In this episode of the Sleep Edit podcast, we welcome Dr. Shelby Harris, a leading expert in behavioral sleep medicine. Often, parents are struggling even after their kid’s sleep problems are addressed. We talk about the common sleep challenges faced by parents focusing on the impact of stress, hormonal changes, and modern technology on sleep quality. Dr. Harris provides insights into the diagnosis and treatment of insomnia, emphasizing cognitive behavioral therapy for insomnia (CBTI) and its effectiveness over medication for long-term improvement. The conversation also explores the practicalities of sleep hygiene, sleep restriction, and the influence of consumer sleep tracking technologies.
Links:
- Dr. Harris’ website
- Dr. Harris’ on Instagram
- The Women’s Guide to Overcoming Insomnia: Get a Good Night’s Sleep Without Relying on Medication (affilate link)
- Room sharing recommendation in 2024
- Directory of providers at the Society of Behavioral Sleep Medicine
- University of Pennsylvania CBT-i Provider Directory
- Orthosomnia
Time stamps:
Video
[00:00:00]
[00:00:00] Craig Canapari MD: Welcome to the Sleep Edit, a podcast devoted to helping tired kids and parents sleep better. We focus on actionable evidence-based sleep advice, so everyone in your home can sleep through the night. Now, a quick disclaimer, this podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice.
[00:00:27] No doctor patient relationship is formed. The use of this information and the materials linked to this podcast and any associated video content are at the user’s own risk. The content on the show is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay obtaining medical help for any medical condition they have.
[00:00:52] Or that their children may have, they should seek the assistance of their healthcare professionals for any such conditions. Nothing stated here [00:01:00] reflects the views of our employers or the employees of our guests. Enjoy the show.
[00:01:09] Shelby Harris PhD: welcome back to the Theme Edit podcast, where we provide evidence-based information for parents and kids everywhere. I am Dr. Craig, Canapari.
[00:01:17] Arielle Greenleaf: Ariel Greenleaf.
[00:01:20] Craig Canapari MD: Today we are pleased to welcome the one and only Dr. Shelby Harris to talk about improving sleep in grownups. Dr. Harris has a doctorate in psychology from Yeshiva University and extensive training in the behavioral treatment of insomnia. She’s board certified in behavioral sleep medicine, one of the few providers in the northeast United States holding that designation.
[00:01:42] She’s a clinical associate professor in the departments of neurology and psychiatry at Albert Einstein College of Medicine and sees patients in person and via telehealth in New York. She also has extensive social media. Following Under the Handle Sleep Doc Shelby has been featured prominently in the media and publications [00:02:00] such as The New York Times and The New Yorker.
[00:02:02] She’s also the author of The Women’s Guide to Overcoming Insomnia, get a Good Night’s Sleep Without Relying on Medication. Shelby, it is a pleasure to have you today on our podcast
[00:02:12] Shelby Harris PhD: I am so happy to be here. Thanks for having me.
[00:02:16] Craig Canapari MD: I think it’s a real truism in the world of pediatric sleep is that even the kids that are sleeping poorly tend to be doing pretty okay during the day,
[00:02:28] compared with their parents, especially younger children.
[00:02:31] little kids, they can nap in the car seat. They can nap in the stroller.
[00:02:34] but even if they wake up and go back to sleep quickly at night, parents do not,
[00:02:38] I would imagine a lot of the patients you see are parents, and I was wondering if you could speak a little to the struggles that parents face, when they become parents and throughout childhood in terms of their sleep.
[00:02:51] Shelby Harris PhD: So, this is something I see a lot and it’s funny, you know, we talk a lot now, at least in social media and online, about perimenopause and menopause being stressors [00:03:00] for insomnia. But a lot of the patients that I talk to, say, oh, it’s worse now, but it started when I had my kids So I think there’s a lot of things that set it off for parents, talking about if you’re carrying a baby,
[00:03:13] right? There’s all the pregnancy stuff, there’s a lot of just that firestorm happening during that time. Then once the baby comes, the parents, whoever’s really there as the caregiver, they’re waking up at varying times.
[00:03:25] And then with all the. Tech that we have now, they’re just listening out and there’s all these little things. Whether it could be things that they’ve had for over the years with the alarmsthat have false alarms or any noise or monitor can really make them be on edge. And then once the baby starts sleeping better.
[00:03:43] the parents just keep listening out for any potential threats, because if I fall asleep now, maybe the baby’s gonna wake up in an hour or two later, and it just continues from there it becomes very hard for parents, especially moms to let go and ease into sleep because they’re always listening out for the [00:04:00] next threat that could get in the way of them actually falling and staying asleep.
[00:04:03] Craig Canapari MD: Either when is my child gonna wake up again,
[00:04:05] or especially when they’re really little. I don’t hear them. Is everything okay?
[00:04:11] Shelby Harris PhD: Yep.
[00:04:12] Arielle Greenleaf: Or it also, is waking when they just stir. I mean, any little
[00:04:17] noise. And we have, so like you’re talking about the technology and it’s like, oh, this is so great, but it’s actually not, I see so many moms in particular who
[00:04:27] are just so glued to their smart monitor of some sort They just can’t, it’s almost like an obsession. They just cannot back away
[00:04:35] from it, and it has such a negative impact on their sleep.
[00:04:39] Shelby Harris PhD: Yeah, I just saw parents that I’ve been seeing on and off throughout the years for, various issues and the mom said to me, is the goal to really have my child sleep through the night and not have any noise or anything? I said, no, that’s. Not the goal noises happen.
[00:04:55] We all just kind of make a noise here and there and The mom
[00:04:58] is like looking at the monitor. Listening to the [00:05:00] monitor full volume. And the dad is a stereotype. I know, but the dad’s like sleeping through the whole thing. not noticing
[00:05:05] any of it.
[00:05:05] Arielle Greenleaf: me in my house.
[00:05:06] Shelby Harris PhD: It was like, you’re making it harder for
[00:05:08] you to sleep. So we, turn that monitor
[00:05:10] down a little bit, maybe.
[00:05:12] Craig Canapari MD: it’s this perception that your vigilance is what’s keeping your child alive, this is especially true in the era of the room sharing recommendation, which I think it’s been around since 2013, but was really strengthened in 2016. I think that makes it harder.
[00:05:28] babies make noise during the night. some parents, especially with their first child, feel like they need to do something, they need to rush over, give that kid the pacifier, do something
[00:05:38] and, and sometimes you just need to let a child work through something a little bit.
[00:05:42] Shelby Harris PhD: Yeah. And I love the point of the room sharing recommendations, right? So when it was a year, especially, I have so many parents that would just, their insomnia was worsened as the baby would be in there 7, 8, 9 months. And there’s a point where you have to also think about your own sleep [00:06:00] because it’s not getting better A lot of the times.
[00:06:01] Craig Canapari MD: I think there was, one of the rationale for the room sharing recommendation it does seem to reduce the risk. Of
[00:06:07] SIDS. And there’s some pretty good evidence for
[00:06:09] Shelby Harris PhD: Yeah.
[00:06:10] Craig Canapari MD: I think the counterfactual is, there was a large study, and I’ll throw in the show notes of a number of nurses.
[00:06:15] They, that was their profession. They were nurses and they found that in the context of the room sharing recommendation, a subset of those parents whose kids were up frequently, ended up making pretty unsafe sleep decisions.
[00:06:28] they’re up with their kid, then they’re falling asleep in a chair or on a couch, which we know is much more dangerous in terms of, entrapment or suffocation.
[00:06:38] And that I, you know, I encourage families that are really struggling with this recommendation and everyone’s sleeping poorly to really talk about their pediatrician to feel what is the safest context. I mean, we, we really. We ask a lot of parents, right? It’s not like generations ago where there be multiple family members.
[00:06:56] We’re supposed to, you know, in the era of attachment [00:07:00] parenting, never let our kids fuss, nurse them on demand, carry them, have them in our bedroom.
[00:07:05] Arielle Greenleaf: return to work,
[00:07:06] Craig Canapari MD: really hard.
[00:07:08] Shelby Harris PhD: well there you go.
[00:07:09] Arielle Greenleaf: we need to return to work and do all those things. how does one even function?
[00:07:13] Shelby Harris PhD: we’re expecting like super
[00:07:14] superpowers.
[00:07:16] Craig Canapari MD: I’m kind of wondering too, because certainly in the US a lot of our listeners, they may be, professionals, A lot of them may be having their children a little bit older than people a couple generations ago, say in their thirties or even their forties versus their twenties.
[00:07:32] How does that prime them to be more vulnerable to insomnia?
[00:07:37] Shelby Harris PhD: that’s an excellent point. When I was talking about perimenopause symptoms, I’m often seeing women who are having children. I had my second child at 38. there are a lot of women in that stage who are starting to have perimenopause symptoms too. So you, it’s like you have hot flashes, you’re having other, and it doesn’t mean you can’t get pregnant, you can still have kids, but there’s a lot of hormonal firestorm going on. then you’re taking on higher level, jobs [00:08:00] that people are going back to. Sometimes people already have a kid or two at that point.
[00:08:03] And then the other big stressor on top of that is with work and more things going on, there can be more anxiety, more depression. But then also the thing that we don’t often think about is that if we’re having kids later, we often have our own parents
[00:08:16] and family that’s aging. So a lot of people are taking care of elderly parents on top of their own kids, on top of trying to figure out what to do in school and all these other things for their kids and having a baby on top of that.
[00:08:30] Craig Canapari MD: I think too, and my wife said this to me, my oldest is gonna be a senior in high school this year. when he was born, my wife a year in actually. was like, I don’t know if I’m gonna ever sleep well again. it was just that sort of anxiety being like, how are they doing in school?
[00:08:45] What’s with their extracurriculars? What’s going on with global warming? all the
[00:08:49] very specific to very. Kind of global anxiety. ’cause you are looking at things not just through your own wellbeing, but that of your child.
[00:08:57] And, I think that is just kind of the [00:09:00] nature of anxiety, right?
[00:09:00] like worrying about a lot of stuff you can’t control.
[00:09:04] Shelby Harris PhD: I think it’s interesting, a lot of people will be like, oh, I just want my kids to sleep better when
[00:09:08] they’re little. it gets hard too when they get older I have a ninth grader, he’s going to ninth grade and he goes to bed later than I do, and I’m already worrying about high school college, and then what’s he doing once I go to sleep?
[00:09:18] the. Tech, all that stuff there’s varying types of anxiety happening worrying about things you cannot control is the big crux of it. when you add in the perimenopause symptoms for some women, that’s the 3:00 AM the 4:00 AM awakenings, and their brain is just racing about a lot of this stuff.
[00:09:36] Craig Canapari MD: God, you make it sound like I’m in perimenopause. I just feel like nowadays, I wake up at three or four in the
[00:09:43] morning and sometimes I’m just kind of
[00:09:44] sweating a little bit, I don’t know if you wanna speak at all to the, I know Ariel had a question here about hormones,
[00:09:50] specifically, I
[00:09:52] Shelby Harris PhD: So
[00:09:52] Craig Canapari MD: wanna elaborate on that,
[00:09:53] Arielle Greenleaf: I’ve obviously, I follow along, on your social media and I know that you post like we’re discussing [00:10:00] perimenopause, but also I feel like there has to be some sort of connection. Postpartum with hormones. Of course we have the smart monitors and the baby and all that, but is there also some sort of driving, biological force is causing women to sleep at poorly?
[00:10:20] Shelby Harris PhD: Yeah. Oh for sure. Oh, for sure. There it’s, I keep saying a firestorm, your hormones are just not. Regulating themselves. it’s all over the place. The first few months. Once you have a child
[00:10:31] if you are breastfeeding that can impact, hormone swings that are happening. A lot of temperature control, temperature regulation in the middle night, issues that are happening. And then you throw on top of that anxiety all the things that we were talking about too, with having a young baby at home and worrying about just keeping your child alive and, and all the things that can happen with that, that they all kind of feed on each other.
[00:10:52] But yes, there’s a lot of hormonal changes that are happening in the first few months that can be really hard for women to settle down to sleep to
[00:10:59] begin [00:11:00]
[00:11:00] Arielle Greenleaf: what sort of treatment would you provide for, is it situational insomnia what are the different scales or, dimensions of insomnia and how do you diagnose that?
[00:11:14] Shelby Harris PhD: That’s a great question. when we’re talking about insomnia, we think about certain areas. So are you having trouble falling asleep, staying asleep or awakening earlier than you’d like to? And how often is that happening?
[00:11:28] is that happening three or more nights a week? for an insomnia diagnosis some people argue for a certain amount of time, some people say it’s about 30 minutes. I don’t like that cutoff because what does 29 versus 31 minutes mean that
[00:11:40] you now qualify for insomnia?
[00:11:42] So a lot of times it’s really perception. I like to think about perception and how annoyed or bothered you are by it. And then also what is it doing? For you, right? or it’s not helping you with. So are you, how is it bothering you in your life? Is it annoying to you? Are you feeling, like we were talking about earlier, that dragging feeling?
[00:11:57] Are you feeling sleepy? Are you having [00:12:00] trouble with concentration? Is it making you feel more anxious? So if these are things happening at least three or more times a week, and then short term is a month, long term is three months, then you’re gonna meet the criteria for insomnia somehow. Now, let’s talk about when you’re postpartum.
[00:12:16] First few months. We know that there’s a good amount of data that suggests that protecting at least four hours for the mom, especially if you’ve had, preexisting depression or anxiety issues before having your baby,
[00:12:28] Can help be a preventative against developing any sort of, postpartum depression or anxiety issues. So I try to be realistic about it. I’m one of those people that sometimes, like people who are about to have a baby, they’re always talking about baby sleep, which I totally appreciate.
[00:12:42] I’ve been there, but they’re not really talking with their significant other, or with their, OB, GYN or midwife about a plan for their own sleep. Once
[00:12:51] the baby comes, right? So let’s try and figure out support for you, so that we can try and at least get that four hours. if they’re still [00:13:00] struggling with being able to sleep a four hour chunk then we will start to do some modified. CBT for insomnia. But we have to be realistic, right? I’m not expecting someone to restrict them to five hours in bed and not have any awakenings at night.
[00:13:12] I know that there’s going to be a baby that’s possibly gonna wake them up, so we try to modify some behaviors around there with giving them a. solid chunk of when to sleep, maybe coming up with a nap schedule, coming up with plans to get help when we can, to then have them be able to protect a certain amount of time for sleep.
[00:13:29] And then as baby starts to get a bit older, then we might modify that.
[00:13:32] Craig Canapari MD: can you speak in general to, How insomnia starts and then what perpetuates it in people.
[00:13:40] Shelby Harris PhD: Yeah. So there, can be a number of things that can start it for people. there are people that I work with who say, I’ve had it my whole life. I have no idea what started it. other people, it can be family history, but you can have a family history for insomnia.
[00:13:53] It doesn’t mean that you’re gonna develop it. oftentimes what can happen is some sort of stressor a biological stressor could be [00:14:00] development of, cancer, fibromyalgia, some sort of medical illness I’m seeing a lot of people over the years with Covid who’ve maybe have some sleep issues.
[00:14:08] Some people do, some people don’t. there can be some biological stressor that could happen. then there could be a psychological stressor. people often think of stress as being bad stress, right? Like there was a job that ended or something, but there can also be good stressors.
[00:14:22] I’ve had patients over the years that are about to get married and they’re super happy about it, but they still develop insomnia because of this anticipatory anxiety or even good stress then there can also be social stressors.
[00:14:33] So a new job or having a baby, sometimes it could even be working. having a significant other who has a different schedule from you can continue it. So like you might be with, you might be having one schedule, but your significant other might that you sleep with might have shift work and that can throw it off or have a.
[00:14:49] Phone that goes off in the middle of the night for work. So then what happens is once you start having some trouble sleeping because of one of those stressors then what we often find happen are these perpetuating factors that build in. [00:15:00] So people will start doing things, and I always say it’s like an issue with common sense. when you start not sleeping well, I’ll start to say, maybe I should take a nap more routinely. Maybe I’ll go to bed a little earlier, sleep in if I can. sometimes people will rely on, over the counter medications, NyQuil, whatever it might be, or start worrying more about sleep or start using medication or alcohol or more caffeine during the day. Those are all the things that we find that even though something else might have started the insomnia, those are the things that continue it in the longer term. And that’s where we really try to focus a lot of the treatment.
[00:15:32] Craig Canapari MD: In your practice? what are the most common unforced errors that you see people making when they’re trying to fix their own sleep before they come to you? what are the common mistakes that people are making?
[00:15:43] there’s a few of them. the first one is trying to catch sleep when they can so they lose track of. A consistent sleep wake schedule. people always ask me, what do you think is the number one thing that’s the most important when it comes to sleep? And I say around the same wake time [00:16:00] every day.
[00:16:00] Shelby Harris PhD: ’cause that really helps to kind of set that rhythm so people will start to push that a bit on the days when they can, they’ll. Sleep a little bit later or go to bed earlier. Just following their body’s cues, which are actually giving
[00:16:11] them probably pretty inaccurate cues at times. So that’s one of them.
[00:16:16] The other thing that people are doing is they’re trying to overthink sleep. So when we’re not sleeping well, we start thinking like, why am I not sleeping? I have to sleep. And some people get to the point where they become so rigid about their sleep wake schedule I know I’m saying to keep a sleep wake schedule, but they start.
[00:16:30] Like having these long drawn out routines before bed with the hope that magically it’s going to help them to sleep. So that sleep wake kind of pressure they’re putting on themselves. If I don’t sleep tonight, x, y Z’s gonna happen tomorrow. That is a really big issue. And then the last thing I see a lot of people do is they start picking and choosing. Supplements, whatever medications. It’s a lot of supplement use. They’re just kind of, oh, I’ll use this for a few days. This seemed to work. And then it stops working, so then they grab another thing. So there’s a lot of random supplement choosing that they’re doing as well.
[00:16:58] Arielle Greenleaf: I see that [00:17:00] regularly among family and friends.
[00:17:02] Shelby Harris PhD: Pediatrics too.
[00:17:03] Arielle Greenleaf: in my personal life, I see it all the time.
[00:17:05] I think it’s true it becomes like an obsession
[00:17:08] when it comes to pediatric sleep, I can easily see how that would translate into adult sleep Well, my partner definitely struggles with sleep and he is an offender of trying the supplements, taking it one night and saying, oh, that didn’t work, so I’m not gonna use that, or reading that,
[00:17:26] tart cherry juice and bananas can help with sleep It’s like, dude, this has been going on for so many years that a banana
[00:17:35] at night is not going to fix your sleep problems.
[00:17:39] Shelby Harris PhD: But that’s where I think social media has made
[00:17:43] it worse since the pandemic, since Instagram has taken off more, which is one of the reasons why I started my social media account was just to try to get a little bit more of like a. More evidence-based approach to it is there are people out there who are these millions of followers who are just like, use this one supplement.
[00:17:57] It’s gonna fix everything. Do this one thing, have [00:18:00] this really elaborate wake up routine, and they’re not really talking to the people who have real entrenched insomnia.
[00:18:07] patients with insomnia, that’s that mismatch that we’re finding a lot of times, yes, sometimes these things can help, but they’re not usually helping the people with real
[00:18:14] entrenched insomnia
[00:18:15] Arielle Greenleaf: my question is. Just from my own experience, even as a child, I had some sort of anticipatory insomnia going on. If I wasn’t falling asleep, I’d be looking at the clock and it’s nine o’clock, it’s 10 o’clock. Oh my gosh, I’m gonna feel so awful in the morning, sort of thing. and then as, as I grew older, I was diagnosed, as insomnia and I was given medication. And now it seems that the first stop is CBT cognitive behavioral therapy when it comes to insomnia. And as someone who has had been to CBT for, anxiety and depression, I’m skeptical about CBT as something that’s really gonna cure insomnia.
[00:18:58] I wanna know how it works. I [00:19:00] really do. I’m really curious
[00:19:01] about it. Because it. is real. Absolutely. I just
[00:19:04] wanna know more.
[00:19:06] Shelby Harris PhD: another thing that can get mixed up is the term CBT for insomnia. as someone who did fellowship training in CBT for anxiety and depression, I think that C-B-T-I-C-B-T for insomnia. Is a bit of a different animal than the other types of CBT. So, and there’s a reason why many people who do CBT aren’t specialized in insomnia because it is a different kind of treatment. for CBTI, the biggest bang for your buck in all of it. It’s, it’s different treatment modules essentially put together into one package. So we have the cognitive part, we have the behavioral part. Therapy for insomnia. So the behavioral part has the most bang for your buck, in my opinion.
[00:19:46] what that consists of is. sleep hygiene. Let’s start with sleep hygiene. That’s the stuff you hear about all the time on the news and in social media that’s like, you know, limit caffeine, limit these things and nine times outta 10 my patients have come to me and be like, I tried all those things, but it didn’t do [00:20:00] anything. Yes, that stuff typically is the control group for most insomnia treatments. But the reality is you still need to do them routinely. To make sure you’re gonna get the most benefit from the other modules. So there’s sleep hygiene. Then there’s something called sleep restriction.
[00:20:16] So my mentor Michael Thorpy, was on one of the original studies looking at sleep restriction in the late eighties. And that idea is that, and this is where it’s different from all the anxiety and depression treatments, we actually look at the amount of sleep someone’s getting on average and restrict them to what they’re getting on average for the past week or two. if someone’s coming to me spending eight hours in bed every night, but I’m keeping a consistent sleep wake schedule, but they’re only getting five and a half hours on average, I’m gonna restrict that person to a five and a half to six hour window.
[00:20:46] And what we find is they fall asleep faster and they tend to stay asleep or wake up, but go back to sleep faster in that window. we teach them ways to calculate, sleep efficiency. How efficient and consolidated their sleep is at night. then we [00:21:00] slowly increase their total sleep time quality first, then quantity. So that’s something that you don’t really get in, all the
[00:21:05] other anxietyIt’s just different.
[00:21:07] And like that’s why I find, honestly, sleep restriction is where I almost always start with patients if I can. And that’s where you, like I said earlier, you tend to get the most
[00:21:15] bang for your buck.
[00:21:16] Arielle Greenleaf: like positive reinforcement because you get them falling asleep easily, and then they’re able to fall back to sleep easily. So they’re like, oh wait, I can
[00:21:24] sleep. And then you slowly add on to the amount of sleep if they’re still tired, you add on to
[00:21:31] that start time gets a little earlier and earlier.
[00:21:35] Shelby Harris PhD: And a lot of it is not easy to do in theory, it’s easy in practice, but getting someone to
[00:21:41] do it is really tough. working with someone on how to stay awake, like the people who don’t have trouble falling asleep at the beginning of the night, but wake up early in the morning, they’re harder because now I’m making them stay up later when they’re already sleepy to begin with. So it’s a lot of problem solving ways to get someone to.
[00:21:55] Stay awake until I need them to building in a nap if we have to. doing all of [00:22:00] that is really where the skill in my opinion, comes in and tailoring it to the patient to see what their specific, issues are. And then the one other piece of the behavioral treatment is stimulus control.
[00:22:10] So everyone hears if you haven’t fallen asleep in 20 minutes, get up and go outta the bed. I don’t love the 20 minutes. ’cause it makes you look at a clock when we say, don’t look at a clock at night. one of my friends Michael Perlis used to always say Just go by annoyance. If you start noticing your brain’s on fire and you’re annoyed, just get outta bed.
[00:22:25] And that’s usually around 20 minutes. So if someone’s just resting their brain’s not on fire, they’re possibly in and out of sleep. But if they’re really anxious and trying to force sleep to happen, that’s when I have them get out of bed. that’s the behavioral stuff. the cognitive part of CBTI is a little bit more flexible with the patient. So. Sometimes for some patients I’ll need to challenge the thoughts they’re having about trying to force sleep what will happen if sleep doesn’t come that night? Also, I’m a huge believer in adding in mindfulness-based therapy for this. Sometimes relaxation that’s more behavioral, but an acceptance and commitment we might add a little bit there. Those fall under the C [00:23:00] part of CBTI, so that. Is more standard when we think about cognitive therapy for depression and anxiety.
[00:23:05] But the behavioral stuff is actually very different and for many people it works in about two to
[00:23:10] 12 sessions. one person said to me, well, my doctor told me it should work in two months. And I said, well, you’re on a lot of different medication. So it also depends on the patient.
[00:23:18] Sometimes we need to taper them
[00:23:19] down on medication and get them to where we need to be. So it’s not a one size fits all kind of amount, but it’s definitely a
[00:23:25] Arielle Greenleaf: That’s what I always say about adults. people find out I help children sleep and they’re like, oh, can you help
[00:23:30] me? And I’m like, adults have so many different things going on. Medications,
[00:23:35] anxiety, depression, any of that. I feel like it’s much more complicated, but. That is so interesting and it makes so much sense to me the sleep restriction piece and then,
[00:23:46] adding in the other things. so thank you. That was really helpful.
[00:23:49] Shelby Harris PhD: You are welcome. But to your point earlier about it being more of a medication in the past, I mean still a lot of people use medication. I have no issue if we’ve gone through the risks and [00:24:00] benefits and figured out what treatments have they tried. but CBTI, although it’s harder at the beginning, has more lasting power.
[00:24:07] if you take the medication away from someone, a lot of times they haven’t learned strategies or tools to sleep better. This will give them something to fall back on if they have a, a almost their, you know, to ever say that someone’s cured from insomnia,
[00:24:19] think is unrealistic. But if it starts to come back, they know what to do to get back on track. Whereas medication makes it harder. But like I said, it’s not a one size fits all approach. We just try to start with CBTI because it tends to have the least amount of side effects and risks
[00:24:33] Arielle Greenleaf: That is so helpful.
[00:24:35] Craig Canapari MD: Is there anyone you’d say is not a good candidate for CBTi?
[00:24:38] Arielle Greenleaf: Hmm.
[00:24:39] Shelby Harris PhD: I sometimes get, patients that will come to me and say, where can I get the pill? If they have zero motivation despite. education on my end, that’s not an ideal patient.
[00:24:48] If someone has a lot of significant anxiety or depression, it doesn’t mean they can’t do CBTI, but if it’s gonna get in the way of them being even remotely consistent with what I’m asking them to do. They might not be an ideal [00:25:00] patient but I think many people can start with it, even if they’re on medications.
[00:25:04] You just have to modify the treatment. I think you might not be ideal for one of the apps, but we can always modify it to try it with patients.
[00:25:11] Craig Canapari MD: we struggle a little bit in our adolescent population, especially kids that are multiple psychiatric medications. They’re already working with a therapist. Otherwise, there’s, there’s the insurance
[00:25:22] layer that sometimes you can’t get coverage for two psychologists at once.
[00:25:26] If nothing is working well, where do you start?
[00:25:30] I have patients with mood disorder, narcolepsy, terrible sleep hygiene, and it’s kind of like
[00:25:35] Shelby Harris PhD: Yep.
[00:25:36] Craig Canapari MD: sometimes we’re sort of just trying to figure out like, where do we even begin?
[00:25:40] Another domain I’ve seen a lot of, especially since the pandemic, are kids with school avoidance,
[00:25:46] kids who are just not attending school and they come to sleep clinic.
[00:25:50] ’cause they’re like, oh, they’re sleeping all day and that’s why they’re going to school. And I’m like, no, they don’t want to go to school. And that, that, that is then they’ve stopped going to [00:26:00] school and then start sleeping all day.
[00:26:01] it’s not that hard to fix a circadian or body clock problem if some, even if someone’s split their dates and nights, all the adolescents did this during the pandemic, and most of them we could switch it right
[00:26:11] back when they went back to school.
[00:26:13] it’s just the kids where there’s a lot of anxiety and behaviors about avoiding things that they need to do, that are perpetuating these really maladaptive sleep problems.
[00:26:24] Shelby Harris PhD: one of the things with the circadian stuff that I see a lot is even with adults, if they say, I just wanna have a normal sleep schedule, but they don’t have an actual reason to get up by a certain time, that’s someone that I find is gonna be more challenging to treat because they don’t have that, external reason
[00:26:40] to have to get up for a certain time.
[00:26:42] Exactly, exactly. But I do think when I was saying like depression, anxiety, if someone’s coming to me, even though I work as a general therapist, CBT stuff, I don’t always take on cases weekly. I don’t always have the room, so I do mostly sleep stuff. So if people are coming to me, they’re like, I don’t know where to start.
[00:26:59] Do I start [00:27:00] with the sleep? Do I start with the depression? I’m one of those people that just says, you know what, let’s start with a few focused sessions of CBT for insomnia or working on whatever sleep issue behaviorally that we’re going to. And sometimes what we see is if someone’s sleeping better, it helps with their coping mechanisms to help with whatever other treatments
[00:27:16] they’re gonna be doing so you get more
[00:27:18] bang for your buck.
[00:27:19] I keep saying that, I really do find that. When it comes to this sort of stuff, if someone’s trying, they can’t stay up until the time I’m asking to because they just wanna get in bed to avoid whatever thoughts that they’re having or to put an end to the day. If there’s a big depression component that’s making it harder, then I might argue first, starting with the depression treatment first.
[00:27:36] Craig Canapari MD: Yeah. if someone is listening to this and they’re like, I’m really struggling with sleep. I wanna find a provider for CBTI, where should they look? Because I know this is. Surprisingly difficult a lot of the time. I mean, it, it took me in the last year we hired a psychologist in our clinic, and it took years and years for us to make this [00:28:00] happen.
[00:28:00] Shelby Harris PhD: Yep.
[00:28:01] Craig Canapari MD: where should people look if they’re looking to find a Dr. Shelby, or someone with similar skills,
[00:28:08] how do they start that search?
[00:28:10] Shelby Harris PhD: I think the first place is you have to think about. what level of qualifications you’re looking for? when I refer for any sort of behavioral sleep medicine issue, the first place I tend to go to is someone who has been board certified in behavioral sleep medicine, someone who has something called a DBSM and that way you know that they have fulfilled the amount of training that’s necessary. They’ve taken the exam, they’ve had the supervision that you know what you’re getting. For for sure. And they’ve got that gold stamp on there. you can go to the Society of Behavioral Sleep Medicine and they will have a, listing throughout the world of people who have, different credentials, but they’ll have also people who have the DBSM designation. Then if you don’t need someone, I mean, you don’t have to have a DBSM, there’s, it’s a lot of extra training, you don’t have to have that to be good at, say CBTI. if you’re looking for that, the Society [00:29:00] of Behavioral Sleep Medicine, but you don’t have someone who’s DBSM, you know, you’re probably gonna get someone that actually is in the know about the field that they’re even going to have their name
[00:29:08] listed on this website. Penn Medicine has a. CBTI provider directory as well. And those are people who have taken, Michael Perlis’s training if you’re not sure if the person has just taken a training, I always say to patients like you’re the consumer when you call to have an initial consultation, talk with this person.
[00:29:26] Ask them how many cases, roughly have you maybe seen how. Have you been supervised by anyone? Like Michael Perlis will be the first person to say like, if you’ve taken my training for a few weekends, I still think you should have some supervision by someone who has a DBSM. So like those varying levels are really helpful.
[00:29:41] There are a lot of people who say they do CBTI on Psychology Today but they honestly are just giving someone sleep hygiene treatment recommendations. That’s not CBTI. So I think going through it in that way is a much more standardized way to think about it.
[00:29:52] Craig Canapari MD: One thing I think is, uh, interesting is the importance of tracking sleep, right?
[00:29:58] [00:30:00] Yeah.
[00:30:01] sleep is so subjective. if I said I’ll give you a million dollars, tell me the exact time you fell asleep last night. Like, nobody can do that.
[00:30:07] It’s just, it’s just not how it works.
[00:30:08] And like, if we want someone to get better at fitness, we’re like, okay, run a mile and then run two miles, then run three miles. I know you run marathons and stuff like that in sleep. It’s like, it’s like trying to control it
[00:30:19] more actually make, can make it worse.
[00:30:22] Shelby Harris PhD: Yep.
[00:30:23] Craig Canapari MD: About the role of, consumer technology in tracking sleep.
[00:30:28] pros and cons because like I, I wear an over ring. I find it useful. I’ve had friends whose kids were like, you need to stop wearing the ring because you’re being really weird about it. Like this sort of classic orthosomnia
[00:30:41] thing, which is where someone’s obsessing about their
[00:30:44] sleep tracker and they can’t sleep.
[00:30:46] where do you see the kind of role of these consumer. Which are honestly as good as the medical technology
[00:30:53] acti we use.
[00:30:55] but they do have some potential downside
[00:30:56] Shelby Harris PhD: Yeah. so I think they have a [00:31:00] really strong use for people who don’t make sleep the biggest priority in their life, and they’re just interested in how they can, optimize their sleep. Like what does alcohol, do to my sleep?
[00:31:10] What does the caffeine do? And in regular sleep break schedule, am I getting enough sleep? Because we know they’re pretty accurate with telling us how much sleep someone’s getting on average. The sleep staging can be a little funky based on, the device and in general. for people burning the candle at both ends and just wanna see how to improve their sleep. I think for the people who have chronic insomnia. Really think a lot about their sleep. I think it is, like you said, ortho somnia, I think it’s the A recipe for disaster because they know they don’t need something to tell them they’re not sleeping well already. And then if they had a night where they thought they slept well, but the device said they didn’t sleep well, then that oftentimes will. gauge how their day is going to go. So I have had plenty of patients, I’ll say, get rid of the device. I just wanna see on average how you think you’re doing. And if you start thinking that your sleep is getting better, that’s all I really care about. I do use the devices, actually, I’m using them more and more. for, circadian rhythm [00:32:00] disorders. for tracking, sleep, wake timing, I’m using those a lot in my practice.
[00:32:04] Arielle Greenleaf: I feel like I know a lot of people who are like, oh my gosh, I only got this amount of deep sleep last night, and I’m like, how do you even know people think that they need nine hours of deep sleep in order to be well
[00:32:15] rested the next day, and that’s just not a fact.
[00:32:17] you get these devices, but you’re not told how to read
[00:32:21] the stuff that’s coming out of them.
[00:32:23] Shelby Harris PhD: I think that we get very fixed on like, I need
[00:32:25] that REM sleep. I need that deep sleep. they don’t really think about the percentages that you’re
[00:32:29] supposed to get throughout the night. people don’t think about other things that impact sleep staging throughout the night. Psychiatric medications you might be taking, other things can definitely impact that, that those devices aren’t necessarily telling
[00:32:41] you about. there’s more to the story than just what a printout or a screenshot might tell you.
[00:32:47] Craig Canapari MD: Yeah. You know, I, I, I’m, I’m very conflicted about this stuff. ’cause on the, on the one hand it’s can be very useful when
[00:32:55] families bring this in. And, the flip side is in the pediatric realm, [00:33:00] sometimes it can create some conflict, especially between teenagers and
[00:33:03] parents. Families with a high level of achievement. They’re wanting to optimize everything in their kid,
[00:33:08] and I’m like, maybe you don’t. need to hold on quite so tightly
[00:33:13] Arielle Greenleaf: I always tell that to parents as
[00:33:14] well. We can’t force people to sleep. We can’t force their sleep stages. it just is what it is. At some point, I mean, youwe’re not robots.
[00:33:25] Shelby Harris PhD: but it feels a little bit like, like you said, policing in a way. Like they’re just watching, are you getting up in the middle, what’s happening? And just that level of control. it’s creating more stress around the idea of sleep, which is what makes it worse for the whole family.
[00:33:39] Craig Canapari MD: I think it is A funny phenomenon as the owner of two adolescent boys, it is a funny thing when, like
[00:33:46] they’re going to bed later than you are, you don’t quite know what they’re doing. I, I tell them, ’cause you know, if they, if they wake me up out of that slow wave sleep, when they’re rattling around the bathroom or something like that, like [00:34:00] I, I am up for
[00:34:01] like an hour and I’m like, look guys, I’m leaving the door open.
[00:34:04] ’cause the air conditioning’s on. Can you brush your teeth and stuff before I go to bed? Because they’re just running up and down
[00:34:10] stairs, slamming doors. it’s crazy.
[00:34:14] Shelby Harris PhD: I know my son likes to make homemade pasta,
[00:34:16] Arielle Greenleaf: Oh God.
[00:34:16] Shelby Harris PhD: 11 o’clock at night. I’m like, really? do, we need to be doing that right now?
[00:34:21] It’s so
[00:34:21] Craig Canapari MD: like
[00:34:22] fire alarms going off and. It’s crazy. So listen, we, we thought this would be fun. I mean, I thought of this, don’t know if Arielle thinks this is fun or not, having guests on to talk about a sleep hack and a sleep confession, things that you might find helpful and things that you do that you know are not best practice.
[00:34:41] I, can go first. my sleep hack is. I love a sleep mask, I only started a couple years ago and I’m like, why have I not been doing this my whole life? I’m light sensitive.
[00:34:51] I like the pressure on my face. Now my 16-year-old loves it. He went to scout camp with a sleep mask. It’s just really funny.
[00:34:59] [00:35:00] Um, my confession is I take a couple of supplements every night. I take a tiny bit of melatonin, I take some magnesium, and I take some L-theanine. And I’ve actually used my Oura ring to be like what actually works. I’ve tried a bunch of supplements. I’m like, this seems to help the most. So yeah, I will say I’ve played around with it, but
[00:35:20] I don’t know if I’d recommend this to everybody, I was talking to Sujay.
[00:35:22] He’s like, there’s not a lot of evidence for magnesium. I’m like, I do feel better when I take it.
[00:35:26] Shelby Harris PhD: I’m gonna like, Exactly. There’s not a lot of evidence for it, but if it helps you and there’s not really any downside to it, just besides spending the money on it and you find it’s helping, then you, I always say
[00:35:37] that.
[00:35:38] Craig Canapari MD: Do you want to,
[00:35:39] my sleep hack You said you’re light sensitive. I am very noise sensitive. I always have been. even in college, I had white noise. I lived in Boston, it was loud. I believe in white noise for people that are sensitive to it. A lot of times parents will say, well, I don’t want my child to get. Used to white noise. But I also say, in my opinion, it feels [00:36:00] like you either sensitive to noise or you’re not, and your baby can’t tell you.
[00:36:03] Arielle Greenleaf: it doesn’t hurt to use it. And then if they tell you later when they have the ability to do so, they don’t like it, take it away. for me
[00:36:10] it really helps a lot.
[00:36:11] my confession is that I’ve been on sleeping medication for years and my mom thinks it’s hilarious that I help people with pediatric sleep. She said I didn’t sleep through the night till I was four. So, I mean, I
[00:36:25] think my body is just, you know, it. And the crazy thing is that I need a lot of sleep.
[00:36:31] if I don’t get
[00:36:32] sleep, I feel. Physically ill, and I think that’s ultimately why I have stayed on medication for so long because it really affects my life when I don’t
[00:36:44] Shelby Harris PhD: yeah,
[00:36:44] And you
[00:36:45] found something that’s working for you, so there you go. Um.
[00:36:49] Craig Canapari MD: do you wanna out yourself for
[00:36:50] sleeping with a TV on all night or
[00:36:52] Shelby Harris PhD: Oh, so my hack, is that I like to keep my bedroom really cold.
[00:36:56] I actually get too cold at the beginning of the night, so I sleep with
[00:36:58] Big [00:37:00] fuzzy socks. for me that helps to keep the room cold. My kids don’t seem to
[00:37:04] care at all. My husband’s fine with it, so it keeps it nice and cold, but my feet aren’t shivering and freezing. then I throw the socks off in the middle of the night. And that actually for some women does, or some people does help with sleep when temperature regulations.
[00:37:15] So that’s what I do.
[00:37:16] mask on an eye mask. I cannot do that. I have so many patients who love to do it and I cannot do it. and then for my confession, I’ve. Two confessions. So one is that I absolutely hate the smell of lavender. people ask me all the time without lavender, and I’m like, I cannot be near it.
[00:37:32] It gives me a migraine. But if you like it, go ahead. the other thing for me is that I actually grew up, my parents hate it when I admit this, but I grew up with a TV in my bedroom that was the thing that I watched every night to soothe myself to go to sleep
[00:37:43] And it’s just one of those things that I. Still have a TV in my room. Do I watch it every single night right before I go to bed? No, but I watch it. I watch like a relaxing show that I like to watch. sometimes it’s something I’ve seen 10 times already, but sometimes I watch that right before bed and I’m good about turning it off and then saying it’s [00:38:00] time to go to sleep.
[00:38:00] So I have a TV in my room and yes, I do watch it before bed sometimes.
[00:38:04] Arielle Greenleaf: Yeah. I have
[00:38:05] that same thing,
[00:38:06] Shelby Harris PhD: Yeah.
[00:38:08] Craig Canapari MD: Rules are meant to be broken, you
[00:38:09] know?
[00:38:10] Shelby Harris PhD: I’m not a hard and fast get rid of all screens right before bed. some people can actually tolerate them a little bit better, so
[00:38:15] Craig Canapari MD: I take a TV in someone’s room over them staring at their phone
[00:38:19] any day. It’s just not as engaging.
[00:38:21] Arielle Greenleaf: passive.
[00:38:22] Craig Canapari MD: it’s, yeah.
[00:38:23] Shelby Harris PhD: But getting people to actually get a TV to put in their room is harder and harder nowadays.
[00:38:28] Craig Canapari MD: So Shelby,
[00:38:29] I have the link to your website and
[00:38:31] your book. is there anything else that you would like to plug here, for our audience?
[00:38:36] Shelby Harris PhD: I think it’s just the Instagram account and then my website and book would be great. Thank
[00:38:41] Craig Canapari MD: Awesome.
[00:38:42] Well, thanks so much for coming. This was super fun. I learned a
[00:38:45] lot and, I think the take home for me is for parents is like, take care of your sleep.
[00:38:50] there’s a reason your body wants to spend a third of your life doing it.
[00:38:54] It’s very important.
[00:38:55] Shelby Harris PhD: don’t assume the number of people on social media, they’re like, oh, once you have kids, your
[00:38:58] sleep is done. that’s
[00:38:59] [00:39:00] not the case. You can work on your sleep and work on your kids as well, because you both need that for yourselves
[00:39:05] to develop.
[00:39:07] Craig Canapari MD: Absolutely. thank you so much.
[00:39:09] Shelby Harris PhD: Thank
[00:39:09] you.
[00:39:10] guys. I will talk to
[00:39:11] you later and, have a
[00:39:13] Arielle Greenleaf: You too.
[00:39:14] Shelby Harris PhD: Thanks so much for listening to the Sleep edit. You can find transcripts at the web address Sleeped show. You can also find video of the episodes at that address as well as in my YouTube channel. You can find me at Dr. Craig canna perry.com and on all social media at D-R-C-A-N-A-P-A-R-I. You can find Ariel at Instagram at Ariel Greenleaf.
[00:39:44] Craig Canapari MD: That’s A-R-I-E-L-L-E-G-R-E-E-N-L-E-A. If you like the flavor of the advice here. Please check out my book. It’s Never Too Late to Sleep. Train the Low Stress Way to high Quality Sleep for babies, [00:40:00] kids, and parents. It’s available wherever fine books are sold. If you found this useful, please subscribe at Spotify or Apple Podcast and share it with your friends.
[00:40:10] It really helps as we’re trying to get the show off the ground. Thanks.
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