Ep. 67 – Tony Ho – Insomnia: Now Playing In A Person Near You
- How our sleep patterns naturally change over our lifetime
- Horizontal worries - what they are and what to do with them
- Habits for healthy sleep hygiene
Insomnia affects 40% of adults and we can lie awake worrying about having it!
Cognitive-behavioral therapy for insomnia is the recommended route to restore sleep patterns for people struggling with insomnia and in this episode, sleep specialist Tony Ho describes how CBTI can realign our relationship with sleep.
Tony is the director of Quadra Wellness & Counselling Centre in Vancouver Canada and a mental health specialist. Join us!
Tony HoTony Ho is a psychotherapist, counsellor, sleep specialist, instructor at the University of Victoria, a guest lecturer at the UBC school of social work, and the director of Quadra Wellness Center, a sleep and counselling clinic in Vancouver BC.
Tony works in a variety of community care settings with older adults and individuals with severe mental health and substance use issues.
Tony’s mission is to work collaboratively with patients in a non-judgmental, evidence grounded, compassionate manner. Tony identifies with the LGBTQ+ community and brings a social justice lens into his counseling, believing therapy should never be aimed at helping people adjust to oppression.
Regarding insomnia, on Quadra's website Tony writes, “Together, I can help you resolve your insomnia so you can start feeling, thinking, and performing your best again - to be more present and engaged in your life.”
Ep. 67 – Tony Ho – Insomnia: Now Playing In A Person Near You
Rachel Cram – Well, good evening, Tony.
Tony Ho – How’s it going, Rachel?
Rachel Cram – Good. This is the end of a busy day for both of us. Sometimes you just have to do that to get in these interviews.
Tony Ho – Yep. No worries. Appreciate the flexibility.
Rachel Cram – Oh, well, I do, too. And I know as a sleep specialist yourself, probably doing work right up until the last moments before sleep isn’t optimum. I would imagine.
Tony Ho – Yeah, I have a four-year-old too, so, you know, life is busy. So it’s about finding that balance.
Rachel Cram – It is all about balance. Well, I’m really looking forward to this conversation for my own learning. I love sleep, I cherish sleep. I remember I used to call my mum when a friend would ask me to sleep over and I’d be like, “Mom, say no,” because I was too embarrassed to say, “No, I need my sleep.”
I don’t know why that is. We’re embarrassed to say that, but it just was not cool.
Tony Ho – You’re a rare child I think then.
Rachel Cram – Oh, do you think so? Yeah, I don’t know. But I do know one of the biggest stressors in becoming a parent was without a doubt, the loss of sleep. I found the tiredness really difficult with night feedings and early mornings and then everything else that comes with welcoming new children into our home.
But you have a four-year-old, how’s sleep going with you these days Tony? This is your first child, right?
Tony Ho – Yes, our first child. And, you know, I think we went through the first year or two of lots of transitions and changes, from a little one that’s waking up every couple of hours to, you know, the first time being in a big kid bed and getting out every 30 minutes. We still have the odd middle of the night body slam or, you know, hear the door creaking open and then a shuffle, shuffle, slam, and I’m up at four. But yeah, it’s, it’s, drastically better than the challenges of the first couple of years.
Rachel Cram – Yeah, well sleep, or lack of sleep is not something we factor into our fantasies for starting off family life, but it’s usually a reality. And we figured it out. Or we don’t, which is why you and your clinic are in such demand. Let’s talk about that. You are both a social worker and a sleep therapist. How did those two areas of study come together?
Tony Ho – Yeah, that’s an interesting question and I often think about that and I’ve always kind of worked in social services. I actually have been an ECE teacher and worked with all ages.
Rachel Cram – Really, that is amazing, I did not know that. The interview that’s going out right before yours was with an ECE male, which is just so rare,
Tony Ho – Very rare
Rachel Cram – There are not a lot of men in ECE. That’s very fascinating.
Tony Ho – Super unfortunate.
Rachel Cram – Yeah, well, now I like you even more. but continue, how did you move into sleep therapy from social work and early childhood education?
Tony Ho – Yeah, before I was an ECE I was a youth worker at the local neighborhood house. That’s when I was introduced to the mental health world, working in facilities and hospital and community, helping people with more severe mental health disorders. And I think sleep’s kind of been this theme all through my life. You know, when I think about the really tired teenager coming into our youth group, really seeing how exhausted they are from a full day of school or having to wake up early and how that impacts them, to being in ECE and being in the nap room and having the two or three-year-old roll around pulling other kids’ hair, to the one who is really upset or seeing a kid have a complete meltdown because it’s close to nap time. There isn’t really a phase of life at all where sleep doesn’t play a factor in your well-being or your resilience. And it carries into adulthood where I work with folks with varying degrees of mental illness and sleep still plays an equation. Any mental health issue that you can think of anxiety, depression or even more severe illnesses like schizophrenia. Sleep’s a theme in there. For a lot of folks poor sleep starts to emerge before the difficulty. So I just find it really fascinating. And since having a kid, all these kind of amalgamate, like how can I help my little one have healthy sleep habits, but also make sure that I have that as well to be a good role model, but also, to be resilient. And I came to realize that more when I had my kid and experienced the challenges of sleep deprivation myself as well as insomnia. So I really wanted to focus on finding really effective, but also non-pharmacological ways to address sleep problems, which is where I start to do more training in cognitive behavioral therapy for insomnia.
Rachel Cram – Hmm. Now, you split your time between your clinic, you have a sleep clinic in Vancouver, British Columbia, and then you also work in a mental health section of a hospital. Is that correct?
Tony Ho – That’s right, yeah. I work in a community mental health team with adults with varying mental health challenges from depression to more complex mental health issues like psychosis. Yeah, so it’s interesting and very challenging kind of difference in the work, but sleep still plays a role in both worlds.
Rachel Cram – Yeah, I was going to ask that are there notable connections between sleep and mental health? What have you found?
Tony Ho – Yeah, it’s really not a chicken or egg. It’s just that when you don’t sleep well, that can affect your mental health, but if you’re experiencing mental health challenges such as anxiety or depression or even a mood disorder like bipolar, sleep deprivation or sleep challenges are a part of really any mental health issue, but when we focus on trying to improve sleep and sleep quality, it doesn’t mean that all the problems will go away or, suddenly everything’s better. It just means that sometimes we’re able to cope a bit better, and that can improve our resilience, it can improve how we feel we can cope with the challenges that show up in our lives. It’s something that is to some degree within our control, where sometimes there are things in our life we cannot, right.
Rachel Cram – Yeah. Well for me, it’s those things in my life that I can’t control that make me lose sleep, that ruminate in my head in the middle of the night. And I’ve found that that’s increasing with my age.
Tony Ho – Yeah, definitely as we get older, you know, stress increases with different challenges, and even thinking of the pandemic, we saw more people reporting sleep problems, especially in the middle of the pandemic when things were really challenging and a lot was unknown. So, you know, stress is often the number one thing that we see leading to sleep problems but then most of the time, those problems start to dissipate and then people start to get back to a usual rhythm. But for a handful of folks, those sleep problems continue even though the original problems or stressors dissipated somewhat, the sleep problems become its own monster is how I kind of describe it and someone may experience those difficulties for decades.
Rachel Cram – Before we jump into talking about therapy for insomnia, can I pick up on your comment that ‘as we get older,’ and I can’t recall exactly what you said after that, but it wasn’t, ‘as we get older we sleep better.’ Are there notable ways that our sleep changes with age?
Tony Ho – Yeah, that’s a great question and one that I really focus on with clients that I work with to help them understand how sleep works, but also how it changes over time. When we think of a baby, most babies will be up several times through a period of a night, every few hours to feed. As they get older their sleep starts to consolidate and becomes more of a rhythm, that internal circadian rhythm. And it’s not just sleep that’s regulated by this internal rhythm, but our blood pressure, temperature, our digestive system, they all kind of work on all these rhythms that we can follow very predictably over a 24 hour period.
And for example, let’s focus on teens. You know, naturally, in our teen years, something really interesting happens as puberty starts to develop and you start to change, the timing of their sleep starts to change. So the timing of the hormone melatonin, when it gets released, moves a little bit later. So for many teens, suddenly your child who usually goes to bed at 9:00, all of a sudden, not that sleepy, you know, 11, 12, sometimes 1. Well, after you go to bed. And then gradually as we age, that starts to shift earlier and earlier. In our thirties and forties and fifties, we start to get sleepy a little bit earlier and once we reach our middle years, many women transition through menopause and as men age, we start to see more disruptions in our sleep. And what’s really fascinating is that the amount of melatonin that our body actually produces is very minimal by the time we get to 70, 80, as well as the need for deep sleep. As we age, our need for deep sleep gradually diminishes because our body isn’t not necessarily focused on physically growing as much anymore. So we need to match our efforts to improve sleep with where we are in life as well.
One study I often draw on when I talk to people about normalizing sleep difficulties, some researchers out of the University of Toronto were looking at the sleep habits of hunter and gatherer tribes around the world, and they looked specifically at one group called the Hadza, who live in northern Tanzania. And so these are folks who live in smaller tribes, and they live essentially in kind of like outdoor kind of buildings. They’re building their structures outside. They’re really exposed to the elements, temperature. So they almost, like, have ideal human sleep hygiene. And what’s really fascinating is that they measured the sleep patterns, over a typical night of 30 some odd people who lived in the group of varying ages. And people were only asleep at the same time for about 30 minutes.
What that tells us is that depending on your age, everyone had a slightly different sleep pattern. So the parents were up in the middle of the night taking care of the children. Some of the older adults would go to bed a little bit earlier, wake up earlier. And the younger people typically stayed up later. Kind of like our teenagers. Right. And there’s some theories around teenagers why that is. Maybe it’s this residual survival component where the younger people stayed up later of protect the tribe. And of course, that can’t necessarily be proven, but it’s one interesting theory. It’s called the Sentinel Theory. Imagine thinking about your teenagers, like they’re not just up being rowdy or, you know, being annoying. In some ways, they’re up guarding the tribe, protecting the group.
And I really like using that example just to take away the stress around sleep, like sleep changes as you get older. Sleep changes in the course of your lifetime. How can we accept that and work with it rather than against it and worrying about it and trying to hack our way into better sleep? How can we support that process that’s built into us as humans?
Rachel Cram – I don’t know why it is, but knowing that people in ancient times had varying sleep patterns seems comforting. Probably because I associate that as a time when everything was organic and in line with nature and simpler and obviously that’s not all true, but if it reduces sleep stress, let’s go with that.
Tony Ho – Oh yes. Exactly.
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Rachel Cram – So our sleep rhythms are going to change throughout our lifetime, that’s historically documented, but clearly, even within those naturally occurring changes, there are times when we’re not getting the sleep we need and that is where I want to go with you right now. Have you ever watched the show Survivor?
Tony Ho – Oh, yes. Big fan.
Rachel Cram – We watched as a family all the time. And one of the things that often captivates me is the necessity of them having the contestants be sleep deprived. I think that deprivation creates the edge of the show because people are off their game. You know, they’re not capable of functioning the same ways that they would have if they’d had enough sleep. What are the clues that we need more sleep? When we’re not in a game and not aware of how our habits and our lifestyle’s effecting us, sometimes we just don’t know. Do you know what I mean? What would let us know we need to address our sleeping patterns?
Tony Ho – Yeah, that’s a good question. Some of the common things that you look out for are if you’re having difficulty getting up in the morning, but also, shortly after you’re falling back asleep, or especially if you’re, for example, driving or doing something and you’re finding you’re falling asleep at the wheel, particularly those signs of sleep deprivation are very concerning. And also looking at stimulant use such as coffee to boost our functioning during the day. If you’re really relying on that to get through the day, another sign that you’re maybe not getting the sleep or quality of sleep that you need to feel good or sustain your energy through the day.
Sleep research hasn’t come to one point that we all agree that sleep is for X, but we know that it serves a myriad of functions around helping people process learning and memory, especially in the deeper restful stages of sleep. For example, dreaming can help manage our emotions, how to regulate challenging emotional experiences.
When we’re sleep-deprived, even being able to make really quick reactive responses, which is important for sports, but also staying safe on the road. All these kind of mental functions are tied to being able to have restful quality sleep over a regular period of time.
Rachel Cram – When you’re saying sports, my son was telling me that LeBron James sleeps 12 hours a day? And he said also, Usain Bolt does as well. I was fascinated by that, like 12 hours?
Tony Ho – Yeah. It’s interesting. I was reading an interview with Serena Williams and she was also talking about her sleep after having children and the challenges that come with that. And again, it’s important to keep in mind that everyone’s different around their sleep. Sometimes people will read that and be like, “Oh, no, I need to be getting 8 hours of sleep.” But sometimes it doesn’t match what you need, right? It’s really about the quality of sleep that you’re getting. Somebody could be in bed for 12 hours but have terrible quality lying there for a really long time awake, you know, and it has more of an impact than someone who sleeps maybe a restful six or 7 hours of sleep.
Rachel Cram – Yeah, I can tell that you’re being so cautious to not create more worry as you explain this.
Tony Ho – Oh exactly. Yeah.
Rachel Cram – But I interrupted you there? So you said we need sleep for memory. We need it for decision-making. We need it for mental processing. Are there any other reasons why we just need to have that sleep for our functioning?
Tony Ho – Yeah, interesting, especially, you know, throughout the pandemic, people were looking at sleep and immunity. When we are ill our need for sleep often goes up for our body to rest and for our immune system to have opportunity to do its job. So when someone has chronic poor sleep over time and disrupted sleep, that can impact really every functioning system in their body that keeps them well.
There was a great book that came out fairly recently, it was quite popular, called Why We Sleep by Dr. Matthew Walker. And some studies have come out from his clinic actually, about reducing the risk of Alzheimer’s. When we have consistent, good quality sleep, it allows this part of your brain to clear out proteins that can increase your risk of dementia, which is really interesting.
It’s tied to other things as well, like how it can impact the regulation of your appetite. It’s interesting that people tend to crave more carbs or have more dysregulation around their ability to notice signals for hunger, which is really fascinating. So when appetite is dysregulated, that can increase your risk of diabetes for example. Blood pressure can be impacted as well, especially if your body is not able to get into deeper restful state to sleep on a regular basis.
Rachel Cram – Hmm. Okay. So we need our sleep, but we’re not to worry about it.
Tony Ho – Yes, we need our sleep, but not to worry about it because your body knows how to do it.
Rachel Cram – Okay. Okay. We’ll get to that part when you start talking about cognitive behavioral therapy, I know. Now, you talk about there being both psychological and medical causes for insomnia. Worry and stress are psychological reasons, and I know that’s the main focus of your work, but what would be some of the medical causes for insomnia?
Tony Ho – Yeah. You know, there are many things that can lead to insomnia, for example, sleep apnea, which I always screen for and which is quite underdiagnosed.
And sleep apnea is a medical condition where the muscles in your throat relax and really obstruct your breathing up to like 30 times a night where you stop breathing momentarily and your brain kind of kick-starts the breathing again, and that’s a sign that you’re gasping for air. You’re trying to get air. But it’s not always the case. Sometimes people just really feel fatigued during the day, but you know you’re in bed for a good amount of time, but you think you should be getting good quality sleep. Again, another sign to get checked for that.
Rachel Cram – I feel like I’m aware of quite a few people that have sleep apnea. How common is that?
Tony Ho – I think the last stats that I saw were 10% of the adult population. And it becomes increasingly more common as we age, particularly in men. And it’s seen more commonly for women post-menopause just because the body composition changes and they tend to kind of put more weight around their neck or just kind of gain more weight. So that increases the risk of obstruction in that airway.
Rachel Cram – I was out for dinner with my dad, and he was telling me that he has discovered that he has sleep apnea and has started using a sleep apnea machine. And he was just singing the praises of this discovery for himself, because he’d been having migraine headaches. He had been finding himself tired during the day. He found that his libido was down, which I didn’t really want to hear about, but he was telling me about it.
Tony Ho – Very important.
Rachel Cram – Important. And the sleep apnea machine just changed all that for him. And I was so fascinated because it wasn’t something I was familiar with. It almost seemed like a miracle in his life. So if we’re feeling exhausted, it doesn’t have to be necessarily.
Tony Ho – No. No, absolutely. And unfortunately, it’s quite underdiagnosed and people often go decades or just blame it on, you know just a snore or just that’s the way they are, right, or accept it as part of aging. And it doesn’t have to be.
Sleep does change and we tend to experience more awakenings, but quality of sleep doesn’t have to diminish, or the restfulness you can get from it. And so it’s important to rule out medical things like sleep apnea that can contribute to poor sleep. And you can go to a local sleep clinic and do a take-home test, and they can look at your breathing, they can look at your heart rate through the night, and they’ll be able to detect whether you’re on that spectrum that qualifies for a diagnosis of sleep apnea.
Rachel Cram – A take-home test. That’s good to hear because I thought you had to go into a clinic and I was thinking “I will never, if I had to test for that, I would never be able to fall asleep in a clinic.”
Tony Ho – That’s what I hear most of the time. Yeah. Yeah. Understandably, you know, it’s hard to sleep in a strange room with people actively monitoring you, but it’s amazing. People do.
Yeah. Rachel Cram – Would there be consequences to not having sleep apnea diagnosed beyond just the ongoing fatigue?
Tony Ho – Well, absolutely, fatigue, of course, is the biggest one, and hypersomnolence where people are falling asleep during the day. But we know that it also increases blood pressure and the risk of heart attacks and strokes because your body isn’t able to get to deeper restful stages of sleep because it’s constantly interrupted with gasps for air. And if you have a partner in bed and you’re constantly snoring, that could also impact your relationship and their sleep as well.
Rachel Cram – Yeah, so, sleep apnea is an example of a medical reason for insomnia. Tony, do you want to mention a few other common medical reasons for sleep deprivation?
Tony Ho – Yeah, so other conditions such as depression can lead to greater amount of time in bed. Also anxiety disorders. If someone’s experiencing a lot of distress that’s keeping them up in the middle of the night.
Chronic pain, you’re just so uncomfortable and hurting that it can really throw off your sleep and then the sleep itself can emerge to become a problem.
Rachel Cram – So, sometimes insomnia starts as a medical condition, like sleep apnea, depression, anxiety, or chronic pain, but then, you say, even as the medical condition alleviates, insomnia might continue because it’s moved into a psychological condition.
Tony Ho – Exactly.
Rachel Cram – Can we move into talking about that then? Psychological conditions for insomnia, and I think part of that comes down to the quality of our sleep patterns and routines. Can we talk about that?
Tony Ho – Sounds good.
Musical Interlude #2
If you’d like to connect further with Tony on his social media platforms or find him at his clinic, or if you’d like to read a written transcript of this conversation with Tony, find links at family360podcast.com. It’s all there waiting for you.
Rachel Cram – So, Tony on your Instagram post, which I loved reading through in preparation for your interview, you post about quality sleep being more important than quantity of sleep. Can you talk to me about sleep cycles? Because I think that’s part of the quality and the quantity. Is that right?
Tony Ho – Yeah, yeah, it plays a really big part in it. Most adults will have the opportunity to cycle in and about four or five sleep cycles a night. And we actually do wake up periodically through the night, often very short awakenings at the tail end of a sleep cycle. And one sleep cycle is a complete rotation through different phases. And each has a different element of how it restores our body and to kind of keep it simple, there’s two phases, there’s non-REM sleep and REM sleep. And when we think about the first active stage of sleep, most people would even recognize that as sleep. It’s kind of like this deep state of relaxation. And the way I describe it to people is, think about when you lie in bed, sleep just kind of washes over you. It’s an involuntary physiological experience. It just kind of this washing over of relaxation and you kind of slip into the unconscious so you don’t remember. And then we start moving into deeper phases of sleep, where we see our immune system starting to work through our body, take care of ourselves.
And then we move into a more active stage of sleep, often referred to as rapid eye movement or REM sleep and when we look at our brainwaves, it’s almost as active as if we were conscious and awake. And a lot of research is looking at the utility of that and how it’s really has a lot to do with the areas of the brain where memory is involved. And so we go through that several times through a night and deeper sleep gets shorter and shorter as the night wears on. And why that’s really important to be aware of is that for many folks, especially who experience insomnia, we oftentimes have like middle of the night awakenings. So you get into bed and all of a sudden you wake up some time at four in the morning and then you can’t fall back asleep, right? One reason for that is that your body’s already gotten a good chunk of deep sleep. Right. And so it’s much harder to fall asleep, especially if your mind’s very active or the mind is associating bed with wakefulness.
Rachel Cram – So to get quality over quantity, what does that mean, then? Are you trying to get more cycles in?
Tony Ho – Mm hmm. The general recommendation is somewhere between seven or 8 hours, and that varies. One person who maybe get 6 hours, but they sleep restfully and cycle through several cycles without much interruption, will probably experience their sleep as much more restful than the person who’s in bed for 8 hours, but they’re awake in the middle of the night for an hour or two. They take a really long time to fall asleep or their sleep is fractured.
So that’s when we talk about quality over quantity, is how can we prioritize your body to allow itself to get back into another cycle without too much effort?
Rachel Cram – You’re saying we naturally wake up at the end of a sleep cycle. But are there times when it actually is more disruptive for us to be waking up? You know, you’re talking about your son coming and leaping on you at four in the morning. Like, are there times where it could be much more detrimental, to you to be woken?
Tony Ho – We are durable human beings. And if we were to crumble, to be waking up at some point in the night, we wouldn’t last as humans, right? And I think it’s more about discomfort. If you’re woken up from a lighter phase of sleep, it’s much more comfortable. You can just transition fairly easily. But if you’re in a deeper phase of sleep, sometimes people wake up feeling very disoriented. And sometimes that can be uncomfortable. It might be there’s a screaming child, you have to go take care of. And it’s amazing how fast we can transition.
Rachel Cram – Yeah, it is amazing how we rise to whole new levels of endurance as parents, because we wouldn’t have survived as a species if we didn’t. And then life just keeps bringing new challenges that keep challenging our sleep.
You know, as you’re talking about these sleep cycles. I know for myself what my sleep cycle is right now that has caused me concern, and it may be because of menopause, as you were mentioning earlier, is that I will go to bed at a certain time and fall asleep really fast, but I will wake up, it seems like at 3:00 am on the dot. Like I’ll look over at my clock and morning after morning it says 3:00. And it amazes me that it can be so regular. And I don’t think it’s because there’s a sound that happens. I think it’s just a cycle that’s completing and is very frustrating. So I’d love to hear more about cognitive behavioral therapy, which you do. And I know that the Mayo Clinic and other sleep specialists say that cognitive behavioral therapy really is the most effective and the first line of treatment for insomnia. So can we talk about that? What is cognitive behavioral therapy, first of all? What does that mean? And then how does it apply to sleep?
Tony Ho – Yeah, absolutely. So many people may have heard of cognitive behavioral therapy as a structured way of looking at how thoughts, behaviors and emotions all really connect to each other. And so when we look at, for example, like anxiety, we can’t really influence our thoughts but we can influence how we respond to those thoughts and how we behave and different ways that we can change the distress around that worrying thought.
And CBTI, or cognitive behavioral therapy for insomnia looks at how we relate to sleep in general. As you mentioned, you know, you’re perhaps transitioning through menopause and experiencing sleep problems, which is really common for many women. But to some degree, it’s out of your control, right. It’s something that’s happening to your body. But for some women who do start to experience insomnia, it becomes insomnia because they get really worried about it. They’re up in the middle of the night but then they get really frustrated. They’re like, “Why me? It’s so upsetting.”
Maybe they’re lying there for a really long time. And then that becomes its own problem that keeps them awake even after they transition out of menopause.
So cognitive behavioral therapy for insomnia looks at how your brain associates bed and sleep, or just kind of sleep in general, but also looks at behaviors that can reinforce insomnia.
So let’s start with one element I call stimulus control. So that’s like the worries, the thinking, the cognitive processes around sleep. So we explore how much time are you spending in bed, awake versus asleep? How much of the time are you lying in bed, either worrying or thinking or doing things other than actually sleeping?
Rachel Cram – Okay. So, just to clarify this for me Tony, the focus is the times where we’re in bed wanting to be asleep, but not sleeping. Not if we’re sitting on our bed reading a book. Or is it both?
Tony Ho – Yeah, yeah, absolutely. When we go through the process of cognitive behavioral therapy, one of the first things that I suggest to folks is to really get back to the basics that reassociate bed with sleep. Can you for a period of time just keep bed for sleep? If you’re going to watch TV or if you’re going to be on your phone, try to do that out of bed. Because we really want your brain to associate bed equals sleep. And that’s really important, especially if you experience middle of the night awakenings. So, it sounds kind of funny, but even like, you know, creating a little nest next to your bed or if you have the luxury of having a chair in your room to get out of bed when sleep isn’t happening. Just get out. Your body knows what to do. You will fall asleep when your mind and your body are ready.
Rachel Cram – Okay. Do you include sex in that? Just wanted to check. Can we still have sex in our bed or are we do that somewhere else too?
Tony Ho – Bed is for intimacy and sleep.
Rachel Cram – Okay. Just wanted to clarify. Didn’t want to go home with that news to my husband, “Hey, we’re going to use a nest on the floor.”
Okay. So bed is for sleep and sex. So the first part of cognitive behavioral therapy is reframing our relationship with sleep. What’s the next element? Or what’s another element of CBTI?
Tony Ho – Yeah, absolutely. So the other element that’s really important, and these kind of go hand in hand, is basic sleep hygiene, and it’s really important to consider things like caffeine use. If you’re having caffeine really late in the evening, that can impact the sleepiness that you experience. Also, alcohol. If you’re having drinks in the evening, we know that alcohol can disrupt sleep cycles. So it’s important to be mindful of how these elements can impact your sleep.
There’s a lot of talk about blue light, but it’s really interesting because we also know people or maybe experience it ourselves where we are on our phone and we’re able to put it away and we fall asleep. But it is something to consider if you’re trying to improve the overall quality of your sleep, to try to move that a little bit earlier, to allow the process of melatonin to start happening, for melatonin to increase in your blood.
Rachel Cram – Does blue light disrupt melatonin?
Tony Ho – Yeah, studies clearly show now that especially particularly with phones, because we’re holding it so close to our face, it can decrease the threshold of melatonin in our system or delay that a little bit later. It doesn’t mean that you won’t fall asleep or you have a hard time, per se, but it could affect the quality of your sleep.
Rachel Cram – Okay. Quality over quantity. Okay. What else can we consider for sleep hygiene?
Tony Ho – There’s general recommendations around keeping a cool, comfortable, quiet space for your bedroom.
Rachel Cram – Would you recommend that windows be open?
Tony Ho – Yeah, I don’t think it’s a prerequisite, but I often recommend folks use blackout curtains that you can get at Costco, creating a space that welcomes sleep. Setting up the stage for that and being really kind of mindful of your mind as you approach sleep too, having a little bit of a buffer, if there’s a lot on your mind, a strategy like is called planned worry. So just making sure that all those thoughts are put on paper and you attach a ‘to do’ item for that for another day, another time, to just kind of deload your mind before bed.
Rachel Cram – Planned worry. I like that and give yourself the space to worry before bed.
Tony Ho – Yeah, exactly. There’s a difference between vertical worries and horizontal worries. We rarely solve problems in the middle of the night.
Rachel Cram – Oh, I am so on board with you, with horizontal worries. Is that what you call them?
Tony Ho – Yeah.
Rachel Cram – You know that lying in bed and this is part of it for me in the middle of the night when I’m waking up at three in the morning, things can seem so dire. Like I can be worried that one of my children went to bed with a cold and my mind works to pneumonia, to meningitis, and then I get up in the morning and I’m like, “Oh no, you’re fine to go to school, this is just a sniffle. But in the middle of the night, when I’m horizontal, as you say, I just go to,
Tony Ho – The worst-case scenarios right?
Rachel Cram – Yeah. It’s worst case scenarios. Okay, planned worry. I really like that concept. So you’re talking about caffeine reduction, alcohol reduction, blue light, cool temperature in a room, dark room, having a buffer before bed. Planned worry. Love that. And a bed is for sleep. Does that cover the big-ticket items for sleep hygiene?
Tony Ho – Those are the big ticket items and I always suggest to people don’t sweat it, because we also know that sleep, at its core, is a physiological process. Your brain, it’s like breathing, right? Imagine we were so particular and worried about our breathing. We probably end up with a panic attack and the same kind of a place to sleep that you can’t actively control it, you can influence it, you can set the stage for it, but ultimately you have to let go in order for it to happen.
Rachel Cram – Okay, this is really helpful. So with cognitive, I’m just going to do a recap. I’m going to be kind of like your PowerPoint here. So with cognitive behavioral therapy, we’re looking at reframing our relationship with sleep. We’re looking at sleep hygiene, and then what else are we considering?
Tony Ho – One of the biggest elements of CBTI with a client is using a sleep diary. So we look at what’s called sleep efficiency. So if your sleep is not really happening, looking at their sleep window and trying to anchor their day with the same wake up every single day, try to make sleep predictable because your brain doesn’t really know if it’s Monday or if it’s Sunday. All it wants to know is ‘am I balancing sleep and awake’. Which is why Mondays are so hard for many folks because we’re up really late during the weekend and then Monday comes and we have to be up really early. It’s like fighting jet lag every single Monday. So all these elements help people understand that they do have some control around their schedule.
Rachel Cram – So when you’re saying keep it regulated, does that mean I set an awake time; say its 7AM, and regardless of what time I end up going to sleep, I’m getting up at 7. Even if I don’t fall asleep until 3AM, I’m getting up at 7? Is that correct?
Tony Ho – Yeah, but we can think about that in terms of when we’re not so stressed, sometimes we were out really late, maybe in our younger years where we just are out late for whatever reason. We go home, we crash, we fall asleep really easily because we’re so tired and it’s really, really late. We wake up, we have to go to work. But then what happens the next night is because your body’s trying to balance sleep and wakefulness, pressure for sleep is really, really high. So people tend to fall asleep a lot faster. And so, for folks who experience insomnia, waking up around the same time every single day, what that means is that nighttime starts to become a bit more predictable. They start to get sleepier around a regular time without any additional effort, because your body’s just naturally increasing that pressure. The pressure for sleep starts to build up around the same time. So that gives you the sense of this internal rhythm. And if you do that every single day of the week, you start to really get that shape and it becomes more predictable and easier for your body.
So discovering that window and improving your sleep that way, that’s a really good first place to start.
Rachel Cram – So, with the sleep diary, we’re recording when we go to bed, when we’re waking up, and presumably the hours we’re awake in the middle of the night. Actually, can I just ask you something else about those hours we’re awake in the middle of the night? If we’re not wanting to associate bed with sleep, would you recommend getting out of bed at that point? Not laying there?
Tony Ho – Yeah, if you’re lying there, and you’re starting to worry or think about your sleep, that’s a great time to get out. Because, like we talked about earlier, we want to have this relationship with sleep all through our life, that sleep will happen when my mind and my body are ready. So get out, do something quiet, until you start to feel sleepy again and get back in, really embracing that relaxed attitude. What can I do? Sleep’s not happening right now. Can I do some light stretching, those physio exercises I’ve been avoiding? Just invite that time to do something relaxing until you start to feel that pressure, that sleepiness, feeling.
Rachel Cram – The thought of getting out of bed and doing something in the middle of the night when I wake up, oh my goodness Tony, I fear this opens up a whole new realm of possibilities for my drive for productivity. Can I be going for a run? Can I clean my office? Make lunches for the next day? Can you give a little more clarity around what we do during that time? Are there things we’re wise to avoid?
Tony Ho – Yeah, yeah. I think we want to do things that invite relaxation and set that stage for sleep. So, I’m never really prescriptive around that time because I think ultimately it’s about just finding something generally quiet and relaxing. We don’t want to associate nighttime with activity, and you’re like, “Okay, now it’s time to do a 30 minute hit workout,” your body’s going to start to expect that adrenaline kick at that time. We don’t want that. So, doing something like Sudoku, honestly, like folding laundry and then kind of like a dim room is just something that’s just not overly stimulating. Listening to a podcast.
Sometimes people ask me, “Well, can I watch TV?” And I never say no. Having a list of things ready to go can be really helpful. So just to take the stress away, it’s like, okay, maybe for you, you wake up at 3:00, rather than lying there too long, have a list of a few things that you can do, some stretches, laundry, collecting receipts, until you get a sleepy feeling.
Every time that you get back into bed and you’re feeling sleepy and you fall back asleep, that’s you teaching your mind, “Hey, 3:00 is not really a time for me to be too awake, right? Bed is where I fall asleep.
Rachel Cram – You’re very calming Tony. You make it all sound so logical and promising, all of us insomniaites will be summoning your optimism as we try to side step worry and slide into sleep.
So, if I can just recap what I’m understanding to be the key components to cognitive behavioral therapy for sleep; you look at reframing thoughts and worries around sleep, sleep hygiene, and then regulating sleeping rhythms.
How long can someone struggling with insomnia expect before they’ll see results? How long before the disrupted sleep patterns end?
Tony Ho – Yeah. If you’re working with a cognitive behavioral therapy for insomnia, it’s a process, it’s not a quick fix. If someone’s experiencing insomnia for a significant period of time, it’s unraveling all these habits around their sleep. So if someone is working on improving their sleep on their own or, they’re following one of the great Cognitive Behavioral Therapy for Insomnia Books, it’s important to be really patient and kind to yourself. This problem probably didn’t emerge overnight. It’s not going to fix itself overnight. And this is the problem with medication, supplements or apps is that someone will try it for a couple of days, it doesn’t work or they try to meditate, it doesn’t work. They blame that thing and then they just try something else and it just adds to that frustration. So, you know, just really getting back to the basics around how sleep works. If I don’t sleep tonight that well, tomorrow is probably going to be easier if I get up and get going around the same time. I want sleep, to be predictable.
Musical Interlude #3
Thanks for listening to family360 and our conversation with social worker and sleep specialist Tony Ho. There’s more to come.
Our next episode is with Dr. Katie Rinald, a renowned expert and sought-after speaker on toileting. Learning to use a toilet is often our first move toward independence. It can be a stressful time, a sensory time, and a time for great celebration. Katie’s approach is professional, practical, caring and fun. If toilet training is on your horizon, you will enjoy and appreciate this conversation.
And now back to the conclusion with Tony as he answers a few last quick questions on sleep.
Rachel Cram – Tony, I have a handful of questions I’d love to put to you in a rapid-fire format before we end, if that’s ok with you, just seeking your input on other measures for finding sleep. Oh sure (already used this one) The first one is sleeping pills. Should we use them or should we not? To use or not to use? That is my question.
Tony Ho – That’s a good question and a tricky one. But, in summary, I would say, the research shows that it can be helpful for short-term if someone is experiencing sleep difficulty that’s coming from stressors at work, loss of a loved one, different stressors that can impact our sleep. Sometimes the medication can be helpful to ease our mind until we get back to that regular rhythm. Long-term can be really bad, especially for older adults. Increases the risk of falls and seizures, so definitely as we get older, rely less on things like sleep medication, because it can impact our overall well-being and safety.
Rachel Cram – Okay, next question. You posted that hitting the snooze button can throw off our circadian rhythm, which was alarming to me because I always have two hits on my snooze button. That is my rhythm.
Tony Ho – You wouldn’t be alone. You wouldn’t be alone. You know, I think I always say that because I really get people to think about the time that you get up and, when your eyes are exposed to light your internal clock starts to tick. But if you’re waking up at irregular times, especially in the morning, that can also influence the time that you feel sleepy. So cutting that snooze, committing to a regular time can be really helpful in just making sleep more regulated.
Rachel Cram – Okay, so one hit or no hits?
Tony Ho – Yeah. I’d say no hits.
Rachel Cram – No hits. Ok, ok, I’m going to listen and obey Tony and I think my husband will really appreciate that answer because he gets up half an hour later than me because I get up to exercise in the morning and my two or three hits. He’s been a good sport about it. But yeah.
Tony Ho – Reduce the disruption.
Rachel Cram – Yeah. Okay. Naps. What do you think about naps during the day?
Tony Ho – Yeah. You know, long prolonged naps can increase difficulty falling asleep, but also more disruptions at night. So I encourage people to nap like a ninja, like thinking of naps not to make up for lost sleep but just improving your alertness. So micro naps, like 15 to 20 minutes can be enough to just make you feel more alert, and then allowing you to still fall asleep at nighttime. So boosting alertness rather than making up for lost sleep.
But it’s also important to recognize the difference between sleep and tiredness and fatigue. Sleepiness is like this overwhelming physiological sense of you slipping into the unconscious. But sometimes we also recognize that we’re tired. Are you getting enough breaks? Just a mental break in the middle of your day, allowing yourself to really intentionally step away from whatever you’re doing. Doing something calm, soothing, or even just closing your eyes for 10, 15 minutes can be really restorative and also decrease the amount of stress that perhaps you’re bringing to the evening with you. So just making note of having those mental breaks, physical breaks is important to rest.
Rachel Cram – Hmm. I really appreciate you saying that because I know for myself there are many times in the day, especially after lunchtime, I find where I feel like I’m so sleepy, but as you’re saying that, I think actually what it is, is I’m so tired and I’ll realize I have not sat down today, I haven’t taken a break. It can often feel like too, in the afternoon, I can start feeling not only tired but also grumpy. Like just feeling like, “Oh, life is so hard. I can’t keep going.”
And if I do just sit down and take a rest, like you’re saying, put my feet up for a few minutes, it does, things shift. Like you just feel like, oh, okay. It’s restorative.
Tony Ho – It’s restorative. And it’s interesting you mentioned about that tiredness after lunch because we look at cultures such as Spain, where people do shut down their stores around that time.
Rachel Cram – Siestas. Yes.
Tony Ho – Siestas, right. So there’s a cultural element, but our alertness tends to dip after lunchtime, so, having a little bit of a rest, having a short snooze, that can have a huge bearing on how you approach nighttime if you’re not so stressed.
Rachel Cram – I think our world would be a better place if we instituted a siesta from 3:30 to 4:00 every single day for everybody everywhere.
Tony Ho – Yeah. Nap times in preschools, nap times in adult working environments. I’m okay for that.
Rachel Cram – The whole world could stop.
Tony Ho – People would just be nicer to each other.
Rachel Cram – Yeah, I think so. Oh, this has been so informative Tony and I’m wondering if we can close off with a form of relaxation practice I’ve seen you demonstrate – progressive muscle relaxation. And I think this is something we could do during our rest in the afternoon, or at any time in the day.
Tony Ho – Yeah, it is. And just like you said, I encourage people to practice it throughout the day. The idea is that especially when it comes to sleep, we often carry stress with us if our mind’s really busy. But stress doesn’t just exist in our minds, it also exists in our body. So when you, for example, if you feel very anxious before bed, you’re just noting what anxiety feels like. Sometimes people describe that as tightness in their chest, tightness in their back and shoulders. So progressive muscle relaxation is kind of a guided exercise. You can find many great ones on YouTube or there’s some on my site as well. And it’s an invitation to let go.
Rachel Cram – Could you walk us through that quickly? Could you kind of do it in just a few moments, like speed it up?
Tony Ho – Absolutely. Why don’t we just give it this a try just to get you the gist of it and how it can be helpful.
Rachel Cram – Okay, I love it.
Tony Ho – So just for a moment, close your eyes if you’re comfortable and just focus on your feet. Notice what your feet feel like in your shoes, or if you’re barefoot, what it feels like on the ground and just tighten the muscles in your feet. Clench your feet, your toes up for a second and then let it go. And now let’s focus on our calves. Tighten the muscles in your calves, really, really, really tight. Just a second and let go. And gradually, as we move up, focus on your core. Tighten your abs. Suck in your tummy. Just really, really strain those muscles. Just tighten them up and let go. And last group. Tighten up the shoulders, clenched the arms and fists, if you like, really make that scrunched up kind of sensation and then let go. And just for a moment gently notice what that feeling is when you let go. Can you just notice what that feels like?
Yeah. And that’s just kind of a quick version, but how do you feel? Do you feel that kind of like wash of relaxation or that release feeling?
Rachel Cram – I do. And often I realize I haven’t actually recognized that I’m holding some of those muscles tight. Especially in my jaw.
Tony Ho Yeah. Yeah. It’s really common in our jaw and in our backs. And it’s just an invitation that we can influence some of that tightness. And when we start to let that go, sometimes our mind will follow suit as well. Our mind starts to let go. So when we practice that, this is not going to make you sleep, but it’s going to create a better environment for that to happen.
Rachel Cram – Tony, I want to thank you so much for your time this evening. I know you have a little boy to put to bed and you have to get up at a certain time tomorrow.
Tony Ho -Yeah, maybe you do, too right.
Rachel Cram – I do too. So I don’t want to hold you off your rhythm. Thank you so much for this conversation.
Tony Ho – Yeah, thank you so much for having me. It’s been great.