Addressing Substance Use Issues in Higher Ed: Lessons Learned from Treatment Providers

Addressing Substance Use Issues in Higher Ed:

Lessons Learned from Treatment Providers

When considering issues related to alcohol and other drug (AOD) use in higher education, the focus is frequently placed on collegiate binge drinking.  Like a family preoccupied with the substance use of a member, higher education tends to focus on its student drinkers.  However, because one drinker in a family has a problem, that does not mean all drinkers in the family do. Likewise, because some students are high-risk drinkers does not mean all students are.  What if an entire college or university were approached as an identified client in need of assistance, in much the same way a treatment provider engages the family of a problem drinker when providing assistance?  What has the treatment community learned over the years that enable it to work effectively with families?  Perhaps such topics of importance to those treating families might be of interest to senior administrators in higher education looking to approach collegiate drinking differently.

Treatment facilities focus on helping families recognize that…what causes a problem is a problem when it causes a problem.  This truism is pretty clear when dealing with individuals and families; it is less clear, however, when considering how this applies to a college of university.  How do we help Institutions of Higher Education (IHE) to understand "their AOD problem" is not exclusively the student drinker? 

Focusing attention on the high-risk drinker has yielded evidence-informed approaches to intervention with these consumers, but this is more an informed “reaction” to the “perceived problem" than indicative of definitive “action taken” to prevent it.  Just as families learn that they cannot stop a member from drinking or drugging, IHEs need to recognize that neither can they stop collegiate drinking.  What families learn in treatment is how to focus on their issues and concentrate on that over which they do have control.

For families, change manifests itself in the form of establishing and consistently maintaining appropriate boundaries, assertively and proactively intervening when encountering unacceptable behavior, understanding the true nature of substance use disorders (SUD), and accepting that the issue of primacy is not changing the user, but recognizing that the family, as a whole, must address its problem.  Families working on their issues accept the things they cannot change, but nonetheless work to change the things they can.  For IHEs, addressing issues of concern regarding AOD use re remarkably similar to the objectives of families in treatment. 

Like the family, an IHE needs to establish and maintain realistic boundaries.  In the prevention literature this is part of what is called environmental management.  Where families assertively and proactively intervene with members displaying maladaptive behaviors, IHE employ brief motivational interventions or employ evidence-informed programs like Brief Alcohol Screening and Intervention for College Students (BASICS).  When families come together to consider that its problem is not the result of an individual with a SUD, but the family as a unit that needs to accept its responsibility to act on its needs rather than react to the member “with the problem,” IHEs can collaborate with its stakeholders in the community, both on and off campus, to establish and then embrace a collaborative, solution-focused approach to a perennial and heretofore perceived intractable problem.

There is much that IHEs can learn from families that have received treatment for a SUD.  Although social scientists of all descriptions are consistently contributing to the body of knowledge related to campus “binge drinking” and drug use, there is room for the SUD treatment community to proffer assistance to its colleagues in IHEs.

What do you think?

Short College Programs Only Briefly Successful in Helping Students Reduce Drinking  - click to read entire article

Brief alcohol education programs are only temporarily effective in convincing college students to reduce their drinking, a new study suggests.

Some thoughts regarding “short term"/awareness programs:

As stand-alone efforts to change drinking behaviors, “awareness” programs are of little use affecting long-term behavior change.  NIAAA lists such programs a Tier 4, Evidence of NIAAA Tiers of Effectiveness.  This is not to say, however, that such programs are useless or have no value.

Ineffectiveness

For those familiar with Prochaska’s Tran-theoretical Model of Change, you will recall that there are processes of change that work best for each stage of readiness to change (for a quick tutorial on the TMC, visit.  The purpose of these processes of change or “stage-specific interventions” is to motivate movement to the next stage on the continuum of readiness.  To move from the 1st stage of readiness to change, which essentially is no sense of readiness to change, what Prochaska calls pre-contemplation, one needs to become aware that, as Joe Martin used to say, what causes a problem is a problem when it causes a problem.

“Short college programs” as the headline suggests may not be very effective as regards long-term behavior change, but they can play an important role in a comprehensive campus program of prevention and intervention.  In short, no one changes a behavior until reaching a point where it is discovered that to continue the status quo is more hassle than the change.  These “short college programs” can be helpful in making individuals aware of “what constitutes a problem…and the possible connection between “X behavior” and “Y experience.”  Although few will “hear a lecture” and immediately change their drinking behavior, that lecture/poster/program/phone app/mouse pad/water bottle logo/screen saver/etc., especially if similar messages are shared consistently via various media and coordinated in their use around campus over an extended period of time, can motive individuals to “start to think” about their behavior.  Now, “thinking about my behavior” is not going to result in making a change—we all have personal stories to document that fact—but thinking if change might be appropriate is essentially the 2nd stage in Prochaska’s continuum; contemplation.

Not to make this a dissertation, suffice it to say, short college programs do not work if behavior change is the objective and the short program is the be all and end all of the campus program.  They can be useful, however, f employed as a part of a comprehensive plan designed to affect the campus culture. 

As an aside, how many of you have “contemplated a change” in your auto insurance after a 5+ year exposure to annoying TV ads :)

What do you think?

Dr. Robert

Can colleges and universities reduce incidences of high-risk, dangerous drinking by adding civility and social consciousness criteria to their admissions process?

Can colleges and universities reduce incidences of high-risk, dangerous drinking by adding civility and social consciousness criteria to their admissions process?  

Currently, most colleges and universities assume a defensive position regarding high-risk, dangerous drinking, and other drug use, often reacting to their untoward consequences after-the-fact.  Policies outline what is and is not permissible behavior, residence life and campus security concentrate on

enforcement of said policies, faculty tend to view substance use issues as other than their responsibility, and campus recruiters often proffer a “wink-wink, nudge-nudge” response to questions about partying, while some administrators theorize the solution to the "collegiate drinking problem" is to lower the drinking age.

Might a more proactive approach to the problem of how "some collegians drink," rather than seeing all collegiate drinking as THE problem, be to screen applicants at least as judiciously regarding their views on and activities related to civility and social consciousness as they screen for SAT scores, quintile standings, and other indicators of academic performance?

The past 20-years have enabled us to learn much about high-risk drinking and its associated behaviors, including which students are most likely to engage in behaviors resulting in untoward consequences.  Many of these untoward consequences translate into the quality-of-life issues that become the reason many students transfers from one institution of higher education (IHE) to another, not to mention being a mitigating factor in academic probation, academic dismissal, or behavioral dismissal from the IHE.  

With personal essays specifically crafted to solicit student views on social behaviors, expectations of collegiate life "outside the classroom," and specific instruction regarding letters of recommendation and their need to address issues of civility and social consciousness, can IHEs affect the frequency of high-risk and dangerous drinking and other drug use following matriculation by changing their recruiting and admissions practices?

What do you think?

Dr. Robert

The Likely Cause of Addiction Has Been Discovered, and It Is Not What You Think

http://www.huffingtonpost.com/johann-hari/the-real-cause-of-addicti_b_6506936.html

There is much to be said about the merits of Hari's argument outlined in the essay.  First—and foremost—the War on Drugs is, at best, an antiquated response to the drug problem and, at the worst, a monumental disconnect from the real problem of understanding SUD.  It is essentially based on the 18th-19th Century Moral Model of addiction that suggests that drugs are bad and therefore so are the people who use them.  Consequently, this view of addiction suggests that the way you deal with “bad people” is to punish them, and in our culture you punish “bad people” by incarcerating them.  As noted in the article, this not only does not deter use, it likely reinforces it. 

Next, we have long understood that boredom is highly correlated with both use and, for those pursuing recovery, relapse.  AA addresses this with its famous acronym, H.A.L.T.  When someone is “hungry,” “angry,” “lonely,” or “tired,” that individual is standing on the slippery slope of relapse.  It is tempting to infer that the Alexander “Rat studies” seem to indicate that the results of rats living in isolation vs. residing in “Rat Park” “explains” their penchant for consuming drugs and is somehow transferable to explaining human drug use, but we all know this is a spurious connection at best – correlation is not causation…and rat behavior, although informative, does not necessarily equate with human behavior.

I do believe, however, that the basic premise of this article—and I must confess that I have not read its author’s book nor those referenced in the article—that “drugs” do not cause addiction. I suspect that the etiology of addiction is more readily explained by social science than biological science.  It will not surprise me, for instance, to see our understanding of addiction move away from the current mainstream argument that addiction is a brain disease and that for those with this disease, that drugs "hijack the brain."  This does not mean that there is no physiological/genetic predisposition to addiction, as I suspect that there may well be, but I am becoming less convinced that addiction will ever be something that can be predicted via a simple blood test added to the mandated screen panel conducted on newborns labeling them at birth as “one of them."  I suggest this for many of the reasons Hari outlines in his article, namely that there are more likely socioeconomic and psychological variables that increase or decrease the one’s susceptibility to a SUD.

What the article does not seem to address is how do we explain the absence of addictive behavior in individuals who are exposed to the same isolated or socially dystopian environment yet do not turn to drugs?  Just as the argument that alcohol, tobacco, and marijuana are “gateway drugs” is questionable because it does not consider all users of these substances, including those who experimented with these substances, but do not go on to use these drugs let alone become addicted; we must be cautious about claiming that living in The Hunger Game’s “district 12-type” environment is the "cause" of addiction.

That said, it is not a new argument to suggest that the environment to which a recovering person returns affects the prognosis for sustained recovery.  We have known for decades that an unsupportive and/or drug using environment all but guarantees relapse.  What is interesting and worthy of further study, however, is the extent to which such environments affect the etiology of addiction.  What is it about/in those individuals who do not “turn to drugs” although exposed to the same environments that precludes their becoming SUD? (NOTE: I have raised a similar concern regarding high-risk collegiate drinking when suggesting that we can learn much to prevent such behavior by studying moderate drinkers and abstainers in order to understand why they make the choices they do when exposed to the same collegiate environment as the “binge-drinkers.” We spend way too much time and money studying the problem drinker rather than those who seem immune to it, but this is another discussion).

Frankly, I believe that there are multiple variables associated with “becoming addicted.”  These include the drugs themselves, but although drugs may be necessary for "drug addiction” to occur, they are not likely sufficient to explain its etiology.

Lastly, in this brief reaction to the article, a large area concerning addiction goes unaddressed and this suggests, at least for me, a potential “fly in the ointment” of Hari’s argument: what about the process addictions?  I suspect that individuals may seek refuge or relief from the boredom of a socioeconomically deprived existence, one with no access to job, education, adequate housing, etc., by turning to sex or gambling or other “addictive” behaviors, but this too requires more study :)

What do you think?

Robert

Cognitive-Behavioral Counseling and Effective Treatment

With any technique, there are a number of variables that affect the clinical outcome.  For example, a practitioner’s level of proficiency in employing a particular technique is a significant variable, as is

the individual’s basic prowess as a counselor.  Add to this the variables that can affect an individual’s ability to respond to counseling, for example, personal expectations of counseling, the propensity for optimism or pessimism, family/community support, etc., and you begin to see how the significance of a particular therapeutic approach can quickly  when considering “what works.”

Scott Miller, Mark Hubble, and Barry Duncan wrote an article entitled, No More Bells, and Whistles (to download a copy, visit http://bit.ly/1INZHhh) that reviews the sources of efficacious counseling.  They suggest that there are “4 common factors” that determine the outcome of counseling: (1) Therapeutic Technique (accounts for 15% of the outcome of counseling), (2) Expectancy and Placebo (15% of outcome) , (3) Therapeutic Relationship (30% of outcome), and (4) Client Factors (40%).  I will skip reviewing each of these 4 “factors,” but suffice it to say that in affecting but 15% of the outcome of counseling, debating the merits of a particular therapeutic approach while stimulating may be more of a footnote in the discussion than than issue of primacy.

It seems to me—and CBT-related techniques and cognitive theory (I always liked George Kelly’s Personal Construct Psychology) are frequently used tools in my counseling toolbox—that IF there were a theory of counseling that truly outperformed all the others, we would at least have a clear indication of its existence by now.  Rather we find practitioners employing various approaches claiming success in their work and the individuals they counseled reporting symptom relief.  This would seem to confirm, albeit unscientifically, what Miller et al. suggest in their article; that it is the therapeutic relationship itself and the individual factors the client brings to therapy that contribute the lion’s share of efficacious outcome in counseling.

There is no doubt that CBT has passed the rigors of scientific scrutiny regarding its efficacy.  What this suggests, to me however, is not so much that it should be used exclusively or even predominantly, but rather that it is deserving of consideration as an evidence-informed, best practice to which our students should be exposed.  So the issue for me is not that CBT is used “too much” or that it has taken on “rock star” status.  The issue is, does CBT—or any other counseling theory for that matter—enable me, as the practitioner, to understand my client’s presenting problem(s) in such as way that I can: (1) design an appropriate treatment strategy to affect symptom relief, (2) assist my client in understanding the nature of the presenting problem and its origin, and do so in such a way that ensures that the client recognizes that she or he has a problem rather than is the problem, and (3) can accomplish this in a reasonable amount of time with non-invasive and cost-effective strategies.

What do you think?

Robert

Does Confrontation Work?

Confrontation, especially confrontation in the process of counseling, is a topic I ask my students to consider in my Intro to Addictive Disorders class – click to review the class assignment associated with this request.  Invariably, students who argue that confrontation does not work point out that

aggressive, in-your-face confrontations are too direct and actually deter meaningful engagement…what Miller refers to as Attack Therapy.  However, those students who do believe confrontation has a place in effective counseling--or in the treatment of individuals with a SUD more specifically--are influenced by Miller & Rollnick’s first chapter in the 3rd edition of their book, Motivational Interviewing (link included in the linked assignment).  They come to see one’s definition of confrontation and, more importantly, he means of delivering a confrontation, as the issue of primacy when considering the utility of this aspect of counseling.

Confrontation—effective confrontation—is, if nothing else, the ability to "hold one’s feet to the fire" without causing injury.  Effective counselors do this by employing what I refer to as the Three Ps of counseling: (1) Patience, (2) persistence, and (3) perseverance.  As Rollnick suggests in a clip from his video on MI (see http://bit.ly/1C9SW66), change can happen quite rapidly when facilitated by a trained and experienced practitioner.  He suggests, and I paraphrase, If you act like you have all day, it (change) can happen in 15-minutes, but if you act like you only have 15-minutes, it can take all day; I can  attest to this, as I imagine many clinicians can. As a matter of fact, one of the nicest compliments a client ever paid me was after a particularly confrontational session, one where I employed the “3-Ps,” as we shook hand at the end and he was leaving the office, he turned, looked me in the eye and said, “You know, Dr. Robert, you could kick someone in the ass and he would turn around and thank you.”

There is a difference between confronting someone when the interaction is viewed as a contest where someone wins at the expense of the other person losing, and one that is approached as an attempt to address an issue of concern, but without the delivery of unsolicited advice or directives steeped in judgmental recommendations.  Remember the quote by Bern Williams: Unsolicited advice is the junk mail of life.

Confrontation a la Wesley Snipes, Bruce Willis, or Keanu Reeves does not work; Wm Miller of Motivational Interviewing fame calls this Attack Therapy.  Confrontation, however, employed by a skillful practitioner who is respectful, understanding, but nonetheless persistent, does.

What do you think?

Dr. Robert

Conflict of Interest or Good Marketing?

VOCATIV posted a controversial article recently on its website—see http://www.vocativ.com/culture/society/college-jello-shots/#!bO7SmR—suggesting, Colleges Profit by Getting Students Drunk off Jell-O Shots.  If you read the article, you get the impression that the institutions involved intentionally licensed their logos intending their use as “Jell-o shot cups”; the good news is that this was not the case.  Indeed, Kraft did secure permission to use school logos and create individualized Jell-O molds, likely for a licensing fee, but not with the intent of producing Jell-O shots

for tailgating.  Their intent in licensing the use of their logo was much the same as the reasoning behind T-shirts, hats, sports bottles, stadium blankets, and various sundry other items.

That said, the VOCATIV article does raise an interesting question: does a conflict of interest exist, however inadvertently, when institutions with serious and stringent alcohol policies, especially policies that are consistently enforced, license merchandise that directly or indirectly is associated with drinking in general and high-risk drinking specifically? What does it say to a prospective high school student touring campus who makes the obligatory stop at the campus bookstore and sees an array of shot glasses, beer mugs/scooners…and Jell-O molds?  And although Jell-O molds with the school logo at the bottom are apparently similar "innocent novelties," few are the students of any age who do not know of Jell-O shots and the recipes to make them – see http://www.kegworks.com/company/jello-shot-recipes for one of 2,670,000 Google hits when searching “Jell-O, shots, recipes.” 

So the original question remains, do such innocent novelties represent a conflict of interest for the institution with strict alcohol policies?  Should such “paraphernalia” be relegated to the online catalogue for the campus bookstore or is the display of such novelties innocent enough to avoid consideration as a “conflict of interest” and scrutiny of AOD prevention advocates?  Is the decision by some to divert the use of what many prevention specialists advocate, the use of a shot glass to measure a serving of alcohol when pouring drinks, sufficient cause to question the sale of such “paraphernalia” in the campus bookstore?

As we all know from our life experiences to date, rarely are things “just” what they seem to be on the surface or at first glance; what do you think?

Dr. Robert

The futility of brief interventions for illicit and prescription drug addiction—or is it?

An interesting article in the online journal, Medscape (see http://www.medscape.com/viewarticle/829612) suggests that brief interventions with those addicted to illicit substances and prescription pain medications may be futile.  I found this interesting, especially in light of my long history providing “brief interventions” with college students regarding all manner of high-risk behavior, not the least of which was drinking and other drug use. 

As disheartening, at first glance, as the cited research studies may be, I am not too concerned about these results.  First, although both cite the use of Motivational Interviewing (MI), neither seems to have truly applied MI as designed and it is questionable how Screening-Brief Intervention, Referral to Treatment (S-BIRT)…or what is now being referred to as SBI, Screening and Brief Intervention…was employed.  There is a literature that suggests the role of the interviewer as opposed to the use of MI as a technique alone affects the likelihood of movement as the result of a sessions(s); no matter how adroit the practitioner in the application of MI technique, if the individual using MI is “stiff,” distant, or otherwise “unavailable” to the individual being counseled, that individual is not likely to engage in “change talk."  As there is little indication of the skill level of those conducting the single session MI interviews in the cited research articles—and admittedly I have yet to read either study in its original form—that could affect the reported (lack of) results as well.

Returning to my opening comment regarding a question about a true (accurate?) use of MI, it is clear in Miller and Rollnick’s newer 3rd Edition of their text, Motivational interviewing: Helping people change (2013, Guilford Press), MI is more about arranging conversations so individuals talk themselves into change than about actually motivating the desired change.  This suggests that a “single session” on MI, even if done correctly and by a practitioner who is both knowledgeable and effective, may not be sufficient to actually result in immediate reductions in use or arrests, etc.  MI is not an “action stage of readiness to change” (see http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm) intervention so much as a means by which practitioners can increase the likelihood that “pre-contemplative” and “contemplative” changers move in the direction of readiness to change, AKA, towards taking “action.”  Assessing the stages of readiness to change of randomly selected individuals and then exposing them to MI and reassessing their readiness to change might produce a more meaningful measure of MI’s efficacy.

Miller & Rollnick acknowledge that MI does not change behavior so much as facilitate change talk in the individual being engaged.  They actually argue that practitioner do not change behavior, in that all change is internal and many individuals will actually change their behavior, w/o treatment, once having come to a point where the tipping point in their ambivalence is reached and continuing old behavior becomes more of a hassle than instigating new.  MI is about hastening the advent of this “tipping point” rather than getting folks to change their substance using behavior.

In short, these research studies are interesting, to me, but not because they disparage MI so much as underscore the importance of understanding the difference between the “spirit” of MI and its practice as well as recognizing that MI is not so much a “velvet club” by which a “motivate” resistant changers as a “shoe horn” that can facilitate the potential changer’s “easing into” change by recognizing that it is a personal choice resulting from a simple cost-benefit analysis of the facts regarding current patterns of behavior.

What do you think?

Dr. Robert

Questions that Motivate a Consideration of Change

Conducting a conversation around the subject of change is a challenging task, especially if directing the conversation toward a less than willing individual.  Historically such conversations are structured, task oriented, and designed to “get the individual” to “see and admit to having a problem.”  Consequently, these conversations typically take on the rhythm and pace of an interrogation; have you ever done ‘this’; how often have you done ‘that.’  Such interviews are reminiscent of the old adage; Never teach a pig to sing; it wastes your time and annoys the pig.

The principles of Motivational Interviewing outline a very different way to engage individuals in what it calls, change talk (Miller & Rollnick, 2012).  What follows is a series of 5 questions from Miller & Rollnick's 3rd edition of their text that increase the likelihood that, as Miller suggests, one can dance rather than wrestle with the individual being interviewed regarding change.

1.     Why would you want to make this change?

a.     The abbreviated version: Why change?

                                               i.     Benefits/Pros of change

                                             ii.     Risks/costs/cons of not changing

2.    How might you go about it in order to change?

a.     The abbreviated version: How to succeed

                                               i.     Identify personal strengths – protective factors

                                             ii.     Cope with challenges – resiliency skills

3.   What are several of the best reasons to make this change?

a.     Selfish reasons

b.     All around good reasons?

4.   How important is it for you to make this change?

a.     Mentally

                                               i.     Peace of mind

b.     Physically

                                               i.     Wellness

c.     Spiritually

                                               i.     Connectedness; feeling “part of” something rather than “apart from” everything

5.  So, what do you think you will do now?

a.     What half-step can you make to begin moving towards change?

Miller, W. & Rollnick, S., 2012. Motivational Interviewing: Preparing people for change, 3rd Edition.  Guilford press

Addiction, Imbalance, and the Family

One of the benefits of living and writing during the digital age is the easy access that exists to information from various and sundry media outlets. This tends to make education--not to mention psycho-education used in clinical treatment--more engaging.  Such is the case regarding the short video, “Balance.” (https://www.youtube.com/watch?v=7wJj58aLvdQ). 

I use this video to facilitate discussions related to addiction in the family, homeostasis, etc. Notice how

as the film begins, the “family” works together to maintain balance whenever one its member “moves.” In class, we discuss this in the context of altruism being the primary motivating factor among the various members as regards their motivation for acting. As the video progresses, however—and the film is only 7-minutes long, so the progression is rather obvious—altruism gives way to self-interest, egoism, and ultimately, selfishness.The discussion really becomes interesting when considering the “trunk” as addiction with its “contents” being the curious, alluring “something” that becomes so beguiling. I find the video an interesting “visual metaphor” in its usefulness as an icebreaker.

At the end of the class in which I use this videos—entitled, Addiction and the Family: The Anatomy of an Imbalance and Chaotic System—I show the 2-part video (about 17-min total), Man on the Back (https://www.youtube.com/watch?v=T0m9iu6O3dg). I process the first video before showing the second part (about 7-min) and then we process the entire video in the context of the lecture following its conclusion - you may access the second part of the video by clicking its link to the right on the screen of Part I. This is always a crowd pleaser and generates no end of comments…even though the entire video is in Icelandic with English subtitles! All sorts of interesting discussion results from this screening...enabling, “co-dependence,” addiction, etc. NOTE: Both videos linked here can produce equally spirited discussion regarding other disorders and stressors besides SUDs; it is all in the “lead in comments" the facilitator makes and the discussion that follows. 

A third “series” of videos (10, 10-min videos) that is useful in “understanding addiction,” especially alcohol dependence, is entitled, “Rain in my heart” (https://www.youtube.com/watch?v=NP0InrPZpjg)  This is a BBC documentary that is quite graphic and extremely realistic in its depiction of the impact of alcohol dependence, on both the drinker and the drinker’s significant others. This video is not a “metaphor” for anything and certainly is not “entertaining” as the previously cited videos may be viewed by some. This is a frank, “hard-hitting” look at the impact of chronic alcoholism, and a “must-see” for professional counselors and those going into the medical professions.

Should you "screen" one or more of these videos, please feel free to leave your comments on them and their use.

Dr. Robert