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Article 36

CHOICES About Alcohol

A Brief Alcohol Abuse Prevention and Harm Reduction Program for College Students

George A. Parks and Mark S. Woodford

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CHOICES is the most recent outgrowth of the evidence-based harm reduction modality of the Alcohol Skills Training Program (ASTP) (Kivlahan, Marlatt, Fromme, Coppel, & Williams, 1990). This latest ASTP model can be used for all three levels of alcohol abuse prevention for college students. For example, CHOICES can be used as an indicated prevention program serving the needs of college students who have already developed alcohol-related problems. CHOICES can also be directed at all college students on a campus (universal prevention) because its content applies equally to all levels of alcohol use from students who abstain from drinking to those who are frequent heavy drinkers. In addition, CHOICES can be a targeted intervention for subgroups of students at higher risk for alcohol abuse (selective prevention), such as freshman, athletes, or members of the college Greek system (Larimer & Cronce, 2002).

Alcohol Skills Training Program Modalities

Research conducted at the Addictive Behaviors Research Center (ABRC) at the University of Washington by Alan Marlatt and his colleagues demonstrating the efficacy of ASTP in reducing student drinking and alcohol-related harm provides the evidence base for the development of CHOICES. ASTP is based on cognitive behavioral skills training, such as relapse prevention, and motivational interviewing strategies that are designed to address a student’s level of readiness to change his or her drinking behavior (Baer et al., 1992; Kivlahan et al., 1990; Miller & Rollnick, 2002). While the various ASTP delivery modalities appear quite distinct, they all incorporate a core curriculum of basic alcohol information, cognitive-behavioral skills building, and an engaging delivery style that meets students where they are regarding their drinking behavior.

Following are descriptions of four separate indicated prevention modalities based on the ASTP research:

1. ASTP Student Self-Help Workbook:This modality consists of a self-guided instructional manual containing six units based on the facilitator guide used in the 6-week classroom version of ASTP. Each section of the workbook includes graphs and diagrams of important points, “new ideas,” and exercises that elaborate on important points. An advantage of this program is that it is self-contained and does not require instruction. A disadvantage is that it requires considerable self-initiative and motivation by a student to complete. Students who completed the workbook had comparable reductions in drinking to those completing the 6-week ASTP classroom course, but only 11 of 30 students or 37% completed five of the six sections of the self-help workbook.
2. ASTP Classroom Course:This 2- to 8-week course offers students brief didactic presentations and small group discussions lead by a peer educator or health professional. Exercises consist of class dialogues and demonstrations including role-playing. The 6-week course includes a discussion of models of addiction and a “placebo drinking challenge” in a simulated bar including a discussion of the role of expectancies in alcohol consumption (only for students over 21 years of age). The classroom format provides the advantage of developing positive peer relations that value reduced risk drinking and fosters open discussion of drinking experiences and their consequences. As a result, ASTP classroom participants benefit from a broader range of information and develop skills that they might not have within one-on-one sessions.
3. Brief Alcohol Screening and Intervention for College Students (BASICS)(Dimeff, Baer, Kivlahan, & Marlatt, 1999): BASICS was modeled after the Brief Drinker’s Checkup (Miller & Sovereign, 1989) and consists of two 45- to 60- minute sessions: one to assess a student’s drinking pattern, related attitudes about alcohol, and motivation to change drinking, and a second to provide the student with the feedback about personal risk factors and advice about ways to moderate drinking. Students who complete BASICS receive computer-generated personalized graphic feedback summarizing the material reviewed in the second feedback and advice session. Although brief, BASICS combines information about alcohol effects, identification of personal risk factors, discussion of specific cognitive and behavioral strategies to moderate drinking, and motivational interviewing strategies aimed at building interest in changing heavy drinking behavior (Miller & Rollnick, 2002).
4. CHOICES: A Brief Alcohol Abuse Prevention and Harm Reduction Program:The previous three ASTP modalities are all indicated prevention program while CHOICES, the newest member of the ASTP family, was developed to serve the needs of students at risk for alcohol-related problems, but not yet showing any signs or symptoms. As such, CHOICES is typically implemented as a selective prevention, although it has also been used in universal and indicted prevention applications. As is true of the other ASTP modalities, information about alcohol and related risks is embedded within a broader frame of lifestyle behaviors in this brief group intervention.

Outcome Research on the Alcohol Skills Training Program

In this section, three studies conducted to empirically test the effectiveness of the Alcohol Skills Training Program are briefly reviewed. The initial study (Kivlahan et al., 1990) compared the efficacy of an 8- week ASTP classroom course for high-risk drinkers to an Alcohol Information School format modeled after the Washington State program for first time offenders convicted of driving while intoxicated. An assessment- only control group was also included in the research design. Students assigned to the control condition participated in all baseline and follow-up assessment procedures, but received no prevention program until after the completion of the 1-year follow-up period. At the baseline assessment, students in all three groups reported an average of 15 drinks per week and an estimated peak weekly blood-alcohol level (BAL) of .13% (.08% or above defines legal intoxication for driving in most states). At the 1-year follow-up, ASTP participants reported 6.6 drinks weekly and a peak blood-alcohol level of .07%, compared to 12.7 drinks per week and a peak blood-alcohol level of .09% for students in the Alcohol Information School condition, and 16.8 drinks per week and a .11% peak blood-alcohol level for the students in the assessment-only control condition.

The second ASTP study (Baeret et al., 1992;) replicated the first study and compared the effectiveness of three different delivery modalities: a 6-week classroom format, a 2-hour BASICS brief intervention, and a student self-help workbook based on the content of the 6-week class. Students reported drinking an average of 20 drinks per week at baseline, spread across four drinking occasions. Estimated peak blood-alcohol level was at .14%; and students reported experiencing numerous problems due to drinking. As in the first study, students on average significantly reduced their alcohol consumption during the course of the study. Gains were maintained throughout 1- and 2-year follow- up periods. Average drinks per week declined overall from 12.5 to 8.5 drinks per week. Average peak BAL was also reduced from .14% to .10%. High attrition in the student self-help workbook group limits any conclusions that can be drawn about the efficacy of that modality, although as stated earlier those who completed five of the six workbook sections (37%) had drinking reductions comparable to the other two modalities.

The third ASTP study was designed to replicate and extend the earlier studies of brief motivational and skills-building interventions with college student heavy drinkers (Baer, Kivlahan, Blume, McKnight, & Marlatt, 2001; Marlatt et al., 1998). Briefly, 2,157 incoming freshman were screened while seniors in high school for purposes of participating in a 4-year longitudinal study. The 508 students deemed most at risk for alcohol problems were selected to participate in the study. Risk criteria included a pattern of heavy alcohol consumption at the time of the initial screening or a history of problems due to alcohol. Of these, 366 were ultimately recruited and were randomly assigned to either an experimental or high-risk control condition that received the assessment procedures only.

Results from third ASTP study have been described in the prevention literature (Baer et al., 2001). While high-risk drinkers in both the experimental and control condition reported a mean decrease in consumption of alcohol at 1- and 2-year follow-up, students receiving BASICS made significantly greater reductions in their use. Furthermore, students receiving BASICS reported significantly fewer alcohol-related problems compared to the high-risk control group and fewer symptoms of alcohol dependence as compared to the high-risk control condition. Statistically significant decreases were found for both alcohol consumption and problems, but the size of the treatment effect was greater for drinking problems.

Implementing CHOICES

The delivery vehicle of the CHOICES program is a guided writing process called Interactive Journaling®‚ in which each student receives a copy of a full-color and durable workbook, or interactive journal, that presents the core information of the ASTP program for use as a self-help workbook or for use as a discussion guide in a classroom course. Interactive journals provide students with an experiential writing experience that guides them to reflect on the core information contained in the ASTP and to write journal entries focused on what the ASTP information means to them in ways that encourage positive lifestyle change. Interactive journals are utilized widely in substance abuse treatment, in criminal justice offender rehabilitation programs, in impaired drinking programs, in healthcare programs, and, as with CHOICES, in the alcohol and drug abuse prevention field.

CHOICES implementation applies the same core content and philosophy as other ASTP modalities. Major topics addressed in the CHOICES program include

• transition to college and unique risks of the college experience;

• normative facts vs. expectations;

• decisional balance exercise on alcohol use pros and cons;

• biological/ physiological facts about alcohol;

• expectancy effect;

• calculating BAC, alcohol content by drink type, effects of BAL and tolerance;

• consequences inventory;

• alcohol poisoning risk and response;

• personal risk assessment and harm reduction strategies; and

• self-monitoring and coping strategies.

The recommended time frame for CHOICES delivery is one or two sessions spanning 45 to 90 minutes, each depending on the specific implementation strategy a campus is using.

The first session of CHOICES consists of a presentation of core information, short journaling exercises, and brief interactive discussions of major points. Questions are posed to students for written response within the journal. These journaling activities are important because they assist students in engaging in the material and in applying new information to their individual life circumstances. In order to optimize time and maintain flexibility of implementation, students may complete their written response to the journaling questions in advance, during the group session, or afterwards. Students are encouraged to keep and continue to reflect on the journal content following the session. New variations on this program have also combined advanced Web-based assessment and feedback as a precursor to the CHOICES experience.

CHOICES can also incorporate an optional follow-up session to be held 2 weeks after the initial meeting, making it similar to a group-delivered BASICS feedback session. The emphasis of the second session is on reviewing the results of a self-monitoring exercise, identification of various drinking experiences within the group, and a review of students’ experimentation with the strategies introduced during the first session. The second CHOICES session also includes time to discuss how core concepts from session one have or will influence student drinking choices and how students can continue to effectively employ, in an individually tailored way, the harm reduction strategies presented in session one.

While CHOICES can be implemented individually or in groups, its most common application is in a facilitated group environment. For example, CHOICES can be delivered in freshman classes or orientation programs, on residence hall floors, or as an alcohol abuse prevention program for high-risk groups, such as Greek houses and athletes. The CHOICES program is also frequently used with first-time alcohol policy violators.

Conclusion

The CHOICES alcohol abuse prevention program was designed by placing the core components of the ASTP model within a proven client delivery system for alcohol and drug education, prevention, and treatment. The implementation of CHOICES is supported by a highly structured facilitator guide to assure the fidelity of the clinical implementation of evidence-based programs.

The primary goals of CHOICES are to arm students with accurate information, inform them of their level of exposure to harm, and provide them with a menu of coping strategies that will encourage them, through a self-reflective process, to choose to change high-risk behavior.