[#341 – Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.](https://peterattiamd.com/ashleymason/)

https://www.youtube.com/watch?v=NneZHMv7VBU

## Summary

This podcast transcript features Dr. Peter Attia interviewing Dr. Ashley Mason, a clinical psychologist specializing in Cognitive Behavioral Therapy for Insomnia (CBT-I). Here's a breakdown of the key topics and information:

**1. Introduction to CBT-I and Insomnia:**

* **What is CBT-I?** It's a structured, evidence-based therapy that addresses the thoughts, feelings, and behaviors contributing to insomnia. It's considered a highly effective, "recipe-like" treatment, unlike some other psychotherapies with less predictable outcomes.
* **Insomnia Definition:** Mason clarifies that insomnia isn't just one bad night of sleep. It's a persistent problem (at least three months) that causes significant distress and impacts daily life. It's a *clinical* diagnosis, meaning there's no blood test or sleep lab test that definitively diagnoses it. The distress and functional impairment are key.
* **Prevalence:** About 5-10% of adults experience insomnia at any given time, meeting the clinical definition. Many more (up to 90%) will experience it at some point in their lives.
* **Causes of Insomnia:** Mason explains a three-part model:
* **Predisposing Factors:** These are underlying vulnerabilities like genetics, personality traits (e.g., high psychological reactivity), and a tendency to be a "light sleeper."
* **Precipitating Factors:** These are major life events that trigger a bout of insomnia (e.g., job loss, divorce, car accident).
* **Perpetuating Factors:** These are the *behaviors* people adopt to cope with the initial sleep disruption (e.g., taking naps, using sleep aids, spending excessive time in bed, using screens in bed). These behaviors, while initially helpful in the short-term, become the *main* problem in the long-term. CBT-I focuses on these.

**2. Core Principles and Techniques of CBT-I:**

* **Cognitive Behavioral Therapy (CBT) Basics:** Mason explains the CBT triangle: thoughts, feelings, and behaviors are interconnected. CBT intervenes at different points in this triangle to disrupt unhelpful patterns. For example, challenging negative thoughts about sleep ("I'll lose my job if I don't sleep") to reduce anxiety (feelings), or changing behaviors (taking grandkids to the zoo) to change thoughts about oneself.
* **CBT-I Specific Components:**
* **Stimulus Control:** This aims to re-associate the bed *only* with sleep (and sex). No reading, watching TV, using phones, or even worrying in bed. This is based on the principles of classical conditioning (Pavlov's dog).
* **Time-in-Bed Restriction:** This is a core (and often challenging) component. It involves limiting the time spent in bed to match the amount of time the person is *actually* sleeping, plus a small buffer (e.g., 30 minutes). This increases sleep pressure and consolidates sleep. Mason's approach is slightly modified from standard CBT-I: she doesn't let patients choose their wake time freely, but bases it on their sleep diary data to ensure a realistic schedule.
* **Cognitive Restructuring:** This involves identifying and challenging negative and catastrophic thoughts about sleep. Techniques include thought records (examining evidence for and against thoughts) and "scheduled worry time" (a dedicated time during the day to address worries, preventing them from surfacing at night).
* **Relaxation Techniques:** Progressive muscle relaxation (systematically tensing and relaxing muscles) is often used to help reduce physical tension and promote relaxation before sleep.
* **Sleep Diary is essential**: Used to track bedtimes, wake times, sleep duration, awakenings, and other factors like naps. Used to calculate time in bed, sleep duration and efficiency.

**3. Practical Sleep Hygiene and Lifestyle Factors:**

* **Temperature Regulation:** Mason emphasizes the importance of a cool sleep environment (mid-60s Fahrenheit). She strongly discourages the use of heavy bedding like down comforters, which trap heat. She highlights the circadian temperature rhythm (body temperature is coolest at night) and how heat can disrupt sleep. Warm hands and feet, however, are important for sleep onset (vasodilation helps dump core heat).
* **Light Exposure:** While blue light exposure before bed is a concern, Mason believes the *content* being consumed on devices (e.g., stressful emails, social media) is often a bigger problem. She does recommend orange-tinted glasses (that block blue light) for some patients with sleep onset insomnia, especially if other strategies haven't worked. Darkness in the bedroom is crucial.
* **Caffeine:** Mason recommends cutting off *all* caffeine (including decaf, which can still contain significant amounts) by 11:00 AM for most people.
* **Alcohol:** During CBT-I, Mason generally asks patients to abstain from alcohol (or significantly reduce and standardize intake) to get a clear picture of their sleep patterns.
* **Food:** Avoid eating within three hours of bedtime.
* **Naps:** Naps are forbidden in the first week of her program. In later stages of treatment, naps might be limited to 25 minutes.
* **Exercise:** While exercise is important, intense exercise close to bedtime can be disruptive for some people, especially those who are less fit and have slower heart rate recovery. The timing and type of exercise matter.
* **Medications:** All medications have circadian effects. Consistency in medication timing is crucial, and patients should discuss optimal timing with their doctor.
* **Social Jet Lag:** Mason advises against sleeping in for more than one day in a row on weekends, as it can disrupt the sleep schedule. She suggests choosing one day to "suffer" (wake up at the usual time) to maintain consistency.

**4. Addressing Racing Thoughts:**

* **Scheduled Worry Time:** A dedicated time during the day to address worries, preventing them from surfacing at night.
* **Tracking Degree of Belief:** Monitoring how much you believe a recurring worry throughout the day can help reveal that the thought is often tied to the *time* of day (e.g., early morning) rather than being a true reflection of reality.
* Get out of Bed: if a person can't sleep after 15-20 minutes, they should go to another room and engage in a mildly boring activity.

**5. Sleep Medications and Supplements:**

* **Melatonin:** Mason is skeptical of over-the-counter melatonin due to inconsistent quality and dosing. She believes it's often misused and can disrupt sleep timing. She might consider it in specific cases (e.g., patients on beta-blockers, which inhibit melatonin secretion) after consulting with a physician.
* **Prescription Sleep Medications (Benzodiazepines, Z-drugs, Trazodone):** Many patients come to her wanting to discontinue these medications. Mason works with the prescribing physician to develop a *very slow* and gradual taper, addressing both the physiological and psychological dependence. She emphasizes stability before reduction and uses a "Gem Scale" to achieve precise micro-dosing.
* **Supplements:** She generally advises patients to discontinue sleep supplements during CBT-I to get a clear baseline of their sleep.

**6. Other Sleep Disorders:**

* Mason screens for other sleep disorders like sleep apnea and restless legs syndrome. She refers patients to specialists if these are suspected.

**7. Accessing CBT-I and the Program Structure:**

* **Finding a Provider:** Mason recommends the Society of Behavioral Sleep Medicine website to find qualified CBT-I therapists.
* **Telemedicine:** Telemedicine has greatly increased access to CBT-I.
* **Mason's Program:** Her program is structured (five treatment sessions plus intake and follow-up), weekly, and often conducted in groups via Zoom. She emphasizes adherence and provides education about the science behind the techniques.
* **AI:** Mason acknowledges the potential for using AI to democratize access to CBTI.

**8. Key Takeaways:**

* Insomnia is treatable, and CBT-I is a highly effective, evidence-based approach.
* Focus on the *behaviors* perpetuating insomnia, not just the initial cause.
* Adherence to the CBT-I principles is crucial for success.
* Don't suffer needlessly; seek help from a qualified CBT-I therapist or explore resources like the book "Quiet Your Mind and Get to Sleep."
* Consistency in sleep schedule (especially wake time) is paramount.
* There's no "one-size-fits-all" approach; individual factors and preferences should be considered.
* A slow and gradual approach is key when tapering off sleep medications.

The podcast emphasizes that CBT-I offers a powerful, drug-free approach to overcoming insomnia, empowering individuals to regain control of their sleep and, consequently, their lives.

## Practical Recommendations

**I. Immediate Actions & General Sleep Hygiene:**

1. **Establish a Consistent Wake Time:** This is *the most crucial* first step. Wake up at the same time *every day*, including weekends, during CBT-I treatment. After treatment, limit sleeping in to *one day* per week.
2. **Bedroom Environment Optimization:**
* **Cool Temperature:** Aim for a bedroom temperature in the mid-60s Fahrenheit.
* **Darkness:** Make the room as dark as possible. Use blackout curtains, cover or remove electronic lights, and consider an eye mask.
* **Bedding:** Use *cotton* blankets and sheets. Avoid down comforters, duvets, or anything that traps heat.
* Bed: Limit activities in bed to sex and sleep.
3. **Caffeine Cutoff:** Stop consuming *all* caffeine (including decaf) by 11:00 AM. Do *not* reduce your overall caffeine intake suddenly, just shift the timing.
4. **Limit Alcohol:** Ideally, abstain from alcohol during CBT-I. If that's not feasible, work with a professional to significantly reduce and *standardize* intake (e.g., a small, consistent amount at a specific time).
5. **No Eating Before Bed:** Avoid eating within three hours of your planned bedtime.
6. **Hydration Management (Especially for Men):** Reduce fluid intake with and after dinner, and consider an electrolyte tab (without excessive sugar) to minimize nighttime bathroom trips.
7. **Warm Hands and Feet:** If your extremities are cold, use socks or a small, auto-shutoff heating pad at the foot of the bed to help with sleep onset.
8. **Avoid Naps (Initially):** During the initial phase of improving sleep, eliminate naps completely. Later, if necessary, limit naps to a 25-minute "nappertunity."
9. Don't use screens in bed.

**II. Cognitive and Behavioral Strategies:**

10. **Scheduled Worry Time:** Dedicate a specific time (e.g., an hour) *during the day* to address worries. Write them down and actively work through them. This prevents them from hijacking your sleep.
11. **Track Degree of Belief:** If a particular worry keeps waking you up, track how much you believe that worry at different times throughout the day. This can reveal that the worry is more tied to the time of day than to reality.
12. **Stimulus Control (Get Out of Bed):** If you wake up in the middle of the night and can't fall back asleep within 15-20 minutes, *get out of bed*. Go to another room and engage in a *mildly boring* activity (e.g., reading a non-stimulating book, adult coloring book) until you feel sleepy again. *Do not* do anything stimulating (e.g., work, check email, social media, exciting games).
13. **Progressive Muscle Relaxation:** Practice tensing and releasing different muscle groups to promote relaxation before bed. This can be done in or out of bed.
14. **Don't Believe Everything You Think:** Challenge negative and catastrophic thoughts about sleep. Use a thought record to examine evidence for and against these thoughts.
15. Stop listening to podcasts in bed.
16. If watching TV on the couch, and that's causing you to fall asleep, sit on a stool.

**III. Actions Requiring Professional Guidance/Consideration:**

17. **Seek CBT-I Therapy:** If you meet the criteria for insomnia (persistent sleep problems causing distress and impairment), find a qualified CBT-I therapist. Use the Society of Behavioral Sleep Medicine website to locate a provider.
18. **Medication Review:** Discuss your medications with your doctor to ensure they are being taken at the optimal time of day and are not contributing to sleep problems.
19. **Medication Taper (If Applicable):** If you are taking prescription sleep medications and want to discontinue them, work with a professional (like Dr. Mason) to develop a *very slow and gradual* taper plan. Do *not* attempt to quit abruptly.
20. **Rule Out Other Sleep Disorders:** If you suspect sleep apnea, restless legs syndrome, or other sleep disorders, consult with a sleep specialist.
21. **Consider Orange-Tinted Glasses:** If you have trouble falling asleep at the beginning of the night, and other strategies haven't worked, try wearing *orange-tinted* (not just clear blue-light blocking) glasses for two hours before bed. Do this consistently for two weeks and track your sleep.
22. **Sleep Diary:** Use a sleep diary to record sleep-related information (bedtime, wake time, sleep duration, awakenings, naps, caffeine/alcohol intake).
23. **Don't Use Sleep Trackers (During CBT-I):** If sleep trackers are causing anxiety, take a break from them during treatment.

**IV. Self-Help Options (If Professional Help is Unavailable/Delayed):**

24. **Read "Quiet Your Mind and Get to Sleep":** This book provides a guided, self-help approach to CBT-I.
25. **Consider CBT-I Apps:** Explore CBT-I apps (e.g., Rest) as a potential alternative or supplement to therapy. Recognize that adherence can be a challenge with apps.

**V. Exercise:**
26. Avoid strenuous exercise close to bedtime.
27. Strenuous exercise should be performed in the morning if possible.

## Practical Recommendations 2

**VI. Refining Existing Strategies & Addressing Specific Scenarios:**

28. **"Democracy Within a Dictatorship" Wake Time (Mason's Approach):** If working with a CBT-I therapist, be prepared for them to guide your wake time based on your sleep diary data, rather than letting you choose it completely freely. This ensures a realistic starting point.
29. **A/B Testing Sleep Hygiene Changes:** When trying any new sleep hygiene intervention (e.g., orange glasses, caffeine timing), do it *consistently* for at least two weeks while keeping a sleep diary. This allows you to objectively assess its impact.
30. **Address Social Jet Lag Strategically:** If you *must* deviate from your consistent wake time on weekends, choose *one day* to sleep in (ideally no more than an hour) and accept that the following day may be more challenging. Do *not* sleep in two days in a row.
31. **Unexpected Late Nights:** If you have an unexpectedly late night (e.g., delayed flight), prioritize which day you want to feel better. If it's the *following* day, try to stick closer to your usual wake time. If it's the day *after*, you can sleep in a bit more, but be prepared for a later bedtime that night.
32. **Partner Sleep Issues (Falling Asleep on the Couch):** If your partner falls asleep on the couch while watching TV, encourage them to go to bed when they feel sleepy. If they want to spend time together, schedule dedicated "couch time" *earlier* when they are more likely to be awake.
33. **Hotel Sleep Strategies:**
* Pack black electrical tape to cover annoying lights in hotel rooms.
* Unplug alarm clocks to avoid unexpected alarms.
* Control the room temperature (aim for mid-60s).
34. **Couples:** If you want to watch TV with your partner, but one person tends to fall asleep, watch a different show that is more engaging, or schedule time earlier in the evening.

**VII. Addressing Medication Tapers in Detail:**

35. **Stabilize Before Tapering:** Before attempting to reduce sleep medications, ensure your dosage and timing are *completely consistent* for at least a week.
36. **Micro-Dosing Taper:** Use a "Gem Scale" (a highly precise scale) to measure *very small* reductions in medication dosage (e.g., going from 12.5mg to 12mg of Ambien).
37. **SUDS (Subjective Units of Distress Scale):** Rate your anxiety level (1-10) associated with each proposed dosage reduction. Only proceed with a reduction that feels manageable (a "1" on the scale).
38. **Patience and Flexibility:** Be prepared for the taper process to take a *long time* (months). Allow for periods of stabilization (e.g., three weeks at a new dose) and be willing to pause the taper if life stressors arise.
39. **Communicate with Prescribing Physician:** Ensure your prescribing physician is fully aware of and supports your taper plan.

**VIII. Mindset and Expectations:**

40. **Prepare for Initial Difficulty:** Understand that CBT-I, especially time-in-bed restriction, can be *challenging* initially. You may feel worse before you feel better.
41. **Embrace the "Dictatorship":** Accept that a structured approach with clear guidelines is often necessary for success.
42. **Don't Obsess Over the Cause:** While understanding the initial trigger of your insomnia can be helpful, CBT-I focuses on *current* behaviors, regardless of the original cause.
43. **You Are Not a "Delicate Flower":** Avoid the mindset that your insomnia is uniquely resistant to treatment. CBT-I is effective for a wide range of presentations.
44. **Don't Wait:** Don't postpone seeking help or implementing strategies. There will never be a "perfect" time.
45. **Adherence is Key:** The treatment works when you do it; it doesn't work when you don't.

**IX. Specific Situations & Considerations:**

46. **Illness:** If you are sick, prioritize rest and allow for naps (but maintain stimulus control – nap in bed, not on the couch).
47. **Extreme Phase Delay/Advance:** If you have a significantly delayed or advanced sleep phase (e.g., going to bed at 3 AM and waking up at 10 AM, or vice versa), adjustments to caffeine timing and other strategies may be needed.
48. **Night Shift Work:** Be aware that night shift work is associated with increased health risks, including cancer. If possible, explore strategies to optimize sleep and minimize circadian disruption.
49. **Sauna Before Bed:** If you use a sauna before bed, pay attention to your body's response. If it increases your heart rate significantly and delays sleep onset, adjust the timing or intensity. Also, be mindful of hydration to avoid nighttime bathroom trips.
50. **Cold Plunge before bed:** Do not take a cold plunge before bed.