The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Mon, 24 Mar 2025
View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Ashley Mason is a clinical psychologist and an associate professor at UCSF, where she leads the Sleep, Eating, and Affect (SEA) Laboratory. In this episode, Ashley provides a masterclass on cognitive behavioral therapy for insomnia (CBT-I), detailing techniques like time in bed restriction, stimulus control, and cognitive restructuring to improve sleep. She explains how to manage racing thoughts and anxiety, optimize sleep environments, and use practical tools like sleep diaries to track progress. She also offers detailed guidance on sleep hygiene; explores the impact of temperature regulation, blue light exposure, and bedtime routines; and offers guidance on finding a CBT-I therapist, along with sharing practical steps you can take on your own before seeking professional help. We discuss: Defining insomnia: diagnosis, prevalence, and misconceptions [3:00]; How insomnia develops, and breaking the cycle with cognitive behavioral therapy for insomnia (CBT-I) [7:45]; The different types of insomnia, and the impact of anxiety, hydration, temperature, and more on sleep [11:45]; The core principles of cognitive behavioral therapy (CBT) and how CBT-I is used to treat insomnia [20:00]; Implementing CBT-I: time in bed restriction, sleep scheduling, and the effect of napping [29:45]; Navigating family and partner sleep schedules, falling asleep on the couch, sleep chronotypes, and more [39:45]; Key aspects of sleep hygiene: temperature, light exposure, and circadian rhythm disruptions [44:45]; Blue light and mental stimulation before bed, and the utility of A-B testing sleep habits [52:45]; Other simple interventions that may improve sleep [57:30]; Ashley’s view on relaxation techniques and mindfulness-based practices [1:02:30]; The effectiveness of CBT-I, the role of sleep trackers, and best practices for managing nighttime awakenings [1:04:15]; Guidance on intake of food and alcohol for good sleep [1:16:30]; Reframing thoughts and nighttime anxiety to reduce sleep disruptions [1:18:45]; Ashley’s take on sleep supplements like melatonin [1:21:45]; How to safely taper off sleep medications like benzos and Ambien [1:26:00]; Sleep problems that need to be addressed before CBT-I can be implemented [1:38:30]; The importance of prioritizing a consistent wake-up time over a fixed bedtime for better sleep regulation [1:40:15]; Process S and Process C: the science of sleep pressure and circadian rhythms [1:45:15]; How exercise too close to bedtime may impact sleep [1:47:45]; The structure and variability of CBT-I, Ashley’s approach, and tips for finding a therapist [1:50:30]; The effect of sauna and cold plunge before bed on sleep quality [1:56:00]; Key takeaways on CBT-I, and why no one should have to suffer from insomnia [1:58:15]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube
Chapter 1: What is insomnia and how common is it?
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
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Ashley is an associate professor at UCSF, where she leads the Sleep, Eating, and Affect Laboratory. Her research focuses on non-pharmacologic interventions for mental health, particularly exploring how treatments like whole body, hyperthermia, mindfulness-based approaches can improve mood disorders, sleep, and eating behaviors.
She's also the director of UCSF's Center for Obesity Assessment, Study, and Treatment, known as COAST. Her work integrates clinical psychology with integrative medicine, aiming to develop accessible treatments that address the biological and behavioral aspects of health.
In this episode, we focus almost entirely around one area of her expertise, which is cognitive behavioral therapy for insomnia, or CBTI. Ashley gives us a masterclass exploration of CBTI, including various methods, including time in bed restriction, stimulus control, and cognitive restructuring to combat insomnia.
We speak about how to manage racing thoughts and anxiety, and Ashley shares techniques like scheduled worry time to address stress during the day and prevent sleep disruption at night. We talk about the impact of temperature regulation and the role of warming extremities and optimizing sleep environments for effective sleep onset.
We discuss behavioral and cognitive interventions and the impact of leveraging small, actionable changes in thoughts, feelings, and behaviors to overcome patterns of insomnia and other mental health challenges. Ashley shares some sleep hygiene fundamentals, addressing blue light exposure, food and alcohol intake, and creating bedtime routines for better sleep.
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Chapter 2: How does cognitive behavioral therapy for insomnia (CBT-I) work?
She provides practical tools for tracking progress, like using sleep diaries and A-B testing to identify and refine effective interventions. And we explore the potential for AI and digital tools to democratize access to CBTI and address the growing demand for sleep therapy. So without further delay, please enjoy my conversation with Dr. Ashley Mason.
Hey Ashley, thank you so much for coming to Austin to talk about a lot of interesting things. Let's start with the one that I think everybody listening can probably relate to at least once, which is insomnia. Where did your interest in insomnia arise?
Well, I've been interested in sleep for a long time. I was fortunate to go to the University of Arizona for my doctoral work. When I was there, the late Dick Bootson was also there. And he's one of the co-inventors of cognitive behavioral therapy for insomnia. And I think I found it particularly interesting because it works so well.
We have so many different psychological treatments, and they all have varying degrees of efficacy and effectiveness. And the thing about cognitive behavioral therapy for insomnia is that it's kind of like a recipe. If you do it, it works.
And this was always just so interesting to me because it was so different than so many other psychotherapies out there that had just so much more unpredictable outcomes. I would say that I became much more interested in it after my postdoctoral work when I'd gotten to UCSF. I was a postdoc at UCSF, but I started my assistant professorship at UCSF. And
There was this gaping hole in treatment availabilities for people with insomnia. And I thought, oh, this might be a good way for me to get back into some clinical work. I was doing just research at the time.
I fell back in love with it because there's almost nothing as rewarding as being able to see a patient seven times and that seventh time have them say something to you along the lines of, I have my life back. I'm going to go get my driver's license back. I'm not afraid to drive with my kids in the car anymore. I'm going to go back to work. I have my life back. Not much better than that.
And so I grew the clinic that I do CBT-I in and now I just love it so much that I do it on top of my job. Like I do it at night with patients after hours because it's the most rewarding thing and you can have such a big impact and people need it.
Before we dive into what CBTI is and how it works and how profound it can be, let's maybe help folks understand a little bit about insomnia and maybe go through some of the definitions around the different types of insomnia and maybe some of the different causes for it and maybe even what some of the other treatments are, pharmacologic and otherwise.
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Chapter 3: What are the key components of good sleep hygiene?
I'm more concerned about what you're doing now that's perpetuating the problem. And that's where I intervene. And that's why this particular treatment is so effective for so many different presentations of insomnia and causes of insomnia. Whether people have difficulty falling asleep in the beginning of the night, waking up in the middle of the night, waking up too early in the morning.
You might think on their face, these people all need wildly different treatment, but that's not actually the case.
Yeah, that makes a lot of sense. So the focus is much more on the coping strategy and the behavior that came out of the predisposing factor or the precipitating event actually is really- Used to respond to the precipitating effect.
Exactly.
Okay. Can we talk a little bit about Is there a difference, for example, between the individual who can't fall asleep, this initiation of sleep insomnia, versus the person that I hear much more about, frankly, I experience more, which is, it's not that hard for me to fall asleep, but boy, I will jolt up at
one in the morning with some thought or anxiety that I can't get out of my mind and my mind starts running and I can't go back to sleep or I get up because I got to pee. But when I come back, I erroneously just do something with my mind where I get thinking about the day's problem or whatever, whatever. Do you think of those as difference or the different side, same coin, I guess?
Those people need the same stuff. And the people who can't fall asleep at the beginning of the night, their mind's just racing earlier than yours. Yours is just waking you up. And there's a whole suite of interventions that are part of cognitive behavioral therapy for insomnia. There are a lot of ways that I could approach an answer to this question.
So I think starting by addressing the racing mind issue. I always tell patients, if you don't deal with what's causing you stress or anxiety during the day, it's going to demand to be dealt with in the middle of the night. It's going to say, oh, Peter. I notice you're laying there peacefully, not doing any work or tasks, and you don't have anything you need to do right now.
So you're going to pay attention to me. And it's going to demand your attention at that time. Other people, that happens right when their head hits the pillow at the beginning of the night. Oh, you're relaxing now. Okay, here's your 10 things to worry about. So one of my favorite interventions that's actually born of anxiety treatment
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Chapter 4: How can you manage racing thoughts at night?
And I said, okay, I've got a solution for you. And it's two words. Ready? Stop it. That wouldn't work. It doesn't work. I take the opposite approach. Okay, this is really important to you. This is something you're doing all the time, all day. Guess what? What do we do with things that are really important to us?
Make time for them.
We schedule them. Exactly. Back in the day of paper calendars, this felt like a different exercise. Now people get out their phones, but I have them get out their phone or whatever and say, all right, we're going to schedule a worry time and it's going to be an hour a day for the next seven days. It is non-negotiable.
I may or may not schedule an email to go out to you at the end of that time and you have to go and reply to it and tell me what you did. And what we find is that when people work with this during the day, it does two things. The first is, let's say it's 9 a.m. and you are trying to do something in your life and instead a worry pops up.
You can actually think, oh, okay, I don't have to deal with this now. I'm going to write this down because at 4 o'clock I've got scheduled time to deal with this. So that way you're uncluttering the rest of your day by moving all of the worry into that scheduled time.
So this could be a valuable technique even absent insomnia. Totally. Totally.
I'd say that probably between a third and half of my patients who come in with insomnia, they've got some bad sleep stuff for sure. But for some of those people, it's a primary anxiety disorder and sleep is suffering also. Whereas other folks, it's primary insomnia and that's driving them anxious.
But to rewind back to your earlier question about the middle of the night versus the beginning of the night. So the other thing that scheduling worry time does, besides uncluttering your whole day, is it helps you get it done during the day so that when your head hits the pillow, it's not there. Oh, I already worked on this.
And also the knowledge, oh, I have time set aside tomorrow to work on this or to think about this. So I don't have to do that now. Cognitively, this all makes sense. And you would maybe think you can think your way out of this, but you can't. You actually have to try it. And I've done this with a lot of people.
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Chapter 5: What are the effects of light exposure before bed?
So we're intervening on the behavior to change the thoughts about the self. Like, oh, I'm going to do these things when I'm better. A major problem. feature of cognitive behavioral therapies is intervening on behavior to change thoughts, but also intervening on thoughts to change feelings. And there's just many, many applications for this.
Cognitive behavioral therapy has been adapted for a whole host of disorders, for eating disorders, for insomnia, specifically for anxiety. That's
Is that kind of running the triangle in the other direction? So you change behavior to change thought, you change thought to change feeling?
Yeah. So you can change thought to change feeling. You can work on behavior to change thought. You can operate on any way of those with different techniques that have been just repackaged into different therapies.
And tell me a little bit about the history of CBTI specifically. When did the idea come to existence in a way that's been packaged more or less the way it is today?
Cognitive behavioral therapy for insomnia is actually old news. I mean, we can go back to the 1970s. I remember when I was learning cognitive behavioral therapy for insomnia, one of the most fun studies to read about was this study of, I believe it was college-aged men who were not doing well academically.
And the intervention that they did with them was one of the two pillars of cognitive behavioral therapy for insomnia, which is called stimulus control. And what they did with these young men is they told them, all right, you're going to be assigned a carol in the library. And in this carol is the only place you can study. You can't study in your dorm. You can't study outside.
Can't study anywhere else. Just this carol. And only this amount of time can you study each day. If you're on a roll, we don't care. You have to stop. If you're miserable, we don't care. You just have to keep on doing whatever portion of the studying over and over again that you're stuck on. So they trained these young men to just study in that one place. And it succeeded in helping these men.
And these men were struggling with anxiety or actual insomnia?
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Chapter 6: What role does temperature play in sleep quality?
Because the other key component of CBTI is that we restrict the amount of time that a patient is in bed to match how much time their body can actually produce of sleeping. A lot of times people with insomnia will say, OK, I need to be in bed for at least 12 hours if I want to get seven hours of sleep. I know it's hard to believe, but it's true. And we just obliterate that notion.
And this is another core and very old part of CBT that dates back, what, 1970s, 80s. But when you take those two parts, then you start to add in some of the cognitive components that have been around also for decades. The cognitive therapies part, the Aaron Beck stuff with cognitive restructuring, which is where we take a thought.
Have you ever heard that phrase, don't believe everything you think? So you take a thought and on the classic thought record tool, you'll have patients write down the thought, write down how they feel, rate their feelings from say zero to 90%. And then we have them write down, what's the evidence for this thought?
If you had to go to court right now, and there was a judge and a jury and what have you, and you had to present evidence for your thought, what would you be able to present? Evidence for a thought is not another thought. It's not a belief.
It's evidence.
Last time I slept six hours, I got a worse grade on a test or something. That would be evidence. You got a worse grade on a test. But then we look at all the evidence for a thought. We look at all the evidence against a thought. Like, oh, last time you didn't sleep so well, you didn't get fired, still did fine in school, whatever the thing.
And then we create a balanced thought, which is, even though I'm not going to be as well rested, I'll still get through this day. Then we have people re-rate their emotions, re-rate how much they believe this new thought, this whole song and dance. This is the cognitive component. And that's kind of the bedrock of so much of cognitive therapy.
Of course, people have so many negative thoughts about sleep and dysfunctional thoughts about sleep that aren't true or that are catastrophizing and whatnot. That is also blended in to the treatment. And then we have relaxation techniques, which are things like progressive muscle relaxation that came along as well. And those are part of the treatment.
Progressive muscle relaxation will be like where you squeeze your hands and let it go and squeeze your hands and let it go and then squeeze your arms and let them go and move through your whole body to get out of your head and into your body. And I don't know what order those actually were packaged into CBTI treatment.
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Chapter 7: How can tracking sleep patterns improve outcomes?
Okay, but just to be clear, if you have someone who is using a nap to compensate for their insomnia, step one is just kill the nap. Kill the nap. And then let the cards settle where they may for a week, recalculate actual sleep time, and then go through the exercises described. I've made this point on a podcast before, I think, but just want to get your blessing.
When we're on bow hunting trips, you are going to bed insanely late and waking up insanely early. It's just the nature of when you get back to camp and eating and then you got to be up super early. So I've never been on one of these trips where I could actually be in bed for more than five and a half, six hours in a night. So the strategy is to get that sleep.
But then I always try to get a 90 minute nap at around one in the afternoon. And the reason I pick 90 is to get a full sleep cycle. And I tend to function incredibly well under those circumstances. Because remember, you're also very physically active. Like this is demanding time. So would I be better off not doing that nap midday?
Oh, that's a bow hunting trip and you don't have insomnia. That's not a problem.
Okay. All right. Got it.
Yeah. Totally different monster. And I tell people too, a lot of the last few years, people have had serious illnesses. They've had COVID, they've had whatever. When you're sick, all bets are off. What I tell people is if you need a nap when you're sick, you need to nap when you're sick, but we maintain stimulus control. You don't nap on the couch. We're only napping in bed.
And if you're awake and feeling sick, then you can be on the couch, not in bed.
While we're on that topic, what do you say to the legions of people watching who fall asleep watching TV on the couch? Oh, the worst.
A lot of people fall asleep on the couch because they're just so overtired that the ship has sailed. Their body's ready to go to bed and they're just letting it and they're not getting up and doing the thing. I tell people, look, if you want to prioritize your sleep, pay attention to your body. When you're watching TV, do you notice that you're starting to nod off?
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Chapter 8: What should you know about sleep medications and supplements?
Okay, good. So if that's the issue, then I would say, hey, if this is a priority, what are we going to do? We're going to schedule it. We're going to schedule time to be on the couch together at a time when I can definitely be awake and be spending meaningful time with you.
The problem is sometimes other members of the family who tend to be smaller also tend to be occupying all of the bandwidth during those earlier hours when the member of the family in question is able to be awake.
This is a hard problem to scale. But what I would just say is if you're actually ready to go to bed and your body is saying that you need to sleep, you should probably do that. It's more likely that then you'll be awake the next day and be a more pleasant, exciting partner to be around and be able to have more meaningful experiences with your partner that way.
Otherwise, I tell people, look, this is an issue. If it's really an issue, we're going to get a babysitter. Figure it out. There are ways to get around these things. People just often want it to work like they see in the movies. Like, oh, this should be easy.
Obviously, I'm talking about my wife here, so I'll stop double speaking. But if my wife falls asleep every single time on the couch, but then when said Netflix is over and we go up to bed, she falls right back asleep and it doesn't seem to keep her awake. Is it pathologic?
This isn't necessarily a problem. But what I would say is we sleep more deeply at the beginning of the night. We experience more slow-wave sleep in the first half of the night and more REM sleep in the second half of the night. I think other podcast guests you've had can definitely go into the neurobiology of this much more deeply. But a way that I like explaining this has to do with evolution.
If you think about it, when we're deeply, deeply asleep... We're kind of tuned out. And on the prairie, when we figured, OK, it's safe to go to sleep right now, our bodies prioritized getting that really deep sleep when we knew it was safe.
And then as the night goes on, we sleep more and more lightly, which makes sense because, hey, there could be lions and tigers around or whatever that are going to come and eat us. So evolutionarily speaking, it was adaptive to sleep more deeply in the first half of the night.
Now, if your wife is falling asleep on the couch and getting some of that sleep at that stage of the night and maybe getting more interrupted aspects of that because there's noise from the TV or whatnot, it could be disturbing the quality of that's the drawback.
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