When Awareness Just Is Not Enough

Who in the prevention field has not invested countless hours to raise awareness about the risks associated with high-risk and dangerous collegiate drinking? I know I have...in almost 20-years at La Salle University coordinating its alcohol and other drug program and then, after retiring from La Salle, as a professor of Behavioral Health Counseling at Drexel University…in the classroom, on University committees, and with the former U.S. Department of Ed's supported Network Addressing Collegiate Alcohol & Other Drug Issues.

The argument for making this enormous investment of effort was that if intelligent students simply knew the risks associated with high BAL (blood alcohol level) consumption, they would make the logical decision to moderate their consumption and, thereby, reduce the likelihood of untoward alcohol-related consequences occurring on campus. This reasoning made logical sense and many of us followed it faithfully for years. However, by the later 1990s, we began to realize that information alone was not sufficient to motivate the desired change in collegiate drinking. As we became aware of the work of Prochaska and DiCelemte and their Transtheoretical Model of Change, we realized that although information and awareness might be effective in moving collegiate drinkers beyond a "pre-contemplative" or perhaps "contemplative" stage of readiness to change their drinking behavior, it was not particularly effective in moving students farther along the continuum to an "action" stage of readiness.

Realizing the limits of awareness campaigns being

the only type of "arrow in the preventionists^[1]  quiver" led us to explore more action-oriented means of engaging students, and a good job we have done with this...BASICS and employing brief motivational interviews with feedback when speaking with students, environmental management, employing the ecological model when considering changing the campus culture, and recognizing the role social norming can play in affecting how students view actual alcohol consumption on their campus and in their individual peer groups. That said, we have nonetheless reached a point where the numbers related to student drinking seem to have plateaued. Are those who continue to engage in high-risk and dangerous drinking practices simply intractable or worse yet, incorrigible? Have preventionists reached the limits of their effectiveness? Is high-risk and dangerous collegiate drinking...or drinking by anyone irrespective of college affiliation...just something with which we must learn to live?

Although I have written a number of articles on additional options the prevention field might entertain when pursuing future efforts or approaches to proffering its messages on campus[2], the Stanford Social Innovation Review hosts an article written by Ann Christiano & Annie Neimand entitled "Stop Raising Awareness Already"[3] that is both provocative and of likely interest to all who seek to affect the campus drinking culture. NOTE: This article is long, so be prepared. That said, to "skip ahead to the good part," the good part meaning that section most likely of practical use to AODT preventionists, visit the article and scroll down to Creating Awareness that Leads to Action.

There is a distinct role that increased awareness

plays in forwarding the efforts of preventionists concerned with high-risk and dangerous collegiate drinking. This role is not, however, likely to directly result in behavior change. Put another way, the student who is moved by an inspirational speaker or creative and memorable prevention message on Tuesday is not likely to change her or his drinking behavior come Friday. That said, this student may just move from a pre-contemplative stage of readiness to change and begin to contemplate that what causes a problem is a problem when it causes a problem.

What do you think?

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^[1] “Preventionist” is coined to refer to the behavioral health professional whose interest and focus is the prevention of high-risk and dangerous alcohol and other drug use.

^[2] See essays on the possible role of behavioral economics and social psychology in prevention at https://robertchapman.blogspot.com/ or monographs #1 & #2 on how exploring the process by which students ascribe meaning to alcohol as a substance and drinking as a behavior can "add arrows to the preventionist's quiver" at https://tinyurl.com/yb2v5vta-

^[3] If unable to access this article by clicking its title, the URL is https://ssir.org/articles/entry/stop_raising_awareness_already

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Stacking the Deck for Behavior Change: The Role of Implementation Intention

So, we know that brief motivational interviews with personal feedback result in student willingness to revisit their drinking behavior. Likewise, we know that such reviews often result in a willingness to dial back their frequency of use and/or the amount they drink. In addition, it is not uncommon that the practitioner who conducts such motivationally enhanced intercessions with students find them willing to continue the conversation about changes even when having met their mandated obligation because they come to trust the practitioner. What is needed now is an evidence-based approach to helping students develop an action plan to make changes and to do so with a degree of certainty that they will be successful…and without a waning of commitment, especially when confronted with real-time challenges to their best of intentions; enter Implementation Intentions.

Implementation intentions is a ten-dollar psychological term for the familiar If…then logic statements so commonly studied in an undergraduate philosophy 101 course. They are the self-regulatory behavioral equivalent to the conditional statements used in debates where logic is used to make a debater’s point…If P, then Q…if it looks like a duck, sounds like a duck, and walks like a duck, then chances are good that it is a duck.

Implementation intentions employ a when, where, how reasoning when developing a plan intended to increase the likelihood of one’s behavior change plan resulting in success while at the same time inoculating the changer against the cues and triggers that so often sabotage the best of intentions to change. “When” am I likely to encounter a threat to my change plan? “Where” is this likely to happen? “How” will I act on it rather than react to it?

Obviously, the more specific the details are regarding the answers to these three questions, the more likely the implementation intentions are to shield the changer from a lapse if not a relapse. If I know I am most likely to drink 4+ drinks on a Saturday night (when) AND this is most likely to happen at the TKD (TippaKegaDay) frat house (where), THEN I will go/do _____ on Saturday nights for the remainder of this semester.

The literature seems to suggest that successful changers are not so much those who have the “strongest” willpower but rather those who have so structured their lives as to reduce the frequency of encountering the cues and triggers associated with the behavior they now seek to change. Of course, this seems like common sense…those at all familiar with A.A. have heard the saying, If you don’t want to get hit by the train, don’t stand on the track, and AA’s exhortation to “change people, places, and things” has been around since AA’s inception in 1935. That said, implementation intentions are also very much like a practice used in business when considering project management – conducting a pre-mortem. Essentially, a premortum seeks to consider all likely sources of sabotage or disruption that can preclude success in a considered project. Instead of looking at what went wrong “after the fact” (a post-mortem) management considers what “could” go wrong and then takes steps in advance of implementing the project to prevent such from happening.

So, back to our success when engaging students in revisiting their high-risk and dangerous drinking. The next logical step after having gained (1) student trust by employing brief motivational interviews with personal feedback AND (2) their willingness to revisit their personal drinking behavior is to (3) help them identify a nonetheless brief and noninvasive strategy for developing a specific behavioral plan designed to help them accomplish their objective. To this end, I suggest that implementation interventions may be just such an approach.

What do you think?

The Upside of Change: Finding the Silver Lining

If you always do what you have always done, you will always get what you’ve always gotten. Jessie Potter

In his book, Illusions: The adventures of a reluctant messiah (1977), Richard Bach’s protagonist encounters an enigmatic fellow barnstorming pilot who becomes his mentor. The mentor’s life lessons, collected in a small book with unnumbered pages, the Messiah's Manual & Reminders for the Advanced Soul, is essentially a book of maxims designed to provide the reader with guidance when addressing life’s challenges by simply opening to any page…hence the absence of numbered pages…and then reflecting on the revealed maxim. For example, at one point when Richard, the book’s narrator, is dealing with a vexing challenge, he opens the handbook and reads, There is no such thing as a problem without a gift for you in its hands. You seek problems because you need their gifts (p. 57 in the novel).

 Although I recommend this tome to anyone dealing with the challenges of life[1]—in particular those coming to grips with a substance use disorder—this maxim from the Messiah’s Handbook is of particular interest when considering threats to a personal change plan. Change, while at the same time necessitating the removal of "something," promises to provide by substituting “something else” in its place.  Unfortunately, one of the greatest challenges to a change plan occurs when lamenting the loss resulting from this removal.

Ironically, it is not the abandonment of some “thing” or “activity” that provokes this sense of loss but rather, the resulting void one realizes when following the forfeiture of the usual or go-to means by which to handle pain, stress, anxiety, or any other equally disquieting experience that provokes the need to seek the negative reinforcement provided by the "old behavior." Add to this that the new behaviors implemented to supplant if not block the “maladaptive behavior” are perceived as inconvenient at best and feel awkward or are otherwise viewed as “wrong,” and you have the perfect storm for scuttling even the best-intentioned and well-planned change strategy.

Those successful when implementing a change plan are those who recognize that change “gives something” as well as takes something away. This realization results when conducting something akin to what an economist calls a” cost-benefit analysis.”

Such an analysis quite literally means looking at what it costs to realize some desired outcome, for example, assuage physical or emotional pain, cope with anxiety, or compensate for a perceived defect in character or being. When the cost—and this can just as easily refer to a cost in time, effort, the opinion of others or self-respect as it can to money—of realizing a particular benefit is greater than the benefit itself, then, and only then will the prospect of change become tenable. Put another way, when the cost of the benefit received from continuing to behave in one’s “usual way” is greater than the costs associated with changing, one opts for making the change.

An activity that simplifies this cost-benefit analysis of change options involves the use of a simple 2 X 2 table. When attempting this exercise, referred to as a Decisional Balance exercise by professional counselors, label the columns in the table as "Change” and “Stay the Same” (or “quit smoking/drinking/avoiding exercise/gambling/not taking my meds/whatever” and "keep smoking/drinking/gambling" or "avoid exercise/taking my meds/whatever."

Next, label the rows as “Pros/Benefits” and “Cons/Costs.” Now over the course of several days start to record specifics details associated with each “cell” in the table. NOTE: Doing this over several days rather than “all at once” accommodates changes in mood or insights that may arise from day-to-day. If you are particularly intent on conducting a truly thorough cost-benefit analysis, ask a trusted friend or close family member for her/his input.

When completed, the resulting table provides a more objective, rational “picture” of the costs and benefits associated with both "change" or "no change." Although this certainly does not ensure that change will follow, it does present a clearer picture of “what’s what” regarding one's situation. Not uncommonly, a decision to change just seems to "materialize" when stepping back from the table in order to consider “the big picture.”

Remember...the benefits of changing…or not…can only be assessed by the changer. This means that the motivation to alter one's behavior originates internally. The tipping point for successful change, as Bach suggests in Illusions, occurs when one recognizes that life's problems have their gifts inside, which is why we need them. It would seem that the same can be said of the challenges associated with changing…

What do you think?

Dr. Robert

References

Bach, R. (1981,1977). Illusions: the adventures of a reluctant Messiah. New York: Dell/E. Friede.

[1] I had considered sending a copy of this Bach novel to all members of the U.S. Congress but when realizing the most likely best-case outcome of such an expensive effort would be to just have it assigned to an aide to read, I decided against it.

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