At the University at Albany in 2000, Chad Waxman fit the profile of a college student primed for risky drinking: A freshman male fraternity brother who drank in high school, Waxman chose Albany in part for its balance between work and play. "I wanted that time to let loose," he says.
Despite the predictors, Waxman sailed through college in health and happiness, even serving in student government and winning multiple leadership awards at the university before graduating in 2003. He went on to earn his master's degree in counseling psychology and school counseling from Albany in 2005 and is now a PsyD candidate at Nova Southeastern University.
How did Waxman, now 33, avoid the pitfalls of drinking common among college students? That's a question psychologists are probing deeply. After all, each year, more than 1,825 college students die from alcohol-related accidents and nearly 600,000 are injured while drunk, according to a 2009 study in the Journal of Studies on Alcohol and Drugs. Another 696,000 are assaulted by another student who has been drinking, and 97,000 are victims of alcohol-related sexual assault or date rape, the study found.
Then there's the 25 percent of college students who report academic consequences related to alcohol — a hangover can quickly derail plans for class or study — and the 11 percent who admit damaging property after a night of drinking (Journal of American College Health, 2002). An estimated 5 percent get into legal trouble as a result of alcohol, the same study found. In all, of the 80 percent of college students who drink alcohol, half "binge drink," or consume about four drinks in two hours for women and five in two hours for men, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
"College drinking is sometimes still viewed as a harmless rite of passage, when in fact [college students] are drinking more than any other age or demographic group," says psychologist James Murphy, PhD, of the University of Memphis, who studies addictive and health risk behaviors, including among college students.
That's particularly dangerous given that research shows this age group is much more impulsive even when alcohol's not involved, he says. There's also evidence suggesting that excessive alcohol use in young adulthood may impair brain development, including in cognition and memory, according to the NIAAA.
But college also presents an opportune time to equip students with the skills to approach alcohol intelligently, says Murphy. With 63 percent of young Americans ages 25 to 29 having completed at least some college, according to a report from the Pew Research Center, the setting is "a last prevention point for our society to address the risks associated with drinking," he says. (Most research on college drinking so far involves mainly full-time students in four-year colleges and universities.)
For Waxman, the time was ripe. As a peer facilitator in Albany's Counseling Center, he helped motivate other students — and in effect, himself — to shift their drinking behaviors using one of many emerging interventions designed and tested by psychologists. The approaches address why a student drinks and are tailored for specific populations of students, such as athletes and freshmen. Some interventions are targeted to align with specific events, such as 21st birthday celebrations, as a way to reroute dangerous decisions made on a night that notoriously gets out of control.
"Through learning the realities of alcohol, I realized you don't have to drink like it's a competition to have fun," Waxman says.
Most important, these interventions are evidence-based, says Mary Larimer, PhD, director of the University of Washington's Center for the Study of Health and Risk Behaviors and associate director of the Addictive Behaviors Research Center.
"We know a lot more about what influences excessive alcohol use in this population and we can tailor the interventions to address those risk factors as well," Larimer says. "That's contributed to our ability to make a difference."
One way psychologists are fine-tuning their efforts is by pinpointing who is most at risk for problems related to drinking. So far, research indicates that those most at risk are incoming freshmen, student athletes and those involved in the Greek system. Studies also show that men tend to drink more on average than women — but women progress faster over time from alcohol use to abuse, says Larimer. In fact, one study led by psychologist Bettina Hoeppner, PhD, of Harvard Medical School's Center for Addiction Medicine, found that college women exceed the NIAAA's weekly limits more often than men (Alcoholism: Clinical and Experimental Research, 2013).
"The gender gaps have closed a lot," Larimer says.
Personality factors, such as impulsivity and sensation-seeking, also contribute to risky drinking. Psychological research suggests that how different people respond to alcohol can help predict whose behavior will become problematic. Those who need a lot to experience its effects or who experience more of alcohol's stimulating rather than sedative effects, for example, are at higher risk. Students who overestimate how much their peers drink, as well as those who expect great things from alcohol ("I will feel outgoing and meet my future boyfriend!"), are more likely to overindulge and experience alcohol's negative consequences, such as engaging in unsafe sex, adds Larimer.
Another factor appears to distinguish between students who drink a lot yet remain relatively safe and those who drink the same amount or less yet suffer the consequences: subjective intoxication. In other words, a student's likelihood to get into trouble during or after drinking has as much to do with how drunk he or she feels as it does with how much he or she actually drinks, according to an NIAAA-funded study conducted by Kim Fromme, PhD, of the University of Texas at Austin's SAHARA Lab (Studies on Alcohol, Health and Risky Activities) and colleagues. And those different perceptions could have biological roots, Fromme says.
"We're predicting specific genetic influences on those differences in people's subjective levels of intoxication," she says.
Why a student drinks can also reveal a lot about how problematic his or her alcohol use may become, according to Clayton Neighbors, PhD, who directs the University of Houston's Social Influences and Health Behaviors Lab. While some students drink for social and environmental reasons, such as being at a party, others drink for emotional reasons, such as coping with a bad grade or a breakup. It's the latter group — who may be turning to alcohol to handle another mental health problem such as post-traumatic stress disorder, depression or anxiety — whose members are primed for long-term alcohol abuse, researchers say.
More effective interventions
Up until the late 1990s, most colleges and universities approached risky drinking from a one-size-fits-all perspective. Campus-wide awareness campaigns and educational sessions during freshman orientation were popular but ineffective, the NIAAA Task Force on College Drinking found in 2002.
That changed in 1999 when the late psychologist Alan Marlatt, PhD, of the University of Washington, and his team introduced Brief Alcohol Screening and Intervention for College Students, or BASICS. The intervention is used in varying forms by colleges nationwide when students come in for primary care or mental health services or are referred for an alcohol-related offense. BASICS gives students personalized feedback on their drinking behaviors, including comparing how much they drink with how much the average student on their campus drinks. The intervention also uses motivational interviewing by asking students open-ended, non-judgmental questions to explore drinking behaviors and generate motivation to change. Finally, it offers individualized strategies — such as putting ice in drinks or assigning a designated driver — to help students drink in less risky ways. The method, which has been shown to reduce how much students drink as well as to reduce related negative consequences up to four years out, meets NIAAA's highest standards for evidence-based college drinking interventions (American Journal of Public Health, 2001).
But BASICS doesn't work for every student. Those with high levels of social anxiety, for example, aren't easily influenced to change by the notion that they're overestimating how much their peers really drink. This can make them less receptive to the "norms correction" component of BASICS, a 2012 study in Psychology of Addictive Behaviors finds. About one-third of students who receive the intervention don't change their drinking habits. Another drawback to the intervention is staffing: The traditional method requires one or two 50-minute sessions with a trained facilitator, who is often a mental health professional.
That's why many psychologists are experimenting with variations of BASICS, such as by offering it in a Web-based format or presented by trained peers, rather than by mental health professionals. Researchers are also looking at ways to shorten the intervention: A 2013 study in Addictive Behaviors by Larimer and colleagues found that a 10-minute version of BASICS was just as effective as a 50-minute one.
Larimer says shortening the intervention by picking and choosing from among its individual components — namely, the part that corrects students' misperceptions of campus norms and the one that offers strategies for safer drinking — might be enough to elicit short-term effects and to work for students at lower risk. "The more comprehensive interventions, then, may have longer-lasting effects," she suspects, but she says more research is needed to tease apart which variations work for whom.
There's also evidence that students can deliver the interventions just as effectively as mental health professionals. In one study, Larimer and colleagues delivered a BASICS-like intervention to 12 fraternities, varying who gave them feedback — either a peer interviewer or a professional research staffer. They found that both groups significantly reduced their alcohol intake when compared with controls (Journal of Alcohol Studies, 2001). Another study led by Fromme that looked at peers and professional providers who headed an alcohol prevention "lifestyle management course" for college students found similar outcomes (Journal of Consulting and Clinical Psychology, 2004).
But the research comes with caveats, says University at Albany psychologist Maria Dolores Cimini, PhD, who explored peer facilitators' effectiveness through a five-year study funded by an NIAAA Rapid Response to College Drinking Problems grant and got mixed results. "Students can deliver these interventions, but they must be well-trained and very closely supervised," she says (Journal of Studies on Alcohol and Drugs, 2009).
Waxman, who became trained as a peer facilitator at Albany's Counseling Center during his sophomore year, said his efforts paid off among the peers he intervened with. "Having someone you can relate to … saying, ‘This is the reality,' really changes behavior," he says.
Building on BASICS
At the University at Albany Counseling Center, an intervention called the STEPS Comprehensive Alcohol Screening and Brief Intervention Program takes BASICS and tailors it for specific populations of high-risk drinkers, including first-year students, student athletes and students seeking primary health and mental health care on campus. A student athlete, for example, learns how alcohol affects hydration and athletic performance — even days after taking the last sip.
The key is speaking the students' language, says Cimini, who directs the program. "If we can't engage students and get them in for the intervention in the first place, we lose a golden opportunity to mobilize the change process at a time when students are most resilient and receptive to interventions."
In surveys conducted three and six months post-intervention, STEPS has been shown to significantly reduce alcohol use and risky behavior among each subgroup. Colleges, universities, community-based mental health service providers and higher-education-focused consortia across at least five states, including Washington, Pennsylvania and Mississippi have been trained in the method, and it has been accepted for inclusion in the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-Based Programs and Practices, Cimini says. That means it's been peer-reviewed and is ready to be disseminated.
At the University of Memphis, Murphy's team is further personalizing BASICS by adding a one-hour supplement during which clinicians talk to students about their goals for college and beyond and then show them how their drinking patterns fit in with those aspirations. A student who wants to be a lawyer, for instance, might be given information about a pre-law club as well as the GPA typically needed to get into law school and to earn his desired future salary. The clinician then shows the student a plot based on his responses to an assessment revealing the number of hours per week he typically spends drinking compared with studying or participating in other academic activities. With the graph on hand, the two might then consider potential schedule changes such as dedicating one night a week to law club and another to homework to be more consistent with the student's long-term goals. "Students often [don't] think about their behavior in these sorts of aggregates, and when they're forced to do so," they're motivated to change, Murphy says.
The approach is based on behavioral economics, or the idea that behavior is influenced by availability and cost. In college, where beer is typically cheap and abundant, the framework helps to explain why drinking often gets out of control. But by highlighting appealing alternatives to partying, the approach suggests students will be more likely to steer clear of alcohol's short-lived rewards. "All of that unstructured time, and a lack of awareness of the future benefits of engaging in college or the community, is a lot of what is fueling this binge drinking problem," he says.
The approach appears to be working: In a preliminary study, Murphy's team found that the intervention significantly reduced alcohol problems and heavy drinking among participants. With a new grant from the NIAAA, they're now looking to replicate those findings and track the intervention's long-term effects, on both drinking and college outcomes. "Given that the goals of the intervention are so consistent with the goals of universities, once we can show long-term effects, I'm optimistic that colleges will like it," he says.
Another emerging way to intervene with college drinking targets certain events, rather than people. Twenty-first birthdays are notoriously dangerous: In a 2011 study of 150 students in Psychology of Addictive Behaviors by Fromme and colleagues, participants reported drinking an average of 10.85 drinks on their 21st birthday. Many also experienced blackouts, had unsafe sex and engaged in other risky behaviors.
To keep students safe on that milestone birthday, psychologists are looking at ways to time interventions so that students are reminded to use protective strategies if they plan to celebrate with alcohol. In one study by Neighbors and colleagues, for example, students received one of five BASICS-oriented interventions one week before their 21st birthdays (the interventions varied, with some being Web-based or in person, and some from each group involving a friend). Compared with a control group that received no intervention, the in-person interventions and some of the Web-based ones reduced negative consequences students had on their birthdays. The BASICS interventions that didn't explicitly talk about the risks of 21st birthdays, but rather the risks of drinking in general, reduced both alcohol use and risky behavior, the study found (Journal of Consulting and Clinical Psychology, 2012).
While the event-specific approach is promising, it's a short-term fix for a larger problem, Neighbors says. "The bigger picture question is: How do we change the culture of drinking on college campuses? It will take more time."
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