Utilizing Peers in the Delivery of Brief Interventions

1. 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

2. 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

3. 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

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

5. 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”

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

7. 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

8. The Stages of Change Model (Prochaska & DiClemente, 1982, 1984, 1985, 1986) • Precontemplation • Contemplation • Preparation/Determination • Action • Maintenance

9. Motivational Interviewing Basic Principles(Miller and Rollnick, 1991, 2002) 1. Express Empathy 2. Develop Discrepancy 3. Roll with Resistance 4. Support Self-Efficacy

10. 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.

11. 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.

12. BASICS and ASTP • ASTP is delivered in a group setting • Alcohol content and the skills-training information is introduced in a more structured way throughout the program

13. 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

14. BASICS and ASTP • 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

15. 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)

18. ASTP vs. Information Only Alcohol Skills Training Study I Self-Reported, Peak BAL

19. 1.0 .8 score - .6 .4 Drinking Pattern Z .2 Random Comparison 0.0 High - Risk Treatment High - Risk Control - .2 Baseline 1 Year 3 Years 4 Years 2 Years BASICS 4-year Drinking Outcomes by Treatment Condition

20. 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

21. 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)

22. 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

23. 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

24. 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)

25. 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

26. 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

27. 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

28. 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%

29. 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))

30. 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)

31. 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

32. 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 < .01

33. 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 < .01

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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)

42. Clinical Issues/Future Directions • Formally evaluate issues of time- and cost-effectiveness • 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

43. Percentage of all clients prescribed medication (Schwartz, 2006) ** Data for slide estimated from table appearing in Schwartz, 2006 **

44. 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

45. 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

46. Thank You! Special thanks to Ann Quinn-Zobeck All the best in your prevention efforts! Jason Kilmer kilmerj@evergreen.edu (360) 867-6775