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

Utilizing Peers in the Delivery of
Brief Interventions
Jason Kilmer, Ph.D.
The Evergreen State College
Saint Martin’s University
Kim Hodge, B.A.
University of Washington
Sruti A. Desai, B.A.
University of Washington
Mary E. Larimer, Ph.D.
University of Washington
Study described funded by NIH/NIAAA and the
Dept. of Education grant U01 AA14742
Points for Consideration
Effective strategies to reduce drinking
and/or consequences in college students
The use of peers in intervention delivery
Our study: The Alcohol Research
Collaborative
Preparing peers to deliver brief
interventions
Clinical issues, research questions, and
future directions
Tier 1: Evidence of Effectiveness
Among College Students
 Combining cognitive-behavioral skills with norms
clarification and motivational enhancement
interventions.
 Reductions in drinking rates and associated problems (e.g.,
ASTP)
 Offering brief motivational enhancement
interventions.
 Reductions in drinking rates and associated problems (e.g.,
BASICS)
 Challenging alcohol expectancies.
 Reductions in alcohol use
Task force report available at: www.collegedrinkingprevention.gov
Norm Misperception
Examines students’ perceptions about:
Acceptability of excessive behavior
Perceptions about the rates of their peers
Perception about the prevalence of their
peers
COGNITIVE-BEHAVIORAL SKILLS TRAINING
Moderate drinking skills
Blood alcohol concentration
discrimination
Altering expectancies about alcohol’s
effects
Assertiveness skills (drink refusal)
Relaxation/Stress Management skills
Lifestyle balance skills
“Alcohol specific skills”
Alcohol’s Biphasic Effect
Euphoria - Up
Point of Diminishing Returns
+
Cultural Myth
About Alcohol
Feeling
Scale 0
__
After Tolerance
Develops
Dysphoria - Down
Time
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 if you don’t know
what’s in it
The Stages of Change Model
(Prochaska & DiClemente, 1982, 1984, 1985, 1986)
Precontemplation
Contemplation
Preparation/Determination
Action
Maintenance
Motivational Interviewing
Basic Principles
(Miller and Rollnick, 1991, 2002)
1. Express Empathy
2. Develop Discrepancy
3. Roll with Resistance
4. Support Self-Efficacy
The Alcohol Skills Training
Program (ASTP)
A skills-training approach using
motivational interviewing
techniques in its delivery with a
focus on drinking in less
dangerous and less risky ways
for those who make the choice
to drink.
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.
BASICS and ASTP
ASTP is delivered in a group setting
Alcohol content and the skillstraining information is introduced in a
more structured way throughout the
program
BASICS and ASTP
Content reviewed in ASTP
Expectancies
Standard Drink and Norms
Absorption/Oxidation
BAC, Associated Effects, Tolerance
Alcohol’s Biphasic Effect
Distribution of Blood Alcohol Charts
Consequences
Risk Reduction Strategies
BASICS and ASTP
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)
ASTP vs. Information Only
Alcohol Skills Training Study I
Self-Reported, Peak BAL
0.14
0.12
0.1
0.08
Informational Program
0.06
Skills Training Program
0.04
0.02
0
Pre
4Mos
12Mos
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
Review of individual focused strategies…
Larimer, M.E., & Cronce, J.M.
(2002). Identification, prevention,
and treatment: A review of
individual-focused strategies to
reduce problematic alcohol
consumption by college students.
Journal of Studies on Alcohol,
Supplement No. 14, pp. 148-163
www.CollegeDrinkingPrevention.gov
Research utilizing peers in alcohol
interventions using normative reeducation
Mixed results
Some show change in norm perception
but no effects over time on drinking
behavior (e.g., Barnett, et al., 1996 and Smith, 2004)
One study with freshmen showed drinking
reductions but no differences in norm
perception (Schroeder & Prentice, 1998)
Research using peers to deliver ASTP and
to facilitate Alcohol 101 CD-ROM
Miller (1999) compared 2 assessment
conditions + 2 peer-facilitated interventions
At six month follow-up…
Single-assessment only controls drank more & had
more consequences than students in other groups
Participants in the three-assessment group
generally reported similar decreases in
drinking/consequences
Participant satisfaction was higher in the ASTP
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
Credibility of Peer Providers
 Few studies address credibility of peer providers
 Several authors suggest peers make credible role
models and students may relate better to peers
 Mixed findings do suggest the need for more
research (Fromme & Corbin, 2004)
Research on Lifestyle Management Class
for mandated or voluntary students
Fromme & Corbin (2004) found…
LMC showed reductions in drinking and driving
Voluntary participants higher in readiness to
change showed reductions in heavy drinking
Professionals rated higher on knowledge,
content delivery, and intervention fidelity
Peers equally effective in both mandated and
voluntary samples and for both men & women
What has research shown about utilizing
peers in interventions targeting alcohol
use?
Research supports the idea that peer
programs might be a viable resource
for implementing empirically
supported interventions
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
Possible Barriers to Implementing Effective
Interventions on College Campuses
Barriers can exist to dissemination,
adoption, implementation, and
maintenance (Rogers, 1995)
Source: Larimer, Kilmer, and Lee, 2005
Possible Barriers to Implementation in
Implementing Effective Interventions
Proper training of those delivering a
program
A tendency to “reinvent” innovations
(Rohrbach, D’Onofrio, Backer, & Montgomery,
1996)
Source: Larimer, Kilmer, and Lee, 2005
Possible Barriers to Maintenance in
Implementing Effective Interventions
Therapist drift (i.e., issues of fidelity)
Need for ongoing assessment and
continued training
Source: Larimer, Kilmer, and Lee, 2005
Clinical Issues/Future Directions
Recognize that efforts with peers are one
piece of the prevention program puzzle
Professional staff and peer facilitator time
and energy
For whom are peer interventions most
effective?
Characteristics of peer presenters vs.
intervention recipients
Are problems with college
students becoming more severe?
90% of counseling center directors
perceive an increase in students with
more severe psychological problems in
recent years (Gallagher, 2005)
95% report an increase in students
coming to counseling already on
psychiatric medication (Gallagher, 2005)
Clinical Issues/Future Directions
Formally evaluate issues of time- and costeffectiveness
Best practices in training and supervision
Continue to explore use of peers in other
alcohol- and drug-related interventions
Particularly with less clear prevention approaches
for drugs other than alcohol
Challenges with a possibly more
complicated and complex student body
Percentage of all clients prescribed
medication (Schwartz, 2006)
35
30
25
20
15
10
Percentage
5
0
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
** Data for slide estimated from table appearing in Schwartz, 2006 **
Possible reasons behind perceived increase
in severity of psychological problems
 Actual increase in problems
 Greater similarity between college/general
population
 Greater availability of meds could allow
students to attend college who otherwise might
not have done so
 Lesser stigma attached to mental illness may
have led to an increase is seeking
psychological services
 Students under care of a provider may
discontinue that once in college
CASA, 2003
Possible reasons behind perceived increase
in severity of psychological problems
 Increased academic pressure,
competitiveness, or greater sleep deprivation
 Fewer take time off to become stabilized than
in the past in response to stress or mental
health problems
 Students stop using meds upon entering
college
Assume they’ll be less depressed, don’t want
stigma of being on meds, or want use
alcohol/drugs instead
 Students using alcohol or drugs while on meds
accentuate depressant effects
CASA, 2003
Thank You!
Special thanks to Ann Quinn-Zobeck
All the best in your prevention efforts!
Jason Kilmer
[email protected]
(360) 867-6775