Getting “Unstuck” in Our Thinking about Drinking

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This is a copy of a letter I sent to the Council of Southeast Pennsylvania regarding a recent newsletter – see newsletter at http://bit.ly/H14bFw

Thank you for sending the recent SEPA Council newsletter; Binge Drinking is a Nationwide Problem.  Although the newsletter points out some obvious issues of concerns regarding drinking, I write to share some thoughts on which I would appreciate your reaction if not those of your colleagues at the Council.

First, as important as the shared information is, the newsletter’s design and format presents it in a classic “scare tactics” approach.  From the two photos—one of the young male whose head is on the bar in desperation if not passed out and the other of the dower looking EMT, complete with stethoscope around the neck, perched in front of an ambulance—to the headline itself, complete with exclamation point, the Council’s proactive message about S-BIRT and its evidence-based approach to addressing high-risk and dangerous drinkers is somewhat lost in the implied message of concern if not danger.

Next, as much as the term “binge drinking” has been accepted as part of the lexicon used to describe high-risk and dangerous drinking, it is nonetheless a term that is perceived as being ludicrous by underage and young “of age” drinkers not to mention be called into question by many clinicians who view a binge as being an extended period of excessive use rather than consuming 4+/5+ drinks in a 2-hour period of time type of drinking.  NOTE: I do NOT argue the risk associated with this type of drinking.  Rather, I am concerned about our insistence as a field on using language to share a concern that the population we try to reach rejects as nonsensical, which therefore defeats our purpose.

I suggest that the Council consider these points as it prepares future copy for PSAs and other community-based publications, but more than this, I suggest it also recognize that there is more to the issue of prevention than pointing out what is not working in our system and demonstrating that with an endless parade of reports about “the problem.”  Just as research is showing us that clinical interventions designed to meet individuals with substance use disorders (SUD) where they are ideologically rather than insist that they come to the clinician’s views of substance use and treatment, and/or how the use of “strengths-based” counseling interventions motivate greater numbers of individuals with SUDs to move towards change, so can we who are involved in prevention learn something by listening to what these “binge drinkers” have to tell us about the majority of the time when they choose to drink moderately if not abstain altogether.

In this very newsletter article on “binge drinking,” it points out that the average member of this group drinks “4 times per month” and “8 drinks per occasion.”  Again…this is very high-risk.  But the point that goes unaddressed when focusing on these factoids is that 26-days a month they do not drink and they stop at 8 on those occasions when they do drink.  The question becomes, why?  This is interesting information at the least and potentially very useful when our objective is to reduce harm for both the community in which these drinkers drink and for them as individuals.

We first need to change our thinking about “doing prevention” if we hope to change the thinking of the public at large and ultimately that position of the public that “binge drinks.”  We start this when we begin to ask, Why do those who do not drink until 21 and those who if they do drink, do so in moderation, make the choices they make?

What I propose is nothing short of a paradigm shift when it comes to looking at the issue addressed in the newsletter; I appreciate this.  I also appreciate that fact that this shift is not going to be easy as many stakeholders in prevention efforts find themselves locked into their current way of thinking, which makes any suggestions coming from outside that paradigm automatically suspect.  But let me close with a simple question I use to illustrate being “stuck” in one’s own thinking when addressing this with my students:

Answer this question: What color is a “yield sign”? 

Now, visit images.google.com and in the search box type, “yield sign,” complete with quotes. 

What is the predominate color of all the pictures that appear?

Is this what you expected?

NOTE: If you are like most people above the age of 30, you likely thought, “yellow”; I did.  But “yellow” has not been the color of traffic yield signs since 1971.  So why do most people when asked this question “get it wrong”...because we are “stuck in our thinking.”  We see what we expect to see or worse yet, only look for evidence that supports our position and ignore everything else that does not.  In social psychology this is confirmation bias.

Until and unless we change OUR thinking, we have no hope of changing the thinking of those individuals we target with our programs and PSAs.

Thanks for reading to this point and allowing me to share my position.  I hope that I will be able to converse with you or other council members further.

What do you think?

Dr. Robert

Understanding Twelve-Step Programs

Elevator to sobriety out; use the steps

For 40 years I have had people ask why I would/how I could work with people who have a substance use disorder.  I have stopped trying to answer the question in such a way as to help the asker appreciate my reasons.  Instead, I ask what prompts the question.

Frequently I hear something along the lines of how difficult "those people" are to work with or how frustrating/heartbreaking/exasperating it is to try and facilitate change with someone who "just is not ready."  Instead of an answer intended to change the views of someone who has likely already made up his or her mind about "those people," I ask if they have ever visited places where "the changed" congregate.  I generally get a look that communicates, "what are you talking about" to which I say, "You know...to a 12-step meeting."  Invariably the answer is no.

If anyone has doubts that individuals with substance use disorders change, they need go no further than the nearest "open" AA or NA meeting, take a seat at the back of the room, settle in, and just listen.  The stories of recovery range from heartbreaking to hilarious, but they are all genuine and inspirational.

If you have ever wondered about addiction or are curious about what leads someone with a substance use disorder to pursue change, then attending several open 12-step meetings is highly recommended.  If this sounds like something you might consider, here are some guidelines I provide to my students when directing them to attend meetings as part of my Introduction to Addictive Disorders class.  Considering them may make attending a bit less intimidating and significantly more enjoyable:

What to Expect When Attending “Open” 12-Step Meetings:

 Suggestions regarding Etiquette

1.    Unless you are personally addicted to the substance being addressed at a particular 12-step meeting, e.g., alcohol at an AA meeting, only attend "open" meetings of a 12-step group. "Open" meetings are just that, open to anyone who may want to attend a meeting or learn more about the 12-step program of recovery.

2.    Expect to be greeted at the door when you arrive. The greeter may shake hands occasionally s/he may offer a "hug" (this is not all that common). Be prepared for the greeter to ask something like, "Is this you first meeting?" or "Have you been to a ___ meeting before?" Do not hesitate to say that you are attending because you want to learn more about ___ meetings and this is part of a class assignment. Ask to be sure that the meeting is "open."

3.    While rare, do not be surprised if the person becomes a bit "cool" if you say you are attending as a student in order to learn (this is more likely indicative of the person's lack of confidence when speaking with "a professional" than a rejection of you as a person or "outsider." Remember that "open" meetings are open to anyone.

4.   Unless advertised as a "non-smoking" meeting, expect smoking.

5.    Expect the meetings to last between 1 and 1.5 hours. Some will take a brief break after 30 - 45 minutes (usually the smoke-free meetings).

6.    Most meetings begin with some variation of the following ritual - the Serenity Prayer, greetings from the "chair" for the evening, a reading of the 12-step (perhaps the 12-traditions), perhaps a reading from the big book or other 12-step literature to set the stage for the group.

7.    Expect the chair to ask if there are any new comers attending for the first time. DO NOT feel obligated to raise your hand. If you do, expect to be personally welcomed. It is also likely that someone will approach you at the break or after the meeting and ask if you have questions. DO NOT hesitate to say you are a student and attending the meeting to learn. The person may appear "cool," but this is probably because s/he felt comfortable approaching you as a new comer to the program, i.e., an addict, but is uncomfortable speaking with you as "a counselor."

8.     Expect that a basket will be passed for donations. DO NOT feel obligated to put something in the basket, but if you do, $1 is plenty.

9.    Do not be surprised if you are asked to read something or asked if you would care to speak. I suggest reading the paragraph or step or whatever, but as regards speaking, just say, "I'm here to learn and would like to pass" or something of the sort.

10.       Do not hesitate to let anyone know you are a student and why you are there. MOST members are pleased to answer questions and may even tell you how pleased they are that you are.

111.         Do not be surprised if someone approaches you after the meeting and offers you her/his phone number. This is common practice and part of the tradition of helping, NOT someone trying to hit on you.

112.         Consider attending the meetings with a friend, preferably someone from the class. This will assuage the anxiousness some students experience when attending their first meeting. It is also an excellent way to process the experience after the meeting - remember, you have to write a paper on your experience attending the meetings.

    Enjoy yourself   

    Dr. Robert

An Argument for Harm Reduction to Address Collegiate Drinking

Harm Reduction (HR) and its utility as an approach to address substance use is nothing if not controversial. Although most are aware of HR as regards Methadone maintenance or Needle Exchange, but there is more to this behavioral and public policy objective than these two strategies.

In brief, HR is about considering ways to engage individuals committed to a particular pattern of behavior so as to reduce the likelihood of their doing harm to themselves and/or the community in which they reside and operate.  For a brief overview of HR as it applies to collegiate drinking, visit this article that you may find useful as regards justifying HR techniques and strategies when looking to approach a high-risk community (an indicated population) in a pre-contemplative (not ready) stage of readiness to change.  Visit http://peele.net/lib/reducing.html and scroll down to, Is Harm Reduction a Viable Policy for American Collegiate Drinking?

In brief, our biggest challenge in addressing the concerns related to HR is that arguments against such policies tend to be grounded in moral and/or legal principles while the rationale for HR is steeped in public health and quality of life issues.  Until and unless both sides of the HR debate can find a common ground where they can talk about the issue in neutral terms, there will always be more heat than light generated by this debate.

It seems to me that our challenge is to level the proverbial playing field.  Those advocating HR as one strategy in a comprehensive plan to address collegiate drinking will never trump the moral and legal rhetoric directed against HR with a logic-based appeal that addresses the quality of life of those who choose to use.  You and I can likely appreciate this logic and as the result embrace it, but for those who see drug use as “illegal” and those who use drugs as “criminals”—or its first cousin, “if drugs are bad then those who use them are bad people”—HR is tantamount to “giving in,” “permitting use,” “the first step to legalization,” and/or “pushing current non-users towards use.”

An alternative in this debate is to shift the focus for HR away from the reduction of harm for the user and direct it instead onto the reduction of harm for the community in which the user uses.  In the case of the Greeks, a high-risk community of drinkers on college and university campuses, for example, it is improving the quality of life for the community in which the Greeks live (this is where programs like the Good Neighbor Project at Clarion University in Clarion, PA can be useful – see http://www.clarion.edu/267773/) or reducing costs to the university related to violence and vandalism.  If a case can be made to lower high-risk Greek drinking, its related behaviors, and its negative impact on quality of life issues in general, especially if those quality of life issues affect student decisions to transfer before graduation, then one can argue for HR not so much to benefit to “miscreant drinkers,” but the individual “well-behaved student” in the general university community.

Put another way, if there are “indicated populations” that already manifest indications of problems related to drinking on campus, then the university community as a whole--and not just the errant consumers--is the most likely benefactor of the HR efforts targeting those communities.

What do you think?

Dr. Robert

Providing AOD Services to Students in College

A colleague posed the following questions on an online discussion group to which I subscribe:

I am seeking feedback about how private, Christian colleges provide substance abuse treatment for students.  Specifically, how are referrals from administrative sources such as judicial affairs handled?  Are there separate mandated and voluntary treatments?  How is student confidentiality maintained or addressed in light of community abstinence policies? 

Here is the reply I posted to the list:

These are wonderful questions and ones that get asked all to infrequently, especially by administrators in higher ed. The good news, as the saying goes, is that there are literally thousands of pages written on this general topic and these specific questions…the bad news is, there are literally thousands of pages written on this general topic and these questions J So, where to start…

  

How are referrals from administrative sources such as judicial affairs handled? When student affairs and judicial affairs are walking in sync, this is a relatively easy question to address. When at a small, urban, Catholic university, we negotiated what we called an “alternate sanctions program” for those first-offenders or subsequent offenders where the infractions were minor, e.g., no hospitalization; no injuries. In this program, there were set consequences that would follow specific violations—deferred suspension of housing, probation, etc.—but students were offered the choice between a hefty monetary fine or to participate in an alcohol awareness program modeled on harm reduction and Motivational Interviewing as the last consequence of the violation. This increased the likelihood that students would participate in the educational alternative and do so “voluntarily,” which allowed the practitioner presenting the program to be the “good guy” who allowed the student to save $X, not to mention used choice to more directly involve the student in the process.

How is student confidentiality maintained or addressed in light of community abstinence policies? Regarding the issue of confidentiality, students would be told at the first session that everything that went on in the sessions was confidential and nothing, including attendance info, would be released w/o a written consent to do so. That said, students were reminded that it would be in their best interest to allow judicial affairs to at least know about their attendance. NOTE: A written report would be prepared for Judicial Affairs, but again would not be released until (1) the student reviewed the report with the practitioner and (2) provided the written consent. A similar process was used with MANDATED students. NOTE: As a counselor I addressed the “seeing mandated clients” dilemma by ensuring students that I “work for you and not judicial affairs” and for this reason would not release info unless such was indicative of likely harm to oneself or others. For details/copies of forms/etc. please contact me back channel: Chapman.phd@gmail.com

At the end of every semester I would routinely hear from judicial affairs about how students actually found the alcohol sessions interesting if not enjoyable. I would be asked, “What are you doing over there? When we sent him/her your way, he/she went kicking and screaming.” It was this student compliance with the program that allowed judicial affairs to recognize that approaching high-risk student behavior as something done “with a student” rather than “to a student” was actually more productive…a collaborative rather than adversarial approach.

Where the issues you raise become challenging is when senior administration and/or judicial affairs folks see violation of institutional policy as being a hanging offense AND assert their need to know everything that goes on as the result of that violations. In this day and age we tend to see institutions open to my suggestions above regarding alcohol, but closed to them when the violation is for “drugs other than alcohol.”

I suggest that you look at the literature related to (1) environmental management and (2) Brief Alcohol Screening and Intervention with College Students, BASICS. Basic info on both can be found on my web site. I also suggest that looking at my 3-monograph series entitled, When They Drink, especially the first one, which includes invited essays on all aspects of addressing high-risk and dangerous collegiate drinking. Links can be found at http://robertchapman.net/essays.htm

What do you think?

Dr. Robert

Considering Collegiate Drinking; The Rest of the Story

When considering collegiate drinking, it is important to step back from issues such as student AOD use and consider a larger picture.  As a profession, substance use disorder prevention specialists have a tendency to be myopic in our consideration of "the problem."  As accurate as accounts of this problem may be, they are, nonetheless, incomplete.

Lists of strategies to address collegiate drinking generally include several important and proactive suggestions.  Approaches such as social norms marketing, environmental management along with clinical intervention strategies like Brief Alcohol Screening and Intervention for College Students (BASICS) are on the short list and are important steps that need to be considered when addressing the issue of alcohol and other drug use by students.  As important as these approaches are in addressing high-risk and dangerous collegiate drinking, they do not provide access to the "big picture."  If anything, these are “problem-oriented” strategies, but are the metaphorical equivalent of effective strategies for bailing the water from a sinking ship, but do little to solve the problem of taking on the water being removed from the bilge. 

What we need to ask is, when framing the issue of collegiate drinking, "what is just outside the framed shot.”  What would we capture in our picture of collegiate drinking if we used a wide-angle lens?  I suspect that there are several influential factors that heretofore have been overlooked at best or more likely, simply not considered...at all.  As Paul Harvey used to say in his syndicated radio program, what is, “the rest of the story”?

Just like Pluto--before it was demoted to a dwarf planet--was predicted to exist before it was actually discovered by Tombaugh in 1930, its existence was postulated via mathematical calculations.  So do "other forces" exist that affect the use of alcohol and other drugs by students?  Although I focus on this in great detail in the latter 2 monographs in my 3-monograph series on collegiate drinking, When They Drink (links included at the end of this post), here are three invisible, that is to say, "unstudied," forces I suggest affect collegiate substance use:

•                What do "alcohol" as a substance and "drinking" as a behavior mean to students?  This social constructionist view of collegiate drinking has never been seriously investigated.  "How" does alcohol reach its iconic status for students?  "What" affects the meaning ascribed to alcohol and drinking?  "Why" and more importantly, "how" does this meaning change with time...often in 2 to 3 semesters via the "maturing out" phenomenon?  If we better understood the social construction of use, we would be likely to incorporate this into prevention strategies...again, read my monographs.

•                Explore the "positive consequences" of abstinence and/or moderate use rather than the "negative consequences" of abuse.  We already know that students respond better to "positive" messages than to negative...and we know that "scare tactics" do not work.  How about investigating what students view as being the "pluses" of abstaining and moderating use rather than always hawking the negatives. 

•                "Bystander Behavior" - This comes in at least 2 forms: (1) "the silent majority," to quote Spiro Agnew, who say nothing when John Jones or Mary Brown act like a jerks at a drinking gathering, and (2) "most of us" when we fail to hold drinkers accountable for their irreverent, inappropriate, or otherwise untoward behavior because we "don't want to hurt his feelings" or "she'll get all Jersey Shore on me" if I say/do something.

We have learned much in the last 15 years regarding how to affect the campus drinking culture; this is very good news.  That said, we have a long way to go and, unfortunately, much of the interest and money that drove discoveries of the past 15 – 20 years has gone other places.  But just as we knew Pluto was there before we were able to "see it," so is it likely that "something else" is there as regards changing the campus drinking and drugging culture.

Solution-Focused counselors suggest asking individuals to consider a time "before" the problem existed or imagine "when" the problem no longer exists.  By doing this, they invite us to explore how we acted before the problem existed or consider what happened or was done to solve the problem in the future.  This becomes the focus of the practitioner's intervention...get us thinking about possible solutions rather than being preoccupied with the consequences of problems.  

We all know the old adage about the glass being half empty or half full.  There is another option, however, when looking at that glass, namely, that it is always "fully full."  Think about it…the glass is half full of water and half full of air!  We need to look at the "air in the glass" in order to appreciate that the glass is, indeed, always full.  So, when considering collegiate drinking, with what is the rest of that glass filled?

What do you think?

         When They Drink:Is Collegiate Drinking the Problem We Think It Is? (PDF)

         When They Drink:Deconstructing Collegiate Alcohol Use (PDF)

NJ Legislature Votes to Permit Sale of Syringes W/O Prescription

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Designed to address the transfer of blood-borne diseases via “dirty needles,” the NJ legislature has passed a bill permitting the sale of up to 10 syringes w/o a prescription.  Interestingly, this will not become law until and unless the governor signs it into law, an outcome that is “up in the air.’  Having opposed “needle exchanges” while a US Attorney, Gov Christie is on record indicating he is open to revisiting that opinion. For more on the story, visit http://bit.ly/sYsLHZ

NOTE: making the sale of “up to 10 syringes w/o a prescription” legal presents an interesting spin on the harm reduction strategy of ‘needle exchange.”

1. 1.     By “purchasing” syringes rather than “exchanging them,” some of the potential stigma of “self-identifying” as a “drug addict” is removed in the effort to put clean needles in the hands of intravenous drug users (those in a pre-contemplative stage of readiness to change)
2. “   Purchasing” needles rather than “exchanging” them is consistent with the old adage that, “Something for something is worth more than something for nothing” 
3. 3.    “Purchasing” needles rather than “exchanging” them may permit those who have historically be opponents of needle exchange programs on the groups that they promote drug use to support the intended purpose of such programs—reduce the spread of blood-borne disease—w/o having to “give users paraphernalia

Of course as with all things, there is a down side.  Potential issues related with this Jersey bill include:

1. 1.     Unless regulating the cost of needles, there is nothing to stop pharmacies from charging whatever they like for “loose needles.”  Although most pharmacies will not want to gouge their customers with “legitimate” reasons to purchase syringes, some may want to gouge “drug users” or discourage “them” from coming in their stores by charging an outrageous price for “loose” needles
2. 2.     What becomes of the “dirty” needles?  In the exchange programs, they were disposed of properly, but in a “purchase” type exchange, the “dirty” needles remain “on the street”

Nothing is ever simple and without its controversy, but a tip of the hat to the jersey legislature for considering a new approach to a perennial problem.  Hopefully Governor Christie will weigh in on this issues based of fact and what is in the best interest of the citizens of NJ and not simply make a political decision.

If you are from Jersey or have connections with others who are, you may want to consider contacting the Governor and voicing your opinion.

What do you think?

Dr. Robert