Episode 18: Mindfulness
What is mindfulness? How is it used? How can it help with sleep? These are all questions we try to answer in this episode, with the help of Dr Antonio Fernando (Psychiatrist), Dr Allie Peters (Psychologist) and guest co-host Dr Giselle Withers (Psychologist). Mindfulness can be a great skill to help with sleep, but learning mindfulness takes time and a structured approach with guidance from an experienced teacher.
Dr Moira Junge (Health Psychologist) and Dr David Cunnington (Sleep Physician) host the monthly podcast, Sleep Talk, talking all things sleep.
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00:00 – 00:56 Introduction
- 00:56 – 07:43 What’s news in sleep?
- 00:56 – 02:02 Health retreats and sleep
- 02:02 – 3:10 Mindfulness in May / A Mindful Way
- 03:10 – 05:16 Change of seasons
- 05:16 – 06:10 Featuring research on the podcast
- 06:10 – Theme – Mindfulness
- 06:10 – 09:15 Background – Mindfulness
- 09:15 – 15:02 Guest interview – Dr Tony Fernando
- What is mindfulness?
- How is it used?
- 15:02 – 23:27 Guest interview – Dr Allie Peters
- Why should mindfulness help sleep?
- Research on mindfulness for insomnia
- What did you find?
- What did you learn from your research using mindfulness for insomnia?
- 23:27 – 37:37 Guest interview – Dr Giselle Withers
- What is mindfulness?
- How does mindfulness add to cognitive behavioural therapy for insomnia?
- How can people learn mindfulness?
- 37:37 – 40:21 Mindfulness exercise
- 40:21 – 41:32 Where to get more information on mindfulness
- 41:32 – 42:11 Clinical tip of the month – A wandering mind is normal
- 42:11 – 44:25 Pick of the month:
- 42:11 – 43:02 Moira – Sleep Quality and Mindfulness as Predictors of Depression, Anxiety and Stress
- 43:02 – 44:01 David – The neural correlates of dreaming
- 44:01 – 44:37 Giselle – Mindfulness-Based Therapy for Insomnia – Book
- 44:37 – 45:51 What’s coming up in sleep?
Next episode: June 5th
Links mentioned in the podcast:
- Health Retreats and Sleep
- Golden Door Health Retreat
- Mindful in May
- A Mindful Way – Next guided course starts May 27th 2017
- Seasonal affective disorder
- Sleep and headache – research by Daniel Sullivan
- Chronic headaches and insomnia – review
- Combining mindfulness with cognitive-behavioural therapy
- Randomised controlled trial of mindfulness for insomnia
- Insomnia Severity Index – link to the questionnaire
- Wandering mind not a happy mind – Harvard research
- Melbourne Sleep Disorders Centre – group using mindfulness for insomnia
- A Mindful Way – online mindfulness course for insomnia
- Mindfulness-Based Therapy for Insomnia – Book
- Practical tips for mindfulness – SleepHub post
- Mindfulness and its role in sleep – SleepHub audio interview
- UMass Center for Mindfulness
- Full Catastrophe Living – Book
- A Mindful Way
- Sleep Quality and Mindfulness as Predictors of Depression, Anxiety and Stress
- The neural correlates of dreaming
- Dreaming – Sleep Talk podcast episode
- Mindfulness-Based Therapy for Insomnia – Book
- Sleep 2017 meeting – Boston June 3-7
- World Sleep Congress 2017 – Prague October 7-11
- Sleep Down Under 2017 meeting – Auckland Oct 27-29
Dr Tony Fernando: After completing his medical school training at the University of the Philippines, Dr Tony Fernando trained as both a sleep specialist and psychiatrist in the United States. Tony completed a fellowship in Psychopharmacology and Sleep and Chronobiology at University of Pennsylvania. Tony’s Psychiatry training was completed at St Luke’s and Roosevelt Hospital in New York (Columbia University) and University of Pennsylvania. Tony is now a senior lecturer in Psychological Medicine at the University of Auckland Faculty of Medical and Health Sciences. He is the course coordinator for Undergraduate Training in Psychological Medicine and has published numerous papers in sleep and psychiatry.
Dr Allie Peters is a registered psychologist and a member of the Australian Psychological Society and the Australasian Sleep Association. She has completed a PhD at RMIT University with a focus on Mindfulness and Insomnia. Allie possesses diverse skills in psychotherapy and has worked with a range of client groups. She uses an integrated approach, drawing from a range of therapeutic techniques such as Interpersonal Psychotherapy, Mindfulness Based Stress Reduction, Motivational Interviewing, Existential Psychotherapy, Acceptance and Commitment Therapy, Cognitive Behaviour Therapy and Client Centred Therapy. Allie sees clients at Melbourne Sleep Disorders Centre, Fernhills Clinic and Monash Healthy Sleep Clinic.
Dr Giselle Withers is a Clinical Psychologist with over 20 years experience treating people with mental health and chronic health problems. Giselle has practiced yoga and meditation for over 25 years. Recognising the benefits of these Eastern traditions for healing and personal growth, she undertook further training to become a qualified yoga teacher (RYT200) and mindfulness teacher. She has undertaken MBSR/MBCT teacher training, including teacher development retreats with Jon Kabat-Zinn and Saki Santorelli (Centre for Mindfulness, UMass), Southern Synergy Monash University, and the Mindfulness Training Institute Australasia. Giselle draws on mindfulness-based therapies in her work as a Clinical Psychologist and has developed online mindfulness programs for insomnia, chronic fatigue and anxiety at A Mindful Way.
Dr Moira Junge is a health psychologist working in the sleep field, who has considerable experience working with people with sleeping difficulties in a multidisciplinary practice using a team-based approach. Moira has consulted at Melbourne Sleep Disorders Centre since 2008, and is actively involved with the Australasian Sleep Association (ASA). She has presented numerous workshops for psychologists wanting to learn more about sleep disorders, and is involved with Monash University with teaching and supervision commitments, as well as clinical involvement with the Monash University Healthy Sleep Clinic. She is one of the clinic directors at Yarraville Health Group which was established in 1998. In addition to her expertise in sleep disorders, her other areas of interest and expertise include smoking cessation, psychological adjustment to chronic illness, and grief and loss issues.
Dr David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to SleepHub. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is certified as both an International Sleep Medicine Specialist and International Behavioural Sleep Medicine Specialist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep. David is a regular media commentator on sleep, both in traditional media and social media, and blogs for the Huffington Post on sleep. David’s recent research has been in the area of non-drug, psychologically-based treatments such as cognitive behavioral therapy and mindfulness in managing insomnia, restless legs syndrome and other sleep disorders.
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Dr. David Cunnington: So welcome to episode 18 of Sleep Talk, our monthly podcast on all things sleep. This month, we’re going to be talking mindfulness and as usual, I’ve got Dr. Moira Junge with me.
Dr. Moira Junge: Hello.
Dr. David Cunnington: And joining us for this episode is a guest co-host who is Dr. Giselle Withers. Welcome Giselle.
Dr. Giselle Withers: Thank you. Hi everyone.
Dr. David Cunnington: So mindfulness is something that’s really topical. People hear about it a lot. It’s almost like a buzzword and it gets used for so many different things. So one of the things we’re trying to tease out is what actually is mindfulness and we will get the input of our guests, including Giselle’s input on that. We will try to get to maybe what it isn’t and – but some things to put out is quick fix mindfulness and some of the problems with that and try and review some of the evidence for mindfulness, particularly around sleep, but also for other conditions.
Dr. Moira Junge: So what has been happening lately in media and around the sleep world, Dave?
Dr. David Cunnington: It has been a little bit quiet this month. I’ve been gearing up to go to Golden Door and looking forward to having quite a nice time on a retreat.
Dr. Moira Junge: We often hear about this. Move on.
Dr. David Cunnington: Yeah. I’m planning to do a bit of writing. So it will be work. It really will be work, but talking to the guests there about sleep and one of the things actually that I find when I’m there, which is topical for mindfulness is they teach people or give people exposure at least to other things like tai-chi and yoga and meditation and other contemplative strategies.
It really does highlight one of my messages for the guests. It’s not all about sleep. People often ask me. I’m so tired. How can I sleep better? In actual fact, the tiredness is often due to other things – stress, busyness and as we’ve talked about in other episodes.
Dr. Moira Junge: Diet, yeah.
Dr. David Cunnington: Yeah, exactly. Diet, lack of physical fitness. So it’s a nice place for people to get a bit of orientation around hey, there’s actually lots of different domains to feeling well and not feeling tired because of lack of sleep. It’s also a big month for mindfulness, which is one of the reasons we’ve got the topic of mindfulness on this episode. Also there is a movement Mindfulness in May that has been going now for a couple of years. A nice way of getting into a daily habit of some mindfulness practice and as we will get into a bit later, Dr. Giselle Withers has launched her online mindfulness course A Mindful Way. We will talk about that in a bit more detail. But it’s really exciting and we wanted the opportunity to feature that.
Dr. Moira Junge: So what about you Giselle? What’s topical or what has been happening lately for you?
Dr. Giselle Withers: Yeah. As David mentioned, I’m really excited that we’ve finally launched this course, A Mindful Way to Healthy Sleep. It has been about three years in the making. So it’s an enormous relief to have it live now.
Dr. Moira Junge: Labour of love.
Dr. Giselle Withers: Yeah. And there are students going through the course at the moment and so far the feedback has been really good.
Dr. Moira Junge: Oh, great.
Dr. Giselle Withers: So that’s again a relief and a joy to hear.
Dr. Moira Junge: Yes. So some people have actually finished.
Dr. Giselle Withers: Oh, they’re still working through it. It’s a six-week course. So they’re right in the middle at the moment. So we’re getting ready to launch the next guided course, which will be in June.
Dr. Moira Junge: Good on you. Congratulations on getting that up and running.
Dr. Giselle Withers: Thank you.
Dr. David Cunnington: We will certainly put the dates for your next course and some links in the show notes.
Dr. Moira Junge: I suppose the other thing that’s happening is just that there’s a seasonal change. Yeah, we talked a bit about the Daylight Savings recently in a recent podcast. But the days are certainly getting darker and colder. So I think that people notice the change in their sleep. Certainly it’s a general rule for psychology. I know this is psychology for Melbourne and psychology in Melbourne – because Melbourne is sort of – one of the Southern states of course in Australia and it’s colder and darker.
But you would agree with this too, Giselle. It’s actually documented somewhere that psychologists are much busier between April and October. So as it starts to get darker, April, May, onwards, I think there is a significant shift in people’s mood. It’s literally darker. So it’s sometimes darker outside, sometimes darker inside. How do you regulate the mood?
So I think that’s interesting, just a topical thing. Maybe we will dedicate a whole podcast to perhaps seasonal-affected disorders. So I’m not specifically talking about seasonal-affected disorders, but this just seems to be a general trend in people not coping as well.
Dr. David Cunnington: Yeah. So one of the terms could be light-sensitive mood changes. So not disorders per se.
Dr. Moira Junge: Not a full-on disorder, diagnostic criteria, et cetera.
Dr. Giselle Withers: I really hear that from clients on the other end as we start moving into the lighter, warmer weather again. People immediately saying how much it really boosts their mood and how much better they’re starting to feel.
Dr. David Cunnington: Through the link too to sleep length, you know. We’re creatures of habit. In a modern society, we set our alarm the same time every day, winter, summer, to work at the same time every day. But in actual fact, if we’re living in nature, we would sleep a bit longer in winter and a bit shorter in summer and often – we know naturally some people still have that variation. But they don’t change their alarms and things. So they just find the mornings a bit slower and a bit more sluggish.
Dr. Moira Junge: Well, not everyone has the choice, do they? Most of us don’t have …
Dr. David Cunnington: In a rational-willed society, we would start working an hour later in winter as the sun runs a bit later.
Dr. Moira Junge: One interesting thing that has been happening the last month since that podcast on sleep and headaches was that both of us were contacted by a researcher at Griffiths University in Brisbane in Australia who’s doing his PhD and some really great research in the area of headaches and insomnia and sleep, sleep disturbance. He sent us some papers via email and that was just – it was really, really fantastic and I encourage other people listening. If you’ve – your particular area of research that you’re interested in or might have touched on and we would love you to send us some areas of interest that we could highlight for a future podcast.
Dr. David Cunnington: Yeah, because we really do want to give researchers the opportunity to have their work highlighted and really be able to tease them out. So by all means, yeah, send us the work that you’re doing or something you’ve recently published and we would love to take a look at it.
Dr. Moira Junge: Yeah. So thanks Daniel. It was really, really great to hear from you.
Dr. David Cunnington: So the theme for this month’s podcast as we talked about earlier is mindfulness and mindfulness – well, here are some definitions of mindfulness. But it’s something that has been used for a range of different conditions including anxiety, chronic pain, stress management and increasingly being used in sleep and all of us that you will hear from today have been involved in some research on using mindfulness in sleep and try and give you our perspective around that. How have you found your experience with mindfulness in sleep, Moira?
Dr. Moira Junge: Well, I found it a fantastic tool. I’ve been really excited. I’ve been using it in my practice for a number of years and I remember the exact date when I first heard about it. I might have told this anecdote before. But it was in 2007 at the World Sleep Congress up in Cairns. I saw this fantastic research study. She just was talking about this wonderful thing that she had been doing and it was with a group of adolescents and they had these wonderful outcomes. She had the data up on the screen.
I remember that she talked about the principles of mindfulness, what she called mindfulness. I said, “What’s this stuff? What is this?” Then she called it mindfulness and it was – she credited Jon Kabat-Zinn who we will hear more about as the podcast goes on. The principles of mindfulness were what she listed up there and we talked about those as well.
But when I saw the principles listed and there are things like patience and trust and letting go and non-striving and non-judgemental in the beginner’s mind and acceptance, I think that’s the seven. But what struck me was that by the patients that I work with, who we were working with back then, most of them don’t do those things very well or very easily and particularly their relationship towards sleep. So they weren’t really a patient anymore. I mean they’ve had problems for years or months and letting go and trying too hard, a range of things. It really shifted my focus around. I think it’s fantastic. So I felt like I had a new thing in my bag of tricks.
Since then, of course back in that time, we weren’t actually – there wasn’t a randomised control trial that was done, but plenty of research per se. But leading up to a randomised control trial, which was a number of years ago now. I think 2013, 2014 or so. Jason Ong’s group.
Dr. Moira Junge: And I don’t know how many more have been done since then. That’s in a sleep world like insomnia-specific. But in general terms, in anxiety and depression literature, there was a plethora of randomised control trials with mindfulness. So it has unequivocal evidence that it works and that it’s effective. Yeah, I think it has been a really novel and yet not novel. It’s based on ancient principles.
It’s not new in so far as a lot of talk within the psychology world about traditional CBT and where mindfulness fits with that. It’s not so much different to what we do anyway in terms of challenging – we don’t say that we’re challenging cognitions, but we’re still – we’re trying to get people to basically really have a shift with how they view things. It’s a different language really. We will talk more about that with Giselle. I would love to pick Giselle’s brain about that.
Dr. David Cunnington: Great. Thanks for that insight. So to help kick us off and give us some insights into what is mindfulness from a couple of different perspectives, I had the chance to talk to Dr. Tony Fernando and you all have heard from Tony before in previous podcast episodes. Tony is a psychiatrist and researcher from the University of Auckland.
Thanks Tony. You’ve certainly got a unique perspective in mindfulness and lots of experience both professional and personally with mindfulness. I wanted to ask you in your role as a psychiatrist, how would you explain what mindfulness is and how would you use it?
Dr. Antonio Fernando: So as a psychiatrist, I see a lot of people who have mental suffering typically and depression, substance problems or in some others, sleep problems. The way I explain mindfulness to them is first talk about common situations of the mind for most people, which is that the mind is constantly busy, very ruminative, always spinning stories and that it has a tendency to focus too much on the future, about what will happen. I want this. I want that. All things should be different or for some of us, we tend to focus a lot on the past. Why did they do that? Why did you say that? I’m such an idiot. I don’t deserve this.
This type of thinking often leads to a lot unhappiness. So not living in the moment usually results in a lot of unhappiness in that life just passes us by. So the way I describe mindfulness to people is that it’s a state of learning how to be accepting in a very non-judgmental way our current emotions, our current thoughts, feelings, and temptations and being aware of the present.
That way of thinking if that can be developed, often can minimise if not improve our suffering. In terms of what situations they use it for, I use it for many situations clinically. So I use it for people who suffer from depression, people who have anxiety, people who use substance – even people with psychosis as well as patients who suffer all sorts of sleep conditions.
So I use mindfulness as one of the options to help them.
Dr. David Cunnington: That’s really interesting. Thank you Tony for that insight. So then just from a completely different perspective, as a Buddhist, how do you conceptualise what mindfulness is and how much do you use it in day to day life?
Dr. Antonio Fernando: I use the same definition. But in addition to the conscious awareness of the present and being accepting, non-judgmental, as a Buddhist, I view mindfulness as just one step of the eight steps that the Buddha taught us to liberate us from suffering.
So mindfulness is just one of the eight and that with mindfulness practice, it opens the heart for compassion and kindness and not just for stress really, which is what a lot of people typically want. But that mindfulness will lead us to universal truth and permanence, interdependence, things which might be a little too much for an average person to realise or to accept.
I try to be mindful and I do a mindfulness exercise or a mindfulness meditation sitting or walking. So normally we would recommend people to practice mindfulness initially by doing a sitting practice or a walking practice or a specific mindfulness practice for X number of minutes per day, which is what we call formal meditation practice.
Then there’s the other aspect of mindfulness practice, which is informal or actually living mindfulness in the day to day basis or if possible, on an hour by hour or minute to minute basis.
For me as a Buddhist, I try to live mindfully if I can remember. So this can be almost any situation during wakefulness from walking, to being with patients, to doing shopping, to showering, to driving, to eating. So doing activities in a mindful manner, which means being present, being accepting, not wishing for – not wanting for the situation to get different.
I mean there’s a difference between wanting something different in the future. But in terms of accepting the present, that’s the attitude that I try to develop.
Dr. David Cunnington: So those are interesting insights from Tony from those different perspectives. What did you make of that Moira?
Dr. Moira Junge: I love listening to Tony. He has got such an interesting perspective as a – being a Buddhist, being a psychiatrist, having the really mainstream medical model and then the other influencers although in mindfulness, it’s not meant to have any religious connotations of course. But it is embedded in ancient Buddhist principles. So we find that fascinating. I think that he’s a world leader. He has got some fantastic research in mindfulness. He’s unrelenting with his output.
Dr. David Cunnington: And incredibly thoughtful as well. You know, Tony just always is so reflective and so clever and I really loved his insights.
Dr. Moira Junge: Yeah, really valuable.
Dr. David Cunnington: As you say, the way mindfulness is practiced and the way we talk about it is really in a secular sort of form. So the way it’s being integrated into Western medicine and that has been a really – sort of a 30-year process and with lots of research. So we look then at research in mindfulness. I also spoke with Dr. Allie Peters who has worked with both you and I Moira and as part of her research, undertaking her PhD. As part of her PhD research, Dr. Allie Peters looked at mindfulness as a treatment for insomnia. So Allie, why should mindfulness be a helpful treatment for insomnia?
Dr. Allie Peters: So David, originally mindfulness is being used across the board for a range of health issues; autoimmune diseases, migraines, obesity, muscle pain, just to name a few. One of the things that really stands out with the way mindfulness can help with sleep is its impact on stress. So we know that stress is such a pervasive issue in modern society and it’s also an important consideration when reviewing the underpinnings of insomnia as well. It has got the potential to perpetuate and precipitate the condition and also we know that high levels of stress throughout the day make it harder for the parasympathetic nervous system to reach a state where sleep is likely to occur.
So taking that into consideration, we know that helping people to learn how to reduce that arousal level can help in terms of their ability to get into a sleep state.
Dr. David Cunnington: So to test out whether mindfulness works for insomnia, what did you actually do?
Dr. Allie Peters: So our treatment looked at a replication of a pilot study, which included a combination of mindfulness meditation, sleep restriction, stimulus control and sleep hygiene. Participants attended weekly group sessions for six weeks in that, learned how to meditate and learned a combination of really helpful behavioural techniques, so they can manager their sleep.
Dr. David Cunnington: You gave them some homework. So it wasn’t just come to the sessions. What did they have to do between sessions?
Dr. Allie Peters: They needed to do some things that helped train their brain to quiet down. Some of that was in different types of meditations, so they learned first of all how to attend to the present moment using a breathing meditation and they advanced up to – to learn how to meditate with their emotions and to be able to manage their emotions really effectively.
Dr. David Cunnington: Yeah, I find that part really hard. You know, even at the end of six weeks, we were running through the group of practicing these techniques. It takes a while.
Dr. Allie Peters: That’s correct. The treatment really is aimed to give participants the tools to be able to manage things on-going. So they may not be at a place where they had intended at the end of the six-week program. But they do have the resources and the tools and the skills and the know-how to be able to continue to improve their sleep and manage the hurdles that might come up day to day.
Dr. David Cunnington: So that’s what you did. What did you actually find when you looked at your results?
Dr. Allie Peters: So the results were very promising particularly on a sleep front. There were a number of different changes that we saw over time. The primary outcome measure was the insomnia severity index and we saw really quite large changes when it came to insomnia severity and they were maintained at the three-month follow-up period as well. There were also reductions in sleep latency, improvements in sleep duration and these were also reflected in the ActiGraphy results as well. So people were feeling better about their sleep and they were also reflected in the objective recording of their sleep.
Dr. David Cunnington: I really like the insomnia severity index or ISI as an outcome measure because it does capture people’s distress and how much of an impact insomnia is having on them day to day. How do you find that index?
Dr. Allie Peters: Yeah, I agree. I think we could have two people. One has the six-hour sleep and is distressed about it and would lead them to a high level of insomnia. Another person could be relaxed about it and feel differently about their sleep and that would reduce their ratings of insomnia. So it’s really important to note that the insomnia severity index is not just about the number of hours of sleep. But it’s also about their feelings towards sleep.
Dr. David Cunnington: That has been one of my learnings with insomnia research over the last 10 years or so is it’s actually – we’re looking more to change people’s relationship with sleep and how they feel about their sleep. Actually it seems to translate to greater benefits than necessarily getting them more minutes of sleep.
Dr. Allie Peters: Yeah, that’s absolutely true. Sometimes people are naturally short sleepers and so just being able to learn some of the principles of mindfulness in order to accept and understand what their body actually needs has led some people to have the same sleep, but to improve the quality of their sleep, to feel less stressed about it and to also put sleep into the background and enjoy their lives more. It’s really the aim of this, isn’t it?
Dr. David Cunnington: So that was sort of what we expected. We hoped to find a reduction in the insomnia severity index and people’s distress. What were some of the other things that maybe either were less expected or really changed the way you practiced based on your research?
Dr. Allie Peters: One of the other outcomes that I was hoping to find indeed was the reduction in cognitive arousal. So there’s a measure of cognitive and physical arousal, which we saw change over time. So really that gives us that assurance that mindfulness is able to impact on that racing mind, churning over thoughts from out the day, that people often report.
After doing this research, I was very thankful to have an alternative to cognitive behaviour therapy for insomnia, which we know works well. But in my clinical practice, I often see it being a challenge for some people and it doesn’t fit with some people’s problem areas. Having the ability to be able to teach some people to slow down has been really helpful and it’s also really interesting to be able to notice that people, once they get involved in mindfulness practice, they often notice that other areas of their life improve.
So it gives me a great satisfaction to be able to help people not only with sleep but also with other areas of their life.
Dr. David Cunnington: Congratulations on your research. You did a really great job and on passing your PhD.
Dr. Allie Peters: Thank you.
Dr. Moira Junge: That was a great interview with Allie, David. What were your reflections after that interview?
Dr. David Cunnington: Yes, I really liked that sort of reflection about how it has changed our practice, which made me think about that as well and certainly after participating in all of Allie’s research and going through those groups and doing the program myself a number of times, it really did change the way I would sort of think about what I’m aiming for in insomnia. It is much more changing people’s relationship with sleep, reducing distress. The sort of things that he has captured in that insomnia severity index, less about minutes of sleep.
Dr. Moira Junge: Yeah. It was more overall satisfaction and reduction of stress about sleep, stressing about it. Allie spoke quite accurately in the research reflected that people who really are better able to get a handle on the stress or distress they’re having around sleeping. There were changes in minutes of sleep, et cetera. But the most significant stuff was more the attitudes, et cetera. I remember sitting around because I was involved with the groups as well, observing quite a few of them. A lot of their qualitative stuff that might not be captured. Just the comments that people were saying. Like how they use it now in other parts of their life.
Dr. David Cunnington: Yeah.
Dr. Moira Junge: Not just with sleep. Just in their work stress and a whole range of other stuff that we’re using it for. Again, a bit of an emphasis on the principles. They really enjoy having some – a set of guiding principles around mindfulness.
Dr. David Cunnington: I will throw the question to you. I asked Allie that question and also alluded to it. So as a practitioner, what did you learn or what changed your practice after participating in that research?
Dr. Moira Junge: Probably what I have said earlier from that outset, when I was sitting in that auditorium in 2007. Just I think just having a very good understanding of teaching the principles of mindfulness because I found that sometimes people vary in their actual practice of what they – what they’re prepared to do, what they’re able to do. But if they understood the set of principles around it, in that mindfulness was around increasing your self-awareness, not so much about it’s a relaxant, et cetera. Even though we found that people were able to manage their stress better.
It’s a very subtle but important difference. But it’s not necessarily meant to be a set of relaxation exercises. It’s quite clearly around increasing your ability to be still, on purpose, in the present moment, without judgment, with an open mind and being able to sit with that a bit easier. That’s what we fleshed out with Giselle because that’s what’s not captured in the colouring books that are in the best-selling stands. Oh, yeah, now mindfulness – everyone seems to – it’s a buzzword. It’s a catch phrase.
Dr. Moira Junge: Yes, there are more books around that. There are parodies. People think it’s really funny almost. It’s a lot of depth that’s missed I think and that’s why we’ve got Giselle here today. So it’s my great pleasure to formally introduce Dr. Giselle Withers. She said a little hello earlier. Giselle is a clinical psychologist and a very good friend and colleague of both of us. She has got over 20 years of experience treating people with mental health and chronic health problems. Giselle has practiced yoga and meditation for over 25 years and recognising the personal benefits of that. She really has taken on herself to undertake further training and become a qualified yoga teacher and a mindfulness teacher. A very unique experience really to have someone who’s practicing as a clinical psychologist with all that other amazing qualification and training and philosophy really behind it as well. So she’s a great asset to her clients and to the field.
Giselle draws on the mindfulness principles in her therapy, in her work as a clinical psychologist and as you know, as I’ve talked about, she has recently developed this online mindfulness program A Mindful Way to Healthy Sleep and we would love to welcome Giselle and take further about that. So welcome Giselle.
Dr. Giselle Withers: Thank you. Nice to be here.
Dr. Moira Junge: So tell us a bit about mindfulness for you.
Dr. Giselle Withers: So I can talk a little bit about mindfulness in general initially. So mindfulness, you’ve mentioned this before Moira, but mindfulness is an awareness that comes from paying attention to the present moment with an open and non-judging attitude. So it’s letting go of thinking about the past and about the future and bringing your focus to the present moment, the here and now, facing life as it is. Unfortunately, this tends not to be the natural state of the adult human mind. Our default mode if you like is generally quite a distracted state.
Dr. Moira Junge: Yeah.
Dr. Giselle Withers: So our minds constantly wander off and we plan ahead and we ruminate other problems we’re facing or we daydream. I’m sure both of you, your morning routines, are quite busy, getting the kids off to school and getting ready for work. It’s very hard to be mindful in that morning rush hour.
Dr. Moira Junge: Absolutely.
Dr. Giselle Withers: So when we’re driving to work or riding to work, we’re already thinking ahead about the day and planning and you barely notice the journey. So we operate on a kind of automatic pilot. We’re eating breakfast, brushing our teeth, driving the car without really paying any attention to it. There was a study in 2010. You might have heard about the Harvard researchers asked more than 2000 volunteers from all over the world to use an iPhone app that randomly asked them across different time points of the day what they were doing and what they were thinking about and how happy they felt.
So when the researchers analysed the data, they discover that nearly 50 percent of the time, people are not focused on what they’re doing and their minds are all wandering off and they were thinking of other things. They also found evidence that the more that people were thinking about something other than what they were doing, they reported feeling less happy. So they found what the Buddhists have known for 2500 years. A wandering mind is not a happy mind.
Dr. Moira Junge: Yeah.
Dr. Giselle Withers: So the wandering mind is our default mode and to be mindful, we really need to choose to bring our minds back to what we’re doing and that takes effort. It’s not just about being present. It’s about the attitude that we bring to the moment. So it’s about being willing to face the world as it is, remaining open-minded, non-judging, curious and interested about the good and the bad and it’s not turning away from something just because we don’t like it. This will be relevant as we start talking about people struggling with sleep and insomnia.
Dr. David Cunnington: So we’re used to using CBTI for insomnia and I’ve talked a bit about that. How does mindfulness add to CBT for insomnia?
Dr. Giselle Withers: I think mindfulness adds in a number of different ways. But I’m going to briefly talk about three of them. So the first way is that mindfulness really does change your relationship to sleep in a way that’s much deeper than CBT. So this is where all the principles of mindfulness come into it. They really change the way that we approach any challenge in daily life.
So one of the key components of mindfulness is that it teaches us how to be more accepting of the present moment. So we can accept being awake without judging it. Then we have much less of an emotional reaction to it. So we’re not creating additional stress to the situation.
So in CBT, we teach people to – as you said Moira, change their thoughts and beliefs about sleep and this is certainly helpful to a degree. But sometimes people are already too distressed about not sleeping that they – the horse has bolted.
Dr. Moira Junge: It’s very hard, isn’t it?
Dr. Giselle Withers: Yeah, they just forget about using those skills. In mindfulness training, the idea is to practice during the day, so that becomes really natural to pause before reacting.
Dr. Moira Junge: Yeah, it’s a priming sort of agent, isn’t it? Gets them ready for it.
Dr. Giselle Withers: Absolutely. So then at night, people can stay calm enough to be able to use their CBT tools. So I think it works on a deeper level in CBT. Another principle of non-striving really adds to CBT. So in CBT, we talked to people about not trying so hard to sleep. But we don’t really give them the tools in terms of how to do that. So mindfulness meditation is training in the non-doing, so training in non-striving. That’s what we practice in the meditation. Being in the moment, not trying to get anywhere or achieve anything and just being with things as they are.
So when they discover how to do these in mindfulness practice, they can then translate these skills into letting go of striving for sleep. So all the other principles, accepting that you’re awake, non-judging the experience, letting go of trying to control sleep and then non-striving for sleep. Having the patience just to lie in bed and rest if you’re not sleeping and trust that the body will take care of itself and that sleep will come in its own time. So the second way that mindfulness adds to sleep, I don’t think CBT is particularly good at helping those people with a very overactive mind. It’s not necessarily about unhelpful thoughts about sleep. They’re thinking about work. They’re thinking about other things.
Dr. Moira Junge: Random monkey mind chatter.
Dr. Giselle Withers: Absolutely. They can’t switch off their mind. So relaxation in CBT helps to some degree. But I think this is where mindfulness really comes to the fore. Mindfulness brings to CBT a new core psychological skill called “metacognitive shifting”. So metacognition is the ability to observe our own thoughts. It’s the thinking about thinking. The power of the skill is that when we start observing our thoughts, we’re no longer in the thoughts stream. So we’re standing back and watching thoughts go in and out of our mind. So the analogy for this is standing on a platform at a train station and watching the trains come and go without getting on board. The same way, we watch thoughts come and go without getting on board and getting lost in the thought.
So once you start watching thoughts, you realise that you can let them go. So in the middle of the night, when you find yourself thinking about work or a difficult relationship with someone, the metacognitive shifting means that you can let the thoughts go and bring your attention back to the present moment.
The third way that mindfulness adds to CBT is it really helps to reduce stress and hyper-arousal. So the less stressed we are, the better that we sleep. Mindfulness does this by building awareness. This is what you mentioned before, Moi.
CBT reduces stress through relaxation training and typical stress management skills like taking breaks and exercising, but mindfulness builds the awareness that’s needed to recognise the signs of stress and tension. If people don’t remember to check in with themselves, they don’t notice the signs of tension. They don’t realise that, oh, I need a break. Mindfulness also helps people to recognise the signs of sleepiness. It’s time to go to bed.
Dr. Moira Junge: Because often that’s a big thing is to jump in here. People use the word “tired” a lot. I will go to bed when I’m tired. We talk about sleepiness and they haven’t really – in the first session at least, sometimes they haven’t recognised what sleepiness is for a long, long time. They haven’t’ had that feeling. So the mindfulness training and that self-awareness increases their awareness to even know to help with their CBT adherence about going to bed when you’re sleepy and tired rather than just because it’s 10 o’clock. I think it’s a fantastic tool for really enhancing that ability to even know what sleepiness is.
Dr. Giselle Withers: Yes. So as Jason Ong said in his book Mindfulness-Based Therapy for Insomnia, mindfulness creates the space for sleep to come back.
Dr. David Cunnington: I like that.
Dr. Moira Junge: Yeah, that says it all, doesn’t it?
Dr. David Cunnington: So thanks for all that fantastic insight, Giselle. It sounds like it’s a lot of work. Not something people are going to learn just instantly. So how can people learn mindfulness or develop skills in mindfulness?
Dr. Giselle Withers: You’re right. Mindfulness is a skill and takes effort to learn initially. But once it’s mastered, it does become a very natural way of being. So the best analogy for learning mindfulness is that it’s like learning a new language. So it takes time to learn. People do often give up learning mindfulness quickly because they feel that they can’t do it.
Dr. David Cunnington: Yeah.
Dr. Giselle Withers: So just as you wouldn’t expect to be fluent in Spanish in just a few weeks, it does take a long time to practice and you need to practice regularly. It’s best learned with a skilled teacher and doing a structured course. So I would recommend to people to do a mindfulness course. Without a clear strategy, if you’re just listening to CDs or audio recordings, it takes a lot longer to learn.
Dr. David Cunnington: That’s often what we’ve seen with clients who say, “Yeah, I tried mindfulness. I gave that a go. I listened to those things and my mind was still racing and I couldn’t focus.”
Dr. Moira Junge: Or they say it doesn’t work for them. What do you say to someone who says, “Oh, I tried that and it didn’t work”?
Dr. Giselle Withers: I would say that there could be some misunderstanding about mindfulness. So people often think that the idea is to make their mind go blank, to get rid of thoughts and have this blissful state of zen. I would say that’s where a teacher can be really useful to help just dispel some of those myths and misunderstandings and to help people to recognise that it’s not about making your mind go blank. It’s really just about noticing when the mind has wandered off and to be able to bring your attention back to the present moment. We might need to do that hundreds of times in a meditation practice and that’s the practice.
Dr. Moira Junge: And it’s OK, isn’t it? You will have that awareness that you’re going off track.
Dr. Giselle Withers: That’s right.
Dr. Moira Junge: That’s OK. It’s not wrong or right.
Dr. David Cunnington: So what are the ways people can access that type of structured program?
Dr. Giselle Withers: So first I would absolutely recommend face to face group courses. I know I’ve just launched an online course, but that’s with people who can’t access face to face group courses on mindfulness and CBT and insomnia. So group classes, really it’s – they’re widely available now. So you can Google search a local area and look for a mindfulness-based course. That might be an eight-week program which could be an MBSR type program or it might be a yoga centre offering a mindfulness course.
Dr. Moira Junge: These ones presumably aren’t – they’re not flagged as ones for sleep specifically. They’re just broad and general but people should have an understanding that it would be useful for all sorts of aspects of the struggles they’re having, whether it’s sleep or other things.
Dr. Giselle Withers: But if you would just like to start with some general training and mindfulness, then yeah, you could really do any general mindfulness course. I should say as well that a lot of the Buddhist centres do offer mindfulness training as well, if you’re interested in that kind of spiritual component as well.
Dr. David Cunnington: So there are groups that run at Melbourne Sleep Disorder Centre, facilitated by Dr. Allie Peters and some by yourself Giselle as well. So these people are looking for a face-to-face group and live in Melbourne. That’s one option. But as you said, for people who can’t access readily those face-to-face groups or are looking for that specialised mindfulness and sleep or insomnia focus, an online program can be a really good option. So tell us a bit about your program, Giselle.
Dr. Giselle Withers: Yeah, that’s exactly why I did develop this online course is we have almost three times the number of people interested in doing the course at the Melbourne Sleep Disorder Centre that can actually able – that are able to attend.
Dr. David Cunnington: Yeah.
Dr. Giselle Withers: So with this course, people can join the course from any location, from anywhere in the world and access high quality training and mindfulness and CBT for insomnia.
So there are six modules in the course. They’re all delivered completely online through our website, AMindfulWay.com.au, and students complete one module a week for six weeks and each module consists of a series of video lessons and practical exercises, which takes about an hour to two hours to complete.
Between each module, students are encouraged to develop their skills by practicing mindfulness meditation with some downloadable audio recordings and they make behavioural changes related to their sleep.
So the course is structured in such a way that students are building on skills learned in previous modules. So by the end of the course, people will know what’s causing their insomnia and will know how to reduce or avoid activities that interfere with their sleep. They will know what their optimal bedtime and get-up time will be and they will know how to relax the body, how to quiet the mind and reduce unwanted thinking.
I also learned how to cope better with daytime fatigue and prevent – I guess most importantly prevent chronic insomnia from developing again in the future.
Dr. David Cunnington: That sounds fantastic, Giselle. Some of the research around online programs shows that staying engaged and getting to the end of learning the skill can be an issue. You’re around that. So what have you built into your program to help people and support people in staying engaged?
Dr. Giselle Withers: So I’ve designed the course to be as interactive and as practical as possible. So as people go through the course and they practice their exercises, they will be able to complete reflective practices through a workbook that I’ve developed for the course and I will also be running a number of live Q and A webinar sessions during the six weeks, to allow participants to raise any questions and will also provide them with an opportunity to learn from other’s experiences.
Dr. Moira Junge: Right. Yeah, that’s really important. Sounds great.
Dr. David Cunnington: So now we’ve talked about mindfulness, Giselle. I want to throw an exercise. Give us an experience of what that is actually like.
Dr. Giselle Withers: Well, I’m aware that people listening to this podcast are probably multitasking. They might be walking the dog and listening or driving the car or possibly cooking. So I’m going to lead a practice that won’t involve closing your eyes because I would like you to stay aware and stay safe through this practice.
So I will chime these meditation bells just to mark the start of the practice. So if you would like to join in this practice, let’s begin by bringing attention to the body. So whether you’re standing or walking or sitting, just noticing the sensations and your feet as they contact the ground.
If you’re lying down, noticing the sensations of pressure where your body contacts the surface upon which you’re lying and just feeling your whole body in this position. Noticing sensations in the hands and paying attention to the sensations around the face. Noticing the sensation of the breath just flowing through the body.
So as you breathe in, really feel the breath as you breathe in and feel the breath as your breathe out. So you’re bringing your full awareness to this moment. If your eyes are open, just notice the colours, things that you see around you. You might notice sounds around you. So that you’re bringing again a full awareness to all your experiences right now.
Dr. Moira Junge: That was fantastic, Giselle. Thank you. I’m just coming back up to the surface level at which we operate. I’m getting back into the zone. Thank you so much for giving all your insights and information and experience. So people will want to know a bit more and dig a bit deeper into the world of mindfulness, of what’s available. Dave, you’ve got some hot tips?
Dr. David Cunnington: Yeah. So there are a whole list of resources that we will put on the website. There are some posts on the SleepHub site, specifically about mindfulness, some where I’ve actually interviewed Giselle and we’ve talked about mindfulness and how we use it. By all means, check out some of the other sites. So the University of Massachusetts Centre for Mindfulness is a good resource from where a lot of the research has been done, showing how mindfulness works and a book that we all use called Full Catastrophe Living by Jon Kabat-Zinn who’s really one of the doyens of this area in the use of mindfulness in Western medicine and of course check out A Mindful Way at AMindfulWay.com.au, Giselle’s online course. That’s a really fantastic course based on really good research and good evidence and Giselle’s extensive experience in this area.
So as a guest co-host Giselle, we’re going to pick your brain for a clinical tip. So what’s a pearl for clinicians working with people with sleep problems?
Dr. Giselle Withers: So I think to be aware that if you’re encouraging people to take up some mindfulness meditation practice, people do very quickly give up because they notice that their mind wanders all the time. They’re actually often quite alarmed at how many sorts they’re having during a practice. That can be quite confronting. So I think reassuring clients that this is completely normal and it doesn’t mean they’re failing at the practice and the fact that they’re aware of their thoughts is actually a really good sign of progress.
Dr. David Cunnington: Right. Thanks very much for that tip. So we will move on to Pick of the Month. Moira, what’s your pick for this month?
Dr. Moira Junge: My pick of the month is just a local group of researchers at a university in Queensland. They’ve published in the International Journal of Psychology and Behavioural Sciences and they looked at sleep quality and mindfulness as predictors of depression and anxiety and stress and that was – I just want to draw the listener’s attention to that and have a look at it and put a link to it in our show notes. I just want to give a shout-out really to local research that has been published and just so wonderful for people who aren’t necessarily part of the sleep world, but to be looking – knowing that’s actually an important predictor to look at sleep quality and it’s a predictor of depression, anxiety and stress. Of course the spoiler alert is that sleep quality is indeed a really important factor not surprisingly. What about your, Dave? What’s your Pick of the Month?
Dr. David Cunnington: So mine is also a journal article. We’re both going to be geeky. So mine is a journal article that was published in Nature Neuroscience called The Neural Correlates of Dreaming and it’s a pretty geeky sort of article about looking at how the brain works during dreaming sleep. But the take on the story is that a group under the supervision of Giulio Tononi who’s really a leader in regional sleep and how the brain works during sleep have found there’s a particular part of the brain that operates when we dream and that’s independent of REM, non-REM and can actually be also active when we’re awake. So really it helps us better understand that dreaming is not just about REM sleep. You can have non-REM dreams and you can daydream and you can have dream experiences on the border of wake and sleep. So yeah, really nice to see the neuroscience, fitting with some of the philosophy we talked about in an earlier podcast, about different types of dreaming and different types of dream states.
Dr. Moira Junge: Sounds great. What about you, Giselle? You’ve got a Pick of the Month?
Dr. Giselle Withers: Staying on topic, if any clinicians are interested in reading and learning more about mindfulness-based therapy for insomnia, then I really recommend getting a copy of Jason Ong’s book that he published this year calledMindfulness-Based Therapy for Insomnia. It’s an excellent text and I wouldn’t be surprised if it gets used in universities down the track for sleep subjects.
Dr. Moira Junge: Yeah, I’m sure. Yeah, it’s excellent.
Dr. David Cunnington: Yeah, I agree. Really great book. Even though we had a lot of familiarity with Jason’s work, because that’s a lot of the protocol that we used, still learned so much from reading that book. So thanks for all those tips. Coming up in the next few months, things to look out for are the International Sleep Conferences that we’ve been talking about.
So the Sleep 2017 meeting in Boston in early June and the World Sleep Congress in Prague in October as well as the Sleep Down Under meeting in Auckland at the end of October. Our next episode will be on June 5th. So look out for that one and of course check out A Mindful Way from our guest host Dr. Giselle Withers, and thanks for joining us, Giselle.
Dr. Giselle Withers: You’re welcome. Thank you.
Dr. Moira Junge: Thanks so much. And thanks all for listening and remember, if you have any suggestions to email us at email@example.com and particularly if you like the podcast, review us on iTunes or subscribe via any podcast catcher or via the Sleep Talk app.
Dr. David Cunnington: Thanks everyone.
This podcast is not intended as a substitute for your own independent health professional’s advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition.