Light at the end of the bottle: flourishing in people recovering from alcohol problems

ABSTRACT

Background

The field of positive psychology is fast growing and ultimately aims to increase flourishing. As yet, these concepts have had very limited impact in the field of alcohol dependence. The aim of this study is to compare flourishing levels in people recovering from alcohol problems with two comparison groups.

Methods

An online survey was conducted with people recovering from alcohol problems (n = 107), a community sample of gym attenders (n = 185) and people with mental health problems (n = 130). They completed the PERMA Scale, as well as answering questions about their drinking.

Results

People recovering from alcohol problems scored significantly better than the mentally ill sample on every aspect of the PERMA Scale. In contrast, they scored significantly worse on every subscale in comparison with the community gym attenders’ group. Responses to open-ended questions highlighted the costs of alcohol problems, especially in terms of losses experienced through drinking, along with an unhealthy tendency to focus on the past.

Conclusions

The abstinence model may reinforce a sense of hopelessness and powerlessness in those battling alcohol problems and may inhibit flourishing. There is a need to develop positive psychology interventions that may help individuals recovering from alcohol problems to flourish.

KEYWORDS:

• Flourishing
• Alcohol
• Recovery
• Mental Health
• Wellbeing

Introduction

Flourishing mental health is the epitome of mental well-being and encompasses the presence of psychological, emotional and social components of functioning (Seligman, 2011). Flourishing can be defined as “the experience of life going well and a combination of feeling good and functioning effectively” (Huppert & So, 2013). Seligman (2011) proposed a theoretical model of happiness (PERMA) that consists of positive emotions, engagement, relationships, meaning and achievement. According to Seligman (2011), these five core elements of flourishing guide people toward a life of fulfillment, happiness and meaning. Research has shown that flourishing can act as a buffer to mental health problems such as depression, anxiety and suicidal ideation (Keyes & Simoes, 2012; Schotanus-Dijkstra et al., 2017). Flourishing has been associated with an array of personal, psychological and social benefits (Keyes, 2005; Ross et al., 2013). For example, people who are flourishing are less likely to use substances such as tobacco and alcohol, and are increasingly likely to participate in regular physical activity (Keyes & Simoes, 2012). Recent studies have found that only a modest proportion of the population are considered to be flourishing (Middleton, 2016). One group of individuals who struggle to demonstrate flourishing mental health are those who have problems of alcohol dependency (Keyes, 2015).

While moderate drinking has often been associated with improved mental well-being (El-Guebaly, 2007; Gea et al., 2012; Saarni et al., 2008), much research has demonstrated that individuals with alcohol use disorders, experience some of the worst mental health outcomes (Keyes & Simoes, 2012). Indeed, excessive alcohol use has been strongly linked to poor sleep quality (Park et al., 2015) and long-term depression and anxiety (Kushner et al., 2000; Vitiello, 1997). This can, in part, be explained by the bidirectional relationship between alcohol use and mental health disorders (Keyes, 2015; Rogers et al., 2010). For instance, research has shown that alcohol use is often used as a coping mechanism to “self-medicate” the symptoms of mental health disorders (Boden & Fergusson, 2011; Cooper et al., 1995; Mitchell, 2015). However, alcohol use can exacerbate symptoms of a mental illness as well as increase the underlying risk for developing other mental health problems (Brady, 2006; Norström & Ramstedt, 2005; Rehm et al., 2003). Indeed, people with mental health problems are increasingly likely to use alcohol to excess, while those dependent on alcohol have more chance of experiencing concurrent mental health problems. Therefore, it is of no surprise that individuals with alcohol use problems are lacking in terms of flourishing (Keyes, 2005, 2015; McGaffin et al., 2015). It is important to better understand the relationship between alcohol dependence and mental health problems to guide and inform treatment and recovery interventions for people who are likely troubled with a combination of the two.

Nonetheless, there is growing evidence to suggest that abstinence from alcohol use is associated with drastic improvements in all aspects of life (Laudet, 2013). Generally, those in recovery, who are abstaining from alcohol, report fewer negative life experiences, a more satisfying family life, better financial situations and healthier physical and cognitive functioning (Laudet, 2013). Furthermore, longitudinal research revealed that the extent of alcohol use can predict mental health outcomes over time (McGaffin et al., 2015). Those who became abstinent upon discharge from a treatment program experienced greater mental health improvements, compared to those who continued to use substances (McGaffin et al., 2015).

Historically research and treatments for substance use have largely been concerned with maintaining abstinence (Keyes, 2015). More recently, as an alternative to a strict abstinence model, harm reduction strategies are becoming more favorable as a means to curtail the personal and societal problems associated with drinking (Hester et al., 2011; Muckle et al., 2012). Yet, few studies measure alcohol recovery based on enhanced well-being and the extent of building a positive sober life (Hendershot et al., 2011; Kadden, 1995; Krentzman, 2013; Marlatt & Gordon, 1980). In fact, the association between alcohol use, mental health problems and well-being is overlooked and under-researched (Krentzman, 2013; Laudet, 2013; Makela et al., 2015). Recent research has shown that encouraging flourishing in people with mental illness proves to be particularly challenging (Allen et al., 2020). But what about those who are recovering from alcohol dependence? A population of people who were once languishing, but upon abstinence begin to report mental health improvements? To what extent do these mental health improvements encourage flourishing? Considering the strong association between alcohol use and mental illness, with a cyclic causation and a strong overlap in cases of dual-diagnosis, it would be worthwhile to compare the extent to which both populations are flourishing. Perhaps building the foundation for such an under researched topic can fuel further exploration into a comparison of the two groups. One that considers a deeper investigation of how the prevalence of dual diagnosis and concurrent mental illnesses interact with approaches the treatment and recovery.

The present study

This study aimed to investigate the degree of flourishing observed in people recovering from alcohol problems and compare their flourishing scores to two other samples, a normative community sample and a sample of individuals with a mental illness. Initially, quantitative data was gathered that investigated the extent to which those recovering from alcohol problems were flourishing. It also aimed to provide a qualitative perspective on the experiences of people in alcohol recovery.

Materials and methods

Initially, cross-sectional data were gathered from three participant sample groups. These explored differences in the level of flourishing between people recovering from alcohol problems, mental health service users and a normative population of gym attenders, all of whom were recruited opportunistically.

1. People recovering from alcohol problems. These were 107 individuals who were recruited through several online alcohol support groups. There were 48 females and 58 males (one did not report their gender), mean age = 43.57 (sd = 9.66).

2. Mental health services users. These were 130 attenders at two community based mental health services run by voluntary sector providers, 64 females and 64 males (two did not report their gender), mean age = 43.54 (sd = 10.82). These mental health service users were attending counseling and support services for a range of acute and chronic problems such as anxiety, depression and suicidal ideation.

3. Gym attenders. These were 185 members of a large gym who were approached and asked to complete study questionnaires. There were 73 females and 111 males (one did not report gender), mean age = 30.24 (sd = 12.87).

The PERMA-Profiler is a 23-item tool that is used to measure flourishing (Butler & Kern, 2016). Based on Seligman’s theoretical model of happiness (Seligman, 2011), the PERMA-Profiler was designed to capture the five domains of flourishing (Seligman, 2011). The reliability and validity of the PERMA-Profiler has been continuously demonstrated as the tool was tested and refined in three studies, with an additional eight studies confirming the psychometric properties and validity of the scale (Butler & Kern, 2016; Kern et al., 2015).

Participants in the study were provided with information about it and told that participation was voluntary. The survey was delivered online using the Qualtrics platform. Filling out the online questionnaires was taken as giving consent to use their responses in the research. Following this, participants were asked to respond to a series of questions related to their personal experiences and outcomes of their alcohol use and recovery process. For example, participants were asked “What are your hopes for the future?” and “What new targets have you set yourself in your life, since you stopped drinking?” The research received ethical approval from the Psychology Departmental Ethics Committee at the University of Bolton in line with British Psychological Society Guidelines (British Psychological Society, 2018).

Results

As the data did not meet the assumption of homogeneity of variance, a one-way non-parametric ANOVA (Kruskal-Wallis Test) was conducted. A Kruskal-Wallis Test revealed significant differences in flourishing scores between the three samples. Such that, there was a significant difference in total PERMA between the three samples (H(2) = 175.706, p < .001). In fact, there was a significant difference in all domains of PERMA. To explore differences in flourishing scores between people recovering from alcohol problems and people with mental health problems, an independent samples Mann-Whitney U Test was carried out (see Table 1).

Table 1. Comparing flourishing scores between people with alcohol dependence and people with mental health problems

		Mentally Ill	Alcohol Dependence	z Score	p Value	Effect Size (r)
	N	130	107
Total PERMA	M	62.57	86.47	5.97	.001	.39
	SD	32.48	22.48
Positive Emotion	M	11.36	17.13	6.47	.001	.42
	SD	6.61	5.32
Engagement	M	13.28	16.94	4.32	.001	.28
	SD	7.25	4.94
Relationships	M	12.28	17.41	5.34	.001	.35
	SD	7.68	5.59
Meaning	M	11.92	17.41	6.11	.001	.40
	SD	7.21	5.63
Accomplishments	M	13.27	17.68	5.20	.001	.34
	SD	6.83	5.29
Physical Health	M	12.16	15.24	3.66	.001	.24
	SD	6.91	5.43
Negative Emotion	M	19.59	15.68	4.57	.001	.30
	SD	5.51	6.16
Loneliness	M	6.64	4.61	−5.46	.001	−.36
	SD	2.71	2.56
Overall Happiness	M	3.92	6.07
	SD	2.61	1.93	6.59	.001	.43

M = Mean total score, SD = Standard Deviation.

Findings indicated that total PERMA for those recovering from alcohol problems was significantly higher than for the mentally ill sample, z = 5.97, p < .001, demonstrating a medium effect size (r = .39). In addition, the recovery alcohol group reported more frequent positive emotions, higher levels of engagement, healthier and more satisfying relationships, greater meaning in life and a better sense of accomplishment. In addition, they reported better physical health, fewer negative emotions, lower levels of loneliness and greater happiness (see Table 1).

Secondly, comparisons were made between people recovering from alcohol problems and gym attenders (see Table 2). A Mann-Whitney U Test indicated that total PERMA for the recovering alcohol sample was significantly lower than that of gym attenders, z = −8.87, p < .001 with a large effect size (r = −.52). Likewise, the people recovering from alcohol sample reported significantly lower levels of positive emotions, reduced levels of engagement, less social relationships, lower levels of meaning in life, a weaker sense of accomplishment, worse physical health, more frequent negative emotions, greater feelings of loneliness and considerably lower levels of happiness (see Table 2).

Table 2. Comparing flourishing scores between people with alcohol dependence and gym attenders

		Gym Attenders	Alcohol Dependence	z Score	p Value	Effect Size (r)
	N	185	107
Total PERMA	M	113.09	86.47	−8.87	.001	−.52
	SD	21.27	22.48
Positive Emotion	M	22.12	17.13	−7.74	.001	−.45
	SD	4.58	5.32
Engagement	M	22.47	16.94	−8.08	.001	−.47
	SD	4.86	4.94
Relationships	M	22.18	17.41	−6.94	.001	−.41
	SD	5.83	5.59
Meaning	M	23.02	17.41	−7.71	.001	−.45
	SD	4.88	5.63
Accomplishments	M	23.30	17.68	−8.35	001	−.49
	SD	4.30	5.29
Physical Health	M	22.95	15.24	−10.20	.001	−.60
	SD	4.47	5.43
Negative Emotion	M	10.06	15.68	6.70	.001	.39
	SD	6.02	6.16
Loneliness	M	3.19	4.61	4.40	.001	.26
	SD	2.889	2.56
Overall Happiness	M	7.61	6.07	−6.65	.001	−.39
	SD	2.08	1.93

M = Mean total score, SD = Standard Deviation.

Discussion

Findings indicated that people recovering from alcohol problems reported higher levels of flourishing compared to a mentally ill sample. There are a number of possible explanations for these findings. First of all, previous research shows reduced addictive behavior alone can improve mental health (McGaffin et al., 2015). Further, when someone in recovery begins to experience the benefits of abstinence, it encourages hopefulness and motivates them to remain abstinent and continue with their recovery as they now realize that their life is now more worthwhile (Keyes, 2015).

Complex and long-term mental health problems

Due to the high prevalence of dual diagnosis, it is likely that some individuals in the mental illness sample may have been encountering alcohol use problems (Shivani et al., 2002). On the other hand, it is also possible that those in the alcohol recovery group were experiencing concurrent mental health problems. The exploratory nature of this study meant that potentially vital factors such as these were not accounted for. More rigorous data collection could highlight how the prevalence of alcohol dependence in the group receiving treatment for mental illness, and the prevalence of mental illness in the alcohol recovery group might interfere with positive mental health outcomes such as flourishing. People suffering from alcohol use problems are often suffering from some of the worst mental health outcomes (Keyes & Simoes, 2012; Kushner et al., 2000; Park et al., 2015). Due to the cyclic causation between alcohol problems and mental illness there is a high incidence of dual diagnosis (Carra & Johnson, 2009; Megnin-Viggars et al., 2015). On top of this, alcohol use can lead to irreversible and long-term cognitive impairments, as well as depression, anxiety and psychoses (Lovinger, 1993). Perhaps, the link between alcohol dependence and long-term mental health problems hinders their ability to flourish. Although the mental health improvements often reported by people recovering from alcohol problems are a step in the right direction, it was clear that they were not flourishing. In fact, when compared to a normative population sample of gym attenders, people recovering from alcohol probems demonstrated significantly lower levels of flourishing.

Alcohol recovery requires a complete lifestyle change (Birkenshaw, 2016). It involves a volatile journey of peaks and troughs that in itself is likely to cause doubt, stress and apprehension. That journey to recovery takes a considerable amount of work and resilience, but most of all, it takes time. After all, the benefits of recovery become greater with the length of abstinence (Laudet, 2013). Individuals who were abstinent in recovery for longer, displayed higher flourishing levels and reduced levels of languishing (Best et al., 2012; McGaffin et al., 2015). In the present research, it remains unclear at what stage of recovery each individual was at, and so it is possible that some individuals were in the early stages of their recovery, and yet to experience the greater psychological benefits of continued abstinence.

The costs of alcohol use

According to nationwide research, there are many costs of alcohol problems in terms of physical and mental health, employment and finances, family life and relationships and criminal justice involvement (Laudet, 2013). Problem drinking is often associated with personal injuries, accidents and violence due to the behavioral effects of alcohol, such as motor impairment and memory problems (Brown & Tapert, 2004; Yi et al., 2001). Consequently, these social and behavioral changes begin to cause issues with people’s work life, close relationships and finances. The current research demonstrated that the majority of people recovering from alcohol problems experienced some form of loss. One of the most commonly reported consequences of excessive alcohol use was the impact it had on their closest relationships, with one participant stating that:

I don’t see what’s left of my family after years of arguing … I was killing myself. Lost my family (Participant 74).

To someone dependent on alcohol, the overwhelming power of alcohol may lead them on a downward spiral which ultimately ends in the destruction of family ties, friendships, employment opportunities and income. The stark reality of alcohol dependence is that it grinds down the things people cherish and value the most. Often these are the things we use as a source of comfort and reassurance in times of need and for support to guide us through tough times. Indeed, social support is known to act as a buffer for life stressors (Kawachi & Berkman, 2001), and without it, coming back from “rock-bottom” may prove to be an unending challenge. Put simply, whether their alcohol dependent behaviors have ruined relationships, effected their employment and finances or took its toll on their mental well-being, people in recovery from alcohol problems have lost a lot. Consequently, people in recovery typically admit that this sparks a constant battle with feelings of regret, guilt and shame (Lancer, 2018). Indeed, one participant revealed:

I was destroying my life without realising it. I feel I’ve wasted years of my life and regret the opportunities I missed (Participant 103).

Focusing on the past

Recovering from alcohol problems is a strained and complex process. Among other things, it is coming to terms with the consequences of their drinking and trying to move forward. People in alcohol recovery, bearing the personal costs of their dependence and its aftermath, are burdened with the all-consuming feeling of regret. Such that, one participant admitted:

Yes I have regrets about things I did when I was drunk. I was far too aggressive when drunk, in fact I wasn’t a nice person to be about at all. I lied a lot and was far too promiscuous for my own good (Participant 20).

Becoming trapped in a tormenting cycle of regret and guilt means that those in alcohol recovery are stuck in the past. Living in the past can have detrimental effects on mental health (Petersen, 2017). Indeed, continuous negative introspection and recycled feelings of great shame, anger and guilt fuel anxiety and depression (McKay et al., 2017). It also limits the ability to focus on the present and the possibilities and opportunities for the future. Moreover, being stuck in the past means you are unable to think about or plan for your future. According to Lombardo (2016), future consciousness is a vital component of creating a flourishing future. Indeed, thinking about the future, setting goals and making plans, instills a sense of hope and optimism for the future and the element of control we have over it (Bressler et al., 2010; Catalano et al., 2002; Sun & Shek, 2012). Without these forward thinking thought-processes, it remains difficult to find meaning in life, feel purposeful or become satisfied with your life (Felsman et al., 2017; Van Tilburg & Igou, 2019). For that reason, the negative focus on the past and the lack of positivity about the future, restricts those in recovery from flourishing.

Counterproductive support programs

Popular treatment programs for alcohol dependence, such as Alcohol Anonymous (AA), encourage people recovering from alcohol problems to focus on the past. Regardless, there are 4487 AA meetings in the UK, with over 40,000 members, making it the most common and widespread alcohol treatment program. Yet, only 5% of attendees believe AA actually works, which is apparently similar to the rate of spontaneous remission (Bufe, 2014). This is reiterated by some research that concluded attending AA led to worse outcomes than if those dependent on alcohol received no treatment at all (Kownacki & Shadish, 1999) and that poor quality studies were seeming to overinflate the effectiveness of AA (Tonigan et al., 1996). Moreover, it was stated that “available experimental studies did not demonstrate the effectiveness of AA or other twelve-step approaches in reducing alcohol use and achieving abstinence compared with other treatments” (Ferri et al., 2006, p. 4). However, AA and similar twelve step programs have been shown to produce the most promising abstinence rates compared to other interventions (Kelly et al., 2020). Further, one study revealed that AA and similar twelve-step programs reported a 42% abstinence rate after a one year follow-up, compared to 35% for non-AA treatments such as CBT (Kelly et al., 2020). There is however, evidence to suggest that abstinence from alcohol is not sole influencer for recovery, and a reduction in problems associated with drinking are important (Hester et al., 2011). Hence, harm reduction strategies are becoming a more common intervention for alcohol dependence, which offers an alternative to strict abstinence models (Muckle et al., 2012). Rather than being driven by a zero tolerance policy to continued alcohol consumption, a harm reduction approach aims to curtail the personal and societal effects of alcohol dependence (Muckle et al., 2012). While AA was proven to be efficient at raising abstinence levels over time, over and above alternative interventions (Kelly et al., 2020), retention, severity of dependence and drinking consequence did not appear to be differentially influenced by comparative approaches (Ferri et al., 2006).

In addition, the criticism of twelve step programs such as AA can likewise be attributed to the discouraging underlying message behind such a treatment program. One of the core messages of AA is that “Once an alcoholic, always an alcoholic”, with its attendees endlessly reciting the words “I am an alcoholic” (Bufe, 1998). The issue with such a sad and helpless sentiment is that it forces those in recovery, regardless of the length of their abstinence, to self-identify as an “alcoholic.” For a treatment program that claims to support its attendees in their abstinence and guide them through their recovery process, it seems counterproductive to continuously reinforce the hopeless notion that they are doomed to the life of addiction (Keyes, 1998). This means that people recovering from alcohol problems must identify with the very thing that caused them loss and pain, and in the first instance drove them to seek help. If this is not disheartening enough, then the notion that they will always be an “alcoholic,” the very thing they regret so much, is torturous. Not only does this encourage a tragic preconception that those in recovery will never actually recover, it emphasizes a lack of control they have over their own lives (Bufe, 1998; Keyes, 2015). Likewise, it enforces feelings of dependency, which leads to a lack of self-esteem and contributes toward a lack of control (Connell et al., 2012; Michalak et al., 2006). Gaining control of their lives and empowering people seems more of a reasonable and positive target to encourage recovery (Keyes, 2015). Instead, this “haunting ideology” is likely to instill anxiety and stress (Cook & Chambers, 2009; Rusner et al., 2010), pushing people to a point of despair and even further, toward relapse. With such an unattractive perception of recovery, is it any wonder that people recovering from alcohol problems are not flourishing? It is not surprising that alternative twelve-step programs and harm reduction strategies are becoming more visible within alcohol recovery. It remains important to continue research into the effectiveness of different approaches to alcohol recovery.

General discussion

According to Keyes (2002), the ideals of flourishing are believed to be achievable regardless of the presence, or absence, of mental illness (Huppert & So, 2009; Keyes, 2002). If this conceptualization is extended to alcohol problems, it would be proposed that both those who are dependent on alcohol and those who are not, have the ability to flourish (McGaffin et al., 2015). After all, the longitudinal research carried out by McGaffin et al. (2015) revealed 25% of participants who continued to use substances following discharge from the treatment program were flourishing regardless. Conversely, people who are abstinent from alcohol may continue to suffer from the functional and psychosocial problems that were present throughout their dependence (Gogek, 1994; McGaffin et al., 2015). Likewise, experiencing a deeply gratifying sober life is not enough to deter some people from relapse (Campbell et al., 2008; Krentzman, 2013). What is clear from this research is that people recovering from alcohol problems are not flourishing and that alcohol recovery is more than just abstinence (Laudet & White, 2010; Schwarzlose et al., 2007; Substance Abuse & Mental Health Services Administration, 2011). More research is needed to deepen our understanding of alcohol recovery, differing approaches to recovery, the prevalence of concurrent mental health and how this influences comparisons to other groups and recovery.

There are many possible reasons why those in alcohol recovery are not flourishing. Firstly, those individuals recovering from alcohol dependence may also be experiencing mental health problems, which need to be tackled as well. Next, is the unfortunate truth that those who have been dependent on alcohol have experienced a great amount of loss, leading to overwhelming regret, guilt and shame. People recovering from alcohol problems are stuck in the past, in a torturous cycle of reminiscing about their flaws, failures and wrong doings, unable to hope for their future. Finally, commonly used treatment programs for alcohol dependence can be counterproductive and may transmit a deflating and helpless narrative that hinders recovery. Alternative approaches need to be utilized, that choose a more holistic and positive model such as those beginning to surface around harm reduction. Ultimately, those in alcohol recovery may find it challenging to achieve flourishing mental health, after all the odds are stacked heavily against them. However, it must remain a priority to investigate what mediates the relationship between alcohol recovery and flourishing. A comprehensive understanding of this could help people recovering from alcohol problems to successfully restore their mental health and reintegrate back into society (Laudet, 2009). Perhaps a complete re-think of how alcohol recovery is approached and treated in the wider community is necessary.

Limitations and recommendations for future research

This research has a number of limitations. Firstly, this study used self-report measures of flourishing, which have limitations such as social desirability (Phillips & Clancy, 1972). In addition, the normative sample was comprised of regular gym attenders, a population that may already be at an advantage when it comes to flourishing (Keyes & Simoes, 2012; Von Thiele Schwarz & Hasson, 2011). It also remains unclear at what stage of recovery each individual with alcohol problems was at, which most likely influences their perceived mental health outcomes. Future research, especially longitudinal research, should continue to map the influences and outcomes of recovery over time. It was also likely that some individuals in the mental illness sample were encountering alcohol use problems, which could have affected the findings. Similarly, it is possible that those in treatment for alcohol dependence were experiencing concurrent mental health disorders (El-guebaly, 2004). Indeed, the prevalence of concurrent disorders in the alcohol recovery group are unknown, which could have provided more clarity in the disparity between flourishing mental health outcomes among those in treatment for alcohol dependence and those in treatment for mental health. Perhaps a broader scope of personal and demographic information from participants, particularly related to the prevalence of mental health disorders and excessive alcohol use, from both participant groups would have been useful? Due to the cyclic causation between mental illness and alcohol use and the high prevalence of dual diagnosis, it remains a challenge to distinctly separate the two samples (Krentzman, 2015). Thus far there have been very few studies trying to apply positive psychology interventions with dual diagnosis groups (Ujhelyi-Gomez et al., 2020). In addition, there were many confounding variables unaccounted for that could potentially impact the experience of positive mental health in recovery (Makela et al., 2015). Furthermore, this study did not consider which approach to alcohol recovery or treatment for alcohol dependence was favored or utilized by participants. It is unclear whether participants followed a twelve step program such as AA, or favored alternative approaches to treatment such as CBT. Future research should continue to explore the extent to which such influential factors account for differences in mental health outcomes between the sample groups. This could provide valuable knowledge that contributes toward the current challenge that is guiding those with alcohol use disorders and mental illness to successful and continued recovery.

Acknowledgments

The authors are grateful to Mr Ian Harrison, Psychology Technician for help with the Qualtrics Survey, as well as all the participants in the studies.

Disclosure statement

The authors report no conflicts of interest.