LOGAN ET AL.

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Alcohol Interventions for Mandated Students: Behavioral Outcomes From a Randomized Controlled Pilot Study DIANE E. LOGAN, PH.D.,a,* JASON R. KILMER, PH.D.,b,c KEVIN M. KING, PH.D.,d AND MARY E. LARIMER, PH.D.b aDepartment

of Behavioral and Social Sciences, Brown University, Providence, Rhode Island of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington cHealth & Wellness, Division of Student Life, University of Washington, Seattle, Washington dDepartment of Psychology, University of Washington, Seattle, Washington bDepartment

ABSTRACT. Objective: This study investigated the effectiveness of three single-session interventions with high-risk mandated students while considering the influence of motivational interviewing (MI) microskills. Method: This randomized, controlled pilot trial evaluated single-session interventions: Alcohol Skills Training Program (ASTP), Brief Alcohol Screening and Intervention for College Students (BASICS) feedback sessions, and treatment-as-usual Alcohol Diversion Program (ADP) educational groups. Participants were 61 full-time undergraduates at a southern U.S. campus sanctioned to a clinical program following violation of an on-campus alcohol policy (Mage = 19.16 years; 42.6% female). Results: Results revealed a significant effect of time for reductions in estimated blood alcohol concentration (eBAC) and num-

ber of weekly drinks but not in alcohol-related consequences. Although ASTP and BASICS participants reported significant decreases in eBAC over time, ADP participant levels did not change (with no intervention effects on quantity or consequences). MI microskills were not related to outcomes. Conclusions: Results from this study suggest equivalent behavioral impacts for the MI-based interventions, although individual differences in outcome trajectories suggest that research is needed to further customize mandated interventions. Given the overall decrease in eBAC following the sanction, the lack of reduction in the ADP condition warrants caution when using education-only interventions. (J. Stud. Alcohol Drugs, 76, 31–37, 2015)

C

1999) incorporate personalized normative feedback with motivational interviewing (MI; Miller & Rollnick, 2002). Both ASTP and BASICS have repeatedly demonstrated effectiveness at significantly reducing consumption and consequences for volunteer student participants (Baer et al., 1992, 2001; Borsari & Carey, 2000; Fromme et al., 1994; Marlatt et al., 1998), clearly outperforming education-only interventions (Cronce & Larimer, 2011; Thadani et al., 2009). Despite these generally positive findings, mandated students (students referred for an intervention following violation of a campus alcohol policy) are typically absent from or peripheral to the well-established and frequently published results of randomized controlled trials with volunteer college students. Because mandated students may actually reflect the typical population to which these interventions are applied outside of research protocols, effects found in volunteer research participants may not generalize to this referred population. The number of mandated students and the scope of the sanctions continues to increase (Barnett & Read, 2005; Hoover, 2003; Porter, 2006) as higher education institutions continue to adjust and enforce policies related to underage drinking (as recommended by the Federal “Call to Action” publications [Department of Health and Human Services, 2007; NIAAA, 2002]) without equivalent increases in financial and clinical allocations, often resulting in intervention delays and fidelity concerns. As mandated students pose institutional liability and safety concerns, research that identifies empirically supported interventions while maximizing limited campus resources is imperative.

OLLEGE STUDENT DRINKING CONTINUES TO be of great concern, with 68% of college students consuming alcohol in the past 30 days and 40% reporting having “been drunk” in the past month (Johnston et al., 2013). These risky drinking behaviors are associated with numerous consequences, including 5,500 unintentional deaths, 500,000 unintentional injuries, and 600,000 assaults among college students annually (Hingson et al., 2005, 2009). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has designated Tier 1 interventions that have favorable behavioral outcomes with college students in at least two independent studies (NIAAA, 2002), including the Alcohol Skills Training Program (ASTP) and Brief Alcohol Screening and Intervention for College Students (BASICS). ASTP combines cognitive-behavioral skills, norms clarification, and motivational enhancement techniques (Miller et al., 2001). Individual BASICS feedback interventions (Dimeff et al.,

Received: August 29, 2014. Revision: September 2, 2014. This research was supported by National Institute on Alcohol Abuse and Alcoholism Grant 1F31AA018238-01A1 (principal investigator: Diane E. Logan) and individual awards from the American Psychological Association, the Association for Behavioral and Cognitive Therapies, The Network (Department of Education), and the University of Washington awarded to Diane E. Logan. Manuscript preparation was supported by National Institute on Alcohol Abuse and Alcoholism Grant 2T32AA007459 (principal investigator: Peter M. Monti). *Correspondence may be sent to Diane E. Logan at the Center for Alcohol and Addiction Studies, Brown University, Box G-S121-4, Providence, RI 02912, or via email at: [email protected].

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JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JANUARY 2015

Mandated students differ from volunteer students in significant ways, including reporting more heavy drinking days and alcohol-related consequences (Barnett et al., 2004; Fromme & Corbin, 2004) but lower levels of readiness to change (Palmer et al., 2010; Vik et al., 2000). Mandated students tend to be higher in defensiveness or resistance (Barthelmes et al., 2010; Palmer et al., 2010), which may affect in-session attitudes and behaviors such that mandated students may be even less influenced by traditional intervention approaches involving confrontation or education only (Barthelmes et al., 2010; NIAAA, 2007). Mandated students do not consistently benefit from interventions found to be efficacious with volunteers, demonstrating smaller decreases (and sometimes increases) in drinking behaviors and smaller effect sizes when drinking reductions are detected (Carey et al., 2009; Cimini et al., 2009; Doumas et al., 2011; LaBrie et al., 2006). However, MI-based interventions may simultaneously reduce resistance, build rapport, and increase motivation and intent to change (Barthelmes et al., 2010; Miller & Rollnick, 2002), in part through the use of MI-consistent microskills such as open-ended questions and complex reflections (Tollison et al., 2008, 2013). Indeed, MI-based individual and group interventions demonstrate improved outcomes with reductions in consumption and/or consequences in mandated populations (Borsari & Carey, 2005; Borsari et al., 2012; Carey et al., 2006; Fromme & Corbin, 2004; Hustad et al., 2014). The current study sought to investigate the effectiveness of single-session interventions with high-risk mandated students while considering the impact of MI microskills. We hypothesized reductions in alcohol use and consequences for ASTP and BASICS groups and no change or potential increases for the education-only treatment as usual (TAU) Alcohol Diversion Program (ADP, described below). We also expected MI microskills to be associated with greater decreases in alcohol use and consequences. Method Design This study evaluated single-session interventions with mandated college students at a university in the southern United States. Participants were randomized to an ASTP skills training intervention, a BASICS personalized feedback intervention, or an ADP educational TAU. Participants completed baseline web assessments with follow-ups at 2, 4, and 6 months after baseline. The university institutional review boards of the research site and study site approved all procedures. Participants Prospective participants were undergraduates (ages ≥18) referred to Judicial Affairs after violating a campus alcohol

policy. Of the 90 students who did not decline contact from researchers, 61 participants (67.8%) consented and completed baseline measures (Mage =19.16 years, SD = 1.20; 42.6% female; 96.7% White; 59.0% freshmen and 27.9% sophomores; 78.7% lived in residence halls). Recruitment Recruitment took place during one academic year (October 2009 to April 2010). Students met with a Judicial Affairs representative who determined their sanction. Those referred for ADP were told about the current study, and their contact information was forwarded to the researchers. Students were notified that although research participation was voluntary, intervention attendance was required to fulfill the sanction. Students opting out of the research received the required intervention through Judicial Affairs. Participants volunteering for research were emailed links to complete online surveys at baseline (pre-intervention) and follow-ups 2, 4, and 6 months after baseline. Participants chose to receive either movie tickets (one for baseline, two for 2 month and 4 month) or entry into a drawing for a gift certificate ($250 for baseline and 2 month, $500 for 4 month), and received both (3 tickets and entry into a drawing for a $750 certificate) for the final follow-up. The drawing winner at each time point received a gift card to his or her top choice of a business that did not sell alcohol. Measures Demographics. Participants provided information including age, ethnicity, birth sex, weight, year in school, and housing situation. Alcohol use. A modified version of the Daily Drinking Questionnaire (Collins et al., 1985) assessed the average number of standard drinks and time spent drinking for each day of a typical week in the past month. Estimated blood alcohol concentration (eBAC) was calculated using an equation factoring number of drinks and hours by sex and weight (Matthews & Miller, 1979) independently for Friday and Saturday, and the greater of the two eBAC levels established a peak weekend eBAC. Weekly drink totals were calculated by adding the responses for typical drinks on each of the 7 days. Consequences. The Rutgers Alcohol Problem Index (White & Labouvie, 1989) assessed alcohol-related consequences (e.g., hangovers, missing classes, getting into fights) within the past 2 months, yielding α levels of .88, .85, .94, and .93 at baseline, 2-, 4-, and 6-month follow-ups, respectively. Motivational interviewing microskills. Behavior counts of open-ended questions and complex reflections were coded from session audio recordings using the Motivational Interviewing Treatment Integrity (MITI) 3.0 protocol (Moyers et al., 2005, 2007), described in detail below.

LOGAN ET AL. Interventions Participants were randomized into one of three intervention groups: ASTP, BASICS, or ADP. ASTP is a skillstraining curriculum in which graduate facilitators use MI techniques across structured components (orientation and building rapport, expectancies, assessment of use, alcohol and the body, blood alcohol level, biphasic effects of alcohol and tolerance, and risk reduction) to focus on drinking in a less dangerous and less risky way (Miller et al., 2001). BASICS (Dimeff et al., 1999) is a nonconfrontational harmreduction approach in which graduate student facilitators individually reviewed personalized normative feedback generated from the participant’s online responses. Although ASTP follows a protocol, facilitators may introduce alcohol content, skills training, and risk-reduction plans in BASICS when relevant or of interest to the participant. The ADP educational TAU groups were conducted by the campus police department and did not include MI techniques, cognitive-behavioral skills, or norms clarification. Using a PowerPoint format, this intervention covered the following components: signs of alcohol poisoning, symptoms of abuse and dependence, myths and facts about alcohol, physical and psychological effects of alcohol, state laws on alcohol, and an exam. Data are included from 13 ASTP interventions (22 participants), 18 BASICS sessions (18 participants), and 14 ADP groups (16 participants). (Five participants did not complete an intervention during the study.) All BASICS sessions were individual and all ADP sessions were in groups (as research participants were added into existing cohorts), and ASTP delivery varied because of scheduling limitations (range: 1–5 participants).

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necessary to model change in HLM, so results were not limited to those who completed all four surveys. We estimated power based on our overall sample size of N = 61 and test-specific sample sizes and groups. Based on G*Power calculations (Erdfelder & Faul, 1996; Faul et al., 2007), we had .80 power to detect medium to large effect sizes for independent means (d = 0.65–0.67) and small to medium effect sizes for one-way analyses of variance (ANOVA) (f = 0.17–0.19) (Cohen, 1992). All data were screened for outliers and normality. Analyses identified two notable outliers in consequences at 4-month follow-up who reported extremely high consequences but low eBAC levels for the same time frame. These two responses were deleted and treated as missing for those time points. Square root transformations were performed for nonnormal distributions of the outcome variables. Results Randomization and retention There were no baseline differences between the three conditions on demographics, alcohol use, or consequences. Thirty-five participants (57.4%) completed all three followups, 13 (21.3%) completed some follow-up, and the remaining 13 (21.3%) did not completed any follow-up. Men were more likely to not complete (n = 12, 34.3%) than women (n = 1, 3.8%), χ2(2, N = 61) = 8.27, p < .05. Completers and noncompleters did not differ by condition or outcome variables with one exception: the 4-month and 6-month surveys were completed by ADP participants who drank less at baseline in terms of eBAC and weekly drinking (tmin = 2.63, p < .05, d = 1.32).

Training and supervision Intervention integrity and fidelity ASTP and BASICS sessions were facilitated by four Counseling and Clinical Psychology graduate students who were earning practicum credits and who received an initial 2-day training and maintained weekly phone group supervision. ADP interventionists received no training from the researchers. To assess fidelity, session tapes for all conditions were coded in their entirety by one or two independent coders, each with more than 1 year of coding experience, using the MITI 3.0 (Moyers et al., 2005, 2007). Data analysis plan Analyses in SPSS Version 19 (IBM Corp., Armonk, NY) and HLM 7 (Raudenbush et al., 2011) tested intervention effectiveness and MI microskills. Hierarchical linear modeling (HLM) analyses allowed modeling of trajectories over time (unconditional models) and simultaneous examination of interactions between interventions and time and later MI microskills (conditional models). Listwise deletion was not

Audio recordings were received for 36 of the 45 sessions and analyzed in their entirety using the MITI 3.0 (Moyers et al., 2005, 2007). ADP facilitators provided audio for 7 of the 14 sessions that included study participants, describing “forgetting to record” as a barrier. All 13 ASTP sessions were recorded and coded, as were 16 of the 18 BASICS sessions (2 sessions had equipment malfunctions). Table 1 summarizes intervention features by treatment condition. ASTP sessions lasted significantly longer than BASICS sessions. There were no group differences in timing, or the number of days between the incident, baseline, and intervention. Most participants (62.5%) completed the intervention before the 2-month follow-up, with 25.0% completing before the 4-month follow-up and 6.3% completing before the 6-month follow-up. The last 6.3% did not complete an intervention during the study period; there were no baseline differences between intervention completers and noncompleters. A one-way ANOVA (Table 1) indicated that there

34 TABLE 1.

JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JANUARY 2015 Means, standard deviations, and analysis of variance results for intervention features as a function of treatment condition Planned contrasts

Intervention type

Variable Intervention length Timing (number of days)a Incident to baseline Baseline to INT Incident to INT MITI behavior counts Closed questions Open questions Simple reflections Complex reflections

ADP vs. ASTP/BASICS

ADP (n = 7) M (SD)

ASTP (n = 13) M (SD)

BASICS (n = 16) M (SD)

df

46.91 (10.13)

62.89 (13.67)

45.12 (8.72)

2, 32

44.06 (53.34) 33.50 (43.63) 79.13 (91.42)

35.40 (22.54) 39.68 (42.72) 71.91 (45.39)

41.44 (26.38) 21.56 (30.94) 63.00 (43.12)

2, 58 2, 53 2, 53

22.00 (10.77) 14.29 (12.65) 10.57 (6.37) 2.14 (3.08)

24.85 (14.85) 24.15 (6.71) 23.00 (7.66) 5.54 (5.33)

19.75 (11.60) 27.25 (8.85) 21.13 (12.13) 13.00 (11.68)

2, 33 2, 33 2, 33 2, 33

ASTP vs. BASICS

η2

t

d

.38

1.53

0.53

0.34 1.05 0.30

.01 .04 .01

-0.57 -0.25 -0.64

-0.15 -0.07 -0.18

0.55 -1.44 -0.46

0.15 -0.40 -0.13

0.57 5.09* 3.96* 4.84*

.03 .24 .19 .23

0.02 1.71 2.02 1.40

-1.07 1.07 -0.51 2.28*

-0.37 0.41 -0.20 0.97

F 10.24***

0.06 2.29† 3.78** 3.55**

t

d

-4.33*** -1.51

Notes: ADP = Alcohol Diversion Program; ASTP = Alcohol Skills Training Program; BASICS = Brief Alcohol Screening and Intervention for College Students; INT = intervention; MITI = Motivational Interviewing Treatment Integrity 3.0 Scale. aTiming is the number of days between events. †p < .10; *p < .05; **p < .01; ***p < .001.

were group differences in open questions, simple reflections, and complex reflections, whereas planned contrasts revealed a trend toward fewer instances of open questions in ADP and fewer simple and complex reflections relative to MI groups. Complex reflections were more common in BASICS than ASTP. Main outcomes Descriptive statistics reflected overall decreases in each outcome measure from baseline to 6-month follow-up, respectively (eBAC: M = 0.08, SD = 0.07; M = 0.04, SD = 0.06; weekly drinks: M = 11.13, SD = 9.92; M = 6.29, SD = 7.55; consequences: M = 6.07, SD = 6.66; M = 4.12, SD = 7.52). Outcomes were highly correlated with each other across time points, eBAC and weekly drinks were positively correlated with each other, and early drinking outcomes were positively correlated with consequences across time points. HLM analyses then tested the significance of change over time. Intervention status was contrast coded, comparing ADP (-1) with ASTP and BASICS (+.5 and +.5), then comparing the MI interventions (ADP 0, ASTP -1, BASICS +1). We probed significant interactions at 1 SD above and below the mean. The unconditional models (Table 2) suggested that participants reported nonzero eBAC, weekly drinks, and consequences at baseline (as expected), but there were individual differences in initial levels. More important, on average, eBAC and weekly drinking (but not consequences) declined over time. Last, across all three outcomes, there were individual differences in those rates of change, suggesting that some individuals declined more or less than others (for eBAC and weekly drinking), whereas others experienced more or fewer consequences. Next, conditional models assessed the effects of interventions and MI microskills (Table 2). We evaluated age,

sex, and fraternity/sorority affiliation as covariates for our outcomes but excluded them as they were not significant and decreased model fit. There was an intervention effect (b = -0.013, SE = 0.005, p = .01) on eBAC levels. ASTP and BASICS participants decreased their eBAC over time (slope = -0.011; simple slope p < .01), whereas ADP participants reported no change (slope = 0.007; simple slope p > .10). There were no significant differences in trajectories of weekly drinking or consequences based on intervention group, and MI microskills were unrelated to drinking outcomes. Discussion Prior research in mandated student alcohol interventions had inconsistent outcomes, although results generally favored MI-based strategies and in-person delivery in either group or individual settings. The goal of the current study was to evaluate the effectiveness of a skills training intervention (ASTP), a personalized feedback intervention (BASICS), and TAU alcohol education (ADP) while evaluating the influence of MI microskills. Our results demonstrate a significant intervention effect between the education-only and MI conditions, such that eBAC decreased for those in ASTP and BASICS while remaining unchanged among ADP participants (with no intervention effects observed in weekly drinks or consequences). Overall, these results support implementation of MI-based interventions, although the significant within-group variability cautions against adopting a one-size-fits-all approach. Our results indicated few intervention effects, with an important exception being no change in eBAC following an ADP intervention compared with significant decreases among ASTP and BASICS participants. These findings are consistent with prior research identifying better outcomes among interventions with an MI component in mandated populations (LaChance et al., 2009; White et al., 2007)

LOGAN ET AL. TABLE 2.

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Hierarchical linear modeling: Unconditional and conditional models eBAC

Variable Unconditional models Intercept Time Variance components Intercept Time slope Conditional models Intercept ADP vs. ASTP/BASICS ASTP vs. BASICS Open questions Complex reflections Time Intercept ADP vs. ASTP/BASICS ASTP vs. BASICS Open questions Complex reflections Variance components Intercept Time slope

b 0.071*** -0.010**

Weekly drinks SE 0.008 0.003

0.003*** 0.000***

b 9.43*** -0.93*

Consequences

SE

b

SE

1.05 0.36

5.73*** -0.49

0.79 0.33

48.62*** 2.25*

23.29*** 1.77**

0.065*** 0.033* 0.013 -0.001 -0.001

0.008 0.013 0.010 0.001 0.001

9.16*** 0.27 2.11 -0.02 0.03

1.22 2.08 1.19 0.11 0.14

5.41*** 1.66 0.46 0.03 -0.07

0.84 1.53 1.16 0.11 0.10

-0.006 -0.013* -0.004 0.000 0.001

0.003 0.005 0.004 0.000 0.000

-0.52 -0.90 -0.49 0.01 0.08

0.42 0.58 0.44 0.04 0.05

-0.37 0.33 0.98 0.00 -0.05

0.39 0.71 0.53 0.05 0.04

0.003*** 0.000**

36.28*** 2.03

32.66*** 3.40*

Notes: N = 45–56. eBAC = Peak weekend estimated blood alcohol concentration; ADP = Alcohol Diversion Program; ASTP = Alcohol Skills Training Program; BASICS = Brief Alcohol Screening and Intervention for College Students. *p < .05; **p < .01; ***p < .001.

and potential iatrogenic effects among education-only and/ or web-only programs (Amaro et al., 2009; Doumas et al., 2011; Terlecki et al., 2010). The lack of benefit in eBAC following the ADP condition is particularly concerning given findings suggesting decreases in drinking following a sanctioning event before or independent of a clinical intervention (Barnett et al., 2006; White et al., 2008) and suggests that the immediate effects may be undermined or at least not maintained in an education-only program. Although the study findings add to the research on mandated student interventions, a number of limitations are noted. First, the small sample size decreased power; thus, any null findings are equally likely to represent no significant differences or our limited power to detect them. Second, a lack of a waitlist or control group means that we cannot rule out that the reductions in drinking represented natural development (Labouvie, 1996; Misch, 2007), a sanction effect (Barnett et al., 2006; White et al., 2008), or the result of some unmeasured external variable. Third, the interventions occurred at various time points, introducing concerns of time delay variability. Although this variance complicates postintervention modeling, it allows for accurate postsanction changes during a time frame consistent with typical mandated intervention wait lists. Fourth, because of scheduling and recruitment issues, ASTP interventions varied in number of participants (ranging from 1 to 5 per session), precluding any findings related to individual and group interventions. Fifth, differences in response rates were significant with heavier drinkers in the ADP condition being less likely than lighter drinkers to follow up; our analytic strategies attempted to

minimize this different response rate, although further studies are needed to identify potential relationships between treatment condition and subsequent compliance. Sixth, the homogeneity of our sample, although not unusual for this campus and prior mandated population demographics, limits generalizability. Last, our efforts to meet and maintain treatment fidelity were complicated by missing tapes, particularly in the ADP condition, with only half of the group recordings provided for analysis. However, ADP protocols do not call for any MI-adherent strategies; thus, we included ADP session coding as an additional verification that MI was not inexplicably implemented contrary to existing protocols rather than for fidelity assessment. Despite these limitations, this study provides important information for both researchers and for institutions working with mandated students. A number of future directions are identified to extend the literature. Further evaluations of individual and group interventions are warranted, with an extensive waitlist control to account for naturalistic changes and a sample size sufficient to evaluate intervening variables. Of course, a waitlist control is often a significant challenge with this population because, for both liability and riskmanagement reasons, withholding services from identified students is not seen as a realistic option to college administrators. Additional studies could also seek to extend findings to other “mandated” populations (e.g., incarcerated young adults [Stein et al., 2011] or military populations [Pemberton et al., 2011]) and with other substances, such as marijuana (Lee et al., 2010). Further, a growing number of colleges provide intentional, strategic outreach to students “on their

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JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / JANUARY 2015

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