How to Fix Insomnia: CBT-I with Dr. Ashley Mason | Being Well

0:00 Cognitive behavioral therapy for insomnia is the first line treatment for insomnia. This is what you should be trying before you try anything else. People will get in bed and they'll turn on a podcast and that's the last thing I want because then now you're trying to take awake behavior and use it to blur the lines between being awake and being asleep. I want you to really know there's two things you can do in bed, right? There's sleep and there's sex.

0:23 And if you're not sure if it counts as one of those two, send me a message and I'll get it clarified very quickly for you. If it counts.

0:31 Hello and welcome to Being well, I'm Forest Hanson. If you're new to the show, thanks for joining us today. And if you've listened before, welcome back. At any given time, about 5 to 10% of people are dealing with insomnia. Issues with sleep are very, very common. I have had plenty of them myself. And what makes insomnia in particular such an interesting problem is that many of the things that people do to do something about it, do to help it, like, like sleeping in, going to bed earlier, or even trying harder to fall asleep can actually make it worse.

1:03 It's also interesting because we usually think of sleep as a physical process. But the first line recommended treatment for insomnia is not a prescription medication. It's an approach to therapy. This is incredibly uncommon and it speaks to how effective cognitive behavioral therapy for insomnia, or CBT I really is. So today I'm welcoming an expert on sleep, insomnia and CBT I, Dr. Ashley Mason. So, Dr. Mason, how are you doing today?

1:30 Great. Glad to be here.

1:31 I'm glad to have you. We had a lot of fun talking even before we started recording. And to tell you a little bit more about her, Dr. Mason is a clinical psychologist and an associate professor of psychiatry at UC San Francisco, where she directs the Sleep, Eating and Affect lab. And she also leads the insomnia treatment program at UCSF's Osher Center. I'm not sure if we're going to get into it as much during this episode, but her current research trials also involve the administration of whole body hyperthermia, which is similar to a sauna treatment, and cognitive behavioral therapy as an integrative mind body treatment for clinical depression.

2:07 And way back in Arizona she worked as her doctoral mentor was Richard Boutsen, who invented one of the two core pieces of CBT I in 1972. So I wanted to start a little bit with that history. What drew you to doing this kind of work?

2:23 So I want a couple quick, important things to note. So I did learn how to do this treatment from Dr. Richard Goutson. My primary mentor at the University of Arizona was Dr. David Sbarra. And I had this great good fortune to work with both of them as a graduate student. And I've been interested in sleep for quite a while. I really started to get more interested in how to do this treatment in a way that would reach more people pretty early in my career, because working one on one with someone is wonderful and I love demon it.

2:57 But figuring out how to do this kind of treatment in a larger way in what I call a group, many call a group medical visit, where I'm treating eight patients at once, I really got intrigued by that. And since 2014, I've done nothing but sleep for my clinical practice and figuring out how do I expand this and reach more people? And it just, it happens to be the case that CBTI is also one of the most effective behavioral interventions for a problem that we have.

3:32 People often will think, oh, but that's, that's psychotherapy. And, and yes, I, I guess, suppose technically it's true. But I tell people to think about it more like physical therapy for your sleep. Oftentimes people get an injury to a knee or an ankle or a wrist, and they go to physical therapy for that. Right? I say think about cbt. I like physical therapy for your sleep. It's much less about feelings than it is about behavior and changing habits and behaviors and mentalities than it is about feelings per se.

4:08 Often when we talk about something on the podcast, I have at least a cursory knowledge of it. I knew absolutely nothing about insomnia or treatments for sleep more broadly before I started prepping for today's episode. So I really want to start from zero here. What is insomnia? And particularly what's the line between, you know, oh, it's hard for me to fall asleep sometimes, and what you would call insomnia.

4:32 So insomnia is not just one night of bad sleep. When someone says, I had insomnia last night, they're using the term not quite correctly. Insomnia disorder is a clinical problem that's characterized by having difficulty with either falling asleep, staying asleep, or waking up too early in the morning at least three nights a week for at least a few months. It's gotta cause significant distress or impairment in your day. It's gotta be upsetting, and it's gotta feel like a problem.

5:04 It's not Just something that happens once, you know, in a blue moon. This is something that's affecting your days and your nights. But insomnia disorder is affecting you during the night, during the day, it's a major life problem for people.

5:22 Is it about how much sleep a person is getting? Like, if somebody is getting five hours of sleep a night, is there like a threshold that you think of that qualifies somebody for that?

5:32 There really isn't. Because you can take two people who are sleeping six hours. One person, they might have always slept six hours. This is just what they do. They might be fine. Then you might have someone else who's sleeping six hours who desperately needs more hours of sleep in order to feel well, and they might be really upset about it. Both people sleeping six hours, one person might actually qualify for a diagnosis of insomnia. And when we actually look at different.

5:59 This is one of my peeves about sleep duration. The technical terms, it's just how long you're. It's a fancy way of saying how long you're sleeping. If we take people who are sleeping 12 hours a night and we take people who are sleeping five and a half hours a night, both of these people are more likely to have poor health outcomes in the near future. Why? Well, the people sleeping 12, 14 hours, and I guess what's probably going on for them right now, they're probably sick, they're probably not doing well.

6:27 People who are sleeping that much during the day, they might be receiving chemotherapy for a cancer, they might have some sort of immune disorder or disease, and that's causing them to be completely fatigued and sleep all day, right? They might have something else going on. But then we've got people sleeping five and a half hours. This is a mixed bucket because there are some people who naturally do well on five and a half hours. That's not the average person, but there are these people, they exist, right?

6:56 But then we've got the other people who are sleeping five and a half hours because they have two jobs, three cats, four dogs, two kids, and they're trying to do 12 different things that they don't have time for. So they only have five and a half hours to sleep, but their body actually needs seven. And those people are going into that bucket of five and a half. Those are getting mixed up. So then we've got this bell curve, right?

7:15 Then we've got people who are at seven or eight hours. These people have enough time to meet their sleep need, right? They're meeting it. They're not sleeping too much. So of course those people are end up being the people who look like they're going to do better. The norm is not to be well on five and a half hours of sleep. Most people aren't going to be well on that. But there are some people who are, and there's some people who do great on seven hours.

7:40 There's some people who do great on nine hours. If I ask you, would you rap force, would you rather have eight hours of tossing and turning sleep or would you rather have like 6 hours and 45 minutes of glorious, uninterrupted, refreshing sleep? What would you rather have?

7:58 Yeah, I'm picking the second one every time.

8:00 What CBTI focuses on is quality over quantity. And you have to remember, most of the people that I'm seeing in my clinic coming into the sleep problem, they have major sleep problems. A lot of times they're staying in bed for nine hours because they think, well, I've got to stay in bed for nine hours to at least get however much sleep, when actually they might only need to be in bed for seven and a half hours.

8:24 And then they'll be sleeping that whole time that they're in bed, and they'll feel much better because they're not tossing and turning for that extra hour and a half. The important thing to know is just that different people have different sleep needs. On average, the adult sleep need is likely between seven and nine hours, but there's plenty of people who will do fine on six and a half hours.

8:43 When I did my prep for this, one of the most interesting things that I ran into was this meta analysis that was done back in 2014 that found that people with insomnia averaged only about 23 minutes less total sleep than good sleepers. So the objective differences between these two groups with insomnia and without insomnia were pretty small. You know, 23 minutes matters, but it's not the end of the world If I get 23 fewer minutes of sleep in a night, most nights.

9:08 Right. But the experience of these people was totally different. Right. The people with insomnia experienced a ton of distress around that difference. And of course, for some of the people in that category, they're going to be much bigger differences than 23 minutes a night. But it's interesting that the average was that relatively small.

9:28 What really drives insomnia and the distress experienced in insomnia is the time awake at night, in bed, not sleeping. When you look at the primary outcomes following from a treatment of a course of cbti, there's generally not a statistically significant improvement in total sleep time, or tst, is what it is in the literature. But there normally is a statistically significant reduction in time awake at night, time needed to fall asleep, time awake in the middle of the night, time awake in the morning before getting out of bed.

10:01 These things generally improve. Therefore, this metric that we call sleep efficiency improves. And sleep efficiency is the total amount of time you're spending in your bed asleep divided by the total amount of time that you are in your bed. And we are targeting in treatment a sleep efficiency of 85% or greater. This very commonly improves in insomnia and tracks with people's experience of improvement.

10:31 And what's even more interesting is that, I mean, I've had, I don't. I can't even count how many hundreds of patients I've had at this point, but many of them stick out. And I've always gotten their permission to tell various stories, even though I do so anonymously. But I had one patient who I finished with just a few years ago. And the entire solution to he was trying to go to bed at like 10 o' clock, because that was what time he thought he should go to bed.

10:56 His wife wanted him to go to bed then. This is the bedtime, right? But he would lay in bed awake until 11, frustrated, not fall asleep till 11, and then wake up at the same time and wake up at six, just no matter what. He just woke up at six and the entire fix for him was just staying up an hour later. And you know that phrase, like, man, I wish I could increase the length of my day, like, how can I grow time on a tree?

11:25 You can't. Well, he actually did. He's like, wow, I have a whole nother hour now where my family's asleep. I can do whatever I want. This is great. I go to sleep and I actually go to sleep when I go to bed at 11 o' clock. And I'm like, yeah, now you have an extra hour in your day. And that was the only. That was all we had to do. Now, is he sleeping more? No, no.

11:46 But is he spending less time awake in bed, frustrated? Yes. A whole hour less.

11:52 This gets to another crazy thing that I ran into when I was doing some prep for this. And again, I would love you to clean up anything that I say here. So when I looked at Zolpidem, which is one very, very common medication for sleep, one of the meta analysis I saw said that on average, people fall asleep about 20 minutes faster than they do when on placebo. So that's a difference 20 minutes, but again, 20 minutes, not a huge difference.

12:18 And the authors of this meta analysis described the effects as small and of questionable clinical importance and that the available data said that there wasn't significant improvement in total sleep time or in nighttime waking. But what's interesting about Zolpidem is that some people think that it works not by increasing sleep, but by causing a degree of amnesia. So you might wake up during the night, but you just don't remember it. And I thought that if that was the case, and a lot of what you're getting from a medication like that is the amnesia, it's such an interesting illustration of what you're describing here.

12:53 Right. The experience of nighttime is the big thing that we're changing, not the total amount of time that you're sleeping. So it's kind of another way in to relating to the experience of sleep, I think a little bit differently. I've gotten a lot of illustration of this myself. We recently started fostering a dog and I have been absolutely spending less time in bed, but I'm not actually sure that I'm sleeping any less. And if anything, I feel kind of better when I wake up in the morning.

13:20 And so that movement of the variable that we're focusing on from this, sort of like your ring, tracks the total amount of time that you spent asleep or whatever. To, hey, what was your actual experience of that period of time? I think can already be pretty helpful for people.

13:34 It's true. And when we talk about sleep medications, you know, in 2016, the American College of Physicians came out with a position statement and they said, look, cognitive behavioral therapy for insomnia is the first line treatment for insomnia. This is what you should be trying before you try anything else, such as prescription medications. And these prescription medications can be effective in the short term. They weren't designed for long term, they weren't designed or intended for long term use.

14:05 And if you look at the, the box for, you know, z drugs, Zolpidem, you will see that they're intended for what, like 4ish weeks or something like that? They're not, they weren't, they're not a long term solution. And the great thing about CBTI is that, I mean, hopefully there's no kids listening to this podcast, but CBTI is a lot, it's a lot like Santa Claus. Once you know Santa isn't real, there's no going back. And once you've learned the principles of cbt, I, you will know what makes your sleep better and what makes your sleep worse.

14:36 And you can't unknow that.

14:38 So before we get into the structure of CBT I, which we're definitely going to talk about a good amount, I'd like to learn a little bit more from you about how insomnia develops for a person. Does it just happen out of nowhere? Is there some kind of thing that triggers a person into this kind of relationship with their sleep? Like what's going on based on all the people that you've worked with?

14:56 Yeah. So this is a interesting misconception, I think broadly is that there's this obsession with getting to the root cause of something. Everyone wants to know what really caused it. But guess what? Let's say you've got. You lose your job or you get divorced or your dog dies or something terrible happens. Acutely, you're very, very upset, right? Very upset. And you might try and do all kinds of things to help yourself calm down to be able to sleep.

15:27 Some people pop a bend drill, some people just read in their bed or watch TV or do all kinds of stuff in their bed until they're sleepy and then try and go to sleep. And. And then other people sleep in a lot. And so people might do a whole bunch of behaviors that either mess with their circadian system or change their associations with their bed or cause a physical or chemical dependency. And people start doing these things to help themselves sleep.

15:58 But guess what? No one really gets over the loss of a dog. But the acuteness of it goes away. You might get a new job. The immediately acute thing that caused you to lose sleep gets resolved. But then the sleep loss and the sleep problems continue because you're continuing these behaviors of sleeping in, taking Benadryl, doing stuff in bed. So what started your insomnia? Look, I'm not going to go back 20 years and undo that job loss you had.

16:23 And that's not going to fix the problem. But what's going to fix the problem is addressing the behaviors that people are doing now that are perpetuating the insomnia. And that is what CBT I targets.

16:34 This is great because this is functional analysis which we, we talk about on the podcast all the time. Like behaviors have reasons, right? You do something, it has a short term relief, but then maybe over time it creates a kind of long term problem. Related to this. There's a common experience that I've had that I wanted to, that gets to some related work and it's that I'll feel sleepy, my eyes are heavy, I might be like almost nodding off on the couch.

16:58 I do my bedtime routine. I'm still sleepy. I wash my face, brush my teeth. Okay, great. Then I lie down in bed, and I cannot for the life of me fall asleep.

17:05 And I have.

17:06 I don't know why this happens. I have absolutely no idea what to do about it. What do you think?

17:11 This is something that people report all the time. And one of the questions I often will ask patients when they start. Start treatment is, how well, how do you sleep on vacation? And they'll say, oh, I sleep great on vacation.

17:24 I sleep better, for sure.

17:25 Yeah, right. But guess what that means. That means that your body can sleep, first of all, right? Because a lot of people come to me and they say, my body's broken. I can't sleep. I'm like, well, if you can sleep on vacation, that's not so true. You can sleep. The thing is, you don't have any associations with that vacation bed. That's just a hotel room. When you are at home, you have all kinds of associations with your bed.

17:46 It's a place that you have not slept before. It might be where you read on your phone, you read a book, you argue with your partner. You do all kinds of. You might work, you might take all kinds of things. And when we associate our bed with sleeplessness, being awake, racing thoughts, all those other activities I just mentioned, we get in our bed and our brain says, oh, we're here. We're going to read. We're going to.

18:10 We're going to argue with our partner. We're going to do all these things, right? So a lot of that has to do with associating our bed with things that are not sleep. And I tell people, look, there's two things you can do in bed, right? There's sleep and there's sex. And if you're not sure if it counts as one of those two, send me a me a message and I'll get it clarified very quickly for you.

18:32 If it counts, right? I've had some questionable ones. We live in the Bay Area, right? But most of the time, I can get you a really crisp answer like, yes, no. And there's this. There's this interest that's been growing in the past 1015 since the advent of podcasts and all these audio availables, this idea that, no, no, but it's not helping that people will get in bed and they'll turn on a podcast. Obviously not this one, because this one's riveting, right?

19:01 So no one's gonna fall asleep, but they'll put on a podcast and they will say, you know, I'm just gonna fall asleep this podcast, and that's the last thing I want. Because then now you're trying to take awake behavior and use it to blur the lines between being awake and being asleep. I want you to really know when you're sitting on your couch, wow, I am sleepy. I'm gonna go in my bed and sleep. And if you can't, you're gonna get right out of your bed and go do more awake behavior, like listening, do a podcast.

19:24 We don't want to blur that line between being awake and being asleep. So for someone like you who's having this experience is getting in bed and being wide awake, you just need to get right back out of your bed, go do all that awake stuff on the couch until you, until you're sleepy again and you can go again. And I always say, people are like, we're like airplanes. We're not like toasters. So when you unplug a toaster, it is instantly no longer going to produce a piece of toast.

19:48 There's no residual toasting left in that toaster when you unplug. Float right when you're on a plane. I don't know if you've ever had this experience flying into sfo. I've definitely had it. It's my. It's mildly terrifying when you're about to land and the wheels are down. You're like, you can kind of see the ground. You're like, yeah, it's coming. And then instead the, the. The pilot goes and the plane goes up and you're. Everybody grabs their seat and like, what's going on?

20:11 You're flying back into the sky. And 10 minutes later, the pilot comes on and says, folks, we had some wind shear on the left wing and we're just going to retake this approach. Approach to a different right. So humans are like airplanes. We have to land the plane at night. The approach has to be right, the routine has to be there, all those things in order to land the plane. And if people skip those things and think, wow, yeah, I'm just going to work, work, work, and then go to sleep like, we're not toasters.

20:36 You can't do that. There's this whole process that you need to engage in. It's generally probably about an hour. Most people need about an hour for a wind down routine so that your brain and your body get the message, like, hey, we're getting ready to be unconscious now. We're getting ready to. We're. We're not doing any more of that other busy stuff, we're getting ready to go do this other thing. That's the human experience. And so if you're doing all those things, then you're getting in your bed and you're wired and tired, that means you need to get out of your bed, go do like a brain dump, go do some cognitive exercises, go do something, make a list, get the cognitive stuff out.

21:11 And then you can re approach the bed when you're sleeping and reassociate the bed with sleep.

21:16 So this gets to sleep hygiene content, which in addition to podcasts, is now absolutely everywhere and much of it is on podcasts. Most of the social media content that you'll see out there, that's about sleep, mostly focuses, as near as I can tell, on sleep hygiene. Dark room, no screens, reduced coffee, all of that. It's good common sense advice. Most people have heard it and plenty of people, particularly people with insomnia, have tried all of that and I'm not sure if how much it's helped for them.

21:46 Do you think that this advice is a good place to start? Pretty helpful. Not that helpful. How do you think about sleep hygiene?

21:53 So I think that in order to unpack sleep hygiene, I want to lay out the five pillars of cognitive behavioral therapy for insomnia. So you can understand what this looks like, right? Sleep hygiene is one of them. Then we have stimulus control, which is another one. Stimulus control is nothing in bed except for sleep or sexual. Right. That's what controlling stimuli is. Then we've got time in bed restriction, which is lining up how much time you're able to sleep with how much time you're actually spending in bed.

22:19 And we use formulas for that. Then we have cognitive techniques, which are cognitive behavioral therapy type techniques, paper exercises, thought exercises, and then we have relaxation exercises, which are probably the least important. Now what we know from these five pillars is that the two essential pillars, the two you must have in order for this treatment to work, are time and bed restriction and stimulus control. The other three can be somewhat expendable. You got to do these other two.

22:51 Sleep hygiene being one of the more expendable ones, is often the control condition. In clinical trials testing cognitive behavioral therapy for insomnia, they will just do the full package of the five versus the sleep hygiene. Some trials will actually just do one of the two pillars like time and bed restriction as its own intervention, which for some people does work. There's a lot of people out there who aren't really in their head, who don't have racing thoughts, who don't have all of these issues.

23:21 They just are spending way too much time in bed and all they really need is the time in bed restriction piece and they can go on their merry way. Sleep hygiene, though, does encompass things like the dark room. I always tell people, cotton sheets and cotton blankets. If I had a nickel for every time I took away someone's down comforter. Down belongs in your ski jacket, people, not in your comforter. If I took that away from you, your, your body temperature can more easily regulate itself at night.

23:44 And your body temperature is supposed to be its coolest at night and warmest during the day. Coolest at night and warmest during the day. And if you're trapping all that heat during down and you're waking up at 3am and you're wondering why, well, maybe you're sending a message to your body like, hey, it's, maybe we should wake up. It's warm. Like I'm warm, right? You could be sending a mixed message there. And a lot of women actually will find that when they switch their bedding, they don't need to change their hormone replacement therapy at all.

24:08 Because a lot of people will think, oh, I'm so hot at night, it must be my hrt. No, I would try switching the bedding first before you start changing your meds. But keeping your room cool also helps keeping your room dark. I do tell. Like, my typical caffeine cutoff time for my patients is 11am and wow.

24:26 Yeah, that's earlier than I was expecting.

24:28 Yeah, yeah, I like a full like 10ish hours before bed because the half life of caffeine, gosh, I can't keep track of it because it seems like it's starting to. There's all these studies coming out about how your genetics relate to how quickly you metabolize caffeine. But what I know is that all the people who are having a coffee after lunch and also, you know, having trouble falling asleep, that's pretty easy to fix. You just move it earlier.

24:54 And then there's the people who will say, oh, no, no, I can drink coffee after dinner, no problem. I fall right asleep. The problem is I'm waking up in the middle of the night and it's like, well, I don't think this is like such rocket science because what we can do is we can unpack this when it comes to this thing called sleep pressure, right? We have sleep pressure that we build up during the day. And the more sleep pressure you have, the easier it is to fall asleep and stay asleep.

25:18 And while you're asleep, you spend out that sleep pressure. When you have the most sleep pressure, it's easier to push you down into deep sleep. That's why the first half of our night is when we get our deep sleep. The second half is lighter sleep and REM sleep, which is rapid eye movement sleep. But the first half is really when our deep sleep happens. And that's because that's when we have the most sleep pressure. When we run out of that, we can't cycle down to sleep pressure.

25:40 It's a deep sleep. So well anymore in the second half of the night, as you build up sleep pressure, then you're able to fall asleep at the start of night, then you start spending it out. But guess what happens? You start spending out that sleep pressure. That caffeine is still in your system. If you don't have enough sleep pressure to keep you asleep, boom, boom, you're awake. Because what does caffeine do? It, it blocks those adenosine receptors and it makes it harder for you to actually build that sleep pressure in the first place.

26:02 You don't necessarily have enough to begin with. By the start of the night. You might have enough for, for a few hours, but then you might wake up. So caffeine can make it harder to fall asleep and it can affect your sleep in the middle of the night too. It's just not necessarily obvious why that would be unless you understand that you build up sleep pressure, then you spend it while you're sleeping. So I do tell my patients, look, put your caffeine in the beginning of the day and don't drink extra caffeine if you didn't sleep well last night.

26:26 Don't use a caffeine crutch is what I call it. Don't do that. Part of sleep hygiene is also stopping working. Do as I say, not as I do. You got to stop working with a period of time before beds that you can wind down and actually land the plane. Most people cannot go from like work, work, work, work to sleep. And that's, that's part of sleep hygiene as well. But the time in bed restriction piece and the stimulus control piece are actually quite distinct from the sleep hygiene piece.

26:55 And those get all mixed up because people say, oh, sleep hygiene, don't use your phone in bed. I mean, I'm not going to correct you because I just want you to not use your phone in bed. And I don't, I don't care which thing it falls under. Like if, whichever one you want to put it under. Great. Just don't do it, you know, but technically that would be in the category of stimulus control.

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27:59 It's just a very solid product. For being well listeners, visit shocks.com or click the link in the description box. Use code beingwell for an exclusive discount on all Shocks products. That's S h o k z.com this offer can be combined with other official promotions. It would be great to get a sense of just the arc of treatment itself. So somebody comes to your clinic, they're experiencing a lot of distress about sleeping poorly. It's been the case for a while.

28:29 What happens? Is there somewhere you'll start with people? Are there particular questions you ask them? How do you kind of set this whole thing up?

28:37 Yeah, there's a pretty standard approach to doing cbti. I deviate in just a few small ways that aren't inconsistent with the practice. So when someone comes into my clinic and says, I've got a sleep problem, I do an intake interview with them and I ask a whole bunch of questions ranging from what's the main problem? Falling asleep, staying asleep, waking up too early. When did it start? What do you think caused it? I ask people generalities about their sleep schedule, about what time are you going to bed, about what time are you waking up?

29:10 I ask people what drugs or medications or supplements they're using. Oh, my God, the supplements. The lists are so long these days. So I go through all those and I. And I. What I'm really looking for in the intake paperwork is, is there a quick fix here? Is there something that this person is doing that could be causing this whole problem. And they don't actually need treatment from me. For example, I've had patients coming in saying, oh yeah, I take my antidepressant at night.

29:36 And I'm like, oh, and what antidepressant is that? And they'll say, oh, bupropion, 300 milligrams. And I'll say, aha, I can solve your problem. Does your doctor know that you're taking that at night? And they'll say, oh, the bottle just says take it once day. And I will say that is equivalent to drinking a cup of coffee and trying to go to sleep. How about, let's try taking that in the morning if your doctor's fine with that message your doctor make sure we're cool.

30:02 Dr. Probably already thought you were taking it in the morning, but okay. And sometimes that solves the entire problem. When people do their intake paperwork, my first thing is I look to see is there anything quick that will solve this issue that could have already been resolved? Assuming the answer is no, I then will have them do a week long sleep diary. A sleep diary is like a written paper sleep log. And these are commonplace, I believe.

30:29 Colin Carney published in 2012 a great article with the three different types, and these are the three different types that there's like three lengths that all the researchers really use of the sleep diary. And I'll have people do this every morning. They fill it out for the previous night and they submit it to me. And then I really see what's going on and then they start treatment with me. And treatment is five weeks in a group medical visit.

30:53 I see eight patients at a time for an hour and a half and we get it done. And in the first week, what I really focus on is teaching them the basics of what is stimulus control, you know, what is sleep hygiene. I don't start off the bat with time and bed restriction because A, that would scare a lot of people away and B, it's just not necessary. The first thing I do with tell do is I tell people, look, I cannot wave a magic wand and make you fall asleep at the same time every night.

31:22 I can't do it. But I can wave a magic wand and make you wake up at the same time every day. In the hormone alarm clock, you set an alarm and people say, oh, it doesn't work on me. I'm like, great, get five of them. It's going to work on you. You. I had one patient once, a long time ago, he's an engineer, he told me I could tell the story but like, he, he, he created some sort of alarm that required him to.

31:41 Like, you had, you had options. You could either take a picture of a bathroom sink in order to shut it up, you could solve a whole bunch of math problems. Like, he, he got really creative because he just was alarm resistant, right? But I tell people, look, if I, if you start waking up at the same time every day, that ends in D A Y, Monday, Tuesday, Saturday, Sunday, right? If you keep doing that, then you'll start to get sleepy at the same time every day.

32:06 So what I do for the first week is I look at their sleep driving and I try and we look at a realistic time for them to wake up every day. If someone's waking up every day between like 5am and 7am and they're like, yeah, I want my wake time to be 8:00am and I'm like, you're dreaming. You can't sleep that late. That's not how that works. So we pick a day, we pick a time that they've made it to at least like four of the last seven days, the majority of the time.

32:30 And then they set their alarm for that time. And then over the next week, they do another sleep log. And then I see, okay, how much sleep is your body producing with this wake time? And then I give them a bedtime, and I give them the bedtime of their childhood dreams. Like, if you're eight years old and you go to your friend's house for a sleepover and the mom says, guess what, kids? You can't go to bed until after midnight.

32:51 Everyone says, yes, this is the best mom ever. Best sleepover rate. If you tell that to an adult, they'll be like, I'm done. You know, like, they'll be like, please, like, I'm gonna kill you. That's no, there's no way. Right? I am not doing that. So it's the, it's the, it's the bedtime of your childhood dreams is what I call it. And we calculate that by taking how much time you're able to sleep with a given wake time.

33:14 Add 30 minutes of grace to that, because it's normal to take 10, 15 minutes to fall asleep, to wake up to sleep, bathroom, whatever, in the middle of the night. And then we work backwards. So if your wake time was 8am and you were producing seven and seven and a half hours of sleep, I would add 30 minutes to that, and I'd say, all right, your bedtime is midnight. You can't go to bed until after midnight.

33:34 And you have to Be sleepy when you go to bed. Not exhausted, fatigue, tired. Exhausted fatigue. Tired means you can lay on your couch and watch tv, but you can't work, you can't respond to your boss's emails, you can't think about what you're getting your mother in law for Christmas. No, all you can do is watch tv. Sleepy means I could fall asleep right now. And for people with sleep problems, these things get all.

33:54 Yeah, tangled up. Let's say that somebody has five and a half hours of actual, I'm pretty sure I'm sleeping during that period of time. And they typically wake up at, let's say 7:00am you know, your prescribed bedtime for them once you got to that point would be like one in the morning or something. Something like that.

34:15 That's the starting off point. Yes. Assuming that, that we never, we never assign people less than five and a half hours in bed. We never do that. But the, we would give them 1am and then the thing is, we would track their sleep log again and at the end of that week I would compute their sleep efficiency. And if their efficiency is above that 85% marker I was telling you earlier, then we give them 15 more minutes.

34:35 So then their bedtime becomes 12:45, then we log again, but still above 85. Then your bedtime's 12:30 and we find that sweet spot for you throughout treatment. And then the other parts during treatment that we go over are the cognitive techniques. Right. A lot of people who have sleep problems will start to experience catastrophizing or worrying about, oh my gosh, like if I don't sleep, then this, then this, then this. A lot of times people will have wake up in the middle of the night and they will be certain of a crisis.

35:06 I had one patient once who also told me I could tell the story, who would wake up every morning at like 2 in the morning and would be certain that North Korea was coming for us. The bomb is on its way, we're in San Francisco, it's going to hit here first. It's coming, it's coming. Right? But then if you ask him at 2pm the next day while he's out walking his dog in the park, like, hey, about that bomb, he'll be like, yeah, not so worried about it right now.

35:28 But then that begs the question, well, if a thought, if we're certain a thought is true at 2am but it's not true at 2pm, how true can it really be? Right? Something should be true all the time, right? And so, and I also had A patient once who, when she started treatment, she had a disease called multiple sclerosis and would wake up in the morning and have this thought, I'm never going to make it through the day, never going to make it through the day.

35:55 And it just would just be miserable from like 7 to 9am Just thinking, I'm never going to make it weekend. And then by 10am she'd get to work at a startup, because in San Francisco, work starts at like 10 for startups. I don't understand how that works. I work at a hospital, you know, don't ask me. But, you know, get to work at 10, have her coffee, do her meetings. And then by like two, she's like, okay, maybe I'm gonna make it through this day.

36:14 If you asked her at 6pm Are you gonna make it through this day? She'd be like, yeah, I made it. So then after tracking her how much she believed this thought day in, day out, she realized, wow, I think I'm not gonna make it through the day because it's 7am, not because it's true. So then she was able to say, oh, it's 7:00am that's why I'm thinking that. So that's not true. And I'm going to get out of bed and go learn Italian on the couch, which is what she did.

36:38 And she ends up actually becoming an Italian speaker. And 7am became her favorite time of the day because she got to go do her duolingo on the couch. Right. She can't do that in bed. But the point just is the next. Throughout the next part of treatment, we do a lot of these cognitive techniques where we help people work with some of these thoughts that are. That they're either having at night or about sleep that are disturbing.

37:00 Either their feelings about sleep, their thoughts about sleep, or their actual sleep.

37:04 Big part of this for people, particularly with insomnia, is, like you were saying, worry and fears about sleep. Fears I'm not going to sleep. I've definitely had rough patches where, you know, 10pm comes along and I'm. I'm doing everything I feel like I can to make it more likely that I will fall asleep. And my worry is amping me up. And then me being amped up is driving my monitoring. I'm looking at the clock, I'm thinking about my body.

37:31 I'm wondering about should I be tracking this or not. Tracking itself has been kind of complicated for me in the past because my awareness of the fact that I'm supposed to be tracking some of the worst Sleep I've ever gotten in my life has been when I had this app on my phone that I was supposed to put the phone, like under my pillow or something. And the whole time I was just thinking about, you know, I wonder what the thing is going to say in the morning or whatever.

37:57 Truly, some of the worst sleep of my life. Right. And I have to imagine that that's not just me, both with tracking and specific and these other processes that I'm describing. In general, I'm wondering how you work with people around this.

38:08 Let's unpack a few different parts of that separately.

38:11 Sure.

38:11 The first part is the catastrophizing about sleep is something that we do work with directly. Right. If I don't get eight hours of sleep, then blah. Everybody's got a way to finish that question or that statement.

38:26 Feel awesome, whatever it is for you.

38:28 Yeah, I'm going to botch the presentation. I'm going to get fired. I'm going to this, I'm going to that. We work with a tool called the Thought Record, which is a cognitive behavioral tool that is pervasive in cognitive behavioral therapies, whether it's for depression, panic, anxiety, whatever. Use it for sleep too. Right. And we look at the truth of a thought. Now, we don't try and actually Pollyanna it, but we try and make it a more accurate and more balanced thought.

38:53 Right. So if I don't get eight hours of sleep, I'm gonna lose my. I'm gonna botch this whole presentation tomorrow, for example. Right. Well, what's the evidence that that's true? H. Well, when I've not slept well, I've not felt great about my presentations before, I've stumbled more over my words. Right. Or these kinds of things and. Well, what's not true? Well, I've. I've already made the slides. I've made my, my, my note cards. I know what I'm going to say.

39:23 I've given presentations after bad nights of sleep before, and I haven't been fired yet. So then what's a more balanced thought? Well, if I don't sleep well, I might not give the greatest presentation tomorrow. But I've always gotten through my presentations and it's been satisfactory for my boss for the past 12 years. And that's a less upsetting thought. Right. So learning how to cognitively correct some thoughts. I mean, if you've ever heard that phrase, don't believe everything you think now, you know what?

39:47 Right. I mean, you want to, you want to challenge some of those thoughts and actually Try and make them more true. So I tell people, look, I'm not interested in the difference between five minutes to seven minutes on your diary. I'm interested in the difference between five minutes and 50 minutes. Right? I am not comparing Joe to Bob to Mary to Frank. I am comparing forest to forest to forest to forest, week over week. Right. So as long as you're filling it out the same each week, then we're good to go.

40:11 Because I'm looking at with in person trends and I don't have people use wearables in insomnia treatment for the reason that you mentioned. They often make people crazy. However, I do think that wearables are excellent for certain types of behavior change. And if there's one thing I've loved, loved, loved wearables for is when people tell me that drinking six beers and two cocktails before bed doesn't affect their sleep, I'm like, oh it doesn't, let's see about that.

40:39 You know, and you can actually see that much more clearly in wearables data now I think than ever before. So it's really helpful for within person behavior examination. A lot of people will also say like, oh, I've noticed that on nights when I work really late, it seems like according to my wearable it's taking me much longer to fall asleep. And people will subjectively know that too. But some people need to see it on one of these data platforms to believe it and then to make the behavior change.

41:12 So I like them for with in person behavior change. But if it's starting to make you crazy, it's not a good idea. Take a break.

41:18 Related to the tracking, I'm wondering how you think about just kind of the broader self help ecosystem that we've created about this. Like we've turned sleep into a performance category and whenever you turn something into a performance category, it's pretty easy to get anxious about it. So an actual sleep doctor talking about this might be helpful for people. I'm just wondering what your take is.

41:37 I like to remind people that we've evolved to handle a lot. Our species has been having babies for a long time time. People lose a lot of sleep when they. And here we are, right? We can survive periods of difficult sleep. They will come, they will go, it will be okay.

42:09 There seems to be this preservation on, you know, long term damage of having a bad week of sleep.

42:18 I'm thinking of this. There was a clip that went kind of, I'm gonna, I guess this is a mild call out, but so be it. I'M fine with that. there was a clip that went viral semi recently of Stephen Bartlett on Diary of a CEO talking about, like, drinking a glass of. I don't know what the exact thing was, but it. He was like, oh, I had like two glasses of red wine and it just like, destroyed my sleep for a week.

42:37 And I was like, man, I don't know if it destroyed your sleep for a week, it might've messed it up for that night. And even so, there was just this tone about the whole thing that was very, like, catastrophizing. That I think was a good example of this thing as a performance category and people's anxiety about it and I don't know, just like their pernicious focus on optimization that I'm not actually sure is particularly good for people.

42:59 Yeah, I'm not sure that the orientation is good for people. And I don't like fear mongering. It's a problem. I think that it's a very effective marketing technique. And so I think we're starting to see more and more of influencers using fear to try and elicit behavior change or purchasing. And when it comes to alcohol, you know, alcohol can mess up your sleep for. It's possible to mess up your sleep two nights after you drink it, because the night after you drink it, you're get.

43:36 You're curtailing your REM sleep. So you're waking up too early and you're kind of cutting off your REM sleep. Because remember, REM sleep is in the second half of the night, you're cutting that off. And then the second night, your sleep architecture may reorganize a little bit. I don't know how much REM rebound you get after a night of drinking. There could be some, but it could impact your sleep architecture. Two nights, that's entirely possible. And then if you decide the day after you drink, you skip your workout and then you don't feel great the next day, like, it could, it could cascade.

44:08 And for some people, that's why alcohol just isn't worth it. And they're like, you know what? This is not during treatment, I take people off. I'm like, guys, look, it's five weeks of your life. You can do this. This is not a big deal. If you've been sleeping bad for what, 50 weeks? They've definitely been sleeping bad for 50 weeks by the time they get to me because my wait list is over a year. So I know you've been waiting, and this has been a long standing problem.

44:30 Give me five weeks. To do it my way. And then let's see, you can go back to your way if you don't like it. But a lot of times what people do when they do treatment and they don't use alcohol is they'll find like, wow, like this actually is way better. And then I'm like, okay, well, the good news is you can bring alcohol back. And now you know the price of admission, right? And the price of admission might be really high.

44:50 Someone brings, they come back with two glasses of wine, like, oh my God, that was terrible. And guess what? It reminds, it reminds them of all of the weeks of bad sleep. So when they report it to other people, like what might have happened on the clip that you mentioned, it might have been a reflection, like a reconnection to all of those times of bad sleep when they were using alcohol more, more habitually, like, oh, that was terrible.

45:15 Like, you know, terrible, terrible. So in their mind, their experience of it might really have been like, wow, I was having.

45:21 Interesting point.

45:22 Like, I was really worried that I'd slipped back into the ways that I, I was sleeping before. When people have a slip up, they often will think, oh no, I'm slipping all the way down. The great thing about CBTI is you learn how to deal with one night slip ups and then get right back on the wagon, get the show back on the road. I've had some, I had one patient, it was great, who also told me I could tell the story, but she had to go to these work events that involved lots of drinking.

45:51 It's expected socially, the drinking, right. And there was always red wine, glass after glass of red wine. Right. And she just, she couldn't hand. It was small person also just was like, wow, I'm expected to get up alcohol. Yeah. And she's just expected to get up and produce it, you know, on, as an attorney, like six minute clocks and this kind of thing. And I said, you know what we're going to do? She's like, yeah, I have, I can't not drink at least three, three nights a week at these events or I'll never make partner or this whole thing, it's a social thing.

46:23 And I was like, cool. As much as I'd like to like just tell all those bozos that they're, they're being silly with this social expectation. If we've got to play their game, here's what we're going to do. We're going to go to the, there's, there's, there's some great grocery stores in San Francisco and there's a few that sell really lovely products from all over the world. And some of them sell this like really fancy grape juice in these tiny little adult juice boxes.

46:47 And we're going to put them in your purse. You're going to go to these events, you're going to dump that wine out in the bathroom, you're going to put the, put the grape juice in your wine glass and you're going to go by, you know what, you're just going to do that if we're not going to stand up to the social stigma of not using alcohol. And it was, it was life changing for her because of how much and to the point where you know, when we did a booster session like a year later, she was just like, you know what, it was just so life changing to not feel all of the feelings that came with drinking alcohol, all the hangovers, the guilt, this, that she's like, I do so much better.

47:29 And without having to feel like she was telling people, she's like, you know what, it's my little secret. And I feel so much better about it. And this is just the lifestyle and I'm here to support all of that. I love it when people can be honest. But if people feel like, you know what, this is just something I have to keep to myself in order to feel better, I'm all for that too.

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48:50 That's right, start your free trial@shopify.com beingwell that's shopify.com/being. Well, so stimulus, control. Nothing in bed but sleep or sex. Time in bed, restriction, cognitive techniques. We talked about working with those Thoughts that you were describing, including anxiety, sleep hygiene. We already talked about a little bit. Last one, relaxation exercises, which was the one that you were sort of the most like, well, you can kind of take it or leave it. But it's interesting that that's the one that again, I think there's so much content out there on whether it's like mindfulness based exercises or listen to this, this sleep meditation practice when you're lying in bed or something like that.

49:38 So I actually wanted to ask about that. So even if you're just using something when you're lying there in bed and it's like a meditation thing you're listening to, you're like, no, okay, interesting. Because I'm like, oh, maybe that one thing you've got that cue with or something. But no.

49:53 Sex. That's a no. It's a hard no. You can do that on the couch. You can meditate on the couch, you can listen to a recording on the couch. You can do what's called progressive muscle relaxation, which is where you, you know, you squeeze apart, you let it go. You squeeze apart, you let it go. You move through your whole body to like, get out of your head and into your body. Similar to a body scan, except for there's no squeezing.

50:12 But, you know, my patients.

50:15 That's really interesting to me. Ashley, by the way, like, this is. I haven't heard anybody else say this, I don't think thing. This is good stuff.

50:20 Well, everybody who knows cbt, I will say this. And it's, it's. You can do these things all outside of your bed to, to calm down, but the people I see are much more likely to find it calming to do what's called a brain dump, where you take a pen and you write a list of everything that you're thinking about before bed. For your to do list for tomorrow. You write it down and you put it down.

50:43 And then when you get in bed, you don't have to run through the list. You think, oh, the list sucks on that paper. Oh, I don't have to. The list on that paper. It's kind of like the night before you go to an airport for a. For a flight.

50:52 This is extremely helpful for me, by the way, not to cut you off. But like this, I got a lot of mileage out of this.

50:57 If you ever have an early flight out of sfo, right? Which I'm sure happens to you. And the night before, you're getting, you get in bed and you're like, all right, I need to remember to turn on the porch light, turn off the, the heating, put the dishes, you know, all the. You're like running through your head all these things before I leave. All these things before I leave. People will get in their bed and they'll run through these lists in their head.

51:18 And if instead you just write down everything you need to do in the morning, turn off the porch light, turn off the heater, then you get in bed, you're like, wow, I just have to look at the list and it gets real old real fast. And then you'll fall asleep quickly.

51:32 With this time in bed awareness, you know, if you're going to need to wake up earlier for whatever reason, you would recommend sticking to a consistent, consistent bedtime or would you recommend prioritizing a consistent wake time? Or, you know, I'm just thinking about the reality of normal life for people.

51:51 Okay, let's paint a picture. Let's say you've got a really early flight on Sunday and you've got to wake up three hours before your typical wake time. I would say if you want to shift yourself, you can wake up an hour earlier on Saturday. Cut your caffeine off an hour earlier on Saturday, and you'll be sleeping. You'll go to bed earlier on Saturday night, and then you'll be able to get up earlier on Sunday. You don't need to fuss with it too many days.

52:17 Okay, you can, you can do a longer lead time if you want to, but for most people, their life is structured around the times they're already using, and you don't want to change that too, too much. But when you start trying to go to bed early without having gotten up earlier that morning to build extra sleep pressure, you're setting yourself up for a bad landing.

52:43 So with the, like, meditation, progressive relaxation techniques that people that are on the acceptable list that people will do in bed.

52:51 No, there is no acceptable list in bed.

52:54 Sorry, I'm trying to refer to the relaxation exercises side of it. Are there versions of that that you

53:00 think are acceptable or it kind of runs through your.

53:02 How do you think about this? Yeah.

53:03 So in your bed, when you're falling asleep, if you want to be doing in your mind without the assistance of a phone and everything else, a body scan as you fall asleep or progressive muscle relaxation as you fall asleep for like 5 minutes? I don't care. That's not a problem.

53:18 Yeah. Or when it turns into an activity, I think is part of what you're. You're talking about. Yeah, it's a. Not sleep activity. It's really Interesting stuff. Well, you're going to get some emails from some very large app companies, but I'll let you deal with that. No, I'm kidding. I'm kidding. I can't imagine that they're deeply investing this show.

53:35 They've decided to do that. What you're referring to with all the apps that people are using in bed? Yeah. That's a hard no.

53:42 So, as we've said throughout this conversation, CBTI is a really effective approach to therapy. About 70 to 80% of people respond meaningfully to CBT I. This is a great result in the field. And full remission runs more like 40 to 50% of people. So half of people totally solve their problem when they do a course of CBT I. Very, very good. But this means that roughly half of people still have some kind of symptoms after a course of CBT I.

54:15 And you're running this study right now, I believe it's called the Sleeps study, where you're taking a look at what might help improve the effectiveness of CBT I in general by looking at hyperthermia. In other words, heating people up in order to improve their sleep. And I was wondering if you could just tell us a little bit about that.

54:33 Do you remember earlier how we were talking about how your body temperature is supposed to be coolest at night and warmest during the day? Now, there are some folks who have trouble cooling down at the start of the night. And when you aren't able to cool down, it's harder to fall asleep. Ironically, when your hands and your feet are cold, it's pretty hard to cool down. Why? Because when you have vasoconstriction in your hands and your feet, that means that the blood is not circulating out to your hands and your feet, where it is close to your skin surface, and it can cool off.

55:02 This is why, ironically, taking a hot shower, for example, can actually cool you off. Because you're opening your vasculature, you're vasodilating in your hands and your feet, you're dumping heat from your core, and you're able to cool down. And so what we're doing is we're looking at, well, the people who can't fall asleep at the start of the night, are they having some sort of temperature issue that we can help with by having them use an infrared heating blanket?

55:27 Right. We're just having them use an infrared heating blanket for a period of time, you know, close to bedtime, not in bed. Right. But before bed, to encourage vasodilation, to help their body cool down. So that they can fall asleep more quickly. And we presented data at the International Congress for Integrative Medicine and Health just a few months ago on our first trial where I think 90% of the people had remission from using a CBTI app, basically an online program that we.

56:01 No, no therapist was involved. Right. And using this passive body heating, you know, one to two hours before bed, this combination. So it was, it was pretty remarkable results that, that, that we, we got. And we're doing a trial now where we're randomizing people to either just do the online program, which does pretty great, or do the online program with the pre bedtime heating blanket routine again. Heating blanket outside of the bed. And everybody always asks, so I might as well just say it.

56:33 We're using the, the, the higher dose infrared sauna blanket. That's, that's what that is. And we have them use that outside of bed before, before going. But it's, it's interesting. We're really trying to create this as a mind and body intervention that doesn't involve supplements, drugs, etc, that's, that is going to be good for the long run. So once people get cbt, I, they don't need. Again, it's like Santa Claus, the jigs up, they know everything.

56:59 But they might still need to do a practice that helps them cool down before bed, like a hot shower or using a sauna blanket or whatever so they can fall asleep more quickly.

57:09 I assume that some of the answer here is we're still figuring this out, but could somebody get similar results from a hot bath, a hot shower, something like that, or do you really need like a sauna blanket?

57:20 No, we don't know what you need. We're using the Cadillac right now because we're trying to do a controlled research study. And when I have people, if I were going to have someone take a shower at home, I don't know how hot it is, I don't know how long it is. There's no timer. But the sauna blanket, we can say, look, put it at this level, set the timer for this many minutes, go right. It's controlled in a way that a bathtub isn't.

57:41 You run a bath, the minute you get in there, the water's cooling off. A bathtub is not a hyperthermic tub. It's not like a hot tub that's staying hot right there. There have been studies, and there's been at least one meta analysis published in 2019 on the role of passive body heating and sleep, showing that across several populations, things like warm Foot baths. Warm showers can often help people who have trouble falling asleep at the start of the night.

58:07 That's where I got the idea to write this grant proposal to the National Institutes of Health. And it came about just trying to combine this body based practice that's shown promise in the form of hot showers, hot tubs, baths, whatnot, with this behavior intervention to see, okay, can we make it better? Because like you said, 50% of people get remission. Well, maybe we need to bulk up that package.

58:34 I also wanted to ask you, and we just have a little bit of time here at the end, this could be a whole separate episode about some of your related research where you've looked at the effect of heating and cooling people's bodies as a treatment or as an integrative treatment for depression. Depression, if I'm remembering correctly, that was wild to me as somebody who knows just enough about this stuff to be dangerous, if that kind of makes sense.

58:57 So why would that help somebody who's experiencing depression?

59:01 Yeah, so this is a great question. We're actually about to launch a multi site clinical trial funded by the National Institutes of Health at ucsf.

59:09 Congratulations.

59:09 Thank you. Ucsf, Harvard, Mass Gen and the Cleveland Clinic. Three hospital sites, Ohio, you know, the Boston area and San Francisco area. We'll be recruiting participants starting late 2026. So if that's something of interest. Yeah. Please do stay tuned. The story with heat is fascinating. There is literature from prior decades, several decades, showing that people with depression seem to run hotter, meaning their body temperatures are just higher and they're not, you know, we live around 98.6.

59:45 It's not that much higher. Right. There's a very narrow range that humans live in. Right. We're not talking like many, many degrees here, but they're running a little bit hotter. And what does that suggest? Well, that suggests that they're not as good at cooling themselves down. How do we cool ourselves down? We sweat. Right now you and I are sitting, we're sitting here, we're sweating even though it's in temperate rooms. You know, we're not dripping, but we're microscope, we're sweating and so amounts.

60:05 Right. So people with depression may be less efficient at cooling themselves down. And what these data have shown over the over several decades and what we just showed in a second, another paper we published with 19,000 people in it, we published first one a couple years ago and then published just another one showing that people with depression have higher body temperatures in a graded fashion. The people with the most depressive symptoms were the Hottest, followed by the people with moderate symptoms, followed by the mild file, followed by the within normal limits of symptoms.

60:36 And we had, we did that using OURA rings. We had these thousands and thousands of people wearing OURA rings. And we just found that, you know, and then in the paper we most recently published, we statistically, statistically accounted for the weather on the day in the exact time zone where each of those 19,000 people were to show that it was not because of the weather. But I digress. The point was, over the past several, several decades, there have been all these interesting experimental papers showing that when people's depression gets better, their body temperature regularizes, meaning their body temperature drops and their circadian amplitude, or their Diana amplitude increases, meaning instead of, you know, remember we talked about that, Coolest at night, warmest during the day, that amplitude in people with depression is classically smaller.

61:22 So they're oscillating less. And when their depression gets better, they start oscillating more. And what's interesting is that when people's depression has been treated through whatever means, psychotherapy, electroconvulsive therapy, whatever, their body temperature regularizes. On the flip side, in 2013, there's this great paper that showed that when a heat treatment was given using infrared heating to people with depression, then their body temperature regularized and the degree to which their body temperature dropped over the five days correlated with, with the drop in their depression symptoms.

61:54 So this is fascinating. You can intervene on the depression symptoms to impact body temperature, or you can impact on the, you can intervene on the body temperature to impact the depression symptoms. So it's fascinating that it's going both ways and what we're doing in our, and we've done now two small pilot trials. These are feasibility trials, these are not efficacy trials. And it's important to distinguish that we were not statistically powered for efficacy to show. We were powered for feasibility to show, like, hey, is this feasible for us to do this study?

62:25 And what we found in these feasibility studies, the first study was that I think 91% of the people who did the treatment, which combined cognitive behavioral therapy with a therapist once a week over zoom, and then separately coming in for four whole body hyperthermia treatments in the lab at UC San Francisco, at the Osher center, right. 91% of those people no longer had depression by the end. And then we did the trial again, 86% no longer had depression by the end.

62:53 And then we tried two different levels of heat for that one, and both levels worked. Actually, the sham, which was the lower temperature and the active, which was higher. Turns out what probably mattered was the fact that people in both conditions were sweating their brains out. Didn't matter how high we got their core temperature, because remember, it's all about the sweating. Once we induce sweating, your body is cooling itself. That doesn't. So maybe we don't need to get you as hot, we just need to get you sweating.

63:16 But the point is 86, that was like a 30 person study. And 86% of those people no longer had depression at the end, as assessed by a clinical psychologist doing an interview.

63:26 So pretty good numbers.

63:29 Yeah, feasibility studies, very promising, very small studies. That's why we're next moving to what's called a multi site feasibility study, where we're showing that we can do this simultaneously at three hospitals. And after that, then we get to do what's called a multi site efficacy study. Government willing. And that, that, that is, that's the,

63:47 that's the big boy one.

63:48 Yes, that's the big boy.

63:50 And so that's really, really cool stuff.

63:52 A long time to get there.

63:54 Yeah. This is wild stuff. And I mean, you just think about the potential impact for people if something like this could, could really dial up the effectiveness of an already pretty validated trade mandate. CBT for depression.

64:05 And we are recruiting for the insomnia study, I should say. And that's, that's recruiting across the United States, including Hawaii. It's remotely delivered. So if anybody's, you know, we have about half as as of now today. I think we have 20 spots left in that trial. And then we'll begin recruiting for the depression trial late 2026. And for that trial, folks will need to either, you know, reside in the San Francisco Bay area, the greater Cleveland area, or in the Boston area.

64:36 Well, if you get a sudden influx of being, well, listeners in the greater San Francisco Bay area, I will feel warm and fuzzy inside because this sounds like a really cool treatment. I would love to keep on talking with you about this, Dr. Mason, but we have come toward the end of our time here, so I just wanted to quickly ask, is there anywhere else where people can find you anything else you want people to know about your work?

64:58 Anything at all? Mike's yours.

65:00 Thanks. I confess to being horrible at social media. I think that I have like 8 posts to my name on Instagram. I have ambitions to improve, but I am on Instagram. I think It's Ashley Mason, Ph.D. or something like that. I don't even remember, but my lab website is Sea Lab UCSF Edu. That's A great place to go see what our research studies are, are that are ongoing. If you're interested in participating, there's links from there to see if you're eligible.

65:31 There's also information there for people who may be interested in supporting the work. You know, the work that we do in my laboratory would not happen without the kind of philanthropic support that we have received. And donations to UCSF are all tax deductible. It's, we've had the great good fortune of incredible people for, from Andrew Wilkinson, the Donner foundation, you name it. We've had like unbelievable supporters. So if you want to be one of them, if you're a science minded philanthropist, please do reach out.

66:00 We'd love to talk with you. And then if you were people often email me asking where can I find your scientific articles? And to find the scientific articles you can both see them at my lab website. But also Google Scholar is a great place to go. You go to Google Scholar and you can type in my name and, and you'll. There's a bazillion Ashley Masons, but if you just look for the one that verified for UC San Francisco, you'll be able to then see all like all the listing of all the publications that have come from my lab.

66:27 But those are pretty much the best places to find me.

66:31 I really appreciate you taking the time today. This was great. I learned a lot.

66:34 Great. Good. Thanks for having me.

66:37 I had a great time today talking with Dr. Ashley Mason about CBT I insomnia, hyperthermia, which we got into toward the end of the episode for depression, a lot of really interesting topics and Ashley was just like a great person to talk to and it was great talking to her because I know essentially nothing or I knew essentially nothing about insomnia before I started prepping for this conversation. So we started with the beginning. What's insomnia and how is it different from just a little bit of sleep?

67:03 So insomnia is a persistent disturbance in somebody's experience of sleep. So they might have difficulty falling asleep. Maybe they can't stay asleep and they wake up too early or they wake many times during the night. The typical cutoffs for it are something like three nights a week for at least three months. Ashley was focused more generally and the people who come and see her at her clinic, because her clinic's got a long wait list, they've been dealing with problems for a while and these problems really disrupt their everyday lives.

67:31 This is not just one bad night of sleep and insomnia is incredibly common. About 5 to 10% of people at any given time are dealing with insomnia. And roughly a third of adults report insomnia symptoms in any given year. And one of the really interesting things about insomnia is that it's very counterintuitive. Before I started prepping for this conversation, I thought that insomnia was you just couldn't sleep very well. Right. You got poor sleep. Well, that's a part of insomnia, but it's probably not the bulk of it, because people who experience insomnia, on average, Maybe they sleep 20 to 30 minutes less a night than people who don't.

68:13 And yes, there are some people with insomnia who sleep far less than that. That's what happens when we're talking about averages. Right. Most of the difference, though, between people who experience insomnia and people who don't is that the people with insomnia have a really, really unpleasant experience of their night of sleep. They're worrying about their sleep, they're thinking about their sleep. They're very conscious and aware of the times when they wake up during the night. They're stressing about that.

68:41 So you can have two people who both slept for six and a half hours, but who had radically different experiences of their night in bed. And so CPTI uses that and starts asking questions like, well, what happens if we just tell people, spend as much time in bed as you need to to get to the amount that you typically sleep and no more time in bed. That's time in bed restriction. It was one of the pillars of CBTI that we talked about.

69:10 Another one might be, wow, you're having all of these anxious thoughts about sleep and sleeping and the consequences of sleeping poorly. What happens if we work on those anxious thoughts a little bit and we ask questions about, like, okay, you're now catastrophizing because you didn't get a good night of sleep last night. Well, the last time that you didn't get a good night of sleep, did something bad actually happen or were you just really anxious about the possibility that something bad would happen?

69:38 Sure. You know, maybe you felt a little bit more tired or more groggy or, oh, you didn't feel quite as sharp as at work, but did something bad actually happen or were you just kind of worried about it the whole time? And so it's applying CBTish approaches to the problem of sleep. The five pillars of CBT I that Ashley mentioned are stimulus control. This is nothing in bed but sleep or sex time in bed restriction. Already talked about that.

70:04 1 Then cognitive techniques that's exploring those thoughts, particularly more anxious and catastrophizing thoughts. Although there are plenty of thoughts related to sleep a person might have that could be getting in their way or making it even harder to sleep. Then relaxation exercises. Ashley was kind of the softest on that category, I think it's fair to say. And finally, sleep hygiene, which we talked a little bit about during the conversation. Time in bed restriction can be a pretty hard sell for people who already feel like they aren't sleeping enough.

70:35 But it's based on this idea called conditioned arousal. And the idea is that sleep is a conditioned response to the cues of bed and the bedroom. If we spend a lot of time laying awake in bed, we're learning to lay awake in bed. If you spend hundreds of hours staring up at your ceiling at night, the bed itself can start to become a kind of cue for lying there awake. So what we're trying to do is rebuild those cues and our responses to different kinds of, of stimuli.

71:08 And the way that they do this is by very carefully controlling the amount of time a person spends in bed. Everything starts with learning about a person's sleep patterns. So let's say that a person is spending eight and a half hours in bed, but they sleep for only five and a half hours. If that's the case, there's no real point to the three hours that you spent staring at the ceiling or getting up and going down or whatever, looking on your phone, scrolling away whatever it was that you're doing, right?

71:37 So if in your sleep diary it says, okay, eight and a half hours in bed, five and a half hours of sleep, the prescription becomes something like a six hour sleep window. So your job is to go to bed at 12, wake up at 6, to do that every day, weekends included. If that sounds tough, it's because it can be tough. But if you think about it, you're not actually constricting the amount of time that you spend sleeping.

72:03 You're only restricting the amount of time spent in bed. The wake time in particular is what's really fixed first. And that's what kind of anchors the whole process. And the floor that Ashley was talking about, I believe was about five and a half or six hours, no matter what the diary says. And they then iterate on this, right? They look at how much the person is sleeping, and if they're sleeping better and better, if they're sleeping for about 85% of the time that they're spending in bed, they open up that window a little bit.

72:33 They Say, okay, let's add a little bit of time spent in bed because you're doing a really good job of sleeping during the time that you are in bed. And they work on this until they find your optimal level, including the ideal fall asleep and wake up times. Then, of course, real life intrudes on this whole process, right? Sometimes you got to wake up early, sometimes you go to bed late. These are all things that can affect the quality of the sleep that we get.

72:59 And Ashley talked a little bit about small ways that a person might like, titrate in or titrate out of some kind of known disruption to their schedule. So, for example, if you need to wake up for an early flight on a Monday, then maybe on Sunday, you're going to wake up a little bit earlier than you normally would to kind of get yourself ready for that. But she says, don't really push it so much. A few of the things that I actually talked about that really blew my mind, the first was her hard line around doing anything in bed that is not the task of sleep or the task of sex.

73:33 So if you're listening to your guided meditation, she like visibly recoiled when I suggested that, which was really interesting to me because it flies in the face of a lot of what you hear. And also a lot of people experientially, they put on their guided meditation or whatever, it helps them fall asleep. Okay, great. It's worth emphasizing that Ashley works with people who are dealing with like, real significant insomnia. And I can imagine that there are probably things that are perfectly fine for somebody who has a normal range relationship with sleep, like listening to your guided meditation that might not be so effective for somebody dealing with these levels of insomnia that she typically treats.

74:14 Another interesting thing that you said particular, particularly for me, a habitual coffee drinker, is she thinks that the cutoff for consuming caffeine is something around 11am pretty early in the day if you really want to optimize your sleep. And as a chronic afternoon coffee drinker, that was certainly a bit of a wake up call for me. One of the most interesting things that she said throughout the conversation gets to her work on hyperthermia. I hope I'm saying that correctly.

74:44 And these are like infrared sauna blankets that people will use before bedtime in order to up their core temperature a little bit, and that then seems to help people fall asleep at night. So you could mimic versions of this by, say, taking a hot bath or a hot shower before going to bed, and that might help you sleep a little bit. She's also applied this to depression, which was really fascinating. And we could do a whole other separate episode with her on that, I'm sure.

75:14 I believe that she's actually going to be recruiting for studies on this in late 2026 is what she said toward the end of the episode. And if you're interested in that, I'll try to include a link to that. If one is available. At the very least I'll link to her website. I hope you enjoyed today's conversation. I loved talking with Ashley. She was so great at communicating these ideas, so smart, so brilliant at the work that she does.

75:37 She mentioned where to find her at the end of the episode. I'll also try to include some links. If you've made it this far and you haven't subscribed to the podcast yet, if you could take a moment, hit the subscribe button, give us a like on YouTube, a follow on Instagram, a comment and a rating and a positive review on Apple. That would be fantastic. We'd really appreciate that. It actually genuinely does help us out. You can also find us on Patreon, it's patreon.com being well podcast and for the cost of a couple of dollars a month, you can support the show and get a bunch of bonuses in return.

76:11 And if you've made it this far, that means that you are among a very select group of people who actually finish the podcast episodes. And I've got a question for you. Are you interested in some of the more physical health based subjects that we've been talking about recently? For example, we had that episode with a neurogastro Internet neurologist that was really interesting to learn about. For me, we've got this one on sleep, we've done a couple of others on related physical health topics.

76:37 And I'm just really curious, is this a style of content that everyone's interested in? Because I certainly am. So if this is something that's drawn your attention, if you'd like to see more of it, please let us know. And until next time, thanks for listening and I'll talk to you soon.

76:54 It.