In this episode, Rachel talks to Professor Colin Espie about cognitive behavioural interventions for insomnia. They discuss the importance of sleep, common misconceptions about sleep and the importance of trusting in the body's natural sleep processes.  Colin highlights the high prevalence of sleep disorders and comorbidity with other mental health conditions that CBT therapists will commonly be treating. They discuss factors that maintain sleep problems and key evidence-based and effective approaches to addressing these obstacles that might help you and your patients to get a good night’s sleep!

If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X or email us at [email protected].

Credits:

Music is Autmn Coffee by Bosnow from Uppbeat

Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee

License code: 3F32NRBYH67P5MIF

This podcast was edited by Steph Curnow

Useful links:

Books:

The Clinician’s Guide to Cognitive and Behavioural Therapeutics (CBTx) for Insomnia: A Scientist-Practitioner Approach (2024) by Colin A. Espie.

Overcoming Insomnia and Sleep Problems: A self-help guide using cognitive behavioural techniques (2021) 2nd Edition, by Colin A. Espie.

Papers:

Espie, C.A. (2023). Revisiting the Psychogiological Inhibition Model: a conceptual framework for understanding and treating insomnia using cognitive and behavioural therapeutics (CBTx). Journal of Sleep Research https://doi.org/10.1111/jsr.13841

Link to further papers:

https://www.ndcn.ox.ac.uk/team/colin-espie

Training links

https://www.scni.ox.ac.uk/study-with-us

 

Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who share insights that will help you understand and apply CBT better to help your patients.

Today, I'm going to be talking to Professor Colin Espie about Cognitive Behavioural Interventions for Insomnia. Professor Espie is a Professor of Sleep Medicine in the Nuffield Department of Clinical Neurosciences at the University of Oxford. Since qualifying as a clinical psychologist in 1980, he's accumulated decades of research and expertise in the relationship between sleep and mental health and the understanding and treatment of sleep disorders particularly using cognitive behavioural therapeutics, a term we'll return to later in the podcast. He's also internationally recognised as a leading expert in the field and his work has been disseminated widely, not only through his many journal articles, books, and training programs, but also through his Sleepio app, which has supported improved access to evidence-based help.

So welcome Colin. It's brilliant to have you with us

Colin: Rachel, thank you very much for inviting me. It's great to be here.

Rachel: So, I'm going to start with a question that I've heard you say you always get asked in these interviews. So, we're going to get it right out of the way up front. You're an international sleep expert. How well do you sleep?

Colin: It's the journalist question, Rachel, isn't it? They usually ask at the end of the interview just when you're finishing up, Oh, by the way, how do you sleep? I'm actually a pretty good sleeper. I wake me quite early in the morning, you know, so I'm not a late night person.

Rachel: So, you haven't had to apply these techniques extensively to yourself, or is that something you do?

Colin: Well, the interesting thing, Rachel, is that I, and I'm sure it's true for everyone who's listening to the podcast, thinking about your own life, never mind the life of your clients and your patients that we all at times have difficulty sleeping. It's a normal experience, just the same as we all at times feel a little bit worried or anxious or have a period of feeling a bit depressed. And in some ways, the techniques that we use with our patients are kind of similar to what we try and do ourselves. Except we just need to apply them particularly rigorously, to help to remove more reluctant problems, shall we say. So I try not to lie awake in bed, for example. I try to, I better get up and go back to bed when I feel sleepy again, although it's not the easiest thing to do.

Rachel: So you've practiced what you preach

Colin: I, well, I try. I try.

Rachel: and you've been interested in sleep from very early in your career. So I believe you're only a few years qualified as a clinical psychologist when you organised your first international conference on sleep. And then later you carried out the first control trial in insomnia patients in 1989.

Colin: Yes.

Rachel: And so what got you interested in the field of insomnia personally, professionally?

Colin: Well, I think like, as with most things in life, its curiosity, isn't it? I started work, qualified in 1980 and I worked in primary care, seeing patients referred by general practitioners. That was very new at the time, getting direct referrals from GPs. And after a few months, one of the GPs said to me, “Colin, don't suppose there's anything you can do to help these people who can't sleep?” And I said, I don't know. Because we've never been taught anything really about sleep or its relationship to mental health. I'd been seeing lots of anxious people with depression and so on. So I said, send me a few patients. And I went to a thing called a library. And read some books, and some papers.

Rachel: libraries, what are they like?

Colin: I know, I know, so I, I tried to just find out as much as I could and discovered there was an emerging literature on behavioural therapies for insomnia. But mostly they'd been conducted in student populations and not with patients. So, in the mid-80s, I designed, as you said, kindly, the first trial of referred patients, and of course CBT had never been invented as a term then.

Rachel: So it was, it was all brand new and on many levels.

Colin: yeah, what I looked at initially were relaxation-based therapies and therapies based on something called stimulus control, which is, it's a behavioural approach if you like to try and help reestablish a good pattern. And I looked at something called Paradoxical Intention, which is a cognitive therapeutic, designed to overcome performance anxiety, in other words, to stop you trying to sleep. So these are the three interventions, which when I looked in the papers I could find, these were the three approaches that seemed to have some evidence base but hadn't been tried with patients. And I mounted a placebo-controlled trial as well. Pretty bold stuff, really, I think, back in the day, Rachel.

Rachel: Fantastic. And as you said, this is whole raft of interventions that you now have developed and gone forward to, and we'll talk a bit more about that as we go through this podcast today. I guess you're not the only person who was curious about sleep. I mean, it seems at the moment that we're all pretty obsessed with sleep. I can't scroll through my news app or a Sunday supplement without encountering at least one article on how to sleep better or on sleep problems, which does suggest that it's a problem, or at least a perceived problem for a lot of people. And anecdotally, my friends who work in higher education with undergraduates tell me that Gen Z is absolutely fixated on getting their eight hours sleep and they're in bed before their parents and their professors. So, so perhaps a good place for us to start talking about sleep problems is defining what good or normal sleep looks like, how we would define that, what it's for?

Colin: Yes, absolutely right, Rachel, sleep's everyone's business, it's not just the business of professionals. And in many ways sleep is nature's medicine, its what nature has provided, for us to give us quality of life and we wouldn't be able to function at all without our sleep. And when one thinks about it, we imagine ourselves to be highly evolved species, which I think we are, but we haven't evolved to do without sleep. In fact, we need rather a lot of it. If we spend a third of our life asleep, that's in service of our quality of life. But then what is sleep? I think a lot of people think of it as a kind of oblivion. Yeah and that's what it should be, that you just kind of conk out kind of thing. And that's you for the night.

Rachel: it's the switch off button.

Colin: it's a switch off button, but it's actually really the switch on button. Because there's a lot of research evidence now that, if you were to ask the brain, what's your preferred state, they would say sleep. Because that's when I can go on with my work, when you're out of the way. Because during sleep, a lot of the repair restoration work is done in terms of regenerating cells, in terms of clearing toxic waste from the brain, in terms of infection control and signalling. We need sleep to recover and rest, of course, but there's all these much more sophisticated processes going on. And of course, as people interested in psychology, it's sleep that gives us cognitive recovery. It's during sleep that memories are consolidated, not during wakefulness, or not efficiently during wakefulness, much more efficiently during the night. And it's during sleep that emotions are regulated and reset. So, it's a very complex set of processes and phases and stages, and people will be aware to some degree of REM sleep, Rapid Eye Movement sleep, or dreaming sleep, which occupies about a quarter of a night. and then non-REM sleep occupies about three quarters of the night. And it’s all beautifully architectured if you like, across the night.

Rachel: So those different types of sleep have different functions?

Colin: Yeah, absolutely. And I think one of the difficulties nowadays when one buys some kind of smartwatch or whatever, and it's going to track my sleep and tell me how much sleep I've got, and then tell me how much sleep is in different bins. And you look at the different bins, one of them called deep sleep, and you'd rather, you wish, well, I hope my whole nights in deep sleep. But in fact, from a scientific perspective, deep sleep occupies somewhere between 10 and 20% maximum of your night. And in later life, maybe five to 10%. Deep sleep's quite a rare commodity. But that tells us also that, that all the forms of light sleep are just as important, but we're more likely to waken out of those and dreaming sleep is light sleep, of course.

Rachel: So as psychologists, we really like to measure things and we often are asking our patients to record and monitor and measure things, but it sounds like some of these measurement processes can be oversimplified and lead to sort of negative outcomes in terms of people thinking they're not getting the right kind of sleep or that their sleep isn't directioned in the right way.

Colin: That's right. I mean, I think that's an unfortunate side effect of people's best efforts to look after their health but sleep is not designed to be monitored like that and good sleepers don't do it. In fact, good sleepers have no idea how to sleep.

Rachel: They just do it.

Colin: But just like you breathe, Rachel, I've noticed you're breathing pretty well, but you've probably been unaware of that. Have you noticed that you're breathing?

Rachel: I have not been focused on it.

Colin: Yes, and that's the way our basic physiological functions are designed to work. So breathing and sleeping are designed to be totally automated behaviours. This is why sleep is so interesting from a psychological perspective because I've never met anyone who's able to get to sleep in my career thus far. I've never met a single person who can get to sleep. I've only ever met people who can fall asleep.

Rachel: The difference being an automated versus an intentional process.

Colin: Yes, exactly. That psychology, trying to actively control the sleep process tends to disturb it. Just in the same way as trying to actively control the breathing process can lead to hyperventilation. Now of course one can take deep breaths and, and so on. But one can't switch on your sleep. You can amplify your breathing rate and reduce it, but you can't do that with your sleep. It belongs to a highly automated, regulated system that's done largely automatically. So this is one of the reasons that, that insomnia can be such a difficulty. Either if we have an acute difficulty, I can't get to sleep tonight and I'm struggling. Oh no good. I'm speaking in a podcast tomorrow. What if I need to be properly slept, or, you've got an insomnia difficulty. Then you get caught in this vicious cycle, don't you?

Rachel: So it sounds like, what you're saying is sleep is an automated process, not something we need to actively do. It's something that should happen naturally. It's something that is very active in itself. It's not a switch off button. It's a switch on button for our brain. These cycles of different types of sleep are important. So we don't just want to be in deep sleep, as our sleep apps might tell us, but we actually want to have these variety of functions that the brain is carrying out throughout the night.

I'm going to put a few questions or statements to you about sleep that might sort of tap into some of these myths or maybe true and informative statements so that you can tell us whether they're true or false. So here goes.

Colin: Here we go.

Rachel: Adults require 8-hour sleep to function well cognitively.

Colin: Probably, not quite as much as that, but that would be the average figure, somewhere between, say, seven and a half and eight hours. The difficulty is that 50 percent of the population is always below average. In everything. And that a lot of that proportion is normal. So therefore, we're not all the same. And the best way I can explain this to people is to think of your shoe sizes. We may have an average shoe size for the adult male population or the adult female population. But that doesn't mean we should all hobble around in the same shoes. We should really try to figure out, what shoe fits my foot? What's comfortable? And we do that by trial and error. And that's how we find out how much sleep that we actually need. And I think one of the difficulties is that when you convert sleep into the five fruit and veg kind of thing, well, five fruit and veg, eight hours sleep, the eight-hour sleep is really, it can only be a guide. You try to get to prioritise and value your sleep but try to personalise it and to establish the amount of sleep that you require. And sometimes people spend too long in bed, and they can't sleep through that period and end up having difficulties. Other people have got such busy lives that they're running short and not getting enough sleep. And of course, when we've got mental health difficulties, sleep can be elusive. So it's a complex answer to what seems like a simple yes or no question, Rachel.

Rachel: But actually that complexity is important, isn't it? Because if we're all trying to shoehorn our sleep into a particular amount of time or worried about it being less than that, then that can create problems in and of itself.

Colin: Yeah, because we know, don't we, we know that sleep matters. That's one of the reasons that we get very anxious when you can't sleep, not just because of the horrible experience, but we know it matters. We know deep down in a primitive way that it matters and our response to not being able to sleep well or sleep enough can be very alarming, the same way as if we can't breathe. There's not enough food. There's no drinking water. Because it's one of the basic ingredients of life; sleep, oxygen, food and water. The basic ingredients for survival. So therefore, when one's in shortened sort supply or when we feel it's in short supply where instinct is then to try to control the solution and of course people want to take active set steps to solve a problem that's understandable, but we can take steps that actually make it worse. It's such an important commodity but yet we can't just commoditise it. We have to trust it.

Rachel: And you hinted there, sometimes people worry about getting enough sleep because of particular things they need to do or functions they need to have. So here's another statement, less than eight hours sleep will mean that we're unsafe to drive.

Colin: No, that's not true. Again, it would relate to the amount of sleep you've had. But I think the thing to monitor in relation to safety is your level of sleepiness, not the amount of sleep you had the night before. So, for example, if somebody said, well, I had my eight hours sleep, so I'll just continue driving even if I'm sleepy, that would be a very reckless thing to do, and the courts would agree with that, and you'd be found guilty. If you're falling asleep at the wheel and causing accident or injury, it can be a criminal offence because one has to be responsible. So we need to monitor our sleepiness. And I think the main thing to differentiate there, and I think this is important in our clinical work, too, is to differentiate between experiences of sleepiness and experiences of fatigue. They're not the same thing.

Rachel: So how do those differ?

Colin: Well, sleepiness is a behavioural tendency to fall asleep. When one knows that your head's nodding, that you're yawning, your eyes are closing, you're stretching, your eyes are itchy, you've had some warning signs, you've already had a momentary microsleep, your partner's dug you in the ribs, you spilt the tea on your sweater- and of course people are aware of this driving and it's very dangerous indeed. Whereas fatigue is a sense of weariness and doesn't necessarily mean that we're about to fall asleep. In fact, people with chronic fatigue syndrome often have difficulty sleeping, so it's not inevitable that when you're fatigued, you're going to fall asleep. And fatigue is, to some degree, a good countermeasure to fatigue is activation. If we get up and do something, then we can take the edge off fatigue. Whereas with sleepiness, you really have to have a nap if you're very sleepy.

Rachel: And you've already mentioned that people sometimes spend too much time in bed. So the next statement is in order to get sufficient sleep, we should go to bed and stay there until morning. We should just spend more time in bed if we're not getting enough sleep.

Colin: Well, I think we should experiment. You know, to find the amount of, let's call it the sleep window. That's often the way I think of it. What is the best window for me to sleep? In other words, how long should I be in bed? When should the window be positioned? Some people are more naturally morning people, larks, and will tend to have their sleep window early. The and the gate, the circadian gate as we call it and we can talk about the circadian system a little bit- the times that are sleeping wakefulness. But people who are morning larks will tend to feel sleepy in the mid evening and then a would have a natural sleep period that would wake them up at three, four in the morning. Five in the morning, whenever. And night owls are the opposite. The gate doesn't open till later. So, it's really about figuring out the timing of your sleep as well as the amount of sleep. And experiment. I think one of the difficulties, and of course we find this with clinical practice too in general, that what we do with cognitive behavioural therapeutics is we encourage people to experiment, to try things and if they're unsure whether it would work and if they're unsure whether they could do it, then we encourage them to experiment with it. But we also encourage them to experiment because we're trying to test a formulation to see if there's evidence for it. And this is a bit like that. What is the best time for me to sleep? But I think what people often look for from the therapist is just tell me the answer. Tell me exactly what to do and they want it off the peg whereas we know that's not what works best for people. That's not part of a collaborative approach, but it's not really formulation driven. That's more just a technician approach.

Rachel: So experimenting is good, collaborative empiricism, heart of CBT and I shouldn't be worrying that my teenage sons, we're currently in the summer holidays, are experimenting with getting up long after the sun has arisen, but we'll maybe come back to those issues later on.

Colin: Well, it's a natural experiment, Rachel and it's actually what happens in teenage years, that the body clock is set to delayed phase position. So, so teenagers find, struggle to get to sleep and they struggle to get up in the morning. And of course, when you take away the time givers, the zeit givers, like you've got to get up to go to school, when you take those away you release the break at the end of the circadian period so they tend to be even more phased delayed. That's a biological norm, unfortunately, in some ways. But you said we'll come back to it. We can come back

Rachel: Yeah. Yeah. And it's one that's going to be interesting when they start school again this week. So one that our listeners might have something invested in here. We should never drink alcohol or caffeine if we want to sleep well.

Colin: It's generally a good thing to avoid caffeine as you approach bedtime. A lot of people will go into decaffeinated drinks in the evening. Because caffeine is a stimulant and can delay sleep onset, but in experimental studies it does so just by a few minutes. It's not really accounting for insomnia, unless your caffeine intolerant and of course most people build up some tolerance to it. So, it's much overstated, but that's not to say that we shouldn't pay some attention to it. And of course, caffeine can be found in chocolate and diet aids and lots of other things and it's good to encourage people to experiment again. But sometimes if they hear the psychologist saying, starting the treatment insomnia with sleep hygiene, talking about caffeine levels and beds and comforts and new pillows, mattresses, they might quite rightly think this isn't really going to be therapy.

We don't have a good relationship with alcohol in the UK. And alcohol modifies the structure of our sleep. So quite a lot of alcohol in the evening will obliterate your REM sleep. It will remove your REM sleep. It’s a REM suppressant and as the alcohol wears out of your system during the night, you may have more dreams towards the morning and sometimes more disturbed dreams and nightmarish dreams if people are drinking a lot of alcohol. So, alcohol, although it's a sedative, a drug, a depressant drug in the central nervous system, it does have unwanted effects on the structure of your sleep.

Rachel: So it may initially help us potentially fall asleep or it may hasten sleep onset, but it doesn't help our quality of sleep. Is that right?

Colin: Yeah. And may cause some retrograde amnesia so you don’t know whether you've slept or not, in extreme cases. I'm not saying it's an anaesthetic, but there's a different, there's a different kind of structure to your sleep. So you know, it's not sleep at all costs. So usually the first cycle of REM sleep occurs after about 60 to 70 minutes into the night, you have your first cycle of REM sleep, and that's there because it's meant to be there. But alcohol, if taken in excess will obliterate that altogether. And often an alcohol fuelled sleep doesn't feel like it's a good, had been a good sleep even if you've slept for quite a while. But I don't believe in the ministry of no fun, Rachel. You know, I'm not saying that, we shouldn't be walking a tightrope with our sleep and it's often the way that patients feel with their anxieties or worries or depression, the trauma and with insomnia that they feel very vulnerable. I think one of the things we need to do is to learn to trust that sleep is a highly evolved biological imperative. It won't let us down. We have to kind of try to keep it in a good position and good shape. We need to look after it and one way to look after it is by not regularly drinking too much. Not using alcohol as a sleep aid but that's not to say that I've never had a malt whiskey.

Rachel: So we're not encouraging, total abstinence or black and white thinking when it comes to things that people get some pleasure or enjoyment from, but we're thinking about how that does have impacts, particularly when used and abused.  

Colin: People often underestimate how much they've been drinking and tell you, and tell themselves they've not been drinking much, and tell themselves also that they don't have a problem. So, it can be one of those things that for some people, for some patients, we should encourage them to experiment with that, that it could actually be a factor and perhaps inadvertently alcohol has become a sleep aid for them.

Rachel: And so another statement then for our true and false section. In order to catch up on a bad night's sleep, we should go to bed super early the next night.

Colin: No, there’s a natural homeostasis to our sleep drive. And homeostatic functioning is about, it's a pressure system that creates a balance, drives towards balance. So, leaving aside the alcohol question, let's suppose you're parched and you know you need a drink. Your dog knows, he or she needs a drink, insects know they need a drink. It's not a smart thing to know it's just that you gravitate towards needing to recreate a homeostatic balance, where your fluid intake is concerned. When we're hungry, we seek food and when we're sleepy, we seek sleep. And the drive for sleep, the biological drive for sleep is stronger the night following a poor night. So, so, and interestingly, this is often what people do with pills, don't they? I slept badly last night, so I'm going to take a sleeping pill tonight because I can't afford another one of those. That's the very night they are likely to sleep better anyway, because they had a bad night, because there's a natural recovery. So the best thing that people can do is to establish the pattern and to retain their pattern, rather than to switch it back and forth reactively to poor experiences and to bad nights, because that tends to create a situation where it's hard for the homeostatic system to find its balance point again.

Rachel: So you don't need to actively sleep more to catch up. Actually you need to trust that your body will respond to that, that you will sleep well the next night and that over time, that homeostasis will be reached again.

Colin: Usually if people have slept badly, it's either because they didn't have enough sleep opportunity that night because they were busy, they were doing things, they were up late, they had to get up early, whatever, things in their mind, they catch the flight, so reduced sleep opportunity plus some anxiety about it, or it could have been just one of those nights when they couldn't settle. But either way, the sleep loss accrued, accumulated from that night will help to drive a better sleep the subsequent night. So reasons to be confident in sleep's ability to do its best for you. If you end up going to bed the next night for an even longer period, for example, than you would normally spend in bed then there may not be sufficient sleep drive to carry you through an extremely long sleep period. And then you go, hey, what's happening here? I've went to bed at eight o'clock. I had such a bad sleep last night and I can't get to sleep. And that's possibly because you, well, do you ever normally fall asleep at eight o'clock? What's your normal time of sleep onset? But again, when I talk about experimentation, I'm talking about experimentation towards habit formation. You know, what we do with young kids is we experiment to get them into patterns of behaviour. We support them when they're trying to walk and then we experiment, see if they can walk three steps instead of four steps and fall only two out of five times instead of five out of five times but eventually, they walk, so even things that are going to happen need to be supported by experimentation. But they're in aid of automation, of it becoming just a natural pattern. Which is not really overthought.

Rachel: So final one of our true and false statements. There are good sleepers and bad sleepers, and you just are what you are. You're stuck with it.

Colin: There's some truth in variation in almost everything. So there are some people who seem to be better sleepers. It's often more to do with some people have greater vulnerability to downregulate arousal, for example. Because sleep, to fall asleep, you have to be able to downregulate your arousal level. And some people have higher set points in arousal. Other people had experiences which to some degree have contributed to them being somewhat hyper aroused.

Rachel: Like a lot of our clients.

Colin: yeah, and those things then become the target for what we can do to help people to manage those situations, and I guess psychological therapy is on a bridge between managing a situation to live with it better and curing it, solving it. What I would say is that a lot of insomnia problems can be solved. Don't just live with them. I think this is one of the reasons a mindful approach has not been that successful as a treatment for insomnia disorder. Because the insomnia problem can be sorted. Rather than, you don't need to live with it. But you really have to experiment behaviourally to get the positioning of your sleep right.

Rachel: So it's not just a position of acceptance.

Colin: No, sometimes people say to me about, well, you use the paradoxical approaches and say, is that not just mindfulness and is that not just acceptance? I mean, there's an element of acceptance in every world, religion, philosophy, and creed and it's integral to a lot of psychological therapy, but it's not sufficient to solve a problem that can be solved. For example, if you're afraid of an animal, you can solve that problem, you can overcome it, you don't need to accept the fear of it.

One thing I would say though about good and bad sleepers is I've never met anyone who's good at sleeping. It's not something you're good at, you're not a good breather, you're a great breather, what a great breather, great walker. It doesn't make sense to be good at it. In fact, if you try to be good at it, you're more likely to be end up having difficulties with it.

Rachel: So, I think you’ve really clearly stated there that sleep is an automated process, an automatic process. We don't have any more control of that really than we have over breathing. And you've talked about the need to be sleepy, and, and also the need to be able to get downregulate to feel safe and I've heard you say those are the two things that really need to be in place to feel sleepy and feel safe to fall asleep. You've also just spoken about the homeostatic sleep drive so this kind of builds up this pressure for sleep. Are there other processes that govern automatic processes that govern our sleep, other cycles, rhythms, patterns?

Colin: Yes. So people will have heard of the circadian system. And of course, in relation to sleep, the circadian system regulates the timing of sleep and the timing of wakefulness. But the circadian system is present at cellular level. So if I was to take a one cell out of a strand of your hair, Rachel, and to put that one cell in a little Petri dish, that one cell would follow a 24 hour rhythm all on its own, assuming it had enough energy to survive. But one can demonstrate what's called a molecular clock at cellular level. So this is an intrinsic rhythm. This is integral to our system and all the major organs in the body follow a circadian oscillator system and, you'll have been jet lagged, I'm sure. Yes, and it's a terrible experience, isn't it? It feels like it's got general malaise, isn't it? It's not just about not sleeping well, or at the wrong times. Our digestive system is out of sorts, our light sensitivity is out of sorts, everything is out of sorts. And jet lag is actually what's called internal desynchrony in circadian science and what that means is your bodily systems, your bodily oscillator clock systems are out of sync with each other. It's not just you being out of sync with the clock on the wall and not being able to sleep at night, it's to do with your different clock systems, being out of sync with each other and recovering at different rates. And sleep science and circadian science are coming more closely together in recent years, and at Oxford I'm involved with the Sleep and Circadian Neuroscience Institute where we're interested in basic animal models of sleep and circadian function as well as the clinical human and societal levels, because these are clocks that time us, that time our lives, and time the seasons of our lives at a different kind of seasonal rhythm.

So, what happens is that, when you wake up in the morning, and I've just checked my watch, it's 10 o'clock, right? So I think it's 10 o'clock. So let's suppose you got up at 7 this morning, Rachel, maybe you get up early, I won't ask you a personal question, but 3 hours, right? So in a normal homeostatic system on its own you'd be three hours into your sleep debt. You'll have accrued three hours of sleep debt. You're owing three hours to the sleep banker. And what would happen you would expect is as you gradually go through the day, you get sleepier and sleepier. If you didn't eat anything, you'd get hungrier and hungrier. You didn't, if you didn't breathe, you wouldn't last three hours, right? So the homeostatic system on its own would just accrue debt and the main symptom of that would be sleepiness and danger. The circadian system operates to keep us alert during the day in opposition to the accumulating sleep drive. So it's an alerting system and then, as night falls the circadian system begins to orient towards opening the sleep gate to allow it to flood through and the main hormone that helps us to measure this is something called melatonin. And melatonin's expression is suppressed by light and increased during the dark phase. So these complex bits of neuroscience are all part of the design, if you like, to enable us to sleep at night, to get the recovery that we need, and to maintain an optimal alertness during the daytime.

Rachel: So on the one hand, we have this sleep debt that's rising through the day. And the other hand, we have these kind of body clocks operating. And it's incredible to think on that cellular level, that's a really fascinating example you give about a cell from a strand of hair, it has its own clock regulating

Colin: Yes, and there's a lot of evidence that, circadian disruption is a very common factor in a bipolar illness, in schizophrenia and psychosis and so on. There's a lot of what we do as psychologists and therapists, which we're doing, we think, at the level of the mind is actually having direct effects on behaviour and the brain. Our interventions are really psychobiological even if they're primarily at the operational level, psychosocial, what you're actually doing is you're modifying our adaptation to the world. I think we need to recognise more the fundamental science connection that we need in psychology to take things to the next level, just in the same way as it's happened in medical science, broadly speaking.

Rachel: So it's not just, it's not just psychobabble. We're not just talking about nice stuff and making people feel better. Actually, that body mind connection, interconnection is really fundamental to what you're achieving when you're working in this

Colin: Yeah, I sometimes kind of laugh. I find myself chuckling when I see something in a newspaper about scientists have discovered that there's a relationship between the mind and the brain, kind of thing. What is the mind, if not the brain? Do you know what I mean? Or surprised that some real science behind psychological interventions, it's not all just questions and questionnaires. And it actually makes a difference to how our body functions and how we operate as human beings. Psychological interventions are a lot more powerful than many drug interventions and, if you look at insomnia, for example, cognitive and behavioural interventions are recognised internationally as the preferred first line interventions having effects that are greatly superior to any sleeping pill. And that's not because they're operating just at the level of kind of emotion. They're actually making a difference to people's actual functioning in day-to-day life as well as their sleep at night.

Rachel: And you've spoken about how in certain psychological or problem presentations sleep rhythms can be disrupted. Clinically speaking, how widespread are sleep disorders and what are the issues people with insomnia typically struggle with and seek treatment for?

Colin: well, if you pick up the DSM or ICD and just flick through the classification of mental diseases, you won't find any that don't have sleep disruption as part of them. And I think historically, we've taken the view, quite incorrectly, that sleep is a piece of collateral damage that's associated with mental health problems. The real thing is the bipolar illness. The real thing is the depression. The real thing is the anxiety. And a symptom of all these things is your sleep gets disturbed. I think it's much more of a bidirectional relationship than that, and sleep is much more fundamental than that. So, therefore, the advice nowadays is that you should actively treat the sleep difficulties as part of the disorder you're managing, and that you're likely to get a better outcome if you take a 24-hour perspective on the individual, than just taking a daytime perspective, which is often what we do. So the night time is just a consequence of the daytime, the brain doesn't believe that. The brain would prefer you to think differently, that actually sleep is the engine. And therefore, when people aren't sleeping well, the supply isn't there to live your life well so therefore, addressing both. Because I've got a research background and am a clinical psychologist and others involved in research, you tend to get involved in doing something specific, you become an expert in something, and I think we need more of that research expertise, but equally, I’m a strong believer in the generalist approach that all clinicians should become skilled in understanding the role that sleep and wakefulness play in the presentation of my patients, whoever they are, wherever they are, they will be grateful to you if you ask them about their sleep. If you think, does it really matter? Is this an important thing? They'll tell you it is, and it does, but you know often we don't quite know what to do to help them.

And this idea that in insomnia clinic, it's where people have got isolated insomnia, 80 percent of these people have got comorbid difficulties, physically and mentally, and these other disorders aren't the main problem. They need help with both those things.

Rachel: So is it possible to put your finger on a sort of statistic around the prevalence of sleep problems or insomnia?

Colin: Generally speaking, we think of insomnia as a disorder, which is a difficulty initiating and maintaining sleep three or more nights per week for a minimum of six months as being an insomnia difficulty, and if you take that more rigid definition, then you're probably talking about somewhere between 8 and 10 percent of the population, or between, depends on the surveys, between 10 and 12 percent of the population has an insomnia disorder, and that the prevalence of insomnia increases with age, and tends to be a little bit higher in women than in men.

If you look at insomnia symptoms, then you're probably talking about 20 percent of the population has got chronic insomnia symptoms. So it's a very common difficulty.

Rachel: Yeah. And if we had those kinds of statistics in almost any other mental health presentation, we would be hearing about it even more probably in terms of our therapy. So it sounds, as you say, there's this, focus of attention isn't always on the sleep problems whilst it may be one of the big issues that our patients are presenting with.

Colin: Yes. We did a study with one of the IAPT services, in Buckinghamshire, I think it was, a number of years ago and CBT for insomnia was added to the standard care, and of course, there's a control group and what we found in that is not only did you, could you treat the insomnia symptoms in these people attending IAPT, but their remission rates of depression improved by somewhere around five or 6 percent, depression remission improved when you actively treated the insomnia. So insomnia intervention is not just to address sleep difficulties, it's to address difficulties that present in terms of mental health, emotion regulation, but also in terms of other outcomes important to people like, workplace productivity, things like that are very important to people as well in terms of their functioning.

Rachel: And so regular listeners to this podcast will know we often have a, a particular challenge for our guests. We love a good formulation in CBT but being a podcast, it's an audio medium and you can't have boxes and arrows and diagrams on this medium. And I guess what I'm hearing from you is that this is a broad range of problems and problem presentations we're talking about, not one particular problem presentation; it might be different for different people. Is it possible to have an explanation about how insomnia develops and is maintained?

Colin: it's the same for kind of every disorder, really, and people use different models of thinking, the five Ps model or other things to understand that these are generic models that have been used in medicine, as well as psychology and adopted pretty much that one is, you're going to be more predisposed to have a difficulty and maybe various factors that lead to predisposition. There could be genetic factors, predisposition, factors in terms of early experiences, adverse, life events, some people constitutionally are very hyper aroused relative to others. So there might be some people who have got a predisposition to find it difficult to downregulate arousal, to establish patterns in their behaviour.

And then of course, we're familiar with the acute exacerbation of symptoms during a second P- the precipitating phase when something is triggered and that's usually the point at which somebody would become symptomatic or syndromatic and might seek help and that may be more of an acute episode. And obviously the extent to which that event is going to express itself depends also on the degree of protective factors the individual may have against something causing difficulties.

But what we're often doing with cognitive behavioural therapeutics is that we're addressing the other P, the perpetuating factors, the things that are keeping it going. We often think of as secondary factors. They're not secondary in terms of importance, but they're secondary in relation to, they're the things that drive the vicious cycle of the difficulty, as the person tries to resolve the problem and one thinks of that in terms of anxiety disorders, perpetuating factors might be avoiding the situation, for example, safety behaviours or things like that may come into it. So for insomnia, it's the same types of things, if you like, and this is one of the reasons why people should not be afraid to venture into exploring sleep difficulties with their clients and their patients, because you've got the core skills associated with evaluating a problem. We're looking at, how did this problem, there must be a way that this problem makes complete sense. Why is it logical as a person to have an insomnia difficulty just now? And then you explore the formulation using that kind of three, four, five-piece model, like you're doing at the moment with other problems and often it can be the same kinds of predispositional factors, precipitating factors, perpetuating factors that are maintaining the insomnia as are maintaining other difficulties.

Rachel: What would be some of the sort of major maintenance factors that you see with these kind of sleep difficulties?

Colin: Well, well, I think one of the things that's particularly important with insomnia is that the active attempts to solve the problem are often making the problem much, much, much worse. I wrote some model on this a number of years ago called the Attention Intention Effort Pathway. And we know from a lot of research done over many decades, that the purpose of human attention, selective attention is action. That's why you pay attention to something, to act on it. And therefore when someone reaches a threshold of threat and is causing us concern, we act on it. We want to do something about it. But this is also a little bit of an amber flashing light for insomnia because just be careful what you're doing here because you could be making the situation much worse. You can't get in the driving seat of your sleep. Sleep operates a fully automatic vehicle, there's no manual gears, right? You can't drive it, you can't decide to sleep, you can't decide, you can decide to waken up, you can set an alarm, but you can't set an alarm to fall asleep. It's really about getting things into a pattern. So I think, one of the key maintaining factors, perpetuating factors is intentional behaviour and active efforts to control and manage the sleep process. Now this is true for other difficulties as well, but I think that's one of the crucial ones here.

Rachel: what kind of things do people do to try and intentionally control their sleep that gets in the way of that automatic process?

Colin: Well, they get involved in self-monitoring, thinking about “I think I feel sleepy now, I feel sleepy now, I better get to bed, or what if I don’t feel sleepy, I’m not sleepy anymore...” so their heightened sense of awareness then they need recipes. They approach things like a recipe. They say, “what should I do?” And they read something out some guru's written or they try some device, or they try something they hope it works. Then they think it works, then they think it doesn't work, and then they think it's useless. Then they try something else. They cast it around, feel desperate. They're always looking for solutions. Whereas the good sleeper, falls asleep almost accidentally, they fall asleep in the context of trying to stay awake, pretty much, they abandon wakefulness. And this is why a lot of the behavioural therapeutics, like sleep restriction therapy, which is a way of reducing the amount of time you spend in bed in order to drive up the homeostatic pressure for sleep, so it's a struggle to remain awake, helps you to recognise again that sleep is something you abandon yourself to, it's not something you engage yourself in.

Rachel: Yeah. So I'm hearing you say that a lot of the same precipitating, predisposing factors exist for insomnia as for any mental health presentation including things like anxiety. But the perpetuating factors, similar to other problems, are those things people try desperately to do to fix the problem. In this case, it might be very much attention focused on sleep, and then doing whatever they can to try and make something come under their control. It's actually this automated process and that be the things they're doing to try and get to sleep become a problem in themselves.

Colin Yes. I mean, there are several pathways to go down in, in your formulation with the individual and things to consider. And I've explained a lot of this recently in a book that's coming out shortly. I'm trying to un offload, I suppose a lot of my experience over the years and how best to manage insomnia, not using CBT as a thing, but using the therapeutics within it in a thoughtful way to apply them to the barriers and obstacles that this particular individual is facing.

So it could be, for example, the difficulty the individual have is that they struggle to down-regulate their arousal level so we can address it that way. And one can look at relaxation therapeutics for that. And there are a whole variety of different ones, that one can use there. Another approach may be that the difficult they're having is with sort of mental events, at some level their mind is preoccupied in racing, but there's five or six different cognitive therapeutic techniques that can be effective there. So I think once what one is doing with the formulation approach is moving into what's the domain of interest and then what is the technique that’s most likely to chime or address the nature of the presenting material, thoughts and emotions that the person's having in bed at night. And then, of course, the other piece is the kind of more behavioural domain, which is really based upon stimulus control theory, and the use of sleep homeostatic and sleep circadian functions to drive sleep back into its correct position. And those are actually the most effective techniques of all of them. And often people, at the time they see me or other people who see people with sort of chronic sleep difficulties, by the time they come along, they've often had a sleep problem for a long time, years and years. And their sleep pattern, well, you say, what's your sleep pattern? And they say “what pattern?” so you immediately see that it's a sleep pattern problem, but we tend to calculate something called sleep efficiency, which is very simply how long would you spend in bed on the average night? And how much of that time do you think you're asleep? And you get a figure that you can convert into percentage.

So, if somebody says “well, I spend about eight hours in bed, but I'm only sleepy about six”. Then say, well, that's you, so your sleep efficiency is 75%. And one can use simple tools like this which probably we don't have time to go into them all, but you can use them to then say, well, that would suggest this technique is a very effective therapy for that and it's called sleep compression therapy or sleep restriction therapy or stimulus control or we would often use as you, as we all do, more metaphors. Metaphors for explaining things to people in simple language like trying to get your sleep pattern into proper shape or let's try to put the day to rest, if you use a cognitive control technique and so on.

Rachel: And this might be where we're sort of encouraging people to stay up longer to try and sort of organize their sleep into a shorter, more efficient window of time.

Colin: Yes, that's right. It's a bit of like a reset button you're pressing to see that it can be a struggle to fall asleep and the struggle to waken up and that you feel sleepy again. And that the patient again differentiates between sleepiness and tiredness. And thinks, oh, I do feel sleepy and allow the sleep drive then to dominate and dictate your sleep pattern, rather than you trying to steer it. But these are techniques that we need to learn. There are some important differences, I think, here between some of the things that we use in general psychological practice to manage many conditions with exposure therapies, for example, EMDR is an exposure therapy, is desensitization kind of approach. These are kind of generic things I would say, as there are a lot of relaxation therapeutics and cognitive techniques, but the ones that we use, that are most powerful for insomnia in the behavioural domain, like sleep restriction therapy, sleep compression symbols, control therapy are things that one really needs a little bit of help with learning and training. And they're also rather counterintuitive. There's also a technique in the cognitive domain called Paradoxical Intention, which comes from the work of Viktor Frankl prescribing the symptom, kind of thing, where you encourage people to try to remain awake rather than to try to fall asleep, and to overcome the performance drive to try to get to sleep, and to realise, begin to realise that sleep is an involuntary process. So Paradoxical Intention Therapy can be one of the cognitive therapeutics that one might select depending upon the formulation you come to around a particular individual. And of course, some people find it difficult to get to sleep and some people find it difficult to get back to sleep and some people awaken early. So, you need to take account too of the circumstances, the timing of things and what you could suggest to try.

Rachel: so I'm hearing what you're saying, the reason why you're so keen on this term, cognitive behavioural therapeutics. It sounds to me and correct me if I'm wrong that it's about being first of all, formulation and problem presentation led for the individual. And it's about matching the intervention to the presentation and the particular maintenance factors, which may be very diverse. When we think about CBT for sleep, it's not one thing. It may be very much focusing on a behavioural domain. It may be focusing much more in a cognitive domain, and it may very much vary even within those domains, depending on the particular pattern of sleep problem that the individual has.

Colin: Yes, if one draws a parallel, with pharmaceuticals just for a moment, a lot of the drugs that we have that we use for common mental health conditions, are actually quite similar to each other. But they've got different names. They’ve got different sites of action. They've got different uptake rates, different dynamics and kinetics and so on, but there's a number of different SSRIs, for example, and when a patient goes along to see a medical doctor and they're prescribed an antidepressant, they're prescribed a particular drug. And that may be changed to a different drug, and it is a different drug, and of course the dosing regime may change as well. And these are all different therapeutics and therapeutic options, and we're familiar of thinking of that there's a formulary of drugs and there are formulary of hypnotic drugs, sleeping pills, Z drugs, different kinds of Z drugs, and recent drugs that have come out, which are dual receptor agonists, But we see there's all these different drugs, but actually these drugs are kind of similar to each other. And then there's CBT. So you've got all these different things, and then there's CBT, or there's evidence based psychological therapy. We need to begin to see that CBT is not a thing. That CBT is got an and in it. It's cognitive and behavioural therapeutics. And within that, there are scores and scores of different techniques. So, it really should not be CBT versus mindfulness or CBT versus EMDR or behavioural activation versus CBT, because behavioural activation is part of CBT. Mindfulness is part of CBT. EMDR is part of CBT and CBT doesn't exist. CBT is just a family name.

Rachel: I think we may have to rethink the podcast, Colin,

Colin: well, I don't know. I think you

Rachel: maybe the podcast shouldn't exist….

Colin: Well not at all. I think the podcast should exist, it’s just really about celebrating the diversity of things and I think it's just to do with the way that therapies have emerged over time. We had behavioural therapies, but there were different ones of those, and then cognitive behavioural therapies, cognitive therapies, so we ended up with multi component therapies, and then the term CBT was invented.

We're early days, right, in this journey, but I think a range of therapeutic options and how to deliver them, will take us away from this technocrat approach of, well I just deliver CBT, this is what I do, to thinking what is it we're doing, for whom, and how, and what does, and to what, against what outcome and it will really simplify, I think, a lot of our treatment journeys, and will encourage patients to understand and believe that they haven't, when they say they've tried CBT and it didn't work, that actually you can begin to adjust the interventions and refine them and select from them in such a way that we create a much greater diversity of therapeutic pathways for individuals.

Rachel: you've mentioned that CBT for insomnia is recommended in NICE guidance and across the world in, in, in guidance that therapists draw on suggests that. It's effective, but it also, you've also said that there are different elements to this. What are the most effective elements of CBT for sleep problems? Will it help everyone? Does it help everyone equally if we're thinking about diverse groups and populations?

Colin: The most effective components within CBT, and where I would tend to go initially are something called stimulus control therapy, and sleep restriction therapy which are behavioural therapeutics. These are the most powerful techniques according to the outcome studies. There are also a range of cognitive therapeutic techniques that can be helpful, one of those I mentioned is paradoxical intention. Cognitive restructuring approaches can be helpful as well for some people and the crossover between the cognitive and the behavioural is something called cognitive control. It's really a cognitive form of stimulus control. If you think about, worry time, for example, that people will be familiar with, that's a behavioural technique, really, but what you're doing is setting aside a time to worry, so you're not reacting to each worry as it occurs.

And in cognitive control with insomnia, what you're doing is telling the person put the day to rest before they go to bed at night. So all these techniques can be effective. Relaxation type, techniques can also be quite effective. And there's a whole range of those ranging from progressive muscle relaxation to autogenic training, biofeedback approaches. They're probably a bit less effective than the cognitive ones, and a bit less effective again than the behavioural ones but the relaxation approaches in general tend to be more associated with lifestyle and philosophy of life so therefore, there's other different kinds of benefits from those. And mindfulness, I guess and ACT can fit a bit between cognitive and relaxation. And there's an emerging evidence base for mindfulness and ACT techniques as well, perhaps particularly for people who don't respond to the more active techniques, where it then becomes a case of more accepting and living with the situation rather than trying to resolve it.

So these are the kind of range of techniques that are out there, and that are evidence based. But as I was saying earlier on, I think it's very often a case of helping people move away from just the kind of simple it's all in the mind kind of approach. Because often when you go for therapy, it may seem that, well, you're just encouraged me to relax. You should relax a bit more. Stop thinking about it so much, or get things into pattern, or stop worrying, or face up to it or think more positively. A lot of psychological therapy, unless it's delivered well, can be very trite. So therefore, I encourage everyone listening to develop their therapeutic skills at the level of helping people to engage with tough stuff. Because the power of cognitive behavioural therapeutics is not just in the techniques themselves. It's in the motivational system enabling people to implement things in their life that are actually quite difficult to do, to face up to things that are very difficult, to deal with them differently when they've not been successful in doing that before, and to stick at something that you don't really believe will work or they don't think that they deserve to be helped. These are really where therapy can be transformative, and it's not because you're a great therapist in the sense of, you'll be warm and kind. It's really to do, in some ways, with you being supportive of the person implementing things. Because implementing things is the key to all therapeutics.

Rachel: And I imagine, particularly in some of these interventions when, for example, you're asking people to get out of bed when they've not been asleep for 15 minutes, or you're asking them to stay up way beyond they would normally go to bed. These are things that are quite difficult to shift or, you know, I think of myself lying awake in bed at night and the last thing I want to do is drag myself out of bed.

Colin: They're very difficult, they're very difficult to do, and I say to patients, I wouldn't do it. What? They say- well it's difficult, isn't it? I've tried that. I'm asking you to get up, go to bed at this time, get up at that time, or get up during the night. And it's hard. It's going to be very hard to do that. But many patients would say to you with a whatever difficulty they have that, if there was a surgical procedure that would fix this, I would take it. I would do it. I would do anything to overcome this problem. And I think sometimes we just need to be straight with them and say, therapy can be as hard as that. It can be as hard as that but the evidence is that it can be effective. And there's some aspects of restructuring, the way you're thinking or restructuring your pattern of sleep at night that is quite invasive. It’s stripping out an old way of doing things, an old way of thinking, establishing a new one with a lot of disciplines involved, often not for an immediate gain, but then that's why people do surgery, right? They think, well, I trust the outcomes, trust the science and present things openly and plainly to people and say, I'm going to support you to do this difficult thing. And then they begin to say, okay, see the sleep hygiene stuff I read, or this is different.

Rachel: And ofcourse with surgery they get an anaesthetic, so they get a good sleep. So, you know,

Colin: well, exactly.

Rachel: maybe a secondary motive there,

Colin: Yeah, there might be.

Rachel: but given that challenge that your patients face, you know, when you're, I love that honesty- I wouldn't do it. What have you learned from the people you've worked with? How has this work made a personal difference in your life or the focus of your work as you've been working with people over the years with these kinds of problems?

Colin: No, that's a good question. I guess that's why we do it, to some level to try and make a difference.

The thing that comes to mind to, to share here is actually about someone who came along and took part in one of our research studies, a woman with cancer. And it's a study we did in the Beatson Oncology Centre in Glasgow, many years ago, early, well, the study was published, I think, in 2008, and we were looking at nurse delivered cognitive and behavioural therapy for insomnia as an adjunct to cancer care. And that tells you something immediately that even in situations where you think, well, we know what the problem is, why are we focusing on insomnia, that insomnia really matters?

Now, I got a phone call, one day from the professor of oncology, who was a co-investigator in the CRUK grant, and he said, “Colin, I had to phone you, I've just seen one of the patients in the trial, coming along clinically and she's not very well.” And I said, “Oh, right. Do you think she shouldn't be participating in the trial? Or is there, are you concerned about, you want to withdraw her from the study?” no he said, I've never had a conversation like this in my life. And I said, what happened? And he said, she told me that your CBT for insomnia knocks my chemotherapy into a cocked hat and I said “what do you think she meant by that?” He said “I have no idea, but I mean, she's, this woman's got cancer. She needs her chemotherapy.” And I said, “Jim, I think she's telling you that her sleep really matters to her and that she's grateful that we're addressing that. We're not just focusing on what seems to be a primary illness or model.”

“Well”, he said, “I think that might be right”. That woman had to withdraw from the study a bit later, and she phoned and left a message on the answer machine, apologising for dying, really, apologising that she wasn't going to be able to finish the study because it meant so much to her.

And we say to our patients or students, we're teaching them that intermittent reinforcement is very powerful, and I think what's kept me going over the years is intermittent reinforcement; a lot of working life is hard, not all of it is exciting. We don't go down the corridors of the university or the hospital high fiving people about our successes and it's a lot that's tough. And sometimes we don't know. A lot of people never come back. They don't fill in the outcome measures. They say they got better, and we don't know why. We don't always know what's going on. Once in a while, you get something that's a very powerful, a reinforcement. I think in a way, the triggering factor for me at the beginning with the GP saying that curiosity led me to think, I don't know if I can help. I tried to find out, was stimulating. And I think these intermittent kind of bits of feedback that we get encourage us. Don't they, that, yeah, this was a good choice.

Rachel: What a beautiful story and how incredible that  in those dark times, undoubtedly dark times, dying from cancer can be no fun for anyone, that there was some light in there and hearing that it was focusing on the thing that really mattered.

Colin: yes, that's right. And so I think whatever you're working, if people are listening, whatever you're doing with older adults, with kids, with people in health and mental health settings, community hospitals, or whatever, sleep is going to be relevant to your work and you can broaden the base of what you're doing by taking a greater interest in people's 24 hour lives, not just their waking lives.

Rachel: And if people want to learn more about your work, about this work, I mean, it's such a huge area, Colin, we could talk on and on, and I know you need to go. But if people want to learn more, what training opportunities, how can they get involved in this work and your research and where can they go to learn more?

Colin: Well at Oxford, in this particular week is a residential week, for our program in sleep medicine. we've got people from all over the world here, from America, Canada, India, Jamaica, Australia, various European countries, South America and they're studying with us as part of an online program in sleep medicine. And you can do that as a course, as a diploma, you can do it as a master's degree, or you can take modules from it and it's all online, but they do get a chance to come in the summertime for a week and spend some time with us. So that's one thing that I’ve been interested in trying to establish things that are kind of scalable, if that makes sense.

I do workshops and so on BABCP and other workshops are available. I try and pass on skills. I wrote a self-help book a number of years ago in the Overcoming Insomnia Series, a second edition come out 2021. There's a book coming out this month. The Clinicians Guides to Cognitive and Behavioural Therapeutics for Insomnia: a scientist practitioner approach. Often you get books, don't you, that you think are going to tell me how to do this. So I vowed I'm not going to write a book like this unless it actually tells people how to do things. So, it's my distilled knowledge of how to assess and treat people with insomnia. And that's published by Cambridge University Press, which should be out later this month.

Rachel: we'll put a link to that in the show notes, as well as the self-help other papers that you can recommend.

Colin: And the, and the other piece is you meant, you were kind enough to mention Sleepio earlier on. I get involved in developing a kind of digital approach to treating insomnia. And Sleepio was given a Nice guideline in May, 2022. It's available in the NHS in Scotland and I hope shortly will be England at no cost. It's just part of a funded healthcare package. So, and that can integrate into services. I'm very much a believer in a kind of step care approach and that we should have a range of different ways of doing things with different levels of expertise and skill there. But if we've got a situation as we have that the treatment of choice for insomnia is cognitive and behavioural therapy. We've got a responsibility somehow to make it available to everybody and so hopefully some of these tools or ways of just closing the gap that there's been historically there.

Rachel: That's wonderful. And it is brilliant that you're doing all this work just to get that out there to the people who need it. And thank you for doing today and allowing our listeners to benefit from hearing about the work, a broad area but some really good ideas and thoughts in there for people to take away In true CBT fashion, we like to summarise and think about what we're taking away from each session. So what key message would you like to leave people from this work? If they were to go home and talk to, folk about what they've done in, in, in the podcast today, what would be that couple of sentences that they would bring home from this

Colin: Well, I think, just, your, believe your Gran was right. She always said what you need is a good sleep. Sleep on it. Things will feel different in the morning. Sleep is nature's medicine. It's there to provide for us, for all of us, so we can do our best work and so that our patients can have the best quality of life. So I just encourage people to steadily improve your skills in helping people with their sleep difficulties. It's often a question you don't want to ask because you don't know the answer. So is it, how are you sleeping kind of thing? Because you don't, I don't quite know what I'm going to suggest next. I was curious enough to find out and to figure out ways of it's become really interesting to me. If a little bit of that passes on to a few people on the podcast, then I'll be delighted.

Rachel: And there'll be a lot more in their toolbox and just a little bit of sleep hygiene, if they pursue this plus they're also allowed the occasional malt whiskey which is good news.

Colin: And many brands are available.

Rachel: Thank you so much, Colin.

Colin: Pleasure. Thanks, Rachel.

Rachel:  Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected]

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