1. Brief Interventions with College Student Drinkers: BASICS Jason R. Kilmer, Ph.D. The Evergreen State College Saint Martin’s 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. Specialized Treatment Primary Prevention Brief Intervention None Mild Moderate Severe Thresholds for Action Spectrum of Intervention Response

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. Precontemplation Stage Relapse Stage Contemplation Stage Action Stage Maintenance of Recovery Stage MOTIVATIONAL ENHANCEMENT STRATEGIES ASSESSMENT AND TREATMENT MATCHING RELAPSE PREVENTION & MANAGEMENT Stages of Change in Substance Abuse and Dependence: Intervention Strategies

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. 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)

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

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

18. Examines students’ perceptions about:  Acceptability of excessive behavior  Perceptions about the rates of their peers  Perception about the prevalence of their peers Norm Misperception

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. 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? Questions…

29. Time Feeling Scale + __ 0 Dysphoria - Down Euphoria - Up Point of Diminishing Returns Cultural Myth About Alcohol After Tolerance Develops Alcohol’s Biphasic Effect

30. 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

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. Finances Family History Alcohol-Related Accidents Time Spent Intoxicated Relationships Legal Problems Work-Related Problems Areas In Which College Students May Experience Consequences (continued)

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 Don’t leave your drink unattended Don’t accept a drink when you don’t know what’s in it

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. 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. The Spirit of Motivational Interviewing

42. 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

43. 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

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. 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 OARS: Building Blocks for a Foundation

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. 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

52. 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

53. 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

54. 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. Motivational Interviewing Strategies

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 O’Leary, 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-BASICS83.7%  BASICS74.7%  ASTP67.0%

62. 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) )

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. p <.01 Total Drinks per Week 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

66. p <.01 Peak Drinks per Occasion 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.

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 Co ding 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@evergreen.edu (360) 867-6775