Utilizing Peers in the Delivery of Brief

InterventionsJason Kilmer, Ph.D.

The Evergreen State College

Saint Martin’s University

Kim Hodge, B.A.University of Washington

Sruti A. Desai, B.A.University of Washington

Mary E. Larimer, Ph.D.University of Washington

Study described funded by NIH/NIAAA and the Dept. of Education grant U01

AA14742

Effective strategies to reduce drinking and/or consequences in college students

The use of peers in intervention delivery

Our study: The Alcohol Research Collaborative

Preparing peers to deliver brief interventions

Clinical issues, research questions, and future directions

Points for Consideration

Combining cognitive-behavioral skills with norms clarification and motivational enhancement interventions. Reductions in drinking rates and associated

problems (e.g., ASTP) Offering brief motivational enhancement

interventions. Reductions in drinking rates and associated

problems (e.g., BASICS) Challenging alcohol expectancies.

Reductions in alcohol use

Tier 1: Evidence of Effectiveness Among College Students

Task force report available at: www.collegedrinkingprevention.gov

Examines students’ perceptions about:Acceptability of excessive behaviorPerceptions about the rates of their

peersPerception about the prevalence of

their peers

Norm Misperception

COGNITIVE-BEHAVIORAL SKILLS TRAINING

Moderate drinking skillsBlood alcohol concentration

discriminationAltering expectancies about

alcohol’s effectsAssertiveness skills (drink refusal)Relaxation/Stress Management

skillsLifestyle balance skills“Alcohol specific skills”

Time

FeelingScale

+

__

0

Dysphoria - Down

Euphoria - Up Point of Diminishing Returns

Cultural Myth About

Alcohol

After Tolerance Develops

Alcohol’s Biphasic Effect

Specific Tips for Reducing the Risk of Alcohol Use

Set limitsKeep track of how much you drinkSpace your drinksAlternate alcoholic drinks w/non-alcoholic

drinksDrink for quality, not quantityAvoid drinking games If you choose to drink, drink slowlyDon’t leave your drink unattendedDon’t accept a drink if you don’t know what’s

in it

The Stages of Change Model (Prochaska & DiClemente, 1982, 1984, 1985, 1986)

PrecontemplationContemplationPreparation/Determination

ActionMaintenance

Motivational Interviewing Basic Principles

(Miller and Rollnick, 1991, 2002)

1. Express Empathy

2. Develop Discrepancy

3. Roll with Resistance

4. Support Self-Efficacy

A skills-training approach using motivational interviewing techniques in its delivery with a focus on drinking in less dangerous and less risky ways for those who make the choice to drink.

The Alcohol Skills Training Program (ASTP)

A non-confrontational, harm reduction approach that helps students reduce their alcohol consumption and decrease the behavioral and health risks associated with heavy drinking.

Brief Alcohol Screening and Intervention for College Students

(BASICS)

BASICS and ASTP

ASTP is delivered in a group settingAlcohol content and the skills-

training information is introduced in a more structured way throughout the program

BASICS and ASTP

Content reviewed in ASTPExpectanciesStandard Drink and NormsAbsorption/OxidationBAC, Associated Effects, ToleranceAlcohol’s Biphasic EffectDistribution of Blood Alcohol

ChartsConsequences Risk Reduction Strategies

BASICS and ASTP

BASICS is individually focused and involves the delivery of personalized feedbackAlcohol content and the skills-

training information is introduced throughout the intervention when relevant, applicable, or of interest to the participant

The Basics on BASICS Brief Alcohol Screening and Intervention For

College Students

•Assessment

•Self-Monitoring

•Feedback Sheet

•Review of Information and Skills Training Content

(Dimeff, Baer, Kivlahan, & Marlatt, 1999)

ASTP vs. Information OnlyAlcohol Skills Training Study I

Self-Reported, Peak BAL

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

Pre 4Mos 12Mos

Informational Program

Skills Training Program

BASICS 4-year Drinking Outcomes by Treatment Condition

4 Years 3 Years 2 Years 1 Year Baseline

Drin

king

Pat

tern

Z-s

core

1.0

.8

.6

.4

.2

0.0

-.2

Random Comparison

High -Risk Treatment

High -Risk Control

Review of individual focused strategies…

Larimer, M.E., & Cronce, J.M. (2002). Identification, prevention, and treatment: A review of individual-focused strategies to reduce problematic alcohol consumption by college students. Journal of Studies on Alcohol, Supplement No. 14, pp. 148-163

www.CollegeDrinkingPrevention.gov

Research utilizing peers in alcohol interventions using normative

reeducationMixed resultsSome show change in norm

perception but no effects over time on drinking behavior (e.g., Barnett, et al., 1996 and Smith, 2004)

One study with freshmen showed drinking reductions but no differences in norm perception (Schroeder & Prentice, 1998)

Research using peers to deliver ASTP and to facilitate Alcohol 101

CD-ROMMiller (1999) compared 2 assessment

conditions + 2 peer-facilitated interventions

At six month follow-up… Single-assessment only controls drank

more & had more consequences than students in other groups

Participants in the three-assessment group generally reported similar decreases in drinking/consequences

Participant satisfaction was higher in the ASTP

Research on brief individualized feedback interventions using peers

and professionalsWith Greek System students,

Larimer, et al. (2001) found: Fraternity men in intervention condition

decreased drinks per week & peak BAC No change for sorority women Peers were at least as effective at

promoting change in drinking behavior as professionals

O’Leary, et al. (2002) found peer providers were not as effective for women as were professional providers

Credibility of Peer Providers

Few studies address credibility of peer providers

Several authors suggest peers make credible role models and students may relate better to peers

Mixed findings do suggest the need for more research (Fromme & Corbin, 2004)

Research on Lifestyle Management Class for mandated or voluntary

studentsFromme & Corbin (2004) found…

LMC showed reductions in drinking and driving

Voluntary participants higher in readiness to change showed reductions in heavy drinking

Professionals rated higher on knowledge, content delivery, and intervention fidelity

Peers equally effective in both mandated and voluntary samples and for both men & women

What has research shown about utilizing peers in interventions

targeting alcohol use?

Research supports the idea that peer programs might be a

viable resource for implementing empirically supported interventions

The Alcohol Research Collaborative (ARC)

In ARC, for first-year students with at least one heavy drinking episode, compare several approaches, including three brief interventions Peer-delivered BASICS intervention Peer-delivered Alcohol Skills Training

Program (ASTP) Web-BASICS

ARC assignment to conditionAfter screening and baseline, 637

students were randomized to a condition of the study

399 participants were randomized to BASICS, ASTP, Web-BASICS or Control

86% completed 3-month follow-up, and 83% completed 6-month follow-up

Participant completion rates by condition:Web-BASICS 83.7%BASICS 74.7%ASTP 67.0%

Satisfaction Ratings

Overall high satisfaction, with ASTP (M=5.35) & BASICS (M=4.99) higher than web-BASICS (M=4.58)

More learned about alcohol in ASTP (M=5.68) and BASICS (M=5.49) than Web-BASICS (M=4.87)

Web-BASICS more convenient to participate in (M=5.79) than ASTP (M=4.78) (no difference between groups with convenience of BASICS (M=5.24))

Post-Intervention Impressions of Peers: Percentage rating

mildly/moderately/strongly agree

Participants agreed presenters seemed… Warm and understanding (90.9% of ASTP;

97.3% of BASICS)

Competent and well-trained (97.0% of ASTP; 98.6% of BASICS)

Knowledgeable about alcohol use (93.9% of ASTP; 91.8% of BASICS)

Well organized (87.9% of ASTP; 93.2% of BASICS)

Limitations prior to data analysis

Randomization issues (students assigned to BASICS had fewer drinks per week and lower RAPI scores than in other conditions)

Outcome variables were skewed, so data were log transformed for analytic purposes

p < .01

Total Drinks per Week

4

5

6

7

8

9

10

11

12

Baseline 3 Month 6 Month

Control BASICS web BASICS ASTP

No time by group interactions for total drinks or negative consequences

Specific planned comparisons indicated that BASICS reduced total drinks per week more than control did

p < .01

Peak Drinks per Occasion

4

5

6

7

8

9

10

Baseline 3 Month 6 Month

Control BASICS web BASICS ASTP

Time by group interaction for peak drinks

Significant reductions for ASTP from baseline to 3-mo. and 3-mo. to 6-mo.

Significant reductions for BASICS and web-BASICS from baseline to 3-mo.

Conclusions

Baseline differences make it hard to interpret results

Implementing a peer-led intervention is feasible

Support for all three interventions reducing peak drinks/occasion; only BASICS significantly reduced total drinks per week

Some delayed effects in ASTP Initial reactivity in assessment for controls

on peak drinks that failed to be maintained over time

Peer Therapist Training for ARC

Reading packet for facilitatorsInitial 8 hours of training on alcohol

content & clinical technique Practice facilitating with a mock

participant volunteerWeekly group supervisionPossibility of individual meetings for

more practice and supervision

Peer Therapist Training (continued)

MITI Coding Team reviews for adherence and compliance assessment

Detailed review/feedback written after tape is reviewed by supervisors

Peer therapist facilitates only once MITI Coding Adherence is reached

While interventions occur, facilitators attend weekly group supervision

Facilitators may need to attend an hour individual or pair supervision with an RA during weeks when an session is completed

Possible Barriers to Implementing Effective Interventions on College

Campuses

Barriers can exist to dissemination, adoption, implementation, and maintenance (Rogers, 1995)

Source: Larimer, Kilmer, and Lee, 2005

Possible Barriers to Implementation in Implementing

Effective InterventionsProper training of those

delivering a program

A tendency to “reinvent” innovations (Rohrbach, D’Onofrio, Backer, & Montgomery, 1996)

Source: Larimer, Kilmer, and Lee, 2005

Possible Barriers to Maintenance in Implementing Effective

Interventions

Therapist drift (i.e., issues of fidelity)

Need for ongoing assessment and continued training

Source: Larimer, Kilmer, and Lee, 2005

Clinical Issues/Future Directions

Recognize that efforts with peers are one piece of the prevention program puzzle

Professional staff and peer facilitator time and energy

For whom are peer interventions most effective?

Characteristics of peer presenters vs. intervention recipients

Are problems with college students becoming more severe?90% of counseling center directors

perceive an increase in students with more severe psychological problems in recent years (Gallagher, 2005)

95% report an increase in students coming to counseling already on psychiatric medication (Gallagher, 2005)

Clinical Issues/Future Directions

Formally evaluate issues of time- and cost-effectiveness

Best practices in training and supervision Continue to explore use of peers in other

alcohol- and drug-related interventions Particularly with less clear prevention

approaches for drugs other than alcoholChallenges with a possibly more

complicated and complex student body

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1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Percentage

Percentage of all clients prescribed medication (Schwartz,

2006)

** Data for slide estimated from table appearing in Schwartz, 2006 **

Possible reasons behind perceived increase in severity of psychological problemsActual increase in problemsGreater similarity between college/general

populationGreater availability of meds could allow

students to attend college who otherwise might not have done so

Lesser stigma attached to mental illness may have led to an increase is seeking psychological services

Students under care of a provider may discontinue that once in college

CASA, 2003

Possible reasons behind perceived increase in severity of psychological problems Increased academic pressure,

competitiveness, or greater sleep deprivationFewer take time off to become stabilized

than in the past in response to stress or mental health problems

Students stop using meds upon entering college Assume they’ll be less depressed, don’t

want stigma of being on meds, or want use alcohol/drugs instead

Students using alcohol or drugs while on meds accentuate depressant effects

CASA, 2003

Thank You!

Special thanks to Ann Quinn-Zobeck

All the best in your prevention efforts!

Jason Kilmerkilmerj@evergreen.edu(360) 867-6775