How to Use Cognitive Behavioral Therapy for Insomnia [transcript]

Written by Christopher Kelly

Dec. 13, 2019

[0:00:00]

Christopher:    Well, Ashley, thank you so much for having me again here in Samotea. I very much appreciate you. 

Ashley:    Well, thanks for coming here to meet me. 

Christopher:    I spotted a couple of books on Ashley's kitchen table, Why We Sleep by Matthew Walker. Is it any good? 

Ashley:    Yes. I think it's a great book. I think that Matt does a great job of explaining some complicated processes to people who just want to learn more about sleep and how they can make their sleep better. 

Christopher:    Okay. Did you learn anything from it? 

Ashley:    Sure. I mean, every time I read another book about sleep, I learn something. This is such a big field. There's so much science here. And yeah, it was really nice to you review his section on how identity works for example. It was nice to see how he explains these things in ways that make sense to people without chemistry background. 

Christopher:    And do you think that's important? So, you're more concerned about the practical aspects of sleep like what works rather than how it works?

Ashley:    Absolutely. I think that there is— When we tell people what works, a lot of people aren’t gonna do it until they understand how it works. So, to the extent that I need to be able to explain how it works to my patients in a way that they're gonna understand such that it's gonna motivate them to make the change, that’s what's really important. 

Christopher:    So, it’s finding that intrinsic motivation you think, the how it works, is important. 

Ashley:    Right. If you don't understand why it's unhealthy to eat birthday cake everyday for breakfast, if you don't understand why that's unhealthy, you might just keep doing it. But once you understand “Oh, here's what it's doing to my body”, “Okay, maybe I will stop that now.” Right? So, it works the same way with sleep because in my work with patients trying to help them get to sleep better, they often have to get worse before they get better. I ask them to do things that are hard, that make them more tired, and that seem like they're moving in the opposite direction of where they wanna go. In order to get them to do those things, I have to give them good reasons why. So, that's why I appreciated Matt’s book because it did help you understand a lot of the reasons why you need to go through these certain steps. It wasn't a treatment book so to say, but he does mention cognitive behavioral therapy for insomnia in the book, which is the treatment that I do at the UCSF Osher Center. 

Christopher:    So, I remember Dr. Parsley has been on the podcast. I can’t remember what year it was. It was probably 2014 I first heard him say this, that selling sleep should be like selling sex. And I totally agree with it. Last night, I had the most phenomenal night of sleep and I only woke up because the dog barked and it was already time to get up. And I just felt fantastic when I got out of bed. I know for sure I didn't even move an inch during the night, you know. Like that’s a fucking great feeling when you wake up in the morning feeling like that. Do you not agree with him then that selling sleep is like selling sex? 

Ashley:    I mean, I think that that could be a pretty fair analogy, but I would also argue that a lot of people don't get worried about their sleep until something goes wrong with it. People take for granted the fact that they often sleep well. I guess people often take for granted the fact that they— 

Christopher:    Don't have something in their eye right now. I’ve got nothing in my eye.

Ashley:    Yeah. So, a lot of times when I see patients, they'll say, “I've been sleeping great all my life and then this thing happened. Now, my sleep isn't good. I don't know what to do.” But I also have patients who say, “You know what? I've never slept well. Never.” So, I have a huge variability in my caseload. 

Christopher:    And then talk about this other— So, this is Quiet Your Mind and Go the Fuck to Sleep. 

Ashley:    I wish it was that title, but it does say Quiet Your Mind and Get to Sleep. And this is a book written by Colleen Carney and Rachel Manber. And Rachel Manber is a sleep psychologist at Stanford and she was trained by Dick Bootzin. And Dick Bootzin is also who I learned how to do this treatment from. Dick Bootzin was down at the University of Arizona where I did my graduate work. And both Rachel and I learned how to do this treatment from him. She went on to go and write a book about how to do it yourself at home, a self-help workbook that you can use to do this treatment. And for a lot of patients, getting this book is enough. They can do it with this book. A lot of patients though, they want help because it's hard and they need weekly accountability, and check-ins, and all the kinds of things that come with actually getting Cadillac sleep treatment. So, when folks seem pretty motivated, when they don't have a lot of other comorbid issues, not a lot of interfering pain problems and other things, I do recommend this book for folks on my waiting lists, which unfortunately a little bit too long if they want something in the meantime to see if they can help themselves. And I would say that, yeah, several times a month when I reach out to a patient about movement on a waiting list or whatnot, they'll say, “Hey, you know what? I got it under control. I got that book.”

Christopher:    Oh, that's great. 

Ashley:    So, I have nothing to do with the sale, or publication, or anything of the book. I'm just a provider/consumer because it does have great activities in it and it does explain a lot of the reasons behind the different treatment components. 

Christopher:    Okay. Well, shall we get into it then?

Ashley:    Yeah.

Christopher:    Would you say that CBT for insomnia, is that the correct label? 

[0:05:01]

Ashley:    Yeah. Cognitive behavior therapy for insomnia. We use the term in general in sleep medicine. We use the word “insomnia” to refer to a whole bunch of different kinds of sleep problems. Difficulty falling asleep at the beginning of the night, difficulty with waking up in the middle of the night, difficulty with waking up way too early in the morning, those all can be considered insomnia. I would also argue that people come and seek treatment because they'll say, “You know what? I sleep, but I sleep too much and I don't feel good or I sleep, but I never feel rested and I still find myself napping 3 hours in the afternoon.” Right? So, there's hypersomnia process sees that we do you treat with this treatment as well. So, it's not just for being unable to sleep so to speak. 

Christopher:    And is it possible for you to walk us through the steps without having a specific case in mind? 

Ashley:    Yeah. Yeah. So, there's not much in terms of products with this. This is not a treatment that involves buying lots of supplements, buying all sorts of tools. I tell patients that— 

Christopher:    I like it.

Ashley:    …”Luckily, I’m not going to make you buy anything except maybe an alarm clock if you don't have one.” I don't want patients to be using their phones as their alarms. It’s a big ask and I reassure people that you can go to Walgreens and they've got pretty cheap ones. Amazon's got even cheaper ones. I want alarms to make a comeback. But yes, I can walk you through what this treatment looks like. Now, all different CBTI providers, they might do the beginning of treatment, the steps, in a little bit of a different order. I can tell you about the order that I do because it seems most palatable and doable to patients while also being pretty rapidly effective. So, how I do this treatment is I have— Since I cannot see patients individually all the time anymore because I'm a professor and most of the time I'm doing research, clinical work is actually like 20% of my time, I have patients come in and do an individual intake session with me and I do an assessment of what's going on. When people say they're taking 1 Benadryl a night, I say, “Are you taking 1 pill or your 1 bottle?” And you'd be surprised. Some people will say, “Well, yeah, it's 1 bottle.” Like “Okay. On the rocks. At what time?” Right? 

Christopher:    Wow. Okay. 

Ashley:    So, you have to understand the complexity of the sleep problem that people can bring. I have had every kind of patient I can think of with all kinds of things I never would have predicted. Now, I'm better at predicting them. I've had patients who fly to other countries to go get medications and bring them back here because they're illegal in the U.S. I have patients who have been getting all sorts of interesting things that are not legal in order to be able to sleep, but I've also had patients who order Benadryl in bulk because they drink a bottle a night. So, there's all kinds of things that folks are doing to get to sleep. So, the first part of my process is an interview to figure out what substances are onboard because abruptly quitting certain substances in certain doses is dangerous. 

Christopher:    Wow. Okay.

Ashley:    And I am not a physician. I work with physicians when there are lots of substances and lots of medications. I work very closely to figure out what is a safe taper plan. That is step 1. Safety first. So, during that intake interview, I do all kinds of assessments about what time do you usually go to bed, what kind of problem do you have, do you wake up in the middle of the night, waking up too early, oversleeping, history, family history. Go through all sorts of things. When did this start? I do a whole kind of architecture of what's going on in their sleep world. 19 out of 20 times the patient is a good fit for my group. And I run groups with 8 people in them only because this treatment is a ton of work for the provider. AND that's why I think this treatment is often hard to find in the community because a provider can only bill for the time that they’re with the patient. I'm a little bit lucky because I work at the UCSF Osher Center where I am a professor and I have a lot of control over my time and I also often have a trainee or students, a medical student, a medical fellow, all sorts of folks who wanna learn how to do the treatment. In exchange for learning from me, they help me with the backend of this treatment. And I'll explain more about why that is and what that is now. So, I have 8 patients in each group. Each group is 5 weeks. The 5 weeks are all mandatory. You cannot join the group unless you can attend all 5 weeks. And there's a very specific reason for that. Patients will often say, “Well, can I just try it for a couple weeks?” And I say, “No. Because I'm going to make you worse before I make you better. The first 2 weeks, you're going to hate me. You're going to want to put my face in the middle of a dartboard and play darts with it and that's okay. I can take it. I've been doing this for a long time.” So, I tell folks “You have to come to all 5 sessions. Otherwise, we push you off to a future group. Believe me. You don't wanna go through all of this suffering to not get the full amount of benefit.” Okay. So, folks come in and what they start doing after their first intake interview with me, their only one, they start doing a sleep diary where they're tracking what time they get in bed, how long it takes them to fall sleep, wake up in the middle night, what time they wake up, all this stuff. 

[0:10:02]

    It’s a sleep diary. And in the book that I referenced, Colleen and Rachel’s book, they have an example of what one of these sleep diaries looks like and you can just go and get that from the book. I have folks do that. They bring a full completed sleep diary with 7 nights of sleep into their first group meeting. 

Christopher:    Wow. Okay. 

Ashley:    Now, if I diagnosed someone with or without insomnia based on information about 1 night of their sleep, I would be a horrible diagnostician because what we know about people with bad sleep is that there's nights of horrible sleep, then there's a night of great sleep, then horrible sleep, then great sleep. And it oscillates and it drives them nuts. Right? So, if I happened to get you on a Wednesday and you slept great the night before, okay, maybe I don’t wanna miss something. So, an insomnia intervention, we look at periods of 7 days and this also touches on some of the reasons that you've discussed in previous podcasts about sleep debt accrual, and sleep drive, and that kind of thing and I’ll get into that. So, in the first day of group, everyone comes in. They bring in their week that they've done and the past week of their sleep diary. And then in that first group, I explain all of the different theories about relevant things for the homework they're going to have. So, I talk about stimulus control, sleep hygiene, and the evolution and perpetuation of insomnia process. So, the first week's homework ends up being that everyone has to choose a wake time and set an alarm at that wake time. And for the next 7 days, they're going to get up and get out of bed at that wake time. I don't touch their bedtime yet and I'll say more about why that is in a second. So, I also go over sleep hygiene, which is widely touted about and thought about as “Oh, this is what you need to do. This is the solution to everything.” If that was the solution to everything, I wouldn’t have a wait list going to next August. The sleep hygiene includes things like don't drink extra caffeine on days after you get bad sleep. Right? We don't wanna compensate for that. But the major thing that is— and there's other things too. Right?  Don't exercise at 10 p.m. Try to exercise in the morning. Take your medications at the same time of day everyday. All sorts of hygiene things that are pretty easy to Google and look up. So, just assume if it's sleep hygiene, yes, I think it's useful. The major thing about sleep hygiene that’s kind of buried into it and actually its own separate thing is the stimulus control, which is that starting at group 1 I tell folks “Look, in your bed, you can do 2 things. You can sleep and you can have sex.” If you are someone who has sex more than one time a day, talk to me after. Let’s talk because maybe we need to put sex somewhere else. 

Christopher:    That's a good question. Why is sex is exception?

Ashley:    That’s just where people do that. And it's San Francisco. So, I have had patients who luckily have had guestrooms and we've actually relegated the sex to a different room because we really need to pair the bed with sleep. But I tell people “Look, we don't worry in bed. We don't get anxious in bed. We don’t fight with our partner in bed. We don't decide who's gonna pay for our kid’s college tuition in bed. We don't watch TV in bed. We don’t look at our phone in bed. We don't do any of these things in bed because guess what? We need to associate the bed with sleeping.” But by the time people have gotten to me with their sleep problem, a lot of people have moved into their bed because they're exhausted. So, just in case they can fall asleep, they're gonna work on their computer in bed. Just in case they might catch a nap, oh, I'm gonna have my snack in bed. Oh, just in case I might be able to sleep, I'm gonna take the conference call in bed because then I can just like hang up the phone and go right to sleep. I have people whose whole lives are built around their beds by the time they get to me. So, we need to associate life with life and sleeping with sleeping. So, that is a major change I make the first day they come in. So, nothing in better other than sleep and sex. And you have to get up at this time. Now, people will say, “Well, what about the middle of the night when I wake up in the middle of the night and I'm awake?” I'm like “Well, are you sleeping or having sex?” “No.” I'm like “Then get out of your bed.” If you can't fall asleep within 15 to 20 minutes in the middle of the night, get out of bed. And you know what you have to go? You have to go do something fun. You're not allowed to go pay bills. You're not allowed to go read about global warming. I do not want you to turn on CNN. No politics. Right? You have to go do something that you would feel guilty about doing during the day. Watch old episodes of M*A*S*H. Read a trashy magazine, whatever it is that you would actually not let yourself do during the day because it's just not productive, but you really would love it. 

Christopher:    And you don’t think that would be too stimulating. 

Ashley:    It has to be something that is not terribly stimulating. So, I don't want you to say, “Oh, I’ve always wanted to reorganize my kitchen.” That's not a middle of the night activity. Right? But some folks say, “You know, I've always wanted to check out that new language learning app.” I had a patient who learned Italian and actually her treat for finishing treatment was 3 months later she went on a whole Italian vacation ‘cause she learned so much Italian in the middle of the night when she was not sleeping and was getting to the point of sleeping again.

Christopher:    Oh now, you’re selling me on insomnia. Maybe I'm missing out— 

Ashley:    Yeah. Right. Right. 

Christopher:    …by spending a lot of time in sleep.

Ashley:    So, I tell them “Look you have to have activities that you can do in the middle of the night and you can't think about what they are in the middle of the night. They have to be setup on the couch before you go to bed. The book has to be there. The magazine has to be right next to you. 

[0:15:01]

    Whatever it is, it has to be all ready because what do we do— Do we make great decisions at 2 a.m.? No. We make much better decisions at 2 p.m. Most of us anyway. So, the major things are folks have to get out of bed when they're not sleeping. Now, what happens? You get out of bed when you're not sleeping. You set a little timer. I have a beautiful little kitchen timer right over there that you can see. It’s an old school timer right by my computer.

Christopher:    Oh yeah. Look at that.

Ashley:    And so, they set it for 20 minutes. When it goes off, check in with your body. Am I sleepy enough to go back to sleep? If I am, back to bed. If not, set the timer again, reengage in the activity. Right? We need to retrain that when you're sleepy, you go to the bed. When you are not, you do not go to the bed. And when you are not in the bed, I don't want you lying down on your couch. I tell people “No, no, no. If you need to lie down because you're so tired, that means you need to close the book and go back to bed. So, sit up on the couch.” A good indication of whether it's time to go back to bed is “Oh, I wanna lie down on the couch now.” Well, if you do, okay, back to bed. So, the first few nights are hell. People are miserable. I get emails the next morning from patients saying this is crazy. And I say, “Remember how I promised you that this was gonna happen? I predicted this.” 

Christopher:    So, what happens then? Some people end up spending the whole night doing stuff— 

Ashley:    Sometimes people get up and down, and up and down, and up and down. But the great thing is that by doing that for the first few nights, there's a few things that are really critical that are happening. They're building up extra sleep debt so that by the third or fourth night all of a sudden they're so exhausted. They capitulate into sleep. And then their alarm goes off and they’re pissed and they think I wanna keep sleeping. And I say “I know, but don't because we're starting to anchor you into that 24-hour cycle now.” So, some people come to the second group and they say, “Oh, my gosh, the first few days were horrible, but the last couple days, those have been better.” So, for some people, that setting of the wake time is enough of an orienting response to get a benefit. For a lot of people, it's not. We're not there yet. They're not happy yet. So, at that second group meeting, I collect their sleep diaries again because they've been doing it again for another week. And every time, we take them and we put them into my algorithms and we figure out what is their sleep efficiency. Their efficiency is defined as the total amount of time that they’re asleep divided by the total amount of time that they're in bed and we figure out how much are they sleeping, etc., etc. and then we do something called sleep restriction where I take their diaries the second week and we analyze them the night after group. And during that group— I'll tell you what I talk about during that group in a second. But we analyze those diaries after that group. Within the next day, I email them and I say, “Here's your bedtime. Your bedtime, it's the dream of your childhood. You can go to bed at whatever time, 12 a.m. or later.” So, you can't go to bed until your bedtime. So, when you were a kid, you'd be like “Oh, man, I got to go to bed. It’s 10 o’clock.” When you're an adult now in my group, you’re saying, “Oh, man, I can't go to bed until 10. I have to wait until I'm sleepy?” So, by doing this, we are restricting people's time in bed to match about how long they're sleeping so that their body learns I'm in bed. So, now is the time to be sleeping because this is how much time I have to sleep. So, that second week is people's personal hell. But at the same time, they come back at the third session and they think “Wow, that was some really deep sleep. That tasted really good. I want more of that. I'm not happy, but I tasted it.” So, by the third time people come and see me, they remember what it feels like to really be asleep. Not in this hazy gray zone thing, which is what a lot of people come to me saying. They say, “Oh, you know, I'm kind of asleep all night, but kind of not really and I don't feel good.” This forces them to be in that deeper sleep. And from then on, we start increasing their amount of time in bed by making their bedtime 15 minutes earlier each week provided their sleep efficiency is at least 85%. As long as you’re sleeping 85% of the time that you’re in bed. So, that's kind of how that works. But in the content of the second session, really focusing on why sleep restriction is useful. And in the third and fourth session, I start to really focus on the cognitive therapy-type tools for dealing with anxiety and worry because a lot of folks start off the group worrying about sleep and that's what we're— By the time we’re in the third and fourth week, we're starting to get into some of the weeds and people are actually realizing “Oh, you know, when I wake up in the middle of the night, I’m worrying about these things.” And a lot of folks are suppressing their worrying all day. They think “You know, I’m able to avoid this during the day. But then during the night, I can't handle it.” 

Christopher:    So, the part of the brain that was suppressing those thoughts and feelings like is on offline now and they will come branching out.

Ashley:    Right. So, I say, “Well, you know what we have to do. We have to do this during the day.” You know what I make people do? I make them schedule worry time worry time because worrying is so important that we're going to disrupt our sleep for it. Right?

Christopher:    I start to realize why people love you so much actually.

Ashley:    No. I don't know if they do. They like me well enough by the end. In the middle, they can hate me. But if worrying is so important that we’re gonna disrupt our sleep to do it and we have to prioritize that shit— Right? So, I tell people “Look, we're gonna get worried during the day.” Everyday for the next 7 days, you are going to get worried from 4:30 to 5 or whatever fits in your schedule. 

[0:20:05]

    I have people get out their calendars and like “Look, we gotta book this. This is real important.” And then I give them all these different types of cognitive tools and some of these are in the book that I recommended and others are in a book called Mind Over Mood, which is easily accessible on Amazon or whatnot. But I have folks work on worrying effectively. So, we learn how to worry effectively and how to be anxious and how to actually change our own feelings. 

Christopher:    Oh, let’s get into this. How do you worry effectively? What do people worry about firstly?

Ashley:    All kinds of things. So, we know that this is operating along with the cognitive behavioral theory of distress. So, when we think about the cognitive behavioral therapy of distress, you think about thoughts, feelings, and behaviors and think about them like a triangle with thoughts at the top then going down to feelings to the right, behaviors to the left, leading back up to thoughts. It’s a circle. Okay? So, I'll draw an example from my diabetes work. If someone comes in and has the thought “I can't get my diabetes under control, I can't seem to get my diet right, I'm never going to be able to get off these meds, I'm just a failure at dealing with my diabetes”, how do you think they feel when they think those thoughts? 

Christopher:    Helpless. 

Ashley:    Depressed, helpless, hopeless. When people feel that way, what do they do? 

Christopher:    What do they do? That's a good question. 

Ashley:    They might eat some chocolate cake.

Christopher:    Oh, I see. I see. This is hard for me because this has never been a response. 

Ashley:    Okay. Well, you are special, but a lot of people to cope with with feeling that— 

Christopher:    Yeah. The self-medicating.

Ashley:    …they’ll self-medicate with something that’s not healthy.

Christopher:    Yeah. See, I’ll be more likely to self-medicate with exercise, will be my drug of choice.

Ashley:    Okay. You’re special. If everybody self-medicated with exercise, we might not— 

Christopher:    They probably would— 

Ashley:    We might be at a very different world right now.

Christopher:    Right.

Ashley:    But go with me on this example here. Okay? So, folks aren't feeling good. Someone isn’t feeling good because they have all these thoughts. I cannot deal with my diabetes. I can't seem to get it under control. I feel really bad about myself. I cope by eating a piece of chocolate cake from Costco. And then that reinforces my thought, I really can't do this. 

Christopher:    Oh, I see.

Ashley:    Right? So, we’ve got this cyclic problem. 

Christopher:    Right.

Ashley:    Now, all of the different sides of that triangle represent different things we can intervene on in the process. So, for a nice example, with depression, there's something called behavioral activation. A lot of folks might say, “Well, you know what? When I feel better, I'm gonna take my grandkids to the movies. That's what I really wanna do. When I feel better, I’m gonna take them to their favorite movie.” Guess what we do in behavioral activation? We sit there and we take out their calendar and we schedule all the stuff they're gonna do that week regardless of how they feel. Right? So, the woman might say, “Okay. I took my kids to the movies. And you know what? They had a great time and I felt really good about bringing them to the movies. I guess I think it is interesting and fun to take my grandkids to the movies and it made me feel nice.” So, we’re starting that positive feedback loop somewhere else.” 

Christopher:    I see. 

Ashley:    We're not waiting for the feelings that drive behavior impacting the behavior, which then impacts our thoughts. Oh, I really can go to the movies when I don’t feel well.

Christopher:    Right. So, the motivation comes later. I didn’t have the motivation to go do it. But once I’ve done it, then I started to feel motivated. 

Ashley:    Right. So, that's what behavioral activation will do. Now, with cognitive therapy and what we do here in sleep, we’re really focused on that link between thoughts and feelings. And have you ever heard the phrase “Don't believe everything you think”? 

Christopher:    Yes.

Ashley:    Yeah. I tell people that all the time. Don’t believe everything that you think especially at 2 in the morning. Right? So, in this exercise, I have people identify their thoughts. I'm never going to sleep well again. I'm doomed. That's often how it will start. I have no control over my sleep. There's nothing I can do. And what are the feelings that you feel when you have that? Oh, I feel anxious. And I have them rate their anxiety on a scale from 1 to 10. That’d be a 9 out of 10. Then we go through the evidence for the thought. Okay. Well, I don't sleep well right now. I'm exhausted. Then we go through the evidence against the thought. I'm sitting here with the doctor to get help. I have slept well in the past, whatever the evidence is. And we develop a more balanced thought. Maybe that's I'm not sleeping very well right now, but I can't predict the future. I might sleep well again or I’ve slept well in the past. I'm not sleeping well right now. So, I'm gonna get some help. And then we re-rate the anxiety. Maybe it's down to a 5 out of 10 instead of an 8 out of 10. Right? So, it's not a panacea, but these tools work like a little bit of Xanax. Right? Just a little touch. And so, teaching people how to work with these tools during the day so that the anxiety isn't boiling over in the middle of the night starts to get that process. These are tools for treatment for something called generalized anxiety disorder or GAD. Right? And so, these are something that I integrate heavily into cognitive behavioral therapy for insomnia. By the time that I'm doing individual follow-ups with people, which is what I do after they complete the group, we start looking at some of their thought records and they're much more along the lines of things that have nothing to do with sleep. My daughter really doesn't Love me or what have you. They can be all these other thoughts and turns out those are often the thoughts that are keeping people awake at night. 

Christopher:    Okay. Let me ask you this though. So, one of the things that resonated with me when I fast started learning a little bit about acceptance and commitment therapy, there's a quote here from Russ Harris who I know you know. He's written some pretty fantastic books called The Happiness Trap and The Confidence Gap. And they all rhyme, his books. And I think all of them are good and perhaps not quite what they say on the cover, you know, like you could read it and get a lot out of it even though you don't think you're unhappy, but if you get my point. And anyway, in act, we are not generally interested in whether thoughts are true or are false. We are far more interested in whether it's helpful to get “up” in them or not. So, people have unwanted thoughts that are true. Right? It’s true. I am fat. That’s not something that you could provide ever an evidence to the contrary and win me over like this really is true. And so, it’s maybe not helpful to think whether or not this is true or false and it certainly doesn't stop the thoughts from coming back over and over again.

Ashley:    Definitely. So, I can speak to this. 

Christopher:    Okay. I hand out to my patients a list of something called cognitive distortions. On this list are things like mind reading, catastrophizing, personalizing, shoulding. People should all over themselves. I should have brought a cake to that party. Margaret is so mad at me for not baking a new cake for her baby shower, what have you. Right? Cognitive distortions are what my patients are generally saying. 

[0:25:03]

    They’re not coming in and speaking a— Like there are facts that are upsetting, thoughts. My father has cancer. That is an upsetting thought. It is true and there's no way that I can spot record myself out of that or CBT my way out of that. Right? So, I do think there is a role for acceptance and a whole host of things. And I do also think that we can use mantras along the lines of “You know what? I'm awake in the middle of the night. This has happened to me before. I've been okay. I'm going to continue on with my— I'm gonna get out of bed and go read right now.” Right?

Christopher:    Because the acceptance model, you might say, “Well, was it helpful for me to be worrying about this at 2 in the morning?”

Ashley:    Is it helpful? Right? So, for a whole host of types of thoughts, we can get to that. Is it helpful? And that is a good goal. For a lot of folks, they're not there yet and working with thoughts that are not true by looking at the evidence for and against them and then developing an adaptive thought so that we know there's another thought we could have instead. That is also true. The key thing about developing that adaptive thought is that it has to acknowledge that there is a part of the thought that is true. 

Christopher:    So, it’s not like you’re trying to deceive yourself. In fact, that’s probably not possible. Right?

Ashley:    Right. So, for example, if the thought is people don't like me, the evidence for that might be “Oh, you know what? My friend and I had a big fight. We're not friends anymore.” The evidence against that might be like “Well, I have a family. I have some other friends. I have my siblings that I really like, my coworkers I enjoy spending time.” A balanced thought might be “Not everybody likes me, but a lot of people in my life do like me.” And that's a less upsetting thought than everybody hates me, which is where we started. And it's more true. So, I would argue that these 2 ways of approaching thoughts are not totally incompatible. It's much more useful for me as a clinician to say, “Let's go except the thought that's more true.” Blindly accepting a thought that isn't true, I don't know how useful that's going to be. Just simply sitting there and thinking “Well, how useful is it for me to think the thought people don't like me?” Sure, it's not useful. I know it's not useful. That's not gonna necessarily make it go away. And accepting a lot of those thoughts can be exhausting. I have a patient who actually— It was interesting. I do have a chart that I hand out to certain patients when I'm working with them. And on one side, it says, “Here's what will happen if I if I choose to engage with this thought and here's what I could do if I choose to not have this thought.” And on one side, when he filled it out recently, it said, “Well, if I have this thought, I'm gonna be stressed out. I'm probably gonna feel a little nauseated. I'm not gonna wanna go hang out with my friends.” All this whole host of things. And then if he doesn't have a, he wrote down “Oh, I might go outside on the porch. I might go have lunch with my wife. I might do all these other things.” It’s like “You know what? Examining the utility of these thoughts was like mind blowing for him.” But by the time I did that exercise with him in treatment, he'd started to realize that all of these soap operas, which is what he called them in his brain, these repetitive thoughts about what he should have done when he was— 

Christopher:    Yeah. I like the analogy.

Ashley:    …when he was different age, he’s like “The opera, they're all similar. They're all very, very similar. They're not special. They’re not unique.” It's just which episode of the soap opera am I gonna think about that day. And he was able to realize— 

Christopher:    That’s kind of suspect to me the thought that you could like choose your thoughts. You don’t generally get to choose your thoughts. Right? They keep coming regardless of whether that’s true or not. 

Ashley:    Right. But they don’t necessarily keep coming. It's like you can't unknow that Santa Claus isn't real. 

Christopher:    Right. I see.

Ashley:    As soon as I tell you Santa Claus isn't real, you can’t go back in time. But as soon as we realize “oh, that thought isn’t true, I looked at the evidence for and against it”, then that thought doesn't have as much power we’ve handicapped it. And accepting a thought that is more true isn't Pollyanna. Right? It acknowledges that there’s a kernel of truth to the original thought. It's much easier and more palatable to accept. But with that patient, he was able to decide “You know what? Whenever I have this thought, I can now go back to my rubric and choose do I wanna have this thought or do I not want to.” So, that’s pretty far down the line. 

[0:30:01]

    That’s when patients actually are able to realize “Oh, I do this.” Another exercise I like to do with patients about their thoughts is I like them to track how much they believe in their thoughts. I once had a patient who had something called multiple sclerosis. I tell this story to all of my groups. Multiple sclerosis is a horrible condition. And this patient was quite young. It was particularly upsetting that the patient had that. And in the morning, she would wake up and her first thought would be like “I'm never going to get through this day. I’m never going to make it.” And she had a pretty significant job with people expecting things from her, etc. She thinks “I’m never gonna make it through that meeting. I’m never gonna make it through that lunch with that presentation, all these things. I'm gonna be in so much pain.” We got paralyzed in anxiety every morning. But come 11 o’clock by the time she was at work because, you know, in the Bay Area no one goes to work until like 10, right— 11 o’clock, got her coffee in hand, all the things, whatever, with her admin and what not. She said, Okay. All right. Here’s the plan for the day.” If I ask her how much you believe the thought I’m never gonna make it through this day, I can't possibly do this, if I asked her how much do you believe that at 6 p.m. when you're having a glass of wine with your boyfriend, she'd be like “Oh, no, I don't really believe that. I’m gonna make it through the day.” If you believe a thought at different levels over the course of the day, how true can that thought be? If you are certain that North Korea is going to bomb us at 2 a.m., but you are not certain that that is going to happen at 2 p.m. when the sun is shining, how true can that thought be? 

Christopher:    Yeah. You know, Russ Harris talked about the idea of being hooked into a thought and I think that's what's going on there. Right? Somehow at 2 a.m. it's easier for you to get hooked into that thought. 

Ashley:    But once you have this awareness of the fact that “oh, it’s 2 a.m., this is why I'm thinking that thought”, it completely chops the arms off the thought. 

Christopher:    And is it possible to have that level of cognition when you just said that your cognition is not doing well at 2 a.m.?

Ashley:    Once you go through these motion of examining the thoughts— I think that accepting stuff is very interesting and it has a place in this, but I think that when there are such distortions and distress associated with thoughts, first, we need to do some cognitive correction of what's going on. And this is a tool for people to see “Oh, I always believe this at 2 in the morning. I always think I'm not going to make it a 7 a.m.” You know what happened with that patient? Mornings became her favorite time of the day. She realized “Oh, it's 7 a.m. I'm having this thought, but I'm not going to think this at 11. So, I'm just gonna go and enjoy the morning.” And she started to actually really enjoy her mornings because she’d wake up at 7. She didn’t have to be at work until 10. So, she developed a whole new rituals for the morning. And this happens to be a patient who did go and learn another language and went on a trip. Another example of one because there’s all these language learning apps. Babble and all these things. And was so excited about the fact that her days no longer start with such acute anxiety.

Christopher:    So, maybe the acceptance then is less relevant once you’ve filtered out the truthful component. Maybe like accepting the rest might be useful. But initially, you have to do that filtering. 

Ashley:    I think that accepting what is true is useful, but it just so happens that a lot of the thoughts that patients are coming in with and that are keeping patients up at night are just not true thoughts. 

Christopher:    Right. Okay.

Ashley:    Right.

Christopher:    And do they keep coming? So, what do you find with patients? Are they still having those same thoughts and still going through this process after 2 years or something after— 

Ashley:    Some patients love thought records and that's the tool that I use and it's in this book that I recommended. They use them for a very long time. I once had a patient who when she was done with treatment, as a joke, she got me a paper towel roll, a monogrammed paper towel roll— I don't know how she did it— with thought records on them. It’s like everyone should just have these papers towels in their house so they could use this tool whenever they're upset. When I was moving, apparently that got mistaken as actual paper towel. So, I lost it and I’m really sad about that. But a lot of folks learn how to use this tool. You can't do it in your head. ‘Cause if you do it in your head, you outsmart yourself. You revert back to the original thought, but it’s like going to the gym. The more you do this, the more bicep curls you do, the bigger and stronger your bicep gets. So, folks do often do these thought records whenever things become problematic. Some folks find that they do them all the time. Some folks don't. I've had patients who were surgeons who do thought records all the time. I've had patients who were policemen. I've had all kinds of different folks from different walks of life who have all different thoughts. Very different thoughts. By the time we're done with treatment, thoughts are not about sleep. They are just not. I’ve had patients who come in and say, “My presenting problem is that my daughter is going to major in English and that is why I cannot sleep.” Right? Only in the Bay Area. Right? Like the thought is my daughter should not major in English and then we work on that thought. How can we know if that's true? 

Christopher:    And this must be a cycle, like you said, like if someone’s sleeping better, then surely the nature of the thoughts change too. 

Ashley:    Uh-huh. Yeah. Once they're sleeping better, the nature of the thoughts change and their ability to deal with their thoughts changes. Right? Because who makes wonderful emotionally intelligent insights when they're under slept? 

Christopher:    Right. Of course. 

Ashley:    Right? Who thinks better— 

Christopher:    ‘Cause you just have to look at children to observe that. Right? 

Ashley:    Who thinks better, who makes better decisions on no sleep? Exactly. 

[0:35:00]

    So, it's easier to work with our thoughts when we're sleeping better. So, often those things will change. A major thing that will happen for folks after they're done with treatment— Well, let me back up and make sure I mention that what causes insomnia and sleep problems and what perpetuates sleep problems are different. I once had a patient whose mother brought her in and said, “Help.” This is when I was treating mostly anxiety, and panic, and other things that I was interested in in Arizona. She said, “Help. I feel like I'm a Fed-Ex truck. I make right hand turns all around town with my daughter. She will not make a left hand turn.” I said, “Oh, goodness. Why?” She said, “Well, she got in a car accident when she was making a left hand turn.” So, what caused her to start making right hand turns was the fact that she got in a car accident turning left. What kept her making right hand turns was the fact that she was not getting into a car accident by making right hand turns. So, with insomnia, what may cause insomnia is an acute thing. Losing a job, losing a child, moving, divorce, something. But what might perpetuate the insomnia is actually the behaviors that folks developed to help themselves. Spending more time in bed, taking extra drugs, taking naps, skipping workouts because they're tired, skipping out on seeing friends because they're tired, reducing activities that increase sleep debt which is what you need to do everyday in order to fall sleep. So, the things that cause it and the things that perpetuate it are different. So, this treatment doesn't focus on the cause, doesn't focus on your divorce. It doesn't focus on your job loss. This treatment focuses on all the behaviors you've developed, which could include ruminating about things to try and cope with it that are actually not serving you. 

Christopher:    Is there a way for people to notice— I mean, so, how do you know what you don't know? Right? You got blind spot. You may not notice that you're developing these behaviors that are compensating for this initial event. Is there a way for you to notice that you're doing this? I guess probably not. The only way is to outsource that. Right? It’s to have somebody else notice for you. 

Ashley:    A lot of folks don’t know because they’re honestly trying to do things that help themselves and that's why I think it's so important for sleep clinicians— 

Christopher:    So, my mom gets into the car. Right? It’s like “You know, don't make any left turns.” It’s like “Yeah. You know—”

Ashley:    We had to go make left hand turns out of driveways for a long time with that patient so that she could expose herself to not getting in accidents turning left. Exposure. With the sleep treatment to answer your question, it's so important when someone comes into their doctor and says I'm not sleeping and the doctor just gives them some Ambien and a sleep hygiene handout or whatever and says, “Oh, well, you're doing things wrong.” That's hard for a patient when they think I've been doing all these things trying to help myself. I’ve been spending all this money on this— I had a patient who came in and said, “I went on a Jamaican sleep cruise. It was $15,000. It didn't work.”

Christopher:    What’s a Jamaican sleep cruise?

Ashley:    I know. I know. I was like “Oh my goodness.” So, it’s part of my line now. I’ve got patients who tried Jamaican sleep cruises, bought 10,000-dollar mattresses. They've done everything. 

Christopher:    Oh God. 

Ashley:    And so, the most common outcomes from treatment with me are people at the end they say they're very angry and they’re very satisfied. They're very angry that they didn't know about this first before they spent all that money. They’re very satisfied now they can sleep. But gosh, I was about to make a point, which was just that physicians, and other doctors, and sleep medicine people will often kind of invalidate patients by saying “oh, no, you're doing all the wrong things” when they've actually been doing all those things to try and help themselves. But once I explained to them why I understand that they've been doing those things to try to help themselves and explain to them in these lectures and in my groups why those things are undermining their success, then they're able to let them go. But if you just tell people stop that just like Bob Newhart on those skits, stop it— 

Christopher:    Yeah. Of course. Yeah. I still watch that— 

Ashley:    I know. I love it. 

Christopher:    …quite frequently. 

Ashley:    I love it! 

Christopher:    Oh, so, if you haven’t heard the Bob Newhart stop it, then you’ve gotta come to the show notes and find the video link back because it's really fantastic. 

Ashley:    It's precious. If that worked, I wouldn't have a job, but it doesn't. So, I do. And major part of treatment is helping people understand how those behaviors are undermining them. And without reading one of these books or getting treatment, those are blind spots. They’re hard to see unless people are able to notice “wow, when I take a nap, I sleep even worse” and then make a change, which is hard to do. When you're not sleeping well, it's hard to notice anything other than maybe the Twinkies, right, because we know we like to eat more junk food when we don't sleep well. So, in the last group of my sessions, I go over things like how to deal with time zone changes, how to deal with clock changes. We’re coming up on one. How to use sunglasses when you're traveling to capitalize what we know about to circadian rhythms to reduce jetlag. I frequently will have patients come in a year after treatment saying, “I'm going to Vietnam. I'm going to China. Can we do my flights?” And we figure out when they need to be doing what on which flights because you can way dramatically reduce jetlag. There’s a great New York Times article you should link in your show notes about how to use sunglasses effectively and then there's also the jetlag rooster, which is a way to— 

Christopher:    Yeah. Greg just mentioned that on the last podcast.

Ashley:    Oh, he did? Okay. You can actually plan for things if you're willing to plan in advance of your trip, but yeah.

Christopher:    Let's take a little bit more into the stimulus control. I find this incredibly interesting. My guess is that this wasn't something that was designed for sleep. 

[0:40:03]    

    It was like “Oh, you know you could use that for this.” Like can you talk a little bit about the history of stimulus control? Stimulus control is a fascinating behavioral topic. One of the earliest papers I read about stimulus control was an experiment with college aged men and study habits. And what the study did was it forced the young men to only study when they were at a particular desk in the library and they were not allowed to study outside of that desk. The goal of the study was to figure out how to increase studying in these students and there were very specific instructions if I'm recalling correctly. I mean, the students had to read only a certain number of pages and then they had to stop. They couldn't do more and then they had to leave and then they couldn't do more in their dorm room or anywhere else. They were only studying in their cubicles. What they found is that doing stimulus control increased adherence to actually studying. So, it's been done in a whole number of different behavioral constructs, but the main idea is just that you do a thing in a certain place and then you come to associate that place with doing that thing. 

Christopher:    Which is a learned association. 

Ashley:    Uh-huh. It’s a learn association. And in healthy conditions, we associate bed with sleeping. Patients will often come in and they’ll say, “But you know what? I've always read in bed. Even before I had insomnia, I read in bed.” And I said, “Great. But somewhere along the lines, your association between bed and sleep got messed up. And now, we gotta remake it, which means we got to take out the reading in bed.” And the stimulus control can be applied to everything from when you study to when you do any sort of other behavior. I have a friend who loves watching— What is it? It’s the British baking show. I like it too, but she really likes it. And so, she has said— 

Christopher:    Oh, is it The Great British Bake Off? 

Ashley:    Yeah. Yeah. That one.

Christopher:    I’ve never seen it, but I know the name.

Ashley:    Oh, it’s pretty good. Everyone is so nice to each other. It’s just refreshing. She loves watching that. But guess what? She only watches that when she's walking on the treadmill at her gym with one of those TVs  in front. So, she associates “Oh, I get to watch my favorite show”, but it's associated now with walking. She can't imagine sitting on the couch watching that show because for years it's been that's when she does her form of workout. So, you can train yourself to do this with all kinds of things. And in sleep, we really focus on the bed for this unless— sex is the exception. And if you have a lot, a lot, a lot of sex, then we try and find another place to do that so that we can do a better job of isolating this. But you can definitely adapt stimulus control to serve your all sorts of health goals and it can make a lot of things automatic and easy. 

Christopher:    I mean, that's the goal, isn't it? And so, I don't really want to turn people into health aficionados or health enthusiasts. Is it not like another term that you sometimes hear? It’s like where people who have dedicated their lives to the pursuit of health like I'm not sure that should be the goal. Right? And sometimes you just need to chill out and stop thinking about things.

Ashley:    You might miss out on life.

Christopher:    Yeah. You might miss out on life. Yeah. So, one thing I’ve noticed is the kitchen like I always get super hungry. Like if I try and cook my own food in the kitchen like I find it really hard not to eat whilst still making food and that's why I have a learned association with the kitchen and eating. Right?

Ashley:    You can, but you can also repair that. You can make it “Okay. I can't eat unless I'm sitting down. If I'm not sitting down, I can't eat.” And to facilitate that, you can try out things like “okay, if I’m in the kitchen and I’m cooking, I’m gonna chew a piece of gum” because you can't chew a piece of gum and eat at the same time. Some folks do that to try and reduce their snacking while they’re cooking. There’s all sorts of— Yeah. I mean, you can make it so that your silverware is over at the table and you think “Oh, I only eat with silverware.” So, you kind of have to engineer it to be specific to your needs.

Christopher:    Uh-huh. And then what do you think about the office? It’s so easy now with a laptop.

Ashley:    I’m so guilty. Look, there’s my home office. It’s horrible. I mean, it’s great. It’s wonderful. I’m blessed, but it is a problem. Work is everywhere. And I have some people in my life who are really great examples of “Okay. I'm not at work right now. So, this is it.” And when I hang out with them, I'm like “Wow, this is great.” I'm doing that with you. It's a work in progress I think for a lot of people especially when they love their work. But yes, I'm a big fan of no email in the bedroom. If I could throw everyone’s smartphones out the window, I would, but it's a challenge. And especially in the Bay Area, there's all sorts of different ways of work that are not common in the rest of the country. There's other things that are also uncommon about San Francisco. For example, when you mention stimulus control, people associating their beds with sleep. So, when I do my intake interview and I'm asking them “okay, so, tell me about where you sleep” and they say “well, which night”, I say “Oh, okay. Most nights?” And they’ll say, “Well, half the time I sleep here and I’m in my bed at one partner’s house and then the other half of the nights I’m in a bed at another partner’s house or half of the week I sleep on Japanese mats on the floor with one partner and then the other half of the week I’m in a bed with another partner or half the week I go camping and then half of the week I’m in my house.” 

[0:45:09]    

    So, there’s different types of places that people sleep and then we need to actually apply stimulus control to all of those different places to sleep.

Christopher:    And you think that is possible then. You can learn an association with all of those different things. It’s nothing limited. You don’t have to say “well, it has to be a one thing” and then you’re gonna have a more powerful— 

Ashley:    It has to be not too many things. For example, if someone says “okay, well, half the time I sleep on the floor on my Japanese mats”, I say “okay, well, we don't do anything on those Japanese Matt's other than sleep and sex” and they say “okay.” And the other half of the time, I'm sleeping in this bed and the same rule applies. Right? So, no one is used to checking their email on their smartphone in either scenario. And I would say that I did not encounter this. I did not have much experience with folks having multiple primary areas of sleep until I came to the Bay Area accepting situations where— like parents who are divorced where the kids lived in the same house and then the parents lived in that house different halves of the week with the kids, so the opposite of shuffling the kids just where the parents shuffle.

Christopher:    Oh, interesting

Ashley:    Yeah. I mean, at least I've encountered folks who do that. So, there are different— Yeah. My patients are my teachers. I learn all kinds of things about different ways of doing social structures in life and raising children and all these different things because kids are also a part of sleep treatment. When I do my assessment and they say “oh, yeah”, I’m like “Who’s in the bed?” They’re like “Oh, well, my husband.” I’m like “Aha, anybody else?” “Oh, the kids, the dog, the fish bowl.” You know, all the kinds of things— 

Christopher:    I’m definitely guilty of that. We’ve got multiple kids in the beds and one of them left and then she came back, you know. She was like gone for a long time. She came back. But recently, I just left like this is chaos. I can't do this anymore. And my wife is quite happy to see me go actually. It’s not like I can really contribute anything with a small child during the night that just wants milk. Right? So, like kicking me out into the Eurovan in the garden is actually phenomenal for both of our sleep. 

Ashley:    Well, I do try and convince people to take the pets and the kids out of their beds. That is something that I think for the long term the kids are gonna need to sleep in their own beds eventually provided there's not a medical or really serious reason that they need to be in your bed. It actually can be dangerous for babies to be in beds with adults. Right? That’s a real thing. There’s some danger there. 

Christopher:    Yeah. I’ve not found any of that data very convincing though. It’s usually like a bunch of drunk people with a very new infant. 

Ashley:    Right. Sure. But that is data and that’s real. So, if those people didn’t have the baby in bed, those things might not have happened despite their being drunk. Right? So, there’s good reasons for the only people to be in bed to be 2 partners or the 3 partners, whatever they are, and not the pets and the kids and the phones. All the other social networks. 

Christopher:    Well, that’s what I was going to ask you about. Is there a way that we could use a stimulus control to use less mobile phone, spend less time on the smartphone, right? So, recently, Cal Newport wrote about the idea of reintroducing the telephone foyer. So, this is like a telephone booth that we used to have back in the day when a telephone was something that was connected via a cord to the wall, right, and you physically couldn't move it very far. And so, people have these booths and you’d sit down and make a call. I’m sure everyone listening to this knows what I’m talking about by now. But he suggested that maybe we should do the same with our smartphones where we should just move them into the foyer. And then if you’re gonna use the phone, then you have to be in the foyer. Right? Like I don’t care whether you’re texting or using the. Internet or whatever it is, you need to be in the foyer and then you start to— I mean, he doesn’t actually go into this. He doesn’t even use the term “stimulus control, but I'm sure that's what he's thinking, is you start to learn in association with the phone in this place at this time and only this place at this time and then you don't find yourself at the dinner table just unable to stop him from fiddling with the fun. 

Ashley:    Yeah. Everybody probably can't see me nodding, but, yes, absolutely. That’s what that is. I’m a big fan of doing that. Tethering all kinds of behaviors is really useful especially behaviors that we know we actually want to reduce like using our cellphones. It may be if we’re on our cellphone less, we’re more present with the people that we’re actually there with. Right? So, I am all for that and I'm all for all kinds of permutations of that. People are gonna need to figure out what works for them. Stimulus control doesn't necessarily just need to be a place. There's other aspects of it too. I have one professor who used to have an auto responder that would go on at a certain time of the evening. Maybe Let's say it was like 6 p.m. and then it would go at 6 p.m. starting if you email John Allen, you’d get a reply that said, “John Allen unplugged. I’m not on email between 6 and 8 p.m.” So, he had kind of built up this period of time during which— 

Christopher:    Right. Putting up fences.

Ashley:    …this isn’t when I don’t do those things. So, it’s not necessarily a particular location, but I would say that classic stimulus control is very like physically tangible. 

[0:50:00]    

    And yes, it is location and I love the idea of a phone booth in everybody’s— EMF blocking booth. 

Christopher:    Faraday cage. Lock on my phone in a Faraday cage.

Ashley:    Oh gosh. Yeah.

Christopher:    Yeah. Yeah. I’d have to say actually I’ve had tremendous results with everything that Cal Newport talks about. You name it. I’ll delete it like avoidance is my core strategy. Right? Like you name it, I'll avoid it. But Facebook and Instagram were gone very easily, but then I've also deleted— I’ve unsubscribed from every single email newsletter apart from Cal Newport actually. Of course, maybe this is his strategy. There’s a couple of others actually. Bill Lagakos, I really enjoy his Patreon. That’s really about it. So, you know, go to my inbox. If I was to open it right now, I’d be surprised if there’s more than 2 emails there. It’s usually inbox zero all the time.

Ashley:    I’m jealous.

Christopher:    Yeah. It’s fantastic. 

Ashley:    I get the inbox zero though. I do get there.

Christopher:    Yeah. I must admit I also have help from Tammy and Elaine like a huge part of the reason I have inbox zero is ‘cause the messages are in somebody else’s inbox. Right? She does a much better job of solving those problems anyway.

Ashley:    I strive to have someone like that help me in my life.

Christopher:    But the point is like— So, occasionally— Not occasionally. Frequently I get bored like [0:51:11][Inaudible] I don't know what to do anymore, you know, like I can feel myself I want to go check something like the weather or the forum or— 

Ashley:    That’s not boredom. That’s a craving.

Christopher:    Maybe. But it’s like I think it’s important to sit there and like feel kind of like “Oh.” And then you know what? I’m gonna write some code. That’s what I’m gonna do. I’m gonna write some code. You know? So, that’s Cal’s point, is like that negative stimulus is something that you need to feel in order to go do something hard. It’s kind of like the steam engine letting off steam. If you let the steam off by peeping away at the whistle, then you’re never gonna build that necessary head of steam to go do something hard, but his stuff is really fantastic. So, what are the other gotchas with insomnia? Is there like any pitfalls that you see every single person fall into like “yeah, of course, like I should mentioned that one in the beginning” or is there anything that one then? 

Ashley:    Yes. Yes. So, when folks start, we have to develop a substance and medication plan. When people sleep poorly, they’ll think “Oh, I’m gonna take an Ambien tonight.” But actually, taking that Ambien messes with the whole sleep debt, a cruel process that we’re focusing on. So, a major focus for me is saying, “Okay. You’re gonna be really tempted to take  Benadryl on night 4. Don’t do it. Don’t do it 7 nights. Let’s get the process rolling and you’ve gotta really actually quit.” Or some people they can't quit yet. They were literally on such high doses that we have to titrate them down. So, for example, if someone is taking 25 mg of Ambien, which no one should be doing because that's above what the top limit, and we start cutting them down to 15 in the first week, they have to take that 15 mg of Ambien at the same exact time everyday so that when we’re working with the circadian cycle and we’re working with the sleep debt accrual system, your body is on this clock. Okay? If you're taking it at all different kinds of day, you're totally messing things up. Melatonin is a hormone. Yeah, it’s an over the counter thing and it’s a hormone. And if you’re taking it at different points of the day, different doses everyday, that's whack-a-mole. You’re doing crazy stuff. So, a major thing people also do is they take the wrong dose of melatonin. Melatonin dosing is actually between 0.5 and 1 mg. And it actually should only really be used when you're trying to change your cycle of sleep. So, when you're traveling to different time zone for example, you might take it to try and shift yourself earlier or later. Taking it on the regular, not a thing. Don't do that. For some folks, taking it on the regular makes a little bit of sense. For example, if you’re taking a blood pressure medication, that ends in
-olol. Metroprolol, propranolol. These drugs that we know inhibit melatonin secretion. So, every now and then I get a patient who says, “Oh, you know, my insomnia started 30 years ago when I started metoprolol.” Or they don’t put that together, but I say, “Okay. So, what happened 30 years ago?” “Well, I was diagnosed with high blood pressure.” “Oh. What did you start doing?” “Oh, I started taking metoprolol.” “Oh, anybody tell you that 15% of people on blood pressure meds develop sleep problems?” “No.” So, for those folks half of a milligram, literally half of a milligram, you can’t even buy pills that small. So, I tell people get the liquid melatonin. There's a super cheap liquid melatonin from Walgreens and it seems to be the clear winner. Melatonin dosing and content— And you know all this about supplements. I don't need to preach the choir here, but no one’s regulating that. We don’t know how bioavailable each of those formulations are. We even actually know how much melatonin is in something that says 5 mg of melatonin. Right? And Greg Potter talked about this in the interview with Kirk where they tested a bunch of them and we found it very— Huge variations.

Ashley:    Huge. So, I found one that seemed— And the reason that I seem to feel that this one works is because I’ve had enough patients now on blood pressure medications who’ve come in with sleep problems. They start my group. They do everything. The minute I put them on half of a milligram, I get email the next morning saying I just slept 6 hours for the first time in years.

Christopher:    It’s amazing.

Ashley:    Right. So, for some folks, there is indication for using melatonin regularly. For most folks, I would say that there isn't— And a lot of folks start with me taking a ton of melatonin and it takes me— 

[0:55:00]    

    Sometimes it takes me a while to give the patient to quit so they think it helps them fall asleep, which in those high doses it can, but it isn’t something that keeps you asleep. That’s not how that mechanism works. It’s a circadian secretion process. So, pitfalls are taking melatonin and thinking that it's harmless or that it's not messing with anything because it is. Another thing is that people will often take a THC at night. For some reason, they think that “oh, pot can help you sleep” and then they take these crazy amounts of THC and then their heart is racing. That’s not gonna help you sleep. I'm not a huge fan of that. Some people like to take CBD. I think they're getting a little bit of a more placebo than anything else, but that's cool. Placebos are the most robust and strong effect in medicine. I will not take them away, but I will say if you're gonna use CBD at night, you have to take the same dose same brand at the same time everyday ‘cause I don't wanna start creating this other variability. We have to hold the variables consistent. And then the last thing is that people start to get a little bit— They think “Oh, you know, I'm finally better. I can start sleeping in.” It messes the whole thing up. So, what I teach people is— Let's say for example there's a concert on a Friday night and I wanna go to this concert and I don't get home until 1 in the morning. And my wake time is 7 a.m. The next morning, I could wake up at 7 a.m. It's not gonna be a good Saturday. I'm gonna be tired. Or I could sleep in. If I sleep in on Saturday— Oh, let’s say I sleep until 10. Shit. Okay. I'm not gonna be tired Saturday night until real late. So, I go to bed real late Saturday night, but then I have to get up at my alarm time on Sunday. And so, Sunday is not gonna be a good day. So, I teach people here. You actually can control when you have your bad day based on your behavior. It can be the next day or it can be the following day. You have a choice. And once people realize “oh, you know what, it’s not the sleep God that’s deciding when I sleep poorly, it’s me”, that reduces so much of their anxiety, but the mistake people make is that they say “Okay, I'm gonna sleep until 10 Saturday. Oh, I'm gonna sleep until 10 Sunday.” 2 days in a row, no go. You can only mess with that 1 day in a row. 

Christopher:    Right. 

Ashley:    Yeah. Otherwise, getting back on the wagon becomes much harder. 

Christopher:    This is gonna seem entirely irrelevant, but I can’t resist asking the question. So, do you think this is a general problem in health like people feeling like they don't have control over what's happening? And then I wonder whether that creates a market for certain devices that promise to reduce uncertainty.

Ashley:    Totally.

Christopher:    So, I'm thinking about breath ketones for example. Right? So, really what I want is weight loss and here’s this device that ostensibly tells me whether or not I’m losing weight and what it really is doing is reducing uncertainty or at least that's the story. Does that make sense to you?

Ashley:    With the weight loss example, it’s tricky because you weigh yourself one day. And the next day, even if you ate nothing the previous day other than soy sauce and water, you might weigh more because you’re retraining water. So, you don’t get so much feedback. With those breath ketone things, you’re getting instant feedback. With weight loss, you have to wait. So, there’s some people who just want, want, want. We’ve created a society in which we’re constantly able to get access to all sorts of things. You just have to go to the library to get the encyclopedia to look something up. Now, you just go to Google. Right? This instant gratification culture is driving some of that. And with sleep, once people realize that they have some control over it, it is very reassuring because what is so scary about sleep is that when people are in the middle of the night and they're not sleeping, they think “Oh my God, I might never sleep again. I have no idea what's going to happen to me.” But once they realized “oh, I have these tools, this is how these processes work, I know I'm gonna feel miserable at certain times using these different techniques, but I do know that I can impact my sleep”, it’s empowering. I mean, even last week I had a patient who came in who said, “You know, I’ve noticed that my sleep is changed yet, but I’m way less upset about it. And that’s making my life better.” ‘Cause I also tell people “Look, you’re gonna be in treatment with me for 5 weeks. You’re gonna get the benefits of what you’re doing in these 5 weeks in two more months. Yeah, you're gonna get somewhat better by the end of 5 weeks, but the real benefits are when you stick with this. And we know from studies comparing CBT to things like Tai Chi that have actually measured CRP, your CRP is gonna be way lower from an acute bout of CBT 15 months out. We're talking the long game.” And I tell my patients— They come in. I’m like “You’ve been sleeping badly for 10 years. I'm asking you for 5 weeks of your life. Let me make you miserable for 5 weeks and you can come out on the other side. You're never gonna know if this works unless you do it. Give me these 5 weeks. And if you hate it, you can go back to whatever you were doing. Then again, that's what’s landed you in the chair that you’re in in the first place. So, how much worse can it get?” So, there’s a lot of motivational interviewing that goes into getting people to do a lot of these things. And I would say that a very reinforcing process is when people realize that they have a lot more control over this than they thought they don't need to buy Jamaican sleep cruises or gimmicks or— 

Christopher:    I still don’t know. You didn’t say what a Jamaican sleep cruise is.

Ashley:    I still don’t know what it is. It’s on a boat. It was like a boat in Jamaica where you go and they supposedly like sail the ship certain ways or something so that— 

[1:00:06]

Christopher:    Oh. So, this is absolutely a thing. So, Greg Potter talked about this in the podcast with Kirk as well. He sent me some studies showing that people sleep better like there was these technical things I didn’t really understand. 

Ashley:    Oh, God, the hammock thing?

Christopher:    Yeah!

Ashley:    Yeah. You want to see something funny? I don't know if I can walk far enough to get it. 

[Talk Out of Context]

Ashley:    You’re gonna laugh about this. You will laugh really hard. But I actually spoke to the Wall Street Journal about that. Is it healthy to sleep in a hammock? 

Christopher:    Oh, my goodness. 

Ashley:    Yeah. 

Christopher:    So, we can link to this. 

Ashley:    They interviewed me about whether you should actually be sleeping in a hammock. And you know what the study was? It was an electric bed that they put mice in that was swaying back and forth. 

Christopher:    That’s amazing. 

Ashley:    And I asked them “Well, how is that a hammock?” In a hammock, you’re not swaying. You're laying there. And you might be falling out of it when you go to pee. It's not very sexy getting in and out of a hammock. It can be a health hazard for a lot of older people too.

Christopher:    Yeah. The kids as well like my kids fall out of ours all the time. It’s ugly.

Ashley:    This is not that thing. I don’t remember the study exactly, but it was something about like changing sleep architecture. I don’t remember if it increased deep sleep or what it did. The details I'm not remembering, but I remember getting into it when I was giving the comment for this article that I thought was pretty funny. It would have been cool if I'd been able to tell them that, but it looks like what I told them— I said maybe it's a great place for meditation or talking to a friend on the phone or snuggling with your kid. So then, they went and they talked to a spine specialist instead. But you know, all these gimmicks people want just— Ultimately, they want reassurance. And then once they realize how they can impact their own sleep through certain behaviors, it just cuts the arms off the anxiety and they're able to think more clearly, enjoy their life more clearly. And that comes in advance of the necessarily getting more sleep.

Christopher:    Well, that’s fantastic. Well, actually, is there anything I should have asked you? Is there anything I missed? It’s hard to know.

Ashley:    I mean, I think that a key thing is that when folks are reporting that they've got sleep problems and someone's offering them a prescription medication that the gold standard treatment they should be being offered is cognitive behavioral therapy for insomnia. The American College of Physicians says very clearly the gold standard treatment for sleep problems is CBTI. It should be the first line treatment. It should be what you try before you use drugs. Don't get on drugs and think I'm gonna go use this treatment to quit drugs. You can do that, but you'll be better off if you do this first. 

Christopher:    Yeah. And I think Dr. Josh Turknett explained a very useful model a little while ago, his 4 quadrant model, right? So, the first thing we do is minimize mismatch and we undertake game level interventions, is what we call them in that model. And then there’s some disruptive stuff, which is like some of the therapy that you’ve talked about. And then finally, you can start tinkering in the source code. Right? And then eventually, you get to the disruptive stuff at the source code level, which is the pharmaceutical drugs. Right? Like that’s kind of saying you know something about sleep physiology at the source code level and you're gonna trying and change that with some drug. Do you really know what you're doing? I'm not really sure you do. 

Ashley:    Right.

Christopher:    And so, this is important because it informs us like the order of things like what’s most important, what should we do first before we progress to the whatever drug.

Ashley:    Absolutely. And I would just like to remind everyone that Ambien is technically a benzodiazepine. You think Xanax. You think Valium. Guess what? Ambien will make you test positive for that stuff. It is in that class. It is a serious drug. It's something to be very carefully approached. And I have had very few people who I’ve ever met in my practice who actually benefit from using that drug. 

Christopher:    Uh-huh. That’s good to know. So, I guess we can’t really refer people to your sleep clinic because it's got such a long wait list. What are we gonna do?

Ashley:    You sure can.

Christopher:    I mean, that’s the question, is like so what are you gonna do to scale this? If you’re developing a wait list, how are you gonna scale it?

Ashley:    So, right now, my groups are 90 minutes because I do a live lecture and then I do the individual parts with each patient. So, I go over things in front of people with other people. It’s not a group therapy process so much as it is. I’m talking to individual people in front of the other people. People are learning from each other's examples, but there's no like how do you feel about that, how do I feel about that. There's no feelings there. It's me giving people information and explaining what's going on. In the future, I'm hoping to actually record my lectures and then this way folks will be able to watch those at home, then come in, and I will be able to have much shorter sessions and then I’ll be able to double the number of sessions that I have per night. Turns out that making these kinds of tools and also making an online sleep calculator, which is part of my dream for this too because right now people bring in these paper versions, my assistant, whoever is helping me and also learnings, the medical student, the clinical psychology student, the fellow, the whoever, they enter them in by hand using an Excel. It’s horribly clunky. And then I use those outputs, those formulas to do my things. 

[1:05:03]

    I would love to have that be all online. But of course, I'm not a programmer, engineer, all that kind of things. So, these things are always very expensive. So, I’m figuring out how to try and fund some of these endeavors, but it helps that I can say that I have a lot of demand. So, there is good reason to try and get money to do this. And it’s hard to convince the funder that I need someone to do something when I don't have demand. But by having a wait list, I do have demand. I actually now have the ability— UCSF has made it possible for me to see patients over the internet because I have patients who live hours and hours away, Lake Tahoe, whatever, and they're not gonna drive here for each individual session, although I've had patients who do fly in every week for group and fly home, which is just crazy if they live in another state. If they live in California, I'm able to do some interesting things with internet, but trying to make this more accessible and hopefully broaden the scale potentially with another clinician as well is in my scope. I'm working on that by figuring out how to get these things recorded and how to develop some of these online platforms that are compliant with, you know, HIPAA and other important things is my current challenge. 

Christopher:    Uh-huh. You could automate the whole thing. I mean, such a thing does exist. Right. I bet if I searched for CBT— 

Ashley:    There have been apps. And I believe that the apps that have existed have been bought by healthcare companies. 

Christopher:    Interesting.

Ashley:    They've been subsumed. I remember Sleepio was one. I don’t remember where it went. I think a healthcare company bought it, but don't quote me there. I don't know. But what you were saying, there's information, but then there's also you need buy-in. And for me to get buy-in with these patients, I need to do their individual intakes and explain to them “Look, I've seen you before. I know you're miserable. I've seen this work for people just like you before.” I have to get people's buy-in if they're going to do this actual thing. So, I can only outsource so much of it, but I do think that of my 5 lectures, which generally each of my 5 group meetings is 90 minutes, I think I can cut them down to 40 minutes by making these videos that people would watch at home.

Christopher:    Right. Right. Yeah. I think it’s insulting of me to even suggest that you could possibly automate what you do, the motivational interviewing and all that. 

Ashley:    I think there's a certain amount that can be automated, but someone like me with no skills in building things on the internet and technology isn’t gonna be able to do them. This is something that it's so far outside my expertise that although I can give and prepare the lectures, I need someone to help me or I need multiple smart techie people to do the other end. And that’s where I’m just getting the funds to see if those kinds of things comes in. 

Christopher:    Well, that’s very exciting. I’ll look forward to seeing how that progresses.

Ashley:    You and me both.

Christopher:    Excellent. Well, Ashley, thank you so much for your time. I very much appreciate you.

Ashley:    Of course, thanks for having me.

Christopher:    Oh, but wait, you gotta tell people where we can find you online. 

Ashley:    Oh, okay. So, my lab website is the Sea Lab. UCSF Sea Lab. I think it’s just sealab.ucsf.edu. And from there, there's a link to my clinic, the sleep clinic. And there's also links to my research. So, right now, some of my research is in things that are very different than sleep. One of them being whole body hypothermia for depression and looking at some other mood-related things. But my clinic while link is there and you'd be able to contact me about treatment through that.

Christopher:    Uh-huh. And is there any way for people to support you financially he says knowing the answer? 

Ashley:    Yes. Of course. UCSF loves that. So, you can always shoot me an email at ashley.mason.edu. I know it's dangerous to give out your email address in the internet, but I've actually found that people will find it anyway. It's everywhere. So, I'm happy to give it out. And yes, there's ways to do that. There's all sorts of interesting things I've been learning about UCSF and how they do giving. There's tax deductible things you can do and all these interesting ways of things that people like to do at the end of the year too because it benefits their taxes. And so, I don’t know. There’s all kinds of things to do and there's a professional who I've just met. A lot lovely lady now who if anybody emails me I can always ask her questions and she'll tell us exactly how to do— what's in the preferred interest of whoever's in a position to give. But yeah, that's very thoughtful of you to ask. It's just hard because these are things I can write grants to get money for. There's no money in this. I'm not selling anything other than just trying to get more people into treatment. And my institution is just very happy that I have full clinics and that I have waitlists for my clinics of more patients who will fill the clinics. But the Osher Center is also dedicated to treating as many patients as I can. So, they will also provide all kinds of space and great things that are often hard to get to for the clinicians. So, I’m really grateful for what they've given me so far to make this happen. 

Christopher:    I will of course link to that and everything else that you had mentioned in this episode in the show notes. 

[Talk Out of Context]

[1:10:00]

[Talk Out of Context]

Christopher:    Well, Ashley, thank you so much for your time. I very much appreciate you.

Ashley:    Thank you. It's wonderful.

[1:10:10]    End of Audio

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