Barry Krakow, MD Sleep Dr and Trauma Part 3

Transcription U1 0:01 Hi, this is Rachel on Recovery. We're back with Dr. Barry Creek Co, and he's going to tell us a little bit about a little bit more about sleep. U2 0:19 So what U1 0:20 do you do if you have a patient that's scared of the dark? Because I know that can U2 0:24 it. 7s So let's take that question and move into the psychological aspects of sleep because they're just as important. And that's a great segue, because now you're talking about the concept of when people have conditioned responses that are so powerful, what do you do about it? And the answer is, of course, you go slowly and you have to work out the desensitization program. Somebody needs to be asleep in a lit room, you say, then that's what you do. You don't say to them, you can't do that. You say, no, that's what you do. And what we're going to figure out is what else is going on with your sleep that we can work on? Because there's almost always multiple things. Very few people have just one sleep problem. Most people have as many as five to ten different variables that all are relevant. And so at any given time, you want to work with the individual and say, well, tell me a little bit more about your bedroom. What is it about your bedroom that has made you into a poor sleeper, besides just the fact that you notice that you're sleeping with a light on and that's not such a good thing? And often that person might not be aware, for example, that the temperature in their room is a very crucial factor to how people sleep. A person may just not be aware of it. You would think they would be, because it's so simple, but they may not be. And there's also a budget. A person may have a budget and say, well, I can only keep my temperature at a certain level. We know for a fact that 1s most people sleep better in a cooler temperature with one huge caveat 1s insomniacs, which is a lot of what we're talking about here, have a vasoconstriction problem where their hands and feet it can be very chilly when they go to sleep. 2s And so if that happens, they're thinking, wait a second, I can't go to sleep in a cold bedroom. I'm never going to go to sleep. My hands and feet are already cold. Now, the good news for them is that for most insomniacs, through the process of actually going to sleep, that vasoconstriction in the hands and feet will relax. And now the blood will get into the hands, hands and feet and they will no longer feel that chilly sensation. That's why it's not uncommon for an insomniac to do what? They'll go to sleep with all these covers on because they needed them to go to sleep. But then they wake up in the middle of the night and they've got to remove the covers because now they're too warm. And then you have the problem. What if they can't get back to sleep? Because that is the single greatest complaint, by the way, of all insomniacs. I can't get back to sleep. Many people talk about falling asleep as being a big deal. It is, of course. But if you think about it, falling asleep at bedtime 1s is no different than falling asleep in the middle of the night. It just happens to be at two different times of the night. In the beginning of the night, it's easier because you put in a day, you're already exhausted, you have what's called high sleep pressure. But in the middle of the night you've already slept some. You've eaten up some of your sleep pressure. Now you wake up. Maybe if you're too hot, you're too warm, you can't get comfortable again, you can't easily go back to sleep. And that is the single greatest complaint of all insomniacs. And that's why when they go through the medication approach, the doctors are always saying, well, this one will keep you sleeping through the night. And of course, just briefly, just to interject, it doesn't solve the problem of waking up at night to pee. So the insomnia patient who has a sleep breathing disorder, who wakes up at night to pee, and it takes a couple of minutes to pee, and then they come back to the bed, now they're wide awake. That's a very big deal for them. So for them, of course, they would want to look into this whole sleep breathing connection. But nonetheless, most insomniacs do have the problem of waking up at night and not being able to go back to sleep. And the big question is, what do they do? So we can discuss that now, unless you want to go into a different question. U1 5:01 One question I was going to ask is for, like, asthmatics. How does that correlate with sleep apnea? Because they're both breathing problems. U2 5:14 I thought we were going to stick with the psychological for a while. Why don't we come back to that one? So on the psychological front, 3s the issue of being able to go back to sleep is huge. And the ultimate answer it sounds like you would be very familiar with, since you mentioned the EMDR, is that in the middle of the night when you wake up, 2s you have to be able to get sleepy again. And if you could get sleepy again, you solve the problem. So somebody who doesn't have PTSD, somebody who doesn't have insomnia, they wake up in the middle of the night and what do they do? They roll over and they go back to sleep. 1s But for people who have suffered from insomnia in their life, and I've suffered from insomnia, and anybody out there who knows this experience, he goes, well, you're just not sleepy, so how do you go back to sleep? And so that really does require a lot of discussion and analysis of what exactly happened beforehand to wake you up. What are you doing in bed after you wake up, and what are you willing to commit to doing, to change, to overcome that? The biggest problem is that most people think. 2s They can force themselves to go back to sleep. So the most common response to waking up at night 2s and not having the ability to go back to sleep is to lay in bed 1s trying to go back to sleep. Which in fact makes the problem worse, because that produces the conditioned response of, well, my bed is is not a place to sleep. My bed is a place to lie here and be awake and worry or stress or look at the clock or listen to the traffic or again, worry or just have self talk. And so all that's natural because you're kind of awake or wide awake. But the person has to recognize that's enhancing what's called the behavioral conditioned response. And so that means the fastest way to confront that problem is to do it someplace else. So if you wake up at night and you go, I just don't think I'm going to fall back asleep, the goal should be to say, well, I want to make my bedroom bed sanctified. This is a place where I sleep or make love. This is not a place where I read books or watch TV or listen to the radio or listen to podcasts even. I want to get up and go into the next room. 2s And do something different until I get sleepy again, then I'll come back to my bed, and then I'll go to sleep. That's a huge step to take, and very difficult when insomniacs first hear it because it's counterintuitive, you're going to say, Wait a second, I'm now spending less time in bed. So if I'm spending less time in bed, how am I going to get more sleep? And this is the classic example of less is more. That if you allow yourself to accept the fact that you're making the sleep worse by lying in bed, not sleeping, and teaching yourself to not sleep, if you learn that you can get out of bed and appreciate that difference. And it can work in pretty quick fashion, but it's a big step. It's often important to be coached for that, for people who really struggle with these things. In addition to my book, I have a coaching service 1s at my website, theberrycracomd.com, and I will coach people and help them to understand these principles so they can apply them, because some people really just need more education and instruction to be able to implement the idea. 1s The other thing is, I know a lot of people with PTSD. They struggle with not being able to sleep unless there's noise or TV or. U1 9:32 You know, they just can't sleep. U2 9:36 Right? And that's a very good point because we're talking largely about two things. One might be a fear response where that noise in a certain way may be making them feel comfortable, but the other is they may have self talk. And the chatter just is something that's right now uncontrollable. So I've used these before, things like 3s the black screen on your phone that's playing the sound of rain. That's a very good thing. And that can absolutely dampen some of the self talk. And I encourage people when they're in that level of distress and that's what they need to do. That's what they need to do. There's nothing wrong with that. It's very important to apply these kinds of tools and principles. If they work. If they don't work, then it's go back to the drawing board and say, what's going on here? And I'll give you the best example. If a person has been spending way too much time in bed, awake and. That person may not have as much luck trying to put the phone on rain because they've already spent too much time in bed being awake, whereas if they got up out of bed for an hour or a half an hour, then they went back into bed, then they put the phone on rain. Much more likely to work at that point. U1 11:03 Makes sense to me. Makes sense stuff, right? That's very important for people to understand. Their behaviors have a dramatic impact on their insomnia, and they can learn to take control of that just by changing a few behaviors. 2s Now, we haven't spoken about nightmare, which are big in PTSD. Would you like to talk about that? Going to that area? So the nightmare research is how I got into all of this in 1988, where we did the first randomized controlled trial on the technique called imagery rehearsal therapy, and it was compared to a technique called desensitization. At the time. This was at the University of New Mexico Department of Psychiatry. Just a few years early at the University of New Mexico Department of Psychology, they had tested desensitization at a protocol for nightmare patients. So basically, Albuquerque, New Mexico, was the nightmare treatment capital of the world in the 1980s. And so in 1988, when we did our study, we compared the Desensitization that had already been proven to work with IRT. And the thing about IRT that was unique is that it's got nothing to do with Desensitization. Even though many mental health researchers and mental health professionals thought in the beginning that's what IRT was, they thought, well, they're just rehearsing the nightmare. That's all that's happening. It's exposure therapy. But IRT really doesn't do that. IRT is saying that 1s in your mind. 2s May end up being there because they become learned. In other words, you are traumatized and have a very, very bad event occurring, a bad a stressful life event, something that where you think you're going to die or worse, 1s you're having these kinds of events, and that leads to PTSD. So you go, well, naturally, that caused you to have nightmares. Nobody's surprised about that. It 2s but the question that many PTSD patients have had, as well as researchers, is why do those nightmares linger? And when we first began doing this research in the if you'd ask a PTSD patient, why do you still have nightmares? The answer would be, well, from the trauma, naturally. And we'd say, okay, well, that's certainly a great theory, and I'm not saying you're wrong, but there is another theory. And they go, okay, what's the other theory? And you go, well, it's the learned behavior theory. And they go, 1s what do you mean a learned behavior theory? Say, well, if you have nightmares for a long enough time, it's quite possible your brain has learned to keep having nightmares. And so they'd hear that and they go, and this is very interesting. Half the people who would hear that discussion, because we were doing these in group sessions, so it'd be like 8910 people and very fascinating people, fascinating discussions. Half the people would go, that's ridiculous. You don't learn to have nightmares. It's the trauma. I say, okay, other half a light bulb went off. They go, that is so funny, Dr. Craco, that you said that, because I recently have begun wondering whether my bad dreams have actually become like a bad habit, that they're just there and they just don't go away. 2s So these sessions would last for a few weeks. We'd have these very intense discussions about all these different principles. And what we learned was that for most people, 2s even though they had horrific traumas, 1020 years out, they began to see these nightmares had taken on a life of their own, and they really had begun to develop as an independent sleep disorder and therefore might have been functioning as a learned behavior. And the proof was this when we treated them, we didn't give them a medication. We didn't talk about trauma. We didn't give them psychotherapy. We gave them an educational instruction. We said, if your nightmares are learned well, that means they're susceptible to being unlearned. So how do you do that? Well, simple. Go take a bad dream over here. Change it to something else. The person might go, what do you mean, change it? Well, that's exactly what I mean. Just change it. Now, I'll come back to that in a minute, because when they first asked about it, they said, well, what do I change it to? No, you decide. You decide. You make the change. So people just made various changes to their nightmares. Then they practiced the images. That's where you get imagery rehearsal therapy. You just practice the images you created from that new dream. U2 16:15 And the people did that every day or every other day. And within just a couple of weeks, not only did their bad dreams start getting better, but often the intensity of the dreams got better. And then a month or two months out, their PTSD started getting better. So they bought in very quickly. Once this process unfolded, like, wow, I have control of my dreams. I just have to picture certain things. Not to say that what you picture shows up in the dream, but just by the fact that you're taking control of your imagery during the waking hours and paying attention to it. Is having this effect on your U1 17:00 nighttime a lot like inner child work? And except for with childhood situations, you work with your sleep. U2 17:11 I'm not familiar with that terminology. U1 17:13 With inner child work, you go back to the time period grid where the trauma happened, 3s and you start, 3s if you could pick a mom, what would that mom be like? What would have happened? How would she have responded in that sort of situation? And so I kind of feel like that's kind of the same thing, but with dreams. U2 17:40 I think it's very similar, very good parallel. Thank you for educating me. So, yes, it's not like going back to relive the trauma. It's going back and saying, I'm doing something different with this dream. And so we had people who would change the whole dream. We have people who would change, like, 1s one color in the dream, three words in the dream, one scene in the dream, the whole dream. So it was a process of saying, I'm changing the dream. I'm taking control of the dream. And the one paper we published on it showed that the people who had the best response appeared to make changes where they showed mastery over the situation. So if the dream was one of being out of control, which often dreams are, and under TAC and so forth, the dream change made it more masterful that the individual now had more control. And that seemed to be associated with the best outcomes in people who used IRT. 2s And we have like I said, I've got lots of sections on this in the book Life Saving Sleep. And I want to put in a little note, though, that research again, going back to what I said, in physiology, we're huge proponents of IRT. It's such an easy technique to learn. Again, some people need coaching on it. My wife and did a special manual called Turning Nightmares into Dreams that many mental health professionals purchased to use to teach themselves that training. We also have introductions to IRT videos on my website, Barrycracomd.com, 2s but I just want to get across that. Through the years we have been surprised how many of the nightmare patients also have the sleep apnea. And now there's nine studies in the scientific literature over the last 20 years. They're not the best studies. They're more like anecdotal case reports, retrospective studies, but they encompass a lot of patients. Over nine years, we've published only two of them. Seven other research groups out there have published it. 3s And they all show the same thing. You put somebody on CPAP who has nightmares, and their nightmares get better. 1s So that's pretty remarkable. Here we've been talking about a psychological aspect to nightmares with IRT, which is incredibly powerful technique, by the way. 1s It's it's in the world of what they call effect sizes. In research, they're huge effect sizes for IRT. And yet, on the other side of the equation, we now know that CPAP or PAP therapy reduces disturbing dreams and nightmares in every study that's been published on it. So that's going to become a whole new field as well. And U1 20:51 what percentage of sleep U2 20:53 doctors out there U1 20:54 practice this? Or would you say, is it growing, or has it been out there a U2 20:59 while? 1s It depends which parts you mean by growing. In other words, this is a big issue you're bringing up, which is why I'm hoping to get on a variety of different podcasts to spread the word, because most sleep doctors do not practice the way I'm practicing sleep medicine. They're not aware that most people with PTSD who come in with a sleep problem have sleep apnea. Most of them don't know that PTSD patients don't really get along with CPAP and need bilevel devices or autobilevel devices or ASV 1s many sleep doctors, unfortunately, have not been trained to do IRT. Many sleep doctors are not trained to even do CBTi. So there's a huge gap in there. And my own work over the years has been to train mental health professionals. I've done close to 50 trainings over the last 20 years at mental health facilities where it was like 1020 30, 50 mental health professionals. And I would give them a one, two, or three day workshop teaching them how to do IRT, how to do CBTi, and I'd even teach them a lot of fundamentals about sleep and sleep disordered breathing so they would know how to interact with their sleep centers in their own community. Right now, we've just set up a new program. We're in the process of setting it up. I'm in Savannah, Georgia, and I'm working with 1s Gateway Community behavioral Health Program statewide organization, and they have a psychiatry residency program in Savannah. So we've been working with them for a year on Didactics, giving them all this information that we're talking about today and more. Her everything that's in the Life Saving Sleep book and my other books as well. 1s It. But now, for the last several months, we have a sleep clinic where we're going to eventually have the psychiatry residents learning directly what it's like to treat people from the perspective of a sleep medicine doctor. It's even possible we'll have a sleep lab. We don't know any of that yet. But right now we have a sleep clinic, the Didactics. And we're trying to get the residents to have more hands on experience. That means these psychiatry residents will not just be reaching for prescription pads. They'll be saying to a patient, well, this pill might work for your sleep, but we can also try CBTi. This pill might work for your nightmares, but we can also try IRT. So they're going to get that training. And that's fantastic, because if that can work in one spot, just one psychiatry residency training program, and then it becomes promoted, I believe all the psychiatry residencies around the country, around the world, are eventually going to say, well, we want our residents trained this way. Because I think they know that the medications have their pros and cons 1s and that they would like other options. U1 24:15 Yeah, I know they put me on some pretty heavy sleep medicine and it just made me sleep during the day, U2 24:23 which is not the goal. No. U1 24:26 But if I took your book to my sleep doctor and, hey, can I try this? 1s Would I get a good response? Or would it U2 24:35 just it's a very interesting question because a lot of sleep doctors out there know of me and know of our work. A fair number of them reject it. And why do they reject it? Largely, in my opinion, is that they just don't have the background for it. I was very, very fortunate. Divine providence is absolutely what I call it because I started in the field working with psychiatrists and ended up staying always associating with psychiatrists and psychologists wherever I did stuff in sleep medicine. It was just my niche. Well, the average sleep doctor is a pulmonologist. What's their exposure to psychiatric health depends. But in general, they're not looking to treat a PTSD patient or a depressed patient or an anxiety patient, because those patients actually are more difficult to treat. They're much more difficult to get them to use machine. Very high rates of CPAP failure. So that would be frustrating to them. On the other hand, there's other doctors that do know about the work and do know that it is worth considering. And so they'll say, Well, I've heard about that. What would you like? Would you like to try a bi level device? Yes, we can try that with you. We don't have to put you through the torture of CPAP. 2s But it is hit or miss, and it's unfortunate that it's not more consistent, and I hope this book is going to change that. Okay, U1 26:07 how would we find a sleep doctor that would use this approach? U2 26:13 Trial and error. What city are you in? U1 26:16 I'm in St. Louis. U2 26:19 Right. So undergrad there. Washington University. That's cool. Yeah. And they have many sleep doctors in St. Louis, and it's simply a question of calling around, and you can ask some very key questions like 1s do you prescribe devices for sleep apnea besides CPAP, like bilevel? And if the person on the other end of the line goes, what's bi level? You say, oh, maybe this is not the right place. 1s I have a lot of discussion about exactly this point in the book, life Saving Sleep, where it talks about how are you going to communicate with these doctors, whether it's mental health professionals or sleep doctors, when you want to get more advanced care about your sleep medicine treatment programs. And I point out about how diplomacy works really well, but so does being educated. If you walk in the door to a sleep center and you're talking what you know about bi level and expiratory pressure intolerance and why you think that device might be better for. 2s That usually makes a doctor sit up and listen, like, oh, I'm talking to somebody who's done a lot of reading and knows a lot about sleep medicine, and I should listen to what their interests are and see if I can help them. Most doctors are like that, in my opinion, even if they don't necessarily agree with the way I practice. But most doctors tend to respect patients who've done a lot of homework. In my experience, U1 27:58 it okay. 1s And one thing you mentioned is, like, some of the psychological drugs causing 1s either helping or hurting 1s sleep. U2 28:13 Yeah, there's just so much reliance on psychotropic medication, and that's unfortunate, because we know those medicines don't work to perfection. If they did, there wouldn't be any sleep centers, because everybody whose problems have been solved with drugs, and they're not. And so that's another modality that when PTSD patients walk into a sleep center, the doctors often say. 2s Well, what do you want, a new medication? And see, the person has to go, well, no, I've tried medications. The medications don't work. I think I need a sleep study. It's very sad for me to tell you how many times patients have come to me and said I had to literally beg to get a sleep study. My doctor said, oh, no, there's nothing wrong with your sleep. You need pills. You need psychotherapy. And these patients were crying because these doctors would not listen to say, well, what about the possibility of a sleep breathing condition or a leg movement condition? And so it is a tough road to hoe right now. But my book gives people so much knowledge and makes them so educated on the possibilities that sooner or later they're going to be able to connect with somebody who's going to listen. And that's where 1s I'm hoping things are going to be changing more rapidly than they had previously. U1 29:41 So is a lot of your stuff also taught with sleep therapists? Because I know there's specific therapists that work with people that have trouble sleeping. U2 29:52 Well, the term sleep therapist is a little bit 1s confusing because there's a lot of people on the web who call themselves sleep therapists, and most of them are just trying to be sleep coaches. Others are saying they're doing cognitive behavioral therapy, and that could be an actual 1s trained mental health professional. So in that range, there's a lot of services that can be quite valuable. I'm not saying the confusion means they're not good 1s at providing services, but I'm saying you have to find out what your needs are. Some people can help somebody learn to use a PAP machine better. Somebody else can help with insomnia, somebody else with insomnia. I do all of that. But my point is you have to look on what they're offering, and you have to look at their credentials to get the feel for whether or not that's going to be a good fit for you. That feel what you just said, though, is exploding. Lots of people are trying to become sleep coaches. Lots of doctors, like myself are kind of disappointed in the way some of medicine is being practiced. So I've chosen to open up this sleep coaching service, which is different than being a medical encounter. And that just makes it easier for me. It makes it easier for the patients. U1 31:15 Okay. And does insurance cover 1s the sleep type therapy very much? U2 31:24 If you call it coaching. 2s Often. It's probably not covered. That's why I do it. I want it to be direct cash pay. If you call it a therapy, like I'm giving cognitive behavioral therapy for insomnia, there are billing codes that can be used that some insurances will take. And some people in fact, if you look on the web, you'll see certain providers who will say, we take take insurance. 1s So there are opportunities there as well, and certainly going into sleep centers. If a sleep center has hired a CBTi specialist in their sleep center, then they in all likely they're taking insurance for that. Okay, 1s what would you like to wrap up with? 2s Well, U1 32:16 I know a lot of people that are survivors of this level of trauma, which is usually childhood sexual abuse U2 32:24 or growing up with a borderline or have 2s severe mental health issues. 2s They also U1 32:34 get a lot of autoimmune like asthma and diabetes. And how does that U2 32:40 impact? That's a good closing question. And maybe also I'll just put in a plug for myself if you want to do a future podcast on this. You can see there's a lot more we can discuss. But that's a great closing point, because you're talking my language when you say mind body medicine, and that's what you're talking about. It's amazing how much 2s people with psychological conditions end up with physiological problems too. Now, the core of that, I believe, is what's called psychosomatic medicine, which means and it's not meant to be pejorative. It's a very positive term. It means that the way emotion is processed. 2s Is not as healthy as it could be. And the emotions now get into the body and produce these or part of producing these conditions. And a classic example, of course, would be high blood pressure. If you have not processed your emotions and you are angry much of the time, your risk for getting high blood pressure are much higher. There's also no surprise sleep disordered breathing. Sleep disordered breathing is like smoking a pack of cigarettes a day. Most people don't know that, but that's a good analogy because what does smoking a pack of cigarettes a day do to you? It causes what's called pro inflammatory markers to pervade your body. It causes oxidative stress, which produces more dangerous biomolecules in your body, and then eventually it produces endothelial dysfunction, which just means that the inner linings of your blood vessels don't work and they cause all kinds of damage in wherever those blood vessels are. That's how you get high blood pressure. In fact, most people with high blood pressure have sleep apnea. So if you take the concept of psychosomatic medicine that has a lot to do with how a person has learned to process emotion or not, and you combine that with sleep disordered breathing, you have a lot of explanation there of how people end up with so much physiological disruption to their bodies. And it is an area of medicine where we desperately need more and more doctors to start practicing instead of this mind body dual where, well, I'm over here treating your body, and I'm over here treating your mind. That's not the wave of the future. The two have to converge. And I'm so delighted to know there's people out there that are thinking about this mind body approach because that is where health care has to go. Yeah, well, I mean, I'm sure you've read the Body keeps the score. U1 35:30 Or if you haven't, I recommend it. U2 35:32 I talked to Bessel almost 25 years ago in a conference that he was giving a lecture for us at the University of New Mexico. And I explained to him at that time, 2s keep your antenna up for the relationship between all you're talking about and sleep disordered breathing. So I informed him of that connection all the way back then, because in the mid 1990s, when I met him, that's when we were first beginning to see that connection and absolutely the body. Keep score. U1 36:08 Okay, last question. 2s How has this impacted your faith, working with trauma and 3s being this close to it? U2 36:22 When you say my faith, do you want to elaborate what you mean by that, or is it just take it at face value, take U1 36:29 it whichever way you want to take it. U2 36:31 Okay, well, I first of all, believe very strongly if you can see my little teapot here, I'm an observant Jew, and I've been moved to Savannah particularly to be involved in a Jewish congregation. Ben Abrith Jacob and I believe I actually got into this field through divine providence because a series of steps occurred that led me to do this. 2s I wouldn't have thought I would be the person to do that, but it turns out this has been my destiny, and I have been working with people who've suffered very, very severe trauma. And the part to me that is the most uplifting is the fact that people do recover from trauma. And I'll point this out to you because maybe this is where you're going with it, but I'll just tell you my experience. When I first began reading and learning about trauma in the 1980s, at that time, the discussion was nobody recovers. It was very common for people to say that, well, they never get better. They never recovered. And that just wasn't logical to me. Even though I wasn't a psychiatrist or psychologist, I go, what do you mean they don't recover? Nonetheless, I was not an expert, so I was reading from the experts, trying to understand what they said. And so it was very exciting for me to begin to see people from. Who were told things like, well, your nightmares will never get better. You have PTSD. We're doing the best we can. And then along comes this technique, IRT, and people are getting better. We go, oh gosh, this is an amazing thing. There is hope for individuals. Same thing, especially with insomnia and sleep disordered breathing. You see these changes in people and they realize there's some very famous cases of people who've been cured of their PTSD by treating their sleep disorders. I'm not saying that happens to everybody, but my point is it's very uplifting to know that the human spirit has so much potential to grow. And so I am very much uplifted by having worked with these individuals. I know they suffer tremendously, but I also know they're still alive and they're still working and growing and trying to progress. And we as healthcare providers have the ability to give them tools to have even greater growth and greater recovery. And that's a wonderful thing in the 20th 1st century to know there is so much more potential for that. So that has absolutely enriched my faith. U1 39:16 And I guess last question is, what do you do for self care? U2 39:21 I sleep. 1s I get great sleep. I work on my sleep and have really good routines and take naps when I need to use low doses of green tea on occasion. If I need that, use my ASV device. 2s I make sure that I get really solid sleep, work on that very diligently. And the other self care is exercise and good food. U1 39:50 Okay. 1s Is there anything else you would like to add before we close out? U2 39:57 Just further promotion of my book, Life Saving Sleep and my website. Barrycracomd.com one more tool I haven't mentioned is that if people want to follow some of my commentary on a regular basis, usually every week, every other week, I have a free substac newsletter where I will be commenting on recent research in sleep and giving some interesting tips pros and cons, whatever it's called. Fastasleep substac.com. U1 40:32 Okay. All right, guys, thanks for listening. This is Rachel U2 40:36 in recovery. We'll be back next Thursday at 10:00 A.m.. If you have any questions, reach out to rachelrecovery.com. Always follow us on your favorite social media platform and or podcast, and always subscribe on YouTube.