Sleep Series E2 | The Psychology of Insomnia (w/ Heather Darwall-Smith)

Heather Darwall-Smith is a UKCP Registered and Accredited Psychotherapist, specialising in CBT for insomnia and psychotherapy for sleep. She is the author of How To Be Awake (So You Can Sleep Through the Night), The Science of Sleep and The ADHD Sleep Book. She has been featured on The Guardian, BBC and Forbes. 

You can find out more about Heather here https://www.heatherdarwallsmith.com/.

This episode explores how Heather works with people who have tried everything for their sleep problems and what we can do during our waking life to improve our sleep.

Interviewed by Dr. Anya Borissova with Dr. Rosy Blunstone. Dr. Borissova is an academic psychiatry registrar at the South London and Maudsley Trust. Dr. Blunstone is a psychiatry and psychotherapy registrar in London. 

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Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line. 

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Transcript

Heather D-S 

I'll often use the analogy of a bottle of fizzy drink that we get up in the morning and it's like you shake, you wake up, the first shake of the bottle. So cortisol's high, body pressure's starting and all the way through the day we shake that bottle. If the only time... The first time we open that bottle is when our head hits the pillow. That's come complete carnage. This is insomnia, of course. This is going to hit at 3am in the morning. So the question is, how do you open the bottle all the way through the day? And it's bringing the awareness to that. It's amazing because we don't live in a world where that's considered normal. 

Anya TMP 

Hello, everyone. Welcome back to the Thinking Mind podcast. My name is Anya and I'm a psychiatry registrar working in South London. And today I'm joined by Rosie Blundstone, who's also a psychiatry registrar and psychotherapy trainee working in North London. We're thrilled to be joined by Heather Darwall-Smith today. Heather Darwall-Smith is a UKCP accredited psychotherapist and sleep specialist who works with individuals with ADHD and sleep disorders. bridging the gap between mental health and sleep medicine. Heather is the author of two books, which we will link to if you'd like to read. For now, sit back, relax, and enjoy this latest in our sleep series. Heather, thank you so much for joining us today. 

Heather D-S 

Thank you so much for inviting me on. I'm delighted to be here. 

Anya TMP 

So I'm super excited for our conversation today. You've got a couple of books out on sleep already and some projects on the way as well. And I hope that we can cover the thoughts that you have and the work that you do in this area to hopefully bring some practical ideas to people, but also have a bit of a reflection on the issues that we have with sleep in our society more broadly. And I guess to begin, I'm really curious about your journey because looking at the biography that you have on your website, it sounds like it has been a bit of a journey to finding your interest in sleep. And I wonder if you could speak to us about What brought you to be as interested in sleeping as you are and do the work that you do? 

Heather D-S 

Gosh, that's a big question because I don't have a typical background in this area, I suppose. So originally, my first career, I worked in advertising. I was an art director, so completely non-science background. But over the years, I knew a very long, long time ago that I wanted to retrain as a psychotherapist. And at the same time, when I started training, I trained as a massage therapist and did quite an in-depth anatomy and physiology training. And I had a real light bulb moment when somebody explained how the stress response worked. And it was one of those sort of moments in time Like, oh my goodness, that's how panic works. And that's how this stuff happens. Because when I worked in advertising, I had a period where I was having quite severe panic attacks and problems with my sleep and things. And suddenly it was like turning a key. It's like, oh, this is very logical to me. Of course I couldn't sleep. And it was a real light bulb moment very, very early in my psychotherapy training. And then over time, with psychotherapy, it takes five or six years to train. And over time, what became an interest became something that I was really curious about, because as a psychotherapist, I was wondering if somebody has sleep issues, what is the nature of therapy? Because we are so changed when we can't sleep. And that goes for the therapist too. So it really clarified, yes, this is the path I want to go on. And it's a little bit different as a psychotherapist to specialize in this way, but it just seemed from a relational perspective, if somebody is in therapy, and we're not thinking about what's happening with their sleep, well, what are we doing? And so it's an interesting line to walk because I'm not here to treat, I don't treat people, I work with what's coming up. But obviously I do screen for sleep issues because there's so many different ones. So it's been a really wiggly path to get to this point that started off as a very personal interest and then over the years has become, this is what I do. And when I qualified, I then worked in a sleep clinic. I've studied sleep medicine and it's an ongoing obsession, I would say, because it's endlessly fascinating. 

Anya TMP 

I think Rosie and I can definitely recognise that feeling of the sort of endless fascination and the, you know, when you start to scratch the surface, how much comes out with it. And I'm interested in one part that you said in terms of the, how changed we are by sleep. And I wonder if you could expand on that a bit more. 

Heather D-S 

It's at many levels because it's so, we can't necessarily measure, we do know that sleep deprivation has impacts and I'm always really mindful because I don't like to talk about the negative parts of of sleep because there's so much fear out there and of course fear is a huge driver. But we do know things like we are changed physiologically from a hunger and appetite perspective, sleep deprivation will invert our hunger hormones. If we don't get enough REM sleep, the sleep in the second-half of the night, we know that our ability to regulate our emotions the next day are going to be somewhat wobbly. We might have issues with anger and We go through a whole day and we don't quite know what's going on. It's like, oh, well, actually I didn't, there was a period of sleep I didn't get. And it's so nuanced. It shows up in so many different ways that it's difficult to pinpoint that. But it's also difficult to say, well, what's the difference? How do you know, okay, consistently you've got enough sleep. How do you know that that means that mentally you are? as you would like to be. So it's a very it's a tricky question, but we know for sure that not getting enough sleep does change us. It affects our learning and memory. It affects everything. So it's yeah, it does go on. 

Anya TMP 

So it's interesting that you say how, you know, how much it can change so much about us and also your focus on bringing a more relaxed attitude to sleep. I don't know if that's quite right to say, but it felt like one of the themes of your book was around taking away some of the stress and fear that can get associated with sleep. I wonder if that is something that you find really important in your practice and sort of why that is, if so. 

Heather D-S 

I think it sort of came out of when I was working in the sleep clinic that I've started to notice, certainly with a lot of insomnia patients, perfectionism is quite the bed partner, I would say, to insomnia. And it's probably one of the most common things I see, this idea that someone needs to perfect their sleep. And there is a very well-known book in the sleep world that a lot of people have read and I really like that particular book. I think he did a great job talking about Matthew Walker's book. But I do see clients who are really frightened. And also the media too will often talk about dire consequences if you can't sleep. So it is probably one of the most common things I've seen over the years is the fear factor. But of course, the more frightened we are, the worse sleep is. And if we're then holding ourselves to standards that aren't necessarily correct for us as an individual because sleep is so varied, this idea that we've got to get this thing right becomes really, really problematic. So I really, really take the approach that sleep very much responds to how we spend our days. And it's almost like the more you chase it, the worse it's going to get. So I try to encourage specifically insomnia clients to sort of understand that relationship. What are they trying to do in trying to get this thing right? Because the harder you try, the worse it gets. Because also, how do you know that you've got it right? So that whole piece is very, very difficult for some people. Because it's also, when I say about the perfectionist element of it, These are people who could be very, very successful at what they do. And that drive, that perfectionism that makes you really good and really accomplished at something, it's like, well, at what point do you switch it off so that you can go to sleep at night? If it's applied to absolutely everything, it can become really difficult. So that's why I try to encourage people to step away. I call it let go of worshiping at the altar of sleep. We know how important sleep is, but we also know the more hung up we get on it, the worse it gets. 

Anya TMP 

How easy do you find it to change people's beliefs around the altar of worshipping sleep? 

Heather D-S 

I think I come at it from the perspective of asking someone, do you know how to let go? If we're talking about insomnia specifically, if you can't let go, I mean, sleep is about letting go. So it's coming at it from that perspective of, if you can't let go, how are you going to go to sleep? And it's a little bit softer because I don't, I'm careful about change because if someone's beliefs are their beliefs, but sometimes you just need that sort of gentle reminder, we're not machines. At what point do you stop and go, that's enough and it's time to rest. Because I mean, we live in a world where we're all going really, really fast all the time. And sometimes we just have to say, right, I need to stop now. I need to rest. 

Anya TMP 

I think you point to sort of the individual level at which difficulties with sleep can operate and also the broader social level, which I hope we'll come to discuss in a bit more detail. But before we come to that, I guess thinking a bit more about the individual level, I mean, I think Rosie and I are both really curious Could you take us through a bit of what your clinical approach would be like if someone's coming to see you in clinic? 

Heather D-S 

Well, typically, I get a lot of my clients do come through referral from other health professionals, and they tend to be people who have gone through, they might have gone through CBTI multiple times in cognitive behavioral therapy for insomnia. The people I see tend to have tried all sorts. So by the time they know a lot about what works for them, what doesn't work for them. So the starting point is often understanding. So, okay, what have you tried? There's often a very strong theme. And as I'm speaking, I'm thinking there's a very strong theme, a belief of you can't fix this. And well, it's I'm not here to fix, but I'm here to try and sort of see, well, What are we doing? What else could we do? And why? do you think that it won't work? So the initial piece is often unpicking a lot of what's been going on in a very, very fixed mindset of this can't work. And yeah, it is definitely the case. Sometimes we're successful and sometimes it's not. I'm very honest. I don't make any promises as to I have some magical way of doing this. But I think that that relationship that builds up, and I think that's the nature of psychotherapy too, that it's a sort of layered approach as to how have we got here? Because in doing that, what I'm then starting to bring is looking at the biopsychosocial. So they've come in very much from this angle of I'm trying to target my sleep and I've done all of this, but actually what I'm looking at is the whole picture So what are your relationships in life? What's your work situation? And looking at that, and it's a very sort of layered approach. We might sit and map out together on a big, big piece of paper, what does that all look like? And that can be really interesting, because when we stand back and look at that whole world, we're not then specifically sitting there and talking about someone's sleep. We're sort of widening right out and going, well, what is everything here? It is not uncommon at that point where other issues will come to the fore. We might find that the sleep issue is happening because of X, Y, and Z. It might be that there's a lot of chronic trauma. There might be addiction. There might be relational issues. There might be chronic pain. It expands outwards and doesn't necessarily become about the sleep anymore. Yes, our aim is to improve sleep, but it is, I suppose I have the luxury of space and time to be able to explore that. So we come outwards, look at the whole picture, and then we come back down inwards. Okay, what are we going to do about sleep when we've now looked at all of this? So this sort of expansion contraction process that happens. 

Anya TMP 

And I mean, once someone comes to you and says, I've done all the CBT for insomnia stuff, that's no good. How, if you do then zoom back in on the sleep potentially once you've sort of understood the whole picture, how do you approach the sleep at that point? 

Heather D-S 

I will often come back to CBT-I principles because there may be a lot of chaos in there. So it's like first principle of, okay, can we target getting up at the same time every day? and relooking at do we really understand the biological principles that underlie sleep, why that's important, how we build sleepiness. But it might also be at that point that we've uncovered there's something else going on and we might need to involve other professionals because it's really, really not uncommon for other things to come into play like there might be sleep apnea in there, which hasn't been picked up. So if we've come out and we're going to now go back into the sleep issue, we've looked at, so let's look at something, I'm just thinking on the top of my head, looking at someone in particular and they'll be like, Well, you've done all these different things, but actually your living situation is such that The reason your sleep is not great is because your environment is really noisy. Is there anything we can do about that? It might be quite practical in that way. So in that way, we're looking at the practicalities of it and thinking about, well, what have you tried? What haven't you tried? What can we do about that? It might be that we're dealing with someone who's going through a hormonal change. And so then I might work alongside someone else is addressing the hormonal issues. And again, come back to CBTI principles applied to the hormonal process. And it's quite a long-term process because then we might be mapping medical change at the same time as behavioral change. It's really varied. It's quite difficult to get into, well, what would I do next? Because it's so varied. I mean, sometimes I can think of a couple of instances where Someone's become very frightened of sleep, and just the act of falling asleep has become terrifying. And so we're dealing with fear. And we're dealing with fear and panic, and how do we reduce that hyperarousal and panic attacks so that someone can even think about the idea of going to bed? Yeah, there's so many different things that can come up. 

Rosy TMP 

I was just going to ask, because you mentioned about having the privilege of time, and I think part of our underlying motive for this series is because Anu and I have discussed so many times about why we're not doing very much about people's sleep, but it seems to be this enormous problem all the time, all the time that we're not, we don't always seem to know what to do. And one of the things I was thinking about is just how complex it all is. And the fact of the matter is that for so much of the time, just even being able to drill down to those even seemingly very straightforward and practical interventions takes a real understanding of the person, their environment, the world in which they function, etc. And so I suppose what I'm getting at is there... Do you think part of the reason why we struggle so much sometimes to get to the bottom of sleep problems is because it's just so complex and the time is not on our side perhaps to really drill down into it? 

Heather D-S 

Definitely. I definitely think that's a big, big thing because it's a huge, there's over 80 different sleep disorders and they often come along with friends. There's multiple comorbidities in play. And I think the other issue can be, we live in a world where people are promised quick fixes. Or if you take magnesium, your sleep is magically going to repair. And some of this stuff can really, it's not a quick fix. It does take time and it does often take work too. And that can be really disheartening because if you've had a long-term serious sleep issue, to be told that you're going to have to work at it and actually there could well be nights where this is going to be difficult, but we're going to work through it and we're going to push through to the other side. That's really daunting when you might have a lot on your plate because that's not really what you want to hear. People want me to say, this is what we're going to do and this is going to fix your sleep. And it doesn't work like that. 

Anya TMP 

Some of the process, as I understand it, can involve sort of accepting worse sleep for a time or sort of doing things that maybe will feel counterintuitive, sort of accepting being more tired for a time in order to invest in potential future better quality sleep. But I imagine that that as well can be quite hard for people to get their heads around. 

Heather D-S 

Yes. And I laugh because if one of the things we do with insomnia is sleep restriction. So a very, very understandable way to try and solve a sleep problem is to spend more time in bed. But of course, when we do that, sleep tends to fragment and the brain sort of goes, oh, I'll sleep a bit over here and I'll sleep a bit over there. And sleep restriction is about trying to consolidate it into a smaller time period so that we improve the quality because we're always much more interested in quality than quantity. I would rather you got six hours of quality sleep than eight hours of rubbish sleep, for example. So if you're working with someone on a sleep restriction basis, it is very deliberately going to make you tired, which is really counterintuitive. So I will say to clients, this is a deliberate action because you have to be sleepy to go to sleep. And A big piece of the work is getting someone to understand why we're doing what we're doing before we go anywhere near doing it. And so they're really clear that they know the biological reason why we're doing sleep restriction. They understand that there are implications. You are going to be tired because we've got to think very seriously about living your life at the same time as doing that before we do it. It is true that, and I very often, they really don't like me, especially after the first week or two. It's like, I'm really tired, Heather, can I do? And I'm like, no, just bear with it. This process works. We know that it works. And when it does, it's the most effective thing we've got. It's more powerful than most sleep medications to get sleep reset. And it's uncomfortable, but when it works, happy days. But that is It is the truth because it is hard and is really counterintuitive. Why I'm tired? Why can't I go to bed? Well, are you tired or are you sleepy? These are different things. So these are the things that we've got to get in place. Tired, exhausted and sleepy are three very different things. If you're sleepy, you can go to sleep. If you're tired, well, that could be for lots of different reasons. So I'll often say to people, so sleepy, the body knows how to do it. And if you're going very fast on the motorway and you're sleepy, the body will take that sleep regardless. And that's the primary cause of drowsy driving. If we're sleep deprived and given the chance, the body will step in and take that sleep. So we know that that works. And that's what sleep restriction is based on, the knowledge that if we deliberately make you sleepy and we create a window from which you're going to go to bed at this particular time, same time every single day, we will get there. But it's just not comfortable. 

Anya TMP 

Out of interest, how long does it take or can it take? Sort of what are the ranges? 

Heather D-S 

Ranges, some people, I've seen people turn this around very fast because sometimes cognitively the understanding of what it is we're trying to do just makes sense and Just that shift shifts it. So I've seen it turn around in three or four days, but I would say that is based on a cognitive understanding of the process rather than the physiological understanding of it. But it can take three, four, 5, six weeks. I mean, it's a process. So I never, ever give a time frame because I just don't know. I know what the literature says, but I also know that individuals, it differs. And also, of course, the longer it takes, it's harder to stick to. So then we might be in the territory of not necessarily working with we're on a sleep restriction basis. We're looking at what's going on that means you can't stick to it. What are the behavioural aspects that are coming in? Or what are the lifestyle aspects that mean you can't do this? There's lots of reasons for why it's hard, not just discomfort. 

Anya TMP 

Something else that you've mentioned today and you talk about in your book is the attention that you pay to what's happening in the daytime and it feels like sort of a tuning of attention away from sleep and actually changing the focus up a bit. Why is that so important, do you think? 

Heather D-S 

One of the things I'll do is map out what 24 hours in someone's life looks like. And if we think about how the circadian rhythm works and the biology that sits under it, so we know when we wake up that cortisol is rising to push us towards wakefulness. But of course, if we are already, if there's a long-term sleep problem in play, it may be that someone's already waking up stressed. So we've got the cortisol rise happening and we've got the stress level rising. And then we've got someone who the moment they get going, it's like, let's go. So we might be looking at, right, well, what is going on from the moment you wake up? If at that beginning of the day, stress is already high and now we're gonna go, it's going higher, life, caffeine, all sorts of reasons. And that's how we then continue to go all day long and what we're doing to manage the fact that at that point we are super stressed and how are we going to keep going all the way through the day? Of course, there's a whole cascade of behavioural things that are in play that are going to keep us at that heightened hyper arousal point. So of course, By the time bedtime comes, you may not have had a break, you may not have hydrated, you may not have eaten well, you may have been over-caffeinated, you may be super stressed, and then your head hits the pillow and your brain goes, right, now I'm gonna throw everything at you that you haven't had time to deal with all day and we're gonna deal with it now. Well, this is like worst case scenario. We're not gonna sleep in this state, are we? So we've just gotta pull each of those fragments apart and go, what are we doing here? to try to offload it all and down regulate before we get anywhere near the bed. Because if we create the conditions and bring everything down, the body knows how to do it. We haven't evolved out of needing sleep. A third of our lives are spent sleeping. So our body does know how to do it. We and life get in the way. So that's why I really look at from the moment we get up, what are we doing? Because we are, we can sometimes from right at the beginning, chase away sleep that night. 

Anya TMP 

And yeah, you talk about, I think something like sleep is, sleep being hardwired into our biology. So it sounds from what you're saying, like taking away some of the noise of life, daily life can be a more effective strategy than, well, a more effective strategy than taking a sleeping tablet, for instance. in terms of trying to address sleep. 

Heather D-S 

Well, it's bringing awareness to what are we doing. And I'll often use the analogy of a bottle of fizzy drink that we get up in the morning and it's like you shake, you wake up and it's the first shake of the bottle. So cortisol's high, body pressure's starting, and all the way through the day, we shake that bottle. If the only time, the first time we open that bottle is when our head hits the pillow, That's complete carnage, or it's gonna hit, this is insomnia, of course, this is going to hit at 3am in the morning. That's when the pressure's gonna go, that sort of classic midway through the night waking, because that's the best relationship that sleep has with stress. It's gonna wake you up at that point. So the question is, how do you open the bottle all the way through the day? And it's bringing the awareness to that. And it's amazing that people just Because we don't live in a world where that's considered normal. We live in a world where you get up and you get on with it, you get going. So it's constantly how do we pace ourselves so that by the time we get to bed, we're not going to blow the bottle up? 

Anya TMP 

It's really hard though, right? Like, as you say, we don't live in a world that really acknowledges the need to stop, pause during the day. I mean, I guess speaking fairly specifically about places like the UK, different parts of the world may have different approaches, but even having a proper lunch break, I think in some workplaces is certainly not actively encouraged. And I imagine in some places is perhaps even looked down on. I mean, how does an individual sort of rise up to that, do you think? 

Heather D-S 

That's really common. I mean, certainly if I'm working with people in the banking world, for example, or in the NHS, that long shifts where 12 hours non-stop is not uncommon. So there's often a question, well, how do, because If someone's reality, this is their reality, so how do we get into that reality? So it might be, okay, so you're gonna go to the loo, for example, we're going to do a breathing exercise when you go to the loo. It's building up how we sort of punctuate through time to get that rest. If all you can do is two minutes every hour, And that might be, I'm just gonna then stand and look out the window and breathe and stretch and have a glass of water. But if you do that many times a day, there is a cumulative effect to that because we have to be really real about what someone's life looks like. So we have to work with what have we got here and how are we gonna get at this? 

Anya TMP 

And I mean, what do you think more broadly about the fact that it can really feel like a bit of an act of resistance to to society as a whole, to take these breaks or to prioritize the time that one needs for sleep, even say, so turning down social plans or turning down extra work or, sort of kind of saying no to the non-stop go in order to create a life that is maybe more in line with time for rest. What do you think about the fact that that feels like just quite hard in the world that we live in? 

Heather D-S 

I'm careful with the answer to that. Okay. Because I often refer to insomnia as a hungry monster. And people with insomnia will often start to cancel stuff and to, I mean, they will, sleep becomes the most protected thing and their sleep routine becomes the most protected thing and they will start to cancel stuff. And of course, that feeds insomnia, that keeps it going. We have to starve it out. The more you give it, the more it will take, and it will just come back for more. But that is, I think, different to what you're asking in a societal perspective where we're taking the, as you say, a point of resistance and saying, actually, no, I need to prioritize my rest and recovery so that I'm okay. It's always important to just mention that when it comes to insomnia because It can be staggering how controlling this issue can become or the need to control can become and how it dominates someone's life. So there's a nuance to that. I'm very careful if that's what we're working with. That's a different conversation to saying, talking about how we how we take regular breaks and things. We might, if someone's really, really, really controlling everything, we've gotta work with that control. But yeah, we all need to put the brakes on sometimes, however we can. And that might look different for different people, but we're just not built to keep going all the time. It's not how bodies work. 

Anya TMP 

It's interesting that you bring that nuance and the... again, not one straight answer and not one answer sort of for one person brings me to again think about the point that kind of Rosie brings the amount of time that sort of teasing apart these problems might require and kind of the interaction that there is between sleep issues and our mental health. And I kind of brings me to think about again, how little time we can actually spend on it in psychiatry or in medicine a bit more generally. What do you think some of the solutions might be? Do you think that there is change in the air when it comes to how the health service thinks about sleep and prioritises sleep? What needs to be done? 

Heather D-S 

It's a tricky one for me to answer because I've never worked in the health service as a psychotherapist. That is not an option really in the NHS and certainly as a psychotherapist specialising in sleep. Unless I work purely in cognitive behavioural therapy for insomnia, the work that I do isn't really in that space. So I'm very mindful that I can't necessarily speak to that. But having worked in a private sleep clinic, I am acutely aware that there, and certainly during the pandemic, we saw it with the escalation in mental health issues. There isn't a luxury of time at that point. there may well be psychiatric crisis and that's when I'm very, very quick to refer on to colleagues because there are risk factors in play. If someone hasn't slept for five, six, seven days, that I'm not the person they'll be seeing. That's a very immediate, I can't, this isn't what I do. And then I'm not a medic, so I think there is absolutely a place then for medication because sometimes we need to break that cycle. Somebody needs to get some rest and it's too risky to let it go too far. So that's much more your territory than mine. That's when I'd be picking up the phone going, this person's coming in to see me and I can't see this person. I've got to refer on immediately because they haven't slept for five days. So it's a tricky one, isn't it? Because When there is no time, what do we do with that? And what do we do if there's different things in play? 

Anya TMP 

So that's a huge question, I think. One of the people that we've talked to for this series is Hugh Celsick, who's a psychiatrist who works in sleep medicine as well. And we've talked about medication and the role that they have. And sort of one of his views is medication is absolutely the right thing because people need sleep, you know, people, and it can have such a huge impact on every aspect of life that addressing it in whatever way you may have to address it is so crucial to getting people hopefully back to a good quality of life. So no, I think we're similarly, I think on the page that medication have their place, but it's, you know, it's frustrating how little access we do have to psychological options. And I think CBT for insomnia, we're hearing so much about how beneficial it can be for some people, and yet accessing it can be quite difficult. Although the caveat to that is there are some good sort of app and online programs that I think if people are sort of digitally literate and can work with they're probably a reasonable first place to start. But it feels really, it feels like such a battle at the moment to get that as part of someone's treatment package, you know, to get their sleep really addressed as a core part of their difficulty. 

Heather D-S 

There's many things of what you've just said. So going back to what we were just saying about medication, I'm very, very pro-medication because where it helps, it helps and can be essential. However, I will often work alongside prescribers when people are coming off medication, which can be a very long piece of work because I listen to the podcast that you did with Dr. Tarsik and really appreciate his work in this space because he is one of the leaders in this space. But so often we see people who've been on medication for a while and they then don't believe that they can sleep without it. So coming off medication can take a while, especially if someone's been on something for a very long time, which I have seen many times, or they're self-medicating and they just don't believe they can sleep without it. And then, of course, as someone tapers, there's always a risk of, if it's insomnia, rebound insomnia, so it's going to come back and it can come back with quite the vengeance. So that in itself is one of the hurdles we have here because I heard what he said on his podcast about how, yes, it's helpful, but it doesn't necessarily sort out the underlying reasons for why the insomnia came in the 1st place. So that is always a challenge because Quite often the answer is medication 'cause there's a, what else can we do? There isn't an access to something else. And it's a really tough one, isn't it? But I think it comes up in so many different areas. For example, I might work with someone who's starting chemotherapy treatment and they haven't, it's just by chance that they, They have come to me because obviously they see me privately. Somebody has told them, you're going to be going through chemotherapy. You might want to get some help with your sleep because we know that there's going to be an impact. The points at which sleep problems come up too, it's almost like it needs to be embedded everywhere because there's going to be points at which where it is normal that you're not going to be able to sleep well for a bit. So how do we support you through that? 

Rosy TMP 

I had a thought when we were talking before just about access to services and of course I think we make a very strong case around the importance of medication but I was also reflecting on that There's always seemingly this glaringly obvious adjunct for, I guess, psychotherapeutic input. And in the absence of being able to access a service such as yours, you make an incredible case for the importance of breath work. And you talk a lot about how breathing and like you've sort of spoken about letting the fizz out, but how these interventions can make a really big difference. just thinking about one, why don't we appreciate that more in our own sort of in our own lives and in our practice? And maybe if you could also just talk a little bit about sort of the answer of why that works. Why does breathwork have an effect that improves people's sleep? 

Heather D-S 

I think it's almost like it's like magic. It's really funny. It's one of those things going back to when I was training in anatomy and physiology. And someone said to me, the ancient yogis knew, you know, 'cause yoga is all about breathing. And they explained how when we breathe deeply, we access, the vagus nerve goes down through the diaphragm and that deep breath activates the parasympathetic, the rest and digest response. And it's the depth of the breath that gets gets that movement because when we're stressed, a lot of our breath is very high up in our chest and you can see people often, and I might have to say, remind someone, just remember to breathe for a moment because the breath is all up here. And we don't often breathe deeply. And of course, when we do that, we know that is a trigger. I mean, it's like this magical response. If we can breathe, really consciously and deeply for 10 minutes, it has this huge, huge response in the body because it's just activating the rest and digest response. It seems so alarmingly simple. I feel a little bit like, well, if it's that simple, what's going on? But of course, there's lots of reasons why it isn't, but just to stop and breathe every hour for a minute When I get clients to do it, they're like, this is really mad, Heather, because it really works. I know it's strange, isn't it? But it does. It's so powerful. Just stop and breathe. 

Rosy TMP 

And you say in your book, it sounds a bit too easy, but I think it's really worth sometimes emphasizing that some things really are too good to be true, or maybe that's the wrong expression, but like just because it feels easy doesn't mean it doesn't work. And maybe we don't need to make it so hard all the time. Maybe we can do the easy thing as well as, but I think it's worth just not scooching over that and thinking that, oh, wouldn't make an impact when it absolutely does. 

Heather D-S 

The other one that makes a huge impact is light exposure. And again, that was something during the pandemic that was really, really clear that people were not, because everyone was inside and they weren't getting enough light. We know, I mean, the work of Russell Foster at Oxford and his team and many chronobiologists around the world looking at the importance of light and getting light exposure at the right time. has a huge effect. I mean, it's one of the primary things that resets the sleep cycle. And yet we live in a world where if you get up in the morning, certainly now I'm very conscious here in the UK, in the Northern Hemisphere, it'll be dark in the morning. We get up in darkness, we go to work, we have low light exposure all day, we go home in the dark, and our brains need a certain amount of light exposure in the morning to help anchor the body clock. And light is also, again, one of those mad, free medicines that again, it seems really sort of really what 10 minutes outside in daylight can really help. Yeah, it can massively. It has a huge effect. So yeah, light and bright light and breathing are just like it's free and it's possible. But it's I say that lightly because I do also know There's a very real reason why people struggle to breathe well. There's a very real reason why people can't get a lot of the light exposure they need. And then of course, as someone's mental health goes down, these things become even harder, don't they? So when you're going down, these things that seem so simple just don't become simple anymore. 

Anya TMP 

One specific area that you talk about a little bit in your book, and I wonder if you, might shed more light on is, I guess, special specific circumstances where sleep can be particularly difficult. And this again kind of has relevance in my clinical work where we, I mean, I'm working in addictions at the moment, but we meet a lot of people with often sort of undiagnosed or unidentified neurodiversity. And I wonder if you could speak about why this is something that can be important in sleep. 

Heather D-S 

This is my passion really in many ways in my work. For me, or both areas, addiction to me often comes out of a way to try and manage someone's situation. And I'm always fascinated by what somebody's weapon of choice might be. because what is the need in there if someone is taking cocaine, for example, that does one thing for them versus if they're smoking weed. So it's really interesting to me as to why people use the tools that they use to cope. But from a neurodiverse perspective, of course, I think it's certainly in my own work, I think it's about 60% of my work is in the neurodiverse space. Especially if someone is undiagnosed and unmedicated, And I'm not saying that medication is for everyone because some people do well without it and some people do really well with it. But it's really logical, especially when it comes to sleep, that you're gonna try and manage because we know that biologically with neurodiversity, so for example, with ADHD, 75% of people with ADHD have delayed sleep phase disorder. And every one of us has got a body clock, all these clocks in every cell. And the circadian rhythm has this clock timing. And in theory, we live in a nine to five world, but actually our body clock is very different. I'm very happy to disclose that I have ADHD myself and I am a night owl. Don't talk to me at nine o'clock in the morning. So I work in the evening, but I can do that. But we all do have different timing. And in neurodiversity, this timing is even more pronounced. So the rates of sleep disorders in the neurodiverse population are really high. There's very high rates of, as I say, circadian rhythm disorders, so this timing issue. There are reported cases, certainly in the autism population. Most of us have a body clock, which is 24.2 hours long. You might have a longer clock, so you've got a 25-hour body clock, or I've seen someone one individual who I do have permission to mention that I have seen this individual who had a 27 hour clock. So of course, then you never, ever, ever fit in with a nine to five. So if you've got a delayed clock, you might not be sleepy till one in the morning, but you've got to get up for work at six in the morning. But biologically, you just aren't sleepy. So our work there is how do we move, firstly identify that that is happening and then how do we move that person's clock? And if you think that 75% of the ADHD population with this delay, then you put on top as teenagers where our melatonin signal can delay as well. So you've got a double hit. You've got someone who might have a night owl body clock and you've got that melatonin delay. So why do we expect the teenager to be able to go to sleep before midnight, one, two, three, 4am, and they still need 10, 11 hours sleep? When you look at it from that perspective, it's like, we have a problem. We've got a really, really big problem because they've got to get up to school or you might be at university, you've got to get up for lectures or you're starting work and you You are really struggling. It's really, really significant. So that's a big area. 

Anya TMP 

I mean, 75% is huge. 

Heather D-S 

Yeah, I mean, it's up to the, looking at the literature, it's really high, the delayed sleep phase. But then you may also have, there's a very high level of restless leg syndrome. There's quite a lot of sleep apnea, undiagnosed sleep. There's a huge amount of undiagnosed sleep apnea in general population anyway, but it's layer upon layer in there. And how do we get at that? That's a huge question. 

Anya TMP 

Do you, I mean, you've spoken about how in people with the difference in their clock timings, something that you might do is look at how do you shift when they start to feel sleepy, I guess more in line with what society will enable them to do in terms of their wake up time. Is that an approach that can work? Is that something that you would try with people who have this because of ADHD, for instance? 

Heather D-S 

Yeah, it might work with someone's prescriber. who might look at the timing of their medication, the stimulant medication, and also use melatonin very specifically. And then we use light therapy, the two together, and then look at very steadily moving someone's clock. So we might find, right, okay, your timing is here. So you're going to bed at three and you're getting up at 11. And then if we can, gently move the clock backwards. If someone's got advanced phase, we might be, so they're going to bed earlier, we might be moving them forwards. But yes, I mean, it's like, in some ways, it's like a little bit like dealing with jet lag, but actually this regulated rhythm, it takes work to do to move it and to maintain it. Because of course, if it's a biological delay, it's going to ping back. So it It's a difficult one. But I think there's also something really important in understanding that this is in play, because I've certainly seen, I don't know how many times now, people who are late diagnosed with ADHD and then they've had insomnia issues for years. And they look back and say, well, yeah, when I was a teenager, I was always getting in trouble because I couldn't go to sleep. So I absolutely hate my bed. I hate going to bed. The relationship with sleep is absolutely terrible because they've been trying to do something for years that they couldn't do because biologically they weren't sleepy. So their whole, we're unpicking that too. We're unpicking a very long-term insomnia and relationship with sleep. which is underpinned by this biological delay. 

Anya TMP 

Are those the main issues that you might come across with people with ADHD in terms of sleep or are there other things as well that? 

Heather D-S 

Oh no, there's loads. There's loads, because I mean, in some ways it's really, it then definitely plays into sleep procrastination because why do you wanna go to bed? You're not sleepy. That's a big one. There's, I mean, there's all sorts of things that we know are problematic. We know that there's different, so people may suffer, experience more fragmented sleep due to neurological signaling and I'm very conscious, I'm not a neurologist, so I'm very wary of often getting into territory on that. need a neurologist here to tell me, tell us precisely what that mechanism is. There may also be parasomnias in play. So it's not uncommon to hear someone talk about sleepwalking, sleep talking, hypnic jerks, that feeling of as you're falling asleep, your body jerks. I mean, it happens in the neurotypical population too, but it does, I definitely see it a lot in my neurodiverse clients. So there's a whole bunch of stuff that can be going on here. And so for example, with hypnic jerks, letting someone know that that is normal is really important. If someone's experiencing sleep paralysis, which again, I see is quite common in this population where I like to describe these things as like sliding doors, different parts of the brain should be. going to sleep, but actually one bit's gone to sleep and another bit's come up, the doors have slid, and you get this jerk, or you get this paralysis when you're coming out of REM sleep, you get more of in the second-half of the night, and of course in REM you are paralyzed, but of course part of your brain's woken up, but your body is paralyzed and then you get this terrifying, I can't move. So there's lots of things that can be happening. 

Anya TMP 

And you speak about neurodiverse people broadly. I mean, is this something that is, are there things that you find are more specific to ADHD or is there quite a lot of similarity between people who are autistic and people with ADHD in terms of the kinds of issues that they might have with sleep? 

Heather D-S 

I think one of the things, because we all have a circadian rhythm, so in the morning, If you're woken up at a time where your body doesn't want to be awake, you enter what's called a state of sleep inertia and it feels, you can feel really groggy and just everyone, if you're ever woken up on an alarm, it's like, oh God, I can't function. But it can, sleep inertia in these populations can hang around for a lot longer because there, your alerting signal maybe later in the day than it would be otherwise. So it may be that your most alert time is in the evening. And of course, now we're talking about, right, well, we've got to go to sleep. And people will often say, but I don't want to give that time up. I really like that time. And that's really hard because they're like, well, okay, so what are we going to do? What are we going to do? We've got to get you to sleep because the thing that can't move here is you've got to be at school or work or uni at nine o'clock in the morning. So how do we go with the truth that you might be at your most alert at a time where we're starting to think about going to bed? That's quite common. And it's a time, of course, to, I think very common in this population that come nighttime, because if you've got a delayed clock and you've been going through life with all the stress that goes with this territory, suddenly the world goes quiet and you get some downtime. So you want to be awake in the dark because it's your time. So that can be a very big area of how do we work with that, that you might have to lose that time. And actually it could be a time that's really precious. There's a lot, and another thing that's really common is the hyperarousal caused by masking, the effort of just getting through the day. By the time we get to bedtime, how do we let go of all of that? We might be working with a lot of low self-esteem. There's a bunch of research that shows that people with ADHD before the age of 12 receive 20,000 more negative comments about them. So how do we deal with that? Because if you then layer on top, I can't sleep, I can't do this, I can't do, I mean, it just keeps going. And then of course we get into the territory of, well, what are you using to cope with that? So it's a real tangled web, isn't it? 

Anya TMP 

You touch on the importance of senses there as well, I think, especially with people who might have been overloaded across the day. But again, this was kind of a really interesting part of your book that, and Rosie and I were sort of reflecting on, again, when we're thinking about our patients with the sort of severe mental illness and how deprived of kind of sensory stimulus sometimes people can be, you know, particularly touch. And I guess I'm really interested in your thoughts on this, given your work in massage as well and sort of your work with anatomy. I mean, what do you think about the importance of our senses and sleep or our ability to relax? 

Heather D-S 

Oh, it's huge, isn't it? I mean, we are sensory creatures. Humans are very, because we can think and reason and rationalise in the way that we do, but we are, we feel all the time. A really good example would be someone coming to see me in London. So this person has to maybe get on a train with all the sounds and stimulation of that environment, maybe get on the underground, then come to see me. And so by the time they've got to see me, their senses have received this onslaught of sound, smells, all of this stuff. And so their physiology of course is going to respond. They're going to be in this heightened state. And I will often work with someone to think, how are we going to navigate the environment just to get from A to B? Because when you think of what we are bombarded with all the time from a sensory perspective, I mean, is it any wonder we can't sleep? I mean, neurotypical or not, it's constant sound, smells, and our body's constantly receiving all of this. So when we think sensorily, Like the workplace, a hospital I think is probably one of the worst environments from a sensory perspective because there's beeping, there's sounds, there's lights on at funny times, there's so much going on. I mean, it's just exhausting thinking about it. really, really is. So we're not, we don't just exist in our minds. Our bodies are doing the work too all the time. So I will often work from a sensory perspective thinking about, okay, if you work in an open plan office, can you wear noise cancelling headphones to block out some of the noise? Because the stimulation, I mean, open plan offices for many people are really difficult places because it's just constant sound. Of course, the brain is listening. It's not just doing this, it's listening to that. be that I know the research on, for example, blue light blocking glasses is there's a lot of arguments about that, but it might be that it's quite useful to wear glasses that take some of the glare out of the world just to get from A to B. So a combination of noise cancelling headphones and glasses that just take the edge off from a sensory perspective just drops down a level. Touch is so important, safe touch. activates the parasympathetic again. And the work of Temple Grandin, who did a lot of research in autism, she came up with a machine that she designed, which put pressure all over, that's where the work originates from, put pressure, like a mechanical hug, if you like, which has been shown in the autistic population to reduce stress. So weighted blankets, therefore, can be really, really helpful. unless you've got sleep apnea where they're contraindicated, but they can be really helpful just to reduce the activation stress because that pressure sends a message to the brain, I am safe. And I think that actually is a really important part of my work, that idea of am I safe? Because of course, how can you sleep if you don't feel safe? It's quite a big piece to think about from a sensory perspective. How do I do that? 

Rosy TMP 

I just wanted to come in on that, actually, because the whole time we've been talking, pretty much, I've been ruminating on this idea of the fear around letting go and what that means. And I've been trying to sort of formulate in my mind, like, what is that? Why is that so pervasive? And actually, I think that final point that you just made about feeling safe, safe to let go, and what that means for an individual, I think is probably the bit that is really gnawing away at my brain that it's so important that you can feel safe enough to do the work of letting go of all the things that have kept sleep away. And that in itself is going to take a lot of work, right? Because until this point, perhaps you haven't felt safe enough to do that. 

Heather D-S 

Yeah, and that's Again, that I think is something I see from, if I see a client who has a lot of trauma, who has often been through a lot of CBTI, this point about safety, well, there could be a really logical reason why someone isn't sleeping. Firstly, are they safe? And checking that out, is it safe to sleep? Because the nervous system is going to scan. In light sleep, you can both hear and see light. And the more stressed we are, the more alert we are in light sleep, so the more likely it is you're going to be able to hear sound and light. So a new parent, for example, is going to, one of the reasons their sleep isn't great at times is because you're scanning for sound, you're listening. But if you If your home isn't safe, that is quite significant. And we have to deal with, well, how do we work with that? Firstly, can we do something about it? And if we can't, what are we going to do to do something about it? So that safety point can often be quite a big piece of work. So that's one of the things that working online became a bit of a gift, because of course, as a psychotherapist before COVID, we always worked in person. And suddenly working online means that we're in someone's home. So I might, I use an example of this in the book because it's not an uncommon thing to do. And especially for, again, someone might have, there may be chronic pain issues, there may be disability issues that mean their environment is what it is. So it's like, well, let's look at the environment to see what do we need to do to make it safe. It might be thinking about someone might show me where their bed is and we're looking at, well, where are the doors and windows? Do you know how to get out if you need to? And just that conscious piece of work on someone's safety can make a huge difference because it always comes back to the question, what do you need to support yourself? So, okay, would you feel better if you put another lock in? Would you feel better making sure you've got a clear line of sight to your door? And combining that with things like breathing exercises and understanding how panic works, again, that's where also deep pressure, weighted blankets can also help that sort of combination of are you safe, can you breathe, and what else can we do to bring the system down, starts to really shift something at a level that really makes a massive difference. And that can make a big difference quite quickly, even just acknowledging that this is what's going on. starts to open it up. 

Anya TMP 

Yeah, it's again, trying to draw all of these pieces together and how do you have this, you know, how do you keep it in mind for each individual person that you see? And I think there's a lot for hopefully for any clinicians listening to just to take away and to potentially think about how they can bring into their practice. I'm wondering as we start to draw towards the end, is there any part of your work, Heather, that we've not brought out that you think it would be important that we do think about together? 

Heather D-S 

Just back to that point you just made, I want to also remind you, I get an hour a week with someone, which I think is quite a luxury. And I might see someone for six months, a year, two years, three years, four years. So it's a lot of time. And I really want to acknowledge that point because I think as a psychotherapist, we do have that luxury. So I think that's quite unusual to have that. It gives a spaciousness that is quite important. There's a bigger question there, of course, as to how we get everyone to have more time because these things are tricky. But I think I think that by a psychosocial point is really, really quite a quick access way to go, okay, this is showing up, but actually this could be really logical. If this person can't sleep, well, are they safe? Because if they're not safe, if they don't safe or they come from a history where they haven't felt safe, Well, why are they going to be able to sleep? It's that piece. But I think also it's the scanning for the undiagnosed sleep disorders. I mean, sleep apnea, I think the figure is there's at least 85% of cases with sleep apnea haven't been diagnosed. And sleep apnea diagnosis and treatment is a game changer. It's an absolute game changer. So there's often the question, I think, I mean, in some ways, sleep apnea is a sort of quick win. It's not, if you know what I mean. But if someone's coming into therapy and sleep apnea is in play, well, we really do need someone to be undergoing sleep apnea treatment. And none of this stuff shows up on its own. There's always something, it's really unusual, I think, for one aspect of this to happen in isolation. Insomnia sort of doesn't come out of nowhere. We might never know why it's there, but there might be lots of things that we can unpick. There's so many comorbidities, aren't there? How do we do that? 

Rosy TMP 

You started off by talking about feeling curious, and I wonder that perhaps that is the root of it, is the curiosity to inquire about more than just I have difficulty in sleeping and thinking, well, why? And having that curiosity can just take you places and maybe that's just where you've got to start sometimes. 

Heather D-S 

Never know, do we? But I mean, I think most people do, but it's sort of just reminding ourselves sometimes that the body's quite logical, isn't it? From a physiological perspective, it can be quite logical. If it's in hyper arousal, well, it's not going to be able to sleep. So why is it in hyper arousal? But of course, that's not the only reason. 

Anya TMP 

Just counter that before everybody shouts at me. No, shouting. Helador Smith, thank you so much for sharing your time and expertise with us today. If people want to hear more from you, sort of read more from you, Where should we point people to? 

Heather D-S 

I have a website, heatherdarwallsmith.com. I'm on Instagram as the sleep psychotherapist and there are a couple of books out there with my name on that. So yeah, I'm quite reachable and I do tend to reply if I can. 

Anya TMP 

We can certainly attest to that. Thank you so much for replying to us and agreeing to come and speak to us. We'll link people to all these things. But for now, it's been a pleasure. And thank you again.