SoberDiary: A Phone-based Support System for AssistingRecovery from Alcohol Dependence

Chuang-Wen You†, Kuo-Cheng Wang‡, Ming-Chyi Huangq, Yen-Chang Chen‡, Cheng-Lin Lin∗,Po-Shiun Ho‡, Hao-Chuan Wang�, Polly Huang∗, Hao-Hua Chu‡

†Intel-NTU CCC Center, ‡Dept. of Computer Science and Information Engineering,and ∗Dept. of Electrical Engineering, National Taiwan University, Taipei, Taiwan

qTaipei City Psychiatric Center, Taipei City Hospital Songde Branch, Taipei, Taiwan�Dept. of Computer Science, National Tsing Hua University, Hsinchu, Taiwan

cwyou@ntu.edu.tw, r01922030@csie.ntu.edu.tw, mch@tpech.gov.tw, b98902090@csie.ntu.edu.tw,{b99901156, b00902097}@ntu.edu.tw, haochuan@cs.nthu.edu.tw, phuang@cc.ee.ntu.edu.tw,

hchu@csie.ntu.edu.tw

ABSTRACTAlcohol dependence is a chronic disorder associated with se-vere harm in multiple areas, and relapsing is easy, despitetreatment. This study proposes SoberDiary, a phone-basedsupport system that enables alcohol-dependent patients toself-monitor and -manage their own alcohol behavior, andremain sober in their daily lives. We tested SoberDiary ina real-life 12-week user study involving 27 clinical patients.The quantitative and qualitative results revealed that Sober-Diary helped patients self-monitor and -manage their alcohol-use behavior, and reduced their total alcohol consumption aswell as the number of heavy drinking days. Compared withpatients who received standard treatment alone, this studydemonstrated SoberDiary successfully complemented currentalcohol treatment in reducing patients’ alcoholic cravings anddropout rate over 3-month study period. Follow-up inter-views further revealed the sophisticated use practices andvalue of SoberDiary.

Author KeywordsMobile support system; recovery from alcohol dependence.

ACM Classification KeywordsH.4.m. Information Systems Applications: Miscellaneous

INTRODUCTIONAlcohol dependence is a debilitating psychiatric disorder,and is associated with maladaptive and destructive behavior.Characterized by persistent, compulsive, and uncontrolleddrinking, it leads to marked impairment, distress, and sub-stantial interpersonal and social problems. Up to 50% of pa-tients treated for alcohol dependence relapse within 2 yearsfollowing treatment, even after achieving abstinence [12].

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Therefore, developing a rational approach for enhancing re-lapse prevention is crucial for alcohol-dependent patients whoexperience cravings or the desire to resume alcohol use oncethey have achieved abstinence [15]. This study proposes aphone-based support system that helps alcohol-dependent pa-tients stay sober in their daily lives after completing alcoholwithdrawal treatment.

Previous researchers have developed self-monitoring tech-niques [19] and cognitive behavioral therapy (CBT) [19] toengage or motivate patients to self-manage triggers or chal-lenging life events. To self-monitor their drinking behavior,psychiatrists ask patients to keep a drinking diary, so that theycan find triggers by reviewing their diary. Because of memoryrecall errors, patients might easily forget or record the time oramount of alcohol consumption incorrectly. Furthermore, pa-tients are reluctant to invest effort into maintaining a drinkingdiary. To extend the well-proven treatment of CBT, recentstudies [6, 10, 20] have identified cellphones as a platform.However, these systems either have not incorporated breath-alyzers to facilitate the self-monitoring of patients’ drinkingbehavior during the study [10, 20], or they did not providereal-time feedback that visualizes patients’ progress on theirphones [6]. Furthermore, these studies have evaluated the pa-tients’ sobriety performance based on telephone-based sur-veys [10, 20], or excluded alcohol-dependent patients [6]. Bycontrast, SoberDiary uses a Bluetooth breathalyzer (Figure1) to assist patients in self-monitoring their drinking behaviorby taking breath alcohol tests and providing real-time feed-back to their progress, to raise users’ awareness of alcoholuse. Various support functions are also provided, so that pa-tients can appropriate them to better manage their emotionsand become more sensitive to triggers.

This study involved the use of a phone-based support system,SoberDiary, to help alcohol-dependent patients maintain so-briety in their daily lives once they have completed alcoholwithdrawal treatment. By carrying a Bluetooth breathalyzerthat is wirelessly connected with the SoberDiary applicationinstalled on their phones, patients can perform breath alcoholtests to self-monitor their own alcohol use. To motivate be-havioral change, SoberDiary also records personal progress

and achievements in maintaining sobriety for patients review.SoberDiary also incorporates the principles of the 12-stepprogram [19] to enable patients to learn the concepts asso-ciated with each step, thereby promoting self-fulfillment torecognize the values and beliefs of the community and theself. All test results and momentary feedback sampled by theSoberDiary client are used to provide appropriate recommen-dations for reducing alcohol cravings, and is uploaded to abackend server to enable continuous patient monitoring.

The contributions of this paper are the design, prototype, andevaluation of SoberDiary. A 12-week real-life study involv-ing 27 alcohol-dependent patients using SoberDiary was con-ducted. The quantitative results revealed that the participantsusing SoberDiary were able to self-monitor and -manage theiralcohol-use behavior, and reduced their total alcohol con-sumption and the number of heavy drinking days followingintervention. The qualitative results, obtained from partic-ipant interviews, revealed how patients appropriated Sober-Diary in their regular lives to assist them in staying sober.Compared with patients who received the standard treatmentalone, this study demonstrated SoberDiary effectively com-plemented current alcohol maintenance treatment in reducingpatients’ alcoholic cravings and dropout rate over 3-monthstudy period.

DIFFICULTIES IN STAYING SOBER IN DAILY LIFEThis section provides an explanation on the challenges foralcoholics in maintaining sobriety after completing treatmentat hospitals/centers and returning to normal life. First, wedefine the following terms used in this article:

• A standard drink (or drink) [11] is a unit of alcohol used toquantify the amount of alcohol intake. In the United States,a drink is 14 g of pure alcohol, approximately equivalentto the amount of alcohol in one regular beer containing 5%alcohol (approximately 340 mL).

• A lapse occurs when patients consume any alcoholic bev-erage containing approximately one drink of pure alcohol.

• A relapse occurs when male (female) patients consumemore than six (four) drinks per day.

After completing withdrawal treatment, patients need to re-visit the hospital regularly to attend follow-up maintenanceprograms. To monitor their alcohol use in daily life, psychia-trists ask patients to maintain a drinking diary, so that patientscan identify triggers by reviewing them. However, patientstend to forget to record drinking behavior easily, or recall thetime or amount of alcohol consumption incorrectly, therebyfailing to maintain their drinking diary accurately and consis-tently. Without the drinking diary, psychiatrists can provideonly limited recommendations to patients to improve their so-briety outcomes during each revisit.

The lack of a continuing maintenance program further de-grades the efficacy of CBT [19], which can highlight triggersand coping strategies for relapse prevention. When patientsreturn to their lives, alcohol cues (e.g., alcohol beverages inconvenience stores or alcohol cravings triggered by emotions;

Figure 1: Photos of the Bluetooth breathalyzer.

for instance, stress might trigger alcohol use). Without con-tinuing care to assist them in learning relapse prevention oralcohol management skills, they are bound to relapse easilywhen facing cues or craving alcohol. These observations sug-gest that alcohol treatment professionals cannot rely only cur-rent approaches, and a complementary treatment modality toimprove the efficacy of relapse prevention is required.

SOBERDIARY DESIGNThe SoberDiary system contains three components: (1) aportable Bluetooth breathalyzer, (2) a phone application, and(3) a backend server, which are described as follows.

Portable Bluetooth BreathalyzerFigure 1 shows the front and left and right sides of the breath-alyzer, which measures patients’ breath alcohol concentration(BrAC). During each breath test, alcohol absorption on thealcohol gas sensor [4] causes the electrical resistivity of thesensor to vary, altering the voltage output of the sensor. Ac-cording to the voltage-to-BrAC lookup table learned from acalibration process, a BrAC reading is interpolated and re-turned through a built-in Bluetooth module.

SoberDiary Phone ApplicationThe SoberDiary application provides various supportingfunctions that (1) enable users to self-manage addictive be-havior, (2) suggest proper relapse prevention skills to reducealcohol cravings, and (3) promote self-fulfillment. Relapseprevention [16] involves complex interactions with lifestylefactors (e.g., lifestyle imbalance or stress), intrapersonal fac-tors (e.g., personal mental or physical status), and interper-sonal factors (e.g., social relationships). To develop skills forstaying sober, multiple behavioral theories were used to in-fluence patients’ behavior from various aspects [19] in thisstudy (i.e., self-efficacy theory [21], CBT [19], and self-determination theory [10]). According to self-efficacy the-ory [21], self-monitoring increases patient awareness of riskysituations and behaviors, enhances patients’ self-efficacy andcompetence, and enables them to build the relationships andskills necessary for relapse prevention and sustaining absti-nence. However, self-monitoring can be difficult to maintainwithout adequate support. Therefore, the SoberDiary appli-cation also includes CBT modules enabling cognitive behav-ioral theories [19] to emphasize triggers and coping strategiesfor relapse prevention and functional modules based on self-determination theory [10], to internalize the motivation forrecovery when patients feel that they are able to maintain re-covery (competence), perceive the decision to abstain fromalcohol use as resulting from free will (autonomy), and feel

support from others in their recovery efforts (relatedness). Inthe next section, the application is described.

Backend ServerA backend server receives behavioral data uploaded from pa-tients’ phones for future analysis and continuous monitor-ing. To provide information on sobriety outcomes, the servertracks the rankings of peers’ achievements in alcohol recov-ery. To facilitate the management of patients participated inthis study, a monitoring web service was used to monitorall data uploaded by patients continuously, and provide re-searchers and psychiatrists with a daily summary includingthe details of patients who did not perform adequately.

SOBERDIARY PHONE APPLICATIONThe four modules of the SoberDiary application are the (1)user interface, (2) supporting functional module, (3) app uselogging, and (4) behavioral data store, as follows.

User InterfaceA simple user interface with three full-screen main pages—test, statistical, and self-fulfilling pages—was designed. Pa-tients switch between these pages by using three buttons lo-cated at the bottom of the screen. When patients launch theapplication, they view the test page for self-administeringbreath alcohol tests. After a test is conducted, a summaryappears instantaneously on the statistical page. To facilitatesocial sharing and learn positive self-fulfilling concepts, pa-tients can switch to the self-fulfilling page. Mood samplingcan be initiated by tapping the menu key. The designs foreach page are described in the following subsections.

Supporting Functional ModuleFour functional blocks—alcohol use detection, progress feed-back, a self-fulfilling guide, and mood sampling—are in-cluded to assist patients in maintaining abstinence, describedas follows.

Alcohol use detectionContinuous patient monitoring [21] was identified as crucialfor relapse prevention, and has long been absent from currentalcohol treatment. To reduce the effort required to completethe tests allocated daily, we divided a day into three time slots:(1) a morning slot from 0:00 to 12:00, (2) an afternoon slotfrom 12:00 to 20:00, and (3) an evening slot from 20:00 to24:00. Patients are required to perform at least one test ineach slot to complete the alcohol-screening task and are askedto complete at least two slots per day.

To ensure that a sufficient amount of air from the deep lungaccumulates in the sample chamber, a pressure sensor moni-tors whether patients exhale air into the sample chamber forlonger than an empirical threshold (i.e., a 5-s exhalation pro-cess in this study). To prevent cheating, patients are asked toperform the test with their face in view of the phone’s cam-era. During the 5-s exhalation process, the application cap-tures three photos of the patient’s face. After the test, thefinal BrAC value is extracted by calculating the median of allsamples. Finally, a questionnaire appears, and patients recordtheir momentary emotion and craving indices by responding

completionpercentage

(a) Statistical page

Goal &

completionpercentage

(b) Self-fulfilling page

Figure 2: Screenshots of the SoberDiary phone application.

to a visual analogue scale (VAS) on the screen. To encode theindices in numeric values, 10- and 5-point Likert scales areused for their momentary indices, respectively.

Progress feedbackFigure 2(a) shows a screenshot of the statistical page, whichvisualizes patients’ personal progress, and motivates themwith achievements and rewards based on contingency man-agement therapy [18]. The top of the statistical page providesa summary, and the bottom lists incentives. The summaryregion visualizes personal test results to enable patients to re-view their recent alcohol use on a daily dashboard. The dash-board shows the BrAC value as well as the craving and emo-tion indices of the latest test, and shows whether patients havestayed sober in the morning, afternoon, and evening slots.Each slot is represented in one of three possible state col-orings: (1) the sober state, encoded in green, indicating thatthe patient passed all tests; (2) the drinking state, encoded inred-orange, indicating that the patient failed a test; and (3) themissing state, encoded in dark gray, indicating that the patientmissed a test.

To provide positive feedback to patients, the incentive por-tion shows the rewards earned and their performance in therecovery process. Based on contingency management ther-apy [18], a reward is shown to motivate patients to continueusing the application (i.e., the number of coupons earned). Toencourage competition among participating patients, Sober-Diary also showed patients’ rankings among all patients ac-cording to the average number of credits that all of the patientparticipants have accumulated since the study began.

Self-fulfilling guideFigure 2(b) shows the self-fulfilling page, which enables pa-tients to recognize positive self-fulfilling concepts. The self-fulfilling page also consists of two separate parts: the tophalf displays sobriety goal sentences with drawing illustra-tion, and the bottom half provides visualization of the pa-tient’s emotion, craving and drinking behavior. The sobri-ety goal sentences come from Alcoholics Anonymous (AA),which proposed the principles of the 12-step program [19]to delineate the recovery process from alcohol dependence.This process comprises 12 steps to guide patients in promot-ing their self-fulfillment and staying sober, as shown in the

Figure 3: Screenshots of drawings (a)—(d) displayed in the top half ofthe self-fulfilling page.

subcaptions of Figure 3. The last eight steps were omittedfrom the figure because of space limitations. To encompassthe self-fulfilling aspects of the alcohol recovery process, aself-fulfilling guide is presented in the illustration part, con-taining 12 pages depicting each step. These 12 steps appearin the order specified according to the 12-step principle, withdurations distributed evenly over the alcohol recovery pro-cess. When a step begins, the application shows a new pagewith a colored drawing in the illustration part, along with thegoal sentence and a completion percentage for slots in the pe-riod of the step shown below the drawing.

The bottom part contains four tabs: the emotion index, thecraving index, and the daily BrAC values are plotted as threerespective bar charts, and these trends are overlaid aggre-gately as a line graph in different tabs. By reviewing theself-fulfilling summary, patients can recall relapse preventionskills learned during treatment, and recognize positive self-fulfilling concepts described in the goal sentence. When theyobserve abrupt behavioral changes in the collected data, theycan record their feelings by using voice recordings to remindthemselves of the cause of those feelings in the future.

Mood samplingThe mood sampling block samples emotions and triggers toidentify participants’ negative thoughts based on CBT treat-ment. Because negative moods (e.g., stress) trigger alcoholcravings, they may cause patients to turn to alcohol for relief.To prevent negative moods, identifying and addressing neg-ative feedback is crucial. Using their smartphones, patientscan record triggers of their negative moods when experienc-ing symptoms of depression and anxiety through an ecologi-cal momentary assessment (EMA) [13].

App Use LoggingTo analyze how the participants used the SoberDiary applica-tion in this study, we designed the app use logging module torecord their click/scroll streams with timestamps. All streamsare uploaded to the backend server once daily. To calculatethe application use time associated with one of the four sup-porting functions, the monitoring services on the server la-bel each action as belonging to each supporting function, and

then aggregate the duration of the individual use of a functionin each session to calculate the total use time of a specificfunction.

Behavioral Data StorageThe behavioral data consist of BrAC values, the testing time,sampled emotions, triggers, and corresponding timestamps.To provide continuous monitoring, the collected behavioraldata are sent to the server immediately after patients completetesting, or they are uploaded in a batch when patients launchthe application.

SOBERDIARY PROTOTYPEAs shown in Figure 1, we fabricated a plastic case (7 cm× 5.8cm × 2.5 cm) to hold a customized Arduino-compatible sen-sor board, equipped with a microcontroller [1], a digital pres-sure sensor [2], a Bluetooth module [3], and an alcohol sen-sor [4]. The microcontroller samples the ADC voltage outputof the pressure and alcohol sensors, to detect when patientsblow air into the chamber, and to measure the alcohol con-centration in the exhaled air. The sensor board is powered bya lithium-ion battery, which can be recharged approximatelyevery 10 days by using a USB. Three color LEDs are usedto inform patients whether the sensor is running (red LEDon), low in battery power (yellow LED blinking), or charging(green LED on).

After calibrating the breathalyzers by using a standardalcohol-breath test simulator [5], the resultant accuracy was+/- 0.05 mg/L of breath alcohol within the range of 0 to 0.5mg/L, and within 10% of the range of 0.5 to 0.75 mg/L. Thisis a suitable accuracy level for the classification of each pa-tient’s BrAC values into three categories. However, to reducethe impact of mouth alcohol [7], the final screening thresh-old was set at 0.068 mg/L in this study, slightly higher thanthe original screening threshold of 0.05 mg/L. Three cate-gories were defined: the sober class, representing measuredBrAC values lower than 0.068 mg/L; the lapse class, repre-senting measured BrAC values in the range of 0.068 to 0.25mg/L to detect lapses in alcohol use; and the relapse class,representing measured BrAC values greater than 0.25 mg/Lto detect relapses in alcohol use. The SoberDiary applica-tion communicates with the Bluetooth breathalyzer throughAndroid Bluetooth APIs. An SQLite database (i.e., the be-havioral data storage) is used to store the patients’ BrAC testresults and momentary feedback locally on the phone. Thebackend server records the breath alcohol test results, mo-mentary feedback, and application use logs from all patientsin a MySQL database hosted on an Apache server.

USER STUDYWe conducted a real-life 12-week user study involving 27alcohol-dependent patients who tested the SoberDiary sys-tem. To demonstrate the feasibility of using SoberDiaryto self-monitor patients’ alcohol use behavior, this studyquantitatively evaluated patients’ self-monitoring adherenceand measured differences between SoberDiary-detected andTLFB-recalled drinking days. To further explore how wellSoberDiary complements current treatment in a real-worldsetting, we follow the quasi-experimental design to compare

Name Intervention ControlAvg (Std) Avg (Std)

Craving index (9)* 2.9 (2.7) 1.4 (2.0)# of heavy drinking days (day) 53.1 (35.1) 70.3 (26.4)

Total alcohol consumption (drink) 1239.1(1524.0)

1406.1(1061.0)

Table 1: Variables assessed in baseline medical reviews. The maximalvalues of craving index is indicated by numbers in parentheses.Significant differences of craving index between two groups are

indicated by the “*” symbol (p < .05).

the data from 27 patients in this study with another data fromother 20 participants who only received standard treatment inan ongoing project (i.e., a surrogate measure of sobriety out-come improvement contributed by standard treatment). Fi-nally, this study also qualitatively evaluated how well Sober-Diary helped patients self-monitor and -manage their drink-ing behavior to maintain sobriety.

ParticipantsWe recruited participants through hospital referrals and ad-vertisements. To screen participants, we conducted struc-tured interviews to determine their eligibility according to theinclusion and exclusion criteria. We explained the goal ofthe study, and asked eligible participants to provide informedconsent.

For the intervention group, we recruited 27 participants (i.e.,23 men and 4 women) aged from 31 to 58 years. The av-erage age and standard deviation (std) were 42.7 years and7.4 years, respectively. Eight participants were unemployed,and the others were engineers, salespeople, or clerks, or wereself-employed. All participants were clinical patients whohad completing withdrawal treatment and passed a screeningtest at Taipei City Psychiatric Center (herein referred to asTCPC). To compensate for the cost of revisiting the hospitalfor follow-up assessments, patients were reimbursed US$6.5for each revisit. Depending on the frequency and conformityof the requested SoberDiary usage, each patient was also re-warded with a maximum of four restaurant coupons (approx-imately US$6.5 in value) per week.

For the control group, we leveraged the data from 20 partic-ipants (i.e., 20 controls comprising 16 men and 4 women)from another ongoing project from June to September of2013. All controls collected ground-truth drinking data byusing the timeline follow-back (TLFB) method [11]. Simi-larly, all of the controls were clinical patients who had passedthe same inclusion and exclusion criteria as those used to re-cruit the intervention group. Each control was reimbursedUS$6.5 for each revisit. The age distribution of the controlsranged from 28 to 53 years, and the average and std were 42and 7.44, respectively. The occupations of the control groupwere similar to those of the intervention group.

Table 1 lists the variables assessed using baseline medical re-views, including the participants’ self-assessed craving index,the number of heavy drinking days, and total alcohol con-sumption, as recalled by the participants over 12 weeks beforethe study. Based on the responses, the participants exhibitedvarious unique alcohol addiction behaviors. One-tailed t-test

results revealed no significant differences between these twogroups, except for a significantly higher craving index (p =.01) of the intervention group, indicating that the participantsin the intervention group had a higher alcohol craving com-pared with the control group.

We provided a Bluetooth breathalyzer to each participant inthe intervention group, and the breathalyzer was paired withevery smartphone. We also installed the SoberDiary applica-tion on all smartphones and asked participants to use them astheir primary phones during the study.

ProcedureThe procedure for the intervention group consisted of threeparts: (1) a pre-study medical assessment, (2) a 12-week real-life study with SoberDiary, and (3) post-study interviews.

The purpose of the pre-study medical assessment was to col-lect the baseline craving index and alcohol consumption andcompliance. Recent alcohol consumption and compliancewere measured using the TLFB method in the baseline as-sessment and clinical assessments (described later in this sub-section) of follow-up medical reviews, obtained from partic-ipants’ self-reports. The structured drinking diary recordedthe type and amount of alcohol consumed per day in gramsof pure alcohol. To teach the intervened patients how to usethe phone application and breathalyzer, they all attended a 30-min training session teaching them how to operate the Sober-Diary application and the breathalyzer.

During the 12-week real-life study, the intervened patientsused the SoberDiary application for recovery from alcoholdependence. To collect ground truth data and address ques-tions related to application use, the intervened patients wererequired to attend scheduled medical reviews held duringWeeks 1, 2, 4, 8, and 12 at the TCPC. Each medical reviewconsisted of a clinical assessment session and a technical sup-port session.

Clinical assessment session: The intervened patients under-went medical care, typically available in hospital-based alco-hol treatment services, in Weeks 1, 2, 4, 8, and 12. Intervenedpatients were asked to complete the questionnaires assessingthe craving index in the final medical review in Weeks 4, 8,and 12. When intervened patients lapsed, they were encour-aged to resume abstinence.

Technical support session: We asked intervened patients toreport any problems related to application use, and tested thebreathalyzer’s accuracy in Weeks 1, 2, 4, 8, and 12. We pro-vided rewards (i.e., restaurant coupons) to each intervenedpatient. When they failed to attend the scheduled medical re-views, follow-up telephone calls were made to arrange an-other appointment. A maximum of three contact attemptswere made to ensure the retention of each intervened patient.

For the post-study interviews, we randomly selected 8 par-ticipants from the intervention group who completed the 12-week study. For each selected participant, an audio recorderwas set up to record a 45-min semi-structured interview thatinquired into the intervened patients’ daily application use be-havior, opinions toward each supporting function of Sober-

Figure 4: The completion rate (top) and the average missed rate(bottom) from W1 to W12. The red dotted lines show the trends in

three months.

Diary, notable behavioral changes, and influences on socialinteractions after using SoberDiary. Data saturation [22]was reached after 8 participant interviews in the interventiongroup (5 men and 3 women, aged 33-58 years with averageand std of 48.88 years and 8.36 years, respectively).

For the control group, all controls underwent baseline andfollow-up medical reviews (identical to those for the inter-vened patients) simultaneously, without the SoberDiary inter-vention. The procedure was identical to that used in the inter-vention group, except for the absence of the 30-min trainingsessions at baseline and all technical support sessions in thefollow-up reviews.

Quantitative ResultsAfter collecting data from the participants, a quasi-experimental research method was used to determine how theparticipants’ use of SoberDiary affected their drinking behav-ior. Data from medical reviews and the SoberDiary applica-tion were compared for consistency, and used to justify ab-stinence by observing whether patients using SoberDiary ex-hibited a lower average drinking amount and fewer averageheavy drinking days compared with 20 controls. The drink-ing behavior monitored using the TLFB method was com-pared with that monitored using SoberDiary. Statistical meth-ods were used to analyze the application logs and interpretapplication-use behavior.

The evaluation metrics derived from the variables measuredusing medical reviews were total alcohol consumption andthe number of heavy drinking days measured both 12 weeksbefore and in the ith month during the study. By con-trast, the evaluation metrics for the ith month derived fromSoberDiary-monitored data are as follows. The completionrate measured the average daily number of tests (or slots)completed by the participants. The missed rate measuredthe average daily number of tests (or slots) missed by partici-pants, because patients were required to complete at least twotests in two time slots per day. The application-use time mea-sured the average time a participant spent using SoberDiarydaily.

The statistical methods for analyzing the data are as follows.We used repeated measures ANOVA as the statistical testto check whether or not completion rate, missed rate, and

Drinkingdays

M1 (84 slotsin 28 days)

M2 (84 slotsin 28 days)

M3 (84 slotsin 28 days)

Monthlyaverage

Avg Std Avg Std Avg Std Avgdetected 3.22 4.65 3.96 6.41 2.71 5.59 2.90recalled 2.81 5.23 3.21 6.00 4.90 8.69 3.22

diff 2.41 4.08 2.65 4.74 3.43 5.69 2.44

Table 2: The number of drinking days detected by SoberDiary (i.e., thesecond row) or recalled using TLFB (i.e., the third row) and the

difference between detected and recalled drinking days (i.e., the fourthrow) in the ith month. The monthly average (i.e., the last column) of thedifference between detected and recalled drinking days is calculated by

averaging the absolute values of the difference.

application-use time exhibit significant trends over 3-monthperiod. We used independent samples t-test and paired t-testas the statistical tests to compare the means of measures be-tween two groups and the means of variables between base-line and final assessments on controls or intervened patients,respectively.

Results of patients’ self-monitoring behaviorThe top (bottom) graph in Figure 4 shows the participants’ av-erage completion rate (average missed rate), which was high(low) at 2.6 (0.12) tests per day, and showed no significantchange over the months (F (2, 68) = .24, p = .79 for comple-tion rate and F (2, 68) = .72, p = .49 for missed rate). The highcompletion rate and low missed rate showed that most partic-ipants were able to conform to the twice-a-day SoberDiaryself-monitoring in their daily life.

Differences between SoberDiary-detected and TLFB-recalled

drinking daysTo examine whether SoberDiary generated feedback that re-flected the participants’ drinking days accurately, Table 2 liststhe differences between the SoberDiary-detected and TLFB-recalled drinking days. The columns in Table 2 enable acomparison between the number of drinking days detectedby SoberDiary and those recalled using the TLFB method atthe ith month. Subtracting the number of drinking days re-called using TLFB (i.e., the recalled row) from that detectedby SoberDiary (i.e., the detected row) yields the data for thediff row, which is the absolute value of signed differencebetween SoberDiary-monitored and TLFB-recalled drinkingdays. The average diff was small (i.e., 2.44 days per month).Several possible explanations for the reporting inconsisten-cies between the SoberDiary-detected method and the TLFB-recalled method are provided in the following section.

How well SoberDiary complements current maintenance

treatmentTotal alcohol consumption and the number of heavy drink-ing days in the intervention group decreased significantly by94.4%, and 86.5% (p < .01 for both two variables), respec-tively, which were comparable to the reductions of 93.3%and 88.6% of total alcohol consumption and the number ofheavy drinking days in the control group (p < .01 for bothtwo variables), respectively. Because both groups receivedthe standard maintenance treatment for abstinence, partici-pants in both groups showed significant reductions in totalalcohol consumption and the number of heavy drinking days.

After completing treatment, the intervened patients reportedfewer cravings, and the craving index significantly decreasedby 59.0% (p = .001). By contrast, the craving index for thecontrols slightly increased by 53.8% (p = .09). The dropoutrate in the intervention group was 22% (i.e., 6 of 27 inter-vened patients), which was nearly significantly lower than45% (i.e., 9 of 20 controls) of the control group (p = .051).Although both groups showed comparable significant reduc-tions in sobriety outcomes, the intervention group showedlower dropout rate than the control group. In other words,this study shows that SoberDiary successfully complementscurrent maintenance treatment in reducing patients’ alcoholiccravings and dropout rate in the 3-month follow-up program.Furthermore, 5 intervened patients expressed that they werevery willing to continue using SoberDiary after the 3-monthstudy period.

Application-use behaviorRegarding the daily application-use time for each participantin each week, the average use times were 15.3 min, 16.4 min,and 13.7 min per day in Months 1, 2, and 3, respectively.The application-use time increased moderately in M2, but de-creased slightly in M3 (F (2, 68) = .38, p = .68). This indi-cated that the incentives offered to motivate patients to con-tinue using this application were effective.

Qualitative FindingsData for the qualitative findings were retrieved from the au-dio recordings of the semi-structured interviews with 8 inter-vention participants. We manually transcribed the recordedaudio from the intervention-patient interviews, and coded thetranscriptions to identify salient themes. We organized theemerging themes and findings as follows.

Self-administered monitoring improved self-efficacyThe participants’ beliefs on self-efficacy produced effects incognitive development, and determined how they behave.We found that participants underwent a process of adoptingthe self-monitoring function of SoberDiary to identify self-efficacy. All interviewees responded that they were able tocomplete two test slots in a day, and to fit the test time intotheir working schedules.

My working hours are not from 9:00 AM to 5:00 PM. BecauseI am a consultant, I spent more time reading reports afterconference calls with my colleagues abroad from 10:00 PMto midnight. Therefore, I often slept late, at 2:00 or 3:00 AM.[...] So, I usually performed the tests before going to the bedearly in the morning and after finishing my lunch and dinner.(P17)

Four interviewees commented that requiring tests in two ar-bitrary time slots in a day (e.g., one early in the morning andone late in the evening) could create a cheating window ofopportunity that was sufficiently long for the body to poten-tially metabolize a certain amount of alcohol, resulting in un-detected drinking.

I thought that even completing all three test slots in a day isnot enough [to close the cheating gap]. The night slot startsat 8:00 PM, and ends at midnight. There are 12 hours [of

a window] until 8:00 AM the next day. So, if I complete atest for the night slot, and immediately start drinking or atmidnight, can SoberDiary detect this alcohol use at 8:00 AMthe following morning? (P16)

Among these four interviewees, two interviewees reportedhigher levels of alcohol cravings immediately after complet-ing withdrawal treatment. Specifically, they commented acraving for strong alcoholic drinks such as whiskey. How-ever, they wanted to achieve good results on SoberDiary byattempting to prevent SoberDiary from catching them drink-ing. This motivated them to gradually learn and exploit thischeating window by drinking at a controlled amount (i.e.,they partially relieved their craving and still passed the nextSoberDiary test).

When you fail a test, it is just like ... a kid doing somethingwrong (Uneasy laugh), and being caught by SoberDiary thatI drank alcohol again. [...] I thought a good part of Sober-Diary for me was to remind me not to drink too much. If Idrank too much, I would fail the [morning] test after I wokeup. So, I control myself ... I mean only to drink a smallamount of alcohol to relieve my cravings. Meanwhile, I canstill pass the test tomorrow morning. (P13)

Although the proposed system presented a window of oppor-tunity for participants to cheat, exploiting this window re-quires that participants be aware and control the amount ofalcohol intake, such that sufficient time exists for their bodyto dissipate the alcohol and pass the next test. The partic-ipants commented that they avoided situations where theyrisked out-of-control drinking.

In the beginning of the study, I might have cheated the systemto pass the tests. But later, I felt that it is important to be de-termined, and that I should not continue cheating the system.So, I gradually controlled my behavior. [...] Now, I think I ammore capable of controlling my drinking behavior. For exam-ple, I usually attended parties invited by my colleagues beforeusing SoberDiary. Now, I would be more aware of these oc-casions, which trigger alcohol use, and know how to refusesuch invitations. (P34)

Many participants gradually learned how to control their alco-hol intake. This increased perceived control over their drink-ing behavior helped participants improve their personal ef-ficacy to stay sober through the efficacy-activated processes[21].

Coupons and performance ranking encouraged routine appli-

cation usage, but was ineffective to alter determinationTwo incentives to motivate participants’ continuous use ofSoberDiary were (1) restaurant coupons, and (2) the appli-cation showing each participant’s ranking in a group. Seveninterviewees responded that the reward coupons had an effecton encouraging them to spend more time exploring and usingthe various application functions.

Sometimes, I did care how many coupons I earned. [...] Thesecoupons were ... mental and material encouragements formyself. I would click through buttons to use different func-

tions. As I clicked the buttons, I might have accumulated morecoupons. This is just like self-encouragement. (P5)

In addition, SoberDiary generated competition among pa-tients [19] by ranking each participant’s performance in agroup. All of the interviewees responded that they cared fortheir standing, because they did not want to finish with a lowrank, suggesting a poor sobriety outcome.

I wanted to maintain the above-middle ranking. [Ranking]served as a reminder to me. For example, this was like whenI took exams (in class). If I was ranked 10th on this exam anddropped to the 30th on the next exam, it made me realize that... I should work harder. (P34)

The findings revealed that both restaurant coupons and per-formance ranking motivated participants’ continuous androutine use of SoberDiary. However, routine usage did nothelp strengthen participants’ determination or competencein staying sober, which is the essential construct of self-determination theory [10]. Six interviewees shared similarthoughts, as shown in the following:

I didn’t think the ranking information made me more deter-mined to keep up with sobriety. Keeping up with sobriety ismore about self-regulating drinking behavior. I cared aboutmy ranking because I felt ashamed to lose to other partici-pants. (P13)

Experience reflection and goal setting enhanced determina-

tionMost participants suggested that coupon rewards and perfor-mance ranking were not sufficiently strong incentives to af-fect their determination to stay sober. Instead, the participantsfound the application’s self-filling guide to be more effectivein strengthening determination compared with the couponsand ranking system. Six interviewees provided a similar re-sponse.

The goal sentence [in the application’s self-fulfilling guide]for each week gave me a weekly target. It informed me whichstage I was currently on. Because I might not know whatshould be achieved in these 12 weeks. The only thing I knewwas that I wanted to maintain sobriety, but didn’t know howlong I should take to achieve these goals. [...] I thoughtthis [stepwise] self-fulfilling guide, other than suggestionsfrom psychiatrists or clinical psychologists, is an informationsource for understanding how well you performed. (P17)

The weekly goal sentences in the self-fulfilling guide weredesigned to appear repeatedly as a part of the routine Sober-Diary usage. They reminded participants of the course of ac-tion they could conduct for alcohol recovery. The weeklygoal sentences provided them with positive behavior princi-ples, and enhanced their determination to fight the cravings.Four interviewees responded that the scenarios in these goalsentences were connected to their past experiences of strug-gling with alcohol.

Some sentences made me realize that I have been throughthe same scenarios before. I thought my job was good, butwhy couldn’t I do or keep my job properly? Because of al-

cohol use, I could not show up regularly for work. Then, myboss became less willing to interact with me. These eventsoccurred again and again. Finally, I quit my job. (P18)

Because these goal sentences touched on their experiences,many participants commented that they remembered thesegoal sentences so well that these goal sentences helped themengage in more self-reflection on events in their daily life.

I remembered some sentences or ... keywords in sentences.It’s easy to relate my experiences to these sentences. Thesesentences described... to be determined to maintain sobri-ety. And another one was ... your health conditions or lifewould be better if you continue to stay sober, and so on. [...]Furthermore, one day, when I watched a movie, I was deeplyimpressed by a line in the movie ”Respect yourself” (i.e., theprinciple behind the goal sentences of Week 7). Once youdecide to participate in this study to maintain sobriety, youshould respect yourself. That is, I am doing this not for oth-ers, but for myself. This is about self-discipline, not aboutdoing it for someone else. (P34)

Frequent self-reflection helped participants raise their self-determination and self-discipline to better handle cravings.

During the third week, I remembered that something had hap-pened suddenly. That thing ... made me unable to focus onstaying sober. I can’t remember what happened. But I readthe sentence on the third page of the self-fulfilling guide, andrealized that ... it was my own responsibility to solve thisproblem. I should be actively accountable for solving this,not counting on other people’s help. (P16)

Present SoberDiary results as a way to communicate with

family membersFor most participants, their uncontrollable and repeated abuseof alcohol in the past had seriously harmed their family rela-tionships. Even after medical treatment, their family mem-bers still remained skeptical and suspicious regarding thetruthfulness of their words, and that they had stopped drink-ing. Two interviewees expressed sadness that their words hadlost their family’s trust completely.

In place of their words, many participants presented thebreathalyzer’s results and our coupon rewards as a way tocommunicate with their family members that they were ex-pending effort and progressing toward sobriety.

I think those rewards (i.e., coupons) are an extra for me. Themost crucial point for me was that SoberDiary proved thatI didn’t drink alcohol. First, I proved to my family that ...after wasting 20 years on drinking alcohol ... with the help of[my psychiatrist], I provided proof that I really did not drinkanymore. (P18)

After using SoberDiary, I felt that I had more interactionswith my parents. Actually, I felt that they would be even hap-pier that I performed the tests in their presence. It seemedthat I was actively proving that I don’t drink alcohol. (P08)

Because the family members felt greater confidence becauseof the application and the breathalyzer results comparedwith the participants’ words, two participants responded that

SoberDiary had helped them reestablish trust and improvefamily communication.

DISCUSSIONOne interesting observation is that the requirement for partic-ipants to engage in self-administered alcohol screening andmonitoring appears to produce positive influence on theirdrinking behaviors and attitudes in more than one way. Someof the ways that SoberDiary produces impacts are not fullycalculated or intended at the design stage.

Consideration of Alcohol-Screening FrequencyThere are several ways to cheat the SoberDiary system.For example, patients may purchase another breathalyzerfor pretesting, whereby they would not use the SoberDiarybreathalyzer until they had passed the pretest by using thepretest breathalyzer. Increasing the frequency of alcoholscreening from twice to three or four times daily may rec-tify such issues. However, remembering and performing ad-ditional tests would necessitate additional effort, and placea greater burden on users. The goal and purpose of Sober-Diary is not to burden patients with frequent breath tests, butto raise their awareness of their alcohol-use behavior, whichis evidenced in the interviewee responses. Increasing aware-ness is believed to be a relatively apparent mechanism howSoberDiary influences the patients.

Constructive CheatingWhat’s less apparent yet noteworthy is that allowing peopleto cheat may still be constructive and can be useful to trans-forming their attitudes and behaviors toward reducing alcoholconsumption. On the one hand, cheating certainly discreditedthe results of SoberDiary. However, our interviews revealedthe other side of cheating. Cheating suggested that partici-pants cared and were actively engaged in SoberDiary. It isa signal that they wanted to do well, such as having a goodstanding in their group and presenting positive results to fam-ily members, even when they lacked full capability to controltheir drinking behavior.

By keeping participants engaged in SoberDiary, they willhave more opportunities to learn how to control their drinkingbehavior, as suggested in this study. For the higher level goalof design, some space or flexibility for participants’ construc-tive cheating may help control the drop-out rate. High drop-out rate is certainly not a desirable outcome for this sort ofsystem. While it is important in the design of behavior mod-ification applications to ensure the accountability of loggedbehaviors, we believe that there exists a design space on howto leverage the positive aspect of cheating toward the benefitof the participants by keeping them engaged.

Alternative Stakeholders to Manage SoberDiary in theProcess of Alcohol TreatmentIn this study, the SoberDiary system was managed by re-searchers from National Taiwan University and National Ts-ing Hua University, who closely collaborated with psychia-trists from TCPC. Because participants trusted medical spe-cialties of psychiatrists (i.e., medical specialists), they tended

to respect feedback or recommendations made by the Sober-Diary system. Furthermore, patients who have establishedlong-term psychiatrist-patient relationships felt responsiblefor maintaining sober to adhere to expectations from psychi-atrists. For example, P13 expressed “If I drank alcohol andfailed a test, I felt sorry to [the psychiatrist]”. Therefore,to integrate the SoberDiary system into future alcohol with-drawal treatment, finding reputable institutes/organizations tomanage the SoberDiary system should be crucial for prop-erly transferring SoberDiary to a supervising representativeof psychiatrists. Future studies are required to explore waysto collaborate medical institutes/organizations with psychia-trists to manage the SoberDiary system and evaluate impactson the efficacy of patients’ sobriety outcomes.

Reasons Causing Inconsistencies between System-Detected and Human-Recalled Sobriety OutcomesIn this study, SoberDiary-detected drinking days were com-pared with TLFB-recalled drinking days to measure the ac-curacy of sobriety outcomes with SoberDiary use. The rea-sons attributed to inconsistencies between these two data setsare as follows: (1) Participants made memory recall errors,leading to over-reporting or under-reporting lapses/relapsesin each revisit. For example, patients tended grossly exag-gerated the number of drinking days as the time betweentwo successive hospital revisits increased to 1 month; and(2) breathalyzers might be subject to a false or missed detec-tion because of the slow recovery of the sensor, the morningbreath problem (i.e., residual mouth alcohol not yet metabo-lized), or substances (e.g., certain cold medicines) containingalcohol. Based on interviewee feedback, they may eat foodsor take nighttime cold medicines containing alcohol, whichwould influence the screening outcomes.

Difficulties in conducting randomized controlled trialsRandomized controlled trials (RCTs) are the gold standardfor demonstrating the efficacy of medical interventions. How-ever, we faced difficulties in recruiting clinical patients forthe control group because they expressed strong desires to bein the intervention group during the screening phase. Whenclinical patients found out that they were in the control group(not using the SoberDiary application), they tended to refuseto participate. As a results, this study was based on the quasi-experiment design to explore how well SoberDiary helpedpatients self-monitor and -manage their drinking behavior tomaintain sobriety and complemented with deeper qualitativeinterviews to draw useful results and valuable insights. In ournext study with a different setup, we are accumulating thenumber of controls and will be able to use the randomizedcontrolled trial to further validate the efficacy of SoberDiary.

RELATED WORKPrevious research on designing technology-based interven-tion applications for managing recovery from substance de-pendence has addressed habitual smoking [14], alcohol abuse[6, 10, 20], and drug use [17]. To prolong participation incontinuing care for adults who drink frequently or alcohol-dependent patients, researchers have devised technology-based services [6, 10, 20] to explore how technology can help

patients maintain abstinence. However, these systems haveeither evaluated patients’ sobriety outcomes based on inaccu-rate long-term recall data collected through telephone surveysevery 4 months [10, 20], or they excluded alcohol-dependentpatients from the study [6]. By contrast, SoberDiary providesa Bluetooth breathalyzer and various supporting functions forpatients to self-monitor their alcohol use.

Numerous health-related phone sensing projects have beenconducted to facilitate health data collection or enhance thehealth of users through persuasion, such as Playful Bottle[8], which encourages office workers to drink healthy quan-tities of water, and the UbiFit Garden system [9], whichpromotes physical activity by using on-body sensing andpersonal displays on phones, Based on the design conceptslearned from these related studies, we devised SoberDiary toincorporate the various concepts of persuasive feedback, tomotivate alcohol-dependent patients to stay sober. Further-more, this study evaluated SoberDiary by recruiting clinicalpatients, and we undertook the difficult task of facilitatingself-monitoring and -managing behavior.

CONCLUSIONThis study presented a novel phone-based support systemthat enables alcohol-dependent patients to self-monitor and-manage their alcohol use after alcohol withdrawal treat-ment. The results of this 12-week user study with 27 clin-ical alcohol-dependent patients revealed that patients usingSoberDiary reduced their total alcohol consumption and thenumber of heavy drinking days. The themes identified in aqualitative study showed how patients appropriated Sober-Diary in their regular lives to assist them to stay sober.Compared with patients who received standard treatmentalone, this study demonstrated SoberDiary effectively com-plemented current alcohol maintenance treatment in reducingpatients’ alcoholic cravings and dropout rate over 3-monthstudy period.

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