Articles & Essays Discussion
Recovering Night: Alcohol, Substances and Sleep
A few years ago I found myself at an AA meeting in a small community in Southern California. It had been some time since I had accompanied a friend in recovery to a meeting. Having periodically attended various 12-step meetings around the country over the past couple of decades, I generally knew what to expect. The only surprise here was that the smokers were now huddled outside, quickly getting a last nicotine fix before the start of the meeting. Inside, the coffee drinkers were busy customizing their hits of caffeine.
Aware that the issue of nicotine and caffeine use in recovery had been beaten to death, I let it go and sank into my chair with anticipation of the heartfelt stories to come. I’ve always had a deep regard for the fellowship—the deep sense of welcome, support and openness. But then, surprisingly, I found myself dozing off. Certainly not for lack of interest in the stories. Recent cross country travel had left me sleep deprived and jet lagged. When we are sleepy and happen to find ourselves in a socially safe and supportive environment, it’s really difficult to stay awake.
Later that evening, back home with the friend who had invited me to the meeting, I watched him casually pop an Ambien, a fashionable prescription sleeping pill. I couldn’t help myself. “Hmm. Do you really need to take that?” I asked. He paused, looked me in the eye and said, “Every night… for five years now. I’d be up all night without it.”
I let it go.
But, not really.
The contrast between the spirit of sobriety in the meeting and my friend’s dependence on sleeping pills was striking. As a psychologist specializing in sleep and dreams, it left me thinking about the key role of sleep problems in addictions and recovery. Over the years, I had seen hundreds of patients with troubled sleep who were also dependent on alcohol. And many others who used alcohol more sparingly, but quite consistently as a sleep aid. Then there was an even larger group who routinely relied on other licit and illicit substances like sleeping pills, tranquilizers and marijuana to knock themselves out at bedtime.
Sleep problems are epidemic in our world today. From a simple numbers standpoint, sleep disorders are the most prevalent health concern in America. Seventy-six percent of American adults report symptoms of sleep problems at least a few nights every week. Most struggle with insomnia—difficulties with falling asleep, staying asleep, and/or maintaining quality sleep through the night. Chronic sleep loss leaves us depleted, fatigued and excessively sleepy by day, potentially interfering with all aspects of life. There is strong, mounting evidence that compromised sleep is associated with a wide range of serious medical conditions including cardiovascular disease, infections, diabetes, obesity and even cancer. Fully 80 percent of people with psychiatric concerns also suffer from sleep disorders. Insomnia, which is a classic symptom of depression, is also a major cause of depression. In fact, a year of insomnia is the single strongest predictive factor for future depression.
It’s well known in both professional and recovery communities that most alcoholics have significant sleep problems prior to active drinking, during active drinking, and often through treatment and recovery, as well. While 15 percent of the general adult population struggles with chronic insomnia, more than 50 percent of alcoholics report having sleep problems that predated their drinking by years.
Dependence on substances is also epidemic in our world. We turbo charge our daily lives with counterfeit energies–stimulants including highly processed carbohydrates, caffeine and nicotine. And, then, accelerating out of control, we depend on sedating substances like alcohol, marijuana and sleeping pills to provide a kind of counterfeit rest at night. Part of the special appeal of alcohol is that it initially functions as a stimulant and then becomes a depressant. In this way, it doubles as an agent of both counterfeit energy and counterfeit rest.
There is a common belief in our world that it is often necessary and reasonable to “take something to sleep.” I think it is questionable, however, if sleep inducing substances actually provide true, restorative sleep. Although they might offer us temporary relief by masking symptoms of insomnia, this does not constitute good sleep any more than masking the symptoms of anxiety with alcohol provides good mental health.
Many people believe that alcohol actually helps them sleep. Although it appears to facilitate sleep onset, alcohol suppresses melatonin, alters our circadian rhythms, and significantly disrupts sleep and dreaming later in the night. Drinking is also known to exacerbate snoring and sleep apnea, a serious condition in which breathing is compromised during sleep.
We continue to naively mistake the jittery buzz of counterfeit energies for natural vitality and the doped-up drowsiness of sedating substances for true sleep. Consequently, we remain in deep denial about the obvious link between our dependence on substances and the sleep disorders epidemic. It is striking that so few professional treatment programs address sleep aspects of recovery in a meaningful way, leaving their clients vulnerable to failure and relapse.
Even though sleep problems are common among alcoholics, there is little mention of them in the Big Book. There was limited social consciousness about them since they had not yet become a serious concern. Recovering alcoholics at the time had limited options for addressing their sleep struggles. They could use barbiturates, the highly addictive and potentially lethal sleeping pills available at the time or, as I suspect most did, they could just tough it out.
Because it could seriously interfere with one working the program, the excessive daytime sleepiness symptomatic of chronic sleep disturbance had to be managed in some other way. Enter nicotine and caffeine. These two highly stimulating substances could alleviate excessive daytime sleepiness by providing energy, albeit counterfeit, on demand. I believe that smoking cigarettes and drinking coffee became strongly sanctioned practices in AA because of their effectiveness in masking the daytime symptoms of disturbed sleep.
Although they do not alter waking consciousness the way alcohol does, caffeine and nicotine both interfere with melatonin production, damage circadian rhythms and compromise healthy sleep and dreams. At least as compelling is the negative impact of smoking on health. A recent review in the Journal of American Medical Association reported that alcoholics were significantly more likely to die of smoking related illnesses than from diseases associated with drinking. Despite this, many in recovery remain in denial about their dependence caffeine and nicotine. I believe that the habitual use of these substances can both encourage alcohol dependence as well as disrupt the sleep of alcoholics in recovery.
In large part, sleep and substance problems are linked to our damaged relationship to circadian rhythms–to the daily cycle of light and darkness. In nature, light stimulates and energizes us, while darkness facilitates rest and sleep. Light triggers the release of serotonin, which energizes us by day. Dusk and darkness trigger the production of melatonin, the key neurohormone that mediates sleep and dreams. Unfortunately, modern lifestyles significantly limit both our exposure to natural light by day and to dusk and darkness at night.
Beyond the effects of chronic sleep loss, our daytime energy is further compromised by our peculiar tendency to avoid sunlight. The vast majority of us spend the bulk of our waking hours indoors. In fact, the average American adult gets about one hour of natural outdoor light exposure per day. In contrast to this underexposure to light by day, most of us are overexposed to light at night.
Not surprisingly, evening appears to be the most common period of substance and medication use. While many are concerned with trying to slow the frenetic pace of their days, others turn to energizing foods and substances in search of a second wind. Or, often unconsciously, they turn to light. Light can readily functions much like a substance at night providing significant counterfeit energy. Even relatively small amounts of light in the hour or two prior to bed can discourage rest by suppressing melatonin and encourage wakefulness, activity and productivity.
Six Steps to Serene Sleep
To improve sleep, sleep problems must be addressed in a comprehensive way that includes sensitivity to the full range of biological, psychological and environmental factors. Neither does a “one size fits all” approach work. We must personalize our approach to healing sleep. At the risk of appearing to reduce healthy sleep to a formula, which I do not believe is possible, I would like to offer six general recommendations for improving sleep:
- Practice rest. Become more mindful of the ebb and flow your energy throughout the day. When you feel it is running low, instead of relying on counterfeit energies, experiment with allowing yourself a moment of rest. Consider engaging in a brief meditation, contemplation, prayer, or a breathing exercise. Additionally, experiment with developing special rituals for slowing down and resting an hour to before bedtime.
- Get shady and cool as night. Just like the outer world, we need exposure to darkness and we literally need to cool down in order to sleep well. To trigger a natural rise in your melatonin, dim the lights in and around your home for a couple of hours before bedtime. If this is inconvenient, consider using “blue-less light” products that do not suppress melatonin. (See lowbluelights.com) You can use this time for restful activities such as gentle yoga, journaling, meditation, and/or intimate times with friends or loved ones.
- Create a sleep sanctuary. Re-fashion your bedroom so that it does not tether you to the waking world. More specifically, make sure your bedroom is cool, dark, and quiet. And use a HEPA filter to make sure you’re breathing clean air at night. Over time, gradually move toward using more organic or “green” bedding products. Above all, make sure you feel psychologically safe in your bedroom.
- Surrender to sleep. If you depend upon them, gradually relinquish your use of sleep substances. Instead of “taking something to sleep,” consider “letting go of something to sleep.” Begin looking at sleep as part of your spiritual practice. Falling asleep—whether at the beginning of the night or after a middle of the night awakening-—is not an act of will, but one of willingness. I believe the simplest yet the most difficult aspect of getting to sleep is the surrender of one’s volition. We cannot literally “go to sleep” as an act of will. We can, however, let go of our waking sense of self. In doing so, we let go of our ordinary sense of self and, metaphorically, we die. All complexities aside, we come to understand that falling asleep is an act of faith.
- Manage your nighttime wakefulness gently. To minimize difficulties falling asleep, go to bed only when you’re feeling sleepy. Once in bed, do not watch the clock. In fact, it’s best to get the clock away from your head (it can suppress melatonin) and out of view. Be especially gentle with yourself if you awaken in the middle of the night. To keep your bed from becoming associated with struggles to get back to sleep, get out of bed for a few minutes and sit quietly in a dim or dark space. You can use this time to meditate or pray. Return to bed when you become sleepy.
- Arise with intention in the morning. If awakening is a kind of birth, then morning is the childhood of the rest of our day. Allow yourself to awaken slowly and gradually, being mindful of what we commonly think of as grogginess. Since we usually awaken in the morning from dreams, what we call grogginess is actually an exquisite, hybrid state of dreaming and waking consciousness. Lingering in your grogginess will deepen your connection with dreams. Just allow any dream images to float into consciousness before you get out of bed. Consider journaling your dream experiences.
I believe that people active in alcohol recovery programs could benefit from a firm commitment to improve the quality of their sleep and dreaming. I believe that the practices that support healthy sleep and dreaming are, in fact, consistent with those found in recovery programs. If insomnia or other sleep difficulties persist, however, consider consulting a qualified health care professional.
Our current, conventional, highly mechanistic approach to understanding and healing sleep and dream problems is failing. My work is meant to lay a foundation for a new approach, one that is, in the broadest sense of the term, integrative. Although it wholeheartedly supports the integration of conventional medical treatments with those of complementary and alternative medicine, this work is primarily concerned with an even more fundamental integration, that of the segregated aspects of our consciousness. Truly effective strategies for preventing and healing sleep and dream disorders are hampered by the absence of such an approach.
We cannot meaningfully understand sleeping, dreaming and waking independently of one another and outside of the larger context of their daily rhythmic sweep through our lives. In recognizing their continuity, an integrative approach reinstates a critical sense of something desperately lacking in our highly mechanized and driven world: nature’s fundamental rhythmicity.
This integrative perspective invites subjectivity back into science. It recognizes the importance of personal and social meaning as a balance to hard science’s overly objective posture toward night consciousness. In doing so, it acknowledges, considers, and respects the legitimacy of the personal experiences of sleeping, dreaming, and awakening. Essentially, it restores consciousness itself to night.
An integrative approach also incorporates spirit back into science. It calls for complementing sleep medicine’s objectivity with a depth psychological and traditional, sacred view of night consciousness. Such a spiritual perspective of night is certainly not new. Regard for sacred dimensions of night and night consciousness is found in all major Eastern and Western religious traditions, including Hinduism, Buddhism, Judaism, Christianity, and Islam.
Ancient and indigenous spiritual beliefs and practices, as well as metaphysical teachings, also acknowledge the sanctity of darkness, sleeping, dreaming, and awakening. For example, Rudolf Steiner, the prolific nineteenth-century Austrian philosopher, lectured extensively and passionately about the critical role of sleep and dreams in spiritual life. The integration of sleep science with personal meaning and spiritual perspectives opens the way to a more expansive, magnificent, and mythic vision of night, sleep and dreams.
Narcolepsy is a complex condition with biomedical, psychological, social and, I believe, important spiritual dimensions. An integrative approach invites us to reconsider narcolepsy from a broader perspective. It encourages us incorporate key biomedical knowledge into a larger psychosocial and even mythic framework. Since narcolepsy is a lifelong condition, it also calls upon us to consider questions of deeper, personal meaning we might attribute to our condition.
Among the key symptoms people with narcolepsy encounter are chronic insomnia, cataplexy and intensified dreaming. Fortunately, our understanding of insomnia and techniques for managing it has been expanding dramatically. I believe that overexposure to light at night is the single most important overlooked environmental factor in the contemporary insomnia epidemic. Newly emerging “blue blocking” technology that can facilitate natural increases in melatonin open new avenues for addressing poor nighttime sleep. Likewise, I feel that the psychospiritual process of surrender or letting go into sleep and dreams is a most critical overlooked personal factor in treating insomnia.
Cataplexy is one of the most challenging symptoms of narcolepsy. Because managing the symptoms of cataplexy is essential to living a normal life, our most common treatment response involves symptom suppressive medication. I have long felt, however, that it is also useful to be open to a more mindful understanding of the subjective experiences associated with cataplexy. It is helpful to understand that cataplexy is not so much a “sleep attack” as it is an intrusion of features of REM/dreaming into waking consciousness. Cataplexy, then, is more a dream attack. But even seeing it as an attack introduces a prejudice that may obscure our deeper understanding. Cataplexy, ultimately represents a heightened permeability between the waking world and the world of dreams. If we recognize the creative and spiritual potential of dreaming, we may be able to draw something positive even from cataplexy.
I would like to encourage a greater mindfulness of these experiences and a sharing of what we find. To do this, we must begin by depathologizing cataplexy. What might we discover if we kept our spirits strong when our muscles weaken? What might we learn about where cataplexy takes us if we were a bit less concerned about what it removes us from? In the past, I have looked at cataplexy in terms of “reluctant shamanism.” Shamanic practices involve intentional access of the dream world while awake to facilitate healing.
I am interested in continuing the exploration of the interface of narcolepsy and spirituality. The renowned Sufi poet, Rumi, for example, emphasizes night, sleep and deep surrender in his work. When Rumi’s translator Coleman Barks was asked to describe the poet’s concept of the divine, he said it was “the impulse to laugh.” Laughter, of course, is one of the most common triggers of cataplexy. What has been referred to as “holy laughter” in certain evangelical movements results in a spontaneous loss of muscle tone that looks much like cataplexy. Finally, the contemporary myth of the Superman might offer some teaching about cataplexy, as well. This idealized image of super human power has a dark, powerless side. When exposed to kryptonite, of course, Superman’s strength is suddenly sapped, he buckles and drops to the ground. Sound familiar? Superman’s reaction to kryptonite—an element from his planet of origin— is very reminiscent of cataplexy.
When we dream, we believe we are awake. That is, while we’re actively engaged in a compelling dream, we truly believe we are awake. The only other time we believe we’re awake is– well, when we are actually awake. Dreams mock our very sacred sense of reality. Perhaps, it is one reason we pay such little attention to them, or, more accurately, why we so frequently and persistently try to dismiss our dreams.
On occasion, however, we are all visited by a dream that is not so readily dismissed — what is sometimes called a “big dream.” It might be nightmarish, eerie, or just rich with meaning. Whatever the reason, it simply lingers through the day; it won’t let us go, and it begs for interpretation.
Much has been written across time and cultures about approaches to dream interpretation. Virtually all such approaches allow us to make psychological sense of dream content. They do this essentially by explaining the dream in terms of our view of the waking world. Our psychological sensibilities–the things we just presume to be true become the gold standard we use to evaluate our dreams.
Such approaches presume that we can understand dreams, a form of non-ordinary consciousness, by comparing them to ordinary waking consciousness. Much like the pre-Copernican view of the solar system, this is a comforting but highly psychocentric perspective. It denies the existence or importance of anything that lies outside of our current waking frame of reference. It also sanitizes the unconscious, neutralizes the mysterious, and limits our personal growth.
The spiritually fatal flaw of such dream interpretation is that it implies we can come to fully understand a dream. An alternative approach suggests there is a meaningful but irreducible mystery in dreaming. In the end, is it not more important to know there is meaning in a dream than to know exactly what that meaning is? We can best understand dreams only in the larger context of the process of dreaming itself.
Picture a serene, dimly lit bedroom. Curtains flap in a gentle breeze as an angelic night moth glides gracefully across the room, bestowing sweet slumber upon some lucky soul. Leave the rest to Lunesta says the tagline.
Anyone who has flipped through a popular magazine or turned on a television set in recent months is all too familiar with this scene. Consumers are now being barraged by an unprecedented campaign to promote the sale of sleeping pills or so-called hypnotics—a $4.5 billion a year and rapidly growing pharmaceutical cash cow.
Hypnos, the sweet-natured Greek god of sleep and namesake for hypnotics, would turn over in his grave. The sleeping pills that bear his name do not provide true sleep. At best, they produce a kind of simulated sleep—a chemical knock out with potentially dire long-term health consequences.
Sleep professionals and advocacy groups keep reminding us that sleep disorders are rampant and pernicious, while their pharmaceutical bedfellows simultaneously offer convenient, ”safe and effective” solutions in the form of new and improved hypnotics.
Recent advertising campaigns as well as extensive media coverage of sleeping pills draw our attention to interesting questions of safety, effectiveness, convenience, and side effects. Although such discussions appear to be germane, the question of which hypnotic might work better sets up a false dichotomy. It diverts our attention from a deeper, more substantial and pressing issue—that of how to obtain truly healthy sleep.
Sleeping pills commonly result in dependence. They can alter normal sleep patterns, cause amnesia, residual daytime ”hangovers,” and rebound insomnias upon discontinuation. Although they might offer temporary relief by masking the symptoms of insomnia, they do not provide true sleep. Masking the symptoms of insomnia does not constitute good sleep any more than masking the symptoms of anxiety with alcohol provides good mental health. Perhaps most alarming, evidence suggests that chronic sleeping pill use is associated with a significant increase in mortality.
At best, most sleep aids should be seen as a short-term aid, a component of a more comprehensive sleep health regimen. Like a cast on a broken bone,a sleeping aid can provide a temporary structure that supports, but does not substitute for, real healing. After years of tolerating the unendorsed long-term use of Ambien by consumers, the FDA’s recent approval of a number of sleeping pills for long-term use is tantamount to approving the long-term use of a cast. This will only worsen the already widespread atrophy of our own, innate ability to fall asleep.
In the end, sleeping pills offer only negligible improvements in sleep, extending sleep time on average for less than one-half hour. Recent research suggests that these medications mask awakenings, misleading people into thinking their sleep is much better than it actually is.
Sleep cannot be reduced to squiggly EEG tracings and the cascade of neural humors. There is a critical but forgotten, deeply personal and even mythic dimension to sleep that has been obscured by our narrow, overly-clinical medical approach.
Hypnos, the god of sleep, is calling for resurrection. The favorite son of Nyx, the mighty Greek goddess of night, he would remind us that sleep is naturally born of night and darkness. Research is confirming that exposure to dusk and darkness is an essential though all but absent component of healthy sleep. So many of us have slept poorly for so long, we have forgotten what it is like to experience truly deep and refreshing sleep. Natural slumber calls for a gentle and intentional surrender to night, a voluntary relinquishment of the day, a letting go our waking selves.
Our inclination to take something to sleep must be tempered with a fundamental psychological and spiritual practice of letting go of something in order to sleep. To awaken from our sleeping pill trance, I believe we must carefully reconsider the key role of night, dusk and darkness as a natural medium for letting go. Straight up, in its undiluted form, even with long-term use, night itself may be the best sleep medicine.
An Interview with Dr. Naiman
Dr. Naiman, How did you become interested in sleep health?
Dr. Rubin Naiman: Actually, I became interested in the connection between dreams and health early in my college years. As I came to understand how critical sleep was to general health, I gradually expanded my professional work into that arena. My parents also strongly valued sleep and passed that on to me.
So, it sounds like sleep medicine might be more than a professional interest. Is it also a personal passion?
RN: Absolutely. Not only do I believe that sleep is one of the key components of optimal health, I feel it’s associated with deeply personal and even spiritual matters. Much of what I have learned about sleep and dreams has come from a commitment to practice what I preach. And, given modern lifestyles it’s a great challenge.
What about our modern lifestyles makes healthy sleep such a challenge?
RN: Well, our culture tends to reinforce lifestyles that are too fast, too focused on productivity and activity, and too disconnected from nature. We have lost touch with the art of resting, for example. The vast majority of us don’t really know how to slow down and truly rest. Often, people confuse rest with recreation, and they’re not the same. We’re excessively driven and addicted to seeking energy to fuel this drive. I believe this is one of the reasons we are so dependent on artificial stimulation from highly refined foods, excessive caffeine, and adrenaline producing activities, all of which further disrupt our sleep.
How do you handle these kinds of sleep disrupting challenges in your life?
RN: I try to consciously manage the flow of energy in my life, limiting foods and substances that sharply spike energy, like highly refined carbs, caffeine, and alcohol. I also use supplements to compensate for the inordinate chemical and environmental stressors we all live with. Beyond that, it’s very important to recognize that light itself is a potent form of energy. Most of us unknowingly are overexposed to light at night. Excessive nighttime illumination encourages excessive nighttime activity. And it also suppresses endogenous melatonin production.
Certainly, we all depend a lot upon evening light. Is it really possible to live without it?
RN: I don’t suggest forgoing all light at night, just becoming more conscious of its energizing effect and managing that. I practice dusk simulation, intentionally turning lights way down about one hour before bed. I use dimmers and artificial, low-light candles. If I watch TV or work on my computer, I dim the brightness on the screen or sometimes wear sunglasses. It sounds silly to some, but I’ve found this creates a soothing, more natural, and sleep-conducive environment. Still, it’s impossible for most of us to sufficiently limit light at night.
You said that excessive light at night could also decrease melatonin. What are your thoughts about melatonin supplementation?
RN: I have been taking a small dose of melatonin nightly for more than a decade. Not because I have a sleep problem, but because I believe modern lifestyles mitigate against natural melatonin production. In the same way we need extra nutrients to compensate for the inordinate stressors we are routinely exposed to, I believe we need to compensate for similar stressors in our sleep-wake cycle. Unfortunately, melatonin supplementation is complex. Because it is not a one-size fits all matter, consumers need to become much more informed.
What else do you do personally to maintain healthy sleep?
RN: Well, my bedroom is carefully designed to support quality sleep. I use black out and sound baffling drapes to keep it quite dark and quiet throughout the night. And, I sleep on a very comfortable, adjustable air mattress with a memory foam pad. I also try to keep a regular sleep schedule, getting to bed and getting up at about the same time every day of the week.
Do you do anything psychologically to prepare for sleep?
RN: I believe we need to slow before we can stop. Unless we are significantly sleep deprived, we must slow and rest before we can naturally fall asleep. We slow at night by engaging in quieting and relaxing activities. Evening is an ideal time to practice spiritual techniques like meditation, prayer, and journaling. I also think naturally sedating supplements like chamomile, theanine, or GABA, for example, can be useful on those occasions where we need extra braking power.
Are there occasions when you would use a sleeping pill or natural sleep aid?
RN: Of course. Sleep doctors are not immune to sleep issues. I have had occasional struggles with insomnia and even more with jet lag. To be perfectly candid, I tried a prescription sleeping pill only once in my life and it certainly did “knock me out.” Unfortunately, most people can’t tell the difference between natural sleep and a chemical knockout. Natural sleep involves a more gentle transition and is deeper and more refreshing than what is offered by pharmaceuticals. I generally recommend them only under extreme circumstances. Natural products are generally more conducive to natural sleep. I personally prefer blends of botanicals like valerian, chamomile, skullcap and others with sleep promoting nutrients like magnesium, GABA, and, of course, melatonin. I’m particularly partial to Source Naturals’ selection of bio-aligned sleep products.
Given all of this, is there a secret to a good night’s sleep?
RN: In the end, the quality of our sleep at night depends on the quality of our waking by day. Our nutrition, exercise, attitude, relaxation, and even our faith all play a role in the quality of our sleep. As much as I endorse the use of supplements to help us sleep, I believe we need to use them in an informed and judicious manner, as a part of a larger lifestyle oriented approach to optimal health. I guess, then, the secret of a good night’s sleep would be a good day’s waking.