The Practice of Therapy

Dr. Kevin B Handley
Okay. I'm Dr. Kevin Handley. I'm a licensed clinical psychologist in Virginia. And I'm happy to be on the practice of therapy talking to Gordon about the importance of sleep for us in our clients.

Gordon Brewer
Well, hello, everyone, and welcome again to the podcast. And I'm so glad for you to get to know today. Dr. Kevin Handley, welcome, Kevin.

Unknown Speaker
Thank you appreciate it.

Gordon Brewer
And Kevin is a clinical psychologist up in the Fredericksburg, Virginia area. And Kevin has a start with everyone. Why don't you tell folks a little more about yourself and how you've landed where you've landed?

Dr. Kevin B Handley
Well, it's kind of a long journey. I've been doing this for a while now. But I guess I like to tell people, I like to do a lot of different things. So I enjoy being a private practice clinician, but I also enjoy being a community college professor. And I try to mix up those worlds as much as possible. So after graduating from my internship, I moved to the Fredericksburg area with my wife. And we raised our family here since about 1997. And during that time, I've worked as a college professor, I've worked in community mental health, I've worked in hospitals, worked in private practice. And I've always just really loved giving psychology away, I was trained as a cognitive behavioral therapist. And really, from the get go of my training, and my internship, you know, any opportunity ever had to do workshops or to teach people things. And even on my internship, I was teaching medical residents. I've just always loved it. And I think that comes through in my community college teaching, and in my practice, as well. So

Gordon Brewer
yeah, yeah. So I love that because I feel like a big part of what we do is therapist, we have a term for psycho education that we call it and but I think a big part of it is, is just teaching people things that a lot of us in this field maybe take for granted and don't realize that it's something that probably the public doesn't generally know.

Dr. Kevin B Handley
Absolutely, absolutely. It's certainly a huge part of cognitive behavioral therapy. But that's, that's one of my, the reasons I'm so passionate about sleep, because it's so important. And it's it's amazing that people just don't know about it. Although it's gotten a lot more popular in recent years, but a lot of people who just need some education about what healthy sleep looks like.

Gordon Brewer
Right, right. You know, what, as we were chatting a little bit before we started recording, you know, sleep is something that has become really important for me over these last several years, because I think, and I'm, I'm looking forward to hearing your thoughts on all of this. But I think one of the one there was a time period where you we were all told that we have to push harder and get up earlier and do all these things and you know, burn the midnight oil and all that sort of thing. And if you did those things, then that that was a mark of success. But it's really counterproductive. So yeah, so how did how did you become passionate about this topic?

Dr. Kevin B Handley
Well, I agree with you about the, the shift that's been happening with sleep. And that idea that we just need to go Go, go, go go. My argument is that begins in childhood. I always tell people, if you're a kid therapist, and I'm really not a good therapist, but if you work with kids, particularly adolescents, your best bet is just to assume that they're sleep deprived to some point, because of the way we can from school start times which is changing, you're starting to see a shift in that. I think COVID has had a lot to do with that people have realized the benefits of maybe not running so hard and slowing down a little bit and sleeping. But I got into this kind of in an odd way that is probably 2007 2008. I had three young children or could fit the backseat of my car and car seats at that time. And

Speaker 3
people would often talk about

Dr. Kevin B Handley
bedtime battles and how difficult it is with their kids and so on and so forth. And we just never had that in our household. Now, the reason we never had that in our household is because my wife ran the show and she is very smart about sleep. And she basically had everybody on a schedule, which I didn't recognize it at the time. Honestly, I didn't pay that much attention to it because she had that locked in. Basically, she was running the schedule of the household around our children's circadian rhythms, so that when it was time for bed, the kids were ready to go to bed, which is the best way to do it. People often talk about having to chase their kids around to get them to go to bed and I always tell people in practice, we never want to chase sleep. We want to set up our life so that sleep comes relatively naturally. And it will if we do the right things during the day. So it was about that time that I had a client, I tell the story often that we had a successful treatment for panic disorder, because I specialized in treatment of anxiety disorders still do. And he had a real bad driving phobia. And we had overcome that and was our last session, we were wrapping up and he was moving out of state. And this is before telehealth. So this is probably the last time I was gonna see this guy. And we're talking about it. And for some point, he said, I'm so glad that I'm able to drive again. I just wish I could sleep. Wow. And I was and how did I miss it? Well, I missed it, because I never really asked about it. And at that time, I was operating under the assumption that a lot of therapists are operating under, which is still the predominant belief today that if you treat the presenting problem, any sleep problems that are accompanying it will just resolve themselves. We now know that's not true. Yeah, it's not true. So all those things, those things kind of came together at the same time. And I just got really thinking about sleep. And I started researching it and found out well, yeah, that the treatment of sleep is really not that complicated. It's just that we're not talking about it. And then when I started asking my community college students, I'd often get in community college, we get students who are a little bit older parents, things like that. And they're always talking about sleep. But then I started asking students in general, and today when I asked students on the first day of class, because I give them a heads up, you know, informed consent, we're gonna talk a lot about sleep and art printables, a psychology class. Raise your hand if you feel satisfied with your sleep. And, you know, maybe two people out of a class of 30 their hands go up.

Unknown Speaker
Okay, you know, you'll have sleep. Yeah. Yeah. So yeah, so

Gordon Brewer
what what have you learned about? How do we, how do we fix sleep problems? For better way of putting it? I mean, it's, you know, I think, I know, I've had on and off battles with sleep over the years, as far as you know, kind of the, the, to be transparent here. Typically, one of the things, you mentioned the circadian rhythms. And I've realized that if I don't, if I don't go to bed, when it is time for me to go to bed, my body tells me it's time for go to bed, and I push it through, then I have trouble going to sleep, and then battle it all night long. Or it seems like I battle at all like night long. So what are you? What's your research teaching?

Dr. Kevin B Handley
Well, what research teaches us is we've got very effective treatments for sleep, and they tend to be very brief and focused. We can usually for you know, when I want to talk about sleep, I talked about sleep, health, what healthy sleep looks like, which is applicable to everyone and your sleep story is pretty typical. And insomnia is a little bit of a special case, but very, very prevalent. And so what we know a lot about how to help people sleep better comes from research on the treatment of insomnia, which is essentially figuring out how to help clients move their behavior in a way that is lines up with their circadian rhythms, doing the right things during the day, so that they can fall asleep at night. And unfortunately, we confuse this and we make it way too difficult. It's a bit of a tricky thing, because sleep is a biologically driven process. However, it's one that we as humans override all the time. So I'll let me get one more thing done. Okay. You know, or let me you know, get up in the morning to go to school or to go to work when my body is really telling me I need to be sleeping? Well, I'll just override that with an alarm clock. So how do we wake up well, so that we have enough energy throughout the day, and then fall asleep at night. This is basically what cognitive behavioral therapy for insomnia. It's usually a four to six session protocol that happens over four to eight weeks. And it is remarkably effective at helping people sleep better. And when I'm talking to clinicians about this, I tell people all the time, you don't have to become a sleep specialist. I mean, I've done hours and hours and hours of training and supervision and cognitive behavioral therapy for insomnia. But if, you know we can get people just asking our clients a little bit about their sleep health. You know, people forget that the primary symptom criteria for the diagnosis of insomnia disorder is a dissatisfaction, dissatisfaction with the amount or the quality of sleep, you know, and so if we start asking people about Sleep, which unfortunately we don't, then we have the opportunity to make a big difference, not just in the patient's sleep, but also in the whatever they're coming to treatment for. You know that and there's what we call a dose response relationship between how much you attend to sleep, and how much better it gets. So I tell people, you know, can you do something with your clients? Can you just ask them, you know, you don't have to become a sleep specialist. But once you uncover a few things, then you might find something to work on in counseling, because a lot of people just don't know. Right? Some of its most of us have become so accustomed to being so tired all the time and told well, that's just the way that it is. Or even worse, we wear it as a badge of honor. That they don't realize is another way.

Unknown Speaker
Yeah, yeah.

Gordon Brewer
He said something I want you to maybe repeat it. You said dose to sleep ratio? Is that what you said? Or what did you how did you say that?

Dr. Kevin B Handley
Yeah. I said there's a dose response.

Gordon Brewer
Oh, okay. Yeah, yeah, say, say more about that. I'm really curious about that. Sure.

Dr. Kevin B Handley
So when we talk about sleep health, we talked about things like regularity of sleep, right, feeling satisfied with your sleep, right alertness, you know, sleep efficiency, which is the amount of time that you spend in bed versus awake. sleep duration, when the total duration of your sleep is probably the least interesting of the variables, even though that's the one that people obsess about. So if you help people in any one of those areas, you know, there's lots of different points at which you can intervene to help a person sleep. What research shows is that, you know, if you can just intervene anywhere at all, number one, people improve, but also things that are associated with sleep will improve most notably mood. And, you know, we all have clients who come in for depression. And, you know, if we can work on their sleep, we're also working on their depression. And so I tell people is a great way to help improve your clinical outcomes, is to just ask about and then do a little bit of work on sleep.

Unknown Speaker
Yeah, yeah.

Gordon Brewer
Is there such a thing as too much sleep?

Dr. Kevin B Handley
There is there is it's generally not something that people need to worry about. What tends to happen is that people, whenever we wake up in the morning, we have this transition from sleeping to awake, and where we feel a little bit groggy, and we're slow to move, and we call that sleep inertia. And what people will often do when they're exhausted is they'll sleep an amount of time that's excessive compared to their typical sleep. And as predicted, they'll wake up the next day, and they'll have this terrible sleep inertia. Some people compare it to being hungover. You know, people, it's just harder than others to wake up in the morning, depending on the individual and their biology. But people often take from that is, see I slept too much. I don't feel good when I woke up this morning, because I got eight hours of sleep last night. So that might not actually be the case. Yeah, so need to differentiate particularly in depression. You know, are you sleeping an excessive amount? Or are you spending an excessive amount of time in bed? Those are two very different things. And for people with depression, usually that they're spending an excessive amount of time in bed. somni usually accompanies depression. hypersomnia can accompany depression, but it's the rare form.

Gordon Brewer
Right, right. So if you if you were to outline for us kind of, maybe I know, everybody's going to be different in the way they approach this. But if you were to think about kind of a typical treatment plan for somebody struggling with seat, sleep problems, what, what does that look

Dr. Kevin B Handley
like? Well, you know, what I always do is I tell people think about the transtheoretical model, and think about how we work with all of our clients. Right, we may have the best idea ever for what will help a particular client when they walk in the door. However, we also just have to meet a client where they're at. So you also have to do I think that with yourself as a clinician, is you have to do what you're comfortable with. Right? And start with the simplest thing that you think that you're willing to do. So the first step is just to ask about sleep. Make a part of your take, if you don't have a question in your intake packet, about sleep satisfaction, that's the easiest thing to do is to ask about sleep satisfaction. And then when I teach in my workshops on this, for clinicians who don't want to be sleep specialists, but just want to get better working with clients, I basically suggest four different steps. One of the first of which is creating your sleep space and a great sleep space should be cool, dark and quiet. I always tell people to start with that one, even though it's not the probably the most effective way to improve sleep, but it's often one that you don't get a whole lot of pushback on. It's pretty easy for people to do. You know, can You get extra excess light out of your room. And most people are like, Well, yeah, I can do that, you know, is your room comfortable, you know, if they're not comfortable, then let's talk about that. And some simple changes to the environment can often have a pretty profound effect. The other is, next step is to create your sleep schedule, which is incredibly important. However, most of us grew up being told go to bed, go to bed, you got to sleep at this time. And they think about I gotta get up at this time. So when do I need to go to bed, and it gets, you want to basically try to create a sleep schedule that's roughly in line with your circadian rhythm. Circadian rhythm, and we tell people, we don't choose a bedtime, the rule of thumb, and the effective treatment of sleep is wake up at roughly the same time every day and go to bed when you're sleepy. And we help clients differentiate between sleepy and tired. People are often, you know, for lots of different reasons, sleep deprivation, could be one of them. Stress could be another one, all kinds of different reasons. But sleeping means that what you were describing earlier, you get to that point where it's like, oh, there's a tipping point. And that's when I should go to bed. So we want to go to bed when you're sleeping. That's the sleep schedule. Right? Unfortunately, when we've got kids going off to school at ages at times in the morning, that biologically, they shouldn't be sleeping, they don't really know how to create a sleep schedule that works for them.

Gordon Brewer
Right? Is it possible for somebody to change that up? I mean, if you know, you know, I guess, for lack of a better way of putting it tweak your circadian rhythms

Unknown Speaker
where people try.

Dr. Kevin B Handley
Generally no, and this is one of the bits, one of the principles of working with sleep is that sleep is a biological process, that in most people, most of the time, nothing is broken. There's no biological problem. It's just that we've been trying to live life in a way that's inconsistent with the way our biology works. So the goal really, is to bring your schedule in line with your sleep as much as you can. is organized around early risers? Not organized around night house? Yeah. And us we will change over time. So you can't really change your circadian rhythm that much, but you can, you know, change your schedule a little bit to compensate for it.

Gordon Brewer
Yeah, the I work with a lot of folks are have worked with a lot of folks in my practice with folks that work shift work. And that just is I just My heart goes out to them. Because it's just, you know, they come in, they're exhausted, they're depressed. And, you know, and, and it to me, it's obvious is because they've got their days and nights mixed up. And, you know, and having to push through at night and that kind of thing. Yeah.

Dr. Kevin B Handley
It would be wonderful if you could take on a shift job, and eventually your circadian rhythms would adjust to your behavior doesn't happen. So shift work are always going to have sleep issues. And the reason for that is because sleep is the sleep drive is really mediated by light exposure. And you just can't get enough of it when you're sleeping during daylight hours, unfortunately. Yeah, yeah, just what keeps us up and alert and going, you know, all day long. So if you have a sleep schedule, where you're waking up at roughly the same time, every day, you get exposure to light during the day, however, we're going all day. And so in the evening, this is when we need to start to wind down. And this has to be you know, step three, which I call wind down wisely. We, we have unfortunately, shamed people about using screens and turning off the TV and people are trying to avoid light at all costs. You know, that's, that's all great if you can do that, because most people are not going to put down their phone. They're just not the problem in the evening is too much arousal. And so we can do ask it clients to do something in the evening to reduce overall levels of arousal, so that it's easier to notice that moment when your brain goes, Hey, time to fall asleep, that it makes the process of transitioning from wakefulness to sleep so much easier. People struggling to fall asleep, winding down to reduce physiological arousal is a great idea. Not to chase sleep, but to reduce arousal so that sleep comes a lot easier. Right,

Gordon Brewer
right. Yeah, that makes so much sense. You mentioned several times sleep satisfaction, how can how can people best measure that for themselves? Do you think

Dr. Kevin B Handley
the easiest way is just to ask them, ask them if they're satisfied with their sleep? And what you're going to find are a couple of different answers and then sometimes it requires a little bit more digging around. Some people are satisfied with their sleep. But they, you know, if you can think about the transtheoretical model they be might be in pre contemplation where they just don't, they're just not aware of the fact that they're sleep deprived, and a lot of people aren't. So they may say, Yeah, my sleep is fine. But they may be starting to have some health issues as a result of not getting enough sleep, or they might be engaged in dangerous behavior, like driving, while drowsy, when there's, some people are satisfied with their sleep, and it won't be eight hours a night. And there's no set rule as to what people need. You know, it's, I always tell people that seven, seven and a half hours ish, depending on right, all right, if you're waking up in the morning, feeling refreshed, and you have enough energy to live a satisfying life, and you fall asleep relatively easy and stress free at night, you're probably going to have a high degree of sleep satisfaction. Right? Now, for people who are not satisfied, you'll probably find one of two things. One is that they they have terrible insomnia, they know they have sleep problems and don't know what to do about it. Or they're on a schedule where they have no clue how to fix the problem. That's what therapy is for, we can help them, you know, adjust all those things. The other type of dissatisfaction you'll find is when people complain about not being satisfied with their sleep, but they're suffering from something that we colloquially refer to, as you know, sleep that dissatisfaction syndrome, or ortho SAAM. Nia we sometimes call it, but these are individuals who, because we've preached the importance of sleep so much, are now tracking it on their phone. And they're, they're always up in the morning and look at their phone, and it's like, oh, no, I didn't get enough REM sleep, I didn't get enough. And your phone is not going to be an accurate measure of what your sleep quality is. And so they start worrying about their sleep. But when we actually assess their sleep in a reliable manner, which is using a sleep diary, having people record their sleep, and they wake up in the morning, it's the gold standard for how we assess sleep. We look and you're like, Well, you know, you're falling asleep relatively easy. You're alert throughout the day, you're waking up refreshed. I don't think you have a problem. And so sometimes they're worried about their sleep when they don't need to be.

Gordon Brewer
Yeah, yeah, that's helpful to know. I was just thinking now, I've got my Fitbit that I wear to bed so I can score my sleep and tag count it. I can't get above an ad. But no. All right. All right. Yeah. So

Dr. Kevin B Handley
what do you need to know those numbers? I said, no, no. In fact, I really want you looking at those numbers while we're working on your insomnia. All right. All right, an online form you can fill out or I got paper and pencil, you can fill out that that's what we'll use. Right, right, and compute from that what we call the sleep efficiency, how well are they falling asleep, staying asleep, we calculated nap time, things like that. And so using a very simple spreadsheet, or software, the the treatment is pretty data driven in terms of when you should be getting into bed when she should be getting up, you know, those types of things? It's clinical judgment as well, of course.

Gordon Brewer
Right, right. Well, it's, this is fascinating stuff. Uh, Kevin, what one question I do have is, if somebody you know, a common complaint that you hear from people is, is that I go to bed when I'm supposed to, but I can't turn my brain off. You can't stop thinking about things in it. Any tips on that for folks?

Dr. Kevin B Handley
Absolutely. So worrying, instead of falling asleep is one of the most common barriers to falling asleep. So there's essentially two strategies, two approaches to working with that. Number one is what I mentioned earlier, that's often a problem of too much physiological arousal, that the person needs to find a way to kind of wind down in the evening. And or increase their activity level during the day. Right, they're not around enough. You have to sort of spend expend your energy during the day in order to have enough, you know, depleted energy at night to fall asleep. We go into details of that when I teach it, but that's what you need to do, you'd have too much physiological arousal in the evening. The other thing is just the problem of worry. And for that you treat it like any other worry problem that you you know, whatever your methodology of doing that, I mean, I usually have people take more of a cognitive therapy approach at people jot down their worries in the evening, you know, and then engage in some problem solving around those. It's interesting that you know what, a clinicians will consult with me if this and they'll say I don't my clients worrying and better to do so what do you usually do for worry? Oh, well, I would do X, Y and Z. So why aren't you doing that here? Well, this is a sleep problem. So that's totally different. Well, no, it really isn't. So yeah, whatever whatever you find works for worry do it up if you know, something to reduce physiological arousal, which can be anything that works for you and your client.

Gordon Brewer
Yeah, this is great, because

Dr. Kevin B Handley
we don't want you using substances.

Unknown Speaker
Right?

Gordon Brewer
Right. Yeah. And that was another one thing I was I was thinking about was, you know, things like melatonin or sleep, in a sleep, over the counter sleep medicines and that sort of thing. What are you finding around those things?

Dr. Kevin B Handley
The research really doesn't support using any of those, certainly over the counter sleep aids, and not melatonin. There are some specific cases in some children, particularly children on the autism spectrum, who, for reasons not quite understood, might benefit from melatonin. People who are jetlag can benefit from the use of melatonin, but more most over the counter melatonin that people buy, it's really not having an effect. And it's not an effective treatment. Concerning because people will try those things because they're just trying to sleep and they're doing everything that they can think of. But they're, you know, instead of getting what actually helps they're spending time on something that's not going to help very much in the big scheme of things. Yeah,

Gordon Brewer
that's, that's good information. That's good to know. Yeah. Well, Kevin, I have to be respectful of your time. And this is, I know, we can talk about this all day long. This is fascinating. nating stuff. tell folks how they can get in touch with you. If they want to find out more about your workshops and the things that you're doing and that sort of thing. The easiest

Dr. Kevin B Handley
thing to do is just to go to my website, just Kevin handley.com ke vi n h a nd le y. My workshops are posted there. They're all CE workshops. And I've got a couple of work. I've I'm always running workshops for sleep, but I'll run them on other things as well. One of the things I love doing I love teaching, that's like the education portion. Right.

Gordon Brewer
Right. That's great. And we'll have links here in the show notes in the show summary for people to find those things easily. So well. Kevin, I hope I hope we can get you back on the podcast. Again. This was a great, great conversation and, you know, you've given me some things to think about with my own sleep patterns.

Dr. Kevin B Handley
Well do it for yourself and then do it with your clients. Yes,

Gordon Brewer
sounds great. Thanks again.

Unknown Speaker
Thank you, Glen. Appreciate it.