Transcript...

In this episode, you will learn:

  • Learn what is actually keeping you up at night and that your belief that you have insomnia is really working against you!

  • Learn better sleep hygiene and when to use the bed versus other furniture for times of rest

  • Learn what pain reprocessing therapy is and how it can help you

  • Learn how CBT-i can help you learn how to fall asleep and stay asleep

Episode 22: Sleep Hygiene and Pain Reprocessing Therapy

Katie Wrigley: This is the pain changer podcast episode 22. This week Annie Miller joins me to chat about pain reprocessing. Using her experience in psychotherapy, Annie can help you change your thoughts and patterns around insomnia and chronic pain. I hope you stick around. That's coming up next. 

Before we dive into our chat with Annie, I wanted to call out this week's listener of the Week. This week, it is Cowgirl Mimi, who says “The pain changer is so important. Katie goes right to the heart of it and is putting out life saving, healing information that's much needed by so many. Honored to have shared a podcast with her, great host, great podcast.” Thank you so much Cowgirl Mimi, I loved having you on the show. Please send me a DM on Instagram to @coachktdubs, and let me know you heard me call you out. I will send you a gift as my thank you for your support and your assistance and spreading the word that chronic doesn't have to mean permanent. 

Now for this week's show, it's so funny. Just a few episodes ago, I was asking for a sleep expert. Maybe if I had paid more attention to my content calendar, I would have realized I already had one lined up. Without further ado, I'd like to introduce you to Annie Miller. She is a licensed psychotherapist in private practice in the Washington DC area. She's the owner and founder of DC Metro sleep and psychotherapy. Annie specializes in working with sleep disorders, chronic pain and trauma. Annie uses a variety of evidence based techniques, including CBT-i for insomnia, EMDR for trauma, and PRT- pain reprocessing therapy - for chronic pain. Annie received her BA from the University of Pennsylvania and her MSW from the University of Chicago. Annie is a licensed clinical social worker in Maryland, the District of Columbia, and Virginia. Welcome to the pain changer podcast. Annie, I'm so happy to have you join me today.

Annie Miller: Thank you so much. I'm really happy to get to talk to you.

Katie Wrigley: I think we have a lot in common with what we're doing here. And I'm wondering, would you be willing to share with the audience what led you to your interest in sleep disorders, trauma and chronic pain?

Annie Miller: Yes, absolutely. So, you know, I myself had chronic pain starting as a teenager, and so I had been through kind of a long journey way before I became a therapist, and had been suffering from chronic pain for a while when I already became a therapist. And it's kind of funny, I didn't even really understand the impact of therapy on chronic pain, because like so many other people, I was really kind of immersed in the medical model. And so, there was a turning point for me where I really started to learn about the brain and neuroscience, and really kind of make these connections for myself. And that really changed everything. And it made me realize how important the therapist's role is or coach's role is and what we can really do to help some of these physical issues like pain. So that's kind of how I got into working with chronic pain. From the sleep perspective. Everyone in my family has trouble sleeping at points in time, really. And so, when I started learning CBT for insomnia, and it's a very evidence-based kind of structured therapy, it was so different than the talk therapy I'd been used to doing and I kind of got hooked with it, because I was seeing people get better quickly. And it was really amazing when that happened. So I was excited about it and ready to just kind of learn everything and I really dove into sleep and behavioral sleep and it's just been great and awesome.

Katie Wrigley: That sounds awesome. And I think a lot of people listening resonate with that, that trouble sleeping. I certainly am still working on that myself. So I'm excited to hear what you have to tell us about this and how cognitive behavioral therapy can help. Good, great place to start. So is there anything specific or different about CBT-I for insomnia versus regular CBT? Or actually, maybe I should back up a step. Is it possible to put what Cognitive Behavioral Therapy or CBT is into a nutshell, just to help people explain what we're talking about? Before we dive into any differences?

Annie Miller: Yeah, so, what CBT is really about is about working on thoughts and behaviors, right? So a lot of therapists will help people change, like, work on reframing thoughts. So changing the way you think about something, and helping people understand there's a different way of thinking about it. Plus, in addition, changing our behavior, and so CBT for you know, anxiety, for instance, is kind of separate than CBT-I for which, which is really for insomnia. Both are helpful. So there's, there's an element of kind of regular cognitive behavioral therapy that we use to work on thoughts around sleep, but CBT-I is kind of its own thing, because and it's, as I had mentioned before, it's really structured. And because of that, I think it kind of is in its own category. And what it's really about is changing your thought patterns and your habits around sleep, to get better sleep. Because I think what a lot of people don't realize is it's not this physical thing that it's happening, right. It's your behaviors, your thoughts are absolutely contributing to the problem of sleeping. Yeah. And so those are, you know, addressed. It's very hard for the sleep to get better.

Katie Wrigley: And that makes total sense too, you know, and you made me realize I kind of had an aha moment, so to speak, as you're saying that of one of the patterns is people who have problems sleeping tend to tell themselves how many times a day, “I have a hard time sleeping, I have a hard time sleeping, I have a hard time sleeping”. So that does nothing to change that pattern at all. It's just your brain is like, “yep, we have a hard time sleeping. Let's make sure we show you that again tonight.”

Annie Miller: Yeah. And the fear directly contributes to the insomnia. Oh, yeah. So yeah, it really does. And so it's really, like the therapy part is about working on that fear and the thoughts and changing that based on real evidence because I think a lot of the thoughts we have about sleep are irrational, they're not real, they're not factually based. I work with people all the time, who think “I'm never going to fall asleep tonight.” And then they always do. And then it's the next night, the same pattern repeats. So that, you know, that part of it makes a big difference, but the behavior, so there are things we do without realizing it, that just reinforced the pattern of insomnia. And that's, that's really important to address as well.

Katie Wrigley: So can you give us some examples of what those may be?

Annie Miller: Absolutely. So you know, some of the basics of CBT-I. So what I do is, when I'm working with them, in my practice, I have people keep a sleep diary. And, you know, I have a specific way I do it with specific questions, trying to get at and, you know, get at certain things that I'm trying to understand about their habits. And I have a spreadsheet that I look at, and I'll be able to get a sense of what their patterns are. So that happens in the first session is the sleep diary. And then once I get a sense of that, there's kind of a, you know, overall CBT-I, the basics, which include things like, so I'll have them not look at clocks in the room in the bedroom. So that's one of the first things and most people are pretty okay with that one. But when you have a clock, it just is like this reminder that, oh, I'm not sleeping, you don't need it. As long as you have an alarm set, you don't need to see the time. One of the other things that we work on is using the bed only for sleep. So what that means is that you want to make sure that your bed is not used for things like looking at your phone, which I know we are all sometimes guilty of but we want to keep it really associated just with sleep. So this is all based on this idea of conditioning, which I'm sure you're familiar with conditioning, the brain and Pavlov and the dogs and how we develop what's called these conditioned responses. So we wanted to have a very strong conditioned response that the bed is for sleep. And so in order to strengthen that we use the bed only for sleep, don't do other things in bed. Now, I'm actually not opposed to screens, just not in bed. So the bed is the key factor here. I mean, and the other part of this is if you can't sleep, you don't lie in bed. And that's, I think something a lot of people may be getting wrong is lying there trying to sleep. It just kind of leaves this wide open space for our brain to worry about, “oh, I can't sleep. Now what am I going to do? I have all this stuff to do tomorrow.” And so when I work with people, I have them get up, you know, give it kind of a maximum of 15 to 20 minutes. And this is where it gets tricky, because you're not watching the clock. So we don't know, it's a feeling. Yes. So you're getting up, getting out of bed, go do something quiet, a quiet activity. And then when you feel sleepy, you get back in bed. And so by doing this, you start to train yourself to not lie awake worrying anymore. Hey, if I can't sleep, no big deal, I'm gonna go read this book for a little while. Or I'm gonna go knit for a little while, even watch a show that's kind of calming. And then I'll get back in bed, it is no big deal, you know, as you kind of coach yourself through it. The other piece of it that I work with people on is what's called sleep restriction. And what that's really about is giving yourself a window of time. And I'm base it on the sleep diary that I'm seeing, but a window of time. So you're in bed from this time to this time. And that's it. And it's the same every day. So you have kind of a scheduled wake time. And your bedtime is not earlier than the time we set it, later is fine. So that less is not a bad thing. And this is challenging. It's not an easy thing.

Katie Wrigley: I can imagine! I'm feeling resistance even as you say that I'm like, ooh, but yet I laugh. I got so much out of what you were saying. What you were saying resonated so much. I'm like, oh, that like is almost I'm already hearing a few things like, Okay, this is part of my issue falling asleep. I actually didn't tell you, I had done a couple of sleep studies back in the day. And the last one I did was in 2010 or 2011. I was actually ironically, in DC at the time, and I had no idea what the clinic was that I went to, but it was really good. But long story short, I was taking Cymbalta at the time to help with anxiety and depression. And the psychiatrist who put me on it kind of overlooked the fact that it revved me up. And so I was waking every 36 seconds. I was exhausted all the time. I slept I think nine and a half hours that night. And then I slept on every single nap the next day. 

Annie Miller: Oh wow, it was a Napster MSLT study as well.

Katie Wrigley: I guess so. Yes. You're the sleep expert. But yeah, it was the overnight and then napping during the day. And I was the person that I fell asleep a few times, much to your point, like, you know, in some of what they told me, Well, first of all, they're like, get off the Cymbalta, which I did. And that was the last psychotropic I've taken. I'd had so many side effects, the sleeping disorder was good. We already had enough trouble with that already. But it was the clock, which I still stick to. I don't look unless I think it's close to my alarm clock. And it's safe to get out of bed early. I really try not to look at the clock at all, I trust the alarm. 

Annie Miller: Good. 

Katie Wrigley: And that was a big one. And I could probably, I'm good about using the bed just for sleep for the most part. But there's improvement there, but the sleep study really showed me the importance directly of what you're just talking about, about an idea in your brain of how long you may actually be laying there. We really have no idea.

Annie Miller: No, no. And when we, you know, the sleep study is actually the only time that we really actually do know, right? Because otherwise, you know, we're like I think, we're basing it on maybe 11:30 I fell asleep right, the last time we looked at the clock and that's fine to have estimates it doesn't. You know, it's what it feels like. But, I mean, that's an interesting story. And some of these things may be really helpful, you know, for you because, you know, I really encourage people to stick to having a regular schedule, at least while we're working together and possibly ongoing. But waking up at the same time, every day starts to train your brain and get used to it. And, you know, most people, like the biggest patterns I see most often are if I'm really sleepy, like, so let's say I have a bad night one night, then I'm gonna go to sleep early. And then or just sleep late. So we push it and we get on these patterns where we're not consistent about sleep. So what's different about this is you're not allowed to get in bed early, and you're not allowed to sleep late. So you have your window and your, you build what's called sleep drive is, you know, that kind of innate need that your body has to sleep and we start to build that up. And then it becomes easier to sleep, right? This, the more you stay awake, the more sleepy you get. And when we're talking about, you know, sleep restriction, I'm basing it on the average of their sleep time. So it's not, it's not like they're getting a lot less sleep. But it feels very different. Because they're not allowed, like that allowance on either end, which typically have. So that's what's so different about it. So it's definitely an adjustment for people to get into. But there's that resistance, which you talked about? Yeah, it is incredibly common to feel that way. Because it's like, well, I don't want to change my habits. And that sometimes even makes people feel nervous to change their habits. Yes. But if you're having an issue, doing this kind of routine, you know, particularly with a therapist can be so helpful, because so CBT-I is in the research is between 70 - 80% effective, which is just like mind bogglingly incredible, right.

Katie Wrigley: That really is!

Annie Miller: And so a lot of doctors are starting to refer to CBT-I or even try to learn it themselves, because they're realizing how significant it is to work on behavior. Because, you know, we don't want to prescribe medications as the first line of treatment. Now, I'm not opposed to using medications when people really need it. But it's worth a try to do this first. Because there's, basically the biggest side effect of this is you're more sleepy, which is not a bad thing if you have insomnia, right? 

Katie Wrigley: That's true. That is very true. And I love that you don't start with medication. And I've covered this on a few episodes where, yes, sometimes it's needed. But anytime you can train the body to learn how to do this to source it on your own, that is going to be where you get the most bang for your buck, including with learning how to sleep, you know, and as you're starting to talk about resistance again, my brain immediately went to because I've been trained, okay, if I don't like this way, what can I do? What else is available here? And so immediately, the sticker my boyfriend gave me came to mind it says “nothing changes if nothing changes”. So if your sleep is disrupting your life that much… What have you got to lose?

Annie Miller: I think that's right. Yeah. Aren't you tired? Yeah, may as well try it. And the thing that I really talked to people about is so what's the worst case scenario? If you're really tired, right? What do you think is going to happen? And and, you know, the truth of it is, if we go on vacation, let's say and we're like, out and busy all day, and you know, we don't get a good night's sleep the night before, we were not focused on it the way we are, if you have to work, let's say or true, right? And very true. It's a different experience. If you're doing something you enjoy, it's like you lose track of the tiredness throughout the day, like, oh, yeah, you might feel tired at points, but you know, nothing terrible is going to happen. Now, there are some exceptions to this if you have a huge long drive, right, this is probably not a good idea to do if you're driving you know, driving across the country or something along those lines. Yeah. We have to be careful about this with surgeons, you know, people who have jobs that are very intense and you know, that high level of concentration is needed, right. But for the general general population, this is very accessible. And the fear around it is so intense, like not necessarily around the therapy, but the fear around not sleeping is so intense. And we don't even realize how much we do it like let's say, and this is pre pandemic, let's say you know, you're going out with friends and you're out. You're not thinking that you have insomnia. It's only when you're home staring at the clock, are you focused on how you can't sleep.

Katie Wrigley: Yes, very true. Very true. Yeah. So it's, there's a big mindset and our focus on it. And our thoughts around it matter a lot. 

Annie Miller: As well as our habits, yes. 

Katie Wrigley: As with everything, right. And as with everything and I used cognomovement around sleep a few times, I actually did a session with someone who has been a first responder for decades. And so they have an ability to wake up and their brain is on the second their phone rings in the middle of the night. Little inconvenient now that they don't need to wake up in the middle of the night there, they still wake up. And when they wake up, they're on. Yeah. And one session, we were able to delete the pattern. That's who had held on to that. And then, with cognomovement, we can do what's called mapping in, it's an NLP term. And we basically take the ball on each side of the head, down low, up above, and we repeat what we actually want to do. And so we programmed in his sleep routine. And within, I checked him the next day, and he had slept better. I checked in with him a week later. He was like, Wow, this keeps going and I’m going to be sleeping like a baby. Checked in him another week later. He's like, I'm sleeping like a baby.

Annie Miller: Well, that's great. That's so great.

Katie Wrigley: And it's exactly what you said it's getting. So it's what the ball did in that session, as it got him out of that pattern, it got him thinking about something different. You know, it was one of my favorite things about the podcast is that a lot of us were saying the same thing in different ways. And this is exactly one of my goals of this show is to introduce people to different ways to do things, because what I'm doing isn't gonna resonate with everybody. But if you need relief, go to someone like Annie, go to someone else that resonates more with you, you're not going to hurt my feelings. I want you to go get the help you want. So what would you say on average? Like how long does it take to see whether CBT-I is working for someone or not saying like, healed, cured, whatever, with chronic pain? And with cognomovement, we can have immediate relief, that session. To learn how to manage it, that's going to take time. So pain can ebb and flow. But I can easily say, yeah, you can have a shift in pain in one session, but it's still going to be a process to learn to manage it to keep it down permanently. So for the purposes of hope, it's you know, how quickly can this be affected with CBT-I? To start to see a difference to start to feel that hope of holy cow, I can learn how to sleep?

Annie Miller: Wow. Yeah, no, it's a really good question. And, like the CBT-I, what they usually say is six to eight sessions. I think it can be done in four… so it kind of depends on the person, right, like, as you know, and you've probably seen this in your work, too. I have people who come in, and we kind of do an initial evaluation, start to sleep diary, and then the second session, we kind of go over the skills and you know, the rules for what to do. And then by the third session, things are a lot better. And it may stick around, you know, for a while, because once you know this, and it kind of depends on how quickly you can adopt it and let go of some of the fears. And these, you know, ingrained habits. Yeah, but I think as little as you know, three to four weeks, which, if you've been suffering for years, that's pretty remarkable. I think probably giving it two to three months between a month to three months, something in that range. If I get to the point where we're at three months with someone and there's zero progress, I start to have other tools and I start to pull out some of my other tools to try too, to kind of get at it in a different way. But yeah, so I think there's some people that just take this and run with it. It's like, where's this been all my life? Like, I want that structure? Yeah, it's like this is what I've needed. And then other people it's like, well, this feels scary, you know, there it takes a little bit longer. But I hope that gives you a sense.

Katie Wrigley: It does. Yeah. So what I'm hearing there is people are going to start to feel something noticeable within a few sessions and you're going to be well on your way within a couple of months which is awesome. That's a very short time window. It may feel like forever but what we're talking about is a really slow short time when to shift something so critical on its head, there were a couple of things that you said that I wanted to go back to. One of them is, for those that you've seen who maybe are having a harder time shifting? Is there a is there sometimes or often or any correlation to someone being traumatized and potentially not feeling safe at night? Like, could that be part of the resistance? Just curious if you've seen that at all?

Annie Miller: Definitely. Although, yes, I mean, absolutely. There's, you know, the VA you know, the VA does a lot of work with CBT-I because it's very evidence based. And so they're working with PTSD and they're doing SR-CBT for insomnia and it's very successful when people have you know, co-occurring trauma or PTSD. But, you know, I find that the most the kind of people who have the most difficult time budging with it is like obsessive thinkers, who tend to get really stuck and start to think that, you know, I need X amount of sleep to be functional, or I need my sleep to look this way. I need to read in bed before I sleep, like who really can't adopt a new way of thinking or a new kind of habit. And sometimes that does occur with trauma. Absolutely. Yeah. But I wonder if that gives you a better sense.

Katie Wrigley: That makes so much sense that obsessive thinkers would have a much harder time letting go of the “perfect sleep” if they have that much attached to it, of course. And you had mentioned also that people spend a lot of time fearing sleep, and they waste a lot of energy, just thinking about, “Oh, I'm not going to be able to sleep”, which as we know, is going to make that worse. But if someone has chronic pain, does that change? Like, is there a different fear level there?

Annie Miller: You know, I think so, I think about chronic pain and insomnia coming from the same place, which is the brain, yes, and what the brain is doing. But generally speaking, I think chronic pain impacts sleep, people are afraid. They are very often afraid of not being able to sleep because it's going to impact pain. So there's this direct connection of if I don't get enough sleep, there's going to be more pain. And then that I think, just adds a layer of fear to the whole process. And generally, when that fear is at play around sleep, it's also fear of the pain itself. Yeah. If I feel this, I'm not going to be able to function. If I feel tired, if I feel pain, I'm not going to be able to do the things I need to do.

Katie Wrigley: Yes, yes. And that really resonates with both myself when I was really experiencing a lot of pain. A lot of my clients, I hear that sleep can be incredibly difficult. You know, especially, I don't know if there's an especially, because if any body parts hurting, it's tough to sleep, if it's a shoulder and you're a side sleeper, that's a problem. If it's neck, that's going to affect you, if it's back, that's going to affect you, it doesn't, it doesn't matter what body parts hurts, it is going to make sleep more challenging, and rest is really critical to healing. So I actually have some other questions on sleep. And I really want to go into the pain free processing that you do too, because I'm just fascinated to hear that. Is there like an ideal amount of sleep to get? Does it have to be all at once? Or do naps count? Can you comment on that at all?

Annie Miller: Yeah, so generally, if we're trying to fix nighttime sleep problems, we try to avoid napping. If you take long naps, or you know, let's say, I've worked with a lot of people who wake up early in the morning, and then get up for a little while and actually go back to sleep. So there are these two, you know, distinct periods of sleep. Yes. The ideal is to be able to try to have a consolidated time at night. And some people are more night owls so that, you know, the hours are individual when we sleep, you know, should be about what feels good to you and your body. We shouldn't be trying to force something that doesn't work for you. Yeah. But I mean, generally speaking, most people feel like eight hours is their goal. But some, not all of us need eight hours. So it's it's a guideline. And I don't I don't even know exactly how that started. But you know, what I what I know from the research I've done is between six and nine is normal for most healthy adults, and kids need more. Yeah, so some people do really well with six hours of sleep. Right? And if that's you, and that's the case, you shouldn't be trying to get eight because that's not what your body, the way your body works best. Right? So when we try to do what we think is right, based on the articles, we've found, you know, we're lying in bed for longer periods of time, which isn't helping us overall. So between six and nine, there are people who need less and that's kind of its own thing. And those people are called short sleepers. And they don't need to, some of them need five hours of sleep. And that's okay for them. And, you know, so their biggest problem is that they think they need aid, right? Because that's what they're being told.

But, um, you know, the sleep diary helps me to see what people's patterns and habits are. But when we let go of the fear around needing eight hours, it's really helpful because saying everybody needs eight hours of sleep is kind of saying like, you know, everybody needs to eat the same diet, right? We don't, we have individual needs and it just doesn't all work that way.

Katie Wrigley: And that makes total sense. Everything that you just said and I love the permission, you know, like and really it's, it's how do you feel if you only get five hours of sleep a night, but you're doing everything you want to do. You feel like you have plenty of energy, you're not in pain. Those are your indicators that you're getting enough sleep, right? If you feel good, and you're not feeling good, because you're taking something to feel good, you just naturally are feeling good in the process of your day, you're getting enough sleep. It's that simple. 

Annie Miller: It is, it is. And it should be. Like we shouldn't be focusing on trying to, you know, make our bodies behave differently, because we think it's right, or we've heard it's right, you know, or what our sleep tracker says.

Katie Wrigley: Yes, yeah. And I love my sleep tracker. Actually, I have an Oura ring. And not that I have any affiliation with them or not. I just, I like it because it's just feels less invasive on my finger than my wrist. And I think it's pretty accurate. I mean, there's some things that aren't. But what I've really noticed out of it, and before I got attached the data, I really checked myself and do I think this data is accurate or not? And I've really noticed, like, most of the time when my my ring says, Hey, you're ready to go today, I feel ready to go. And if I don't, I'm like, Okay, why don't I? And I'll look at my data. I'm like, Oh, I didn't sleep very well last night, I didn't realize that. Or, or I had some restlessness, or maybe I worked out too hard the previous day, I still feel good. But the fatigue hasn't hit me yet. But it's showing up on the metrics and the data, but pretty much if you feel good, you're probably getting enough sleep as a general rule there. And you'd already mentioned really being more strict about using the bed only for sleep, would you be able to give any other tips around sleep hygiene, like how long before bed should people start to be calming down? Like what kind of guidance can you give around screen time you had mentioned that you're okay with it as long as the bed for sleeping? Do blue light blockers have a play? Like I kind of gave you a big question there to dissect!

Annie Miller: No, that's okay. Um, you know, so typically, for what we call the buffer zone before bed is like one to two hours, that's a recommendation. And that's just wind down time. So some people wind down by watching TV. And I think as what that looks like as long as it's not like a horror movie, although I mean, you know, we all have different tolerances, but most of the time, that's not like really relaxing. Or sometimes the news could be not so relaxing, depending on how you take it in. Right, but and even stuff like social media can get us wrapped up if we're, you know, experiencing stress around it for some reason. Yes. So it's it matters what the content is, you know, generally speaking, I am not opposed to screen time. I think it's helpful for some people like there's certainly people out there who are affected by blue light, some more than others, people who have circadian rhythm issues. Yep. Were like, you know, I work with some people who are like up really late, like, they really have trouble going to sleep before like 3am. Those are the people who are really struggling with those kind of circadian issues like that, like their schedules really pushed either really early or really late. Yeah, might have a more more of an impact from the like, light and screens. Generally speaking, if we have our phone on night shift, and we're like watching TV, we're not like it's not you're not sitting this, you know, very, very close to the screen. Yep. So, you know, it's not going to impact us that deeply. And like so for instance, if you're someone who wants to watch you know, like comedy shows before bed on TV, I think that's good, if it makes you feel relaxed, because that's more important is how you go into it. Even you know, some people like to listen to podcasts or audiobooks or something. Yes. And I think we have to kind of do what feels good and what works for you. So that I'm like, I'm more concerned about the bed and using the bed and being having it be kind of purely for sleep. Also, I think I've mentioned is not lying in bed trying to sleep. Yes. Not lying in bed in the morning, either. We can lie in bed, you know, for a long time. It's been the morning. So those things matter more than the screens if you'd like you know, looking at things on your phone and It doesn't feel too stressful, then do it but not  in bed, you know, and try to be mindful of the content. Those are those are the kind of advice tips that I would get and give yourself, you know, at least one to two hours, stop working, stop doing like, I don't know, bills or things that are stressful just like make that light, easy time if you want to, you know, knit if you want to take a bath, whatever those things are that you like, do you want to watch TV do it, it's it just as long as it feels relaxing, and not like mentally taxing.

Katie Wrigley: That makes sense. Yeah. And I want to point out, you know, for anyone listening, we touched on this another episode, social media, social media is designed to get a reaction. So the chances of you being able to check Facebook before bed and not react to anything are not that high. So if you're new and you're in a chill state, you're patting yourself on the back like I did it, I got my sleep hygiene down, do not go on to Facebook, please go with it. Pat yourself on the back and tell everybody on Facebook the next day that you resisted and model something different that doesn't get you revved up. Oh,, that's what I want to shift in my routine. I watch TV now. And I use the the blue light blockers which I want to ask you like any efficacy, real data around that. But I do it in my bed. As soon as I start to move, I wake up. So I'm gonna want to figure out something else. Like maybe I can bring a chair up into my room. So then I'm just taking three steps over to my bed, instead of coming up the stairs from my living room. 

Annie Miller: Yeah, and I get this all the time where people have to, you know, be watching TV, like on the couch, and they'll be like falling asleep. And then they come up to the bed and they're just wide awake. And that's, that's based on the idea of conditioning where we develop what's called a conditioned response. Because you're so used to being in bed worrying about sleep, and like lying there awake. When you get back there. It's like, oh, yeah, this is where I worry.

Okay, okay. So I, you know, I do, you know, sleep work with people in all different kinds of settings, studio apartments, college dorm rooms, and as long as I mean, we want to keep the space separate. So as long as there's like a, you know, the new chair is fine. You know, having a little bit of a separate area where I like, watch TV in this chair, because it's not again, it's not the TV, it's just, you know, when I'm ready for sleep, I go, and I get into my bed. And I give myself you know, maximum 15 to 20 minutes. If it's not, if I'm you know, I'm not able to fall asleep, I'm gonna go back in the chair, or, you know, if you'd prefer to go somewhere else, that's okay. But I'm going to watch, you know, watch TV. And when I'm sleepy, I'll get back in bed. It's kind of that routine, Breaking the habit of worrying. And that is what

we're really going for. 

Katie Wrigley: That makes total sense. And you just, you just gave me an idea, actually. So and I can't remember if I mentioned it in this this episode or not. But one of the things we can do with cognomovement is mapping in NLP. I think I did mention that earlier. And I can actually map in what I want to have happen when I hit the bed instead of oh, this is where I don't sleep, I can actually now take the ball and be like, when I get on the bed, I'm ready to sleep.

Annie Miller: Yeah. And if we have a night where that doesn't work the way we want it to. The real key here is no big deal. I nope, no problem here. I'm going to get up and I'm just going to do something else. Because we want to disconnect fear from the whole process. Yes, if I can't sleep, so really and truly worst case scenario is you're going to be tired.

Katie Wrigley: Yeah. Which is not a big deal. And you're probably not going to have pain flare on one night of low sleep, it must be repeated for days on end. Yes, you may see a difference in your pain, but one night shouldn't impact it that much.

Annie Miller: And it's true, but it's hard to disentangle the stress, right from the sleep. So we also often attribute sleep problems, right? Lack of sleep to pain. And, you know, I'm kind of interested. So one of the groups that I think about the most as having lack of sleep is like new parents, right? 

Katie Wrigley: Oh, yeah. 

Annie Miller: Infants, they are not sleeping. Are they all in pain? Right now? 

Katie Wrigley: Oh, good point. Yeah.

Annie Miller: So we wanted to start to disentangle this because stress causes both pain and insomnia. 

Katie Wrigley: Yes, true. 

Annie Miller: So how do we know if it's the sleep or the stress? Right, and it's kind of hard to disentangle this. And then they've in fact done some, you know, not with pain but with insomnia, looked at like this in a sleep lab where they're actually looking at it and the the fear around not sleeping or the thought of being a bad sleeper causes more problems than actual bad sleep.

Katie Wrigley: That that is amazing. And I'm thank you so much for checking me on that. Because I've been saying that a lot. And I'm gonna watch it now it's the stress around the sleep is probably hurting your body a hell of a lot more than whatever lack of sleep you're perceiving.

Annie Miller: Yeah, and that helps to think about it that way. Because it helps to reduce the fear around not sleeping, because when we don't care if it's going to happen, we that's when we sleep. And so that's our real goal is this is no big deal. No emergency, no, you know, this is non threatening.

Katie Wrigley: You just gave me a piece of information that no one had ever and I've dealt with sleep issues a lot. And I've taken stuff for it. That's never been a good idea. But you just in one little nutshell, helped me realize because I realized early on like, geez, I sleep fine on the weekend, but not on the weekdays, because I'm stressing about the sleep. So it's not that magically two nights a week I know how to sleep and the other five I don't, it's that two nights of the week, I'm giving myself permission not to be stressed about sleep. So I sleep.

Annie Miller: Because there you don't have to wake up right is like, can I still wake up at the same time? Right. But it's yeah, it's mindset around it. Yeah. It's amazing how powerful our thoughts are and how all this works. It's, it's really remarkable. Our brain is kind of just unbelievably powerful.

Katie Wrigley: It is and even knowing that I still get surprised all the time that I'm like, I'm still limiting myself. Wow. Like, and then But then now not so much, thank you, because you're helping me to see that and helping other people see that too. That is, that is awesome. So do the blue blue light blockers, do they help with sleep at all? Like with the any extra stimulation that may be coming? Or is there a lot of kind of BS around that? 

Annie Miller: Um, you know, the truth is, I might, the answer that I know is: I think so. I haven't really done a lot of because, you know, because I'm focused on behavior, the product side of things, I don't know, as well. But, you know, again, with the circadian rhythm issues, I think that they can be really helpful for people. You know, also some people really struggle with just generally eyestrain and like screen overuse. And so, you know, I think it's individual if it helps, but I think it's possible, it could help. And again, with the circadian issues when, you know, light can skew our brain to feel like it's daytime. And so that is an issue for some people at night, and they get there. If you're more sensitive to it. Oh, yes, it can be a problem. So we want to have as much natural light in the morning to kind of cue ourselves that hey, look, it's daytime, I should be awake. At night. You know, we're supposed to release melatonin and start to get sleepy because it's getting dark, right? Like that's what our circadian rhythm is about.

Katie Wrigley: Yeah, that makes sense. Thank you. And, you know, and I mentioned this in another episode as well, the placebo effect can work for us. So if you're trying the blue light blockers, and you think that they work, keep using them, because you may be making them work, despite any, any evidence or lack thereof. I want to shift actually, I have one last question on sleep, and I hope it's not too inappropriate. But I have a hunch other people would ask it too, like, where are you supposed to have sex then? If the bed is only supposed to be for sleep? I'm just gonna put it out there. Where's the better place to have sex?

Annie Miller: No, that's a really good question. And I may have not not have specified it in the CBT-I rules like we say the bed is for sleeping, sex.

Katie Wrigley: All right, good. Because I've been using it a lot for both. Okay, and so I asked. 

Annie Miller: Yes, yes. And and that's helpful and important to kind of specify is that's kind of the one exception.

Katie Wrigley: Well, that's good to know. And you know, for people who really want to be strict on sleep, get creative in your sex life, do it on a table, do it on the floor, see what happens maybe you like it, but the beds pretty complex. I would love to shift gears to the pain reprocessing that you do for people with chronic pain. Can you tell me a little bit about that? 

Annie Miller: Yes. So, um, pain reprocessing therapy was, was developed, it's, it's pretty new. So it was developed by therapists, you know, similar to me, but who had been through pain themselves, and to, you know, kind of have found that working on the on pain from the perspective of the brain, and disconnecting pain from fear has been what really made a big difference. And so, there was a recent study this was, it's been almost a year now. So last fall that it came out. And it was amazing. So I would have to look at the specific numbers of what this study showed, maybe you can link to it. It's the Boulder Back Pain Study. And it was the first like, clinical study looking at pain reprocessing therapy or PRT. And so 66%, I believe, of people, the participants were pain free after therapy. 

Katie Wrigley: Wow. 

Annie Miller: I think it was something some 98 or 95% were, had improvement, like some level of improvement.

Katie Wrigley: Nice, nice.

Annie Miller: So this is like a real, you know, true treatment that is really helping people with pain, without medication, without surgeries, you know, without injections. And so it's all about, you know, thinking about pain from the perspective of the brain. And it has. So the components of it. Are, there's a teaching component, like a kind of education component, teaching about the brain teaching about neuroscience, how the brain works. 

Katie Wrigley: Yep. 

Annie Miller: Now, that can sound a little overwhelming, right? Because we're not all neuroscientists, but just like the brief overview so you can kind of buy into it. Yep. And then as the therapists helps to the client or patient to gather evidence about their own pain, and how it behaves. So, for instance, if I associate sitting with pain, right, I sit in, in this chair, and I feel pain all the time. Does it make sense, then if I'm sitting at a basketball game, and I don't have pain, that sitting causes pain, right? 

Katie Wrigley: No, it is not true. 

Annie Miller: Right. So we want to gather evidence that the belief like the beliefs we have about our pain are not necessarily true to the extent we think they are. Yeah. And one of the key components to PRT is also what's called somatic tracking. So it's a kind of a meditation type process, where we watch pain, and we just notice it and practice detaching fear. So this is a sensation. It's not alarming or scary. Yeah. Yeah. Kinda like, if my foot falls asleep, I wouldn't necessarily panic or my stomach growls, it's a sensation like that. It's not the danger thing. That's the danger feeling we typically feel like it is. 

Katie Wrigley: Yeah.

Annie Miller: And then, you know, another part of PRT that we try to work towards is what's called positive effect induction. But what that means is kind of gravitating towards positive feelings. So you're focusing on the breath, where does it feel good to breathe? Where does it, what feels good in your body? What is, you know, something that feels nice, rather than just laser focusing on something that doesn't feel so good?

Katie Wrigley: Yep. Yeah, and I'm grinning because there's so many similarities between what you do and what I do with cognomovement and that that trick, I actually I found that you know, and this is one of the bonuses of me, organically getting into chronic pain management is  I've been there and very recently in the past too, and there was one day I remember I was just I was crying because of the I just had not broken the pain flare yet. It had been like for like six weeks, I was having a really hard time, struggling just before cognomovement. And then I just decided to focus on my toe. Because my all of my focus on my toe and so that's one of the tricks I have people do and I did this in my masterclass a couple of weeks ago, is you start to examine it with curiosity. You're breathing into it. You're feeling it. You're just paying attention to it. What does this pain feel like? Describe it. You know, how do you feel about the pain? And then focus somewhere else? And that's nice. Yeah. People are like, whoa, like someone reported that their pain went from a seven to a three. Doing that was five minutes.

Five minutes. 

Annie Miller: I know it's in when you automatically have these associations. God, I feel this one, when's it gonna go away? How long? You know, how long am I going to have it? How am I going to function tomorrow? What is really going on in my body? That's another really common one.

Katie Wrigley: Yes.

Annie Miller: And when we stop, when we so that's what I mean, when I say disconnecting from the fear, those thoughts are habits. And they're not. They're not rational. They're not based on truth. They're just these thoughts. And we just start to see it as this sensation and kind of, okay, so what if I just let it be there for me for now, right? We're not saying that we want to have pain forever, we're just letting it be there temporarily, to like, disconnect the fight or flight response. And then over time, it starts to let go, because it doesn't, it's not dangerous anymore.

Katie Wrigley: Right? Yeah, that makes total sense. And I talk a lot about fear and pain being so closely linked, and they play together like the quintessential mean girls, they'll stab you in the back, they'll talk crap about you, just when you think you're free, they're gonna come up again and start playing. And I've found in every, every client I've worked with, and some higher than other and myself included, there is at least a level of anxiety, and some full on fear and they and reason to fear, they have been through a lot, some people I've worked with have been through atrocious events. And, of course, fear came with it. Like, you know, I know people who have had really bad skydiving accidents and have survived. And there was a lot of fear that gets locked in. And that was one of the things I learned along the way. It was it was introduced to me before I had had any buy in. And I really started to examine this later on my own. But there were some I don't even remember who the person was. But it was some TED talk or something this guy's talking about going out into the brush in Australia. And nothing had ever happened to him before. So he didn't think anything of it. And you know, something kind of felt sharp on his leg, no big deal. And then he's like walking along and he's feeling dizzy, and he realizes he's been bitten by a snake. And he's freaking out. And then the fear as soon as he realized he's been bitten by a snake, his fear spikes. We'll fast forward, he's in the brush three weeks later, again, a brush, piece of brush hits his leg. He immediately spikes fear and pain thinks he's been bit by a snake again, looks down and it's just a twig. And he's giving this as the example of this is what your mind does. And it's not because you're crazy. It's not because you're weak. It's because your subconscious is there to protect you. So it's gonna go back to the worst thing that happened to you again, like this may have happened. Yeah.

Annie Miller: Yeah, and I think that's really helpful to kind of specify too, because one of the biggest obstacles in the, you know, pain work that I do is people feeling like, well, you're saying to me that this pain is in my head, right? And I mean, I can't stress it enough. And as someone who has, you know, dealt with pain in the past, I know that it's not made up, there's no possibility that it's imagined pain is, is never imagined, even if it doesn't have a physical basis. It's still real, and you're still feeling it. And that's always the case right? There. I think the way that I try to help clients understand it is never imagined, it's never made up. But it's it's a mechanism in the brain that is making you feel the pain rather than something physical in body. Like a structural problem, or, you know, the snake bite example is perfect, because that person who experienced that is feeling real pain. So just because the snake didn't bite them in that second moment, they're still feeling the pain, yet the brain is functioning to create the pain response.

Katie Wrigley: Yeah, and and that's what I tell people too, it's in your head, and it is real. Yes, you know, and it's good news that it's in the brain because this means we can change it. We actually want pain to be in the brain. Because that means we've got control over it once we learn how to feel it, but it's a no and I really had resistance to that. And then I'm like, Oh, it really is in the brain and it's real. And I read Eckhart Tolle’s The Power of Now a long time ago, and he had said pain is an illusion. And I actually, and I have still have no buy into that on one level. And it's only been recently that I have a buy in at all on any level, because I've so very, very strongly feel that you do, that it is in the head. It is a mechanism in the brain. And it is also real. But he's saying it is an illusion, because the, and we're gonna get a little esoteric, kind of getting out there a little bit there. But there's love, and fear are the two primary emotions, only one of them is real. Pain is not love. And so therefore it would be an illusion, because it's not love and love is the only real emotion. But again, I'm going way out there for most of us who are rooted into what we see and feel as reality with other emotions other than love also feeling real, whether they are or not, again, that's going into grounds I'm not going to go into on this episode. It is absolutely real, and what you're experiencing is real, and the emotions around it are real. And there is nothing wrong with you for feeling anything you're feeling about your pain.

Annie Miller: No. And, you know, I've heard this way of framing it before that the pain is an opinion. Right? And it's kind of an interesting way to think about it right? Is it's the brain makes kind of its felt, but it's the brain is making that judgment as something being dangerous versus not dangerous. And so, you know, we want, we want to shift that this is a sensation, again, just like some other, you know, feeling or sensation, we have like our stomach growling.

We don't feel afraid of that. No, we don't feel worried about that. That's kind of an everyday thing. And when we start to apply that to a pain, sensation, changes, it changes our perception. And that's what that's what, you know, my goal is a therapist, working with people with pain is to try to change the way they perceive it.

Katie Wrigley: Yeah, and that that's my goal with cognomovement, too, is because when you change that perception, the pain can be gone. Or at a minimum, much less than what you feel. Yes. Okay. And it's it's getting much easier for me to watch people hold on to their pain. Like, I'll see like, oh, yeah, I want to get rid of it. And then as they're talking, I'm like, Oh, and there's where they're holding on to it. And we're out of time for this session. So we're gonna start there next time. And but I'm starting to and it's not conscious. I'm saying this was zero judgment whatsoever, I do the same thing. And I still like, I consider myself pain free. I've considered myself pain free for a while. And I've actually been surprised I was, I've hit other levels of pain free, like, oh, that still was bothering me. Because the perspective and the perception shift has been so radical from where I was, like, I actually want to go, part of me wants to go get imaging again, the other part of me doesn't want to because one, it's expensive and I have already had 16 MRIs, I'm kind of over being shoved into a tube. But I'm really curious to see what's actually changed in my body, because cognomovement can actually bring about physical changes too, not just perception. And so I'm really curious what's changed in my back because I know I've regained two thirds of an inch. I got measured before cognomovement, and I was down to 5’ 5 1/3”. To start at 5’ 7 ½” but not good at skydiving, bulging discs and worsened scoliosis that was over two inches. And I was standing up, it's as tall as I could too because people would say Ah, you're slumping. Like NO. Every time I get measured, I'm standing up as tall as I possibly can consciously. And then I got measured again, three weeks after my first cognomovement session, I was back to 5’ 6”, and I'm like, Hmm, interesting. So I'm curious. You know, and I've heard that from other people, too, where there has been imaging before and after, like we've seen MRIs with multiple sclerosis and the nerves have routed themselves around their sclerosis. And it's not just cognomovement. It's that happens. 

Annie Miller: Yeah. Yeah. Well, you know, I mean, I think it's an interesting thing to see, you know, and to kind of understand: What's happening and what's changing? I mean, certainly we can see on imaging changes in the brain when we're more relaxed. Yes, you know, when we go through processes, there's, there's absolutely things we can see in the brain, if we're, you know, if we're looking at it. But generally speaking, you know, when you relate to things differently, you start to relate to other things in your life with more ease and a more relaxed attitude. And that changes kind of everything, and this constant state of stress starts to diminish. And, you know, that's where the healing really comes from, is not perceiving everything as a threat or an emergency. Because we don't need to, you know, there are things we need to perceive as emergencies. But in our general day to day life, that's not happening very often. So we need to cut out of our mind that in terms of pain, in terms of sleep, but also in terms of, you know, thinking other things in our life, you know, getting emails you know, we're doing the dishes for some people, it's, it just depends, right, we, but that's the overall goal is to start to reduce threat that we experience in a lot of these scenarios.

Katie Wrigley: That makes so much sense. That's, that was beautifully said too, thank you, and it is how you look at it, you know, like if the, if the dishes are a chore you dread, and you're going to be stressed out about it. If it's just something that you're doing because you like your kitchen clean, that's a completely different perspective. Like, oh, I'm gonna go do the dishes because I love to have a clean kitchen. Now, it's not a chore. Now, it's something you want to do for the end goal, whereas like, Oh, I hate doing the dishes. Now it's a chore. 

Annie Miller: Exactly. And all those thoughts matter, right, because they will signal to the brain. Hey, this is okay. Or this is not okay. 

Katie Wrigley: Right. So that stuff is significant and the way we think about that

is, it does you know, and I'm big on the verbal side, and I'm constantly learning how much more I still have to learn on the verbal side. Like, and it's we talk ourselves into the stress all the time. Starving. Are you really, when was the last time you ate? Like, are you really starving? Or are you just really freaking hungry? And you know, oh, I can't wait to do that. Can you really not wait? Or are you just so excited that waiting is just difficult right now like and but it matters? A lot. Language. 

Annie Miller: Yeah, the self-talk. It does, right? If we, you know, this is an example that I use a lot in terms of self talk. If you were talking to a kid, you know, you wouldn't in that, let's say you were talking to a kid who was just about to start school for the first time. It matters. If you say, school is terrible, you're going to have homework, and you're going to have to follow all these rules and people pick on you, right? That is going to signal to them, oh, no, this might be a bad thing. No. But if you tell them, hey, this is going to be great. You know, you're going to make friends and you have all these fun things that you get to do at school, they're going to have a completely different, you know, approach going into it. And so the way we talk to ourselves matters. Like that is a very different picture. We’re painting the same thing. Right? And it's, it's really important.

Katie Wrigley: Yeah, absolutely. And I bring that up a lot on here, you know, and I'm still, I had someone who's Gestalt trained coach, that was on a couple episodes ago, and he’s a cool man, he takes verbal to a whole new level, I'm gonna have him come back again to do a deep dive into semantics and the power around them. This has been such a great conversation. I could go into a whole other tangent around words and all the things but we've already covered a good bit between sleep and PRT, pain reprocessing therapy. Thank you so much for joining me today, Annie. If you can tell people again where they can find you. And are you available online at all? Or is it just in person?

Annie Miller: So yes, and thank you so much for having me. I am available online. So I'm in the DC area. You know, one thing I did recently was I created an online forum for chronic pain. So people dealing with chronic pain. That is something that anyone can do anywhere. And you can find that on my website. This is just DCMetrotherapy.com. And, you know, my practice is DC, Maryland, Virginia, we are licensed in that area. But different states. So I really go by what the state's rules are. So we do work with some other areas, depending on what their licensing rules are and how it works, because I want to make sure we're doing it. 

Katie Wrigley: Right. Right. Understandable. So thank you for that. But you you can, in theory serve greater than the DC metropolitan area, Maryland, all of that, depending on various

State laws? 

Annie Miller: Yes, yes. And I think that's part of the reason I developed the online course, too, is because I wanted to be able to actually, you know, have a lot of people get access, who might not, you know, be able to do therapy or are out of the area?

Katie Wrigley: Yeah, that is beautiful. I'm glad you put that out there. We'll make sure that I put a link directly to that. Is it a quiz or an assessment? Or what would you refer to it for those that are in chronic pain?

Annie Miller: So the course the whole course? Yeah.

There's a tab on my website that links to it.

Katie Wrigley: All right. Yeah, I'll make sure we have a direct link to that as well. So I'll put your website out there. And then the link to the course that anybody can take anywhere in the world. Thank you again, and what thought would you want to leave people with today and as someone that maybe wants to dive into sleep hygiene or is ready to desk shift their pain completely?

Annie Miller: That's a good question. You know, I think generally, what I want people to come away from working with me or from the course is just to start to approach pain, sleep and general things in their life with more ease, that I think that the danger we tend to associate with things is not what we think it is. Right. So it's starting to live with more ease is my my hope to impart

or to live with more ease. 

Katie Wrigley: Yes. So what I think I hear in there is maybe also an invitation to question the associations. 

Annie Miller: Yes. As part of that living. Yes. 

Katie Wrigley: All right. That is great advice to end on. Thank you so much again. And thank you to everybody for joining me today. As always, I so appreciate your support on the show. Next week, Kathy White is going to join me to talk about the benefits of yoga for pain. And I hope you'll come back again to learn a deeper understanding about how movement and specifically yoga and specifically some poses in yoga can help aid you on your journey out of chronic pain.