On a scale of 1 to 4, how would you rate your quality of life? Think about it and then write your answer down. Now, how did you decide on that answer? Did you think about every area of your life as honestly and as carefully as you could, give them all a numerical value, estimate the average, and then put that? If not, did you do something just as thorough?
According to famed psychologist Daniel Kahneman, chances are you did not. His research suggests that we are much more likely to substitute an easy question, such as “how do I feel right now?” for a more complex one, such as “how would you rate your quality of life?” and answer accordingly. In his seminal book Thinking, Fast and Slow (Kahneman, 2011), he cites an experiment in which people were asked to complete a questionnaire on life satisfaction. Before they started, half the respondents were randomly assigned to make a photocopy. As they did, they stumbled upon a dime that had been left on the copy machine. That small but positive bump led to a significant improvement in their reported quality of life, suggesting that how we feel in the moment influences how we think about our lives on the whole.
When single numbers fail us
So it was with some skepticism that I read a recent article suggesting that people who’ve stayed abstinent since going through treatment for alcohol reported higher quality of life than people who’ve tried moderating their drinking. The article draws heavily on a recent research project, known as the “What Is Recovery? (WIR)” study, that surveyed people who were in addiction recovery (Subbaraman & Witbrodt, 2014). It separated them into two groups based whether they reported currently drinking: those that don’t were labeled “abstainers” and those that do “non-abstainers.” In the analysis, the authors found that abstainers rated their quality of life higher than non-abstainers, and that abstinence was one of the strongest correlates of quality of life. However, I took a closer look at the study and found two pretty glaring issues.
- The researchers measured quality of life with only one question! As we’ve already seen, asking people to rate their quality of life is vulnerable to some bias. Perhaps the survey was structured in a way that it primed non-abstainers to feel guilty about their drinking before they answered that question, leading them to feel worse in that moment and to substitute that feeling for their answer. No matter the circumstances, by only using one question the researchers are at risk of getting a very inaccurate picture of true well-being.
- The difference in quality of life between the two groups was incredibly slim. The single question they asked had respondents indicate a number between 1 and 4, with 1 representing poor quality of life (QOL). The researchers state: “We found that compared to total abstinence, non-abstinence was associated with 0.3 to 0.45 point-reductions (on a 4-point scale) in QOL.” Not only is that difference very minute, it brings up another issue: what if people who drink moderately live less on the margins? Perhaps they think about their lives in shades of gray, whereas people who are abstinent think in more black-or-white terms. They might have given themselves a 1 when they were using, but now that they’re abstinent they’ve gone up to a 4.
Rightfully so, the researchers admit these flaws in discussing the study’s limitations. They write: “the WIR quality of life measure is based on a single question; future studies could use instruments that detail various aspects of mental and physical functioning.” Lucky for us, other studies have done exactly that.
Moving towards a more complete picture of well-being
Another recent study looked at about 1000 people who had been through outpatient treatment for alcohol problems and followed up with them 6 months and 12 months after they finished (Kline-Simon et al., 2013). They divided the subjects into three categories based on their reported drinking in the last 30 days:
- “abstinent” (no drinking)
- “low-risk drinking” (drinking, but not having 5 or more drinks on any one occasion)
- “heavy drinking” (drinking and having 5 or more drinks on at least one occasion)
They compared how these different groups fared in answering the Addiction Severity Index (ASI), one of the most widely used instruments in the field of addiction treatment. The ASI is an incredibly thorough assessment that gets a comprehensive view not only of someone’s substance use, but also their physical and mental health, employment and education, and family and social lives. When all taken together, the ASI can yield a pretty accurate picture of the quality of someone’s life, so that somebody at the top of their game would probably do really well on the ASI.
The researchers found that the low-risk drinking (what we here at Alternatives would considerate “moderate”) and abstinent groups did not differ from each in any statistically meaningful way when it came to these areas of life. In fact, the moderate drinkers were in better physical health than abstainers after 12 months. Altogether, these results suggest that moderate drinkers were experiencing a quality of life on par with that of non-drinkers, and so much so that the researchers conclude that moderation “should be considered acceptable as a successful outcome by policy makers and clinical guidelines.” Why does this matter? Moderation may be a more attractive goal for people previously resistant to treatment or who may not be ready to commit to abstinence. This has the potential to increase the number of people engaging in treatment as a whole—a much welcome change in a sector of healthcare where only 10% of people who need treatment actually seek it.
The Alternatives approach
Here at Alternatives, we give our clients the opportunity to choose between abstinence and moderation, as we believe that moderation can be a realistic goal for the right person. Research suggests that people in early to late adulthood (Rolland et al., 2016), who’ve had less severe alcohol problems over less time (Enggasser et al., 2015), and who believe moderation can work (Rosenberg, 1993) may be better candidates for moderation. These are all factors we take into consideration when we guide our clients towards the right goal.
Finally, we look beyond the black and white thinking of abstinence vs. non-abstinence as outcomes. We firmly believe that quality of life matters, and we measure it comprehensively by tracking our clients’ health functioning, anxiety and depression, affect, and more through a battery of psychological instruments, including the ASI. Because quality of life can’t be reduced to a single number and it never should be.
Enggasser, J. L., Hermos, J. A., Rubin, A., Lachowicz, M., Rybin, D., Brief, D. J., . . . Keane, T. M. (2015). Drinking goal choice and outcomes in a Web-based alcohol intervention: Results from VetChange. Addictive Behaviors,42, 63-68. doi:10.1016/j.addbeh.2014.10.036
Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux.
Kline-Simon, A. H., Falk, D. E., Litten, R. Z., Mertens, J. R., Fertig, J., Ryan, M., & Weisner, C. M. (2012). Posttreatment Low-Risk Drinking as a Predictor of Future Drinking and Problem Outcomes Among Individuals with Alcohol Use Disorders. Alcoholism: Clinical and Experimental Research,37(Suppl 1), E373-E380. doi:10.1111/j.1530-0277.2012.01908.x
Rolland, B., Paille, F., Gillet, C., Rigaud, A., Moirand, R., Dano, C., . . . Aubin, H. (2015). Pharmacotherapy for Alcohol Dependence: The 2015 Recommendations of the French Alcohol Society, Issued in Partnership with the European Federation of Addiction Societies. CNS Neuroscience & Therapeutics,22(1), 25-37. doi:10.1111/cns.12489
Rosenberg, H. (1993). Prediction of controlled drinking by alcoholics and problem drinkers. Psychological Bulletin,113(1), 129-139. doi:10.1037//0033-2909.113.1.129
Subbaraman, M. S., & Witbrodt, J. (2014). Differences between abstinent and non-abstinent individuals in recovery from alcohol use disorders. Addictive Behaviors,39(12), 1730-1735. doi:10.1016/j.addbeh.2014.07.010