Failure of Brief Alcohol Screening for College Students (BASICS) in the college environment- Tavierney Rogan

Introduction

Binge drinking and alcohol abuse among the college population is a significant public health concern. A majority of college students are between the ages of 19 and 29, the age range at highest risk for current and lifetime excessive drinking and diagnosable alcohol and substance-use disorders (1). Reports from the Harvard School of Public Health College Alcohol Study indicate that 44.4% of students binge drink (2). Approximately 1,700 fatal injuries occur annually as a result of binge drinking and 500,000 unintentional injuries are alcohol related (3). Excessive drinking increases the risk of fatal and non-fatal injuries, violence, sexual abuse, unsafe sexual behavior, academic failure, trouble with the law, and possible development of alcoholism (3). Public health interventions are necessary to reduce the harms associated with excessive drinking.

This public health issue has been the focus of intervention and prevention programs over the past few decades. Past programs are primarily education based and have been minimally successful in decreasing the incidence of excessive drinking on college campuses (1). Recently public health professionals transitioned into using approaches that are less directive and more interactive in an attempt to reach through to students. Motivational Interviewing (MI) was introduced by William Miller in 1983 for promoting change in cases of substance abuse (4). MI is described as “a directive, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence” (5). MI developed from Prochaska and DiClemente’s Transtheoretical Model of Behavioral Change (6). MI is applied through brief patient encounters. Personal feedback intervention (PFI) is a type of brief motivational interviewing (BMI) that includes informational feedback on the individual’s behavior, the risks of the behavior, and how to change the behavior (3). PFI is used on college campuses in an effort to prevent and reduce binge-drinking. One of the first and most widely used programs is Brief Alcohol Screening for College Students (BASICS). The BASICS model is a compilation of Miller and Rollnick’s MI with cognitive-behavioral skills training in an effort to reduce harm associated with excessive or binge drinking (3). BASICS is conducted over 2 sessions. The first session assesses the drinking habits of the individual through an interview. Educational information about the effects of BAC levels and negative health effects is also provided. During the second session the facilitator gives students feedback about their own drinking patterns as well as strategies to reduce drinking. Feedback is given in the form of a facts sheet that compares their drinking habits to those of other students on their campus, as well a list of personal risk factors (3).

The goal of the BASICS model is to use motivational enhancement (e.g. feedback on the extent of one’s personal risk, alcohol use and expectancies in relation to peers) to increase clients’ readiness to change and to help them through the process of change (3-5). It is also expected that the MI will change the students’ perceptions about risk, peer use as well as alcohol expectancies and in response the student will reduce drinking and harm (3). Lesley Perkins and Alan Bromowitz’s Theory of Social Norms plays an important role in the efficacy of BASICS. Research strongly shows the college students most often overestimate the amount and frequency their student peers drink and make decisions to drink based on that (7). The Theory of Social Norms states that behavior is hugely influenced by the norms set by an individuals’ social circle and that an individual will behave in order to fit within the social norm. BASICS operates on the idea that once students find out that their peers do not drink as much as them or less then they assumed, then the student will reduce their own drinking. While BASICS and other programs based on PFI (a type of BMI) are more effective than education-only based prevention and intervention programs, research still has yet to see a significant decrease in binge-drinking among the college population and binge drinking over the long term for individuals (3). As a result of the individualistic approach the BASICS program does nothing to change the community or environment as a whole, leaving the individual vulnerable. The BASICS model also fails to account for the fact that behavior is unplanned, out of the individual’s control, and dynamic. Finally the BASICS plan is likely to invoke psychological reactance due to its statistical nature and dissimilar messenger.

BASICS individual focus ignores the college community and environment as a whole

BASICS relies heavily on the Social Norms Theory. The program assumes that students’ will change their behavior once they are aware of that their peers on average drink less than what they previously assumed. Social norms are vital in understanding social order and human behavior. Group norms dictate attitudes, expectations, and behaviors. The individual will act according to their reference group, i.e. their groups of friends, family, religious community, and school community. Research shows in the peer group is the most influential reference group for college students (3).

The BASICS program does employ Social Norms Theory, however, it does so in an intangible way (i.e. a facts sheet). It does not change what the individual sees their friends and peers doing in their own college environment. Research indicates that the following are the most common reasons students drink: to relax, feel better about themselves, or to “fit in” with their peers (2). Students do not create this misperception entirely by themselves; it is based on what they see on their college campuses (2). Students report several drinking centered locations on their campuses: bars, dance clubs, fraternities and sororities, and even certain residential buildings (7). They are essentially surrounded by drinking atmospheres.

Research demonstrates that a self-fulfilling prophecy among students occurs as a result of the misperception of drinking norms. In response drinking norms are pulled higher (7). Moderate drinking students also report being discouraged to publicly express opposition to heavy drinking and from intervening in the drinking behaviors of peers because of their misperception and the presence of strong drinking environments on campus (7). Those conservative drinkers report feeling alienated from their universities and peer communities and thus the misperception is perpetuated. Therefore a discrepancy is created between what they are told by the BASICS personnel and what they see in their own environment.

Humans are socialized from the moment they enter the world and continue to develop as a result of socialization throughout their entire lifespan. People learn how to behave according to what they see others do and what their social group determines as acceptable behavior, this is termed modeling. The Social Expectations Theory explains this dynamic as the drive behind human behavior and therefore the drive behind behavior change (8). Social Expectations Theory operates on the idea of social norms however its focus lies on social organization and how that construct determines behavior (8). It is a group level model and therefore has strong implication for the problem of drinking on college campuses because it focuses on interactions of the community as a whole, which is a vital part of the college experience.

Research shows that in the presence of the intervention students understand the statistics provided (1,2,3). Intellectually they can accept that their peers do not drink as much as they thought. However, they do not see their community being addressed as a whole. Therefore their environment in which they have taken part in drinking and in which they developed their misperception does not change. BASICS is meant to reduce ambivalence between their values and behaviors (9). According to the Social Norms theory they develop these values based on what their peers determine to be important (7). Therefore it is important that the values of their peers change in a way that is visual. The Social Expectation Theory says the rules of the group, determined by social organization, should be targeted in order to induce behavior change rather than the thoughts of the individual in relation to the group (8). This is especially important in the college environment because young adults put much more value the opinions and lifestyle of their peers, than adults who are past their college years (7). The BASICS program’s lack of individualistic focus thus leaves a gap between the individuals’ behavior and motivation to change and the motivation for the community to change as a whole. The individual cannot change if the values and expectations of the community he or she sees in reality and not on paper does the not change.

BASICS is likely to invoke Psychological Reactance due to its statistical and clinical nature.

An important premise for the efficacy of the BASICS program is that it is done in an empathetic, non-confrontational, and non-judgmental manner. However, the intervention is delivered by trained personnel (i.e. a public health worker, registered nurse, clinical social worker). The program itself is clinically based with a focus on feedback based on health risks and statistics. This poses problems for its efficacy among college-aged students. BASICS is likely to induce Psychological Reactance in its participants due to the structure and deliverance of the program.

Psychological Reactance Theory (PRT) is the behavioral phenomena where an aversive affective reaction occurs when regulations or impositions threaten the freedom and autonomy of the individual (10). PRT postulates that when an individuals’ freedom is threatened they are likely to behave in an opposite manner. When a public health intervention urges a particular behavior in a way that the individual feels as though their freedom is being taken away they will do the opposite behavior (i.e. the behavior that the intervention is attempting to stop or reduce). This is termed reactance (11).

Psychological reactance can be avoided if a public health intervention or prevention program contains certain characteristics. An important characteristic is similarity. When the target individual or group feels a similarity to the person or group giving the public health message reactance is reduced (11). The “trained personnel” used by the BASICS program does not provide that similarity for college students. Even though the environment is considered non-confrontational, reactance is likely to occur because of the lack of interpersonal similarity.

The BASICS program is essentially indicating that what the student doing is wrong and that he or she is not matching up to his or her peers. This can create an emotional and psychological disturbance in which the individual feels his or her freedom to choose his or her own behaviors is threatened. This is particularly severe for a college student who has just gained their independence from their parents (7). Psychological reactance is often created as the result of an authoritarian figure (11). While the BASICS program is non-confrontational it could easily be misconstrued, creating the desire to continue the drinking even though being warned against it.

BASICS does not account for the irrationality of behavior

BASICS assumes that as a direct result of norms correction and the health risks of drinking that the individual will be motivated to change, develop a strategy for change and successfully implement change. Research shows that human behavior is often irrational, out of the individual’s control, and dynamic (12). Humans often act according to their emotional centers and the influence of the environment rather than according to their intellectual understanding of the risks involved in certain behaviors. This common human trait is illustrated in a wide variety of research on anything from failure to lose weight to the inability to save money. Research shows that in some cases it is a matter of a lack of self-control (12-13) but it is also the result of a behavioral phenomenon called unrealistic optimism. Unrealistic Optimism is the idea that people tend to think they are not vulnerable to negative consequences of risky behavior (14). Research shows that people tend to underestimate their own risk of a negative event (14). This is especially important in college students who binge drink. The risk of negative consequences (injury, sexual assault, and violence, penalties from school, arrest, academic failure and death) due to binge-drinking is very high, and most students are aware of this however, they still routinely take part in these high-risk activities. They do so because they truly believe that “it won’t happen to me”

The BASICS program contains two vitally important flaws. Risk is not necessarily a strong enough motivator for behavioral change. In the BASICS program, not only does it assume the students will change once they or informed of their risks and misperceptions but it does not provide substantial on-going support to help overcome the irrational nature of humans. Once the feedback sessions are over, the students are left to face the temptation and stress of their college environment. The influence of the information provided by the feedback fades and the irrational nature of humans takes over (15). A problem occurs because the time between intent and action is not considered. Although many studies have found reduction in binge-drinking behavior a majority of studies are based on short term follow-up (a majority under 2 years) (3). In one study, the number of drinks was reduced in a group receiving the BASICS program compared to an assessment only, however the volume of alcohol consumed per occasion, frequency of drinking or alcohol-related problems were not significantly different from controls (3). In another study, the BASICS group were found to have reductions in drinking at 3 and 6 months but were not significantly different from the control group by month 9 (3). This demonstrates that programs such as BASICS lacks an element that will help guide the student in his or her new behavior once the initial assessment is completed.

Proposed Alternative Intervention

In order to overcome the three main flaws of the PFI program BASICS, it is necessary to take a group approach that involves peer facilitators and provides on-going support for the new health behaviors. A campaign for a lifestyle that does not include binge-drinking would help accomplish the reduction of binge drinking amongst the college population.

A program like BASICS based on PFI should still be available for those students who break Universities rules involving underage drinking, public intoxication, or providing alcohol to minors or for students who are concerned about their own drinking. As a way of avoiding psychological reactance, the PFI should be facilitated by trained peers. By using peers that students feel more familiar with they are less likely to feel threatened or as if they are being told what to do. Rather they feel a similarity and bond with someone their own age, gender, or someone from their own school (11). The absence of a threat makes the choice to reduce drinking more empowering and more autonomous rather than something being mandated by an authoritarian figure (10). When a student feels as though they are making their own decision a sense of ownership develops and the decision to partake in a certain behavior makes it more valuable (12-16).

In order for a public health intervention to more effectively reduce binge-drinking among college students it needs to infiltrate the college environment and community in a long term way. Research shows that advertising and marketing campaigns are an effective way of reducing negative health behaviors (16-18). Creating a campaign through mass media would create widespread exposure to the cause (16). Campaigns are more successful when they use a mix of media channels in order to reach as many members of the student body such as print, web, and television (18). The content would include a set of advertisements with the statistics and facts about the actual drinking habits of the college campus. As a result, the wider community is exposed to normative corrections. There is also potential for it to spread quickly as a controversial topic. Conversation about the normative drinking behaviors of the student body would take place between students rather than facilitator and student (18). By targeting the community as a whole Social Expectations Theory is more accurately applied (8).

In order to overcome people’s aversion to statistics and number while also creating some familiarity, the advertising and marketing campaign would also include a set of advertisement with real life stories of members of the college community. They would include stories from people who have experienced the decisions involved around binge drinking. The stories could range from people who have suffered from the negative consequences to people who actively chose every day to not partake in binge drinking. By showing a college aged person sharing a story about consequences, psychological reactance is less likely to occur because it is not an admonition; it’s a cautionary story from someone just like them. Furthermore, they demonstrate how drinking took away their freedom and the regained it by choosing a different lifestyle.

On the other hand, the student that does not to binge drink is a real life representation of the majority. They are an example of how to hold on to their freedom by not drinking but also a tangible representation of the norm. It also humanizes the statistics and information about drinking making it more relatable. Creating familiarity and similarity goes back to the idea of inducing compliance by reducing reactance (11).

Furthermore, the use of causal arguments through relatable stories creates a sense of peer leadership. It breaks the stigma of a person who does not fit in because they do not drink by putting them in such a prestigious and celebrity-like position. The advertisements would need to portray images that attract college students and appeal to their values (i.e. healthy, attractive youths, who have their lives together) (8-19).

The marketing aspect of the campaign can take further advantage of the tenets of Social Expectations Theory by challenging those who hold high rank in the social organization to get involved. If groups on campus that are viewed as leaders amongst the community get involved then people will pay attention and act accordingly because those at the top of rankings, peer leaders, have the most influence on the norms set for the group and therefore the behavior of the members of the group (8). By using the existing social rankings, campus group leaders, and also creating new leaders by portraying the norm (those that don’t binge drink) in an attractive and desirable light than the structure of the community as a whole can be changed.

An important aspect of Advertising and Marketing Theory is that it takes advantage of the power of branding. Youths and young adults today are heavily saturated and influenced by media. The TRUTH campaign in Florida is a prime example of how a public health campaign can be viewed as a brand that the target population wants to buy. In turn, the youth buys into that brand which creates the desired behavior change. A brand represents a product that brings its consumer happiness and success in life (16). People learn to trust a brand and they believe that brand can help them achieve their innermost goals and desires. Through accumulated awareness, the campaign becomes recognizable and respected among the college community (16). If the lifestyle brand that the campaign sells is something that the students believe will bring them happiness and help them achieve their goals, then they will buy into it.

The campaign would be more effective with the addition of celebrity endorsement. As mentioned previously, this could include on campus leaders (club presidents, team captains and varsity athletes), but also celebrities from the world of TV, music, and movies. As DeFleur explained, “the mass media through selective presentation and emphasis of certain themes, create impression among their audiences that common cultural norms concerning the emphasized topics are structured or defined in some specific way….the media [would] then [serves]… to influence conduct” (17). Images that are seen in the media have a profound effect on the individual’s determination of appropriate and acceptable behavior. Furthermore, media consumption studies show that young adults consider what they see in the media to one of the strongest influences (after the influence of peers) for the decisions they make about their own image, which includes their own behaviors (19).

The final stage of the proposed intervention would include the development of a support system for the lifestyle that is being advertised. As discussed before, intention does not necessarily lead to action. There needs to be an avenue for college students to develop the skills it takes to lead the kind of lifestyle they choose to lead. Therefore students not only need help in developing the skills it takes to be more responsible around drinking (18) but also social situations in which this is encouraged. Therefore it would be ideal for lifestyle groups to be created around campus for students who would like the opportunity to find support in dealing with the stresses and temptations of the college environment. Self-efficacy increases when thee students feel like there is an opportunity to develop the skills they need to create lasting behavioral change (18). Furthermore, creating organizations and support groups allows for norm to become a tangible reality. Once again this must be based on a brand and a movement, a product students can feel connected to but also a product that is widely accepted in their community (8).

This new lifestyle could be based around student events and activities not focused on drinking or clubs that chose to partake in activities not based around drinking. It would also be important advertise more openly and aggressively the professional resources that are available on campus for people who think they might need help. This opportunity for support offers empowerment and ownership while also making a visual shift in the perceptions of students on their environment.

Conclusion

The incidence of binge drinking among college students is a serious public health concern. Studies show the over 44% of college students abuse alcohol. Binge drinking increases an individual’s risk for injury, violence, academic failure, mental health issues, sexual assault, trouble with the law, and death. Recently public health interventions have developed passed educational-based programs to interventions based on brief motivational interviewing. More specifically a majority of the intervention programs use personal feedback interventions. Programs such the Brief Alcohol Screening for College Students are developed on the two assumptions: that the student overestimates the amount their peers drink and that once a student is informed about their risks and the actual amount that their peer drinks that they will change their expectations and values constructed around binge drinking. Research shows that this interventions effects are short term and inconsistent across studies.

There are three major flaws that can explain its lack of success and consistency. First, its’ focus on changing the individual’s behaviors and values ignores the college community and environment as a whole. This is problematic because people of college age are particularly concerned with the values and behaviors of their peers and their environment. They are also highly susceptible to temptations due to the stressful dynamic and pervasive drinking environment of college campuses. Additionally, BASICS is likely to invoke psychological reactance in its participants due to its statistic nature and the unfamiliarity of its messenger. BASICS is administered by trained professionals. Research shows that if the person who delivers a particular message is too dissimilar to the person receiving it, they experience a threat to their freedom, called reactance. This reactance has the ability to drive the individual to react in the opposite way the message is trying to encourage. Finally, BASICS does not account for the irrational and emotional drive behind human behavior. This intervention is targeted at members of a higher education community who can understand the risks involved without a struggle and yet they still take part in that behavior. There is no guarantee that a reminder of the risks involved or the correction of a normative misperception will create action in the long term even if intention is implied.

An alternative intervention would thus need to target the community as a whole in order to correct norm misperceptions. The structural organization of the college community is an important influential factor in the incidence of binge drinking (students do it to “fit in” and be like their peers). In order to target the community as a whole the intervention would need to create a campaign centered on a way of life that does not involve binge drinking that is also endorsed by community and media leaders. Furthermore, in addition to presenting the correct norm to the community as a whole it would be important to provide a human aspect to the campaign so that the statistics and the lifestyle become more tangible. It would be important for a PFI program to continue but it would be more advantageous to be facilitated by peers in order to avoid psychological reactance. As a whole the campaign should be enacted through the voice of peers in order to keep the power in the hands of students. Finally in order for this type of campaign to have long term effects a system of support for the skills needed to reduce binge drinking and an outlet for the new lifestyle would need to be created through campus events and organizations.

References

1. Crimini, MD, Martens, MP, Larimer, ME, Kilmer, JR, Neighbors, C. Assessing the Effectiveness of Peer-Facilitated Interventions Addressing High-Risk Drinking Among Judically Mandated College Students. Journal of Studies on Alcohol and Drugs 2009; 16: 57-64.
2. Fager, JH, Melnyk, BM. The Effectivenss of Intervention Studies to Decrease Alcohol Use in College Undergraduate Students: An Integrative Analysis. Worldwide Views on Evidence-Based Nursing 2004; 2: 102-117
3. White, HR. Reduction of Alcohol-Related Harm on United States College Campuses: The Use of Personal Feedback Interventions. International Journal of Drug Policy 2006; 17: 310-319.
4. Levensky, ER, Forcehimes, A, O’Donohue, WT, Beitz, K. Motivational Interviewing. American Journal of Nursing 2007; 107: 50-58.
5. Rollnick, S, Miller, WR. What is Motivational Interviewing? Behavioral and Cognitive Psychotherapy 1995; 4: 325-334.
6. Prochaska, JO, DiClemente CC. Transtheoretical Therapy: Toward a More Integrative Model of Change. Psychotherapy 1982; 3: 279-288.
7. Perkins, HW. Social Norms and the Prevention of Alcohol Misuse in Collegiate Contexts. Journal of Studies on Alcohol Abuse 2002; 4: 164-172.
8. DeFleur, ML, Ball-Rokeach, SJ. Socialization and theories of indirect influence (pp. 202-227). In: Theories of Mass Communication. White Plains, NY: Longman Inc., 1989.
9. NREPP US Department of Health and Human Services (Substance Abuse and Mental Health Services). Brief Alchol Screening and Intervention for College Students. National Registry of Evidence-Based Programs and Preventions. http://nrepp.samhsa.gov/viewintervention.asp?id=124
10. Brehm, SS, Brehm JW. Psychological Reactance: A Theory of Freedom and Control. 1981. New York: Academic
11. Silvia, PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology. 2005; 3: 277-284.
12. Ariely, D. Predictably Irrational. New York, NY: Harper Collins, 2008.
13. Nordgren, LF, Chou, EY. The Push and Pull of Temptation: The Bidirectional Influence of Temptation on Self-Control. Psychological Science 2011; 11: 1386-1390.
14. Weinstein, ND. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology 1980; 39: 806-820.
15. Edberg, M. Individual Health Behavior Theories. In: Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
16. Hicks, JJ. The Strategy Behind Florida’s “Truth” Campaign. Tobacco Control 2001; 10: 3-5.
17. Defleur, ML. Theories of Mass Communication, 2^nd Ed. (New York: David McKay, 1970), p. 129.
18. Dejong, W. The Role of Mass Media Campaigns in Reducing High-Risk Drinking Among Students. Journal of Studies on Alcohol 2002; 14: 182-192.
19. Brown, J. and Witherspoon E. The Mass Media and American Adolescents’ Health. Journal of Adolescent Health.2003; 31: 152-170