Screening Adolescents for Alcohol Use Disorders

You may find the following of interest - see  Screening for underage drinking and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition alcohol use disorder in rural primary care practice - http://findings.org.uk/PHP/dl.php?file=Clark_DB_2.abs&s=eb

One  of the more frequent challenges professionals in counter when interviewing college students in adolescence is obtaining accurate information. Without reliable information, it is difficult if not impossible to accurately screen or assess someone regarding her or his drinking. This article seems to suggest that asking students to less charged question, "how often do you drink" is perhaps more effective when screening for an alcohol use disorder than asking the more invasive, "how many do you have when you drink" or other "amount-based" questions.  In addition, asking students about the number of drinks they have when consuming is not only invasive, it likely results in inaccurate estimates. Either because of poor recall, a lack of familiarity with standard drink sizes and a realization that "a drink" can measure 2, 3, or more "standard servinugs" of alcohol--or both--student estimates regarding how much they drink can result in notoriously inaccurate responses to such questions when asked by screeners.  

There are several key elements involved in conducting an effective screening interview with a young adult or adolescent. First, the relationship is of paramount importance.  Anyone conducting a screening interview like a parent or cop conducting an investigation can expect resistance. Unfortunately, this resistance is then interpreted as denial, which in turn is viewed as suggestive of a problem. Ironically, this resistance says more about the interviewer's ineffective approach than about the adolescent's use.

Next, effective interviewers know that it is as important to identify low-risk as it is important to recognize high-risk when screening for alcohol use disorders (AUD). The referenced article suggests that as useful as a single question about frequency of use is in identifying high-risk of an AUD, it is more effective in identifying low-risk. NOTE: We are talking about determining low-risk for an alcohol use disorder here. It is possible to drink infrequently and have a low-risk of an AUD, yet still drink enough on any single occasion as to be at risk of an untoward incident.

A third element of an effective screening interview is recognize the importance of autonomy when it comes to considering recommendations following the interview. If behavior change appears warranted, the typical adolescent is not likely to respond to directives based on what the interviewer believed the adolescent "should do." Adolescents, like most people faced with a decision about considering behavior change, tend to move towards a change they "want to make" rather than changes they feel "directed to make." 

The referenced abstract--including its link to the entire research article on which it is based--suggests the efficacy of a simple question based on the frequency of one's drinking rather than the quantity. Such an approach to screening will likely reduce the likelihood of what William Miller of "Motivational Interviewing" fame calls "wrestling" with a client and, instead, facilitates what he recommends instead...dancing. What do you think?

Dr. Robert 

Peering Through the Smokescreen - II: Recommendations for Higher Education

Determining where to plant one’s flag regarding the issue of marijuana is challenging, to say the least. With the increasing attention marijuana receives in the media, it comes as little surprise that numerous states have approved the sale of medical marijuana and 4 additional states have joined Colorado, Washington, and the District of Columbia in making “recreational marijuana” legal. We are, as a culture, “all over the map” as the saying goes regarding this issue.

So, what are student affairs professionals and administrators in higher education to do regarding not only the public policy issues surrounding marijuana but how to address the issue if not the use of marijuana where our students are concerned? This second part considering this issue will address this question by proffering suggestions and recommendations tailored for the student affairs professional.

1.    Conduct more research regarding student use – traditionally marijuana research has focused on adolescents in general and middle and high school students specifically. This research has essentially been concerned with “who is doing what and how often.” Higher education needs a more robust understanding of marijuana and its use on campus in order to develop and implement more meaningful programs of prevention, intervention, and treatment. For example, student affairs professionals need to understand not only “who is using” and why, but who chooses not to use and why. Understanding why students who choose to eschew marijuana use do so will likely yield useful information regarding prevention. In essence, such research enables higher ed to focus less on preventing use and more on promoting alternative behaviors. Our research on marijuana and its use needs a focus on contemporary collegians, not just adolescents in general or those in middle school or high school.

2.    Be mindful that not all students use or have ever used marijuana – as noted in #1, understanding why students who choose to abstain do so is of great value when considering the development of proactive prevention strategies and effective policies and procedures related to marijuana and its use. In addition, for those students who do use, that use frequently tends to be periodic; for those more frequent users, that use is not always—or necessarily even predominantly—to “feel good or get high.” Self-medication of social anxiety is often cited by students who use when asked about their consumption. Learning more about such reasons for use through research will not only aid in the development of proactive prevention strategies but better inform student affairs professionals regarding the need to address issues of anxiety in general and social anxiety more specifically.

3.    Listen to understand and not just to respond - When listening to students regarding their involvement with marijuana, it is important to truly listen so as to understand what these students have to tell us rather than to simply hear them out in order to reply with a “one-size-fits-all” reactive response that comes from the policy and procedure playbook.

4.    Know where you stand personally - Student affairs professionals and those in higher education, in general, are advised to carefully consider their personal opinions about marijuana and its use as such will significantly frame any discussions on the topic. Whether one is on the “pro” or “con” side of the marijuana debate, it is difficult to remain objective and “act on” rather than “react to” issues related to marijuana and higher education without first having seriously considered one’s personal position on this topic. Even having done so, it is suggested that student affairs professionals discuss how best to serve the needs of students and/or adhere to an institution’s mission statement with campus peers and colleagues.

5.    Avoid minimizing the significance of high-risk drinking - It may appear as if marijuana is the issue of primacy when considering student substance using behaviors, but issues related to the use of all drugs together pales into insignificance when considering the problems associated with high-risk and dangerous collegiate drinking.

6.    Avoid talking about marijuana use as “smoking marijuana” - when addressing the topic of marijuana on campus, be mindful that the phrase “smoking” refers to the means of consumption. Although smoking may be the more common way marijuana is consumed on a campus, it is far from the only way it is consumed. As students choose to experiment with marijuana and realize that the smell of its smoke is the single largest contributor to “being caught,” they will likely increasingly turn to drinking or eating it in order to realize its psychoactive effects. Use terms like, “marijuana use” or “marijuana consumption” as alternatives.

7.    Irrespective of the law in the state where a college or university may be located, remember that federal laws regarding marijuana supersede state statutes -This means that students may believe they have the right to possess and use marijuana because of laws in the state where they reside and/or attend university, but federal law prevails for institution accepting ANY federal funds…student aid, federal grants, etcetera. Most institutions are conscious of this and their policies reflect this awareness, but students are not. The perception of an institution’s “Draconian measures” when encountering an institution’s efforts to comply with federal mandates may well lead to debates if not confrontations with students found in violation of marijuana policies and may even result in the involvement of their parents if not costly litigation.

These are but a few recommendations for the student affairs professional when considering the issue of marijuana and its use on campus. Although these suggestions do not ensure resolution of any, let alone all issues related to marijuana and its use on campus, they may, if taken under advisement, enable student affairs professionals to generate more “light than heat” when engaging in discussions on the topic.

It is important to note that there are many arguments, both for and against marijuana and its use. For this reason, it is not likely that marijuana will be far from the headlines anytime soon. Likewise, as long as the media keep marijuana in the spotlight, higher education will find itself dealing with how to address its use on campus. For this reason, it is incumbent upon student affairs professionals if not senior administrators, in general, to be proactive when considering this issue.

As the old adage goes, where there is smoke, there is fire. As regards marijuana, there is definitely smoke on our college and university campuses.

To watch 2 brief lectures (about 20-min each) on this topic delivered by Dr. Chapman at a colloquium in the Philadelphia area in January of 2016, visit the following links:

1. Framing the issue of collegiate marijuana use: http://bit.ly/2gyLb5F
2. Wrap up: http://bit.ly/2eDoDnK

Peering Through the Smokescreen

Allow me to begin with an apology for my recent hiatus. I have been preoccupied with relocating to a new residence in a different state and all that entails. 

This essay is the first of a two-part consideration of Marijuana on campus. It is intended to present an objective look at marijuana and collegiate life (Part I) and proffer some recommendations...or at least suggestions...regarding what contemporary preventionists might consider as regards addressing marijuana and its use on campus (Part II).

Part I

Students tend to maximize what researchers call “utility” when considering options during their collegiate experience. What this means is that options that register as yielding subjective payoffs like “happiness,” “satisfaction,” and “contentment” tend to receive priority over those that result in “good grades,” “recognized leadership potential,” and “career or professional development.” AOD-related options, especially alcohol and marijuana-related options tend to maximize utility, at least in the short run, for example, an opportunity to party can win out over studying or engaging in other activities that may result in a more lasting and tangible payoff.

Students are essentially two types of people; doers and planners. Each of these personas are in competition with one another and all students tend to possess both, albeit one or the other may tend to be dominant depending on the individual student. The “doer” makes decisions when emotions are hot and “planners” when they are cool. Ask students on Tuesday what they are likely to do on Saturday and their “planner” will provide a reasoned response like, “hangout with some friends and watch a movie” or “go to the ball game.” Ask these same students on Saturday night, in the heat of the moment when passed a pipe with marijuana or standing at the keg at a “buy the cup and drink what you want” party, and the “doer” will respond.

Such dual personality collegians present contemporary preventionists with a rather challenging if not a daunting task; how to prevent high-risk drinking and marijuana use when almost exclusively they are restricted to reaching students when they are in their “planner” mode. Such prevention efforts are often dismissed by students because they believe they do not apply to them because they would never be the type of student that would take the risks that traditional prevention messages address.

Prevention specialists have traditionally used strategies steeped in what are called social-cognitive theory to inform their efforts in AOD prevention. Historically, prevention efforts have essentially focused on alcohol, but with increased concern regarding the risks associated with excessive drinking and the increased attention given to legalized medical if not recreational marijuana use make it incumbent upon preventionists to address marijuana use on campus.

The social-cognitive theory has tended to focus prevention efforts on exploring expectancies related to use and to teach students coping skills related to how to moderate behaviors like drinking. As we begin to focus more specifically on marijuana, we tend to do what we know how to do and therefore look at marijuana as simply a different pew in the same church of prevention. For example, as useful as social norms marketing is when addressing high-risk behavior and as important as it is to champion strengthening intrinsic motivation in order to lessen students taking unnecessary risks with alcohol and marijuana, these remain “thinking-related” strategies best suited for the rational “planner” but are not particularly effective when attempting to influence the emotional “doer.” Add to this that “planners” tend to dismiss social-cognitive related approaches to avoiding risks associated with excessive alcohol or marijuana use because they do not find them personally realistic and the stage is set for prevention to expend maximum effort in order to realize minimum results.

This two-part essay is dedicated to specifically addressing the issues associated with marijuana use on campus. It considers the issues marijuana use pose for contemporary campuses and, more specifically, student affairs administrators and prevention specialists.

Marijuana presents a particularly interesting challenge to those involved in higher education because of the media attention it receives and the way this attention tends to frame the issue. This in no small way affects the public’s understanding of marijuana and its use. 

In Part II of this essay, you will find a list of suggestions and recommendations related to approaching marijuana and its use on college and university campuses. Although none of these can ensure a problem-free campus as regards marijuana and its use, they will likely serve as food for thought and likely generate proactive discussions on this topic. 

What do you think?

Dr. Robert

New Essays Now on LinkedIn

To find additional essays and "professional musings" related to counseling, collegiate drinking, personal change, and other topics, please visit my LinkedIn Profile and check out its "Posts" section.

Thank you for visiting this blog site and I trust that you will enjoy the more than 100 essays archived here. You can always contact me via my professional email: chapman.phd@gmail.com or through LinkedIn.

Best regards,
Dr. Robert

Applying Behavioral Economics to College Drinking

In my retirement I have found time for more reading; I am becoming a student of "behavioral economics" (BE) - see books like Thinking Fast and Slow by Kahneman and Nudge by Thaler & Sunstein. One aspect of BE is the concept of "choice architecture" or engineering the environment so as to offer individuals subtle "nudges" designed to help them make personal choices and behavioral decisions that enhance their quality of life, personal health, social responsibility, etcetera. One such architectural device is "priming."

Priming refers to subtle influences that can affect the likelihood that certain information comes to mind when considering various topics...like whether to drink or not, and if so, how much, how fast, etcetera. By priming students regarding these choices, it is possible to affect the decisions they make. Although there are numerous ways to engage in priming, one way that occurs to me as relatively easy to implement and of possible significance regarding collegiate drinking is to simply ask individuals if they intend to drink and then ask about their plan regarding that intention.

Assume for the sake of discussion that a nurse in the campus health center is conducting a routine interview with a student--it can just as easily be a counselor in the counseling center, faculty member in an advising session, or coach in the athletic center. The presenting issues is unimportant; what is, is that the nurse is conversing with the student. During the conversation the nurse asks, "If you plan to drink during the coming week, how likely are you to moderate use?" Irrespective of how the student answers, the nurse then says, "I'm curious; how do you intend to do this?" NOTE: Authority figures like coaches and faculty members will likely elicit a less than truthful, "I have no plans to drink" response. This is fine...more on "less than truthful" responses in a moment. 

The simple act of asking about intent increases the likelihood that the student will engage in the expressed behavior. This has resulted when asking individuals about their intentions regarding everything from plans to vote, to flossing their teeth, to exercising. To follow the first question with a second that specifically asks about "the plan," causes the student to first, think about "how" to moderate drinking and second, what might that plan look like. 

When routinely interviewing students about drinking, I used to take this a step further and would ask what "moderate consumption" means. Generally, I would get answers like, "3 to 5 drinks." NOTE: Even if this is a lie, the fact that the student defines moderate as "3 to 5" creates dissonance in any consumption that exceeds 5 as it creates an uncomfortable emotional state that students tend to dissipate by acting in accordance with their original statement. I would then give the student 5 cardboard "poker chips" (actually, the were the "holes" from state Liquor Control Board door hangers on blood alcohol level) and instruct students to place these "chips" where they keep keys, cell phone, etc. in their residence.

I then suggested that before going out: (1) ask yourself, "am I going to drink?" (2) if yes, "how many," and then place that number of chips in the dominant-hand pocket, then (3) when having a drink, move one chip from the dominant pocket to another pocket. I would then ask the student, "When you put your hand in your dominant pocket and the chips are gone, what does that mean?" The student generally would say it meant 3 - 5 drinks were consumed. I would agree and then ask, "will that ensure that you will not have another?" Usually, the student would look at me and pause. I would smile and comment that, "no, it does not keep you from having more, but it does ensure that if you do, you will know that you have decided to exceed your own limit for the outing." 

Generally, this conversation ends by discussing the "gimmick" as a simple way to ensure thinking about whether or not one wants to drink before going out and if so, how much. In short, the entire activity was an exercise in priming.

Historically, prevention projects have sought to change behavior by controlling physical environments, increasing awareness about risks and social norms, and utilizing non-invasive conversations with students to invite them to consider their behavior. The point of this post is to suggest that considering BE--with priming being but one example--may enable us to add additional arrows to the prevention specialist's quiver.

What do you think?

Dr. Robert

Self-Directed Behavior Change: A 9-Part series on personal change

Who has not identified a personal behavior in need of modification…if not a major overhaul? How often have resolutions made on December 31st been abandoned, justified with rationalizations that indicate a return to the “status quo,” often before the 1st of February?

Behavior change, although difficult to accomplish, actually involves a rather simple process. As with any “process,” there are steps or “tasks” to complete, in succession, in order to realize “success.” In the case of changing a personal behavior or “a habit,” there are 9 of these steps or “tasks,” which I will outline in a series of posts here. For more detailed information regarding self-directed behavior change, read Watson & Tharp’s 2013 book, Self-Directed Behavior, 10th edition, Wadsworth (9th edition available, used to reference this post, used online).

1 of 9: Clearly, specifically, and objectively outline the behavior you wish to change. Deciding to “lose weight” is not a particularly helpful behavioral objective; it is too vague. How much weight? Over what period of time? Instead, use a “My goal is…when…” formula to specify the desired change: My goal is to eat less  when I am very hungry. This simple statement opens a path to several specific behavior change options. For example, eating small amounts, several times a day to avoid ravenous hunger, or drinking an 8-oz glass of water before eating and then slowing down when eating, perhaps chewing my food a minimum of 10 times, giving time for food consumed to register as satisfying hunger.

Next post: Listing the details of the behavioral change objective.

Dr. Robert

Studies Report New Data RE Collegiate Drinkers

Although it is not surprising that collegiate women reporting blackouts also consume more alcohol, experience more alcohol problems, report drinking for enhancement reasons, and have lower semester grade point average (GPA), documentation of this fact may be of use when interviewing these women clinically. At a recent meeting of the Research Society on Alcoholism (RSA) in San Antonio, researchers from Miami University of Ohio reported a significant correlation between blackouts in women and these drinking-related characteristics. The significance of this small study (N = 424) remains to be determined by subsequent investigation, but suggests that practitioners may find such correlational data useful when conducting brief motivational interviews with collegiate women. For example, frequent use or reports of higher consumption may warrant additional exploration of blackouts, or as some students suggest, brown out for partial blackouts or trouble recalling all aspects of a drinking experience. The presence of these significant behavioral indicators of a substance use disorder may become useful data when facilitating “change talk” (Miller & Rollnick, 2013).

In a related presentation at the RSA conference in San Antonio, researchers at the U of Nebraska-Lincoln reported on the relationship between drinking, sleep deprivation, and academic performance. Although it comes as no surprise to those familiar with collegiate drinking, poorer academic performance appears related to the impact of drinking on a student’s amount and quality of sleep. Prevailing opinions regarding the negative correlation between drinking and academic performance suggest that it is the time spent drinking and recovering from its effects that explain poorer academic performance, but this study suggests it may be the mitigating effects of disrupted sleep patterns that explain issues related to poorer academic performance and drinking. NOTE: There is ample evidence suggesting alcohol’s ability to disrupted REM sleep –  To read more, search alcohol REM Sleep disruption using your favorite search engine.

In yet another presentation from the RSA conference in San Antonio with significance for those interested in collegiate drinking, investigators at the U of Houston in Texas report on an emerging drinking-related phenomenon resulting from the nexus of “collegiate drinking” and “social media” like Instagram, Facebook, Pinterest, and similar digital outlets that permit the posting of photos. Called Body Vandalism, this phenomenon involves drawing pictures on individuals, giving them unflattering haircuts, posing them in suggestive positions, etcetera, and then photographing the individual and posting on social media. Although alcohol consumption is involved in both victim and perpetrator, victims tend to report being more highly intoxicated. Poor decision making and victimization are nothing new when considering high-risk drinking, the advent of digital media and the ease with which such photos are placed online suggest yet another consequence of drinking that practitioners may wish to explore when interviewing collegians regarding their drinking—To read more, search Body Vandalism Drinking using your favorite search engine.

The 3 studies reviewed in this post suggest additional areas of interest for contemporary practitioners to explore when working with college students. Engaging students in such a way as to invite the telling of their individual stories related to collegiate drinking can increase the likelihood of helping arrange conversations so that students talk themselves into change.

What do you think?
Dr. Robert

Miller & Rollnick (2013). Motivational Interviewing: Helping People Change, 3rd Edition.

Is It a “Minor Relapse” or a Lapse?

Is It a “Minor Relapse” or a Lapse?

Pop culture is alive with Jonathan Rhys Meyers comment about his "Minor Relapse.”  Quoting from US Magazine, The Byrd and the Bees actor — who has struggled with substance abuse for years — opened up about a "minor relapse" he recently had via Instagram on Tuesday, May 26 - see http://usm.ag/1d1P1k2 

What is described in this article is not so much a "minor relapse" as a "lapse," or a temporary return to substance use. The distinguishing characteristics of a "lapse," as opposed to a "relapse," include: (1) a prompt return to abstinence, and (2) steps taken to learn from the lapse so that one's recovery is enhanced as the result of the experience.

Experiencing a lapse, although never recommended as a therapeutic step in recovery, can provide insight regarding vulnerable points in one's recovery and alert one to "triggers" that can initiate the urge to use. It is as likely that such "vulnerability" is related to positive or "good things" as it is to problems and challenges as they both represent risks to one's recovery.

When experiencing a lapse, it is important to take steps to ensure it results in a "prolapse" rather than a "relapse." A "prolapse" is the realization of the issue(s) that prompted the return to temporary use and learning from it (them) so as to strengthen both one's resolve to remain sober and ability to do so. This generally involves the opportunity to review if not deconstruct the "lapse" with a sponsor in a self-help program or professional counselor or therapist, but can result from serious self-reflection. The most important element of a "prolapse" is the ability to get outside one's own head and look, objectively, at the factor(s) that facilitated the lapse in the first place. It is also important to recognize that a relapse is NEVER an event; it is always a process. This process can start hours or days or even weeks before the "event" of picking up. Recognizing the process can often result in averting the lapse and, unaddressed, an ultimate relapse.

In summary, a "prolapse" results from acting on a lapse rather than reacting to it. When one "acts on" the lapse, there is the opportunity to learn from the experience and, paraphrasing Nietzsche, realize that, "what does not kill you make you stronger." If one simply feels guilty because of the lapse, what is called the "abstinence violation effect," that guilt is a reaction to the experience and all but guarantees progressing into relapse.

To read more on the topic of “lapse” vs. “relapse,” visit http://pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf

What do you think?

Dr. Robert