Brief Interventions with College Student Drinkers: BASICS Jason R. Kilmer, Ph.D. The Evergreen State College Saint Martin’s University.

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

Specialized

Treatment

Primary

Prevention

Brief

Intervention

None

Mild

Moderate

SevereThresholds

for Action

Spectrum of Intervention Response

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)

PrecontemplationContemplationPreparation/Determination

ActionMaintenance

PrecontemplationStage

Relapse Stage

ContemplationStage

ActionStage

Maintenanceof

RecoveryStage

MOTIVATIONALENHANCEMENT

STRATEGIES

ASSESSMENTAND TREATMENT

MATCHING

RELAPSEPREVENTION

& MANAGEMENT

Stages of Change in Substance Abuse and Dependence: Intervention Strategies

Motivational Interviewing Basic Principles

(Miller and Rollnick, 1991, 2002)

1. Express Empathy

2. Develop Discrepancy

3. Roll with Resistance

4. Support Self-Efficacy

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 feedbackAlcohol 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)

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

4 Years 3 Years 2 Years 1 Year Baseline

Drin

king

Pat

tern

Z-s

core

1.0

.8

.6

.4

.2

0.0

-.2

Random Comparison

High -Risk Treatment

High -Risk Control

Examines students’ perceptions about:Acceptability of excessive behaviorPerceptions about the rates of their

peersPerception about the prevalence of

their peers

Norm Misperception

EXPECT

Alcohol No AlcoholG

ET

No A

lcoh

ol

Alc

oh

ol

• 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

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 absorptionFood in stomachWhat one is drinkingRate of consumptionEffervescence

Factors affecting oxidationTime!People burn off a very

predictable .016% from their BAC per hour

Blood Alcohol Level

.02% Relaxed.04% Relaxation continues,

Buzz develops.06% Cognitive judgment is

impaired

.08% Nausea can appear, Motor coordination is impaired

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

Factors Affecting Blood Alcohol Level

TimeB.A.L. is reduced by .016% every

hour

WeightSex differences

Very pronounced differences between men and women

Example

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

160 pound man120 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.

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…

Time

FeelingScale

+

__

0

Dysphoria - Down

Euphoria - Up Point of Diminishing

Returns

Cultural Myth About

Alcohol

After Tolerance Develops

Alcohol’s Biphasic Effect

How Explanation of Alcohol’s Biphasic Effect is Used

Point of Diminishing ReturnsHighlights 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

ConsequencesAcademic FailureBlackoutsHangoversWeight GainToleranceDecisions Impaired sleep

FinancesFamily HistoryAlcohol-Related AccidentsTime Spent IntoxicatedRelationshipsLegal ProblemsWork-Related Problems

Areas In Which College Students May Experience Consequences (continued)

Specific Tips for Reducing the Risk of Alcohol Use

Set limitsKeep track of how much you drinkSpace your drinksAlternate alcoholic drinks w/non-alcoholic

drinksDrink for quality, not quantityAvoid drinking gamesIf you choose to drink, drink slowlyDon’t leave your drink unattendedDon’t accept a drink when you don’t know

what’s in it

Motivational Interviewing: A DefinitionMotivational Interviewing is a

Person-centeredDirectiveMethod of communicationFor enhancing intrinsic motivation to change by exploring and resolving ambivalence

What is resistance?Resistance is a function of

interpersonal communicationContinued resistance is predictive of

(non) changeResistance is highly responsive to

counselor styleGetting resistance? Change

strategies.

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

Four Principles of Motivational InterviewingExpress 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 FoundationAsk Open-Ended Questions

Cannot be answered with yes or noProvider does not know where

answer will leadAffirm

Takes skill to find positivesShould 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?

Listen ReflectivelyEffortful process: Involves

Hypothesis TestingCan be used strategically (amplify

meaning or evaluation or contrast)Summarize

Periodically through sessionsDemonstrates to client you are

listeningProvides opportunity for shifting

OARS: Building Blocks for a Foundation

Building Blocks for a FoundationStrategic goal:Elicit Self-Motivational

StatementsSelf 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

listeningStatements, not questionsVoice goes downCan amplify meaning or feelingCan be used strategicallyTakes hard work and practice

Hypothesis Testing Model

2. What speaker 3. What listener says hears

1. What speaker 4. What listener means thinks speaker

means

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.

Motivational Interviewing Strategies

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 ResistanceArgument

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 professionalsWith 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 conditionAfter 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

p < .01

Total Drinks per Week

4

5

6

7

8

9

10

11

12

Baseline 3 Month 6 Month

Control BASICS web BASICS ASTP

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

p < .01

Peak Drinks per Occasion

4

5

6

7

8

9

10

Baseline 3 Month 6 Month

Control BASICS web BASICS ASTP

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.

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 facilitatorsInitial 8 hours of training on alcohol

content & clinical technique Practice facilitating with a mock

participant volunteerWeekly group supervisionPossibility 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/MeasuresGenerating Graphic

Feedback/Personalized BAC cardsTraining of providersSupervision/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 [email protected](360) 867-6775