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Utilizing Peers in the Delivery of Brief
InterventionsJason Kilmer, Ph.D.
The Evergreen State College
Saint Martin’s University
Kim Hodge, B.A.University of Washington
Sruti A. Desai, B.A.University of Washington
Mary E. Larimer, Ph.D.University of Washington
Study described funded by NIH/NIAAA and the Dept. of Education grant U01
AA14742
Effective strategies to reduce drinking and/or consequences in college students
The use of peers in intervention delivery
Our study: The Alcohol Research Collaborative
Preparing peers to deliver brief interventions
Clinical issues, research questions, and future directions
Points for Consideration
Combining cognitive-behavioral skills with norms clarification and motivational enhancement interventions. Reductions in drinking rates and associated
problems (e.g., ASTP) Offering brief motivational enhancement
interventions. Reductions in drinking rates and associated
problems (e.g., BASICS) Challenging alcohol expectancies.
Reductions in alcohol use
Tier 1: Evidence of Effectiveness Among College Students
Task force report available at: www.collegedrinkingprevention.gov
Examines students’ perceptions about:Acceptability of excessive behaviorPerceptions about the rates of their
peersPerception about the prevalence of
their peers
Norm Misperception
COGNITIVE-BEHAVIORAL SKILLS TRAINING
Moderate drinking skillsBlood alcohol concentration
discriminationAltering expectancies about
alcohol’s effectsAssertiveness skills (drink refusal)Relaxation/Stress Management
skillsLifestyle balance skills“Alcohol specific skills”
Time
FeelingScale
+
__
0
Dysphoria - Down
Euphoria - Up Point of Diminishing Returns
Cultural Myth About
Alcohol
After Tolerance Develops
Alcohol’s Biphasic Effect
Specific Tips for Reducing the Risk of Alcohol Use
Set limitsKeep track of how much you drinkSpace your drinksAlternate alcoholic drinks w/non-alcoholic
drinksDrink for quality, not quantityAvoid drinking games If you choose to drink, drink slowlyDon’t leave your drink unattendedDon’t accept a drink if you don’t know what’s
in it
The Stages of Change Model (Prochaska & DiClemente, 1982, 1984, 1985, 1986)
PrecontemplationContemplationPreparation/Determination
ActionMaintenance
Motivational Interviewing Basic Principles
(Miller and Rollnick, 1991, 2002)
1. Express Empathy
2. Develop Discrepancy
3. Roll with Resistance
4. Support Self-Efficacy
A skills-training approach using motivational interviewing techniques in its delivery with a focus on drinking in less dangerous and less risky ways for those who make the choice to drink.
The Alcohol Skills Training Program (ASTP)
A non-confrontational, harm reduction approach that helps students reduce their alcohol consumption and decrease the behavioral and health risks associated with heavy drinking.
Brief Alcohol Screening and Intervention for College Students
(BASICS)
BASICS and ASTP
ASTP is delivered in a group settingAlcohol content and the skills-
training information is introduced in a more structured way throughout the program
BASICS and ASTP
Content reviewed in ASTPExpectanciesStandard Drink and NormsAbsorption/OxidationBAC, Associated Effects, ToleranceAlcohol’s Biphasic EffectDistribution of Blood Alcohol
ChartsConsequences Risk Reduction Strategies
BASICS and ASTP
BASICS is individually focused and involves the delivery of personalized feedbackAlcohol content and the skills-
training information is introduced throughout the intervention when relevant, applicable, or of interest to the participant
The Basics on BASICS Brief Alcohol Screening and Intervention For
College Students
•Assessment
•Self-Monitoring
•Feedback Sheet
•Review of Information and Skills Training Content
(Dimeff, Baer, Kivlahan, & Marlatt, 1999)
ASTP vs. Information OnlyAlcohol Skills Training Study I
Self-Reported, Peak BAL
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
Pre 4Mos 12Mos
Informational Program
Skills Training Program
BASICS 4-year Drinking Outcomes by Treatment Condition
4 Years 3 Years 2 Years 1 Year Baseline
Drin
king
Pat
tern
Z-s
core
1.0
.8
.6
.4
.2
0.0
-.2
Random Comparison
High -Risk Treatment
High -Risk Control
Review of individual focused strategies…
Larimer, M.E., & Cronce, J.M. (2002). Identification, prevention, and treatment: A review of individual-focused strategies to reduce problematic alcohol consumption by college students. Journal of Studies on Alcohol, Supplement No. 14, pp. 148-163
www.CollegeDrinkingPrevention.gov
Research utilizing peers in alcohol interventions using normative
reeducationMixed resultsSome show change in norm
perception but no effects over time on drinking behavior (e.g., Barnett, et al., 1996 and Smith, 2004)
One study with freshmen showed drinking reductions but no differences in norm perception (Schroeder & Prentice, 1998)
Research using peers to deliver ASTP and to facilitate Alcohol 101
CD-ROMMiller (1999) compared 2 assessment
conditions + 2 peer-facilitated interventions
At six month follow-up… Single-assessment only controls drank
more & had more consequences than students in other groups
Participants in the three-assessment group generally reported similar decreases in drinking/consequences
Participant satisfaction was higher in the ASTP
Research on brief individualized feedback interventions using peers
and professionalsWith Greek System students,
Larimer, et al. (2001) found: Fraternity men in intervention condition
decreased drinks per week & peak BAC No change for sorority women Peers were at least as effective at
promoting change in drinking behavior as professionals
O’Leary, et al. (2002) found peer providers were not as effective for women as were professional providers
Credibility of Peer Providers
Few studies address credibility of peer providers
Several authors suggest peers make credible role models and students may relate better to peers
Mixed findings do suggest the need for more research (Fromme & Corbin, 2004)
Research on Lifestyle Management Class for mandated or voluntary
studentsFromme & Corbin (2004) found…
LMC showed reductions in drinking and driving
Voluntary participants higher in readiness to change showed reductions in heavy drinking
Professionals rated higher on knowledge, content delivery, and intervention fidelity
Peers equally effective in both mandated and voluntary samples and for both men & women
What has research shown about utilizing peers in interventions
targeting alcohol use?
Research supports the idea that peer programs might be a
viable resource for implementing empirically supported interventions
The Alcohol Research Collaborative (ARC)
In ARC, for first-year students with at least one heavy drinking episode, compare several approaches, including three brief interventions Peer-delivered BASICS intervention Peer-delivered Alcohol Skills Training
Program (ASTP) Web-BASICS
ARC assignment to conditionAfter screening and baseline, 637
students were randomized to a condition of the study
399 participants were randomized to BASICS, ASTP, Web-BASICS or Control
86% completed 3-month follow-up, and 83% completed 6-month follow-up
Participant completion rates by condition:Web-BASICS 83.7%BASICS 74.7%ASTP 67.0%
Satisfaction Ratings
Overall high satisfaction, with ASTP (M=5.35) & BASICS (M=4.99) higher than web-BASICS (M=4.58)
More learned about alcohol in ASTP (M=5.68) and BASICS (M=5.49) than Web-BASICS (M=4.87)
Web-BASICS more convenient to participate in (M=5.79) than ASTP (M=4.78) (no difference between groups with convenience of BASICS (M=5.24))
Post-Intervention Impressions of Peers: Percentage rating
mildly/moderately/strongly agree
Participants agreed presenters seemed… Warm and understanding (90.9% of ASTP;
97.3% of BASICS)
Competent and well-trained (97.0% of ASTP; 98.6% of BASICS)
Knowledgeable about alcohol use (93.9% of ASTP; 91.8% of BASICS)
Well organized (87.9% of ASTP; 93.2% of BASICS)
Limitations prior to data analysis
Randomization issues (students assigned to BASICS had fewer drinks per week and lower RAPI scores than in other conditions)
Outcome variables were skewed, so data were log transformed for analytic purposes
p < .01
Total Drinks per Week
4
5
6
7
8
9
10
11
12
Baseline 3 Month 6 Month
Control BASICS web BASICS ASTP
No time by group interactions for total drinks or negative consequences
Specific planned comparisons indicated that BASICS reduced total drinks per week more than control did
p < .01
Peak Drinks per Occasion
4
5
6
7
8
9
10
Baseline 3 Month 6 Month
Control BASICS web BASICS ASTP
Time by group interaction for peak drinks
Significant reductions for ASTP from baseline to 3-mo. and 3-mo. to 6-mo.
Significant reductions for BASICS and web-BASICS from baseline to 3-mo.
Conclusions
Baseline differences make it hard to interpret results
Implementing a peer-led intervention is feasible
Support for all three interventions reducing peak drinks/occasion; only BASICS significantly reduced total drinks per week
Some delayed effects in ASTP Initial reactivity in assessment for controls
on peak drinks that failed to be maintained over time
Peer Therapist Training for ARC
Reading packet for facilitatorsInitial 8 hours of training on alcohol
content & clinical technique Practice facilitating with a mock
participant volunteerWeekly group supervisionPossibility of individual meetings for
more practice and supervision
Peer Therapist Training (continued)
MITI Coding Team reviews for adherence and compliance assessment
Detailed review/feedback written after tape is reviewed by supervisors
Peer therapist facilitates only once MITI Coding Adherence is reached
While interventions occur, facilitators attend weekly group supervision
Facilitators may need to attend an hour individual or pair supervision with an RA during weeks when an session is completed
Possible Barriers to Implementing Effective Interventions on College
Campuses
Barriers can exist to dissemination, adoption, implementation, and maintenance (Rogers, 1995)
Source: Larimer, Kilmer, and Lee, 2005
Possible Barriers to Implementation in Implementing
Effective InterventionsProper training of those
delivering a program
A tendency to “reinvent” innovations (Rohrbach, D’Onofrio, Backer, & Montgomery, 1996)
Source: Larimer, Kilmer, and Lee, 2005
Possible Barriers to Maintenance in Implementing Effective
Interventions
Therapist drift (i.e., issues of fidelity)
Need for ongoing assessment and continued training
Source: Larimer, Kilmer, and Lee, 2005
Clinical Issues/Future Directions
Recognize that efforts with peers are one piece of the prevention program puzzle
Professional staff and peer facilitator time and energy
For whom are peer interventions most effective?
Characteristics of peer presenters vs. intervention recipients
Are problems with college students becoming more severe?90% of counseling center directors
perceive an increase in students with more severe psychological problems in recent years (Gallagher, 2005)
95% report an increase in students coming to counseling already on psychiatric medication (Gallagher, 2005)
Clinical Issues/Future Directions
Formally evaluate issues of time- and cost-effectiveness
Best practices in training and supervision Continue to explore use of peers in other
alcohol- and drug-related interventions Particularly with less clear prevention
approaches for drugs other than alcoholChallenges with a possibly more
complicated and complex student body
0
5
10
15
20
25
30
35
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Percentage
Percentage of all clients prescribed medication (Schwartz,
2006)
** Data for slide estimated from table appearing in Schwartz, 2006 **
Possible reasons behind perceived increase in severity of psychological problemsActual increase in problemsGreater similarity between college/general
populationGreater availability of meds could allow
students to attend college who otherwise might not have done so
Lesser stigma attached to mental illness may have led to an increase is seeking psychological services
Students under care of a provider may discontinue that once in college
CASA, 2003
Possible reasons behind perceived increase in severity of psychological problems Increased academic pressure,
competitiveness, or greater sleep deprivationFewer take time off to become stabilized
than in the past in response to stress or mental health problems
Students stop using meds upon entering college Assume they’ll be less depressed, don’t
want stigma of being on meds, or want use alcohol/drugs instead
Students using alcohol or drugs while on meds accentuate depressant effects
CASA, 2003
Thank You!
Special thanks to Ann Quinn-Zobeck
All the best in your prevention efforts!
Jason [email protected](360) 867-6775