Brief Interventions with College Student Drinkers: BASICS

1
Brief Interventions with
College Student Drinkers
BASICS

• Jason R. Kilmer, Ph.D.
• The Evergreen State College
  Saint Martins University

2
What does research show about college student
drinking?

• Up to ninety percent of college students drink
  alcohol
• Twenty-five to fifty percent are heavy episodic
  or binge drinkers
• Students who abuse alcohol are at high risk for a
  number of negative consequences

3
Spectrum of Intervention Response
None
Mild
Moderate
Severe
Thresholds for Action
Specialized Treatment
Brief Intervention
Primary Prevention
4
What is Harm Reduction?

• The ultimate goal of harm reduction is abstinence
  this is clearly the best way to reduce and
  eliminate negative consequences.
• However, harm reduction approaches acknowledge
  that any steps toward reduced risk are steps in
  the right direction

5
How are these principles implemented in an
intervention with college students?

• Legal issues are acknowledged if you are under
  the age of 21, it is illegal to drink.
• For those who want to abstain, appropriate skills
  and strategies are reviewed.
• However, if one makes the choice to drink, skills
  are described on ways to do so in a less
  dangerous and less risky way.
• A clinician or program provider must elicit
  personally relevant reasons for changing.
• This is done using the Stages of Change model and
  Motivational Interviewing.

6
The Stages of Change Model (Prochaska
DiClemente, 1982, 1984, 1985, 1986)

• Precontemplation
• Contemplation
• Preparation/Determination
• Action
• Maintenance

7
Stages of Change in Substance Abuse and
Dependence Intervention Strategies
Maintenance of Recovery Stage
Precontemplation Stage
Contemplation Stage
Action Stage
Relapse Stage
MOTIVATIONAL ENHANCEMENT STRATEGIES
ASSESSMENT AND TREATMENT MATCHING
RELAPSE PREVENTION MANAGEMENT
8
Motivational Interviewing
Basic Principles
(Miller and Rollnick, 1991, 2002)
1. Express Empathy 2. Develop Discrepancy 3. Roll
with Resistance 4. Support Self-Efficacy
9
Brief Alcohol Screening and Intervention for
College Students (BASICS)

• A non-confrontational, harm reduction approach
  that helps students reduce their alcohol
  consumption and decrease the behavioral and
  health risks associated with heavy drinking.

10
Brief Alcohol Screening and Intervention for
College Students (BASICS)

• BASICS is individually focused and involves the
  delivery of personalized feedback
• Alcohol content and the skills-training
  information is introduced throughout the
  intervention when relevant, applicable, or of
  interest to the participant

11
The Basics on BASICS
Brief Alcohol Screening and
Intervention For College Students

• Assessment
• Self-Monitoring
• Feedback Sheet
• Review of Information and Skills Training Content

(Dimeff, Baer, Kivlahan, Marlatt, 1999)
12
What to assess? Some areas used for feedback
include...

• Drinking Patterns
• Quantity/Frequency
• Daily Drinking Questionnaire
• BAL Estimates
• Drinking Problems
• RAPI
• YAAPST

• Drinking Norms
• Alcohol Outcome Expectancies
• Stages of Change

13
BASICS 4-year Drinking Outcomes by Treatment
Condition
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
Norm Misperception

• Examines students perceptions about
• Acceptability of excessive behavior
• Perceptions about the rates of their peers
• Perception about the prevalence of their peers

19
EXPECT Alcohol No Alcohol
GET No Alcohol Alcohol
20
What Is A Standard Drink? Absorption and
Oxidation Blood Alcohol Level and Effects
Factors Affecting Blood Alcohol Level
Tolerance Biphasic Effect Drug
Interactions
Information Reviewed During Feedback
21
What Is A Standard Drink?

• 12 oz. beer
• 10 oz. microbrew
• 10 oz. wine cooler
• 8 oz. malt liquor
• 8 oz. Canadian beer
• 8 oz. ice beer
• 6 oz. ice malt liquor
• 4 oz. wine
• 2 1/2 oz. fortified wine
• 1 1/4 oz. 80 proof hard alcohol
• 1 oz. 100 proof hard alcohol

22
Absorption and Oxidation of Alcohol

• Factors affecting absorption
• Food in stomach
• What one is drinking
• Rate of consumption
• Effervescence
• Factors affecting oxidation
• Time!
• People burn off a very predictable .016 from
  their BAC per hour

23
Blood Alcohol Level

• .02 Relaxed
• .04 Relaxation continues, Buzz develops
• .06 Cognitive judgment is
  impaired
• .08 Nausea can appear, Motor coordination is
  impaired

24
Blood Alcohol Level (continued)

• .10 Clear deterioration in cognitive
  judgment and motor coordination
• .15-.25 Black outs
• .25-.35 Pass out
  Lose consciousness Risk of Death
• .40-.45 Lethal dose

25
Factors Affecting Blood Alcohol Level

• Time
• B.A.L. is reduced by .016 every hour
• Weight
• Sex differences
• Very pronounced differences between men and women
• Example

26
Example of B.A.L. differences between men and
women

• 160 pound man
• 120 pound woman
• Both have 5 drinks over 3 hours
• What blood alcohol level will they obtain?

27
Tolerance
Siegel, S. Ramos, B.M.C. (2002) Applying
laboratory research Drug anticipation and the
treatment of drug addiction. Experimental and
Clinical Psychopharmacology, 10, 162-183.
28
Questions

• When people start to lose their buzz, what do
  they usually do?
• Do they ever get their buzz back?
• For people with tolerance, is the buzz you get
  now as good as the buzz you used to get when you
  first started drinking?

29
Alcohols Biphasic Effect
Euphoria - Up
Point of Diminishing Returns

Cultural Myth About Alcohol
Feeling Scale
0
After Tolerance Develops
__
Dysphoria - Down
Time
30
How Explanation of Alcohols Biphasic Effect is
Used

• Point of Diminishing Returns
• Highlights point at which positives are maximized
  and negatives are minimized
• Demonstrate Why Tolerance Results in Increase In
  Negative Health Risks
• Help Put Student Experiences In a Context

31
Drug Interactions

• Potentiation
• Antagonistic

32
Areas In Which College Students May Experience
Consequences

• Academic Failure
• Blackouts
• Hangovers
• Weight Gain
• Tolerance
• Decisions
• Impaired sleep

33
Areas In Which College Students May Experience
Consequences (continued)

• Finances
• Family History
• Alcohol-Related Accidents
• Time Spent Intoxicated
• Relationships
• Legal Problems
• Work-Related Problems

34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
Specific Tips for Reducing the Risk of Alcohol Use

• Set limits
• Keep track of how much you drink
• Space your drinks
• Alternate alcoholic drinks w/non-alcoholic drinks
• Drink for quality, not quantity
• Avoid drinking games
• If you choose to drink, drink slowly
• Dont leave your drink unattended
• Dont accept a drink when you dont know whats
  in it

38
(No Transcript)
39
Motivational Interviewing
A Definition

• Motivational Interviewing is a
• Person-centered
• Directive
• Method of communication
• For enhancing intrinsic motivation to change by
  exploring and resolving ambivalence

40
What is resistance?

• Resistance is a function of interpersonal
  communication
• Continued resistance is predictive of (non)
  change
• Resistance is highly responsive to counselor
  style
• Getting resistance? Change strategies.

41
The Spirit of
Motivational Interviewing

• Direct persuasion is not an effective method for
  resolving ambivalence.
• The counseling style is generally a quiet and
  eliciting one.
• The counselor is directive in helping the client
  to examine and resolve ambivalence.
• Readiness to change is not a client trait, but a
  fluctuating product of interpersonal interaction.
• The therapeutic relationship is more like a
  partnership than expert/recipient roles.

42
Four Principles of Motivational
Interviewing

• Express Empathy
• Research indicating importance of empathy
• Develop Discrepancy
• Clients values and goals for future as potent
  contrast to status quo
• Client must present arguments for change
  provider declines expert role

43
Four Principles of
Motivational Interviewing

• Roll with Resistance
• Avoid argumentation
• Confrontation increases client resistance to
  change
• Labeling is unnecessary
• Providers role is to reduce resistance, since
  this is correlated with poorer client outcomes
• If resistance increases, providers shift to
  different strategies
• Client objections or minimization do not demand a
  therapist response

44
Four Principles of Motivational
Interviewing

• Support Self-Efficacy
• Clients are responsible for choosing and
  implementing change
• Confidence and optimism are predictors of good
  outcome in both therapists and clients

45
OARS
Building Blocks for a Foundation

• Ask Open-Ended Questions
• Cannot be answered with yes or no
• Provider does not know where answer will lead
• Affirm
• Takes skill to find positives
• Should be offered only when sincere

46
Examples of Key Questions

• What do you make of this?
• Where do you want to go with this now?
• What thoughts do you have about what you might
  want to do about this?
• What ideas do you have about things that might
  work for you?

47
OARS
Building Blocks for a Foundation

• Listen Reflectively
• Effortful process Involves Hypothesis Testing
• Can be used strategically (amplify meaning or
  evaluation or contrast)
• Summarize
• Periodically through sessions
• Demonstrates to client you are listening
• Provides opportunity for shifting

48
Building Blocks for a Foundation

• Strategic goal
• Elicit Self-Motivational Statements
• Self motivational statements indicate client
  concern or recognition of need for change
• Arrange the conversation so that client makes
  arguments for change

49
Reflective Listening
A Primary Skill

• Hypothesis testing approach to listening
• Statements, not questions
• Voice goes down
• Can amplify meaning or feeling
• Can be used strategically
• Takes hard work and practice

50
Hypothesis Testing Model
51
Motivational Interviewing Strategies

• Reflection
• My partner wont stop giving me crap about my
  drinking.
• Your partner is concerned about your drinking.
• -- or --
• And that annoys you.
• -- or --
• It feels like your partner is always on your
  case.

52
Motivational Interviewing Strategies

• Amplified Reflection
• I dont see any reasons to change my
  drinking...I mean, I just like drinking alcohol.
• Sounds like there no bad things about drinking
  for you.

53
Motivational Interviewing Strategies

• Double-Sided Reflection
• Student Ive been drinking with my friends in
  the dorm. My parents are pissed about it.
  Theyre always saying that it makes my depression
  worse.
• Clinician Sounds like you get a hard time
  from your parents about how drinking affects your
  depression.
• Student Yeah I mean, I know that it affects my
  mood a little, but I dont drink that much and
  when I do, I really enjoy it, you know?

54
Motivational Interviewing Strategies

• Double-Sided Reflection
• Clinician What do you enjoy about drinking?
• Student I like the fact that it helps me chill
  out with my friends.
• Clinician Let me see if I am getting you right..
  Sounds like on the one hand you enjoy drinking
  because you feel that it helps you chill out with
  your friends, and on the other hand it youve
  noticed that it has some effect on your mood.

55
Resistance Strategies

• Why is it important to pay attention to
  resistance?
• Research relevant to resistance and client
  outcomes
• Motivational interviewing focuses on reducing
  resistance

56
Types of Resistance

• Argument
• Challenging
• Discounting
• Hostility
• Interruption
• Talking over
• Cutting off
• Ignoring
• Inattention
• Non-response
• Non-answer
• Side-tracking

• Denial
• Blaming
• Disagreeing
• Excusing
• Reluctance
• Claiming Impunity
• Minimizing
• Pessimism
• Unwillingness to change

57
Signs of Readiness for Change

• Decreased resistance.
  The client stops arguing, interrupting,
  denying, or objecting.
• Decreased questions about the problem.
  The
  client seems to have enough information about his
  or her problem, and stops asking questions.
  There is a sense of being finished.
• Increased questions about change. The client
  asks what he or she could do about the problem,
  how people change if they decide to, etc.

58
Signs of Readiness for Change

• Resolve. The client appears to have reached a
  resolution, and may seem more peaceful, relaxed,
  calm, unburdened, or settled.
• Self-motivational statements. The client makes
  direct self-motivational statements.
• Envisioning. The client begins to talk about how
  life might be after a change.
• Experimenting. If the client has had time
  between sessions, he or she may have begun
  experimenting with possible change approaches
  (e.g., going to an A.A. meeting, going without
  drinking for a few days, reading a self-help
  book).

59
Research on brief individualized feedback
interventions using peers and professionals

• With Greek System students, Larimer, et al.
  (2001) found
• Fraternity men in intervention condition
  decreased drinks per week peak BAC
• No change for sorority women
• Peers were at least as effective at promoting
  change in drinking behavior as professionals
• OLeary, et al. (2002) found peer providers were
  not as effective for women as were professional
  providers

60
The Alcohol Research Collaborative (ARC)

• In ARC, for first-year students with at least one
  heavy drinking episode, compare several
  approaches, including three brief interventions
• Peer-delivered BASICS intervention
• Peer-delivered Alcohol Skills Training Program
  (ASTP)
• Web-BASICS

61
ARC assignment to condition

• After screening and baseline, 637 students were
  randomized to a condition of the study
• 399 participants were randomized to BASICS, ASTP,
  Web-BASICS or Control
• 86 completed 3-month follow-up, and 83
  completed 6-month follow-up
• Participant completion rates by condition
• Web-BASICS 83.7
• BASICS 74.7
• ASTP 67.0

62
Satisfaction Ratings

• Overall high satisfaction, with ASTP (M5.35)
  BASICS (M4.99) higher than web-BASICS (M4.58)
• More learned about alcohol in ASTP (M5.68) and
  BASICS (M5.49) than Web-BASICS (M4.87)
• Web-BASICS more convenient to participate in
  (M5.79) than ASTP (M4.78) (no difference
  between groups with convenience of BASICS
  (M5.24))

63
Post-Intervention Impressions of Peers
Percentage rating mildly/moderately/strongly agree

• Participants agreed presenters seemed
• Warm and understanding (90.9 of ASTP 97.3 of
  BASICS)
• Competent and well-trained (97.0 of ASTP 98.6
  of BASICS)
• Knowledgeable about alcohol use (93.9 of ASTP
  91.8 of BASICS)
• Well organized (87.9 of ASTP 93.2 of BASICS)

64
Limitations prior to data analysis

• Randomization issues (students assigned to BASICS
  had fewer drinks per week and lower RAPI scores
  than in other conditions)
• Outcome variables were skewed, so data were log
  transformed for analytic purposes

65
No time by group interactions for total drinks or
negative consequences Specific planned
comparisons indicated that BASICS reduced total
drinks per week more than control did
Total Drinks per Week

p lt .01
66
Time by group interaction for peak
drinks Significant reductions for ASTP from
baseline to 3-mo. and 3-mo. to 6-mo. Significant
reductions for BASICS and web-BASICS from
baseline to 3-mo.
Peak Drinks per Occasion

p lt .01
67
Conclusions

• Baseline differences make it hard to interpret
  results
• Implementing a peer-led intervention is feasible
• Support for all three interventions reducing peak
  drinks/occasion only BASICS significantly
  reduced total drinks per week
• Some delayed effects in ASTP
• Initial reactivity in assessment for controls on
  peak drinks that failed to be maintained over
  time

68
Peer Therapist Training for ARC

• Reading packet for facilitators
• Initial 8 hours of training on alcohol content
  clinical technique
• Practice facilitating with a mock participant
  volunteer
• Weekly group supervision
• Possibility of individual meetings for more
  practice and supervision

69
Peer Therapist Training (continued)

• MITI Coding Team reviews for adherence and
  compliance assessment
• Detailed review/feedback written after tape is
  reviewed by supervisors
• Peer therapist facilitates only once MITI Coding
  Adherence is reached
• While interventions occur, facilitators attend
  weekly group supervision
• Facilitators may need to attend an hour
  individual or pair supervision with an RA during
  weeks when an session is completed

70
Implementing BASICS

• Determining Assessment/Measures
• Generating Graphic Feedback/Personalized BAC
  cards
• Training of providers
• Supervision/Consultation if needed
• Therapist drift (issues of fidelity)
• Need for ongoing assessment and, if needed,
  training

71
Thank You!

• Special thanks to Ann Quinn-Zobeck
• All the best in your prevention efforts!
• Jason Kilmer
• kilmerj_at_evergreen.edu
• [phone]