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The heuristics of addiction: Decision making in problem drinking and recovery
Robert B. Cutler
Abstract
Recent findings from judgment studies make it possible to re-conceptualize addiction in
new terms: as a manifestation of normal judgment processes. This article focuses on the decision
“Should I drink?” in non-intoxicated problem drinkers.
First, three characteristics of this decision are identified. They are: its unremitting
reoccurrence in problem drinkers, the surprising complexity of that decision, and the high speed
of its resolution. The result is that continued abstinence is very difficult because it requires
making quick difficult decisions repeatedly over the relatively long time span that is required for
recovery.
Next, five factors that cause normal human decision error are discussed in relation to
problem drinking. They are: (1) Base Rate Neglect, which causes underestimation of the
probability of a negative drinking outcome; (2) Duration Neglect, a cognitive illusion which
causes overestimation of the positive effects of drinking; (3) the Affect Heuristic, which causes
both overestimation of positives and underestimation of negatives (this effect abates with
protracted abstinence); (4) Cognitive Load, which limits accessibility of corrective
considerations at the decision moment, and (5) Narrow Framing, which causes both
magnification of immediate positives and minimization of remote negatives. Each of these
factors has implications for insightful decision making, possibly shedding light on why
resolution of problem drinking has been characterized as resulting from “heightened reflective
experience.”
1
Introduction
In 2002 the Nobel Prize was awarded
to the psychologist Daniel Kahneman for his
work in human decision making. Although
this is a relatively new field it has become
well accepted in recent years. Many of the
practical applications of the findings have
been in economics, and it was in the field of
economics that Kahneman received the
award. Judgment study concepts, such as
heuristics and biases, offer a new way of
viewing addictive behavior. Heuristics are
the simple everyday “rules of thumb” that
we use to make decisions and choose
courses of action.
Judgment study findings may be
applied to addiction because they deal with
choice, and particularly with errors in
choice. By identifying factors that cause
errors it becomes possible to change error
rates. Some decision theory concepts have
begun to be applied in the addiction field,
but here they have been primarily related to
nicotine addiction and gambling, rather than
to alcohol addiction 1 - 4. This may be
because smoking and gambling are
sometimes considered to be more under
“rational” control whereas alcohol addiction
is often regarded as an irrational obsession,
due to its seemingly intractable and
involuntary nature.
However, judgment heuristics
distinguishes between intuitive "irrational"
processes and the relatively slower
“rational” processes (in the two-system
model), but incorporates both processes in
explaining how decisions are made. Indeed,
the studies have shown that many of our
decisions are not particularly rational.
Modern decision theory is associated with
an "attack on the rational agent model" of
decision making. The concept of rationality
has now been amended with the overarching
concept of “bounded rationality” 5. The
research has found that people do not
usually think hard about the decisions that
they make each day, but instead they choose
a course of action that quickly comes to
mind.
The focus here is restricted to nonintoxicated decision-making because alcohol
causes an impairment of thought 6. Nearly
all active problem drinkers spend parts of
days and/or series of days in a row in a nonintoxicated state. Vaillant, in his 1995 book,
"The Natural History of Alcoholism
Revised" wrote that alcohol addiction is
characterized by "unpredictable oscillations
between use and abuse of alcohol … during
any given month a majority of so-called
alcoholics will be observed to be either
abstinent or drinking asymptomatically… It
is not an off-on phenomenon, and …
remissions and relapses are common." 7
Sober periods of time are common, and most
problem drinkers have tried unsuccessfully
to quit 8. This makes it possible to consider
decision making during those times.
Some decisions are not “free”; they
are made under forced conditions, with
serious consequences. For a problem
drinker, the decision to drink (or not) is
often, if not always, made under such
coercive conditions, and the decision
involves great risks and rewards. It is an
emotion-laden decision made in the context
of a tragedy. But it is a decision. The
decision results from cognitive evaluations,
and it is a conscious deliberate judgment
about engaging in the varied and
complicated sets of behaviors that are
required in order to drink such as obtaining
money, traveling to the beverage store or
bar, conducting financial transactions, etc.
This simple operational definition of
drinking behavior as a decision or set of
decisions allows us to apply the findings of
judgment studies to alcohol use, misuse and
recovery. The cognitive processes involved
in the decision to drink (or not) are the
2
subject of this article. The next section
discusses three characteristics of the
decision, and the final section describes five
areas in which errors are made.
The Difficulty of the Decision
There are three decision
characteristics that make the consistent
choice to not drink a particularly difficult
dilemma for a problem drinker. As
described below, the decision is (1)
complex, partly because outcomes are
unpredictable, (2) rapid, because decisions
are typically concluded very quickly, and (3)
frequent, or continually reoccurring. In
combination they put the non-intoxicated
problem drinker in the unenviable position
of repeatedly and hastily making formidable
choices.
Complexity of the decision
A decision can be analyzed in terms
of both the intuitive judgments and the
deliberate thought processes associated with
it. The intuitive elements are quick, and
highly accessible. Kahneman likens the
normal decision making process to a simple
perceptual task (such as viewing a
photograph) where the different elements of
a situation are readily apparent 5. He points
out that, when the decision task is more
difficult, then a second process, a
deliberative process, can modify the initial
intuitive judgment. This is termed the two
system theory. System one is the
immediate intuitive judgment, and system
two is a corrective “reasoning” process.
Just as decision theory gives a
central role to the gains and losses that come
to mind when a decision is to be made, the
thought processes involved in the drinking
decision have been divided into positive and
negative factors 9 or expectancies 10. For the
problem drinker, the rewards of drinking are
the almost irresistible feelings of pleasure,
well-being, and peace, the abatement of
withdrawal symptoms, etc. The risks of
drinking are a host of unpredictable
consequences such as loss of social status,
financial loss, and injury 11. Positives and
negative aspects of the decision to drink will
be discussed as shown in Table 1.
Table 1. The two sides of the decision
Should I Drink?
Rewards or
Certain Probability of feeling
very good
(highly accessible)
Gains
AND consideration of
Risks or
Unknown Probability of feeling (unknown) bad
(relatively inaccessible)
Losses
3
The highly accessible content: Positive
considerations
The rewards and risks of drinking
differ in accessibility—some come to mind
much more easily than others. In an active
drinker the initial intuitive perception is of
the reward. Heavy drinkers give precedence
to the perceived positive benefits of drinking
rather than to perceived negative effects 10 12
13
. The active problem drinker certainly
expects drinking to feel good, making these
considerations highly accessible to the
decision process.
The relatively inaccessible content:
Negative considerations
Griffith Edwards referred to negative
thoughts as "cognitions" that promote
abstinence 14. Heavy drinkers are aware of
the risks and negative consequences of their
drinking, but these calculations are more
uncertain and difficult 15 16. Orford 12 noted
"the drawbacks of drinking are rarely clearly
and separately delineated" in ongoing heavy
drinkers. Drawbacks consist of sets of
possibilities with varying probabilities and
varying intensities. These are particularly
difficult to predict because they would
depend partly on that unknown quantity of
alcohol that will be ultimately consumed.
There are other associated possibilities that
are also unknown, such as the actions of
other people and of one's self when
intoxicated. Heavy drinkers actually expect
fewer negatives than do light drinkers 17 and
they tend not to reflect on the negatives 18 19.
There have been a number of
judgment studies involving uncertainty, and
a primary finding is that unpredictability is
poorly represented in quick intuitive
judgments. Choices that involve uncertainty
are more likely to be ignored. For these
reasons negative drinking outcomes are
relatively inaccessible. The decision
literature also indicates that judgments of
relatively inaccessible properties are much
slower and more susceptible to interference
by other thoughts (discussed below in the
Cognitive Load section).
But overall, both elements of
drinking, risks and rewards, are considered
12
during the decision moment. Norm theory
shows that, to the extent that these are two
competitive interpretations of reality, they
suppress each other 20. The decision is made
when a dominant role is assigned to one
side. The general risk/reward concept has
been termed the decision balance process in
drinkers 21 22. A Decision Balance Scale
has been developed for smokers 3. See
Orford for a more general discussion on
applying a theory of gain and loss to
problem drinking 12.
Further complexity
As shown in Table 1, a number of
investigators have further subdivided both
reward and risk into two parts, a likelihood
and a specific value (or "strength",
“intensity”, or "valence") 3 23 24. Some have
even proposed adding a third element, the
multiplicative product of likelihood and
value 25 - 27.
The concept of the problem as a
decision balance is probably unrealistic 12
because it appears to be too simplistic. It
might prove to be more useful to consider it
more flexibly, for example, a process with
two decision balances, one related to the
risks and rewards of drinking, another to the
risks and rewards of not drinking. In
addition to considering the decision in terms
of its “prototype attributes” as I have been
doing here, the decision maker can consider
it in “extensional attribute” terms, e.g., when
an active drinker is contemplating extending
the number of drinking days by one (with
the expected minimal costs of that decision
versus the relatively minimal or non existent
benefits of a first day of abstinence), or
when an abstinent individual is
contemplating extending the number of nondrinking days by one (with the attendant
potential costs and benefits). Kahneman
4
argues that the elements of extensional
attributes are low in accessibility. 5
Additionally, as noted earlier, there
are many different types of interacting and
competing positives and negatives in
drinking. It may be less productive to think
in terms of a dichotomous balance – with the
focus on two opposing forces, and more
productive to think in terms of the
accessibility of corrective thoughts.
Kahneman writes “people rely on a limited
number of heuristic principles, which reduce
the complex tasks of accessing probabilities
and predicting values to simpler judgmental
operations. In general, these heuristics are
quite useful, but sometimes they lead to
severe and systematic errors” (emphasis
added) 28, and “people who are confronted
with a difficult question sometimes answer
an easier one instead” and “The essence …
is that respondents offer a reasonable answer
to a question that they have not been asked.”
5
For example, instead of answering the
question “Should I drink?” the decision
maker may instead answer “Will it be
possible to obtain alcohol?” or “If I drink
will it be possible to avoid (some specific
negative consequence)?”
Inability to categorize factors leading to
resolution of drinking
There have been a number of
attempts to list all the different types of
factors leading to resolution of drinking,
organize them into meaningful categories,
and find relationships between them and
drinking outcome. Investigators have
proven no better than problem drinkers (the
actual decision-makers who are of interest
here) in conceptualizing these factors in a
coherent way. For example, one author
listed 19 categories with “Intrapsychic
factors” and “Specific
frightening/humiliating experience” at the
top of the list 9, while another listed 14
different categories with “Health-related”
and “Negative personal effects” at the top 29.
Another classification scheme began by
organizing negative consequences by time,
e.g., proximal (immediate), distal (longer
term) with continued drinking (or relapse to
drinking) as a third category 30. The range
of categorizations in different studies has
been reviewed by Blomqvist 31 32 . One
author referred to the categorization process
as "arbitrary" 29.
The difficulty is probably because
there are so many different types of
negatives and of positives and so many
different individual situations. And just as
drinking is different for the same person at
different times (for example, morning versus
evening, and Saturday versus Monday), the
decision to drink or not requires a different
judgment each time.
Change in decision over drinking career
Over the months and years of
addiction, serious problems often grow more
serious. Negative consequences of drinking
may become increasingly obvious 33, and
accessible to the decision making process.
Conversely, one “puzzle” of recovery is that
relapse is still likely after weeks and months
of sobriety 34 in spite of the benefits of
abstinence. Benefits include greatly
improved mood 7 and greatly reduced stress
9
. (Ironically, as Kahneman points out 5,
being in a good mood makes judgment error
more likely.) However, with an increase in
length of time abstinence, the negative
consequences of drinking may become less
accessible to the decision making process.
Many previous negative consequences may
no longer appear to be relevant. In both
phases of the drinking career the decision
changes over time and therefore remains
challenging.
5
The Difficulty of the Decision: Duration
and Frequency
Two other general characteristics of
the decision making process are particularly
relevant. First, most decisions are resolved
nearly instantaneously. Typically these are
“decision moments” that last only one or
two seconds. As noted earlier, Kahneman
compares the “decision moment” to a
perceptual task, where the different aspects
of a situation are readily apparent and
quickly resolvable. Important elements
might not be considered when making quick
choices.
Second, the judgment heuristics
studies have shown that decision making is a
ceaseless on-going activity of normal
cognition. For problem drinkers many of
those decisions involve drinking. Nearly
half say they think about drinking almost
constantly during the first few weeks of
abstinence [Note 1]. However, the amount
of time spent on the drinking decision
decreases during abstinence, as shown in
Figure 1.
Figure 1
Amount of time thinking about drinking during first 3 months of sobriety.
TOTAL TIME PER DAY
2
1
0
0
1
2
3
Months of Sobriety
Figure 1. Decrease in time thinking about drinking in newly abstinent alcoholics. Time was
measured on a categorical scale, with 2 indicating “1-3 hours a day” and 0 indicating “None”.
Participants were 25 individuals who completed a 3 month outpatient medication trial. [Note 2]
6
Figure 1 also shows that time
thinking about drinking does not drop to
zero after 3 months of sobriety. In addition
to the total amount of time thinking about
drinking, data from a related variable,
number of times thinking about drinking
each day, showed the same pattern. Number
of separate times thinking about drinking
also showed a statistically and clinically
significant decrease [see Note 2].
Additionally, after 12 weeks of sobriety
61% said that they continued to think about
drinking every day. The decision, to drink
or not, continues to be made even during
long periods of abstinence.
Five factors that cause decision
errors taken from the judgment
heuristics literature
These factors universally occur in all
human decision making, but here they are
discussed in relation to error in the decision
to drink. They are Base Rate Neglect,
Affective Valance, Duration Neglect,
Cognitive Load and Narrow Framing.
Decision error caused by Base Rate
Neglect.
Base rate neglect, also called the
base rate fallacy, is a mistake in logic that
occurs when a probability judgment is made
from irrelevant information, especially when
actual information about the probability is
available. It is a decision error committed
even by relatively statistically sophisticated
individuals working in their area of expertise
because judgments involving probability are
particularly difficult to make 5.
The type of base rate neglect of most
interest here involves the calculation of risk,
the probability of negative consequences of
drinking. It can be expressed more
accurately as “What has happened in the
past will probably not happen if I drink
now.” In making the current decision to
drink, they are gambling that the probability
of severe negative consequences is not
certain. They know of occasions in the past
when they have drunk and have not had any
negative consequences. Indeed most
problem drinkers have enjoyed many years
of drinking with minimal adverse events.
But for active problem drinkers the
situation has changed. Negative
consequences are now the rule, not the
exception. An outside observer would say
that, every time the active problem drinker
drinks, there are important negative
consequences. For example, each additional
drinking day causes additional social
stigmatization.
The continuing problem drinker
judges that, while recent prior outcomes
were bad, today he or she might be able to
escape a negative outcome. One gamble is
that if a smaller quantity of alcohol is
consumed today (for example, less than the
amount consumed last night) and if it is
consumed under the right circumstances,
then severe negative consequences are
unlikely. However they are also aware that
most often they continue drinking after this
initial smaller quantity has been consumed
and negatives are possible.
In the decision literature, base rate
errors are reduced by educating decisionmakers in statistical probability. However
active problem drinkers may have difficulty
in categorizing prior drinking outcomes in a
systematic manner, in concisely
remembering the negative outcomes of the
last 30 or so times that they drank. Or, they
may be aware of the previous outcomes but
not use this information in their future
probability calculation. The task of the
problem drinker is to determine the
probability of a future negative outcome by
considering the objective frequency in their
recent past.
Such a calculation might foster a
moment of insight. An increase in the
perceived likelihood of negative
7
consequences (to certainty) may sometimes
occur after years of drinking. One example
of revising base rate calculations is the
interesting advice sometimes given by
Alcoholic Anonymous members, to "go
ahead and drink and see if you can get away
with it." The ensuing experience may reveal
the actual base rate probability of negative
consequences to the decision maker in a
highly accessible form.
Decision error caused by the Affect
Heuristic
The evaluation of something as good
or bad is a particularly important natural
assessment. The idea of an affect heuristic
35
is thought to be the most important
development in the field of judgment
heuristics in the last twenty years 5. It is the
main cause of many behaviors, certainly
including drinking.
High levels of positive affect alter
the risk/benefit ratio causing the decision
maker to maximize the expected quantity of
benefit and (inversely) minimize the
possibility of risk 36. This effect can be seen
in various different domains that have a high
affective value, such as money or children,
for which some people will risk everything.
If the potential outcome of an action is
extremely positive, the decision is relatively
insensitive to the probability of a negative
outcome 36.
The overall hedonic impact of
drinking accounts for the seemingly
incomprehensible behaviors it causes.
Active problem drinkers are “blinded” by
the positive effects of alcohol in that they
both overestimate the expected benefits and
underestimate negatives.
The serious problems caused by
drinking can outweigh these high levels of
positive affect and produce a period of
abstinence. In turn, abstinence is
accompanied by a decrease in affective
valence. Craving for alcohol decreases by
about 50% after about 4 weeks of
abstinence, by 75% after 3 months, and by
95% after one year of continuous abstinence
as shown in Figure 2 37.
Figure 2
Craving for alcohol during first year of sobriety.
6
Craving
5
4
3
2
1
0
0
3
6
12
Months of Sobriety
During abstinence craving for alcohol decreased greatly over 12 months. These data show the
same 15 participants at each time point 37.
8
Decision error caused by Duration
Neglect
Our memories neglect the duration in
time our experiences last. Instead, we
remember in terms of specific instances,
split-second moments of time that embody
the experience. A certain few images may
constitute our memory of a trip to the
dentist, or a vacation at a beach, or any other
experience. Judgment studies have found
that memories are primarily composed of
both the peak moment of pleasure (or
unpleasantness) -- that most intense level -and the final ending level of an episode. An
analogy that helps to explain the concept of
duration neglect, is to say that memory is
made of "snapshots"; it is not a
continuously-running motion picture 5.
Problem drinkers think that drinking
causes a state of bliss. A heavy drinking
experience, however, is typically composed
of an initial brief peak moment of elation,
followed by a period of declining pleasure
and memory loss 38 39, then by sleep.
Experienced heroin addicts refer to the brief
peak moment of elation as "overtime".
Overtime occurs immediately after taking
the drug. It is followed by a longer period
of time where the heroin addict feels
relatively normal, although without
withdrawal symptoms. It may be that as
addiction proceeds, overtime become rarer
and rarer.
Duration neglect means that while
drinking is remembered as achieving a
stable state of pleasure, it actually is enjoyed
only during the first few minutes of drinking
-- the peak period of pleasure. The blissful
state of intoxication is an invention of
memory.
Behavioral decision theorists
emphasize this with their distinction
between decision utility and experience
utility 40. Utility is a term that means
“psychological value.” Utility predicted or
expected at the time of decision often differs
greatly from the pleasurable experience that
actually occurs.
The illusion dissolves when
individuals are made overtly aware of the
distortion of memory caused by duration
neglect, that is, by becoming aware of the
time element. (Duration neglect, like all
cognitive illusions, and indeed like all
perceptual illusions, does not permanently
disappear when one becomes aware of it.)
One now largely discredited approach to the
treatment of alcoholism had the potential to
reveal the duration neglect illusion. It
involved showing videotapes to alcoholics
of themselves while they were drinking, or
while they were drunk.41 - 44 Unfortunately,
these were made as part of a confrontational
approach to treatment that likely produced a
high level of embarrassment and shame.
The counter-productive effects of
embarrassment and shame are discussed
below in the section on cognitive load.
Decision error caused by Cognitive Load
Cognitive load is the level of effort
associated with thinking and reasoning, thus
potentially interfering with accurate decision
making. Cognitive load is further increased
by the interference of different cognitive
tasks and time pressure, both of which raise
error rates.
The many difficulties of the problem
drinker, such as shame and social pressures,
raise cognitive load to extraordinarily high
levels. While these problems make initiating
or maintaining abstinence more likely, they
also decrease the cognitive resources
necessary for good decision ability. If
cognitive load is high during the instant the
decision is being made, potential negative
consequences are less likely to be
considered.
The hopelessness, guilt and anger
caused by past intoxicated actions are
addressed by AA in their admonishment to
make amends, and by therapists who often
9
explicitly deal with these feelings. The goal
would be to minimize or negate their effect
as the problem drinker faces the re-occurring
temptation to drink. The traditional wisdom
of Alcoholics Anonymous appears to
address the problem of cognitive load with
the slogans, "Keep it simple, stupid" or
"KISS," and “One day at a time.”
Decision error caused by Narrow
Framing
Framing effects are shown when
different ways of presenting the same
situation make different aspects of it
accessible 45. There are a number of
famous demonstrations of embarrassing
framing effects. For example, it has been
shown that experienced physicians prefer a
90% survival rate to a 10% mortality rate 46.
Decisions are made according to the
immediate situation and its immediate
consequences (narrow framing). No one
actually lives in “the long term.” When
external observers view the behavior of
active problem drinkers they see a long term
pattern of behavior that appears to be
incomprehensible. But, in reality, all people
see their current situation as a unique shortterm problem to be solved now, rather than
as an instance of a broader class 47. Active
problem drinkers drink in order to have a
successful day today, just as all people strive
to have a satisfying day.
The way decisions are framed is
influenced by a number of factors, some of
which were enumerated by Kahneman 5. 1.
Outcomes that are certain will have a large
influence on the decision. The active
problem drinker believes that alcohol will
certainly result in extremely good feeling,
but is uncertain about negative outcomes.
2. Rich descriptions of the situation are
powerful influences. The positive effect of
drinking has a rich description. The richness
of descriptions of the unpleasant effects of
drinking are evaded and also minimized by
intoxication, blackouts, and the fact that they
slowly accumulate over the years of the
drinking career. The exception to this is the
experience termed "hitting bottom," where
remission sometimes results from the
increased salience of iconic events. 3. A
clear cause and effect relationship is another
powerful influence on framing, but the
relationships between drinking and the later
undesirable consequences are unpredictable
and variable (as discussed previously). 4.
An order effect on framing has also been
demonstrated, in that some effects can be
eliminated from the decision process by
becoming overtly aware of them in advance.
Because decisions are made in the
realm of narrow framing, it can be helpful to
expand the frame of the decision (i.e.,
"thinking broadly about your life -- what
would be the best thing to do today?" "If
you had your whole life to do over, would
you have begun drinking when you did?",
etc.) One way to expand the frame is with
cues or reminders. Many successfully
recovered problem drinkers use such recall
aids in order to influence the decision
process 48. For example, a reminder that
signifies a powerful event may cause the
decision to be framed in terms of its longer
term outcomes.
Conclusion
By dealing with alcohol addiction in
the decision theory framework we consider
it as a normal aspect of human behavior,
where cognitive mistakes are pervasive in
everyday decision making. Viewing it this
way shows why it can be so difficult for
problem drinkers to abstain. After the initial
decision to abandon this great source of
reward, they must somehow put into place a
plan for future decisions. Three
characteristics make consistent “no”
decisions a nearly insolvable dilemma: they
are continually reoccurring; they pose a
uniquely different challenge each time; and
10
they are resolved nearly instantaneously.
Judgment studies show us that
decisions are made by choosing the most
accessible thoughts, thoughts which are
often not the most relevant to a good
decision. For active problem drinkers, those
thoughts are the expected joy and relief that
result from drinking. Judgment studies
show that uncertain options are generally
ignored. These are the potential negative
consequences. As problem drinking
continues negative consequences become
more likely and more accessible, sometimes
leading to periods of abstinence. With
abstinence the decision situation changes yet
again. Over extended abstinence decision
frequency and craving decrease. However,
negative considerations may become less
accessible.
How does one raise the accessibility
of the negative aspects of drinking to such a
degree that they will be the most accessible
elements under diverse decision-making
conditions, such as high cognitive load and
high alcohol craving? Judgment heuristics,
with its focus on the elements of the
decision making process, and primarily on
the factors that cause errors, suggests
strategies that may be useful. Judgment is
influenced by temporarily raising the
accessibility of particular thoughts in order
for the decision maker to realize explicitly
that one of the options is absolutely better
than the other. Primes and reminders are
effective in influencing subsequent
decisions. For problem drinkers, other
insightful strategies may include such
methods as establishing belief in the base
rate certainty of negative consequences, and
re-evaluating the affective benefits by
understanding that the duration of pleasure
is really very brief, although it is
remembered as lengthy. Others include
expanding the frame of the situation,
recognizing the dangers of cognitive
interference, and realizing that the current
difficulties will dissipate over time. Table 2
summarizes the five decision theory factors
that were discussed.
Table 2
Base Rate
Neglect
Insight
That probability of a negative
consequence is essentially certain.
Duration
Neglect
Alcohol provides only a very brief
interval of pleasure.
Affect
Heuristic
Cognitive
Load
Desire to drink will eventually
decrease to become a minor concern.
Pressure threatens judgment (keep it
simple).
Narrow
Framing
Reconsider decision in larger context.
Strategy
Determine probability of future
negative outcome by cataloging
past drinking outcomes.
Calculate duration of pleasure,
contrast that with duration of
negative outcome
Monitor decrease in craving
over months of abstinence
Make plan to exclude
interference (such as time
pressure) at decision moment.
Get a powerful reminder that
will be encountered during
decision moment.
11
Three characteristics of decisions
and five factors identified in judgment
studies were presented here. We know little
about those effects and their relation to
problem drinking. Data was presented that
showed that alcohol craving, i.e., affective
load, decreases over time as abstinence
proceeds. And the same was shown about
frequency of decision making -- whether to
drink or not. Both are positive natural
processes. But there is much to be learned.
Each of these error causing domains has
been studied in economics. Use of the
techniques developed in that area should
make it possible to decipher the decision
factors operating in problem drinking and in
other substance abuse.
Forty years ago recovery was
described as "a change in the alcoholic's
attitude toward the use of alcohol based on
the person's own experience which in the
vast majority of cases took place outside of
any clinical interactions" 7. Vaillant wrote
"The sudden transformation of a drunkard to
a teetotaler is analogous to the sudden
change of heart, the abrupt religious
conversion, and the scientist's experience of
Eureka.” 7. (Curiously, both “eureka” and
“heuristic” derive from the same Greek
word.)
Vaillant describes the classic
alcoholism text by Tuchfeld in 1981.
Tuchfeld 11 interviewed 51 individuals who
had been abstinent for at least a year; mean
abstinence length was over 6 years. He
describes the abstinence precipitation events
as "heightened reflective experience".
Vaillant wrote "The actual
circumstances…are mysterious, ill-defined,
and unique to the individual." 7 Judgment
heuristics, with its focus on the everyday
persistent errors that are universal in human
thought, provides tools to begin to
understand how these mysterious, ill-defined
experiences influence the decision making
processes of problem drinkers.
12
Note 1 This question was "Do you constantly think about drinking? Yes or No". It is item 18 on the commonly used
Alcohol Dependence Scale (ADS). In this study 45% (57/126) of abstinent alcoholic volunteers answered "Yes”. They had
been abstinent for 2 to 14 days. Study Design. Briefly, the participants were recruited by newspaper ads for a free alcoholism
treatment trial. Treatment consisted of randomization to receive either experimental medication or placebo and for all to receive
weekly counseling sessions that continued for 3 months. These volunteers were, on average, in their early forties, two thirds were
male, and most were white. They were all in good health, did not abuse any other drugs, and all received a DSM diagnosis of
alcohol dependence. The data is described more fully in 37 as the nalmefene data set.
Table N-1 (below) demonstrates the validity of the item by showing that those who thought about it constantly had
significantly higher alcohol dependence and significantly more alcohol craving.
Table N-1
Do you constantly think about drinking?
No
Yes
Mean
SD
Mean
SD
13.6
7.2
20.7
7.1
-5.03
5.8
2.9
7.3
2.5
-2.84
15.0
5.2
18.4
5.3
-3.16
Alcohol Dependence Scale Total Score
How much do you crave alcohol (0-10)
Obsessive-Compulsive Craving Scale
*Highly significant
t
df
102
100
98
p
0.000*
0.005*
0.002*
Even more interesting, those who thought about alcohol constantly had better outcomes! For those who answered
"Yes" to "Do you constantly think about drinking?" there was a significantly longer time to first drink (35 days vs 20 days for the
No answers, t= 2.28,102, p= .025). These problem drinkers were classified previously 37 as either as having become essentially
abstinent or as moderate drinkers (1 drink a day) for the duration of the 12 week trial. The ones who said they thought about
drinking constantly were subsequently much more likely to be in the abstinent group (Chi square= 6.74, 1, p=.009, Fisher z (twotailed) p=.012). Only 3 of 18 "Yes" answerers were classified in the higher drinking group, whereas of the "No" answerers more
than half (13/23) were in the higher drinking group. The high significance levels show the importance of this variable – thinking
about drinking. Typically studies are unable to predict drinking using baseline data.
Note 2 The analysis here is of two items taken from the Obsessive Compulsive Drinking Scale; both are related to the quantity
of decisions that are made over time. Data were the same as in Note 1.
The first item asks "How much of your time when you're not drinking is occupied by ideas, thoughts, impulses or
images relating to drinking?” Possible answers were “0-None,” “1-Less than 1 hour a day” and ranged up to “4- Greater than 8
hours a day.” Over the 12 weeks of the study, of those who were constantly thinking about drinking, scores decreased by 47%,
indicating a change from approximately 4 hours a day to 1 hour a day. These hours are, apparently, an estimate of the total sum
of time over the day in which drinking is considered, in these newly abstinent problem drinkers. That data are shown in Figure 1.
The second question was about the frequency of decision making. "How frequently do these thought occur?" Possible
answers were “0- None,” “1- No more than 8 times a day,” “ 2- More than 8 times a day,” and ranged up to “4- Thoughts are too
numerous to count.” Scores decreased by 38% in those who were originally thinking about drinking constantly, reflecting an
approximate decrease of from 12 times a day to 8 times after 12 weeks." (See table N-2).
Table N2 shows how these two measures of thinking about drinking changed over time in the four subgroups of Note 1.
Two of the subgroups were formed with a Constantly/non-Constantly division (see above), and two separate subgroups were
formed with the Abstinent/Mild division of the participants. Table N2 shows that these measures of thoughts of drinking
decreased for nearly every subgroup, most declines were highly significant. Only one group did not decline on one measure
(bottom row), the "Mild" subgroup– those participants who continued to drink about one drink a day.
Table N-2
1
Hours
thinking
about
drinking
2
Frequency
of thinking
about
drinking
Subgroups
Constantly
Not Constantly
Pretreatment
Mean SD
2.11
1.0
1.16
0.7
Week 12
Mean SD
1.11
0.9
0.81
0.6
t-value
5.01
2.47
df
26
31
2-tail Sig
0.000
0.019
Abstinent
Mild Drinking
1.77
1.20
1.1
0.9
0.59
1.07
0.6
1.0
5.51
0.56
21
14
0.000
0.582
Constantly
Not Constantly
1.58
0.91
0.9
0.5
1.00
0.81
0.7
0.5
3.64
0.90
25
31
0.001
0.374
Abstinent
Mild Drinking
1.36
0.80
1.0
0.6
0.68
0.87
0.6
0.6
3.38
-0.56
21
14
0.003
0.582
13
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