-: So, I have the task of trying to introduce
you to individually focused strategies
over the course of the next time slot.
And the truth is my overwhelming disclaimer
is that I mean we can spend all day on some of these.
And I'm obviously not gonna do that.
So, with no disrespect to any that I spend less time on
or perhaps even don't mention,
It's recognizing again it's a mix of strategies.
But, there are some underlining common threads
of the mix of strategies.
So, over the course of the afternoon
I'll tell you about messaging
in the individually focused interventions.
We'll talk a bit about the role of norms.
We'll talk about the role of expectancies,
development of the Alcohol Skills Training Program
and how that gave birth to BASICS,
Brief Alcohol Screening and Intervention
for College Students.
We'll talk about personalized feedback interventions
that don't even involve another human being
sitting across from someone,
as well as some other individually focused strategies.
If time permits, largely fueled by
some input I got at lunch,
I have a couple of bonus slides just to show you some
of the things we're dealing with
in Washington as we consider
alcohol still is the primary drug of choice.
But, things that have happened post marijuana legalization.
It's been a weird last couple of years,
when I've had the honor of presenting
at places across the country.
'Cause when people find out I'm from Seattle
for a full year, they knew us as the team
that had won the Super Bowl.
For a full 12 months after they knew us as
the team that lost the Super Bowl. (audience laughs)
That's what sadness looks like.
And they also knew us as the state that legalized marijuana
for recreational purposes.
Marijuana is the one drug most associated,
not with just exacerbating, but causing attention,
concentration, and memory problems.
And that leads to driving behind Seahawks fans
who can't spell the word Seahawks. (audience laughs)
Which is,
very heartbreaking.
What blows my mind about the Seahawaks there
is that that's not in concrete,
that's not a tattoo, they could have changed it.
But, they're like, ah close enough,
and went ahead and kept it up there.
(audience laughs)
the highlight of the academic year so far
for me truthfully, as the guy that always loved
pro sports and pro athletes and stuff,
I was asked to do, this is not just unique
to college campuses that we're trying to figure
this stuff out.
I was asked to present to the treating clinicians
for the National Football League in October.
When they called and invited I thought it was a joke
from one of my friends, and I'm like okay
I'll get back to you.
Then I Google the guy and I'm like, oh my God it's real.
So, I called him back and I was like, I wanna show,
I know what I think is funny to colleges,
and I know it's funny to college students.
And I was like, but I want something funny
to these guys.
I'm like what can I possibly do.
So, I ended, I don't know why I'm showing you this,
but I ended my presentation with them.
And I said, "I just wanna thank you
"for the honor and opportunity of presenting to you all.
"Plus, it's a chance for me to give back to a league
"that I was a part of for eight years. (audience laughs)
"Which is not true," I said, "but on PlayStation
"I'm not gonna lie I've had a hell of a run."
Because on, (audience laughs)
on Madden for the PlayStation 4
you can create yourself.
And I pointed out to them two really impressive things
about this really great graphic program.
One is my unbelievably impressive 153 and 0 record,
as head coach of the Seattle Seahawks.
And second is the unbelievably life-like sweater vest
that is on it.
(audience laughs)
It's so life like.
Alright so, when we look at why the need
for potential individually focused approaches,
Keeping in mind that it has to be
in that context of environmental too.
I actually took this slide out.
I stuck it back in after a lunch time conversation.
I always feel bad showing this slide
'cause I feel like I'm making fun of another college
and that's not the intent.
But, it's Duke.
I was asked to be the opening speaker
at a conference that Duke University was hosting
on college-student drinking and drug use prevention.
I was so geeked up, because if you looked
at the lineup of speakers they were like my idols
in the field.
I'm like how do I even belong at this thing.
And so, when we got the conference center
to check in at the hotel,
they're like, "What are you here for?"
And I'm like, "The alcohol and drug thing."
And they're like "That's a weird call."
I'm like what, "No it's not."
People seemed pissed that we were there
and nobody could figure out why
until we got to the Duke University conference center.
Here's a tip, if you're making a sign advertising
for an event, proof it.
See if there's any missing words or anything like that,
'cause it can fundamentally change
what you're trying to advertise.
Because blocked off in all the parking lots
surrounding Duke University conference center
was the following sign,
Lot Reserved for College Student Drinking
and Drug Use May 18&19, 2010.
(audience laughs)
The sign maker of course left off
the word conference or meeting
or anything that would have made that look less creepy
to people walking by.
(audience laughs)
What I love about that is you gotta figure
at least one guy walking his dog,
was like, "Well, at least they're cutting
"those kids off at five."
That's, (audience laughs)
I think they call that harm reduction.
But, you were told, I mentioned the Monitoring
the Future study.
The most recent Monitoring the Future study
showed the following.
And I just wanna show that to you for a couple of things.
One, three quarters of students report
that they have consumed alcohol in the past year.
To me there's two very important conclusions
to draw from that.
One, is that one in four students don't drink.
Whether they're life long abstainers,
students in recovery, students that have drank,
but it's been more than 12 months.
We have to keep these folks in mind
with what we're doing as well.
It's important for those students to feel supported
in their decision to abstain and know they're not alone
in the decision to abstain.
But, the second thing we can conclude
is obviously 75% of college students aren't over 21.
So we do have some underage students drinking.
If you look at that past month data
63%, the numbers shrink reporting in drinking.
Where actually under half report
that they have been drunk.
What does that mean?
That means that most students in the last 30 days
either don't drink at all,
or if they do drink, they do so in a way
that doesn't involve getting drunk.
Obviously, if you work in conduct,
if you work in law enforcement,
you've seen the group that's doing things
in a more extreme manner.
But, it's keeping that range of students in mind
when we think about it.
When you ask people this question
it's gonna result in a very different answer.
You know your campuses best
but as you think back over the course of the year,
and I will repeat for people listening remotely.
What holidays, what events, what times
of yours stand out as being kind of bigger drinking days?
What would you all say?
Go ahead.
St. Patrick's day?
Fortunately it's very far away.
Say again.
Student: Game day. -: Game day?
Yeah, and so some people say there's a study
by Dan Neal at the University of Texas
had often called hook' em horns and it looks at UT Austin.
And he actually found at home and away games
actually were associated with elevated drinking.
What else in terms of holidays or times of year?
Finals, New Years.
Student: Spring break -: Spring break.
Student: Halloween. -: Halloween.
Woman: They go home and they--
-: Thanksgiving break.
So, what's the not so good news?
Obviously, a lot of unwanted consequences
can go along on with those events.
What's the better news?
We know when all of those are.
(audience laughs)
So the opportunity to do events specific prevention
is very, very, much there.
There's a study of Frandell Boke
is the first research that did this.
But, there's a study at Canada that initially
it looks like a headache of a slide,
but it's most easier to digest
if you understand that the bold line at the top
are weekly drinking totals.
That kind of littler line at the bottom
are actually daily totals.
They had students keep diaries of their drinking
their entire academic year.
It was online, it wasn't like, dear diary
I had a beer today.
You know, xoxo. (audience laughs)
Look at the variability.
If you did a screening you'd say
what's the most you've had to drink in the last two weeks.
You might miss students
that might otherwise be struggling.
Or have an elevated risk for folks
who genuinely aren't drinking that heavily.
But, of note is that in this particular sample
they even highlighted that it's
the weekends surrounding holidays.
Halloween happened to fall on a Tuesday.
But, the weekend before, it's brutal.
St. Patrick's day was the single biggest drinking day
of the year, happened to fall on a Saturday.
But, whether it's alcohol, whether it's marijuana,
420, things like this,
there's a chance for event specific prevention,
but this also highlights the importance
of keeping in mind events like this
when you're planning assessments.
When you ask students what they have experienced
when drinking, the National College Health Assessment
showed that among students that drank
within the past year, doing something they later regretted,
number one most endorsed effect.
Blacking out, forgetting where they were, what they did
at just under a third, one in five had unprotected sex.
This is a check all that apply.
So, realize that all these things can happen in one night.
Someone says I hooked up with someone,
don't totally remember if he used protection or not.
Something's not sitting right.
So, realizing, and of course brings it into
the realm of conversation, the important work we do
around issues of consent, I co-present and tag team
with our sexual assault prevention program coordinator
quite a bit for that reason.
In fourth place physically injuring themselves.
I put in here, and we'll talk about this in a bit,
about the language we use
in individually-focused interventions.
We can look at this and go wow,
those are negative consequences.
But, how do the students see these?
Kim Marrow used to work with us and now
works at Penn State University.
And she asked college students,
this around to the nearest integer or so,
so some of these will add up to like 101%.
But, she asked students, here are some unwanted effects
or just here are some effects.
Rate if they're negative, neutral, or positive.
Our foot in the door of college campus
is that there's not a single student
that says that getting a lower grade
because they're drinking is a good thing.
What's interesting is I've talked to people
that say I don't wanna write up this person,
I wanna document them, I don't wanna arrest them
I'll ruin their life.
3% of students say, "Getting documented saved my life.
"I was the one that was like, nothing's bad
"ever happened to me.
"And it's a wake up call."
If a student sees himself as I'm the good kid
that hasn't got in trouble, and now they're across
from a police officer that could be a wake up call.
Look at even vomiting.
You got one in a 11 students saying vomiting
is a good thing.
If you puked, that's, you must've had an epic night.
Move down to this middle realm.
Only half of the students agree
that blacking out is a not good thing.
You've got a good chunk that see it as neutral.
12% see it as a good thing.
The one that blows my mind,
I mean you've got movies dedicated
to the whole, let's piece our night together, hangover.
A quarter of the students say a hangover is a good thing.
I've seen people, their foot in the door that's been,
think of all the, you'll feel better in the morning.
Think how great it would be if you don't have hangovers.
We're asking students one in four of them
to part with something that they see is actually
part of the epic experience.
Not only did you probably have a crazy night,
you now get to go out for breakfast
and eat greasy food, and bond with your friends
who also feel like crap.
And so, I think that when even how
we talk about negative consequences,
it's important to keep in mind
because it comes down to what does the student
we're working with see as good and not good.
Obviously, all of these conversations
about alcohol are being done in the context
of other substances.
Any illicit drug use are reported
by 38 and a half percent of students.
If you just ask about weed 34.4%.
Dump marijuana from the equation,
any illicit drug other than marijuana,
20.8% report past year use.
Obviously, this plus this doesn't equal this.
And that's because in that 38 and a half percent
are people that use marijuana
and something else, poly-substance usee.
They have over 40 drug categories.
In Monitoring the Future, I arbitrarily drew a line at 5%.
These were the three categories endorsed
by over 5% of the students.
Amphetamines, this is largely prescription stimulants
taken for non-medical reasons.
This excludes people with legit prescriptions.
Adderall drives most of that.
And around finals I mean there's gross enormity
of misconceptions about how frequent this is.
And then, Ecstasy, MDMA, Molly at least once
in the past year by 5%.
I think it's worth pointing out
that a lot of students could be slipping through the cracks.
And this not just about substance use,
but other health issues.
Wu and colleagues documented
as many other studies have,
that one in five college students
meet past year criteria
for an alcohol use disorder.
A stunning 3.9% of them, that's it,
actually wind up getting connected to services
of any kind.
96%, did nothing.
Only 36% used screened positive for depression,
wind up getting help.
And this breaks my heart.
Bob Gallagher at the University of Pittsburgh
runs the counseling center director surveyed,
whenever there's suicide people will ask
was the person getting counseling.
And the overwhelming percentage of suicides
on college campuses, the person never made it
through the front door of counseling.
Only 14% were current or past clients.
So, this raises the idea of how might we actually reach
some of the students who are high risk
or struggling a great deal.
And finally, just knowing that what we do about this
will pay dividends in the classroom.
The last time I saw Ralph Hingson present,
and I thanked Ralph for this.
He's done a great job highlighting some of the data
about the cost and impact on mortality and morbidity.
But, he's actually moved to even showing some of this.
Some of these slides.
And some of this data.
And it was good inter-reliability for me
to see that every site that I have on this slide
he showed as well, and deemed as a decent
and worthwhile study.
Students the more that they drink
the more they report being tired all the time
and lower their GPA is.
What's interesting about that is, of course,
is alcohol affects quality of sleep.
Heavy drinking is associated with lower GPA in general.
Students at research universities who are heavy episodic
or binge drinkers, are less likely to be engaged
in interactions with faculty.
AAC&U is among the many groups that show faculty engagement
is an important predictor of thriving, flourishing,
and even retention.
And finally, not just doing binge drinking
but doing it often is associated with lower grades.
So, that highlights then the importance
of what we look at when it comes to messaging.
I spent most of the last couple of weeks
presenting to different student groups.
When a fraternities hears, hooray the alcohol guy
is coming to our chapter, hooray.
People tend to have a stereotype in mind
about what someone like me is gonna say.
What do students expect to hear?
In terms of an alcohol prevention message.
Don't drink.
Don't drink, that's a good finger wag too.
Don't drink, you're bad if you do, Just Say No.
Does Just Say No work with college students?
-: [Audience Members] No.
Not only no, but some laughter with that no.
Why does Just Say No not work with college students?
Woman: They might not be underage.
-: So, what if they're over 21, you ask them
to say no to something that's actually legal for them?
Why else might Just Say No not work with college students?
They're adults and they're experimenting.
They're trying to figure out what works for them
and what doesn't work,
and here's somebody telling them, don't drink.
Why else might Just Say No not work with college students?
Yeah, there's that whole
if you tell me not to do something,
for those listening remotely, a rebellion factor,
some people are like if you tell me not
to do something I kinda wanna do it even more now.
Why else?
Yeah, look how good, they say you did it,
why can't I you turned out great.
So, and you're like, thank you.
They're like why can't I do this too?
You save researchers a lot of time and grant money
because you look at the research and fact only,
information only, typically abstinence only approaches
you already saw Toben say, these are not effective.
At best they show an increase in knowledge,
but no change in behavior.
And we're really worried about that change in behavior.
We'll keep that in mind as we talk about that
because anything we do has to fit in the overall puzzle.
Toben showed you an adaptation of this
and I'll show you a different adaptation.
Along the top, this is from the Institute of Medicine,
are the consequence associated
with a person's use.
Along the bottom are the strategies
we might use in response to those.
What often gets lost in the shuffle
is that the majority of students at my school,
at your schools are on the left.
They either don't drink at all
or if they do, have no to mild problems associated
with their use.
This is still an important group of people
to keep in mind when it comes to prevention.
Primary prevention or using more recent terminology,
universal prevention, targets the whole campus,
it casts a wide net.
And the goal of universal prevention
is to keep abstainers abstaining,
so delay the initiation of use,
or have whatever use is out there,
keep that from progressing any further.
You can absolutely see universal prevention
on college campuses.
But, classic universal prevention you see
in like younger high school, middle school,
even elementary school.
I took these next slides out,
but I saw the guy that I experienced this with
just a little bit ago.
So, I stuck' em back in.
Clayton Neighbors who's a good friend of ours
left the University of Washington a few years ago
for the University of Houston.
We were presenting at a school district
north of Seattle and we put up this slide
and one of the prevention specialists raised his hand.
And he said, "I've been cursed by primary prevention."
We were like, really, that's a weird thing
to be cursed by.
Frankly, like vampires I get that.
But, why would you say primary prevention?
He's like "I'll be right back."
This guy brings me this box of proof.
If I hadn't seen the box, I'm not sure
I would've believed him.
He was asked by the superintendent
only get something cheap, effective,
one more time, cheap, that will help,
that we can get in every kid's hands
from first through fifth grade
with a drug prevention message on it.
That's hard, I have no idea what I would suggest.
But, he was like wait.
Little kids are learning how to tell stories.
And they're learning how to write cursive
on those really big sheets of paper
that are like half picture and three lines.
So he was like, "What if I ordered pencils?"
So, this guy worth thousands of pencils
that said "Friends Don't Let Friends Do Drugs."
And they were hit.
The little kids got the pencils.
The little kids used the pencils.
And they liked the pencils.
And they sharpened the pencils,
first winding up with pencils
that say let friends do drugs.
And then finally, just do drugs.
(audience laughs)
Man: That's awesome.
-: He said the first time he walked
by an eight year old with a do drugs pencil
he was like, "Shit we're gonna have
"to get those pencils back."
(audience laughs)
So, the poor guy ordered all these mechanical pencils
and little kids are like can't use them,
and they're shooting lead everywhere.
So, he was right, he was cursed
by primary prevention.
On the far side are the people for whom, as Toben mentioned,
more specialized treatment might be indicated.
Who do I work with, what's most of what I'm going
to be talking about, the folks in the middle.
But, again mix of strategies,
keep these multiple audiences in mind.
Brief interventions are for those people
that have made a choice to drink,
may be experiencing mild to moderate consequences.
I asked you about if Just Say No works
with college students and you gave me
perfectly great reasons why it probably does not.
Reason why students will also chime in and say
is that it has that very, I like the finger wag.
It has that very parental or preachy kind of
you know, bad, bad college student,
and nobody wants to be on the delivery end of that.
And I imagine certainly wants to be in the receiving
end of that either.
The other thing is we want that message
that fits on a pencil.
I get asked, I don't think I'm exaggerating
when I say I get asked on a monthly basis minium.
Is it true if you have a drink
an hour you're fine?
First, for a small woman that could be
a very dangerous night.
Secondly, what are you calling a drink?
This next picture has not been photoshopped, it is real.
I was speaking at a fraternity risk management training.
And the guys said, "I just sent you a picture,
"you have my permission to use it,
"just don't say where you got it."
And so I continue to honor that.
But they had an alumni group that had a tailgating event
that was getting crazy out of control.
They were gonna shut the Alumni group down.
But the alums came back with a counter proposal,
and said, "What if we have a one drink maximum
"at our tailgate?"
And they were like, "Well that sounds fair."
And he sent me this picture.
That's manipulative.
That's ha ha, there's your one drink.
That guy in the green coat in the middle
is gonna have back problems when he's older
because he's not lifting with his legs.
Lift with your legs. (audience laughs)
But, as stupid as this is you don't have to go any further.
My state, a couple of years ago.
We had over a dozen students in one of our state schools
hospitalized for alcohol poisoning.
The ones that had not lost consciousness
said at the ER, "We've been roofied.
"Please test us for rohypnol."
They said, "Why do you think that?"
And they said, "Because a lot of people only had one drink.
"Nobody had more than two."
It made national news when results came back,
nothing but alcohol.
And it later came out that the one or two drinks
people were having were one or two cans of Four Loko.
Four Loko is 12% alcohol by volume.
What does that mean?
Every 4.2 ounces counts as a standard drink.
What's the catch?
It comes in a 23 and half ounce can.
That means one of those is five and a half standard drinks.
The students that were only having two, got 11.
For women 145 pounds and lighter, that's a lethal dose.
And thank God, knock on wood, none of those students died.
For a couple of them that was very close.
So, sometimes we need a message
that's a bit more complex than simply a blanket rate
for everyone to appeal to.
And finally there is the sense that college
is where this happens.
I mean I watch more television
than anybody should ever admit to, frankly.
Like when I leave the house for a trip like this,
it's like bye to my partner
and then DVR don't let me down.
You've gotta remember to record everything.
But, from season three of South Park
you have to go way back, but in South Park
there's an episode where Mr. Mackey tells the kids
that drugs are bad.
And Chef, voiced by the late Issac Hayes
is debriefing with the kids if they know why drugs are bad.
And Carmen says something a lot of people
in Washington think is funny.
Carmen says I know why drugs are bad
because if you use drugs you're a hippy.
And hippies suck.
And there is some research that's looked at.
(audience laughs)
But, what Chef ultimately settles on
is he says, "Look children, this is all
"I'm gonna say about drugs, stay away from them.
"There's a time and a place for everything,
"and it's called college."
I remember the first time I heard that
I was like, "No, don't say that."
Because some people think South Park is a documentary
and that's why we're all in here for six hours on a Friday.
So, if we can't just tell people to Just Say No,
what can we do?
And this is where very controversially
in the 1980s, Alan Marlatt said
"What about harm reduction?"
It's certainly a thing in Europe.
But, what if we don't just tell people
to Just Say No and conversely,
we don't just tell them to just say yes.
What if they do say yes?
Can we talk about ways to do it
in a less dangerous or less risky way?
Why was this so controversial when Alan proposed this?
Well, at the time there was not
as single published study of a randomized control trial
with college students that showed reductions
in drinking and consequences in the US, not one.
What did we have according to the Reagan National Library?
12,000 Just Say No clubs.
So, to suggest anything other than Just Say No,
was actively in the face of and against
what was happening very nationally.
If there's a misunderstanding of harm reduction
is that it is some how anti-abstinence.
And nothing could be further from the truth.
If a student says, "I want to avoid all
"of alcohol's unwanted affects," stop drinking.
The most risk free and harm free outcome
after harm reduction approach
in fact is abstinence.
What a harm reduction approach acknowledges
is that any steps toward reduced risk
are steps in the right direction.
I come to you drinking 40 drinks a week,
and you sit down with me and do something
and now I'm drinking 10 drinks a week
with way fewer consequences.
Well done.
If your treatment outcome goal is abstinence though
I'm a treatment failure.
You can't pretend to call me anything but that.
In a lot of programs in our country, I'm kicked out.
Because I'm still drinking.
But, it's like but how could you overlook
a reduction that dramatically,
particularly if this was with a population
that maybe didn't even need treatment.
Sometimes reducing harm makes look it like we did nothing,
to quantity.
You're working with a student,
not a huge person, pretty smallish,
they tell you I drink six every Thursday,
six every Friday.
They admit those six are all shots
over about three minutes, each on an empty stomach.
They get to a pretty high blood alcohol level,
lots of unwanted affects.
Now, we go through a program that emphasizes harm reduction.
They decide I'm gonna switch from hard alcohol
to beer, I'm gonna alternate with water,
I'm gonna eat prior to or while drinking.
I'm gonna stretch out my drinking over five hours.
Way lower blood alcohol level.
Way fewer consequences.
But, we look at their data pre, post.
They were drinking six when they got to us,
they're drinking six now.
Awe, we didn't do anything.
That's not true.
If it's a reduction in harm, even keeping quantity
the same, if people are using more protective behavioral
strategies or achieving fewer consequences,
or achieving a lower alcohol blood level
still it's that idea of a step in the right direction.
The question is how do you give a message like that
and not seem like you're being flippant
about policy or law, or sending a mixed message?
Legal issues are always acknowledged.
Everything we give students make clear
if there's any we hand them,
if they're under 21 it's illegal to drink.
Driving after drinking, not recommended.
If the main harm a student is trying to avoid
are legal based things,
some that have said, "I've gotten in trouble once
"and I'm on probation," they may in fact choose to abstain.
That may be the best way
to avoid subsequent legal harm.
For those who want to quit,
strategies on how to abstain are provided.
But, the language here is clear.
This is very deliberate.
We never tell students
how to drink safely,
because any positive blood alcohol level
there could be unwanted consequences and risks.
You don't make statement like "Listen,
"I know you guys are all gonna drink
"so if you do duh, duh, duh, duh, duh."
There's a number of misconceptions,
but now we as health educators have
helped throughout the.
For the abstainers in the room
they're like, "Wow, that person thinks
"we're all gonna drink.
"Is that true, does everyone drink?"
The language is important.
If you make the choice to drink
we can talk about ways to do that
in a less dangerous or a less risky way.
That wording is very deliberate,
because it keeps the choice on them.
It's not a mixed message.
It's not a normative misperception
of wink, wink, I know you're all gonna drink.
Nor does it suggest that there is somehow
a way that this can be safe.
Here's the key, if I'm an 18 year old
and some guy in a sweater vest, what up,
is telling me here's how you can drink
in a less dangerous or less risky way,
why would I even want to do that?
Like, what's in it for me, to do that?
That's where a facilitator, a provider,
a student affairs professional, a program provider,
has to elicit personally relevant reasons for changing.
What's in it for me, as that college freshmen?
What's in it for me as that person a week away
from my 21 run, to make a change in my drinking?
And that's done using the Stages of Change model
and the Motivational Interviewing.
I wanna introduce you to those two things next
and that then lays the foundation
for examining the individual strategies
that are housed within CollegeAIM.
Before I talk about Stages of Change
and Motivational Interviewing
can I just see in general either what questions,
what comments people have
or anything I can clarify at this point?
Alright, this is not new.
This came out by Jim Prochaska and Carlo DiClemente
in the early 80s.
Actually, the publications were all throughout the 80s.
In response to tobacco cessation,
they pointed out that rarely do you meet
the tobacco user who's unaware of the health consequences.
We don't talk to students that are like wait, what,
this is bad for me?
No one told me.
But there are different levels of readiness
to have a healthcare provider say,
"You need to quit smoking."
And depending on which version of the publication
you pick, there's your five, six or seven
of these stages of change.
It's either drawn as a ladder, a continuum like this,
a wheel with different entry and exit points.
But, just for the sake of discussion
let's look at these five different stages of change.
Just by show of hands how many people are
already familiar with this model?
Some of you, okay, a few people who are not.
For those familiar with it
I hope this is a generally brief review,
but I hope this is still helpful
in conceptualizing messaging.
Pre-contemplation, that's a made up word.
I think that's pretty cool.
Like if you're gonna make up a theory,
you might as well make up a word too.
Because every time you type pre-contemplation
into Word you get the little red squiggle.
Bless you, and with pre-contemplation
this tries to capture the student
who is not just contemplating, they're pre-contemplating.
They haven't even begun to think
why do I need to make a change in my drinking.
Someone has 15 drinks on campus break stuff
and have to go through conduct.
Lost in the shuffle, they had 15 drinks and broke stuff
and instead they make statements
like, "Don't the cops have anything better do
"than pick on college students?
Or, "This isn't my fault, this is my roommate's fault,
"because my roommate answered the door when the RA knocked.
"Why don't we just lower the drinking age?
"Then there wouldn't be a problem."
No recognition of a need to change.
Contemplation is what it sounds like.
Maybe a person is noticing stuff.
"Wow, this is the third weekend in a row
"where I don't remember part of my weekend.
"That can't be good."
What if they notice, "I had 100 bucks in my wallet
"on Friday, only place I went was the bars all weekend.
"It's now Sunday and I have zero dollars."
Like five grand a year.
Spending a lot on alcohol.
So they may be noticing stuff.
They may be weighing the pros and cons of change.
The key to this stage of change is ambivalence.
If you hear the word, but, the person's probably
in a stage of change.
I really wanted a fifth pizza in the buffet,
but I know it's not very good for me, ambivalence.
Yeah, I wish I could exercise more, but when,
where would I fit it into my day?
If I cut down on my drinking, sure I'd feel better
in the morning and I'd probably do better at school,
but what would I do for fun and I wouldn't be having
as much fun as my friends are having and that would suck.
I carpool with a woman that I'm convinced had the worst job
known to humanity when she was in graduate school.
She was a student of Bill Miller's,
the man who, along with Steve Rollnick,
developed Motivational Interviewing.
At one point in grad school for 20 hours a week,
she had to listen to therapy videos for a study
and every time the client spoke,
code which of these stages of change
their statement was most in alignment with.
That is a horribly dull job
and that has no choice but to trickle
into your daily life.
(audience laughs)
So, we'll pull over to a drive-through coffee place
on I-5 and they're like, "Hi, can I help you?"
And Denise is like, "Ooh, that's contemplative."
(audience laughs)
I'm like, "Wow, you really need to stop that,"
and that's not contemplative.
But there's times when we're stuck in traffic on I-5,
which increasingly feels like all the time,
where we will assign different stages of change
to different songs we're listening to
which is a little bit nerdy
and also an unbelievably fun road-trip game
if you get the chance to play that,
but she pointed out one song, at least a portion of which
sums up contemplation, probably better
than anything out there and it comes from Michael Jackson's
1982 Thriller album and it's the song
Wanna Be Starting Something.
In the song, Michael says, "Wanna be starting something,
"Gotta be starting something.
"You wanna be starting something,
"you gotta be starting something.
"Too high to get over, yeah, yeah
"too low to get under, yeah, yeah,
"You're stuck in the middle, yeah, yeah,
"and the pain is thunder, yeah, yeah."
(audience laughs)
Now this is the same song that later says
you're a vegetable, you're a buffet,
still they eat you, you're a vegetable.
You shouldn't read too much into this song
because that's crazy talk, as we call it in psychology,
but too high to get over, too low to get under,
you're stuck in the middle and the pain is thunder.
This is not just a wishy-washy stage
where people are like, eh.
It can suck to be in this stage.
I have a colleague who told me about a client she saw
who with tears in his eyes said,
"My partner of the last 10 years told me,
"'Show up drunk again and we're done.'
"I can not do this any more."
The person said, "This is the love of my life,
"and I got drunk last night.
"I had to lie about my car breaking down
"so I didn't have to face my partner."
The person that gets bad results at the doctor
who says, "You must change X health behavior,"
then promptly goes out and engages in that health behavior.
I've talked to students who with tears in their eyes say,
"I'm the first person in my family to go to college.
"Getting a degree, most important thing.
"I've already gotten in trouble once.
"If I get in trouble again, I'm out,
"and I was at a party that got busted last night.
"I had to go out a back window to avoid getting caught.
"Why would I risk this?"
So this isn't just a, eh,
it can be hard for people to be in this stage of change.
Preparation, a person's thought about it
and says, "I'm gonna make a change."
They haven't changed yet and if they are very bold,
they're declaring their intent to people around them.
The high season in our country for this stage of change
is late December.
Why would you imagine?
Good, New Years resolutions.
Think of the difference.
A pre-contemplator's like, "I don't need to exercise,
"I'm awesome."
A contemplator might say, "I do want to exercise more,
"but I'm really tired, I don't know where
"I would fit it into my schedule."
A person who's in preparation says,
"I'm gonna start exercising January 1st."
Action's what it sounds like,
a person's actively making a change in a behavior.
Maintenance is also what it sounds like.
A person's made a change and they have now maintained that
for six months or more.
I asked you, 10, 15 minutes ago,
does Just Say No work with college students?
And you gave me perfectly great reasons
why it probably does not,
but I would encourage you to rethink the answer
to that question through the eyes of this model.
Truthfully, do with all of this as you wish,
but I feel like if there's three things to take out
of today, I actually think it's the messaging
around this that's one of those.
Just Say No is an action-stage request
and if we're saying it to a group of students
that are pre-contemplative or contemplative,
there's an absolute disconnect between what we're asking for
as the prevention specialist, the program provider,
the peer health educator, and where that student
or group of students may be in terms of their level
of readiness to change.
What that means is just say cut down,
just say moderate, just say drink in a less dangerous
or less risky way, based on this theory
would be as equally dismissible
and equally laughable a goal as Just Say No
if it's asking for action in people
who aren't there yet and would you believe,
the data backed that up.
Kim Fromee, University of Texas Austin,
Will Corbin who worked with her and is now
at Arizona State University, they did a study
saying welcome to college 18-year-old first-year students.
We're done with that high school stuff,
you're in college now.
Here's how to drink in a less dangerous or less risky way.
It behaved just like an abstinence-only program.
Knowledge increased, no change in behavior.
What was missing, based on their argument?
Something, they were diving right in with how to change
with people who weren't even thinking about it yet.
The question became, what could we do for those
that are in pre-contemplation to perhaps plant seeds
or prompt thinking about it?
For those that are contemplating,
or feeling stuck, what might help them get unstuck?
How can we explore and resolve ambivalence.
What might we do to have them either prepare
to make a change or even make a commitment to change
if that's in line with what's important to them, ultimately?
So what that means is, think about how many
action-stage messages our undergrads hear.
Oh, you should go to the academic advisor.
That's an action-stage request
and if they're at the stage of, "I'm not sure
"that I need help, I just don't think my professor likes me
"or maybe I should be in a different major,"
we're giving them advice, the people aren't there yet.
Having problems with my roommate.
"Oh, talk to your RA, you should talk to your RA.
"Have you talked to your roommate?
"You should talk to your roommate."
What they should do, action stage, with people
who aren't there yet
and so what that means is, again, what can we do
to maybe move people beyond this?
I hope we have time for this, I know we started
10 minutes late, and largely because I told you
I like television shows, I'm gonna do it anyway
because I really like game shows
and this is a game show that has no chance
of ever making it in the real world, but it's a game show
called Name That Stage!
So, the problem with the, (audience laughs)
please contain your enthusiasm.
(audience laughs)
The problem with this terminology is we don't identify
using these terms, right?
You can't walk into a group and go,
"Where are my contemplators at?,"
because people don't identify that way,
so you need to hear it.
I'm gonna show you statements a student could make.
Let me know as a group what stage of change
that best reflects.
My drinking's a problem sometimes.
What stage of change is that?
Audience Member: Contemplation.
Instructor: Contemplation, well done.
I don't think I drink too much.
Audience Member: Pre-contemplation.
Instructor: Pre-Contemplation.
I quit drinking right after my sanction last week.
Action, good.
I quit drinking right after my sanction last year.
Maintenance, also good.
I'm planning to limit myself to two drinks
at the next party.
Audience Member: Contemplation.
Instructor: Well done, awesome,
so especially if you're working with a single individual,
there's a chance to kind of read the room,
get a sense of where are they coming from,
but it's keeping that in mind.
I mentioned that the good news is that there is a strategy
for meeting people where they are
and perhaps either prompting contemplation
among pre-contemplators or even a movement toward action
among those who are in contemplation
and that comes from Bill Miller and Steve Rollnick,
Motivational Interviewing.
They're up to their third edition.
I always joke that they're on an about every 10 years
schedule of a new edition, so we're looking forward
to the fourth edition in 2022,
but Motivational Interviewing, it's changed what we do.
It's absolutely changed what we do.
Motivational Interviewing is a non-judgmental,
non-confrontational clinical approach.
It was designed for one-on-one work
with individuals, but you'll hear me say
this can be done in groups.
When it's done in groups, we talk about MET,
Motivational Enhancement Techniques
and Motivational Enhancement Therapy,
if it's done in a therapy context.
It very much emphasizes meeting people where they are
and it's all about eliciting personally relevant reasons
to change.
What's in it for me?
To maybe drink a little less tonight, tomorrow night.
What's in it for me to try something different.
When people are ambivalent, explores and resolves
that ambivalence and if relevant,
discusses behavior change strategies.
It acknowledges that one of the biggest predictors we have
of people not changing is resistance.
We have very few absolutes in our field.
One of them is this.
As resistance goes up, outcome goes down.
That's the bottom line.
And what do we know about resistance?
It's very much affected by how we talk to someone.
It is expected, it is normal, it's verbal.
I used to struggle with that because in grad school
we learn about non-verbal communication,
but you can read a transcript and you can say,
"Oh, there's the resistance right there."
Why is it expected and normal?
Because it sucks being told we're doing something wrong.
Sucks being told we don't get it.
I, couple months ago, I had a dentist appointment.
And if you're anything like me,
I floss like crazy for the three days
leading up to the appointment to maintain the illusion
that I've been doing this every day for the last six months
because I know the speech is coming.
It's like, "You need to floss more."
I'm like, "You need a hobby, seriously."
(audience laughs)
Go on, floss with your little dental friends.
(audience laughs)
Because it sucks being told,
"Well we would have been out of here sooner
"if you would have flossed better,"
or "You're the bad patient."
That's hard, but that's no different than when people say,
"You need to cut down on your drinking,"
or somehow make the appeal of
"Well couldn't you just do this?"
or "Couldn't you just do that?"
When people are ambivalent, direct persuasion
is not a horribly effective strategy.
We know this.
Take it out of alcohol.
You're talking with a senior who's like,
"I don't know if I should go straight to grad school
"or take some time off, travel a bit, make some money,
"and then go to grad school."
If we say, "You're one of the smartest students
"I've ever met, I'd go straight into grad school,"
999 times out of a 1,000, what will they do?
Defend the opposite.
"Yeah, but if I took the time off, I could travel a bit,
"recharge, and maybe even get into
"an even better grad school and do better when I get there."
Alright, well, do that then.
"Yeah, but use it or lose it.
"If I go straight into grad school,
"I could keep the momentum going."
So it's not the Jedi mind trick.
It's not that we're telling them the opposite,
but if they're genuinely stuck,
trying to persuade them, this is not the key.
If we go faster than them, it could result in resistance.
Because it's so associated with not changing
and so responsive to our style, we want to do what we can
to reduce resistance.
I want to make very, very clear,
just between these two, the impact of non-judgmental,
non-confrontational in the impact of resistance.
The research on this and the research on avoiding arguing
has gotten so clear that it's causing us
to rethink some pretty classic concepts in our field.
Even the concept of, in quotes, "denial."
If someone sits me down and says,
"Jase, I'm worried about you, man,
"I think you have a problem,
"I think you're an alcoholic,
"you need help and we're here for you,
"I think you need treatment."
If I go, "Whoa, back off, you got a problem,
"you need treatment," classically, we'd say
I'm in denial, but the research on motivational interviewing
would say, really, what's the person supposed to say?
You labeled me.
Diagnosed me, you got a problem.
You told me what I need to do.
You need to go to treatment.
The current state of the science on denial
is that it is not a characteristic of the individual,
it's a byproduct of a conversation.
I can make a student sound in denial in five seconds.
I wouldn't want to, but I could.
Let me talk with you about the problems
you've been having with drinking.
What problems have you had?
I don't have a problem, I gotta meet with you.
There we go, resistance,
so I can't believe I'm still defining theory,
but this will hopefully make the rest of this
go very smoothly.
So what are the goals of a brief intervention
if there are signs of potential risks
or existing harms, we could provide early intervention
and perhaps alter a trajectory.
If ultimately in line with what motivates the person,
prompt contemplation of change.
That's what's key.
We can't decide for someone if they change or not.
We talk about finding the proverbial hook.
What if a hook for someone is I want to do well in school?
Or athletic performance is key to me?
A big thing that can prompt thinking about change
is developing discrepancies between what's of importance
to the student and ways in which the status quo
could be in conflict with that.
What's my value?
I want to kick butt academically?
What's the reality?
I haven't been to class in the last three mornings
because I was hung over.
What's my value?
I want to be a good partner in a relationship.
What's the reality?
I'm a jerk when I'm drunk.
What's the value?
I've been working my tail off in the training room.
I want to have the best season possible.
What's the reality?
Drink 40 beers a week, that's 6,000 calories a week
coming from alcohol, interfering with probably
the time they're putting into training,
so it's really about that idea of what's of importance
to the student, what's in conflict with that.
If ultimately in line with what motivates the person,
prompt commitment to change or even initial action.
If the only thing you do is reduce resistance
or defensiveness, that's something.
One of the studies on the Alcohol Skills Training Program
that I'll show you in a bit looked at predictors
of outcome among mandated students.
One of the predictors of fairing well in that program
was having a lower degree of defensiveness
when they left the meeting with the conduct officer.
The conduct officer does not need to be the one
to deliver the intervention, but if they use
more non-judgmental and non-confrontational,
resistance-reducing strategies,
it sets the student up for success and the facilitator
up for success.
And explore behavior change strategies
and discuss skills.
One last thing about motivational interviewing
and then I'll introduce you to,
I'll take questions, introduce you
to the individually-focused stuff.
The four basic strategies of MI
include open-ended questions, affirming,
reflections, which are the biggest strategy,
and summaries.
But I just want to show you again
how important word choice is when talking to a group
or even an individual student.
Open-ended questions are ones that can't be answered
with yes or no.
When we're pressed for time, we ask a lot
of closed-ended questions.
Were you there?
Were you drinking?
Were you drunk?
Were other people drinking?
Were you scared?
They're going, no, yes, no.
And we're like, "Wow, that person was quiet."
Well actually, we didn't give them a chance to talk.
It was all closed-ended questions.
We don't know where the answer will go.
What do you make of this?
Where do you want to go with this now?
What ideas do you have about things that might work for you?
How are you feeling about stuff?
How is the school year going?
The one open-ended question that ends with a period,
tell me more about that.
That is very different than the closed-ended,
could you or can you tell me more about that?
I'm having a tough time this quarter, this semester.
Tell me more about that.
Well, I've noticed that duh, duh, duh, duh.
I've been having a tough time this semester.
Could you tell me more about that?
No.
It performs differently and we have the data
to show this.
And so it's even keeping that in mind.
I want to show you that you need no expertise at all
on a substance to be able to ask a student questions
about things that might prompt thinking about,
in quotes, "consequences,"
things that might prompt talking about what gains
they would make if they made a change.
And even identifying strategies for change.
We can ask a student, what are the good things
about fill in the blank, what are the good things
about drinking for you?
They will be delighted to tell you.
I talked with someone at one college that says,
"We tried that and it totally backfired."
I said, "How did it backfire?"
And they said, "Well, we walked up in front of the group,
"and we said, 'So what's so good about drinking?'"
I was like, wow, that's a way different question.
What are the good things for you?
What are the not so good things?
That is a fundamentally different word choice
than what are the negative consequences,
what are the problems, what are the harms?
I have the honor of running the Mandated Student Groups
for students that have violated marijuana policy
in a state that has legalized marijuana
for recreational purposes.
When I'm in front of a group of eight to 10 students,
usually two of whom are wearing clothing
with a pot leaf on it, and I ask them,
"What are the not so good things
"about marijuana use for you?,"
how long a list am I getting from them?
Getting lots of very pessimistic, none, very little.
Purely for illustrative purposes,
from two back to back groups, and I eliminated
the duplicates, here's my list.
Actually, the last group I ran I had a new staff member
to observe.
I said, "I'll give you the contents of my wallet
"if the not so good list is shorter than the good,"
and I got to keep my money, because I knew,
every single time, these are students
that are huge marijuana fans, but when you ask them,
"What are the things you like?
"What are the things you don't like as much?
"What are the good things, what are the not so good things?"
They will tell you.
If you start with the not so good things,
they'll tell you less.
When you start with the good, you're saying,
"I want to know why this matters to you,"
and that's part of expressing empathy.
What are the not so good things?
They will tell you.
What would it be like if some of those not so good things
happened less often?
Anything they say that's affirmative is,
in motivational interviewing, what we call change talk.
It's them saying if I were to change,
these are the gains I could expect.
You said you don't like blacking out.
What would make that happen less often?
Well, I never keep track, so if I keep,
anything they come up with is a student-identified strategy
for making a change in behavior.
So I show you this not to try and derail this
and turn it into a mini-motivational interviewing training,
but so much of what works in the individually focused matrix
involves understanding MI, readiness to change, and so on,
so I hope I've laid the foundation for considering that.
Sometimes, truthfully, even when you ask
an open-ended question, it can still backfire.
This is my single favorite text exchange of all time.
Mom texts and says, "What does IDK, LY & TTYL mean?"
So that's an open-ended question.
So we tell mom, "I don't know, love you, talk to you later."
And mom says, "OK, I will ask your sister."
(audience laughs)
"Well mom, that's what those mean."
Alright, so, before I talk about the individually-focused
strategies, let me call time out for a sec,
see what questions people have, comments,
or anything I can clarify about the theoretical stuff
I've discussed so far.
I hope this is helpful and I fully realize
in the post-lunch slot, I hope this is okay for folks,
so I'll keep moving forward.
Norms.
Norms play pretty prominently in the individual matrix
and the key to understanding norms is,
again, this is not new.
We've known since the '40s that we as people
are influenced by a subjective sense of a situation
than the actual situation.
If you walk into a room and you go,
"This is sketchy and I'm getting out of here,"
you leave, even if it's not a sketchy situation.
We're influenced by our perception of others' attitudes,
behaviors, and expectation rather than
their actual attitudes, behaviors, and expectations
and unfortunately, our perceptions and interpretations
aren't always so accurate.
What do we know about norms clarification?
Alan Berkewicz, Wes Perkins, Carinne Johanneson,
Pat Fabiano, Jeff Linkenbock,
these are all the people that really,
late 80s, early 90s, helped us as a field move forward
and they showed that there are three very predictable
realms in which students misperceive norms.
One is the acceptability of excessive behavior.
We talk about attitudes like that,
those are called injunctive norms.
We know a little bit less what to do with injunctive norms
in individually-focused programs,
largely because injunctive norms can feel confrontational.
You say you're okay with this, but your peers
say they're not.
That feels confrontational,
but there may be more universal prevention opportunities
and I have been reading a lot of literature lately
that talks about the value of injunctive norms
in things like bystander approaches
for everything from drinking to sexual violence
to you name it.
What does this mean, acceptability of excessive behavior?
If you ask a student, how do you feel about someone,
on a school night, staying up until two in the morning
in the residence hall playing their music loud
because they're partying?
I hate that.
How do you think the typical fill in your school name here
student feels?
Well they're probably cool with it,
because it's college, whatever.
We pool all the data together, 99% of people hate it.
The 1% of people who do it are like, "That's cool,"
but the 99% of people who hate it
mistakenly say and do nothing because they believe
they're in the minority and they believe
everyone's okay with it.
And again, may then choose to not intervene,
may choose to not check in on someone.
Again, those are injunctive norms.
Where the research has gone a lot further
is descriptive norms.
Students tend to way overestimate how many people drink
and they tend to think that those who drink
drink more than they really do.
This is not unique to college students
and this is not unique to alcohol.
Take it away from alcohol for a minute.
The best example of this I've ever heard
came from Jeff Linkenbock.
Imagine you're driving on the interstate for 30 minutes
and there's no crazy traffic, there's no backup.
In 30 minutes on the freeway,
what are the cars that really stand out to you
and really get your attention?
What would you say?
I hear some people whispering answers.
Thank you.
Cars that really stand out to you and get your attention.
Man: Police cars.
-: Police cars.
Woman: Ones driving fast.
-: Ones driving fast.
Either answer works.
How many police cars do we see in 30 minutes?
Three, four, five?
How many of the ones weaving in and out of traffic
do we see, three, four five?
What's the first thing we say when we get out of the car?
"Man, cops were everywhere today!"
Or, "God, no one knows how to drive around here,
"everyone drives crazy!"
For whatever reason, we don't notice
the 1,000s of cars that weren't police officers.
For whatever reason, we don't notice all the ones
doing exactly what we're doing.
We don't notice the ones going slower than us,
because they're all behind us,
except for the people in the left lane
who need to get over.
(audience laughs)
You know who you are.
Just get over.
But, the same thing happens with college student
substance use.
If you had 100 typical students at a party,
based on the data I showed you earlier,
40 of them are drinking water or soda,
based on past 30 day data.
Another are drinking one the whole night.
Another 20-ish are drinking two the whole night.
It's only three students drinking five, six,
seven, eight, nine, or more.
Well who does everyone talk about on Monday?
Right, you don't hear people say,
"I was at a party this weekend and there was one guy
"drinking a beer and it's like, whoa, slow down buddy."
You hear about the extreme.
Shawn McCabe has done this research with Adderall.
What do you hear about at finals?
You don't hear people sit down at the dining hall
finals week and be like, "I stayed up on the reading
"all quarter long, and I went
"to bed early last night, what?"
You don't hear about that.
You hear about the person that loudly boasts
that they haven't slept for two days
and wrote a paper in the last 48 hours.
Everyone's like, "Oh man, everyone's taking Adderall."
You saw the data, that's not true.
Just shy of 10% that even do it once in the past year,
so this provides an opportunity then for correcting norms
through a range of different approaches.
Certainly, and this was on the environment,
it looks at social norms mass media campaigns.
I'm not even gonna get into that,
I only want to show and share something with you.
I think that in this field we've always said
a compliment is when things even get done
in a parodying kind of way, as a parody.
Christine Lee was at a farmers market
in Victoria, British Columbia and took this picture
and sent it to me.
It was an ad about farming and it said, one in five
teenagers will experiment with farming
and they add stuff like digging is a gateway to gardening,
a mom confronting her child,
"I found heirloom seeds in your room...we need to talk."
(audience laughs)
"Answer me honestly, how long have you been planting."
"Your mother and I raised you to do more than this."
"Stop labeling GMO foods at the supermarket!"
Know the warning signs of farming.
So, I saw thought, when she sent that I'm like,
"That's spectacular,"
but there is obviously mass media opportunities.
I'm gonna be talking to you about
the individually-focused normative re-education.
Expectancies are another part that plays prominently
in a number of other interventions
and even solely on the matrix.
And if we ask students the very questions I'm gonna ask you,
what are some of the ways alcohol affects you positively
in social situations, whether you personally believe
what you're about to tell me or not,
what do students tell us?
How does alcohol affect them in a good way socially?
Woman: Helps them.
-: Helps them talk or be more social.
Man: Lowers inhibition.
-: Lowers inhibitions in general.
Woman: Calms them.
-: Calms them down.
Woman: Makes them funnier.
-: Makes them funnier.
Man: Better dancer.
-: Better dancer. (audience laughs)
People say that and then they see the video
and they're like, "Wow, not so much, actually."
(audience laughs)
How do I delete that from the cloud?
You get the general idea.
People say more funny, more outgoing, more talkative,
more social, more sexy, more flirty,
get the better dancer thing.
What are some of the ways alcohol might affect people
in a not so good way in social situations?
Woman: They slur when they talk.
-: Slur their speech, go ahead in the back.
Woman: Makes you mean sometimes.
-: Get mean or aggressive, one of the top three things
people tell us.
Do stuff they wouldn't normally do,
say stuff they wouldn't normally say.
We then ask people, "Have you ever had alcohol
"do different things for you at different times?"
People will always say yes to this question.
That should seem really weird, right?
We never say that, usually we can say
if you take this drug, this happens,
if you take that drug, that happens.
With alcohol, you do not see that same level
of predictability.
You could have all in one weekend.
Someone drinks on Friday, life of the party,
more outgoing, social, funny, talkative,
got the better dancer thing happening.
The very next day, getting ready to go out,
they grab their phone, they get a text,
and the person they've been dating dumped them by text.
We always tell students don't do that to people.
Now, they go out and they drink the same stuff
they drank the night before, they even drink
the same number of drinks they had before,
but instead of having all that great social stuff happen,
now they're drinking and getting really down
and giving really long, philosophical speeches
about love to people, right?
Trying to find friends to watch The Notebook with them,
which if that happens, you should call for help.
(audience laughs)
Or make them watch The Vow, because it's so good.
(audience laughs)
But the question is, what's going on?
It was Alan Marlatt that said, "I think it's expectancies."
When someone says tequila, whoo, that makes me crazy.
That's an expectancy.
There's no crazy ingredient in tequila.
He's credited with research on alcohol's placebo affect
using the balanced placebo design.
Truly in interest of time, I will describe this briefly,
but you can bring students who are over 21 into the lab.
They all drink, they're all over 21,
they all sign consent forms that say,
"If you give me alcohol, I give permission for that."
You then tell them, "We're gonna have you drink
"with classmates in a simulated tavern.
"We're gonna serve you alcohol or we're gonna give you
"no alcohol."
We then actually give them alcohol or give them no alcohol.
If alcohol makes people more social,
the entire group at the top should be social
because they got it.
If there's more to the belief they've been drinking,
it'd be everybody on the left.
Upper left hand corner, we say we're gonna,
pardon me, any time you do research,
you want to generalize to the outside world,
so in Guthrie Hall, our psych department, Room 242,
from the outside it looks like a regular class.
On the inside, Alan built a bar.
Everything in our field has to spell a cool acronym,
it's one of our laws, and it's the BAR lab,
the Behavioral Alcohol Research Laboratory.
This is the BAR lab.
Awesome looking setup, looks like a bar,
very much a lab.
The mirror, two-way mirror.
The Dos Equis sign, camera.
There are sprinklers on the ceiling for fire code reasons
and the pointer doesn't work but if you look
at the Oley beer sign, the neon sign,
go up to the light over to like 10:00,
there's a little dot on the ceiling,
that's a microphone.
We can tune in to different conversations
around the room at different times.
So it's an awesome way to study behavior
in a non-intrusive way.
Upper left-hand corner is told they're getting alcohol
and they get it.
They drink beer or vodka and tonic and we sit back
and watch a group that looks like college students drinking.
Nothing magical happens here.
Clear them out, lower right-hand corner,
tell them they're getting tonic water or near beer,
actually give them that.
It's a much quieter group.
At best, it looked like students who don't know each other
were asked to hang out and drink water together for an hour.
(audience laughs)
Where do we see the really cool stuff happen?
Lower left-hand corner.
Again, I tell you this, I hope I'm not going too fast.
I tell you this in the name of science,
not to go mess with people.
You can make the most convincing vodka and tonic
in the world if you take tonic water,
put a lot of lime in it and all you do
is put vodka right around the rim of the glass.
I made hundreds of these in grad school.
I got pretty good at it.
But think about it.
Vodka's on the lower end of taste and smell anyway.
When people bring the glass to their mouth,
they smell the hard alcohol on the rim of the glass,
but the clincher is that first sip.
First thing touching their lips is the hard alcohol
on the rim of the glass, so we have a lot of students
on that Dos Equis home video who take one sip
and they go, "Woo, that's a strong drink,
"well done, scientist." (audience laughs)
And they stir it up and don't even think twice about it.
Beer.
Sometimes people will drink the non-alcoholic beers
and be like, "Man, not even close, doesn't taste like beer."
Knowing that was the concern, Alan did an independent study,
took four different types of near beer,
made this El Primo near beer blend,
did a little bit of dumping, made this concoction
that, in taste tests, people couldn't tell the difference
between this near beer blend and the real thing.
We had students at the end of this say,
"Man, you should bottle that and sell it."
(audience laughs)
And we looked into that and that's actually really illegal.
(audience laughs)
Who knew?
Again, everyone was over 21, they all signed consent forms,
said, "If you give me alcohol I'm cool with this."
We had them blow breathalyzers to make sure
they hadn't pre-partied or pre-gamed for the experiment.
They come in, what do we see?
Coders can not tell the difference between the two groups
on the left.
By the 20 minute mark, that lower left-hand group,
the volume of the group has increased,
people are interacting a lot more.
They do not look different than this other side.
By the 40 minute mark, that's when you start seeing
the ridiculously awesome stuff happen.
The original experimenters did not predict
people were going to report feeling physical effects,
but it never fails, some people report physical effects.
Some students talk about what a great buzz
they think they have.
Some students are really conscientious,
which is a good thing, I don't mean to make light of that,
but you'll hear students who say,
"Man I'm really glad this experiment's on campus,
"because I know me, shouldn't be driving right now."
We're always like, "Okay, you should get that checked out."
(audience laughs)
In the social realm, it's incredible, though,
someone usually serves as kind of the standup comedian
of the group, someone usually surfaces as the loud,
annoying person of the group.
What would you guess is the top interpersonal behavior
we see more than anything else?
Hooking up, flirting, and really shmoozy stuff too.
We see people walking up to people going,
"So, uh, what are you doing after the experiment?"
and hitting on people.
We're behind the mirror going,
"Wow, good line there brother."
(audience laughs)
Going home alone, friend.
(audience laughs)
We've at times, I mean people are pushing tables together
and playing drinking games.
End of the hour, lights go on bright,
stereo goes off, we say,
"Surprise, you didn't get any alcohol."
All the years these studies have been done,
no one's ever been pissed off at that announcement.
Depending on what you said or did during that hour,
you definitely differ in your reaction to that announcement.
I've seen groups of women who, never in a scary way,
women who will scream.
Guys are the funniest for me to watch,
because it never fails, there's the one guy
that kind of looks around and goes,
"Yeah, I knew there was no alcohol."
(audience laughs)
But what's crazy is the belief they were drinking
led to all that social stuff happening.
Upper right-hand corner,
oh go ahead, there's a hand up here.
Man: Quick two quick questions.
How many drinks did they get
and how many were there?
-: Varied.
I can't stress to you enough
that this is exactly one of the most well-researched things.
The question for people listening remotely
is how many drinks did they get.
That's been varied.
We've done some where it's like,
drink as you normally would.
We've done some where we put a cap on it.
Group size.
The best study was people said,
"What if it's just contagious?
"What if it's about being around people?"
So at the University of Wisconsin they said,
okay, we're gonna do this with one person.
(audience laughs)
Person's alone, like, hey.
And it even extends that way.
You see it's more important what a person believes
than what they got.
Truly in the interest of time,
upper right hand corner, they're told they're getting
no alcohol but they actually get it.
They're all over 21, they all do drink,
they sign consent forms that said that's okay
if you give me alcohol.
This usually do control for,
because what if someone's like, "Yes, tonic water!"
and starts pounding, we have to be careful with that.
We've either given them up to .06,
based on their birth, sex, and weight.
That Wisconsin study got them to .1.
What happens here?
They don't act any different.
But the physical effects kick in.
They make different attributions.
"I'm tired, I've had a long day."
Well it's a depressant.
Flushing, "It's hot in here."
Get a little clumsy, they're like, "Sorry I'm clumsy."
The science shows that alcohol does a lot of stuff,
but the social things we get from drinking
are way more due to what's up here
and the setting we're in than what's coming from
the big red cup, the can, the bottle,
the shot glass and so on.
Research by Jack Derkiss and Mark Goldman
showed that the mere act of going through this
leads to people cutting down their drinking.
We do not send this out to try and take the fun
out of drinking for students,
but instead if someone says,
"I drink drinks one, two, and three because I like the taste
"and I like the buzz," there you go.
If they say, "I drink drinks four through 10,
"because it makes me more funny, talkative, and outgoing,"
we have no evidence that's coming from the alcohol
and by drinking four through 10,
it's costing more, they feel like crap the next day.
If this lessens a barrier to making a change,
we've done something good.
The research in the matrix shows that if all you do
is lecture about this, that's not effective.
If it's folded in to motivational interviewing-based
brief interventions, it's an effective component
of both the Alcohol Skills Training Program
and BASICS.
The live expectancy challenge in and of itself
is associated with reductions in drinking,
so by telling you this I've actually conquered
three parts of the individual matrix,
just because this was reflected in those other domains.
I did that in a third of the time I would normally do,
but again, it's like what do I cut here.
So before I move on, can I see what questions people have
or comments about expectancies?
Alright, the Alcohol Skills Training Program.
This was developed in the late 80s.
I mention Alan Marlatt quite a bit.
I do what I do today because of Alan.
Alan was my advisor in grad school.
I started working in his lab, you heard me say,
for then grad student Ray Larimar in '89.
Alan passed away five years ago last week, actually,
and he continues to influence this field dramatically.
And on top of a obviously big personal loss
to those that worked with him,
it was a big loss in the field, but Alan developed
the Alcohol Skills Training Program and compared it
in a randomized controlled trial to a control group
in the state's alcohol information school,
which was abstinence only, very physiologically focused.
The abstinence information school focused on cirrhosis,
death, Korsakoff syndrome, all legitimate concerns
of drinking but things that are like, potentially,
to a college student, 48 years into the futuree.
Alan said, "What about 48 hours into the future?
"What are the things that are the most salient the
"and relevant to a student?
"How do we meet them where they're at
"and elicit what's important the them?"
And NASTP really wanted to focus on if you make the choice
to drink, ways to do it in a less dangerous,
less risky way.
He did this using research that had come out of Europe
on alcohol's biphasic effect.
We asked students, "If you're at a party, get a buzz,
"start to lose that buzz, what do you usually do?"
And a room full of students will tell you, drink more.
The million dollar question is do you ever get
that same buzz back?
And students will tell you no.
I have never heard yes and I've been doing presentations
on this stuff since 1991.
One day I will.
That's an impressive streak.
I've never heard a yes.
What do they say and feel instead?
The drunk feeling, sick, tired, sleepy.
Scientifically, we totally know why.
We can ask people with tolerance,
"Is the buzz you get now as good as the buzz
"you used to get when you first started drinking?"
People never say yes to this.
Here is why.
Even though alcohol is a depressant,
it's a funky depressant, because the initial effects
have a buzz.
If a person takes a sip of alcohol,
the body's initial experience of alcohol
is the stimulant effect.
Depressant effects kick in,
depressant effects get done doing what they're doing,
body goes back to the baseline.
If you tap out after one sip and you're like,
"That's it, I'm out," you'll still experience
a curve like this, but as we drink,
while our blood alcohol level is going up,
this is actually at a constant for a while
until we hit and exceed a certain blood alcohol level.
Once we hit and exceed that level,
the effects of alcohol change irreversibly
for the remainder of that drinking occasion.
So now, the positives get less positive,
the depressant effects get more pronounced.
This is why the more we drink, the more we don't
get our buzz back, and the more we feel, in quotes,
the "drunk part."
What's the cool news as a field?
Well, certainly, there's a very clear point
where the positive effects have been maximized,
the depressant effects have been minimized
and a very clear point when you clear it,
positives get less positive, depressant effects
get more pronounced.
What's the even better news as a field?
We've tracked this shift down to between
a hundredth of a decimal.
We know that shift occurs at a blood alcohol level
of between .05 and .06%, so if a student says,
"I do want to drink, but I want to drink
"in a less dangerous, less risky way,
"I want to avoid hangovers, I want to avoid blacking out,"
setting a limit that goes up to but doesn't exceed
this point can allow that shift beyond 06
to be avoided.
Why do people with tolerance not get as good a buzz
as when they first started drinking?
Because for people with tolerance,
this shift has actually already occurred.
Far from handling alcohol better,
the blow to the system's actually more pronounced
and you don't get as good a buzz.
Tolerance, when you ask students about tolerance,
on the one hand there's the status,
I can hold my liquor thing.
But students will tell you it's expensive to have tolerance
and they're not trying to be funny.
And they'll say they actually don't feel it as good,
so the good news about tolerance,
it's like weight, you can gain it, you can lose it,
they can lose it by calling time out for a while.
Science shows as short as two weeks, but typically a month,
and then if they lose their tolerance,
that will shift back up and they can reunite themselves
with that buzz.
We go over strategies, and these are just some examples
of protective behavioral strategies
that we would elicit from the student.
If you make the choice to drink, what are ways
to reduce the risks associated with that?
When it comes to setting limits,
part of it is making sure they're on the same page
about what counts as one drink
and we make sure they're very clear on that,
but it also is based on their sex and weight.
What would a limit be?
Again, the pointer doesn't work,
so I can't show you, but I can walk you through it.
Imagine we've got a woman that says,
"I always drink six drinks over three hours."
Go down six, she'd be at a .102 blood alcohol level.
And she says, "I want to set a new limit.
"I'm gonna be out for three hours."
Go to the three hour column and go down
until you find a point that doesn't exceed .06.
You see .052, you go to the left,
you look at what that translates to.
All she does is shave off two drinks,
but she cuts her blood alcohol level in half.
If she says, "Four, I wouldn't even feel that,"
probably means she's developed tolerance.
If she goes, "Four, I was thinking
"of cutting down to three," well stick with the three.
But if she says, "Four, that's a limit
"that would work for me,"
you can again explore these different strategies
and it's all about eliciting from the student
what makes some sense.
What did the Alcohol Skills Training Program show?
In going over things like expectancies, standard drink,
norms, how alcohol gets in and out of the body,
blood alcohol level, the biphasic effect,
giving people charts, talking about consequences
from the student, and talking
about harm reduction strategies,
ASTP, compared to the alcohol information school
and a control group showed significant reductions
in drinking and consequences.
The good news, it worked,
the not so good news, at least in the initial version,
it was actually eight sessions long.
Bless you.
He did a followup looking at a six session
compared to, there were these rumblings out in New Mexico
about motivational interviewing,
six session with a group,
one session with an individual.
That's the study that gave birth to BASICS.
In that time, there have been evaluations
of two-session ASTPs, ASTPs with mandated students
and even one-session ASTPs.
We were talking at dinner last night about the chance
to even do ASTP content in contexts
that focused on high-risk contexts.
Hugh Spitler, at Clemson, for example,
did research on delivery to Greek students
as a way of looking at this.
It is a piece of the puzzle, it is a mix of strategies,
but this could be part of that plan.
It is a group and so it's done a bit more structured,
but you see more individual flexibility
when you do an approach like BASICS.
BASICS came out as a book in 1999.
Baer, Kivlahan, and Marlatt were three
of the six members of my dissertation committee,
so I still get nervous when I look at this slide.
I'm like, "Don't ask me about moderators,"
but this was developed, again,
it came out of ASTP.
It looked at a six-session group compared
to a one-session, feedback session,
using motivational interviewing,
compared to a control group.
The group, the individual session,
significant reductions in drinking and consequences
compared to the control group.
No differences between the two groups.
You got as much in one 50-minute feedback session
with an individual as you did in six hours with a group.
That laid the foundation for BASICS.
BASICS looked at following incoming first-years students
to a large northwest university, as the article said,
and compared them to a high-risk control group
and a general college student control group.
I'll cut to the punch line.
Four years after getting BASICS,
significant reduction in drinking and related consequences
after a 50-minute intervention.
What does BASICS involve?
There is an assessment.
When this was first developed, that was in person
and with paper and pencil surveys.
Why?
It was 1990 and there was no internet
and there was no surveys online.
Subsequent studies have shown you can replace
that entire first session as long as the alcohol screening
happens, online even.
Students would self-monitor, come back and get
a feedback sheet and a provider trained
in motivational interviewing would review the feedback,
go over the information and skills training content
when relevant to the person.
What does it mean to do BASICS?
The AS is the alcohol screen
and it was originally a separate in-person session.
Again, it was achieved online in subsequent studies.
It does need that screening though.
The I is the intervention.
That was originally the second session
that was done in person, so still a one-session intervention
but a second in-person session,
guided by personalized graphic feedback.
If you give feedback online or in print,
that's not BASICS.
That's delivering a PFI and we'll talk about that too.
But it must be delivered with fidelity
to motivational interviewing,
adherence to MI spirit, style and strategies.
It allows you to flop around a bit more
based on what's of interest to the student.
So if I'm meeting with a student that says,
"Well what about tolerance?"
you would never be like, "Slow down, that's coming."
We'd move right to there and meet them where they are.
The original BASICS feedback did not look gorgeous.
This was side one, this was side two.
This was associated with four years later
reductions of drinking and consequences.
This feedback sheet was made in WordPerfect for DOS.
(audience laughs)
We had to hire a graphic designer, for real,
to make that big number one and that big number two
and the logo of the named Lifestyles '94 Project,
which was the first working name of BASICS
and then clip art came out and we had to let her go.
(audience laughs)
It went over feedback on things like
how much they drank, their blood alcohol level,
how that changed since high school,
perceived and actual norms.
This was early application of normative feedback.
Consequences they endorsed, family history risks,
symptoms associated with dependence,
using at the time DSM-IIIR terminology,
beliefs about alcohol, expectancies,
and their own concern and perceived risk.
It got a little prettier in subsequent years.
Here's one from 2002, but it was a similarly
just one sheet of paper.
Side one, side two.
I told you that the hardest part of doing,
we always have to name things with acronyms.
Hardest part of getting a new grant
is coming up with a cool name for the study.
We came up with, for this one, MC squared,
which stood for Motivating Campus Change.
We're like, "That's awesome!"
No it wasn't.
That stupid little superscript two
was the bane of my existence for the entire life
of that project, because depending on what program
we were using at the time, that was hard
to make that number two.
I feel bad showing this because I feel like I'm picking
on the guy that made this sign,
but I used to work at a different school.
One day I was walking into the building.
I saw this sign that was the directory
and I'm like, how long has that been there?
Not only had it been up for a year,
it was up an additional four years.
Here's me in front of the sign
and it actually said, "MC2 (Bob, this should be squared)
"Motivating Campus Change."
(audience laughs)
Gonna go out on a limb and say that Bob
the sign maker didn't think very critically
about the note he had received.
(audience laughs)
And they put that up.
That sign is actually in my office
at the University of Washington now
because my wife told me we had to get it out
of our dining room.
(audience laughs)
But when they remodeled the building,
I'm like, "Please let me have that sign,"
so I'm the proud owner of it,
but we can give feedback on,
it goes back to what's of importance to the student.
Imagine this is someone that said,
"I lost a friend to drinking and driving,
"I would never drink and drive.
"That's why I party, stay the night at my friend's house,
"drive home the next day."
This is a person for whom their peak blood alcohol level
takes 17 hours to get back to zero.
If they're at their peak of .27 at midnight,
they're not blowing a zero until five
in the afternoon the next day.
If they realize, what's important to me,
not drinking and driving, what am I learning?
I'm drunk driving every weekend.
That could be some of the prompts,
contemplation of change,
or even active commitment to change.
The issues with BASICS.
BASICS is the most well studied
of the individually-focused interventions,
clearly shows an impact, but I gotta say,
these are some of the things,
there's still more research that needs to be done,
adjustments in feedback length or content
without evaluation.
I was at one school where they said,
"Hey we want to show you are BASICS feedback,"
and it was 22 pages long!
I was like, "How are you even discussing this
"in a 50-minute session?"
That's a research question.
Again, the feedback doesn't have to be gorgeous
and you saw that the best outcome data ever,
from a sheet of paper.
Conflicting or confusing measures is about what's effective.
We get, at least at my school,
everything from messages from sales people,
like, this is the most effective, things like that,
so knowing what is the best way to go,
especially even in, in quotes, "buying feedback" is hard.
You heard me say in the morning,
best practices in training for BASICS.
Staffing and practical needs.
I talked to one school that they said,
"We don't have enough people,
"so we made the intervention 30 minutes."
They're like, "Are we still doing BASICS?"
I'm like, you might be but you have to evaluate that.
Bringing the intervention to scale.
I'm at a school of 44,000 people.
The needs to bring that to scale might be different
than at a school, the old school I used to work at
was 4,400, so I've seen a ten-fold increase,
just by switching jobs and the size of the campus.
MI adherence and issues of fidelity.
If people get trained in motivational interviewing
and then kind of stop doing that, that becomes a problem.
And again, reaching students that might slip
through the crack.
What we then saw happen in the field
is because BASICS worked,
people looked at, in quotes, "BASICS-like interventions."
Can you have no graphic feedback?
Can you just do the motivational interviewing?
Absolutely.
Motivational interviewing in healthcare settings.
Paul Grossberg, I know was out here at Lincoln,
in particular, showed that adherence to MI was the key.
But a healthcare provider, kid come in for a flu shot,
do an alcohol screening, do a brief intervention.
The most reliable interaction components
reflected the underlying principles of MI.
In Paul's study, he identified the top ten clinical tools
and looked at how they hung with expressing empathy,
developing discrepancy between values and goals
that were of importance to the students,
supporting their confidence or optimism
that they could change, and rolling with resistance.
And the top 10 things were going through the things
they liked, the things they didn't like,
the good things, the not so good things,
looking at their goals, considering how alcohol
was in conflict with that, making a decision
to reduce drinking, making a risk agreement,
feedback on how much they drink and how much they,
in quotes, "binge", per month, tracking drinks,
rating their readiness to change,
just asking about those stages of change,
scale of one to 10, how important is it for you
to make a change in your drinking, giving norms,
number seven, compared to national,
caloric feedback, BAC, and also,
norms explicitly in number 10.
What about personalized graphic feedback
if there's no person to discuss it with?
This is the idea of everything from mailed feedback
to web-delivered feedback to some
of commercially available products,
because a number of them were commercially available,
rather than show you any one as an example
at the expense of showing the others,
know that there are commercially available products
in CollegeAIM.
But I mentioned MC squared, this was one we stuck in
through the mail.
We had 1,488 people, we assigned them to get feedback
in the mail with these little tip postcards
or they just filled out surveys.
And we gave them this.
It included things like norms, expectancies,
money spent, weight concerns, you name it.
Participants that got the feedback
drank less at followups than the people
that got the control
and when we did a composite score
looking at peak BAC, monthly frequency,
past-year frequency, total drinks,
the feedback participants were more likely to refrain
from heavy episodic or binge drinking
than people in the control group
and to show you graphically what that looked like,
you know when we're talking about percentages of students,
this becomes a big deal from a population level impact
in terms of the groups that got no feedback,
compared to people in the feedback condition.
I mentioned we always try and keep standards in mind.
One of the cool side effects of our study,
is abstainers that got personalized feedback
were two times as likely, one year later,
to still be abstainers than abstainers
in the controlled condition.
Think about what they got.
They got norms saying look at all the things
you're avoiding not drinking,
look at how many people have joined you
in the decision to abstain
and what we found is that again, the percentage
of people in the feedback condition,
compared to the people in no feedback
when we looked at the percentage of students
made a big difference.
Protective behaviors mediated intervention efficacy
in the people that got the intervention
increased the frequency of protective behaviors
relative to the control group.
The web-based stuff I can't do justice.
As examples, just from colleagues
that I've collaborated with, Clay Neighbors,
who I shared the pencil story with,
looked at 21st birthdays and showed that giving
personalized feedback reduced BAC levels
on the day of their 21st birthday.
Alcohol-related sexual behaviors, Melissa Lewis,
another friend and colleague at U dub,
in the handouts that you'll be sent as a PDF,
there's a link from one of NI triple A's journals
that reviews 32 electronic or web-based interventions,
including several of the commercially available products.
There's a way to give this feedback out there
as part of that mix of strategies.
Screening.
You know, Ralph Hingson had a study where he asked people,
the only inclusion criteria was do you drink
and have you been to the doctor?
He asked people then about the degree to which
they were asked about their drinking by their physician.
Only 14% of those exceeding low risk drinking guidelines
were asked and advised about risky drinking by their doctor.
The age group most likely to exceed the guidelines
but least often asked were 18 to 25 year olds.
We're at the point where the efficacy of screening
and brief interventions in health centers
has been established.
Jim Schaus, my idol, University of Central Florida,
I've heard people say, "I don't know,
"we have a pretty busy health center."
They're one of the top five largest health centers
in the country.
They screen every student for every presenting issue
for alcohol.
If they flag, they get connected with a brief intervention.
Mike Fleming, now at Northwestern
but was at Wisconsin.
The findings are so cool that it's led Ralph Hingson
to conclude that if more campuses screened,
and referred interventions, it would achieve, ultimately,
population-level benefits, because you connect people
to services that could be having an impact.
The barriers related to screening is, again,
picking the right tool.
If you're like, everyone's flagging,
we're having too many false positives, that's an issue.
Training people to do that,
resistance toward conducting screenings,
if there are already busy healthcare providers
concerned about more work,
or concerned about, what if someone flags,
then what do we do?
Real world issues related to resources,
plus the idea that it still requires someone
to come to a health center or counseling center,
so, again, how do we catch the students
that might slip through the cracks.
I mentioned that I'd let you know
that you can do motivational interviewing in groups.
It's still non-judgmental, it's still non-confrontational,
but you cast a much wider net.
You acknowledge that there might be a blend
of drinking practices in the group,
so you ask open-ended questions as much as possible
and you reflect when possible.
When someone in the group goes, "Whoa,"
and we say, "That's really different than you thought
"it would be," all the other 10 people
that didn't say whoa but thought it
are nodding too.
You can reflect to one and impact the others
in the group and the science shows this.
Consider hooks for the group.
We talked at dinner last night about the work
we're doing with Greeks,
asking a fraternity or sorority,
"How would you like to be seen as a chapter?"
And they'll say things like respectful,
fun but responsible, good guys, whatever it might be.
How do you think you are seen?
What gets in the way of being seen the way you'd like?
And if any of that is alcohol-related,
there's an opportunity to consider
what that shift might be.
Eliciting personally relevant reasons for change
and letting the group generate protective
behavioral strategies, then filling in what they miss.
I showed you on a slide in the interest of time,
here are some protective behavioral strategies.
Well what would that be?
Going with action-stage suggestions with people
who might not be there yet.
If we ask the group, "If you make the choice to drink,
"what are some strategies a person could use
"that would allow them to stick to a limit
"or in general, be more in control of their night?",
a pre-contemplator can answer that question.
Well I suppose they could set a limit.
Does that mean they're gonna?
No.
But if they're generating it, it's coming from them,
not us in the front of the room.
So, why is it collectively also important
they can all be part of that mix of strategies
considered through CollegeAIM.
When you look at CollegeAIM, in that upper left-hand corner,
including normative re-education,
and this was electric or personalized normative feedback,
skills training strategies with an alcohol focus,
including just self-monitoring and self-assessment.
There is research that shows if you have people
fill out surveys a lot, their drinking will go down.
This is the fourth survey these people are giving me
where I endorsed doing less well in school
than I wanted because of my drinking.
Wow, maybe I should do something.
Literally, even monitoring can make a difference.
There is, again, the commercialized available stuff
in that middle realm.
You can see that it includes skills training, again,
with an alcohol focus, exploring goals,
there's the Alcohol Skills Training Program
mentioned by name, there's BASICS mentioned by name,
there's personalized feedback interventions,
generic or other.
If you're a NCAAA Division III school,
one of the studies that lays the foundation
for the 360 Proof program that was a collaborative launch
between NASPA and NI triple A,
the entire PFI is based on an article cited in that section.
That is a personalized feedback intervention
free to all NASPA small colleges and Division III schools.
Linda Major's gonna be presenting in our next
learning collaborative webinar, in fact.
When you look at some of the ones that are
moderate effectiveness, the expectancy challenge on its own,
there are these other skills trainings.
You see the word skills training
and motivational intervention a lot.
Parent interventions, the work that Rob Tereesee has done,
remain extraordinary.
When we look at the fact, in the time I have left,
that there are these barriers, though,
to getting it out there.
You, on your campuses, as you're discussing these,
have a chance to overcome those barriers.
Part of the hope is that CollegeAIM helped lessen
barriers here.
Among the barriers to getting evidence-based programs
in place is dissemination.
That's on researchers, in many ways.
A lot of researchers publish in journals
that no person would ever have a reason to read.
(audience laughs)
Seriously.
I have a colleague that just got her work summarized
in Cosmo and her mom was like, "Now you've made it."
(audience laughs)
And she wasn't trying to be funny.
It's like, now this has real world meaning.
It didn't have real-world meaning when it was
in the Journal of Something Fancy.
And even if it is published in a journal,
it doesn't say how to do it,
plus some publications or evaluations
are not very user friendly.
We log-transformed the data and,
and you're like, "Wait, so what's the mean?"
You're not even sure what you're interpreting any more.
Adoption, reactions from key people involved in the process.
They feel strongly, no, we must do it this way
if that leads to moving forward.
Diversity of opinion is great and we encourage it
on college campuses, but it could lead to difficulty
in committing.
The Try-ath-an Cultural Center in Colorado
actually has an institutional readiness to change
questionnaire.
I showed you the stages of change.
You can fill it out as a department,
pool it all together and say,
"Maybe we're all in agreement something needs to change,
"we're contemplative about what that should be."
Or maybe we are in fact all on the same page.
Or, man, everyone's in totally different places,
so we maybe need to go a bit slower.
Another barrier to adoption is unreasonable expectations.
Okay, fine, we'll buy this one program
and all this will go away.
Well, no, that's one program and it's one part
of that mix.
Insufficient buy-in.
The campus that does a norms campaign
but puts up a single poster.
That's not appropriate buy-in.
Not enough time working with the folks
that are gonna be involved in developing or delivering
the program.
The implementation, for the third time I'll say,
proper training,
and plus there's a tendency to reinvent innovations.
That's okay, but if you tweak it too much,
it's not the evidence-based strategy any more.
Instead, it's just a new program that needs to be evaluated.
Organizational factors, like resources, money-wise,
issues in the real world impacting effective delivery,
attitudes among leaders, resistance amongst staff
familiar and comfortable with just doing it
the way we've been doing it,
and finally, the idea of therapist drift,
again, the idea that we have to do continuing education
in issues of delivering an intervention with fidelity.
This highlights the need to monitor and provide
continuing training.
There's also a tendency to move toward
the next best thing.
Ooh, let's do this.
Or some administrators that believe if we direct
too much attention to this, does that suggest
to the community that there's a problem?
I would think on the contrary.
It shows that you're looking at the health
and wellness of your students.
So in wrapping up, this was a lot and I appreciate
you guys putting up with a whirlwind tour,
but I added this because we talked about it as well.
Bob Salts, who is one of the nicest human beings
I have ever met, has one of the greatest smiles
on the planet Earth, and is just a genuinely great guy,
has really warned, as we're looking these approaches,
that there may be more support for policies
than we realize.
I thought Toben did such a great job of highlighting
the importance of that policy on the front end.
What if you've got a program like BASICS?
What if people aren't getting referred to it consistently?
What if there's not consistent enforcement of policy?
What if you want a new policy, but people are dragging
their feet to do it?
One article showed that a small group of students
might be so vocal on campus to the point
administrators don't make policy changes
because they mistakenly assume the student body
doesn't support them, but Bob showed
there was a universal tendency to underestimate
student support for policies.
Because I'm firmly of the belief that he can say it
better than anybody else, quoting directly from his article,
"campuses would actually have more incipient support
"for a variety of alcohol prevention policies
"than is likely to be perceived by the students themselves,
"and, by extension, administrators and others
"belonging to the campus community."
"Unless students are persuaded that such support
"is not limited to a fringe element, new policies
"are likely to be met with at least passive,
"if not active, resistance."
"This then, suggests that today's campus prevention
"interventions, which now often comprise campaigns
"to correct students' perceptions of peer alcohol
"consumption, may want to incorporate a parallel effort
"to correct their perception of peer support
"for policies as well."
"This information may prove revelatory to some,
"and critical to the chances of having a significant impact
"on alcohol-related problems on campus,
"which is the ultimate target."
In the spirit of that idea of, a mix of strategies is best,
consider the audience and targets for a variety
of what you're doing.
What are you offering your abstainers?
What are you offering in terms of programs
for returning veterans?
Study abroad programs?
I'll talk about that in just a bit.
Students in recovery, Greek members, student athletes,
high-risk events, St. Patrick's Day.
I made the joke, well at least that's far away.
That's in 13 days.
There's a chance to do something there.
Recognize and utilize expertise in your community for sure
and add to the science on what works,
not only in affecting alcohol use, but help advance
the field on other drug use, violence, the overlap
of these issues.
Certainly things like prescription drugs and marijuana.
With the time I have left, I did, at the request
of a couple people in the audience, just want to say
a quick word about the science that,
I'm not being dramatic when I say this keeps me up at night.
I worry a lot.
I hope I outgrow that some day, but given where I am
age-wise, apparently I will not outgrow it,
but this research is insane
and it has implications for Spring Break,
it has implications for 21 Runs,
students studying abroad, new students in the fall.
It's an article that came out,
the article that kicked this all off came out in 2002,
Siegel and Ramos, and they said,
"What's up, addictive behaviors field?
"We failed to pay attention in Intro to Psych,
"because if we looked at Intro to Psych,
"we would be scared to death of tolerance."
Pavlov taught us that if you food in front of a dog
and ring a bell, it looks at you funny.
If you put food in front of a dog and ring a bell
over and over and over, in time, ring the bell,
the dog salivates.
The bell can elicit salivation as a conditioned response.
When I teach in the med school, I always show this slide.
It's Pavlov from the view of the dog.
The dog says, "Watch what I can make Pavlov do.
"As soon as I drool, he'll smile and write
"in his little book."
(audience laughs)
I think it went down that way,
but jump forward to human beings and drinking.
I know this is not true, but imagine the only place
you ever drank was right in here.
If you're in this room, it's drinking time.
You walk in this room, drink.
Walk in this room, drink, walk in this room, drink,
walk in this room, drink, what are you doing?
You're probably violating a policy of some kind,
(audience laughs) but you're also pairing this room
with drinking, no different than that bell
to Pavlov's dog.
Why does that matter?
In physiology, we know there's something called
the opponent process theory that says,
shove the body one way, body shoves back the other.
Jack up the heat, we sweat, make it really cold, we shiver.
If you have a drug like alcohol that has a depressant,
slows the body down, walk in this room and drink,
slows the body down, walk in this room and drink, slows
the body down, in time, walk in this room,
body starts speeding up.
The cues that tell the body, oh, we're about
to receive a big dose of a depressant
lead to the body making an anticipatory response
in the direction opposite the way the drug acts.
Researchers call this a conditioned compensatory response.
Without using all the fancy words,
imagine this is the level of a depressant
that lets someone say,
"I'm good, I'm gonna call it a night."
They come on here on Day 1, drink, Day 2, Day 3,
Day 4, Day whatever.
At some point, they walk in the room,
the body sees these cues, the body goes,
"Okay, we're drinking," ever so slightly,
the central nervous system starts to speed up,
heart rate increases, Galvanicks-Ginn response changes,
blood pressure changes.
What's the catch?
Here's how much the person drank the last 50 times
they went out.
They now drink that exact same amount.
Subjectively, do they feel it in the same way?
Nope, so what do they do?
Drink more.
Do they feel it now?
Yeah they do?
Do they look any different?
No, they're holding their liquor,
they're developing tolerance.
And we can see over a great deal of time
that this is then what tolerance could be.
This is how tolerance develops.
Now, what's the relevance to us in a college setting?
Researchers then said, "Oh my god, then maybe
"if what have we've been calling a drug overdose
"all these years, what if what we've been calling
"alcohol poisoning has less to do with someone
"going out and just having a big damn dose of alcohol?"
Instead, what if they drink the exact same amount
they've had the last 80 times they went out,
but they go out around a completely brand-new set of cues?
Well, as crudely and simply measured
as a brand new environment.
In a brand new environment the cues
that would make this anticipatory response happen
aren't there.
If the person pounds the same amount they've been drinking,
isn't it conceivable that that could happen?
Isn't it conceivable that that is what
an alcohol poisoning is, that that is what
a drug overdose is?
Study in Michigan looked at 61 consecutive drug overdose
admissions into a hospital setting to see
if they had anything in common.
60 of the 61, what did they have in common?
Brand-new environment.
That's terrifying.
The language used in our field at this moment
is the word fail.
Tolerance fails to follow someone to a new environment.
Why does that make me nervous about Spring Break?
What does Spring Break represent for a lot of students?
Road trip.
What does that road trip represent?
Brand new environment.
The tolerance they had on campus will fail to follow them
wherever they go for vacation.
Students studying abroad.
"Hooray I'm in a new country, and guess what,
"there's even a legal drinking age now."
What does that new country represent?
Brand new environment.
The tolerance they had on campus, wherever they live,
will fail to follow them there.
I'm in a bar for the first time,
happy 21st birthday to me!
Brand new environment.
Why does this keep me up at night in the fall?
What do our incoming students represent to us?
People for whom our campus is a brand-new environment.
If the only harm a student is trying to avoid
is like, they say, "I want to drink and have fun,
"but I don't want to wind up dying,"
I mean, good goal, and that would mean
that this even could be a foot in the door
and a hook to discuss with students.
I can look you in the eye and say the science on this
has gotten ahead of our knowledge of what to do with it
in interventions.
I can also look you in the eye and say
that in our Spring Break interventions,
our 21st birthday interventions, we're making sure
all of our BASICS facilitators know about this,
because the implications here are huge.
In fact, keep in mind that cues can be a lot of things
and one study even acknowledged that taste
could be a cue.
If you have a favorite drink and you take a sip
and you're like, "Oh, yeah, there we go,"
that's a cue.
So that a study in Canada, with 19-year-old college students
looked at what if we give them drinks
that are the same size, same alcohol by volume,
get to the same blood alcohol level,
but one tastes insane.
We'll have one look, taste, smell like beer,
the other one be insanely bright blue
and really pepperminty.
Their theory was, drink the one that's kind of like beer,
the body goes, "We're drinking,"
makes the anticipatory response.
People drink a drink they've never had before,
no anticipatory response, they'll feel the full effect
of what they've consumed in a more pronounced way.
Exactly what the science shows.
Students say subjectively, "I feel it, what did you put
"in this blue thing?"
They feel it more and objectively they showed
greater signs of impairment.
Again, I'm asking out loud, "Do you drink beer?"
"Sure."
"Do you drink green beer?"
That's a change in visual cues,
that even makes St. Patrick's Day,
the same six they always have, could be different
if we've changed appearance or taste.
So I show you this just as one other example
of we've got a lot more work to do as a field.
So, we've talked about the situational specificity
of tolerance, says that if alcohol is presented
in a manner divorced from the usual stimuli,
the effects are enhanced.
I started 10 minutes late, and I tried to catch up
and I think I caught up, but I'll end just by saying
I love what I do, it's easy in this field
to feel outnumbered and I always love stuff like this
because we're not alone in this
and I hope, I genuinely, when I said let's clap
for the people new to the field,
that's so important, but all of us
that have been doing this, we're very much in this together.
I talk a lot about why I do what I do
and sadly, I bore my family with it all the time
and I don't have any kids, so I have embraced
the cool uncle role as best as I can
and I have a niece, I actually texted
and asked for permission to share this
and I was told that she said yes.
I told her I was gonna be talking with people
about alcohol and why are you talking with them
about alcohol.
Well, because it's what advice we should give
college students and she says, "I totally know
"what advice I would give college students."
I'm like, "Go on."
So this is the last time we were hanging out.
So this is Amelia, Amelia says hello to everybody.
Amelia said four things
that you should tell college students.
One, don't smoke, two, don't use drugs,
three, don't drink, but if you do, only drink a little.
And I was like, "Wow, good job."
And number four, don't walk on the train tracks,
which I was like, "Really that's your advice?"
But I thought it was kind of cute.
I will again thank the team I work with
and again, Toben, for the chance to tag team.
I put Amelia on there.
If there's any of the studies I made reference to
or if there's anything I can send your way
that makes your life easier, that's my email address
right there.
So I was asked to end at 2:30, it's 2:31.
I'm gonna hand the mic back over to Ian, I believe.