Transcript When Alcohol Isn’t the Issue: Other Drugs of Abuse and the

Brief Interventions with
College Student Drinkers:
BASICS
Jason R. Kilmer, Ph.D.
The Evergreen State College
Saint Martin’s University
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
None
Spectrum of Intervention
Response
Mild
Moderate
Thresholds
for Action
Severe
Specialized
Treatment
Brief
Intervention
Primary
Prevention
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
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.
The Stages of Change Model
(Prochaska & DiClemente, 1982, 1984, 1985, 1986)
Precontemplation
Contemplation
Preparation/Determination
Action
Maintenance
Stages of Change in Substance Abuse
and Dependence: Intervention Strategies
Precontemplation
Stage
Contemplation
Stage
Action
Stage
Maintenance
of
Recovery
Stage
Relapse Stage
MOTIVATIONAL
ENHANCEMENT
STRATEGIES
ASSESSMENT
AND TREATMENT
MATCHING
RELAPSE
PREVENTION
& MANAGEMENT
Motivational Interviewing
Basic Principles
(Miller and Rollnick, 1991, 2002)
1. Express Empathy
2. Develop Discrepancy
3. Roll with Resistance
4. Support Self-Efficacy
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.
Brief Alcohol Screening and
Intervention for College Students
(BASICS)
BASICS is individually focused and
involves the delivery of
personalized feedback
Alcohol content and the skillstraining information is introduced
throughout the intervention when
relevant, applicable, or of interest to
the participant
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)
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
BASICS 4-year Drinking Outcomes by
Treatment Condition
Drinking Pattern Z
-score
1.0
.8
.6
.4
.2
Random Comparison
0.0
High -Risk Treatment
High -Risk Control
-.2
Baseline
1 Year
2 Years
3 Years
4 Years
Norm Misperception
Examines students’ perceptions about:
Acceptability of excessive behavior
Perceptions about the rates of their peers
Perception about the prevalence of their
peers
EXPECT
Alcohol
No Alcohol
Information Reviewed During Feedback
•
•
•
•
•
•
•
What Is A Standard Drink?
Absorption and Oxidation
Blood Alcohol Level and Effects
Factors Affecting Blood Alcohol Level
Tolerance
Biphasic Effect
Drug Interactions
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
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
Blood Alcohol Level
.02%
.04%
.06%
.08%
Relaxed
Relaxation continues,
Buzz develops
Cognitive judgment is
impaired
Nausea can appear,
Motor coordination is
impaired
Blood Alcohol Level (continued)
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
.10%
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
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?
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.
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?
Alcohol’s Biphasic Effect
Euphoria Up
+
Point of Diminishing
Returns
Feeling
Scale
Cultural
Myth About
Alcohol
0
__
After
Tolerance
Develops
Dysphoria Down
Time
How Explanation of Alcohol’s
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
Drug Interactions
Potentiation
Antagonistic
Areas In Which College Students May
Experience Consequences
Academic Failure
Blackouts
Hangovers
Weight Gain
Tolerance
Decisions
Impaired sleep
Areas In Which College Students
May Experience Consequences
(continued)
Finances
Family History
Alcohol-Related Accidents
Time Spent Intoxicated
Relationships
Legal Problems
Work-Related Problems
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
 Don’t leave your drink unattended
 Don’t accept a drink when you don’t know
what’s in it
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
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.
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.
Four Principles of
Motivational Interviewing
Express Empathy
Research indicating importance of empathy
Develop Discrepancy
Client’s values and goals for future as potent
contrast to status quo
Client must present arguments for change:
provider declines expert role
Four Principles of
Motivational Interviewing
Roll with Resistance
Avoid argumentation
Confrontation increases client resistance to
change
Labeling is unnecessary
Provider’s 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
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
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
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?
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
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
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
Hypothesis Testing Model
2. What speaker
says
3. What listener
hears
1. What speaker
means
4. What listener
thinks speaker
means
Motivational Interviewing
Strategies
Reflection
My partner won’t 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.
Motivational Interviewing
Strategies
Amplified Reflection
I don’t see any reasons to change my drinking...I
mean, I just like drinking alcohol.
Sounds like there no bad things about drinking for
you.
Motivational Interviewing
Strategies
Double-Sided Reflection
Student: I’ve been drinking with my friends in the
dorm. My parents are pissed about it. They’re
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 don’t drink that much and when I
do, I really enjoy it, you know?
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 you’ve noticed that it has
some effect on your mood.
Resistance Strategies
Why is it important to pay attention to
resistance?
Research relevant to resistance and client
outcomes
Motivational interviewing focuses on reducing
resistance
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
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.
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).
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
O’Leary, et al. (2002) found peer providers were not
as effective for women as were professional
providers
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
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%
Satisfaction Ratings
Overall high satisfaction, with ASTP (M=5.35)
& BASICS (M=4.99) higher than web-BASICS
(M=4.58)
More learned about alcohol in ASTP (M=5.68)
and BASICS (M=5.49) than Web-BASICS
(M=4.87)
Web-BASICS more convenient to
participate in (M=5.79) than ASTP (M=4.78) (no
difference between groups with convenience of
BASICS (M=5.24))
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)
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
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
12
11
10
9
8
7
6
5
4
Baseline
Control
3 Month
BASICS
6 Month
web BASICS
ASTP
p < .01
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
10
9
8
7
6
5
4
Baseline
Control
3 Month
BASICS
6 Month
web BASICS
ASTP
p < .01
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
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
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
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
Thank You!
Special thanks to Ann Quinn-Zobeck
All the best in your prevention efforts!
Jason Kilmer
[email protected]
(360) 867-6775