Sleep waves and recovery from drug and alcohol dependence: Towards a rhythm analysis of sleep in residential treatment

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A language of rhythms: the circadian and entrainment

The paper reports on a study of the sleep of men and women living in drug and alcohol residential treatment services. Prompted by a biomedical literature that indicates that good sleep can play a critical role in recovery (Conroy and Arnedt, 2014) and a separate sociological literature that indicates that in residential treatment sleep, subjectively at least, can improve, the aim of this article is to deploy Lefebvre’s(2004 [1992]) rhythmanalysis to make sense of empirical data on sleep in these settings. Lefebvre’s rhythmanalysis, at once a conceptual and a methodological approach, is apposite to sleep.

natural and social science disciplines. We then offer a summary of Lefebvre’s rhythmanalysis and his use of the wave metaphor. We find that across disciplines there is an emphasis on the play between multiple endogenous (internal) and exogenous (external) rhythms indicating scope for the analysis of sleep as embodied: viscerally and socially. These analytical insights give purchase on the interpretation of our empirical data, which comprise qualitative interviews, self-completion sleep diaries, and actigraphs. Throughout our analysis we play with the idea of sleep waves as a foil to the neurophysiological articulation of the term as used in the vocabulary of ‘circadian rhythms’ and ‘slow wave sleep’. We introduce these terms that are core to sleep science and then turn to Lefebvre’s conceptualisation of rhythms and waves, and suggest that a sociological notion of sleep waves serves to capture the extent to which sleep is repetitive and rhythmic and always a combination of biological and social contingencies.

because it seeks to examine the temporal, material and relational aspects of embodied social life. The central concept – rhythm – takes many interconnected forms. Embodied rhythms are, for instance, related to spatial rhythms, temporal rhythms, natural rhythms, and cosmic rhythms. This focus on temporalities and rhythms finds resonance in biomedical literature on sleep in general, and sleep and drug use in particular, indicating potential for interdisciplinary research on this topic. The lexical affinities of sociobiological clocks and rhythms, although rooted in divergent epistemological traditions, offer opportunities for dialogue across the human sciences. Rhythmanalysis may therefore be a way to respond to calls within the sociology of health and illness for interdisciplinary exchange between social and natural scientists. We foreground our empirical data with a brief review of how sleep is described in temporal and rhythmic terms within the crime, disorderliness and safety, and availability of transport.  In combination, studies point to the interconnectedness of socio-temporal, spatial, experiential and biological rhythms, suggesting that Lefebvre’s rhythmanalysis may be a particularly apposite analytic for comprehending sleep within given socio-spatiotemporal configurations. Lager et al. (2016) suggest that Lefebvre’s rhythmanalysis links chronobiology with chronogeography, highlighting how the ‘rhythmic orderings of people and place come into being and inform their experiences’ . As we have seen, the life sciences focus on the endogenous but also acknowledge  although they do not elaborate on – the exogenous. So rhythmanalysis offers a tool to integrate disciplinary approaches.

Sleep scientists work on the premise that sleep combines two interrelated processes: sleep pressure (a homeostatic process) which increases as individuals remain awake and decreases as they sleep, and circadian rhythm (the ‘internal biological clock’) which is unaffected by sleep deprivation (Borbely, 1982). They assert that the homeostatic and circadian processes are interlinked: homeostatic processes primarily determine ‘slow-wave sleep’, whilst the circadian rhythm regulates Rapid Eye Movement (REM) sleep. In ‘healthy’ sleep, the endogenous circadian clock is aligned with, or in the language of sleep science ‘entrained’ by, diurnal cues, known as ‘zeitgebers’, such that ‘normal’ sleep is in tune with the day/night cycle. Light is considered the dominant stimulus for this ‘entraining’ of circadian rhythms to local temporal environments.

Sleep science, then, frames sleep as a series of chronobiologically endogenous processes and circadian rhythms which are nevertheless influenced by external social factors and social ‘clocks’. Research on sleep and addiction currently prioritises a focus on endogenous (internal) processes; exploring alterations in circadian systems with exposure to substances of abuse. For example, studies of alcoholdependent adults at two weeks into withdrawal show phase differences in melatonin profiles relative to ‘healthy’ controls (Hasler et al., 2012). Additionally, male heroin-dependent individuals show disruption in cortisol rhythms three days post cessation, but not by day ten, suggesting that the first few weeks of abstinence may be a key time for chronobiologically informed treatments. However, the same individuals also show longer-term disruption to the rhythms of the ‘clock’ genes. These genes are also implicated in reward processing, with clinical scientists suggesting that their continued disruption may contribute to persistent craving and withdrawal. Despite this focus on endogenous processes, the model of sleep underpinning this research remains one which talks of both internal and external rhythms. The study of chronobiology can be linked to ‘chronogeography’, wherein social places are continually ‘(re)made through the intersection of multiple rhythms’. Places are understood to be generative of rhythmic events (such as, job shifts, opening hours of shops, transport timetables, festivals and so on) which are said to act like ‘pacemakers’ (or zeitgebers see above), pacing both single behaviours and constellations of behaviours.‘Pacemakers’ of the night-time economy, for example, may include opening hours and availability of nightlife facilities, perceptions of

Rhythms, waves, everyday life and sleep

Rhythmanalysis is primarily an approach that seeks to capture the interplay of multiple rhythms e biological, experiential, spatial, temporal and social. A rhythmanalysis involves an ‘analytic operation’ to identify ‘the plurality of rhythmic interactions’ which Lefebvre refers to as ‘polyrhythms’ (2004:42). It is crucial here to appreciate how he conceives rhythm; specifically, it involves repetition, but unlike the mechanical repetitious thud of machines, embodied and social repetition or rhythms never replicate their repetition, instead they invariably generate ‘something new and unforeseen’ (2004:8). Lefebvre most effectively communicates this idea of rhythm through the use of a maritime metaphor. ‘To grasp rhythm and polyrhythmias in a sensible, preconceptual but vivid way, it is enough to look carefully at the surface of the sea.

monophasic pattern we would expect movement to be concentrated in the middle of each day with little movement to the far right and far left of each line. In which represents the total two-week period from a single participant, what is immediately of interest is (i) the constant and continuous movement across the 24- h period and  a lack of any clear demarcation between day/night movement. The actigraphy data were downloaded prior to the interviews and used during them to encourage participants to reflect on and interpret their personalized graph. The self-completion diaries (when completed) were also used during the interviews as prompts to recall and to help participants ‘make sense’ of the actigraphy data. The actigraphs and diaries in effect acted as what Latour (1987) would call ‘inscription devices’; encouraging a richer understanding of sleep as they provoked participants to reflect subjectively on seemingly objective measures of movement, rest and sleep. As well as prompting individuals to reflect on the actigraphy and diary data, the interviews explored participants’ biographies, substance use, experiences of rehabilitation, and accounts of their sleep throughout their life course. Particular attention was given to their sleep during the two weeks prior to the interview when most had been wearing the actiwatch. All interviews were audio recorded and transcribed, and ethical approval was secured from Universities of Surrey and York. Names of all participants have been changed for anonymity. Participant identifiers were used to link the interview, diary and actigraphy data, with labels ‘C1’ and ‘C2’ indicating whether participants were interviewed in Centre One or Two respectively. Interview and actigraphy/diary data were initially analysed independently. Meadows used the raw data from the actiwatch to create non-parametric circadian rhythm variables.

These included:  the ‘interdaily stability’ (IS; a single summary score of the day-today variation between the rest-activity rhythm) and ii) the ‘intradaily variability’ (IV; a single summary score of sleep disruption, such as the occurrence of daytime napping and/or night-time arousals over the two-week period). Scores of 1 and 0 are considered ‘perfect’ for IS and IV respectively. Diary data assisted in the identification of periods when the watch was removed (missing data). A graph was then created which plotted each individual’s IS against their IV to give an indication of their circadian temporality across the two weeks and in relation to others. Nettleton coded the data using Atlas. ti version. Transcripts were also read by the wider team looking for, ‘interferences between linear and cyclical time’ while being sensitive to ‘ambience, tempo and repetitions present in the empirical materials’ (Rantala and Valtonen, 2014: 22). This analysis of rhythms helped to forge sleep wave as an emergent concept. Team members discussed the findings emerging from the interview data alongside the actigraphs in order to generate clearer insights into the patterns and variations in the IS and IV plots

The routine and rhthyms of residential rehabilition

The empirical data presented in this article were generated through a study of 28 men and women who were in receipt of support for their recovery from addiction to alcohol and/or other drugs in England. At the time of the study, they were living in one of two residential rehabilitation services. Centre one provided support for men and women and offered supervised detoxification, which lasted four to six weeks, followed by a main treatment programme comprising group therapy, one-to-one counselling, creative workshops, complementary therapies, and participation in household duties. Days and nights were highly structured, with regular times for waking, meals, classes, bed, and sleep. Each day began with a collective meeting and, when residents left, if successfully completing their treatment, there was a formal gathering to acknowledge their achievements. Centre Two provided support only for women and involved a less structured programme. Residents shared daily activities, such as shopping, cooking, eating and budgeting and, as their recoveries progressed, were permitted to come and go from the service and have overnight stays at home. Bedtime rules were more flexible than in Centre One, although there was still a requirement that residents be in bed at night and up during the day. In both centres, all residents shared bedrooms, and total abstinence was required, although smoking tobacco was permitted. These particular settings provide a pertinent example of those spaces that Lefebvre describes as being akin to the ‘cloister’, where ‘real life’ is suspended and contemplation encouraged (1991:94). Moreover, Lefebvre advises that methodologically ‘in order to grasp and analyse rhythms, it is necessary to get outside them, but not completely’ (2004: 37). The rhythmanalyst has to find a means to listen and look for patterns, and to this end, our empirical data comprised interviews, self-completion diaries and actigraphy records.

Two of the authors visited the rehabilitation centres and presented the aims of the study to the residents. Potential participants were given written and verbal information about the study including the length and nature of commitment required, and the contact details of the investigators. Prior to participating in the research, all individuals were given the opportunity to ask questions and reflect on their involvement. All participants signed a consent form that clarified that their participation was voluntary, confidential and independent of any professional support they may have been receiving. Twenty eight individuals were interviewed (19 women and 9 men), 25 returned actigraphy data and 19 completed diaries. The youngest was aged 24 and the oldest was 83 years. Seven had been educated to degree level, although most had left school at 16, some with few, if any, qualifications. All had previously received support from either residential and/or community services for their addiction.

Author: Robert Meadows  , Sarah Nettleton  , Joanne Neale