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Article 84

“We Thought You'd Just Tell Us ‘Don't Do Drugs’”

A Collaborative Substance Use Intervention Program for College Athletic Teams

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Paper based on a program presented at the 2016 American Counseling Association Conference, April 2, 2016, Montreal, Canada.

Catie A. Greene

College student-athletes have been identified as a population at risk for the development of specific mental health issues such as problematic substance use (Brenner & Swanik, 2007; Ford, 2007). Though student-athletes often identify as a part of a group and typically use substances with teammates (Ford, 2007), a vast majority of interventions reported in recent literature have been designed for individual student- athletes only (Doumas, Haustveit, & Coll, 2010; Turrisi et al., 2009). There is a paucity of research on interventions for reducing substance use and related risks that addresses an entire team dynamic (Parcover, Mettrick, Parcover, & Griffin-Smith, 2009). Furthermore, when athletic coaches do contact counseling services or campus health promotion for intervention programming for the entire team to reduce problematic substance use, the expectation that the student-athletes tend to hold is that they will be lectured about change rather than change being evoked from the team itself.

This paper will provide an overview of the design and implementation of a 6- week program for counselors to support college athletic teams in making culture changes surrounding substance use. Motivational interviewing (MI), a non-confrontational, evidence-based approach that is a particularly effective counseling modality for reducing college students’ problematic substance use, will be presented as the overarching framework for the program. The benefits of utilizing a team-based MI approach that evokes change talk from within an athletic team, conceptualizes the stages of change from a group rather than individual perspective, and rolls with both individual and team resistance to change will be highlighted.

Review of Literature

Problematic Substance Use Among College Student-Athletes

Student-athletes generally abuse alcohol more so than non-athlete peers (Mastroleo, Scaglione, Mallett, & Turrisi, 2013). Both individual personality factors, such as risk-taking and competitiveness, and peer influences have been associated with this difference (Mastroleo et al., 2013). The consequences of an individual athlete’s problematic substance use include negative impacts on health, and athletic and academic performance that ultimately impact the team as a whole. For example, 30% of student- athletes surveyed in 2014 reported experiencing a blackout due to drinking, which increases the risk of injury, alcohol dependence, and other major health and legal consequences (Hainline, Bell, & Wilfert, 2014). More than 25% of those surveyed reported missing class and another 16% reported performing poorly on an exam or in practice due to drinking. Student-athletes who reported using marijuana within the past 30 days of the survey reported failing grades at three times the rate of those that reported no marijuana use (Hainline et al., 2014). These consequences ultimately impact the health of the team when an individual athlete is unable to meet the team’s academic and athletic performance expectations due to problematic substance use.

Additionally, student-athletes have been found to significantly overestimate peer- athlete drinking norms in comparison to non-athletes (Perkins & Craig, 2012; Yusko, Buckman, White, & Pandina, 2008). Perkins and Craig (2012) found that student- athletes’ overestimation of male athletes’ drinking norms predicted increases in both male and female athletes’ personal alcohol consumption, whereas overestimation of female athletes’ drinking norms predicted increases in female athletes’ personal alcohol consumption. These misperceptions, when left uncorrected, may lead to significant substance use concerns for student-athletes both individually and for the athletic team as a whole (Perkins & Craig, 2012).

Intervention Programming for College Student-Athletes

Because peer substance use misconceptions have consistently been found to significantly influence college students’ personal substance use, structured interventions with individual college students mandated for treatment typically address both peer influence and overestimation of peer alcohol consumption from an MI framework (Dimeff, Baer, Kivlahan, & Marlatt, 1999). For example, in the Brief Alcohol Screening and Intervention for College Students (BASICS), students are provided psychoeducational feedback on personal substance use and perceptions of peer use as compared to campus norms and are able to openly process their reactions to the information. A counselor, guided by MI techniques, helps foster the students’ personal change talk related to substance use. BASICS has been adopted by several universities nationwide for its effectiveness in reducing problematic substance use among college students (Dimeff et al., 1999). Cimini and colleagues (2015) modified the BASICS program to provide individualized feedback about norms specific to student-athletes and found significant reductions in alcohol use and related consequences and increases in use of protective behavioral strategies along with corrections of norm misperceptions at 3 months post-intervention. Doumas et al.’s (2010) Web-based normative feedback program for individual athletes at high-risk for substance use concerns also resulted in significantly greater reductions in drinking and changes in assumptions about peer drinking than an education-only comparison. Gregory (2001) delivered similar programming to student-athletes in a group format, to include personalized feedback on alcohol use, norms, and consequences, as well as risk-reduction skills. This intervention resulted in decreases in perceived drinking-related norms and positive expectancies related to alcohol use but no significant decreases in actual alcohol use and consequences. This program was delivered to groups of student-athletes who met inclusion criteria for potential substance use concerns rather than to entire teams.

Support for Team-Based Interventions

The aforementioned interventions for high-risk individual athletes are supported by the literature on general universal prevention, intermediate, and targeted intervention programming on college campuses, as it is often not necessary and may even be detrimental to include both individuals who are in need of targeted intervention programming and those who may only need universal prevention programming into one program (Mann et al., 1997; O’Connell, Boat, & Warner, 2009). However, the unique qualities of the subculture of athletics, such as the notion of the team’s culture, teammate influence on substance use, and the expectation that the individuals are working towards universally held goals, may call for interventions that do target the entire team when problematic substance use has impacted some of its members. This is particularly indicated when athletic coaches request such programming.

In response to the frequency of requests from athletic coaches for counselors to provide consultation to entire teams for concerns such as substance use, Parcover and colleagues (2009) proposed a systemic model for counselors called to facilitate such programs. A systems approach to substance use counseling with college student-athletes may be justified by the known role that teammates and social norms play in increased substance use among college student-athletes. As it was previously highlighted that perceived social norms significantly influence college students’ and student-athletes’ personal substance use, unlike individual approaches, a team-based intervention focused on encouraging authentic discussion may demystify teammates’ perceived substance use patterns and reduce the influence of these misperceptions on student-athletes’ personal drinking behavior.

An additional benefit of a team-based intervention is that the team’s culture can be discussed as something larger than each of its individual members. Schroeder (2010) interviewed 10 NCAA head coaches to identify the leadership strategies used to change collegiate athletic team culture and found that identifying the dysfunction, establishing a vision, and creating psychological safety were among the several ways athletic coaches helped their teams to shift from less to more effective team cultures in and out of competition. A team-based intervention, as opposed to individual-only or a group with athletes identified as being at high-risk from several teams, allows for the opportunity to talk with the entire team about how current substance use fits or does not fit within a desired team culture.

Program Description

Program Development

The current program was developed due to a demand from athletic coaches for team-based interventions on the college campus where the author was the co-director of a substance use counseling training clinic. This training clinic provides substance use counseling services to the student body from an entirely motivational interviewing framework, as its clients are largely mandated for treatment, and this approach has a strong evidence-base for evoking change with mandated populations (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). In response to these requests for team-based programming, the author developed a 6-week, three-session program based on the extant literature on athletic team culture change and individual substance use interventions for student-athletes. The program is informed by MI and modeled after the treatment protocol the training clinic provides to individual clients.

Overview of Motivational Interviewing

MI is a person-centered, strategic approach that utilizes the processes of engaging, evoking, focusing, and planning with the intention of working alongside individuals through the stages of behavior change (Miller & Rollnick, 2013). The ultimate goal of MI is to strengthen a person’s own change talk in the face of ambivalence and resistance. The transtheoretical model of behavior change suggests that counselors tailor therapy to the client’s presenting stage of change, generally calling for insight and awareness-building modalities for those in earlier stages of change and action-oriented therapies for those in later stages (Norcross, Krebs, & Prochaska, 2011). The objective of MI is to empathically and intentionally support change with four therapeutic processes that roughly correspond with the transtheoretical model’s stages of change: (1) engaging, (2) focusing, (3) evoking, and (4) planning (Miller & Rollnick, 2013).

In brief, the engaging processes consist largely of empathic reflection and some paradoxical interventions, such as amplifying reflections (overstating the person’s arguments against change with the expectation that the individual will then argue against that reflection in the direction of change) or double-sided reflections (presenting arguments for change and against change back to the individual and intentionally placing arguments for change last with the expectation that the individual will then continue to argue for change). The focusing process consists largely of identifying a direction for change, and the evoking process consists of drawing out the individual or team’s reasons for change in this direction. The planning process consists of continuing to engage with, focus, and evoke change talk and change plans from the individual or group (Miller & Rollnick, 2013). Most importantly, Miller and Rollnick (2013) identified a spirit that characterizes an ideology held by those that effectively practice MI to include a belief and emphasis on client autonomy, unconditional positive regard, and collaboration.

Conceptualizing the team’s stage of change.In the current program, an emphasis is placed on team culture as an ideology each individual student-athlete has ownership of (Schroeder, 2010). With an emphasis on team culture, throughout this intervention the team can collectively determine if they are currently satisfied with the role of substance use in their culture (pre-contemplation), considering making improvements to the role of substance use within their culture (contemplation), ready to make improvements to the role of substance use within their culture (preparation), actively engaging in making improvements to the role of substance use within their culture (action), or working on strengthening recent improvements to the role of substance use within their culture (maintenance). The role of the facilitators of the program is to conceptualize as best as possible the team’s stage of change and for that conceptualization to inform the appropriate selection of MI therapeutic processes (engaging, focusing, evoking, planning) to support the entire team’s movement from one stage to the next.

Intervention Protocol

The following is the general protocol for the three-session, 6-week intervention with corresponding MI processes to be applied in each 90-minute session. As was previously mentioned, these processes may be somewhat different depending on team stage of change.

Session one: Engaging and focusing.The first 10 minutes of this session begin with introductions to include or not to include the team’s coaching staff who may wish to make a statement to the team regarding their reason for requesting the program. After the coach exits, the facilitators explain their roles and that they’ve determined that maintaining the team’s confidentiality regarding what they share with the facilitators is an important part of this program. The facilitators then inform the team that they have decided that the team itself should have ownership of what and how they share their progress with their coach, who may be expecting to hear from the student-athletes about their progress. The facilitators then allow time for the student-athletes to decide how they would like to inform their coach and suggest that other groups have invited their coach to some portion of the last session. From experience, this tends to be the most powerful option. Another option to provide to the team may include appointing one or more team members (such as a captain) to meet with the coach after each week’s session.

A note about trusting the process in session one.It is through this discussion that the facilitators are able to set the tone for the program, which is to emphasize the student- athlete’s ownership within the mandated process. As with all the interventions that follow within this program, this is a major risk undertaken by the facilitators. Questions arise such as: What if the student-athletes decide they don’t want to tell their coach at all? What if they come up with an idea that’s unrealistic? It’s important that the facilitators model trusting this process. This reflects a trust that the team is inherently good and that its members are in fact equipped to determine what’s best for their team culture.

Following this discussion, the student-athletes then complete the pre-assessments determined for program evaluation by the facilitators along with whatever informed consent forms are needed. Over the next several minutes, the facilitators acknowledge and evoke the team’s potential reservations, frustrations, and low expectations for the program. Within these first few minutes, the facilitators’ role is to empathically reflect these concerns with the intent of listening for some change talk within these statements. For example, a student-athlete might say: “I don’t understand why coach made us come here. We drink a lot less than most teams on this campus. We’ve had a few slip ups the past few weeks but we definitely don’t have a problem with drinking.” To this, the facilitator might respond with: “It’s really frustrating to be here and it even feels unfair given that your team doesn’t drink as much as other teams. There have been some slip ups with drinking lately that you don’t feel are a reflection of your team’s values.”

The discussion continues in this way with facilitators mindfully collecting barriers and motivators for the team’s change. It is not suggested that the facilitators remind the student-athletes of their reason for being mandated to the program, as this is expected to increase the student-athletes’ arguments against change. What facilitators have noticed is that by not asking for these incidents, the student-athletes often reveal these themselves throughout this discussion. This is considered to be much more meaningful for change than if facilitators did so and is likely a response to the facilitators not meeting their expectation of shaming them for those incidents (Miller & Rollnick, 2013).

After some time, the facilitators may ask the team, having been mandated to this process, what they would like to see happen in the space. Through experience, student- athletes tend to be better able to identify the activities or approaches that they would rather not see in the space than what they would like to see. Evoking what they would not like to see happen (such as being lectured about problematic substance use) is considered to be equally important to evoking what they would like to see happen. The facilitators also may offer the team an option of viewing psychoeducational materials specific to student-athletes in the following sessions.

During the final 20 or so minutes of this session, facilitators summarize the team’s barriers and motivators to change and are mindful to summarize motivators to change last. It is important to highlight the positive aspects of the team’s culture that are noticed by the facilitators and that this is communicated to the team, being mindful to insert the term team culture when doing so. The facilitators and the team discuss what their roles or homework will be before the next session in 2 weeks. Perhaps this already includes some behavior change ideas decided by the team, one of the team members meeting with the coach, and the facilitators gathering requested psychoeducational material specific for those particular student-athletes.

Session two: Focusing, evoking, and planning.This session begins with a check-in regarding how the last session was for the student-athletes, what efforts have been made between sessions on their part, and continuing the discussion from the previous session about barriers and motivators to change. If psychoeducational materials were requested, the team may be asked if they’d prefer to review the information together in the beginning or end of the session. After about 20 minutes of discussion and facilitator summary, the facilitators then ask permission from the team to do a more structured activity in regards to their overall team culture.

With the team’s permission, the facilitators then ask two team members to volunteer to write for the team either on a whiteboard or large paper. The first volunteer is asked to draw a large circle and the entire team is asked to name qualities or activities that they really like about their current team culture and want to continue. This could include qualities such as competitiveness at practice or team gatherings outside of athletics. The other volunteer is then asked to draw a triangle within that large circle to represent a slice of the team’s culture that takes up no more than an eighth of the large circle. The team is then asked to identify the qualities or activities within their team culture that they would like to remove or improve.

A note about trusting the process in session two.During this structured activity, the team is asked to identify any and all qualities or behaviors they really enjoy or may want to improve about their team. It is the facilitators’ hope and trust in the process that the team members will identify some aspect of problematic substance use as something that they would like to be different for their team’s culture moving forward. Effective program facilitators trust that, by virtue of the student-athletes being mandated to this program and the strength of the facilitator’s skills in applying MI in the discussion to evoke change talk from the student-athletes in the first session, identification of problematic substance use will emerge as expected in this activity.

Once substance use is mentioned by team members, the facilitators ask the writer to circle the items related to substance use that are identified in the triangle of qualities the team would like to see improve about its culture. That member is then asked to draw arrows extending out of the circles and then the entire team is asked to identify ways they may be able to go about making that particular change. For example, we have seen that athletic teams are typically able to identify a particular time of year that their team engages in more problematic substance use, resulting in getting into trouble by their coaching staff or the university. If the team identifies their first month off-season as a problematic drinking month and something they would like to improve, the team is then asked to identify what they might be able to do differently before or during that month, and the writer lists those ideas.

It is in this session that the facilitators are notably more hands-off than in the first session as the team members engage in dialogue, or maybe even disagreements with one another over their desired changes and ideas for how to go about those changes. The facilitators’ role during this process is to offer summaries and evoke change talk through reflections when needed. It is helpful during this process to continuously acknowledge the healthy aspects of the team’s culture that they are hoping and wanting to maintain.

At the end of this session, the facilitators can offer to e-mail the entire team or one member the final results of their activity and goals for moving forward. Team members and facilitators then discuss homework or responsibilities before the final session in 2 weeks. If team members chose to have their coach be present for some portion of the final session, the details of how the team will share their message with the coach is discussed with the team and the exact time the coach is expected to be present is determined.

Session three: Evoking and planning.At the outset of this final session, the team members and facilitators review the activity from the previous session and troubleshoot potential change plan options that may have been realized as unrealistic or not effective within the 2 weeks since the last session. The team spends time discussing and planning how they would like to share their message with their coach. Team members typically write the main points that they would like to express. The facilitators’ role in this process is to continuously evoke the team’s coach as a major motivator to their change. When discussing how they’d like to share their message with their coach, the team members typically acknowledge that their coach would like to hear a realistic, sincere message. This process may take some time as team members challenge one another on the authenticity of their message and change plans.

A note about trusting the process in session three. It is during this session that the facilitators will notice that they are almost insignificant as the team exchanges ideas about change planning with one another and prepares to share their message with their coach. The facilitators may feel some responsibility over the team’s change and concerned that the coach may be unhappy with the progress the team reports and so may be frustrated with the facilitators. Throughout the program, the facilitators’ role is to encourage the team to take ownership of their time in the intervention and for their changes. It is important for the facilitators not to lose sight of this intention and to instead welcome the coach’s expression of frustration with a lack of progress, as this can fuel the team’s motivation to change and encourage deeper reflection between team members. For this reason, it is suggested to leave ample time for processing with the team and their coach, with no less than 30 minutes for this process.

This final session ends with team members completing post-assessments selected by the facilitators for program evaluation, as well as any evaluation forms the facilitators have designed for the student-athletes to provide feedback about the program. The team has likely written some concrete change goals and plans in this session that the facilitators can offer to e-mail. The coach may request a follow-up session with the team at a later time in the year that may be arranged.

Program Evaluation

Suggested assessment tools for monitoring student-athletes’ pre- and post-attitude and behavior change include: the Alcohol Use Disorders Identification Test (AUDIT; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), the Drug Abuse Screening Test (DAST; Skinner, 1982), and the Short Inventory of Problems for Alcohol and Drugs (SIP-A; SIP-D; Alterman, Cacciola, Ivey, Habing, & Lynch, 2009), which measure frequency and quantity of alcohol use, severity of drug use and related consequences, problems experienced as a result of alcohol use, and problems experienced due to drug use, respectively. In accordance with the spirit of MI, it is recommended that the student- athletes be provided with an opportunity to provide feedback about the intervention at post-assessment. This can be accomplished through a rating scale with some open-ended questions with space for comments about the program and its facilitators.

Conclusion

Considerations for Adaptation

There are several elements of this program that may be adjusted in order to meet the specific demands of student-athletes on a particular campus. Perhaps there may not be six full weeks left in the semester when the request from the coaching staff for this program is made, so the program may be run over the course of three consecutive weeks. At times facilitators have found it to be appropriate to split into small groups in order to focus on one specific aspect of their change plan to bring back to the team. Perhaps the team determines that it would like for the coach to be present after each session, which would change the dynamics of each weekly program.

In terms of conceptualization, if facilitators notice that the team generally seems to remain in the pre-contemplation stage of change late into the second session, it wouldn’t be suggested to have the team come up with change plans, as their lack of readiness for change would contraindicate this activity. It has been found that the facilitated discussions and use of MI do help to move the team from pre-contemplation to contemplation quite quickly; however, if this is not the case, it is suggested to continue to utilize the engaging and focusing processes of MI, even if this is all that is done for all three sessions, resulting with the team at least being able to identify some reasons for change.

Typically, precipitating events for a request for this program may be one or several individual team members testing positive for drug use or having received other academic, medical, or legal consequences related to substance use. This program is not intended as an alternative to those individuals needing treatment for substance use concerns, but rather an intervention for the entire team. Student-athletes who are also undergoing individual substance use treatment at the same time that their team is involved in this programming could certainly be involved in the team’s program with no major anticipated conflicts. From experience, we have found this only to enhance individual treatment.

Conclusion

The motivation for developing this program was due to a demand from athletic coaches. College counselors or health promoters across college campuses may be similarly asked to deliver such programming to athletic teams. It is ideal if facilitators have some personal or professional experience with college athletics, as knowledge and appreciation of this subculture is helpful when counseling student-athletes (Ward, Sandstedt, Cox, & Beck, 2005). It is also highly recommended that facilitators of this program have a working knowledge and experience applying MI with college students with concerns related to substance use. The defining element of this program is the expertise placed on the student-athletes and the team as a whole to identify their vision for their team culture and to identify their goals and objectives related to reducing problematic substance use in order to move towards that vision. It’s most important that facilitators of this program trust that it is rare that a team of student-athletes identifies problematic substance use as a part of their vision for their optimal team culture. With all of the consequences student athletes face as a result of problematic substance use (Hainline et al., 2014), reducing these consequences is a value the team likely intrinsically holds. The power of the program is in the facilitators’ ability to evoke this value from the team itself so that the changes made are lasting and meaningful. This concept of evocation for lasting change is the basic underpinning of the MI approach (Miller & Rollnick, 2013).