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

0:07Forrest Hanson: Hello and welcome to Being Well, I'm Forrest 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 5-10 % 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 sleeping in, going to bed earlier, or even trying harder to fall asleep, can actually make it worse. It's also interesting because we usually think of sleep as a physical process.

0:43Forrest Hanson: 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 CBTI, really is. So today, I'm welcoming an expert on sleep, insomnia, and CBTI, Dr. Ashley Mason. So Dr. Mason, how are you doing today? Great, glad to be here. 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.

1:21Forrest Hanson: And she also leads the insomnia treatment program at UCSF's Osher Center. I'm not sure if we're gonna 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. And way back in Arizona, she worked as her doctoral mentor, was Richard Butson, who invented one of the two core pieces of CBTI in 1972. So I wanted to start a little bit with that history. What drew you to doing this kind of work?

1:58So I want a couple quick important things to note. So I did learn how to do this treatment from Dr. Richard Butson. My primary mentor at the University of Arizona was Dr. David Sparrow, 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 doing it. But figuring out how to do this kind of treatment in a larger way in what I call a group, what many call a group medical visit where I'm treating eight patients at once.

2:43I 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. People often will think, oh, but that's psychotherapy. And yes, I guess, I suppose technically it's true, but I tell people to think about it more like physical therapy for your sleep. Oftentimes people will get an injury to a knee or an ankle or a wrist and they go to physical therapy for that, right?

3:24I say, think about CBTI 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.

3:43Forrest Hanson: Often when we talk about something on the podcast, I have at least a cursory knowledge of it. I knew absolutely nothing about Itzavdia 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? 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 got to cause significant distress or impairment in your day.

4:35It's got to be upsetting and it's got to feel like a problem. 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.

4:57Forrest Hanson: 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? 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.

5:31And when we actually look at different, this is one of my peeves about sleep durations with 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. People who are sleeping that much during the day, they might be receiving chemotherapy for a cancer.

6:05They might have some sort of immune disorder or disease that's causing them to be completely fatigued and sleep all day. 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. 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.

6:39So 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? Then we've got the 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.

7:11And there's some people who do great on seven hours. There's some people who do great on nine hours. If I ask you, would you rather have eight hours of tossing and turning sleep, or would you rather have like six hours and 45 minutes of glorious, uninterrupted, refreshing sleep? What would you rather have?

7:31Forrest Hanson: Yeah, I'm picking the second one every time, totally. 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, you know, however much sleep, when actually they might only need to be in bed for seven and a half hours. 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.

8:04The 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.

8:17Forrest Hanson: 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, right? But the experience of these people was totally different, right? The people with insomnia experienced a ton of distress around that difference.

8:54Forrest Hanson: 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. 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.

9:35These 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. And what's even more interesting is that, I can't even count how many hundreds of patients have 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.

10:18But I had one patient who I finished with just a few years ago and the entire solution to it, he was trying to go to bed at like 10 o 'clock because that was what time he thought he should go to bed. 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's 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 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.

11:07I 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. That was all we had to do. Now, is he sleeping more? No, no. But is he spending less time awake in bed frustrated? Yes, a whole hour less.

11:24Forrest Hanson: 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-analyses 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. 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.

12:03Forrest Hanson: 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. 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, 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.

12:37Forrest Hanson: I've gotten a lot of illustration of this myself. We recently started fostering a dog, and I've 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. And so that movement of like 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. 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.

13:18This 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. And if you look at the box for Z drugs, Zolpidum, you will see that they're intended for what, like four-ish weeks or something like that? 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 like Santa Claus. Once you know Santa isn't real, there's no going back.

13:59And once you've learned the principles of CBTI, you will know what makes your sleep better and what makes your sleep worse. And you can't unknow that.

14:06Forrest Hanson: So before we get into the structure of CBTI, 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? Yeah. So this is an interesting misconception, I think, broadly, is that there's this obsession with getting to the root cause of something. Everyone wants to know, well, what really caused it? But guess what?

14:39Let's say you lose your job or you get divorced or your dog dies or something. terrible habits. 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. Some people pop a bandryl. 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 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.

15:22And people start doing these things to help themselves sleep. 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, right? 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 and 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, 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.

15:57And that is what CBTI targets.

15:59Forrest Hanson: This is great because this is functional analysis, which we talk about on the podcast all the time. I'm 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. 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.

16:31Forrest Hanson: And I have, I don't know why this happens. I have absolutely no idea what to do about it. What do you think? This is something that people report all the time. And one of the questions I often will ask patients when they start treatment is, well, how do you sleep on vacation? And they'll say, oh, I sleep great on vacation. I sleep better for sure, yeah. Right. But guess what? 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.

17:07That's just a hotel room. When you are at home, you have all kinds of associations with your bed. 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 as 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, we're going to argue with our partner. We're going to do all these things. Right?

17:42So 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 message and I'll get it clarified very quickly for you 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 10 15 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.

18:25Obviously not this one because this one's riveting, right? So no one's going to fall asleep to this, but they'll put on a podcast and they will say, you know, I'm just going to fall asleep to 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 going to go in my bed and sleep. And if you can't, you're going to get right out of your bed and go do more awake behavior, like listening to a podcast. We don't want to blur that line between being awake and being asleep.

18:53so for someone like you who's having this experience of 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 there's no residual toasting left in that toaster when you unplug 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 mildly terrifying.

19:23When 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 pilot goes, and the plane goes up and everybody grabs their seat and like, what's going on? 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 to a different way. 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.

19:55And if people skip those things and think, wow, yeah, I'm just going to work, work, work, work, and then go to sleep. Like we're not toasters. You can't do that. There's this whole process that you need to engage in. That'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 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.

20:26That 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, and then you can re-approach the bed when you're sleeping and re-associate the bed with sleep.

20:40Forrest Hanson: 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 how much it's helped for them. Do you think that this advice is a good place to start? Pretty helpful, not that helpful? How do you think about sleep hygiene?

21:17So 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 sex, 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 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 in bed restriction and stimulus control.

22:09The other three can be somewhat expendable. You got to do these other two. Sleep hygiene being one of the like, quote, 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 in 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. 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.

22:50Sleep 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 comfort, down belongs in your ski jacket, people, not in your comforter. If I took that away from you, your body temperature can more easily regulate itself at night. 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 3 a.m. and you're wondering why, well, maybe you're sending a message to your body like, hey, maybe we should wake up.

23:20It'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 because a lot of people will think oh i'm so hot 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 cut off time for my patients is 11 a.m and wow yeah that's earlier than i was expecting yeah yeah i like a full like 10-ish hours before bed because the half-life of caffeine gosh i can't keep track of it because it seems like it's starting there's all these studies coming out about genetic your 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 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?

24:32We 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. 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 to sleep, right? 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 into sleep pressure, into deep sleep so well anymore in the second half of the night.

25:05As you build up sleep pressure, then you're able to fall asleep at the start of the night, then you start spending it up. 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 blocks those adenosine receptors and it makes it harder for you to actually build that sleep pressure in the first place. You don't necessarily have enough to begin with by the start of the night. You might have enough for a few hours, but then you might wake up.

25:30So 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 and 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. Don't use a caffeine crutch is what I call it. I'll do that. Part of sleep hygiene is also stopping working. Do as I say, not as I do, right? You got to stop working with a period of time before beds that you can wind down and actually land the plane.

26:05Most people cannot go from like work, work, work, work to sleep. And 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. And those get all mix 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 care which thing it falls under. I'm like, 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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30:03Forrest Hanson: And when Quince asks where you heard about them, let them know it was being well. It's a great way to support the show. Now, back to the show. 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. 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? 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.

30:43So 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? 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 of those. And what I'm really looking for in the intake paperwork is, is there a quick fix here?

31:17Is there something that this person is doing that could be causing this whole problem and they don't actually need treatment? For example, I've had patients coming in saying, oh, yeah, I take my antidepressant at night. 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 a 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.

31:52message your doctor, make sure we're cool. Doctor 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 Colleen 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.

32:32And 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 and a group medical visit. 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 what is stimulus control you know what are what are what is sleep hygiene I don't start off the bat with time in bed restriction because a that would scare a lot of people away and b it's just not necessary the first thing I do is I tell people look I cannot wave a magic wand and make you fall asleep at the same time every night 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 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 gonna work on you i had one patient once a long time goes an engineer he told me i could tell the story about like he he he created some sort of alarm that required him to like you have 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 He just was alarm resistant, right?

33:44But I tell people, look, 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. So what I do for the first week is I look at their sleep diary 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 5 a.m. and 7 a.m. And they're like, yeah, I hope my wake time to be 8 a.m. And I'm like, you're dreaming. in. We 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, you know, the majority of the time.

34:20And then they sit there alone 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 wait 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 everyone says yes this is the best mom ever best sleepover right 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 add 30 minutes of grace to that because it's normal to take 10, 15 minutes to fall asleep, to wake up, to use the bathroom, whatever, in the middle of the night.

35:11And then we work backwards. So if your wake time was 8 a.m. and you were producing 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 and you have to be sleepy when you go to bed. Not exhausted, fatigued, tired. Exhausted, fatigued, 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.

35:41And for people with sleep problems, these things get all tangled up.

35:45Forrest Hanson: 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 a.m. Your prescribed bedtime for them once you got to that point would be like one in the morning or something like that 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 1 a.m 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 percent marker i was telling you earlier then we give them 15 more minutes so then their bedtime becomes 12 45 if we log again but still above 85 then your by times 1230.

36:32And 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. I had one patient once who also told me I could tell the story, he would wake up every morning at like two in the morning and would be certain that North Korea was coming for us.

37:04The 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 2 p.m. the next day, well, he's out walking his dog in the park like, hey, about that bomb. Yeah, not so worried about it right now. But then that begs the question, well, if we're certain the thought is true at 2 a.m., but it's not true at 2 p.m., how true can it really be? Right. Something should be true all 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.

37:42Never going to make it through the day. And we just would just be miserable from like seven to 9am just thinking I'm never going to make it. And then by 10am, she'd get to work at a startup because in San Francisco work starts at like 10 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'd be like, okay, maybe I'm going to make it through this day. If you asked her at 6 p.m., are you going to make it through this day? She'd be like, yeah, I made it. So then after tracking how much she believed this thought day in, day out, she realized, wow, I think I'm not going to make it through the day because it's 7 a.m., not because it's true.

38:17So then she was able to say, oh, it's 7 a.m. 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. And she ended up actually becoming an Italian speaker. And 7 a.m. became her favorite time of the day because she got to go do her Duolingo on the couch, right? She came to bed and bed. But the point just is the next part of treatment, we do a lot of these cognitive techniques where we help people work with some of these thoughts that they're either having at night or about sleep that are disturbing either their feelings about sleep, their thoughts about sleep, or their actual sleep.

38:49Forrest Hanson: A 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 10 p.m. comes along and 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. 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, like 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.

39:35Forrest Hanson: 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. 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. Let's unpack a few different parts of that separately. Sure. 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. You know, everybody's got a way to finish that question or that statement.

40:11Forrest Hanson: Feel awful the next day, whatever it is for you. Yeah. I'm going to botch the presentation. I'm going to get fired. I'm going to this, some of that, right? And 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. We 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, right? So if I don't get eight hours of sleep, I'm going to lose my, I'm going to botch this whole presentation tomorrow, for example, right?

40:47Well, what's the evidence that that's true? Hmm. 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 what's not true? Well, I've already made the slides. I've made my note cards. I know what I'm going to say. I've given presentations after bad nights of sleep before, and I haven't been fired yet. But 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.

41:23And 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, right? I mean, 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?

41:51So as long as you're filling it out the same each week, then we're good to go because I'm looking at within-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, you know. And you can actually see that much more clearly in wearables data now, I think, than ever before.

42:30So 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. So I like them for within-person behavior change, but if it's starting to make you crazy, it's not a good idea, take a break.

43:00Forrest Hanson: 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 talker talking about this might be helpful for people. I'm just wondering what your take is. I like to remind people that we've evolved to handle a lot. Our species has been having babies for a long time. People lose a lot of sleep when they've got young babies and here we are. We can survive periods of difficult sleep.

43:42It will come, it will go, it will be okay. There seems to be this perseveration on long-term damage of having a bad week of sleep.

43:56Forrest Hanson: I'm thinking of this. There was a clip that went kind of, 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 was like, oh, I had like two glasses of red wine and it just like destroyed my sleep for a week. 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, catastrophizing that I think was a good example of this thing as a performance category and people's anxiety about it.

44:29Forrest Hanson: And I don't know, just like their pernicious focus on optimization that I'm not actually sure is particularly good for people. 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, you're curtailing your REM sleeps.

45:12You're waking up too early and you're kind of cutting off your REM sleep. Cause remember REM sleeps in the second half of the night, 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 after 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. And for some people, that's why alcohol just isn't worth and they're like, you know what?

45:47This 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? And 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 longstanding problem. Give me five weeks, 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.

46:17And 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. They come back with two glasses of wine. I'm like, oh my God.

46:29Forrest Hanson: Yeah, just can't do it. That was terrible. And guess what? It reminds them of all of the weeks of bad sleep. So when they report it to other people, like what might have happened in the clip that you mentioned, it might've been a reflection, like a reconnection to all of those times of bad sleep when they were using alcohol more habitually. Like, oh, that was terrible, like, you know, terrible, terrible. So in their mind, their experience of it might really have been like, wow, I was having, like, I was really worried that I'd slipped back into the ways that I was sleeping before. You know, when people have a slip up, they often will think, oh no, I'm slipping all the way down.

47:06The 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 who also told me I could tell the story, but she had to go to these work events that involved lots of drinking. It's expected socially, the drinking, right? And there was always red wine, glass after glass of wine right and she just she couldn't handle it was a small person also just was like wow i'm expected to get a lot of alcohol yeah 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 gonna do she's like yeah i have i can't not drink at least three nights a week at these events or i'll never make partner or this whole thing it's a social thing that it's up 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.

48:02If 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 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 and you know what you're just going to do that if we're not going to stand up to the the social stigma of not using alcohol.

48:33And it was life-changing for her 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, the this, that. She's like, I do so much better. 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?

49:12This is just something I have to keep to myself in order to feel better. I'm all for that too.

49:18Forrest Hanson: Back to the show after a quick break. I'm excited to let you know that the Turning Points Navigating Mental health podcast is back with a new season. On Being Well, we've spent a lot of time talking about how affected we are by our environment, and particularly by the information that we take in. So one episode this season really caught my eye. In it, host Francis Lees, a clinical therapist, talks with Lisa Thalhammer, a journalist who burned out covering negative news every day, and who now studies what constant news exposure does to the people who are reporting it. Lise also speaks with Sherry Turkle, founding director of the MIT Initiative on Technology and Self, and they look at the psychological costs of an always-on media world.

50:02Forrest Hanson: Other episodes this season cover caregiving, parenting in the age of social media, starting therapy in your 40s, finding love again after losing a spouse, and a variety of other important topics. Every story is different, but they share a common thread, support, community, and the hope that a turning point might be closer than it seems. Check out Season 6 of Turning Points, Navigating Mental Health, a podcast from Tufts Health Plan in collaboration with Boston Globe Media. available wherever you get your podcasts. I run a podcast, so you probably could have guessed that I'm a bit of an audiophile, and I'm pretty picky about headphones.

50:41Forrest Hanson: So I was excited when Shox reached out to sponsor the show, but I was also clear with them that I was a bit of a tough audience. Well, you're hearing this ad, so clearly I liked them quite a bit. Shox's new OpenFit Pro have a very cool open ear design, which means they don't actually go into your ear canal. In part because of this, they are very comfortable, and they stay put. I just wore these to the gym. The open-ear noise reduction is also really impressive. Background noise feels like it's further away, like somebody gently turned the world down a few notches, but you can still hear what's going on around you so you don't feel totally cut off from other people.

51:16Forrest Hanson: They sound great. They're well-built. They've got three microphones, so the call quality is really good. 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 Shox products. That's shokz.com. This offer can be combined with other official promotions. Now, back to the show. 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.

51:55Forrest Hanson: Last one, relaxation exercises. Yeah. 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 sleep meditation practice when you're lying in bed or something like that. Oof, that's not a lot. Are there – 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.

52:31Forrest Hanson: Absolutely not. Because I'm like, oh, maybe that one thing you've got that cue with or something, but no. Sleep or sex. Mm-mm. 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 squeeze apart and you let it go. You squeeze apart and 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 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 this is good stuff oh well everybody who knows cbti 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, you put it down.

53:24And then when you get in bed, you don't have to run through the list. You think, oh, the list's on that paper. Oh, I don't have to, the list's on that paper. It's kind of like the night before you go to an airport for a flight.

53:33Forrest Hanson: This is extremely helpful for me, by the way, not to cut you off, but like this, I've got a lot of mileage out of this. 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 heating, put the dishes, you know, all the, you're like running through your head. I have to do 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. And if instead you just write down everything you need to do in the morning, turn off the porch light, turn off the heater, da, da, da, da, da.

54:05Then you get in bed. You're like, wow, I just have to look at the list. Just have to look at the list. And it gets real old, real fast. And then you'll fall asleep with it.

54:12Forrest Hanson: With this time in bed awareness, if you're going to need to wake up earlier for whatever reason, you would recommend sticking to a consistent bedtime? Or would you recommend prioritizing a consistent wake time? I'm just thinking about the reality of normal life for people. 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.

54:54You don't need to fuss with it too many days. 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.

55:23Forrest Hanson: So with the meditation, progressive relaxation techniques that are on the acceptable list, that people will do in bed. No, there is no acceptable list in bed. Sorry, I'm trying to refer to the relaxation exercises side of it. Are there versions of that that you think are acceptable? You can kind of run through your bed. How do you think about this? 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 five minutes, I don't care.

55:57That's not a problem.

55:59Forrest Hanson: Yeah, or when it turns into an activity, I think is part of what 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 invested in this show. I know, they've decided to do that. But what you're referring to with all the apps that people are using in bed, yeah, that's a hard no. So as we've said throughout this conversation, CBT-I is a really effective approach to therapy. About 70 % to 80 % of people respond meaningfully to CBT-I.

56:35Forrest Hanson: 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 CBTI. And you're running this study right now, I believe it's called the SLEPS study, where you're taking a look at what might help improve the effectiveness of CBTI 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.

57:13Do you remember earlier how we 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. 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.

57:54And so what we're doing is we're looking at, well, is 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? 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 no therapist was involved, right?

58:42And using this passive body heating, you know, one to two hours before bed, this combination. So it was pretty remarkable results that 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. We're using the higher dose infrared sauna blanket. That's what that is. And we have them use that outside of bed before going. But it's interesting. We're really trying to create this as a mind and body intervention that doesn't involve supplements, drugs, etc.

59:27that is going to be good for the long run. So once people get CBTI, they don't need it again. It's like Santa Claus, the jig's up, they know everything. 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.

59:46Forrest Hanson: 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? 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. With 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.

1:00:19You 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 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. And that's where I got the idea to write this grant proposal to the National Institutes of health and, you know, 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?

1:01:05Because like you said, 50 % of people get remission. Well, maybe we need to bulk up that package.

1:01:10Forrest Hanson: 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, 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. So why would that help somebody who's experiencing depression? 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.

1:01:45Oh, yeah. Congratulations. Thank you. UCSF, Harvard MassGen, and the Cleveland Clinic, three hospital sites. Ohio, you know, 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. It's not that much higher, right? There's a very narrow range that humans live in, right?

1:02:25We'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 we're sitting here. We're sweating, even though it's in temperate rooms. You know, we're not dripping, but we're microscopic. We're sweating in small amounts, right? So people with depression may be less efficient at cooling themselves down. And what these data have shown over several decades, and what we just showed in another paper we published with 19 ,000 people in it, we published the first one a couple of years ago, and then we published just another one, showing that people with depression have higher body temperatures in a graded fashion.

1:03:03The people with the most depressive symptoms were the hottest, followed by the people with the moderate symptoms, followed by the mild, followed by the within normal limits of symptoms. And we did that using aura rings. We had these thousands and thousands of people wearing aura rings. And we just found that, you know. And then in the paper we most recently published, we 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 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 dianar 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.

1:03:55So 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 the drop in their depression symptoms.

1:04:27So this is fascinating. You can intervene on the depression symptoms to impact body temperature, or 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 that. that we were powered for feasibility to show like, Hey, this feasible for us to do the study. And what we found in these feasibility studies, the first day was that I think 90, 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 hyper, whole body hyperthermia treatments in the lab at UC San Francisco at the Osher center, right?

1:05:1991 % 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. And then we tried two different levels of heat from 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. So maybe we don't need to get you as hot.

1:05:48We just need to get you sweating. But the point is, that was 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.

1:05:59Forrest Hanson: Pretty good perspective numbers, 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 will. And that's the big boy one. Yes, that's the big boy. That's really, really cool stuff. A long time to get there. Yeah, this is wild stuff. And I mean, you just think about the potential impact for people if something like this could really dial up the effectiveness of an already pretty validated treatment of CBT for depression.

1:06:38And we are recruiting for the insomnia study, I should say, and that's recruiting across the United States, including Hawaii. It's remotely delivered, so if anybody's, 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 reside in the San Francisco Bay Area, the greater Cleveland area, or in the Boston area.

1:07:07Forrest Hanson: 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? Anything at all? Mike's yours. Thanks. I confess to being horrible at social media. I think that I have like eight posts to my name on Instagram. It might be for the best.

1:07:39I have ambitions to improve, but I am on Instagram. I think it's Ashley Mason PhD or something like that. I don't even remember. But my lab website is seaclab.ucsf.edu. That's a great place to go see what our research studies are that are ongoing. If you're interested in participating, there's links from there to see if you're eligible. 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 of incredible people from you know 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 i'd love to talk with you and then if you were into the people often email me asking where can i find your scientific articles and to find the scientific articles.

1:08:40You 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 there's a bazillion Ashley Masons, but if you just look for the one at Verified for UC San Francisco, you'll be able to then see all the listing of all the publications that have come from my lab. But those are pretty much the best places to find me.

1:09:01Forrest Hanson: I really appreciate you taking the time today. This was great. I learned a lot. Great. Good. Thanks for having me.

1:09:14Forrest Hanson: I had a great time today talking with Dr. Ashley Mason about CBTI, 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? So insomnia is a persistent disturbance in somebody's experience of sleep. So they might have difficulty falling asleep.

1:09:48Forrest Hanson: 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. 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.

1:10:25Forrest Hanson: 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. 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 unpleasant experience of their night of sleep.

1:11:08Forrest Hanson: 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. 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 CBTI 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.

1:11:47Forrest Hanson: 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? Sure, you know, maybe you felt a little bit more tired or more groggy or, oh, you didn't feel quite as sharp at work, but did something bad actually happen or were you just kind of worried about it the whole time?

1:12:26Forrest Hanson: And so it's applying CBT-ish 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 one, 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.

1:13:05Forrest Hanson: Time in bed restriction can be a pretty hard sell for people who already feel like they aren't sleeping enough, 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 stimuli. And the way that they do this is by very carefully controlling the amount of time a person spends in bed.

1:13:51Forrest Hanson: 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? 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 six to do that every day, weekends included.

1:14:31Forrest Hanson: 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. 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.

1:15:09Forrest Hanson: 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 kind of wake up early. Sometimes you go to bed late. These are all things that can affect the quality of the sleep that we get. 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.

1:15:44Forrest Hanson: 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 Ashley 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. 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.

1:16:22Forrest Hanson: 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 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. Another interesting thing that she said, particularly for me, a habitual coffee drinker, is she thinks that the cutoff for consuming caffeine is something around 11 a.m., pretty early in the day if you really want to optimize your sleep.

1:17:06Forrest Hanson: 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. 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.

1:17:46Forrest Hanson: And we could do a whole other separate episode with her on that, I'm sure. 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. is so smart, so brilliant at the work that she does. She mentioned where to find her at the end of the episode. I'll also try to include some links.

1:18:17Forrest Hanson: 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 slash beingwellpodcast. And for the cost of a couple of dollars a month, you can support the show and get a bunch of bonuses in return. 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.

1:18:53Forrest Hanson: 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 neurogastroenterologist. 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. 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.

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