, a lot of extra stress. And part three of the program is all about how to manage worry in general and worry about sleep and sleep anxiety. Brilliant. So I think probably at this time that's going to be

fairly useful. So yeah, I have a free webinar. We've got lots and lots of free resources, you know, before people need to pay for stuff. There's lots and lots of things that people can start changing themselves. Which is brilliant. Yeah, I know I found it really useful and I know lots of my patients do. So thank you very much. So just finally, are you able to just, give three very basic take-home tips for people that are struggling with their sleep. What are the top three things they could easily do to help? So I think the top three tips would be shorten time in bed. Go to bed later, get up a bit earlier.

Start from tonight. If you struggle with sleep, however late, on however early, you can do without feeling like it's creating tons of anxiety. Even if you can only go to bed half an hour later without worrying about it, just do that. Set your alarm half an hour earlier, go to bed half an hour later. If you can do more, do more. Shorten that window. The second thing that I would say is when you wake up, the first thing that we all do is look at the clock. We can't resist. We need to know the time. We need to just establish exactly how bad the situation is and how much we need to worry.

So set your alarm for the morning. If you use your phone, turn it over, put it on the other side of the room. If you use an alarm clock, set it for the morning and then turn it to face the wall. And resist that temptation to look during the night because actually every time you look at the clock, you're reestablishing this same pattern, this same routine again. and you're making it more and more likely, plus your mind will start racing as soon as you see how late is or how early it is. So resist the temptation to look at the clock. And the third thing would be manage your worries and your anxiety. So I think at this time where there's a lot of sort of anxiety and uncertainty going on, I would advise people, don't worry about getting less sleep now.

We're absolutely designed to have periods of less sleep. You know, if we weren't, then babies would be born knowing how to sleep through. We as humans, we are designed to cope with some sleep loss. you will be absolutely fine in the end in this time, just make sure that you are managing your worries. If you're very anxious, write stuff down. Learn mindfulness. Rather than focusing just on your sleep,

this is a difficult time to improve sleep on its own. So rather than focusing entirely on that, do a few things that I've advised today, but focus a lot on actually stress levels. Get out of your sort of fight or flight, your sympathetic nervous system, try to learn to relax and be calm, because that in itself will have a big impact

on your energy levels, your mood and your state, mind more than simply just looking at sleep as being the main cure for everything at the moment. Brilliant. So thank you. Really, really good advice. Thank you ever so much for spending some time today. And hopefully we'll get you back to talk specifically about sleep with menopause and perimenopause. So thanks ever so much, Catherine. For more information about the menopause, please visit our website www.w.mendopause.com.uk. Thank you.