More on Alcohol, Marijuana, and Collegiate Life: Can Colleges & Universities Craft More Equitable Policies Regarding Illicit Behavior?

I am heartened by the umber of readers who have chosen to comment on my last post. Although most seemed to be in agreement with the argument that the penalties for alcohol and marijuana violations on campus should be the same, several questioned if such could ever be because of the illegal nature of marijuana.

This post is not intended to be an argument to legalize marijuana...that is another discussion and one fraught with any number of provocative issues. Rather, it is intended to address a common concern I hear about the hands of higher ed being tied by the current laws governing marijuana and the need to retain current policies regarding use and possession of this controlled substance by students. It is a misnomer to suggest that simply because a substance is illegal that a college or university has no flexibility as regards its response to a student's decision to use or possess illicit substances, in this case, marijuana.

Colleges and universities routinely establish and enforce policies regarding alcohol use and possession for underage students that may well differ from state statutes. For example, it may be a summary violation or at worst, a misdemeanor, to possess or consume alcohol if under the age of 21. This said, a college or university may hold students accountable for their violation of the institution’s policies but not necessarily turn the student over to the local authorities for prosecution. The truth be told, most local police departments do not want to be bothered with underage alcohol violations referred by a college or university. If, for example, a Resident Assistant (RA) finds an underage student drinking in his or her residence hall room, that student is likely to have an IR (incident report) written that documents this act and its violation of institutional policy. This violation is then dealt with via the institution’s own internal judicial system. Unless there is some related criminal activity associate with the drinking, it is unlikely that the institution is going to report this student to the local police for arrest and prosecution. If, on the other hand, it is the local police that find the underage student drinking, the student may well be cited by the police and then this be routinely reported to the college or university where its judicial system will review the case and likely mete out additional consequences.

If the college or university has a “campus police” force as opposed to a “campus security” department, the campus police, as sworn police officers, must enforce the laws of the state in which the college or university is located. This will result in the student receiving both institutional as well as state consequences associated with the underage use or possession even if this occurs on campus only. Campus security, on the other hand, are not sworn police officers and simply monitor and enforce campus policies. These officers do not have the power to arrest and, consequently, will likely intervene in policy violations and document them for review and adjudication by the campus judicial system. This is what happens with alcohol violations...campus policies are enforced and these often mirror if not exceed the underage drinking statues in the state where the IHE is located, but again, such violations are often not reported to the local police.

This same approach can be implemented as regards student use or possession of marijuana. Should a student choose to possess or use marijuana and “get caught,” the institution could choose to deal with this internally...and often does. The problem is—-and this was the focus of my previous post—-is that this frequently results in the student being suspended from campus if not expelled. This strikes me as a missed opportunity to engage the student in a conversation around his or her use of marijuana. This conversation should focus on conducting a cost-benefit analysis of the use rather than lecture, preach, or moralize about what the student should be doing...or not doing as the case may be. In brief, help students look at their use objectively and address a simple question: is the benefit you perceive receiving from your use worth the costs associated with that use? This is what is being done regarding alcohol use, with underage as well as of age consumers...and it works. Students frequently will embrace an opportunity to engage in an objective review of personal use that is devoid of recriminations and recognize that the “good things” about use are related with consumption at the lower end of the range of “typical drinks consumed” while the “less good things” are associated with use at the upper end of their range of use.

Students are insightful, intelligent, and able to see the proverbial forest from the trees when presented with the opportunity to do so in an objective, non-confrontational and collaborative way. If this can be done regarding student use of alcohol, we should provided students with the opportunity to do the same thing as regards their decisions to use marijuana. For this to happen, however, colleges and universities need to amend their “drug use policies” so as to afford the opportunity to engage such students in this conversation rather than punish them for breaking the drug law with suspension or expulsion. NOTE: We are not talking about the student holding pounds of marijuana for distribution on campus, but relatively small quantities associated with personal use.

Not only does the lack of parity in the way alcohol and marijuana are addressed on campus make no sense, it is also way behind the curve as regards current thinking by the law enforcement community and the criminal justice system in general as regards marijuana use. In the last month the new District Attorney for the City of Philadelphia announced that the City will no longer prosecute individuals for possessing 30 grams (about an ounce) of marijuana or less (see http://www.philly.com/philly/news/homepage/89894257.html. This has been reduce to a summary violation and those found holding will forfeit the marijuana and pay a fine of about $300...that is it...no criminal record. This de facto decriminalization of relatively small amounts of marijuana simply presents another argument for why colleges and universities should rethink how they address marijuana use and possession on campus...move towards “acting on” this issue rather than “reacting to it.”

Please do not misinterpret this post...I am NOT advocating marijuana use or suggesting that it is better than drinking or admonishing colleges and universities for having policies regarding marijuana possession or use. Rather I am suggesting that the number one objective of these policies should be to engage students in a conversation about their use essentially fostering a consideration of the question, "is what you get worth what it costs you the get it?" For this to happen a first step is the pursuit of parity between alcohol and marijuana policies on campus.

What do you think?

Robert

Marijuana instead of Alcohol; advocating "responsible partying" rather than "responsible drinking": Interesting topics for higher ed's consideration

There is a provocative editorial in the Chronicle of Higher Education entitled, Waiting to Inhale (click title to read). As with any "provocative" editorial, it gives one pause to think...initially about the article itself and then about one's own views on the topics discussed. This is such an article.

I tend to agree with the editorial's cited argument that the penalties for the use or possession of marijuana should be no greater, or different, than those associated with the use or possession of alcohol. It does not, for instance, make sense to provide students who have violated an institution’s policies regarding alcohol with options for alcohol education if not an intervention grounded in an evidence-based approach like BASICS for changing personal behavior and then to suspend a student for a similar violation where the only difference is the substance. For example, it is quite possible that a student found with alcohol in his or her room, say a “relatively significant amount” like a “handle,” may have the alcohol confiscated, a fine levied, and be placed on deferred suspension from housing (if a residential student) and referred to an alcohol education program while the same student could be suspended from the institution for having a “relatively small quantity” of marijuana, e.g., say, a gram or less. Although marijuana is an illegal substance, so is alcohol for those under 21.

Regarding the argument to substitute marijuana for alcohol, there seems to be an informal logic to this argument when looking at the types of consequences that tend to follow from the excessive use of either of these substances—the cases of alcohol related violence are notorious while such does not appear to be the case with marijuana. The excessive use of either of these substances, however, strikes me as being equally deleterious when considering the scope of consequences associated with each drug and therefore renders this argument something of a non sequitur. True, the student who smokes to excess may be less of a threat to other students on campus as a rapist or physical aggressor—the operative word here being “less” assuming that student is not engaging in overtly violent acts like fighting or sexual assault. That said, if driving a car, operating machinery, or attempting to negotiate an escape from a burning building, etc. I suspect it is all but irrelevant regarding which substance is responsible for the student’s inebriety and the resulting risk to self and others. Suffice it to say that impaired is impaired.

The question about pursuing “responsible partying” rather than “responsible drinking” is, in my opinion, perhaps the most compelling argument outlined in the piece. “Responsible partying” implies so much more than just “responsible drinking.” First, it means that I may or may not have anything to drink yet still be charged with “partying responsibly.” This could mean that I assume certain responsibilities while at the party...to speak up if I witness a social injustice, to interrupt a racial joke being told, attempt to deter others from engaging in self-demeaning or embarrassing acts, or attempt to initiate protective factors that may result in harm reduction for any and all at the party. I must agree that I support this argument and suspect that this is, indeed, a worthy pursuit and that groups such as the Amethyst Initiative be advised to add this to its mantra if not adopt it as its new objective.

This is a provocative article, one that invites the reader to rethink his or her position on a number of alcohol-related issues as they impact higher education. I am a big fan of dialogue. I believe that if anything, as a nation we have tended to move away from meaningful discussion and debate in the pursuit of partisan “drum banging,” the purpose of which appears to be more focused on deterring such open dialogue. Frankly, any discussion that generates more light than heat is a productive discussion.

Regarding the reference to the "Amethyst Initiative" and its admonishment to lower the drinking age, I suspect there is as much evidence to support its increase to 25 as there is to support its lowering to 18...let’s face it, auto rental companies have not permitted anyone under the age of 25 to rent a car for years...what do they know that we do not? In addition, how come there is not a “Hermes Initiative” to roll back this age discrimination? NOTE: If Amethyst is the Greek sober stone named after the maiden of Greek myth who was turned to a pillar of quartz by Artemis to protect her from the wrath of Dionysus who unleashed his tigers in rage to punish her for violating his garden on her way to worship at Hermes's temple only to feel pity for her and pour his “tears of wine” on the quartz staining it “amethyst,” then the "Hermes Initiative," Hermes being the Greek god of roads and travel, might be the appropriate name sake for a contemporary group looking to change the age when one can rent a car.

To return to seriousness, however: (1) a discussion about the penalties for marijuana possession and use in higher ed as compared to those related to alcohol does make sense; (2) the argument to substitute "weed" for "booze" by college students seems a bit of a stretch to me; (3) pursuing “responsible partying” does strike me as a more noble and altruistic objective than “responsible drinking,” which is, by the way, the tag line for any number of brewers and distillers—not to mention, “drink responsibly” implies the command that all college students should drink.

What do you think?
Robert

Legends, Urban Myths, and Collegiate Drinking
Legends, actual and urban, are fascinating. They capture both the interest and the admiration of those who hear them and then the listener feels compelled to pass them along. For instance, Ernest Hemingway purportedly wrote the world’s shortest story on a bet while lunching with friends at the Algonquin Hotel’s famed “round table.” Hemingway bet his lunch mates that he could write a complete short story, including a distinct beginning, middle, and end, in just 6-words. No one present agreed and so accepted the bet. Hemingway took out a pen and on a table napkin wrote, “For sale. Baby shoes. Never worn”; he won the bet.

Although frequently cited and repeated online ad nauseam—Hemingway and baby shoes yields 17,500 Google hits—there is no actual evidence that this event ever took place…or if it did, that Hemingway was the original author of the baby shoes story. A variation on this theme is Garrison Keeler’s 1997 quip in which he includes all five elements of humor—religion, money, family relationships, sex, and mystery—in one cogent sentence: “God,” said the banker’s daughter, “I’m pregnant! I wonder who it was?”

As mildly entertaining as this introduction may be, what does it have to do with collegiate drinking? The connection lies in the almost irresistible obsession we humans have to repeat a provocative or “sexy” sound bite and elevate it to the status of legend. This has happened with the term “binge drinking” as it relates to college and university students. Coined in December of 1994 in an article published in the Journal of the American Medical Association, “Health and Behavioral Consequences of Binge Drinking in College: A National Survey of Students at 140 Campuses,” this term referred to “…five or more drinks in a row for men and four or more for women at least once during the 2 weeks preceding the survey” (see http://www.hsph.harvard.edu/cas/Documents/54/).

This post does not question the “risk of harm” or “dangerous nature” of consuming 4+/5+ drinks “in a row,” but it does raise question regarding the utility of calling such consumption a binge (see details of this concern in my essay on this at http://www.robertchapman.net/essays/about.htm). The point of this blog post is to cite the transition of this term from a “sexy sound bite” that captured the attention of the media in the mid 1990s, became the rally cry of parents and student affairs professionals to “do something” regarding collegiate drinking through the mid 2000s and is now firmly ensconced in the lexicon of all who refer to the use of alcohol by anyone, irrespective of age, academic status, or problems associate with alcohol use, when consuming 4+/5+ drinks in a row (1).

Where a “binge” was once a quasi-clinical term that referred to drinking similar to Ray Milland’s in the 1945 classic film, The Lost Weekend, Jack Lemmon’s and Lee Remick’s drinking in the 1962 classic, Days of Wine and Roses, or the more recent Nicholas Cage portrayal of an alcohol dependent drinker in the 1995 Leaving Las Vegas, it is now used to reference any drinker’s consumption of 4+ drinks if a woman or 5+ if a man…and we wonder why college students consider the warnings of adults regarding their behavior to be spurious.
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(1) The NIAAA redefined a “binge” about 5 years ago (see http://pubs.niaaa.nih.gov/publications/arh283/111-120.htm) to inclued a peak blood alcohol level of .08 when consuming in a 2-hour period. Although an improvement, this still does not address a number of the issues raised in my essay on this cited above.

Collegiate Drinking and GPA - A Negative Correlation, But Not a Slam Dunk

The negative correlation between “number of drinks consumed per week” and “grade point average” is well know, but somewhat deceiving. Although it is clear that this correlation exists, we cannot infer that drinking more will result in lower grades—or the inverse, that drinking less will increase grades. Although both outcomes are possible—even likely—we have to be careful when looking at academic probation as being a potential access point to engage high risk drinkers.

This is not to suggest that such screening not be done—personally, if we could afford it, I would recommend screening all students if not providing them with the chance to complete BASICS (brief alcohol screening and intervention for college students). What I do suggest, however, is that this screening not result in an automatic assumption that drinking is: (1) the reason for the academic difficulties if the student indicates use or (2) that reducing drinking for high-risk and dangerous drinkers is all that needs be done to enhance academic performance.

Just as faculty and administrators who neglect to consider alcohol or other drug use as a mitigating factor in academic or other collegiate life problems may seem naïve if not truculent if they refuse to do so, those of us who know collegiate drinking is a major public health problem for contemporary collegians need to be careful that we are not so myopic as to view reducing it as the panacea for all contemporary student problems. As with so many things in life, reality exists somewhere between the extremes.

Knowing as we do, however, that the negative correlation between collegiate drinking and grade point averages is a strong as it is suggests that remedial efforts to address such risk factors are warranted. Just as we know that certain collegiate sub-populations are at higher risk—first-year students, athletes, Greek-letter associations—so do we now know that there are other high-risk populations on campus, e.g., those in academic distress. And just as we know that all first-year students, athletes, and Greeks are not high-risk and dangerous drinkers, so do we need to be mindful that neither are all students in academic distress.

That said, any S-BIRT (Screening-Brief Intervention, Referral to Treatment) that can be done with any higher risk population, e.g., academic probation, is warranted.

Robert

What About the 21-Year-Old Drinking Age?

Taking a formal position on whether the current minimum drinking age should be changed is one that at first glance seems easy to defend. To make such a decision, however, and do so based on fact rather than emotion--something we Americans are not prone to do, by the way...we want what we want and we want it right now...is clearly an act that should result from a formal vetting process; there are pros and cons on both sides of the issue that need to be discussed and then considered.

That said, I believe that having a frank and thoughtful discussion on the subject is a good thing. This can be argued in light of the fact that no one under the age of 25 was alive the last time this topic was aired publicly and completely. As a result, many under the age of 21 now see the 21-year-old drinking law as “arbitrary and capricious” and resulting from the efforts of old timers who are looking to cramp the style of contemporary young people.

There are many groups qualified to weigh in on the debate, although I am not prepared at this time to do so on the “pro change side” or the “maintain 21 side” of the debate. Think about what has changed as regards what we know about alcohol and those who consume it today as opposed to the last time it was publically debated in 1984. Although it is true that the then Reagan administration held highway safety dollars hostage until individual states signed on to the 21-minimum drinking age law, the issue was publicly debated and the latest science on both sides was on the radar screen of the popular media. Whether the age remains the same, is lowered or—and this is not proffered facetiously—raised to 25 (hey...car rental companies have discriminated against under 25 drivers for years) based on the new brain research, I, for one, think that INCASE can champion this discussion.

So much has been learned about alcohol, its affects on the body, how it affects the behavior of those who consume it, risk facts for alcohol use disorders, not to mention the development of the human brain. Suffice it to say that at the end of the day, increased access to more (rather than less) evidenced based information vetted via the scientific method regarding this topic is a good thing.

What do you think?
Robert

Can we train students to be empathetic?
Although it is true that there are certain skills associated with being empathetic and I can teach students to display (feign?) these, but is this conveying empathy? Is the “genuineness” we seek something that can be instilled or rather are we relegated to simply cultivate that which is present when a student arrives for training? I tend to lean towards the latter. As I question my ability to teach empathy, I have resigned myself to teach about it and include experiential exercises and assignments that tend to hone existing skills in an effort to expose the “empathy” within, like the gemologist cleaves the raw crystal to reveal the gemstone within.
Here are 2 sample exercises I use to accomplish this:

1. Attend open 12-step meetings…and not just one, but a minimum of 2 and preferably a number. By hearing recovering people share their stories…their experience, strength, and hope…students are able to understand addiction and recovery and see the “person who may have the diagnosis” as opposed to just the diagnosis that needs to be addressed when working with a person. A byproduct of this exercise is the opportunity to talk about “listening with the heart” rather than just “hearing with the ears.” And what is empathy if not understanding those with whom we work on a more affective level?

2. Change a personal behavior…in this exercise, students are instructed to “add, eliminate, and significantly change” a personal behavior and do start this within the first week of class and report on the experience at the end of the course. Students are told they can, “add 20-minutes of exercise 3X/wk, eliminate eating chocolate chip cookies, or shower in the evening rather than the morning”…in short “anything” is acceptable as a personal behavior change. The must keep a journal, they must report in the journal regularly, and they must write a detailed personal account of their experience that chronicles the entire experience.

a. This is often done in concert with classes/readings related to stages of readiness to change

b. Students almost always discover early on that what they thought was going to be an “easy ‘A’ grade” is at least a challenge if not a “pain in the a__,” but this then becomes a wonderful opportunity to discuss how change is almost never accomplished by changing only one thing…to add 20-minutes of exercise 3X/wk, e.g., I have to “dress to exercise,” go to the gym, shower after, schedule my day to “find the time, etc. NOTE: As students become more familiar with the stages of readiness to change, they often realize they are at an “action stage” of readiness regarding one aspect of the change challenge but at a contemplative if not pre-contemplative stage at other associated changes…this can do wonders as regards understanding, nay, empathizing with how difficult change can be for a person in counseling

c. Students learn to appreciate how difficult change can be to make, and if this challenging when they want to make the change in something “as simple/easy” as exercising or not eating chocolate chips cookies for example, then how challenging it must be to quit drinking/drugging/smoking, etc. And if I can better understand how difficult change is “first hand,” am I not better able to empathize with the “struggling changer in counseling” who says he/she wants to change but is sputtering and hesitating in working on identified changes in the treatment plan?

What do you think?
Robert

Adolescent Risk Taking: They May Be More Rational Than We First Thought

A truism in the field of alcohol, other drug, and violence prevention, at least historically, has been that adolescent risk taking is the result of impulsive choices driven by an under developed capacity to think rationally. This belief has driven the work of AODV prevention professionals for years...up to and including the present. But recent research coming out of Temple and Cornell Universities is suggesting that this staple of conceptualizing prevention programming for high school and college adolescents may need to be revisited...if not rethought.

" Decision research shows that adolescents make the risky judgments they do because they are actually, in some ways, more rational than adults. Grownups tend to quickly and intuitively grasp that certain risks (e.g., drunk driving, unprotected sex, and most anything involving sharks) are just too great to be worth thinking about, so they don't proceed down the "slippery slope" of actually calculating the odds. Adolescents, on the other hand, actually take the time to weigh risks and benefits — possibly deciding that the latter outweigh the former. (It is during adolescence, in fact, that the parts of the frontal lobe that govern risk/reward calculations undergo significant maturation.)" This is a quote from a piece published in the Association of Psychological Science's Observer - see http://bit.ly/aJBUr3 for the full piece.

This is a very intriguing piece of information. If this is true--and the science appears to exist to suggest that it is--this may mean that we involved in the prevention of "high-risk" drinking and other drug use by high school and college students may need to rethink our approach to prevention, not to mention the term used to refer to the type of drinking these students do. Most of us involved in the prevention of "high-risk" collegiate drinking are aware of the controversy that has existed in the field regarding how to refer to collegiate drinking since the Harvard School of Public Health coined the term "binge drinking" in 1994 to refer to the consumption of 4+ drinks for women and 5+ drinks for men during an outing. The field has been divided as to the utility of this term when discussing the phenomenon of collegiate drinking ever since - see my essay on the subject -- http://bit.ly/aT3UgS

In that 2003 essay I suggested referring to this type of collegiate drinking as being "high-risk," but it would appear that this too may be no better a moniker for this type of collegiate imbibing than is "binge drinking." If, as I suspect, Drs. Reyna at Cornell and Farley at Temple are correct, we in the prevention field need to not only rethink how we approach adolescents with our prevention messages, but revisit the language we use when doing so as well. If there is a "Type-T" personality (Thrill-seeking) as these researches proffer, this type of student may actually be titillated by our messages designed to reduce "high-risk" consumption. Perhaps Linda Lederman's suggestion to refer to this type of collegiate drinking as dangerous is the more appropriate way to proceed.

What do you think?

Robert

Your Cerebral Cortex Can't Overcome Your Nucleus Accumbens...

...or so a physician friend tells me. The point he was making is that we--practitioners treating addictive disorders or individuals experiencing them--cannot change addictive behavior with information and knowledge alone. True, information can be useful in motivating an individual to move from a pre-contemplative stage of readiness to change to a contemplative stage, but this is movement as regards "readiness to change" and does not directly translate into change per se.

It is true that one will never move from a point of seeing alcohol or other drug use as a solution to a life problem until and unless able to recognize his or her substance use as a problem--the cost of continuing is greater than the cost of changing. It is likewise true that the first step in this metamorphosis is beginning to question the substance use as a "solution" to one's life problems. This happens as individuals step back and can see the bigger picture, thereby beginning to recognize that, "what cause a problem is a problem because it causes a problem."

The cerebral cortex is that part of the brain responsible for much of the higher functioning that separates us humans from other creatures in the animal kingdom. It is our ability to think and reason, to problem solve and to learn as the result of our experience that builds the bridge from the past through the present to the future where change can take place. This earns us our cherished position at the top of the evolutionary ladder. But the physiological and neurochemical rewards that are associated with substance use, rewards that can be connected to a much more primitive but nonetheless necessary function of the human brain, that helps explain addiction.

Once addicted, there is a demonstrable process by which the use of substances results in the activation of a "pleasure pathway" of sorts, and the nucleus accumbens is an integral part of that pathway. Once activated, mere information and knowledge about addiction, substance use disorders and/or consequences associated with the continued use of my drugs of choice are not going to supersede the physiological rewards associated with continued substance use.

To be succinct, logic and reason are no match for the physiology of addiction or, to reiterate my friend's quip, "your cerebral cortex can't overcome your nucleus accumbens." That said, the prevention of substance use disorders requires a concerted effort that addresses a number of factors. As individuals with addictions are able to move along the continuum of readiness to change from a pre-contemplative stage of readiness where the substance use is actually perceived to be a solution to life's problems to the next stage on the continuum, "contemplation," where change is not yet a perceived option, but the use is no longer viewed as a solution. It is this ambivalence that is actually welcomed by those practicing motivational interviewing rather than viewed with disdain and attacked as indicative of denial.

This movement along the continuum of readiness to change comes as practitioners resist the temptation to confront the user, which historically has been predicated upon the belief that a refusal to change behavior, even when willing to change perspective, is tantamount to denial. The traditional approach to counseling addicted individuals, even in a contemplative stage of readiness to change, has been to confront the user directly in an attempt to "break through" the denial and, as William Miller, the father of Motivational Interviewing has written, "wrestle" the addicted individual into submission. This is tantamount to the bully on the playground that engages his adversary and does not stop until the victim cry, "uncle!"

Miller goes on to suggest that counselors therefore have two choices when engaging an addicted individual: (1) to wrestle with that client in an adversarial relationship where counseling’s success necessitates client failure, or (2) to dance with the client. Notice the difference in these two metaphors; both clearly cast the counselor in the lead position, but as any ballroom dancer will tell you, the pair collaborate in a symbiotic relationship built on mutual respect for the other and his or her role in accomplishing the end goal..

To return to my opening admonishment; knowledge may appeal to the cerebral cortex, but it does not hold sway over the nucleus accumbens. Yet historically, prevention programs have been heavily if not exclusively steeped in delivering information in the misguided belief that rational beings will make good choices, avoiding high-risk and dangerous behaviors, if only they are given the information and knowledge on which to base those decisions. And as if this placement of all the prevention eggs in the knowledge enhancement basket were not enough, the information presented has tended to be at the same time negative--"this is your brain...this is your brain on drugs..." and steeped in scare tactics, as if the combination of knowledge and fear would be sufficient to void the activation of the pleasure pathway in the brain.

So the next time you are tempted to intervene in the high-risk behavior of a client, acquaintance, or loved one with a lecture or information about the risks and consequences associated with substance use, remember, "Your cerebral cortex can't overcome your nucleus accumbens."

What do you think?

Robert

Motivating Physicians to View Treating Addictions Differently

I suspect that an important part of having an impact on an audience composed of medical students and physicians is being able to invite them to see beyond any individual case of effective treatment, e.g., "the case of Brad," and focus on a more generic patient with an addictive disorder. They will all know of or at least heard of patients who “quit.” For them to become motivated to consider doing something different, however, they are going to have to see beyond "Brad" and recognize that “these patients,” that is, "addicted patients," can change and the way they change is by my doing “more of this” and “less of that.” This is the challenge I believe we face when inviting physicians to rethink the treatment of patients with addictive disorders. I suspect physicians may be more motivated to consider changes in their treatment strategies if seeing the “The case of Brad” as the result of an effective process to which "Brad" responded rather than something idiosyncratic about him as an individual that resulted in, for lack of a better term, a spontaneous remission.

When presented with the opportunity to speak with physicians or medical students, my goal is to impress upon at least some in the audience that: (1) change is an inside job, i.e., “physicians do not change patients (at least those with addictive disorders), but patients change patients,” and (2) the physician’s job with addicted patients is almost counter intuitive when considering what physicians generally do when treating “real” diseases. Historically, physicians conduct a differential diagnosis, prescribe a course of medical treatment, administer that treatment, follow-up on that treatment, and then discharge the patient...end of story. At best, the patient is a passive participant in the change process. With addictive disorders, however, nothing changes until and unless the patient makes that internal decision—choice, if you will, to change...the “inside job” mentioned earlier. Basic factors in the “keys to success” when treating an addictive disorder are: (1) recognizing that the addicted individual has progressed from a pre-contemplative stage of readiness to change to an action stage and eventually on to a maintenance stage, and (2) this happened because the individual realized he or she wanted to change rather than felt obligated or manipulated or forced to do so...again, the “inside job.”

I do not believe that the way to motivate physicians to think about treating addiction differently is to charm them into doing medicine with addicts differently—they will have 100 examples of how treatment does not work and even more reasons why this is so. Rather, it is to present them with a way to lessen their personal frustration when working with addicted patients. Put another way, we cannot push them into treating addicted patients differently, but we might be able to lure them into reducing their personal frustration when interacting with such a patient. It is sort of like Tom Sawyer getting his buddy to paint Aunt Polly’s fence...he entices the buddy to want to have the experience rather than talk him into doing his work for him.

As Sandra Anise Barnes has suggested in her poetry, "It is so hard when I have to (change), and so easy when I want to."

What do you think?

Robert

Keeping it Green:
Maintaining a Positive Focus as a Professional Counselor

The issue—or some might say problem—of managing frustration and avoiding cynicism as a counseling professional is one that may be more pervasive than many in higher education imagine. Addressing the issues of high-risk student behaviors like underage and dangerous drinking, indiscriminate use of illicit substances, or unprotected sexual activity to mention but a few of the more frequently cited examples from the media, is enough to dampen the spirits of even the most stalwart counseling professional. Not only can media-reported national stats about percentages of high-risk drinkers and untoward incidents related to alcohol or other drug use on campus prove to be frustrating for counseling professionals, the potential threat to their optimism in and efficacy regarding the COUNSELING profession would appear to be an all too likely consequence of a steady diet of bad news from the media and personal stories of heartache resulting from high-risk student behavior on their individual campuses. At times it may seem that practitioners are like the knot in the middle of a rope in a huge tug-of-war with individual clients refusing to change their individual behaviors on one end and national trends regarding high-risk or "dangerous" drinking on the other. Yet not only do we not see COUNSELING professionals leaving the field in droves, unlike many religious orders, the number of vocations that attract young professionals to a calling to work in counseling in higher education are encouraging.

It would seem that regardless if individual counseling professionals weather the problems on their individual campuses or know something the media seems to be oblivious to that allows them to keep their collective heads above water, it would appear that as much—if not more—of the frustration and cynicism experienced by some counseling practitioners results from their personal perceptions on the issues that arise when working in this field. In other words, dealing with high-risk students and their behaviors may be an occupational hazard associated with being a counseling professional, but that does not mean that each professional in the field will experience the chronic frustration and institutional cynicism. As with so many things in life, one tends to find what is expected. The practitioner that expects to see new prevention strategies fail or individual students refuse to change, regardless of the evidence presented to them supporting such, will likely find evidence to support this belief.

If this sounds vaguely familiar, I suggest you dust off your old notebooks from undergraduate social psych and review "confirmation bias" and "illusory correlation." Because one thinks something is true, the relatively few cases experienced that support the belief held are touted as proof that the hypothesis IS true. The classic example of this in addiction counseling is the belief that effective addictions counseling necessitates breaking through a client's denial with directive confrontation (some call this "attack therapy") in order to enable clients to improve. True, some clients exposed to such counseling techniques respond and get sober, this being the illusion of support for the practice that has become the mainstay of the addictions treatment industry for 30 years. Unfortunately, most clients introduced to treatment via attack therapy drop out prematurely. Ironically, these clients are deemed "not ready" to get sober so the client is blamed for the failure to improve when it is more than likely that an inappropriate treatment choice was made by the counselor. This is also roughly similar to what we have seen over that past several years in the published research from the Harvard School of Public Health. This research reports on the steady if not increasing rates of "binge drinking" and then assigns "blame" to social norms and other proactive strategies as being ineffective and unsubstantiated. NOTE: Unsubstantiated does not mean "ineffective," it simply means the technique has yet to be substantiated, but this is another essay :)

So how does the counseling practitioner keep from burning out or becoming so cynical about addressing high-risk student behavior as to consider a career change to welding? There are numerous ways to accomplish this and here is a representative sample:

1. Like the bumper sticker on a liberal's hybrid gas-electric powered auto might suggest, "Think globally, but act locally." Counseling professionals know what they are doing on their individual campuses. They all know the prevention programs, therapy groups, policy reforms, and environmental changes they have been able to affect. We still confer virtually and in person regarding the field, including the "bad news" nationally, but we do so knowing that we make a difference. Just as people do not change by dwelling on mistakes and missed opportunities or by obsessing on the final goal, counseling professionals realize that change is a process rather than an event; they know that on their best days they can help others, but we cannot save them.

2. Many in the Counseling field have come to realize many think and believe as they do. This realization results in most of these professionals seeking out these "others" and conversing with them. The best antidote for the "six o'clock news syndrome" is to speak with others about what is really going on. Just like we all know that not" all 16 to 25 year old members of a particular racial group" are doing what the six o'clock news constantly suggests is the norm, so SA aware of the myriad opportunities to receive various points of view. To paraphrase Woody Guthrie, "Let them that have eyes see and them that have ears hear!" With online news services like JoinTogether.com, newsletters like NASPA’s AOD Knowledge Community and The Network's News From the Front; conventions, workshops, and seminars like the U.S. Department of Education’s National Meeting the field has access to "what's what." This is a powerful antidote to the media's constant barrage of, "We’ve got trouble, right here in River City, and that starts with "T" and that rhymes with "B" and that stands for BOOZE."

3. We are also becoming more sophisticated as a field. Many (most?) have become familiar with Prochaska's Transtheoretical model of counseling with its view of readiness to change occurring on a continuum (see http://robertchapman.net/treatingaddictions.htm for additional information). The appropriateness of meeting someone on this change continuum where he or she is and working to motivate movement to the next stage of readiness rather than instantly trying to move that person to the last stage is very empowering and a powerful inoculation against burnout. To read more, see my essay "IF It Walks Like a Duck and Looks Like a Duck, Why Should I Be Surprised When it Quacks?" - http://www.robertchapman.net/essays/essay.htm click on "Preventing burnout when working with substance abusers."

Counseling professionals are a resilient bunch. We know how important our work is. We know that academic success cannot occur until and unless addressing the issues of students outside the classroom. This does not mean that every student that enrolls in college or university will receive a degree after completing the requisite number of courses. Likewise, anticipating and addressing every high-risk student behavior before it results in a tragedy is unrealistic. That said, it does mean that counseling professionals need to be cognizant of where they seek information lest they inadvertently place themselves on an informational junk food diet. Just as too much fast food can result in hardening of the arteries, too much fast information can result in hardening of the attitudes, a condition just as prone to shortening careers.

Robert

Intervening with Individuals with Addictions Always Works...100% of the Time

I believe that every intervention with addicted individuals always works, 100% of the time…never fails. I cannot prove this, I just know it.

I learned this in the 1970s when I would call at the Olean (NY) City Jail each morning and interview anyone intoxicated when arrested the night before. The entire interview might last 5-minutes, which was just enough time to introduce myself and convey the message, “You do not have to feel this way anymore…there is something you can do.” I would like to say that most interviewees had a “Paul on the road to Damascus” epiphany and immediately asked for help; that was the rare exception rather than the rule. There was, however, one gentleman who showed up in my office the better part of a year later, with a crumpled up copy of my business card in his hand, asking if I remembered speaking with him in the jail many months before. Of course I did not, but this was one of those occasions when God lets us tell a lie and still leaves open the gate to Heaven…"yes," I respond, “I remember.” He proceeded to share about what those in AA refer to as having become, “sick and tired of being sick and tired”; he went into treatment.

It was at this point that I realized that any and every effort made to proffer assistance works because although it may take 50 crises, interventions, and “trips to the bottom,” there could not be the 50th event that resulted in change had there not been the 25th…the 10th…the first! We never know…and whether we mount intervention #1 and never see the person again or intervention #50 and shepherd the individual to recovery, there could be no "final intervention" if there was no "initial intervention."

A related experience involved a student I saw when working in a university counseling center. I had conducted an assessment, shared my concerns — rather bluntly I might add — and proffered assistance. The student politely declined and left. A number of years went by before this student returned…quite a number of years. He asked to see me and told me that he left my office that day and went back out and “did his thing” until he hit that final brick wall; he turned to AA; he got sober. He then reached in his pocket and took out his 5-year brass medallion celebrating his 5-years of sobriety in AA and gave it to me saying that his process of change started the day we had our last session when I shared that, “what causes a problem is a problem when it causes problems” and he wanted me to have it as his way of saying thank you. You just never know…

By way of closing — and to not extend this post too much — I include two web links to further experiences I have had that serve to ground my belief that interventions always work. I share them as I know you will appreciate them:

• http://bit.ly/Hvq1h
• http://bit.ly/8IpGJ4 - scroll down to “Rain in My Heart” (this is an earlier post recorded on this blog)

Robert

How do you spell “addiction”?
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"Addiction" may not be what most people think it is at first glance. Most of us "know" what addiction is "when we see it," but too often this recognition is of the disorder in its latter stages.

Can someone be addicted when not using a drug? Can someone be physically dependent on a substance, but not be addicted to it? Is there one all encompassing definition that would address the beliefs of all who wish to describe an addiction or more importantly, diagnose an addicted individual? These are questions that have not been answered with anything approaching a consensus in the “helping professions” so I do not expect that we will reach a consensus this semester where the fields of medicine, psychology, biology, sociology, and numerous other disciplines have failed to accomplish such to date.

This post attempts to expand on what you have hopefully begun to recognize as the foundation for your approach to “understanding addiction,” namely, a personal consideration of the etiology or “origins” of an addictive disorder. This is of the utmost importance for the counselor providing counseling services to the addicted client and her/his family.

If a counselor is unable to explain the diagnosis to the diagnosed individual’s satisfaction (understanding), it will be difficult if not impossible to engage that individual in the recommended course of treatment. If you tell me, assuming I’m your client, that after having conducted an assessment, it is your opinion that my presenting problem involves the abuse of or dependence on substance “X,” but you are unable to help me understand what that means other than the judgmental meaning ascribed by "the public," I am not very likely to embrace the treatment suggestions that you might make. And if you can explain an addictive disorder, but that explanation is steeped in hearsay rather than documented fact, then your efforts to “get the horse to drink” once you have led it to the water is rather slim.

In this post you are invited to consider some of the major models that have been used to explain the etiology or “origins” of an addictive disorder. Reviewing these models and determining which has the greatest utility in effectively treating an individual's addiction, is a crucial piece in engaging that person in treatment. If your he or she hears you calling him a bum or her a tramp when you suggest that s/he is an “alcoholic” or an “addict,” then that client will resist your treatment efforts if not refuse to work with you altogether. Remember: just as you and I have formulated an opinion of what an addiction is and what an addicted person is like from our “observations on life,” so have our clients. Many “hear” addict/alcoholic/etc and think “failure,” "loser," "degenerate," etc.

As you read the assigned material this week (http://wings.buffalo.edu/aru/ARUreport04.html), I would like you to identify which outlined model most closely captures your understanding of the etiology of an addictive disorder. Consider posting your comments on this topic/reading, be prepared to explain: 1) what is attractive about the model you most strongly related to; and/or 2) what argument might you mount if you were to use this model in order to explain it to a client you have diagnosed as having an addiction. NOTE: In responding to your positions, I may pretend to be your client, listening to your explanation of my addiction in the context of your model. I will then “give you feedback” as I would anticipate a resistant client might do in response to your explanation :)

Later in this series of posts we will talk about “premature” treatment, that is, suggesting action oriented treatment before the client has made a commitment to change. For now, however, we will assume that the client is at least willing to consider changing in order to improve—although that does not mean this change will automatically include a willingness to abstain from “X” simply because you have suggested it.

If you have the time, you may enjoy this review of various models that are used to explain addictive disorders - http://www.indiana.edu/~engs/cbook/chap1.html

What is addiction?

As you can surmise from the title of this post, Understanding Addictions, the intent is to invite exploration of addictive disorders and their treatment. But what is addiction?

Everyone – literally EVERYONE – has an understanding of what addiction is as a “problem” and who addicts are as individuals. The problem, however, is that these personal definitions of addiction are fraught with “facts” born of the “nudge, nudge; wink, wink” personal descriptions of addiction and addicted individuals, often based on “Hollywood’s” spin on these disorders. Consequently, every person on the street has an opinion about what an addiction is and how to "spot an addict." Have you seen Train Spotting, Leaving Las Vegas, or When a Man Loves a Woman? Did you have any doubt about who was addicted and who was not? But while any observant human being may be able to identify the individual in the later stages of dependence, i.e., the classic symptoms of physical withdrawal, serious medical complications resulting from chronic abuse, and the litany of socioeconomic problems associated with addiction, it takes a trained counselor to recognize the problems of abuse and dependence in their earliest stages so as to increase the likelihood of effective treatment. This is not easy to accomplish without a clear understanding of what an addiction is and how it evolves.

As you can image, “street definitions” may not be the most accurate source of information about addictive disorders on which a professional counselor can base a diagnosis and develop an effective treatment plan. Unfortunately, relatively few counseling and medical professionals have much if any direct education about or training in understanding addictions and their treatment.

The Assignment
To learn more visit the online article on addiction by Howard Schaffer. Consider his attempt to answer the question, “What is an addiction”? Think about how like/unlike Dr. Schaffer’s position is from your “preexisting” beliefs.

In addition, also read Peter Cohen's essay on addiction—I think you will find this essay interesting as it argues there is no such thing as addiction, suggesting instead that addiction is a “social construction.”

As will become clearer when you dig deeper into the issue of addictions, rarely does someone present at a counselor’s office saying, “The war’s over, I lost and am ready to do whatever you say to get better.” In fact, most clients do not even realize the extent to which their use of alcohol, other drugs, or involvement in compulsive behaviors such as gambling affect their lives and those of their significant others. It is our job as professional counselors to invite our clients to consider what one mentor of mine used to suggest…“what causes a problem is a problem because it causes problems.”

Robert J. chapman

Home for the Helidays

In just over 2 weeks, student from alcohol & other drug dependent families will head home for T-giving and Christmas breaks. It is that time of the year again…time to share a reminder of The Network’s brochure, Home for the Helidays. This brochure presents an overview of what students face during this time of the year when preparing to return to an alcohol or other drug dependent family. There are several suggestions proffered regarding how to help students prepare and cope with what can be an extremely trying experience.

Please consider referring students to the brochure online or printing copies for those students you know may appreciate such…if not all students you know who can “pass it on” to quote an old AA slogan. And please feel free to pass this along to others who may be able to share this information with students if not be able to use it themselves.

The brochure can be found in PDF format on The Network addressing collegiate alcohol and other drug issues web page and is based on an essay I wrote some years ago with the same title.

Robert

Fake IDs: Who Values Them Most

The issue of false identification, A.K.A. "Fake Ids" is not news, especially when considering the importance of alcohol and drinking as icons of contemporary collegiate life. A recent article in the Roanoke Times outlines this issue and hints at both its prevalence and the sophistication of these IDs in the 21st century.

This post is not so much intended to comment on Fake IDs as a contemporary social problem as to shine some light on the underage individuals who most highly prize possessing such identification. More to the point, some students value fake id as not only a status symbols or an accoutrement of the savvy, well prepared collegian, but as an absolute necessities to salvage a successful collegiate social life.

When conducting qualitative research on collegiate drinking, both as part of a formal research methodology in the mid 1990s and unofficially in conversations with underage collegians from the late 1980s throughout the 1990s (and on to the present) I had expected the 18- or 19-year-old first-year student to be at the head of the pack in advocating the importance of the "fake id"; I was surprised to learn that I was wrong.

Although fake id, especially "good" fake id, is prized by entering college students, they were not seriously inconvenienced if they did not have access to identification that could stand the scrutiny of trained "gatekeepers" at licensed drinking establishments. Many of these students told me that they did most of their collegiate drinking with friends and acquaintances at clandestine locations, often the "$X at the door, all you can drink" house party where there was no id check or if ids were required, a "note from your mother" was sufficient for entry.

For these entering collegians, it was the ability to produce fake id and display it, like the "condom in the wallet" of the 1960s male, that was significant. It was a trophy or talisman of sorts, that evoked awe and respect from other "less fortunate" underage collegians. And even if the entering student had a "high quality" piece of fake id, the chances are that it would be used far less frequently that either "we" or its owner would have thought because the venues desired for collegiate socializing by entering or "inexperienced" first-year students were the clandestine sites frequented by friends and these simply did not require id.

Surprisingly, it was the 20-year old junior or senior student who not only coveted "quality" false identification, but who recognized that her or his ability to socialize, and do so with specific friends who were of age, depended on such. Many junior and senior students--students I refer to as "experienced" students--realize what in the literature is referred to as the "maturing out phenomenon." For these students, the allure of the keg party attended by "100 of your closest friends" has passed. Juniors and Seniors report that they prefer to go out in small groups and frequent establishments where alcohol is served and frequently is not the focal point, i.e., "the entertainment." Such students of age, planning to go to a club requiring id, will inadvertently present their 20-year old friends with a dilemma...either talk the group into a different social venue or secure quality false identification that will ensure entry to the club. It is this student, the 20-year-old junior or senior, for whom fake id is an issue of social primacy.

It would seem that false identification has always been an issue for "underage" students, but as the sophistication of such identification has increased and its importance for specific underage students is recognized, we can begin to appreciate why some students will go to great ends and invest significant amounts of money and resources in securing "quality" fake id.

Robert

All College Students Drink the Same...or Is that a Myth?


College students drink. And that, it is safe to say, is not news. But how many people know that one-third of the students consume three-quarters of the booze on American campuses?

Why is it that these intelligent people put themselves at risk, and what can be done about it?

My university counseling experience and time in the classroom has taught me that most students believe they are immune to the consequences of heavy drinking. Students claim that alcohol related tragedies are results of “bad luck” or that they occur because the victims were “stupid.” In short, they cannot imagine themselves experiencing a similar tragedy. Even when students would see me when referred by the University judicial system after a crisis resulting from a bout of heavy drinking, they often used the same reasoning to explain their own experience: “I have the worst luck” or “I was just stupid.”

This attitude is similar to social psychology’s just world hypothesis. This phenomenon suggests that "people get what they deserve"...good things happen to good people and bad things happen to bad people. Applying this to college students, most feel immune to danger when engaged in high-risk behavior because they believe that they are good people, and therefore bad things will not happen to them...they are "bullet proof" as one student informed me. So, even when students have been educated about the risks of alcohol abuse, it comes as no surprise that they often experience serious, and sometimes tragic, consequences from excessive alcohol consumption.

Another contributing phenomenon that may help explain why some engage in excessive consumption also comes from social psychology; Groupthink. This phenomenon occurs when the leader of a cohesive group influences the other members, often resulting in poor decision making during stressful situations. The hallmarks of such flawed decision making include a group’s belief that it is invincible and has a moral responsibility to act in a particular fashion. There is also a tendency to view individuals outside the group as "others" and to justify this by using stereotypes. The group employs a buffer that insulates it from outside influence and censors contrary or alternative views to those expressed by the group. As a result, individual members are led to support the group’s decision. This may explain the hazing phenomenon seen in some collegiate groups or lend an explanation to the violence that can emerge when rival groups, for example, Greek lettered organizations, clash following an evening of drinking.

Taking these phenomena into consideration, it is helpful to recognize that the beliefs and perspectives of students who do not drink or who do so moderately are a valuable source of information about campus culture. It is important to understand why these students act responsibly, and then apply this understanding in approaches to programming. For instance, many first-year students tell me that they arrive on campus believing alcohol is integral to an active collegiate social life. This is important to know because it provides an indication as to what these students expect of a successful university experience. To the extent that students expect drinking to be associated with collegiate life, they are primed to pursue that expectation. Recognizing this allows us to develop proactive means for confronting these student misperceptions. It is important to alert students to the myth of collegiate drinking: that not everyone drinks and for those who do, not everyone gets drunk. This may shift the desire from conformity through alcohol abuse to abstinence or moderation, teaching students that just because they are sober, their collegiate experience is not wasted.

Robert

Pursuing a Graduate Degree in Counseling

A student recently wrote to thank me for assisting him in a course he was taking and to ask about graduate schools...and whether I thought the rewards were worth the investment of time, money, and effort. I share my reply here...

Emails like yours bring a smile to a professor’s face because they mean that what you have accomplished in “all” your education to date is exactly what should happen in all educational opportunities...that you had most of the questions you brought to the course answered only to be replaced by 1.5 times as many new questions. Of course, these new questions mean that you need to return to the classroom — or read more books and journals or attend workshop or apprenticeship or “whatever" — to get those new questions answered. Of course, as you can see by the formula outlined at the start of this missive, you will always have more questions than when you started, but the trick is to ensure that these are “new questions” that result from the answers you received to your “old questions.” In short, this make learning a life-long commitment that is never completed, and this, in part, is the joy of learning...and the pursuit of wisdom. My efforts to articulate this are likely a bit boring and perhaps difficult to follow so I suggest you read the lyrics to Dan Fogelburg’s song, “The Higher You Climb” – click on http://bit.ly/1D0GN and to listen to the cut from the Dan Fogelberg "High Country Snow" album, http://bit.ly/1OWeHB.

Regarding your questions about graduate schools, I suggest several questions for your consideration:

Why do you want a doctoral degree? There are many reasons for pursuing a doctorate and all are good reasons because they are your reasons. This question is not intended to discourage you, but sharpen your focus. Once you know “why” you want a doctorate, this can help inform the final decision you make as to what type of program you will pursue.

What would you like to do with this doctorate? I am assuming you are interested in a doctoral degree in behavioral health or counseling or some related human service. If you want to teach, you are likely looking at a PhD rather than a PsyD or EdD, although both of these doctorates will enable one to secure a teaching position, although both tend to be more “applied” degrees than “academic” degrees — the exception is EdD when teaching teachers, but I do not suspect that is what interests you. You can always teach adjunct with any terminal degree, but a tenure-track position is likely going to require a PhD.

Why do you want to go directly from a bachelor’s program to a doctoral program? This can significantly increase the difficulty of finding entrance to a program, especially if you are interested in a doctorate in counseling. The competition is immense for PhD programs in clinical and counseling psychology and you will be competing with individuals for admission who have already earned a master’s degree as many people earn master’s degrees in counseling and then pursue the PhD. The upside is that an earned master’s plus any published writing or research completed while earning that degree — not to mention the grades earned that will likely surpass those earned in one’s bachelor’s program — can make the applicant more attractive to a doctoral program. The down side, of course, is that it could be 2 to 3 years to get the master’s and then another 4 to 5 to get the PhD, depending on how many of the master’s credits can be transferred into the doctoral program. NOTE: Some doctoral programs allow a student to pick up a master’s on the way to the doctorate, which can be useful in that the faculty making decisions about who gets into the doctoral program know the applicant who did his master’s in that program.

What do you want your doctorate in? There are a number of degrees that can prepare one for teaching and/or applied work in behavioral health. Which type of degree to pursue goes back to questions 1 & 2 above. You can do a PhD in clinical or counseling Psych; a PsyD in Psych; a PhD or EdD in Counselor Education; a DSW in social work, just for some examples. What degree you pursue should be a function of what you want to ultimately do professionally...and to a lesser, but nonetheless important degree, what you want to study. For example, my PhD is in Counselor Education. That degree, from Syracuse, was awarded by the school of education. Although I was taught “about” counseling, the focus was on “teaching” counseling to future counselors rather than “practicing” counseling — my master’s degree is an applied master’s, i.e., “how to do counseling.” I did not want to be a psychologist so I was not drawn to a doctorate in psychology. Because my interest was not there I never would have been able to remain focused and driven to do the work that was required to accomplish a doctoral degree had that been in psychology.

In summary, the decision to pursue an advanced degree or degrees (master’s and doctorate) is wonderful. Having come to that conclusion, you now need to zero in on just how to pursue your dream and that should be rooted in what “you” want to do...and become. Remember there is no wrong decision, just various forms of the right decision.

Dr. Robert

Rain in My Heart: Understanding the Affects of Alcoholism

Shortly after I started to work in the addictions field in January of 1974, a colleague in social services, what was then called the "welfare department," suggested that I shadow him on house calls as he would visit his case load. He introduced me to 4 alcoholic gentlemen whom I befriended...his clients. They all lived in what used to be called a “flop house,” up over a paint store on North Union St. in Olean, NY. Each had one room, which consisted of a bed, a table, a hot plate, and a chair; there was a communal bath on the floor. There was exposed wiring in the halls and rooms, a single light bulb hanging on a wire from the ceiling, and these gentlemen would cook on and heat the room with the hot plate - NOTE: this was rural Western NY where it was not uncommon for the temperature in the winter to reach –30’ F...why the building never burned down was beyond me.

These gentlemen were all acquaintances and would, on occasion, drink together. They generally drank muscatel (a fortified wine), usually 3 to 4 bottles a day each, and as many as 8 (each) on a bender when they had the money. One shared his room from time to time with an alcoholic woman, but unfortunately I never got to know her or her story very well. In the winter I would visit with them in their rooms...in the warmer weather I would visit them as the drank in the tall grass by the railroad tracks as they sat on the switch box for the Erie Lackawanna Railroad in a “bottle gang.” I did not know it at the time, but I was conducting ethnographic research. The gentlemen came to trust me and accepted me as I would listen to their stories about their “early days” of drinking and try to understand the etiology of their alcoholism. They would always pass the bottle to me, inviting me to drink with them as the bottle made its rounds in the group...I always passed the bottle along w/o imbibing. I remember being floored by their candor as every one of these gentlemen readily admitted that he was an alcoholic and when I would proffer help, that he had no desire to quit. It was as if they had resigned themselves to the fact that life had passed them by and there was no hope for any of them...life would just run its course and they would eventually die of their alcoholism.

I can remember calling on them on occasion when they were in much the same shape as the alcoholic individuals in the BBC documentary, “Rain in My Heart,” which is available online along with commentary (http://news.bbc.co.uk/2/hi/programmes/newsnight/7140605.stm)...eyes yellow with jaundice, unable to leave their beds, hardly eating and only drinking.

The first gentleman to expire due to his alcoholism died, if I remember correctly almost 35 years later, from massive organ failure, a complication of his long drinking history; he was in his 30s. The 2nd was stomped and beaten so severely by the 3rd, over a bottle of wine, that he was admitted to hospital and never left...he died of the beating. I can remember visiting him in the hospital and watching as he smoked cigarettes through the tracheotomy tube in his throat...the first time I ever saw that...yet another addiction he had--yes, patients were permitted to smoke in their rooms 35 years ago. The gentleman who put "Lavern" there was convicted of manslaughter and sentenced to Attica, where he died before completing his sentence—a side bar story is “Don’s” stories about making alcohol in prison when previously incarcerated...he would ferment peach juice he would get by bartering with trustees working in the kitchen where large cans of peaches would be used to serve inmates. The recipe for the "prison hooch" was peach juice, water, and bread (for yeast), and place the mix behind the dryers in the laundry to ferment.

The 4th gentleman, “Francis” had peripheral neuropathy so advanced that he could not walk...but, believe it or not, he could ride a bike! It was quite amazing to watch "Francis" ride all over town, but when he would stop his bike, he could hardly move. When he was the only one of the group left, he went on a bender one time and found himself in a sever alcohol-induced crisis. I managed to play a role in getting him admitted to a local hospital to be detoxed—keep in mind that in 1975 in Olean, NY there were no such thing as a detox unit. Individuals had to be "dried out" in a med-surge ward under a general med diagnosis in what was affectionately known as “scatter bed detox”—and while he was being dried out I arranged for him to go to the Alcohol Rehab Unit at Gowanda State Hospital, south of Buffalo NY. Interestingly, he linked up with some other patients, got involved in AA and managed to stay sober after discharge—although some would have argued he was little more than “dry.”

These 4 gentleman, plus the 100s of AA meeting I attended and about 4 or 5 other specific “late stage” or “sever alcoholics” as they were referred to in the BBC documentary, "Rain in My Heart," were clients I recall vividly. These individuals thought me as much about alcoholism as any book, workshop, or training program I ever attended. What moved me most about the BBC documentary was that “I knew these people” and I had worked with each of the 4 individuals whose stories were chronicled. Although the documentary was made in Kent, England in the UK, I had nonetheless known each of these individuals and had dealt with the same issues as were documented in the film. If anything, the film falls short of portraying the extent of devastation that can be caused by late stage alcoholism because you can only see and hear what was going on...you could not smell, taste, or touch the consequences of alcoholism as it would permeate the very environment in which they were living and drinking and, unfortunately, dying.

The entire documentary, about 90+ minutes, can be viewed on YouTube in 10 installment. The first can be found at http://www.youtube.com/watch?v=NP0InrPZpjg From there, just click on links to #2, 3, etc. NOTE: This is NOT an easy film to watch, but it is “spot on” in its portrayal of alcoholism and its impact on late stage alcoholic individuals and their families.

Robert

Harm Reduction:
Managing One's Use of Psychoactive Substances
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Marijuana, along with alcohol, nicotine, and caffeine, are among the most widely used drugs of choice by collegiate students in the U.S. Although U.S. policy regarding drugs is driven by a definition of drugs as being illicit substances and its overarching objective when establishing public policy regarding such drugs is interdiction, all four of these substances, plus prescription medications and many over-the-counter compounds (OTC) available without prescription include psychoactive compounds.

These four common drugs of use for college students should be viewed with equity when discussing substance use with contemporary collegians, especially if a Student Affairs professional is discussing the results of the substance use assessment with an individual student. This is meant to suggest that students need to be asked about their use of these legal substances and their declaration of "in moderation" when acknowledging use, of whichever substances are reported, be discussed from a "harm reduction" point of view. Although few readers will likely have a problem with talking about "low risk" use of caffeine, some, I suspect, will question doing this with alcohol and many will likely question the appropriateness of doing so with marijuana and tobacco…let alone other real drugs. Keep in mind, however, that when doing this I use my definition of low risk and not the client's, and I have yet to find a reasonable definition of "no risk" for any of these substances. In short, the consumption of any psychoactive substance—but especially these four psychoactive substances—all include risk, be that health, legal, social, vocational, personal (a.k.a., impaired judgment) or whatever.

Now, when talking about the management of psychoactive substances, there are certain guidelines, or as an old friend of mine who first introduced me to these guidelines almost 30 years ago called them, "rules for psychoactive management" (Weitzel, 1981) that need to be heeded. These include:

1. When there is an opportunity or inclination to consume a psychoactive, especially in order to feel good or get high, consider zero consumption. As a matter of fact there are clear indications when no use is responsible use, e.g., alcohol and driving, Central Nervous System depressant substances and operating machinery, e.g., antihistamines, or tobacco when being treated for asthma.
2. When a decision to consume has been made, consume as LITTLE as necessary, rather than AS MUCH as possible.
3. Discuss the sought after effects of the substance being used with another
4. Research the side effects and discuss with others
5. Include, among those with whom you discuss these effects, non-consumers of the substance you are considering using.
(NOTE: These suggestions were first presented by William Weitzel at workshop at the PA "Governor's Council" Drug & Alcohol Conference, Oct. 28, 1981)

We need to be careful in our rush to "do the right thing" that we do not close the door on the one place that students can turn to get objective information, us. If we are perceived as "narcs" or the "campus DEA," as students wish to discuss the dangers of drugs, we will only have mandated conversations with closed mouthed students. Student Affairs professionals and faculty ARE the appropriate individuals on campus with whom students should be discussing issues of drug use, and this means open and frank discussions.

Of course, as professionals working in higher education, we should not advocate the use of any drug, licit or illicit, for any reason. Rather, we should recognize that many students do use drugs, especially the "big four" mentioned above, frequently with minimal risk. Does this mean we should say, "Hey, if it feels good and you're not hurting anyone, go for it?” absolutely not. If anything we should be inviting students to review the first rule mentioned above" and the risks associated with ANY psychoactive use in order to make objective decision based on accurate facts. A likely motto for the effective Student Affairs professional in higher education may well be, "Good decisions begin with accurate information."

It is entirely possible that there is a continuum for marijuana use just as there is for alcohol, caffeine, or other drug use. This continuum runs from "no risk," i.e. abstinence, to "guaranteed risk," i.e., dependence. I believe it is part of our responsibility to invite students to consider this fact and to make decisions accordingly. Students have come to expect our professional reaction to a discussion of psychoactive use to only include the "no risk" end of the continuum. If we act as they expect we all but guarantee failure in affecting the decisions our students/clients are making as regards drug use as we argue with each other from across the resulting abyss.

When inviting students to look at "the big picture," which includes the risk end of the continuum, we may well be confronted, sometimes quite bluntly, with a student’s perception that we are being subjective and trying to tell them how to live their lives. Be this as it may, there are students who have decided to continue to smoke pot - drink caffeine/alcohol, smoke tobacco, use OTC compounds contrary to directions, etc. - even after our conversations. What is interesting, however, is that they frequently do so, but on a level of significant reduction in frequency and quantity from that presented when seeking counsel or feedback from a professional familiar with the rules outlined above. Is this a no-risk decision? Again, this is absolutely not true. But is it a more proactive approach to engaging contemporary collegians in a discussion about the choices they make? You decide.

To close as I began, often we are the source of accurate information and to deliver that information requires that we recognize that sometimes to deliver "all" of the information necessitates that we include "some" of the information that, in and of itself, we do not condone.

What do you think?

The “Bic Syndrome”

There is a phenomenon in contemporary American culture that appears to be at least 20 years old. As a counselor who both teaches and practices the art of counseling, I have observed this phenomenon in both my students and the individuals with whom I do counseling throughout this period. I refer to this “quirk” in contemporary human behavior as the "Bic Syndrome."

While I must admit that I most frequently observe this phenomenon in clients who seek counseling to address a personal problem or students in the classroom who are more interested in a degree than the knowledge afforded by education, I have also noted the Bic Syndrome in part time employees in entry level positions, couples in relationships where the initial passion of the pursuit gives way to the challenges of learning to live together, and even those who believe that life’s offerings by a particular birthday are not fulfilling, boring, or just plain dull. The "Bic Syndrome" takes its name from the popular disposable razor so successfully marketed for the past 15 to 20 years.

The beauty of the disposable razor is that its relative economy allows one to simply discard the razor when it is perceived to be dull and replace it with another "new" and sharper one. There's no muss, no fuss, and no one thinks twice about the practice. Now with razors--and cigarette lighters for that matter--this may be convenient and economical. It would seem, however, that we have become something of a "disposable" society. It often seems easier and more convenient to discard an item that becomes “dull” or is “old” when compared to the latest model. Sometimes it even seems that we would rather discard and replace an item than invest the effort or time necessary to properly maintain or fix it. If this is true on any level, does it suggest that we have become a pleasure-seeking culture that believes it is somehow our right to expect immediate gratification and not have to tolerate things “inconvenient, dull or tedious”? To discard razors and lighters may be a relatively harmless practice in the grand scheme of things, but what happens if this “consumer’s view” of convenience affects our commitment to jobs, friends, or relationships, especially at those times that will always surface when they become dull or tedious or are in need of maintenance?

To a large extent, we humans know what we have learned and learn what we have been taught. Now, this does not mean that one cannot predetermine her/his own course in life and pursue the learning that permits the pursuit of a dream, but if one is overly involved in the Bic Syndrome, the desire for the newest, sharpest, brightest reality can undermine one's resolution to work on a problem relationship rather than to simply discard it and move one.

I have often overheared the rumblings of students about "how hard" school is and how "professors should know we have jobs and personal lives" when receiving an assignment that requires significant reading, field work, or unyielding demands for quality in papers or other assignments that require significant investments of time or effort. The expectation is that professors should "lighten-up" and required standards should be driven by the convenience of the student rather than the professor’s expectation of scholarship. While this may be a minority of students, I question if the "Bic Syndrome" has not affected our next generation of students. And what of the impact of the Bic Syndrome on relationships? What relationship maintains the same level of passion and intensity through month and years of togetherness that was present when the parties first became involved? How is it possible to avoid differences of opinion or the problems related to blending two independent personalities into the intimacy of a maturing relationship?

There is something to be said for the old "straight edge and razor strop" approach to maintaining the edge on one’s personal relationships. Richard Bach perhaps said it best in his book, Illusions, “There is no such thing as a problem without its gift inside. The reason we have problems is because we need their gifts.” To discover that my Bic razor no longer has an edge and I risk cutting myself if I shave with it may justify discarding the blade and replacing with a new one. But if I discover that my relationship with my kids or spouse or lover is strained or dull or requires maintenance, I think I will consider the lesson of the straight-edge and barber’s strop.

What do you think?

Changing collegiate drinking is a lot like ridding a lawn of dandelions: nothing changes until you address the taproot.

There is an interesting piece on collegiate drinking in the latest edition of Hazelden’s Recovery Matters – see http://www.hazelden.org/web/public/prev70430.page It is “sort of” right, in MHO :) To a certain extent, the article proffers what those of us familiar with the field of collegiate drinking might tend to view as “same ole, same ole.” The impetus for changing collegiate drinking is placed on changing the campus culture that supports that drinking. This is, as far as it goes, fine and not something of concern to me...there are things that campuses and communities can and should be doing to address this concern. What is of greater concern to me is the fact that the focus for such interventions and strategies to affect change is placed on external factors controlled by the administrators and other “adults,” that is, the “dominant culture” on campus, e.g., environmental management, and again this is good. But to solve the collegiate drinking problem is for “us” (adults) to change “them” (students)—and to suggest that all collegiate drinking is a problem necessitating a solution is perhaps misguided and another argument I have outlined in my 3rd monograph on collegiate drinking, “Is Collegiate Drinking the Problem We Think It Is?” (see http://bit.ly/DeeCg).

Although what is suggested in the Hazelden article is sound and appropriate to pursue, it is not all there is that needs to be pursued regarding high-risk and dangerous collegiate drinking. My argument has been that until and unless we understand: (1) the symbolic meaning that alcohol and drinking hold for contemporary collegians, (2) the process by which that meaning is ascribed by students...and more to the point, re-ascribed, and (3) how to employ that information to hasten the process by which students pass through the period of high-risk and dangerous drinking, “the problem” is not going to change. Because students essentially disagree with us that “any” drinking is a problem they will resist efforts by schools and their administrators to change their involvement in this behavior. And because what administrators are trying to change and what students perceived administrators trying to change are two different things, there will be continued resistance.

We need individual-based, campus-based, and community-based intervention as suggested in the article, but until and unless we acknowledge that what students perceive alcohol and drinking to be as icons of collegiate life and recognize the different from what administrators and parents and law enforcement professionals perceive them to be, we will continue to generate more heat than light when attempting to change the campus culture.

It is hubris on the part of administrators to think that they can ever end the use of all alcohol by college students--change how and when and where it is used, yes, but end it, not likely. And it is naïve to state that students do not arrive on campus already prepped if not preordained to engage in the type of drinking that has come to be described as “binge drinking.” The irony is that the very factor that fans the flames of collegiate drinking goes unnoticed if not ignored as an important determinant of this collegiate behavior. It is like the conflict that has existed in PA for sometime regarding efforts to regulate gun sales in Philadelphia.

For 20-years, the City of Philadelphia has tried to regulate the sale of guns. Each time this happens, Philly is told by Harrisburg that such regulation is not within the City’s purview. When the issue is then introduced in Harrisburg by Philly legislators, such efforts are soundly defeated. It would seem that “Philly” hates guns and “Harrisburg” loves them, but that is a biased and overly simplistic assessment of the difference. The issue is that Philly views guns as “weapons,” which it seeks to regulate for purposes of public safety, and Harrisburg views them as “recreational equipment” that are a right for residents to possess, use, and enjoy.

The language used by the legislators in Philly and in Harrisburg is the same, but the perception of these legislators as regards the symbolic meaning of the term being debated is different. A “gun” in Philly is used to break the law and reek havoc on the public whereas in most of the rest of PA, a gun is a sporting person's recreational device used in licensed hunting and recreational target shooting. In short, a gun is what the person referring to it says it is. This understanding will, in turn, affect how that person uses the gun and also how that individual responds to the efforts of another to “change the culture” surrounding the gun and its users. It is no different when we look at alcohol, drinking, and collegiate life.

It would seem logical that we can operationally define “alcohol” and “consumption/drinking,” but we would be wrong. Ask students, as I have for the past 20-years, what alcohol is and what drinking is and what these icons of collegiate life are and how they affect one’s collegiate experience and you will discover a different perspective than if asking student affairs professionals, law enforcement professionals, parents, and residents whose properties are contiguous to campus or student-occupied housing.

To end as I began, I do not take exception with most of what is suggested in the Hazelden article. What I suggest is that it does not look at the root of the issue. Like trying to clear your lawn of dandelions by just picking the blossoms, the next day the lawn is again full of dandelions. Until and unless the taproot is addressed, nothing changes...and the number of dandelions may actually expand. The “taproot” in collegiate drinking is the meaning students give to alcohol and drinking and therefore, the way to change the campus drinking culture is to change this meaning. Study what these icons of collegiate life mean, understand the dynamic that generates that meaning so we can better affect it and you will see a change in student behavior and many such individual changes equals a change in the campus culture. The irony is, this happens naturally in the maturing out phenomenon—I write about this in the 2nd of the 3 monographs I have written on collegiate drinking (see http://bit.ly/qrpJA). The problem is that this maturing out takes 2 to 3 years and a lot of the untoward consequences of collegiate drinking that are showcased on the NIAAA web page cited in the Hazelden article can happen during that time. If we can hasten this process we will not only reduce the untoward consequences, but change the campus culture. As experienced students change their behavior sooner they will influence less experienced students and instead of the negative peer pressure mentioned in the article, positive peer pressure can increase the likelihood of moderating behavior, a.k.a., change the campus drinking culture.

Conducting Assessments of Drinking/Substance Use

A reader contacted me asking my thoughts on conducting assessment and which instruments I might recommend...good topic and question, although I may not have “the” answer...I do have an opinion and a couple thoughts...

I find the BASICS (Brief Alcohol Screening and Intervention with College Students) approach to provide the best “assessment.” Although it does not yield a “likelihood” of a particular pathology or individual scales that can be indicative of co-occurring issues like the SASSI (Substance Abuse Subtle Screening Inventory), its opportunity to provide genuine feedback in a “what do you think” manner open more conversations and ultimate referrals than other “instruments.” That said, I do like the ASI (Addiction Severity Index) as it is relatively non-invasive when administered by a trained practitioner and its results tie in nicely with the development of a formal treatment plan, although it is something of a bear to administer and can take time. It is also not likely that a pre-contemplative or even a contemplative (early stage of readiness to change) client will be very helpful/compliant in completing the ASI.

I have found that the old standards work quite well too – MAST, CAGE, etc. — but I have modified their use. Instead of ask the questions associated with these screening tools, I answer them for the client after having invited the client to share his/her story. This “narrative” approach accomplished 2 things: (1) it recognizes that clients are “more willing to share their stories” with someone willing to listen than to “tell an ‘interrogator’ their business” and, (2) I can always answer questions like the closed-ended MAST or CAGE based on a history in which the client has addressed these “areas” in response to individual open-ended questions intended to facilitate conversation. Coincidentally, by the time I have listened to a client’s story, perhaps through 2 sessions, I have often earned my “street creds” that enable me to provide the feedback, including an interpretation of the MAST and CAGE without having the client, “up and run.”

Almost as an aside, how one looks at assessments is as important a determinant affecting outcome as is what is done during the assessment. For example, if I am interested in uncovering pathology and categorizing problems, I will approach the individual with whom I am working in a different manner than if I am interested in encouraging that individual to look at the “facts” in his or her life from a different perspective in order to better answer the basic question, “Is what I am getting worth what I have to pay to get it.” The “old objective” suggests that it is “me,” the practitioner, who needs to know what is really going on with a client so that I can then “fix the problem.” This works well when the ‘patient’ has shoulder problems and a diagnosis of a torn rotator cuff is made and a surgical intervention is planned to fix the problem. Such an approach, I believe, is not quite so well suited to interacting with a substance using individual in order to “address the drug problem.”

We know from the literature and research done on Motivational Interviewing that the old “you have a problem and I know this because of these diagnostic symptoms and this is how you can fix it” approach does not work well...as a matter of fact this results in counseling being more about “wrestling” with clients than “dancing” with them to borrow from Wm. Miller’s metaphor. If I approach assessment as not so much the pursuit of what “I need” to “fix your problem,” but rather a process by which I invite the individual to consider the facts related to personal use in such as to more accurately answer the question, “is what you get worth what it costs you to get it,” then the outcome can be much different. It is something akin to the City Slicker’s experience in this old “Pa and Pa Kettle” movie clip from the 40s – see http://www.youtube.com/watch?v=yG7vq0EMvgE In the clip Ma & Pa argue their position much like individuals with no intention of changing behavior argue theirs, in other words, like many collegians when approached about their drinking...I do not need to change because you are wrong in your assertion that a problem exists. If the goal of counseling is to show the client the errors of his or her way, then this is a contest where someone can only win by someone else losing. Traditional assessment tools often facilitate this “battle of the wills” approach to addressing questions related to drinking “problems.”

To summarize, we professional counselors have to assess client needs before attempting to treat them. But the onus is on us to determine why we are doing this. If it is so I know if John or Mary has problem “X” or not, that may yield an entirely different result—mind you, not necessarily “wrong,” just different—than if my quest is to invite John and Mary to looks at the facts in their lives from a different perspective. Remember Sandra Anise Barnes’ quote, “It’s so hard when I have to, and so easy when I want to.” It is like someone living in Boston considering how to get to Philadelphia...is I-95 always (ever?) the best way? The answer is, “it depends.” If the assessment process helps us better articulate the variables that affect the admonition, “it depends,” I submit that the assessment process will be beneficial. If, however, the assessment is to stockpile facts and evidence to prove why the client is wrong or quantify “the problem,” I am not so sure the result is the same.

What do you think?