Running Head: ALCOHOL MISUSE AMONG COLLEGE STUDENTS 1

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1 Running Head: ALCOHOL MISUSE AMONG COLLEGE STUDENTS 1 Examining Alcohol Use and Misuse among College Students: A Comprehensive Review Natalie E. Chase Illinois State University Natalie E. Chase, Department of Psychology, Illinois State University Correspondence concerning this review should be addressed to Natalie E. Chase, 400 Kingsley St. Apt. #10, Normal, IL [email protected]

2 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 2 Abstract Alcohol use among college students is prevalent. While many students may view drinking as a normal part of a social life during college, alcohol use can get quickly out of hand and result in various alcohol-related problems. The following paper is a review of the existing research literature on the topic of alcohol use and misuse among college students. This review will cover six important sections that may aid counselors in their work with this population. The six sections include: foundations of behavior, assessment, treatment, cultural considerations, ethical considerations, and future research.

3 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 3 Introduction Drinking and college students are two terms that seem to go hand in hand. While it is a myth that all college students drink and drink heavily, researchers have found that a large portion of college students partake in binge drinking (four or more drinks in a sitting for women, five or more drinks in a sitting for men). In fact, according to the College Alcohol Survey (CAS) which was conducted by Harvard University over an 8-year span, about two in five college students (44%) at 4-year universities binge drink. The CAS results showed that this level of binge drinking remained stable in all four research studies that they administered to college students between 1993 and In addition, the findings of the CAS supported several other major research projects that showed similar results (Wechsler & Nelson, 2008). At times, the heavy drinking of college students becomes clinically significant. A study that included over 14,000 students from over 100 four-year universities found that 31% of the students met criteria for a DSM-IV diagnosis of alcohol abuse and 6% met criteria for a DSM-IV diagnosis of alcohol dependence. Results also clearly showed that there is a connection between heavy episodic drinking and abuse or dependence as students who reported frequent binge drinking were 13 times more likely than non-binge drinkers to meet criteria for abuse and 19 times more likely to meet criteria for dependence (Knight, 2002). Alcohol use among college students is not an issue that can be ignored. Much attention has been paid to this topic in the research literature. The following paper will attempt to review the literature in five categories related to college students and alcohol use. The first section will examine the foundations of drinking behavior among college students. More specifically, two subgroups with high alcohol usage will be examined as well as a theory that explains how and why college students may drink. The next section reviews the assessment process when working

4 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 4 with students with alcohol-related problems. The third section covers the literature on alcohol prevention programs for college students as well as various treatments that can be used with this population. Next, cultural consideration will be discussed. This section will examine how culture plays a role in the assessment phase, the treatment phase, and the therapeutic relationship. Suggestions will be given for effective work with particular diverse populations. Finally, the last section of the literature review includes ethical considerations when working with college students with alcohol-related problems. Various ethical dilemmas will be discussed. The paper will conclude with a section on suggestions for future research in each of the five sections previously mentioned. Foundations of Behavior The following section examines possible reasons that a college student would engage in heavy drinking behaviors. The section includes a discussion of the environmental factors that may contribute to alcohol use as well as individual factors that may influence drinking. However, before looking at these specific factors associated with heavy drinking among college students, it is important to consider the general question of, Why do people drink problematically? Research indicates that people drink heavily for many reasons. However, one of the main reasons is to cope with life stressors. The correlation between use of alcohol and coping with distress and other negative emotions is well established in the literature (Buchmann et al., 2010; Howell, Leyro, Hogan, Buckner, & Zvolensky, 2010; Ohannessian et al., 2010). People may use alcohol as a coping strategy to escape their problems, relieve stress and pressure, forget their loneliness, or boost their self-confidence. Within the overall idea that alcohol is used as a coping strategy, some individuals may also use alcohol specifically to self-medicate and relieve symptoms of depression, anxiety, or other disorders (Dixon, Leen-Feldner, Ham, Feldner,

5 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 5 & Lewis, 2009; Gonzalez, Bradizza, & Collins, 2009). Using this general knowledge about reasons for heavy drinking may be useful in explaining why certain college students drink problematically. The remainder of this section will now focus on specific contexts or factors that may influence problematic drinking among college students. However, it is important to keep in mind these general, underlying explanations when considering the specific explanations for why college students engage in problematic drinking behaviors. Social Environment College campuses are unique social environments that allow students particular social experiences unavailable during other times in life. Many of these experiences involve being part of close-knit groups that typically are made up of very homogeneous populations. Students may come into these groups with shared values and ideas, or their values and ideas may be molded once a part of the group. Either way, research has often indicated that two groups in particular, student athletes and students involved in sororities or fraternities, have much higher rates of risky alcohol behavior (binge drinking or high frequency of drinking) than the typical college student (Ford, 2007; Hildebrand, Johnson, & Bogle, 2001; Park, Sher, & Krull, 2008; Wechsler, Kuo, Lee, & Dowdall, 2000), suggesting that the social environment may be a contributing factor to alcohol use. Much of the following research supports this idea that social influence contributes to alcohol use; however, there is some evidence to the contrary. The majority of this section will examine the research involving risky alcohol behavior among college athletes and members of a Greek organization. The end of this section will look at the effects of living situation on alcohol consumption. College athletes. Numerous researchers have found that both male and female college athletes are more likely to be involved in risky alcohol behaviors than male and female college

6 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 6 student who are not athletes (Ford, 2007; Hildebrand et al., 2001; Leichliter, Meilman, Presley, & Cashin, 1998; Nattiv & Puffer, 1991; Nelson &Wechsler, 2001; Wechsler, Davenport, Dowdall, & Grossman, 1997; Wilson, Pritchard, & Schaffer, 2004). More specifically, athletes were found to drink alcohol more frequently than non-athletes (Hildebrand et al., 2001; Wilson et al., 2004). Hildebrand et al. (2001) found that 39% of athletes drank two or more times per week compared to only 21% of non-athletes. Numerous researchers have also found that athletes tend to consume more drinks per sitting than do non-athletes and consume more alcohol per week than non-athletes (Hildebrand et al., 2001; Leichliter et al., 1998; Nattiv & Puffer, 1991; Nelson &Wechsler, 2001; Wilson et al., 2004). Over 62% of athletes average three or more alcoholic beverages per sitting compared to only 44% of non-athletes (Hildebrand et al., 2001). Viewed in a different way, athletes consumed an average of 5.35 drinks per sitting compared to only 2.45 drinks per sitting for non-athletes (Wilson et al., 2004). Male athletes average about 10 drinks per week compared to only six for male non-athletes. Female athletes average a little less than five drinks per week compared to only about three drinks for female non-athletes (Leichliter et al., 1998). Looking further into the subgroup of athletes, it appears that athletes who are in a leadership role on their teams consume more alcohol per week than their teammates who are not in leadership positions (Leichliter et al., 1998). Even more problematic, athletes are more likely to binge drink than non-athletes and also binge drink more frequently than non-athletes (Ford, 2007; Hildebrand et al., 2001; Leichliter et al., 1998; Nelson &Wechsler, 2001; Wechsler et al., 1997; Wilson et al., 2004). Almost half of the non-athlete population reported no binge drinking compared to only a little over a quarter of the athlete population. In addtion, 42% of athletes reported binge drinking a few times a month while only 27% of non-athletes reported this statistic (Hildebrand et al., 2001).

7 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 7 So what is it about athletes that make them more likely to participate in risky alcohol behaviors? One explanation may be athletes level of social influence (Nelson &Wechsler, 2001; Ford, 2007). Many college athletes likely belong to a peer intensive environment. While all college students are in a social environment surrounded by peers, athletes tend to be in a social environment that involves the same group of peers every day and at every social encounter with little exception. They spend the majority of their time with their teammates or with other athletes. This likely leads to less time with other students and isolation from the general student body. In a peer intensive environment, people are more likely to be influenced by group norms (Ford, 2007). Looking more specifically at levels of social influence, athletes were more likely to report having five or more close friends than non-athletes. In addition, athletes reported that the majority of their friends were binge drinkers. Athletes reported spending more time throughout the week socializing with friends, on average at least two hours per day, than did non-athletes. (Ford, 2007; Nelson &Wechsler, 2001). In summary, the combination of having more friends, having more friends who are heavy drinkers, and spending more time socializing with these friends may influence the level of alcohol consumption seen in college athletes, especially if athletes find themselves isolated in peer intensive social groups with other athletes. I speculate that many college athletes feel the need to fit in with their teammates and that this promotes heavy drinking. This may be particularly relevant in sports that are considered team sports such as soccer, basketball, football, and softball. Team sports are designed around the concepts that the team comes before the individual and all team members must work together to reach a common goal. These same concepts may transfer over to social situations when teammates who do not desire to drink feel the need to in order to fit team concepts. I also

8 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 8 speculate that peer pressure is a major contributing factor to drinking behaviors among college athletes. Although no empirical evidence was found supporting the connection between alcohol use, college athletes, and peer pressure, I believe that male athletes may experience more overt peer pressure from their teammates and female athletes are more likely to experience subtle peer pressure from teammates. Members of a Greek organization. Student who are affiliated with the Greek system are more likely to drink than students who were not affiliated with Greek life (Ford, 2007; Champion et al., 2009; Dorsey, Scherer, & Real, 1999; Park et al., 2008; Kahler, Read, Wood, & Palfai, 2003; Neighbors, Lee, Lewis, Fossos, & Larimer, 2007; Theall et al., 2009; Wechsler et al., 2000). In a survey of 239 college students, 84 of whom belonged to a fraternity or sorority, over half (54%) of students who reported drinking in excess or binge drinking within the previous two weeks were Greek members (even though they made up only 35% of the population surveyed) compared to only 46% being non-greek members (65% of the population surveyed). More strikingly, out of the students who reported no binge drinking within the previous two weeks, 86% were non-greek members leaving Greek members at only 14% (Dorsey et al., 1999). In another study, Park et al. (2008) found that alcohol use changed as status in a Greek organization changed. More specifically, participants completed a survey asking questions about several different factors including alcohol use and Greek affiliation. Students took these surveys twice, with approximately 2.5 years separating the two survey times. Participants were classified into one of four Greek statuses; constant non-greek members, constant Greek members, late joiners (non-greek to Greek), and droppers (Greek to non-greek). Looking at results from the first survey, initial Greek members (constant Greeks and droppers) had higher rates of alcohol use and heavy alcohol use than initial non-greeks members (constant non-greeks and late

9 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 9 joiners). Results from the second survey indicated that constant Greeks increased levels of heavy drinking more than constant non-greeks. Students who had dropped out of their fraternity or sorority by the second survey decreased heavy drinking levels more than constant Greek members. Students who joined a Greek organization during the two and half years in between the surveys increased heavy drinking rates more than constant non-greeks. Overall, drinking levels correlated with Greek status even when Greek status fluctuated over time. Viewing sororities and fraternities as cohesive social networks is another way to explain heavy drinking among this population (Dorsey et al., 1999). A cohesive social network is one in which members have a high level of direct communication among themselves. Other characteristics include having common norms and expectations, models of normal behavior, rewards for acting within the norms, strong ties, and minimized diversity. Considering Greek organizations as cohesive social networks may explain why most members of these organizations would conform to the norms of the network, in this case engaging in binge drinking or other risky drinking behaviors. While Greek members tend to drink and binge drink more than other college students, not all Greek members participate in heavy drinking. How can the different levels of binge drinking among Greek members be explained? One explanation may be levels of self-consciousness (Park, Sher, & Krull, 2006). Self-consciousness is defined as attending to certain aspects of the self (Park et al., 2006, p.85). Private self-consciousness refers to personal aspects including attitudes, motives and feelings, whereas public self-consciousness refers to observable aspects such as behavior and appearance. People who are high in private self-consciousness are more accurate about their own affect and behaviors due to intense introspection. On the other hand, people who are high in public self-consciousness focus on themselves from a social perspective

10 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 10 and are constantly comparing themselves to social expectations. Therefore, those with high public self-consciousness are more likely to be influenced by social pressure than both people with low public self-consciousness and people with high private self-consciousness. Considering this information in the context of Greek members and alcohol consumption, self-consciousness appears to be a factor in Greek members level of binge drinking (Park et al., 2006); however, it affects men and women differently. More specifically, fraternity members with high public and private self-consciousness engaged in less binge drinking than fraternity members with low public or private self-consciousness. Fraternity members who are high in both types of self-consciousness likely act according to certain internal and external standards. These standards often inhibit impulsive or maladaptive social behaviors such as getting excessively drunk. On the other hand, those who are low in public self-consciousness are likely not concerned with others opinions of their heavy drinking. High private self-consciousness had an opposite effect on sorority members as it increased likelihood of binge drinking. Based on this finding, Park et al. hypothesized that female Greek members with high private selfconsciousness may use drinking as a coping strategy to avoid internal reflection which may lead to negative self-evaluation. Researchers have found that actual membership in a fraternity is not necessary to influence drinking behaviors, but merely the intent of joining may be influential (Read, Wood, Davidoff, McLacken, & Campbell, 2002). Incoming male students with intent to join a fraternity showed higher alcohol consumption than incoming male students who did not intend to join a fraternity. Similar results were not found with women. This finding brings up the question about whether students who are heavier drinkers join Greek organizations, if joining a Greek organization leads to heavier drinking, or both.

11 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 11 O Connor, Cooper, and Thiel (1996) found evidence supporting the first notion. Men who entered college with a history of high alcohol consumption in high school were found to pledge fraternities in a much higher proportion than men with histories of low or moderate alcohol consumption. Perhaps it is the perceptions of a heavy drinking environment that attract heavy high school drinkers to join a fraternity. Perceptions about drinking and social norms will be discussed in the following section. Similar to college athletes, I believe a major contributing factor to heavy drinking among members of a Greek organization is peer pressure. Pledges may feel pressured to drink in order to fit in with current members, and current members may feel pressured to drink to meet the perceived social norms of drinking within the organization. I believe many Greek members feel the need to drink because that is what they are supposed to do as members of a sorority or fraternity. In addition, I speculate that many prospective members or current members have learned drinking behaviors through observational learning. Many college students likely get a chance to observe or hear stories about fraternity parties or initiation ceremonies around campus. However, no research was found to support the connection between Greek membership, alcohol use, and observational learning. Living situation. A final social factor to consider is living situation. Researchers have found that living environment effects drinking behaviors. Students with more supervision in their living environments, such as living at home or a residence hall, were less likely to binge drink than those with little or no supervision in their living environments, such as a Greek house or off-campus (Champion et al., 2009; Wechsler & Nelson, 2008). In addition, for those students living on campus in a residence hall, those who lived in a substance-free setting were less likely to drink than those living in a hall that allowed some alcohol (Champion et al., 2009). Students

12 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 12 with roommates reported higher levels of alcohol consumption than those who lived alone (Theall et al., 2009). I speculate that students with little or no supervision in their living environments likely drink more because they are more easily able to keep alcohol in their rooms, houses, or apartments. With more alcohol readily available, drinking becomes a realistic option at almost any point throughout the week. In addition, higher drinking rates are likely found in this population either because there are no policies against drinking or because there is a lower threat of being caught breaking policies and having to endure the subsequent punishment. Students living in supervised dorms or at home likely have rules about drinking that are supposed to be followed. In addition, the thought of facing punishment if the rules are broken is likely to be a deterrent for some supervised students. Individual Factors On the opposite end of the spectrum from social influence, individual factors contribute to the tendencies to drink among college students. While social influences refer to aspects outside of the person, individual factors refer to aspects within the person. The majority of the following section will examine the effects of individual beliefs on alcohol use. The section will begin with discussion on the Theory of Planned Behavior. Researchers working on this theory attempt to explain factors that contribute to behavior. Next, components of the Theory of Planned Behavior will be examined as they relate to alcohol use among college students. Research on social and peer norms as well as attitudes about drinking will be examined. The Theory of Planned Behavior. The Theory of Planned Behavior is a theory that explains causes of behavior. Applied research has shown that there is a correlation between particular beliefs about social and peer norms and drinking behavior, but the theory of planned

13 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 13 behavior can more thoroughly indicate how these beliefs, along with other variables, combine to explain such a big part of actual behavior. As reviewed by Azjen (1991), the Theory of Planned Behavior states that behavioral intentions and perceived behavioral control account for a large portion of variance in actual behavior and can be used directly to predict accomplishing a particular behavior. The concept of behavioral intentions highlights motivational factors that lead the individual to perform a certain behavior. In other words, intentions are indicators of how hard people are willing to try, of how much of an effort they are planning to exert, in order to perform the behavior (Azjen, 1991, p. 3). There are three factors that predict one s intention to engage in a behavior: attitude toward the behavior, subjective norms, and perceived behavioral control. Attitude toward the behavior refers to the degree to which a person has a favorable or unfavorable evaluation or appraisal of the behavior in question (Azjen, 1991, p. 10). Subjective norm refers to the perceived social pressure to perform or not to perform the behavior (Ajzen, 1991, p.10). Perceived behavioral control is an individual s perception of the level of difficulty of performing a particular behavior. Not only is perceived behavioral control a direct factor that influences behavior, but it is an indirect factor that influences behavior through intention. The stronger the intention to perform the behavior the more likely it is to occur as long as the added factor of control over the behavior is also met. In other words, in addition to perceived behavioral control, the individual must also have the ability to decide whether or not to perform the behavior, have opportunities to perform the behavior, and have the resources needed, such as time and money, to perform the behavior. These factors make up actual behavioral control. However, it is the concept of perceived behavioral control, not actual behavioral control, that is

14 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 14 one of the main aspects in the theory of planned behavior and will be discussed further in the next section. Perceived behavioral control is similar to the idea of self-efficacy which states that an individual s behavior is largely dictated by one s confidence in his or her ability to perform a behavior. This type of perceived control usually varies across situations. The prediction of behavior made from perceived behavioral control is strengthened if perceived behavioral control realistically reflects actual control. Collins and Carey (2007) set out to test the Theory of Planned Behavior as it applied to binge drinking among college students. They predicted that past binge drinking, drinking attitudes, subjective (social) norms, and drink refusal self-efficacy would predict intent, and as the theory demonstrates, intent would predict future binge drinking behavior. Tests indicated good fit between the theory and the results with a few exceptions. Contrary to the Theory of Planned Behavior, the results indicated that subjective norms did not predict intent. In addition, the model that included intention and past binge drinking to predict future binge drinking was a good fit; however, the model that did not include past binge drinking was a better fit. In theory, subjective norms and past binge drinking make perfect sense as predictors of future binge drinking, yet this was not reflected in the research. Perhaps the Theory of Planned Behavior would better predict actual drinking among college students with a few alterations. On the other hand, more research and support is needed to make the proposed changes. The following section examines research on two of the main aspects that predict behavior according to the Theory of Planned Behavior. Subjective norms and attitudes will be discussed, and support for their role in predicting drinking among college students will be examined.

15 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 15 Perceived social and peer norms (subjective norms).while actual levels of alcohol consumption among peers appear to influence drinking behaviors for certain college groups as mentioned previously, another major reason cited for heavy drinking among college students is their misperceptions about drinking norms among their peers (Larimer, Turner, Mallett, & Geisner, 2004; Perkins, Meilman, Leichliter, Cashin, & Presley, 1999; Theall et al., 2009). In other words, many college students overestimate the amount and frequency that other students are drinking (descriptive norm), and this may lead them to drink more themselves. The latter part of this hypothesis can be found in elements of Bandura s (1986) social learning theory as well as the social comparison theory (Festinger, 1954). More specifically, people compare themselves to others in order to determine their own opinions and abilities (Festinger, 1954). In addition, according to Bandura (1986), people do the majority of their learning through observing the actions and attitudes of other people and then modeling this behavior. If college students not only compare themselves to other students in terms of drinking behaviors but also misperceive what they are observing, their drinking behavior is likely going to imitate how they believe other students are behaving. Social comparison as well as the need to imitate others behavior could understandably cause a sense of social pressure to behave in a certain way. The Theory of Planned Behavior states that if students feel social pressure to behave in a particular way they will have a stronger intention to perform the given behavior, in this case drinking. In other words, according to the Theory of Planned Behavior (Azjen, 1991), it is the social pressure felt from the subjective norms that influences intent to perform the behavior. Let us take a look at some of the research that supports subjective norms as a predictor of alcohol consumption among college students.

16 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 16 There is empirical evidence that indicates that college students do overestimate alcohol usage norms (Perkins et al., 1999). For example, when students from 100 different colleges with varying levels of average alcohol use were asked to predict alcohol use (no use, yearly use, monthly use, weekly use, or daily use) for the average student on their respective campuses, only 28% of students were able to predict this statistic accurately. Only 3% of students underestimated the amount of alcohol consumed by the average college student, whereas 69% of students overestimate the norm. Even on campuses where the average student drank on a weekly basis, 22% of students still overestimated the norm and believed that the average student drank on a daily basis. One reason that college students may overestimate alcohol norms among their peers is the idea that students might more quickly and vividly recall times of high exuberance and drinking atmospheres than times that are calm and alcohol-free (Perkins et al., 1999). Therefore, social settings involving alcohol use get a disproportionate amount of attention from students and the media compared with daily activities in the life of a college student. This disproportionate amount of attention may explain the overestimation of alcohol usage norms by college students and the media. Once these overestimations occur, Lewis and Clemens (2008) found that there is a correlation between perceived alcohol use of others and one s own consumption of alcohol. Students were specifically asked to estimate the amount and frequency of alcohol use among their closest same-sex friend and closest opposite-sex friends. Results indicated that there was a significant positive correlation between perceived alcohol use intensity of the closest oppositesex friend and alcohol use intensity for the respondent. In addition, there was a highly significant positive correlation between perceived alcohol usage intensity of the closest same-sex

17 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 17 friend and alcohol use intensity for the respondent. While this study did not examine perceived social norms because the respondents were only asked to estimate drinking behaviors of two close friends, results indicate that perceptions of behaviors of closest friends may account for the largest percentage of variance that accounts for actual drinking behaviors. While perceived social norms is an important factor, perceived norms of close friends, rather than a large social group, may be more important. In addition, I speculate that perceived norms of close friends likely puts more social pressure on students than perceived social norms of the larger student population. As mentioned earlier, it seems that social pressure may be the mediating factor between perceived norms and drinking behavior. Another contributor of drinking behavior is a type of subjective norm called an injunctive norm. In terms of alcohol consumption among college students, an injunctive norm would be the perceived acceptability of drinking among a particular social group (Colby, Colby & Raymond, 2009; Larimer et al., 2004). Injunctive norms fall under the umbrella of subjective norms and combine with attitude and perceived behavioral control within the Theory of Planned Behavior (Azjen, 1991) to help predict behavioral intent and behavior. When considering both descriptive norms and injunctive norms within a college population, it has been found that not only do both types of norms influence drinking (Larimer et al., 2004) but that these social norms are one of the best predictors of alcohol use among college students (Neighbors et al., 2007). In a study that examined multiple predictors of drinking including demographics such as gender and Greek affiliation, social norms, motives, and expectancies, most of the variance was associated with perceived descriptive norms and perceived injunctive norms (Neighbors et al., 2007).

18 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 18 When looking at a specific college population, members of a Greek organization, Larimer et al. (2004) found that descriptive norms, in this case perceived drinking among other members of the fraternity or sorority, helped to predict current drinking behaviors. On the other hand, students perceptions of injunctive norms, in this case acceptability of drinking within their respective fraternity or sorority, helped to predict drinking behaviors one year in the future. While much of the literature indicates that perceived social and peer norms are the main contributors to problem drinking among college students, there is some evidence to show that attitudes, one of the other elements from the Theory of Planned Behavior, also contribute to alcohol consumption among college students. Attitudes are described in the next section. Attitudes. Ford et al. (2007) examined one particular high-risk college subgroup, athletes, and found that students whose beliefs are more accepting of drinking alcohol and binge drinking were more likely to actually binge drink. More specifically, some of these beliefs included believing that parties are an important part of college social life (Ford, 2007; Nelson & Wechsler, 2001) and believing that the legal drinking age should be lowered (Ford, 2007). Burden and Maisto (2000) examined the effects of attitudes and expectancies on college student drinking behaviors. Attitudes towards drinking were defined as the evaluation, either good or bad, of performing drinking behaviors. Expectancies of drinking were defined as the likelihood of an event occurring due to drinking behaviors. Results indicated that attitudes towards drinking accounted for a large proportion of the variance in drinking behaviors once demographic variables and social norms and attitudes towards college life were taken into account. In addition, the evaluation, good or bad, of outcome expectancies of drinking accounted for a large proportion of the variance in the level of alcohol usage. However, overall

19 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 19 it was found that attitudes towards drinking were more important than expectancies in predicting alcohol consumption. Wilson et al. (2004) found evidence to support this link between beliefs in alcohol as a coping mechanism and alcohol consumption. Students who reported using alcohol as a way to feel better consumed more alcohol and drank more frequently than students who did not report this as a reason for drinking. This result was found for all groups of students in the study except for male athletes. Other coping methods used by some groups of students that were found to be associated with higher frequency of drinking included to get through a problem or for venting. This link between beliefs in alcohol as a coping strategy and alcohol consumption suggests that students who have trouble regulating their negative moods might be more at risk for drinking. There is an empirical reason to believe this is true. Kassel, Jackson, and Unrod (1999) investigated the relationship between Negative Mood Regulation (NMR) expectancies and problem drinking. NMR was defined as positive expectations of one s ability to handle and manage negative affect. After accounting for factors such as age, gender, alcohol consumption, and affective distress, a strong negative correlation was found between NMR and problem drinking behaviors. As expectations of one s ability to cope with negative affect increase, problem drinking behaviors decreases. Perceived behavioral control is one of the major aspects of the theory of planned behavior; however, an exhaustive search for research supporting the link between perceived behavioral control and alcohol use among college students resulted in no findings.

20 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 20 Assessment Assessment is an important component of the overall treatment of alcohol use problems with college students. Accurate and reliable assessment is needed so that therapists can fully understand the problems of their clients. Once an assessment has taken place, and the therapist has a solid understanding of the student s problem, the therapist can then consider the next course of action for treatment. However, without good assessment tools, the process is halted and the student may never receive adequate treatment. The following section includes information on four assessment tools used when working with clients who potentially have issues with alcohol. Each tool will be explained in detail, and empirical support will be included. However, before discussing specific assessment tools, it is important to focus on diagnostic criteria for alcohol use disorders. Diagnosis Assessments are typically conducted to determine if a client exhibits enough criteria of a disorder to be diagnosed. Other times, assessment may be done to examine risky behaviors or patterns of use that could eventually lead to a full-blown disorder. Regardless of the severity of the problem, it is important that therapists understand the diagnostic criteria that are being assessed. Understanding these criteria will help therapists not only better understand the tools they are using, but also better understand symptoms and signs they are looking for in their clients. It is important to note that many assessment tools do not comprehensively measure all criteria under the categories of Alcohol Dependence and Alcohol Abuse in the DSM-IV-TR (American Psychiatric Association, 2000). Many tools are used to examine some of the criteria of dependence and abuse such as patterns of use or problems related to drinking. The diagnostic criteria in the DSM-IV-TR for alcohol dependence and alcohol abuse are included here:

21 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 21

22 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 22 Table 1 DSM-IV-TR Criteria for Alcohol Dependence Alcohol Dependence A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: (1) tolerance, as defined by either of the following: a. a need for markedly increased amounts of the substance to achieve intoxication or desired affect b. markedly diminished effect with continued use of the same amount of the substance (2) withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance, alcohol includes: i. cessation of (or reduction in) alcohol use that has been heavy and prolonged. ii. two (or more) of the following, developing within several hours to a few days after cessation 1. autonomic hyperactivity (e.g., sweating or pulse rate greater than 100) 2. increased hand tremor 3. insomnia 4. nausea or vomiting 5. transient visual, tactile, or auditory hallucinations or illusions 6. psychomotor agitation 7. anxiety 8. grand mal seizures b. the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms (3) the substance is often taken in larger amounts or over a longer period than was intended (4) there is a persistent desire or unsuccessful efforts to cut down or control substance use (5) a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects (6) important social, occupational, or recreational activities are given up or reduced because of substance use (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

23 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 23 Table 2 DSM-IV-TR Criteria for Alcohol Abuse Alcohol Abuse A. A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (2) recurrent substance use in situations in which it is physically hazardous (3) recurrent substance-related legal problems (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance B. The symptoms have never met the criteria for Alcohol Dependence Alcohol Abuse can be classified as any use of alcohol (quantity is not mentioned) that results in impairment or distress for an individual in a key domain in life, including work, school, safety, law, or relationships. The problem becomes Alcohol Dependence when multiple physiological effects begin to occur (i.e. needing more alcohol to achieve the desire effect), behaviors related to use increase in intensity or reach a particular threshold (i.e. a great deal of time is spent trying to obtain, use, or recovery from alcohol), loss of control occurs (i.e. there is a persistent desire or unsuccessful efforts to cut down or control use), or a combination of all three. As soon as the symptoms meet the criteria for Dependence, the individual s diagnosis will not switch back to Abuse. Assessment The following section will review four alcohol assessment tools that have been used with college students. The four assessment tools are the Alcohol Use Disorders Identification Test (AUDIT), the Michigan Alcoholism Screening Test (MAST), the Substance Abuse Subtle Screening Instrument (SASSI), and the Brief Alcohol Screening and Intervention for College Students (BASICS). While these tools do not directly measure all dependence or abuse criteria,

24 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 24 the DSM-TR-IV and these tools have the same purpose: to classify drinking use, problematic drinking patterns, and related problems. There are additional instruments that could be used to measure alcohol use but are not described here. Tools such as the Structured Clinical Interview for DSM Disorders (SCID-IV) Substance Abuse Module and the Diagnostic Interview Schedule (DIS-IV) Alcohol Module can be used to directly measure DSM criteria of alcohol dependence and abuse, but these lengthy interviews would likely not be used with college students due to their length and time required to administer and interpret. Also, a commonly used screening instrument with college students, the CAGE (Myerholtz & Rosenberg, 1998), will not be discussed in this paper due to some research that has found that the CAGE is not an effective alcohol screening tool for college students (Cooper & Robinson, 1987; Heck & Lichtenberg, 1990; Heck & Williams, 1995; Smith, Collins, Kreisberg, Volipicelli, & Alterman, 1987). Alcohol Use Disorder Identification Test (AUDIT). Quality assessment includes being able to identify people with alcohol dependence but also people who are early-stage problem drinkers (Bohn, Babor, & Kranzler, 1995). There are two types of early-stage problem drinkers: hazardous drinkers and harmful drinkers. Hazardous drinkers have risky patterns of alcohol use but have not yet had any alcohol-related problems. Harmful drinkers have experienced physical or mental issues related to alcohol but are not deemed to be dependent. The AUDIT was designed to specifically help with identifying hazardous and harmful drinkers. It was proposed that a combination of a brief interview, clinical examination, and one or more laboratory tests may be key in assessing dependence and early stage problem drinking. The AUDIT includes a short questionnaire and physical examination instrument (Bohn et al., 1995). The 10-item questionnaire (AUDIT Core) assesses alcohol consumption, dependence

25 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 25 symptoms, and personal and social harm related to drinking. The Core specifically focuses on drinking and its effects over the past year in an attempt to identify persons with relatively current problems. The frequency of occurrence of harmful behaviors and behaviors related to dependence help differentiate the AUDIT from other assessment tools such as the CAGE and MAST, which only focus on the presence or absence of harmful and dependence behaviors. Examples of questions from the Core include How often do you have a drink containing alcohol? Never, Monthly or less, 2 to 4 times a month, 2 to 3 times a week, 4 or more times a week and How often during the last year have you failed to do what was normally expected from you because of drinking? Never, Less than monthly, Monthly, Weekly, Daily or almost daily. Each multiple choice answer is assigned a score from 0-4. The AUDIT s overall focus on current or heavy problematic drinking is designed to identify persons appropriate for therapeutic intervention. The Core is simple and easy to administer. It takes participants approximately 5 min to complete. Scores on the Core range from 0-40, where 40 correlates with very problematic drinking behaviors. The physical examination instrument (AUDIT Clinical procedure) was included considering the idea that not all participants would answer the Core questions accurately (Bohn et al., 1995). The Clinical instrument has 8 items and assesses three factors reflective of alcoholrelated physical effects: trauma history, abnormal physical examination findings, and GGT level (a liver enzyme in which high levels may indicate liver disease). The items included in this instrument do not directly refer to drinking. Examples of items include Have you injured your head since your 18th birthday? Yes, No and Hand Tremor: Not present, Mild, Moderate, Severe. The Clinical instrument is filled in by the administrator, rather than by the participant,

26 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 26 and takes about 10 min to complete. It produces scores from 0 to 24. The Core is often administered without the complementary Clinical portion. Hazardous drinkers are identified by examining the quantity and frequency of drinking behaviors (Bohn et al., 1995). Standard regulations state that daily quantity in excess of g for men and g for women, or a weekly consumption of 6 or more drinks in one sitting indicates hazardous drinking. Harmful drinkers are identified by examining the frequency of physical or mental issues related to alcohol use and the lack of dependence symptoms. The AUDIT takes into account scores that are produced from items measuring quantity, frequency, mental and physical harm, and dependence symptoms and to produce an overall score. This overall score is compared with a cut-off score to determine whether the participant is a problem drinker (hazardous or harmful). Looking at the specific item scores that produced an overall score above the cut-off point can help therapists determine if the participant is a hazardous or harmful drinker. Past research has indicated that scores from the AUDIT are reliable and valid for a sample of college students (Fleming, Barry, & Macdonald, 1991). When using the recommended cut-off score of 11, the instrument exhibited a sensitivity of.84 and a specificity of.71. These results indicated that 84% of problem drinkers (hazardous and harmful) were correctly identified and 71% of normal drinkers were correctly identified and demonstrates evidence of construct validity and reliability. The major benefits of the AUDIT are it is quick to administer, simple to interpret, and designed to detect at-risk drinkers who may be helped through a therapeutic intervention before the alcohol-related problems become more severe. For these reasons, the AUDIT, particularly the Core questionnaire, seems to be a suitable screening tool to use with college students who may be referred or mandated to the student counseling

27 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 27 center (O Hare & Sherrer, 1999). Many of these students may not fit enough criteria to be diagnosed with alcohol abuse or dependence, but they may fall into the categories of at-risk, harmful, or hazardous drinkers based on their alcohol use and alcohol-related problems. Michigan Alcoholism Screening Test (MAST). The Michigan Alcoholism Screening Test (MAST; Selzer, 1971) and its shortened forms have been widely researched and used to detect alcohol problems among a wide variety of populations (Shields, Howell, Potter, & Weiss, 2007). The MAST can be used as a structured interview, which was its original purpose (Nystrom, Perasalo, & Salaspuro, 1993), or as a self-report measure that includes 25 items used to assess symptoms of problematic drinking and negative consequences associated with drinking (Shields et al., 2007). Participants answer each item with either a yes or no response. Examples of items on the MAST include, Do you feel you are a normal drinker?, Has drinking ever created problems between you and a near relative or close friend?, and Have you ever gone to anyone for help about your drinking? Higher scores indicate alcohol problems. The MAST is simple and quick to administer. The MAST has been identified by directors of college counseling centers as one of the most commonly used alcohol screening tools (Juhnke, Vacc, Curtis, Coll, & Paredes, 2003; Myerholtz & Rosenberg, 1998) and has been researched in studies involving college students (Cannell & Favazza, 1978; Nystrom et al., 1993; Silber, Capon, & Kuperschmit, 1985). Some of these studies have merely examined whether the MAST could be used with college students from a practical standpoint, rather than a psychometric standpoint (Cannell & Favazza, 1978; Silber et al., 1985). Nystrom et al. (1993) found that a shortened version of the MAST, which includes 9 items, had good specificity (.87 for women and men) and sensitivity (.64 for women and.86 for men) in differentiating college students who were heavy problematic drinkers from college

28 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 28 students who were occasional or social drinkers. However, no research has been found that has examined specifics of the reliability and validity of scores from the full 25-item MAST assessment with a sample of college students. Although the MAST has been commonly used with a college population, it is important that future researchers examine the psychometric properties of the test with this population. Counselors should be cautious about the MAST until further research is conducted. Substance Abuse Subtle Screening Instrument (SASSI). College directors of substance abuse programs have also identified the Substance Abuse Subtle Screening Instrument (SASSI) as one of the most commonly used assessment tools (Laux, Salyers, & Kotova, 2005; Myerholtz & Rosenberg, 1998). One of the main characteristics of the SASSI that differentiates it from other screening tools is its supposed invulnerability to faking. This means that the tool has a component that allows clinicians to detect when a participant is answering untruthfully. Untruthful answering can occur when participants answer questions in a way that will minimize their problems (faking good) or when participants answer questions in a way that will make their problems seem worse that they are in reality (faking bad). Empirical studies that have measured this feature of the SASSI will be discussed at the end of this section. The most recent version of the assessment is the SASSI-3. The SASSI-3 is a self-report measure that includes direct and indirect questions about alcohol and other drug use (Laux et al., 2005). There are multiple subscales within the overall test that can help therapists gather comprehensive data related to a client s alcohol use and develop a treatment plan. Administrators of the assessment tool can direct participants to answer according to their lifetime use, the past 6 months of use, or any other 6-month time frame. This allows therapists to determine whether the participant is currently struggling with an alcohol abuse problem or had

29 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 29 one in the past. Another benefit of the SASSI-3 is that men and women are compared with different norms. This feature of the SASSI-3 acknowledges that men and women experience alcohol abuse differently from both a biological and social perspective (Dimeff, Baer, Kivlahan, & Marlatt, 1999; Gomberg, 1993). This differentiation allows for more accurate results. The first part of the SASSI-3 has 67 true-or-false questions (Laux et al., 2005). The questions do not relate directly to alcohol or other drug use. This first part includes eight subscales. The Obvious Attributes subscale determines a person s willingness to admit personal limitations associated with substance abuse. The Subtle Attributes subscale, which includes 8 items that do not directly relate to alcohol or other drug use, is used to differentiate people with alcohol or other drug problems and those who do not have alcohol or other drug problems. People with problems tend to answer items from this subscale differently than do people without problems. The Defensiveness subscale measures a person s willingness to admit normal personal limitations. The Supplemental Addiction measure was designed to help determine if elevated scores on the Defensiveness subscale are due to general defensiveness or are more related to substance use. The Family vs. Control Subjects subscale differentiates between people who grew up in a home where substance abuse was an issue and those who did not. The subscale also helps to identify people who tend to focus on others problems rather than their own and have trouble with assertiveness. The Correctional subscale attempts to measure a person s future risk of having issues with the legal system. The Random Answering Pattern subscale measures response validity and can indicate if a person answered in a way that makes his or her results invalid. The second side of the SASSI-3 involves two subscales that are overtly related to alcohol and other drug use (Laux et al., 2005). Twelve of the items are related to alcohol use, and 14

30 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 30 items are related to other drug use. Participants are asked to indicate whether they have never, once or twice, several times, or repeatedly engaged in a behavior related to substance use. Final interpretation about the presence of an alcohol or other drug abuse problem is determined by examining nine decision rules. Each decision rule results in a yes, indicating a problem, or a no, indicating no problem. The decision is made based on information regarding the participant s own recognition of a problem on the second side of the test, the defensiveness or denial of the participant on the first side, which may indicate that the participant is not willing to recognize or admit to a problem, and a combination of the subtle and obvious subscales (first and second side). A participant with at least four decision rules of yes is considered to have a high probability of having an alcohol dependence disorder. The SASSI-3 takes about 15 min to complete, score, and interpret. Scores from the SASSI-3 have been found to be reliable and valid with a sample of college students (Laux et al., 2005). In terms of test-retest reliability, the effect size for the difference between the scores of Time 1 and Time 2 was negligible. The stability of classification of total scores (indicating a high probability of an alcohol dependence disorder or a low probability of an alcohol dependence disorder) between Time 1 and Time 2 was.63. The concurrent validity of the SASSI-3 was tested compared with the MAST and the CAGE. The concurrent validity was.52 with the MAST and.49 with the CAGE. This level of agreement is in the high to moderate range. One of the subscales on the second side of the SASSI-3 is the Face Valid Alcohol Subscale (FVA). This subscale is considered a unitary measure of alcohol use disorders due to its 12 items that are related directly to alcohol use. When this subscale was specifically examined, solid psychometric properties were found (Laux et al., 2005). Time 1 and Time 2

31 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 31 total score correlations for the FVA was.94. Internal consistency was.92 for this subscale. The range of item factor loadings for the FVA subscale was.54 to.86 with a median of.73. Research indicates that the SASSI-3 is an effective alcohol assessment tool when used with college students (Cooper & Robinson, 1987; Laux et al., 2005). Its scores have comparable psychometric properties to scores from other alcohol assessment tools such as the MAST and CAGE (a discrepancy in the literature as multiple studies have found the CAGE to be ineffective with college students (Cooper & Robinson, 1987; Heck & Lichtenberg, 1990; Heck & Williams, 1995; Smith et al., 1987) and yet, it has comparable psychometric properties to the SASSI-3, which has been found to be an effective tools with college students). However, some research indicates that the reliable and valid nature of scores from this tool are relevant only to the direct subscales and not the indirect, or subtle, subscales (Clements, 2002; Feldstein & Miller, 2006). In other words, despite the fact that screening for faking is cited as a major purpose of the SASSI-3, according to some research, it does not have the special ability to determine if a participant is faking or answering truthfully. The SASSI-3 only has the ability to determine if a participant has an alcohol or other drug problem based on the overt data he or she is willing to supply. Therefore, it seems that the SASSI-3 can still be used effectively with college students as long as administrators and counselors are aware of the limitations that have been found in the research concerning the subtle subscales. More research is likely needed to confirm or deny the clinical relevance of the subtle subscales. Brief Alcohol Screening and Intervention for College Students (BASICS). The Brief Alcohol Screening and Intervention for College Students (BASICS; Dimeff et al., 1999) is a fairly new tool that was designed specifically for used with college students. The intervention

32 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 32 portion of the program (further discussed in the treatment section) is based on a harm reduction model and involves the use of motivational interviewing. The BASICS as an assessment differs from the assessment tools mentioned above because the assessment is a process rather than a single procedure. The BASICS Assessment takes about 100 minutes to complete and involves the client as well as the therapist (Dimeff et al., 1999). The two primary objectives of the assessment are to gather information about the client s alcohol use and to identify clients who have medical reasons not to drink (pregnancy, diabetes, ulcers) or who are moderately to severely dependent on alcohol. For these students, a harm reduction approach, as opposed to an abstinence approach, would not be recommended. The assessment is also designed to be a time to build rapport that will be important during the intervention part of the BASICS (see treatment section). The assessment includes a structured clinical interview and a self-report questionnaire packet, both of which take about 50 minutes to complete (Dimeff et al., 1999). The interview tends to focus on topics directly related to alcohol use, but, if time and resources allow, it can also focus on other lifestyle behaviors (e.g., smoking, use of other substances, using alcohol within the context of dating). Specifics covered in the interview include typical drinking patterns and atypical or episodic drinking occasions for the past 30 days, indices of alcohol dependence, history of conduct disorder, history of alcohol and/or mental health problems, and family history of alcohol or other substance use problems and/or mental health problems. The self-report questionnaire packet helps clinicians assess factors such as drinking (e.g., frequency, quantity, duration), negative consequences resulting from alcohol use over the past 6 months, use of other psychoactive substances over the past 6 months, sexual behaviors involving alcohol and other drug use, alcohol outcome expectancies, perception of health and behavioral risks due to alcohol,

33 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 33 interest in changing and degree of readiness to change drinking behaviors, perceptions of college drinking norms, symptoms of psychological distress, and indices of alcohol dependence (Dimeff et al., 1999). It may be noted that the number and type of tools used during the assessment will vary due to the magnitude of tools that are suitable for examining the variables listed above (Dimeff et al., 1999). Table 3 provides a list of assessment tools that therapists can select from to form assessment packages based on the needs of the client and personal preference. Although it is beyond the scope of this paper to discuss the psychometric properties of each tool, all of the tools in Table 3 have been used in research and were selected for inclusion in the BASICS due to their strong psychometric properties. Table 3 Assessment Tools relevant to the BASICS Brief Drinker Profile Daily Drinking Questionnaire Frequency-Quantity Questionnaire Rutgers Alcohol Problems Inventory Drinker Inventory of Consequences Young Adult Alcohol Problems Screening Test Modified Sexual Experiences Survey Brief Sexual Behaviors Survey Alcohol Dependence Scale Structured Clinical Interview for DSM-IV Axis I Disorders Adapted Short Michigan Alcoholism Screening Test Addiction Severity Index Family Tree Questionnaire Comprehensive Effects of Alcohol Readiness to Change Questionnaire University of Rhode Island Change Assessment Brief Symptom Inventory Life Experience Survey Alcohol Perceived Risks Assessment Drinking Norms Rating Form

34 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 34 Prevention and Treatment Since college campuses are a major hot spot for heavy alcohol consumption, great efforts are made to develop and test measures that are used to help prevent or treat heavy alcohol consumption among college students. The current preventative literature has indicated that certain programs are effective while other programs are rarely effective. It is important that college administrators understand the effectiveness of certain prevention programs before implementing them into their schools. The first part of the following section examines an extensive review of the alcohol prevention literature for college students. Prevention Alcohol prevention programs aim to reduce or eliminate alcohol consumption among college students before it becomes dangerous and reckless. Prevention is aimed not only at students who do not consume any alcohol but also at students who consume some alcohol but not enough to be considered heavy drinkers. In the following section, an extensive preventative literature review is examined. A large number of individual studies were looked at to determine which types of prevention programs are effective and which programs will likely lead to ineffective results. Larimer and Cronce (2007) examined preventative literature for college students from 1999 to The three different types of prevention, universal, indicated, and selective, were all included. Universal prevention is aimed at the entire population, in this case the entire college student population on campus. Indicated prevention aims to prevent the onset of drinking in students who do not currently meet the criteria for binge drinking or alcohol abuse, but are showing early warning signs that this may occur. Selective prevention is aimed at specific high-risk student subgroups such as athletes or Greek members. In addition, multiple

35 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 35 formats of prevention strategies were also examined including one-on-one, small group, classroom, mailed/written, and computerized/internet. Each study that was included in the extensive review had to met several criteria. The study needed to include at least one type of alcohol prevention program. The study also needed to measure at least one behavioral outcome such as reduction in drinking or reduction in binge drinking. A control group was needed along with random selection of participants to the control or prevention groups. Overall, 42 studies were included in the review. The studies were grouped under three major categories: education/awareness programs, cognitive/behavioral skills-based programs, and motivational/feedback-based approaches. Education/awareness programs aim to increase students knowledge about alcohol, alcohol effects, peer norms, and consequences of heavy alcohol consumption as well as increasing awareness about how their own drinking behaviors fit with their values. Cognitive/behavioral skills-based programs include challenging irrational alcohol expectations, learning skills to better cope with alcohol and alcohol environments, learning skills to better cope with life issues, and setting goals to make changes. Motivational/feedback-based approaches primarily focus on building motivation to change unhealthy behaviors or motivation to continue living a healthy lifestyle. The subgroups under the education/awareness programs were information/knowledge programs, values clarification programs, and normative re-education programs. The subgroups under the cognitive/behavioral skills-based programs included specific alcohol-focused skills training, multi-component alcohol skills training, and general life skills training/lifestyle balance. The subgroups under the motivational/feedback-based approaches included brief motivational interventions and mailed or computerized motivational feedback.

36 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 36 As a whole, Larimer and Cronce (2007) found one-third of education/awareness programs to be successful. The best subgroup was the normative re-education programs which were successful in 75% of the studies. Little support was found for the other subgroups. Out of 17 studies that included a cognitive/behavioral skills-based program, almost half were found to be helpful in prevention. Finally, the most successful approach was motivational/feedbackbased programs at almost 80%. The vast majority of the studies in both subgroups were supported. In conclusion, Larimer and Cronce (2007) found almost no evidence to support information/knowledge prevention programs. There was considerable evidence for normative re-education programs that aim to adjust students misconceptions about social and peer alcohol norms. Mixed results were found for skill-based prevention programs. The type of programs that were most widely supported were the brief motivational intervention programs. Larimer and Cronce found that these prevention programs are highly effective whether delivered face-to-face or via the computer/internet. Treatment Before examining types of treatment as well as the effectiveness of treatment, it is important to address client receptiveness to certain types of treatment. If college students are not willing to accept the types of treatments that are provided, the effectiveness of the treatments becomes a moot point. Client receptiveness to treatment. Some researchers (Epler, Sher, Loomis, & O Malley, 2009; Kypri, Saunders, & Gallacher, 2003) have found encouraging evidence that supports the notion that some college students are receptive to certain types of treatments. It makes sense that students would be more likely to follow through with certain treatments and benefit from these

37 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 37 options if they see the options as appropriate and acceptable. Epler et al. (2009) examined the receptiveness to eight different treatment options among a large college population. The eight treatment options included self-help book, self-help computer program, self-help group, group therapy, individual therapy, monthly injection, targeted oral medication, or daily oral medication. Each of the three pharmacological options would involve Naltrexone, a drug designed to reduce alcohol cravings and therefore reduce alcohol intake and the chances of relapse after treatment. The three options would give students the choice of taking a pill daily, taking a pill on specific occasions, or getting an intramuscular, extended release injection once per month. When examining the results from the college student population as a whole, the treatment option with the highest receptiveness percentage was individual therapy at 34.6%. Receptiveness to a self-help book was 23.8% of the participants and receptiveness to a self-help group was 19%. Students were least receptive to a monthly injection at 6.1% and daily oral medication at 6.4%. These results seem to imply that many students would be receptive and willing to use individual treatment options such as motivational interviewing or therapy using the BASICS (descriptions of these interventions are found in the Types of Treatment section). The researchers looked further into receptiveness of treatment options by looking only at the results of students who indicated that they would like to cut down on their drinking (14.2%) or stop drinking (5.2%). Individual therapy and self-help books remained at the top of the receptiveness list for both populations while monthly injection and oral medication remained at the bottom. This finding is particularly important because it focuses on the students who actually want to alter drinking behaviors. Finally, the group of students interested in cutting down or stopping their drinking were broken down further based on the number of alcohol dependence symptoms they displayed.

38 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 38 While receptiveness remained the highest for individual therapy and self-help interventions, Epler et al. (2009) commented on an interesting finding among students who displayed dependence symptoms. Of the 339 students who displayed at least one symptom of alcohol dependence, 25 students (7.4%) indicated they would be receptive to any of the three pharmacological treatment options but would not be receptive to any of the other five options. These 25 students both indicated a desire to cut down or stop and appeared to be at-risk for becoming alcohol dependent based on their symptoms. In my opinion, this would be a subgroup of drinkers that treatment centers would most want to target: at-risk and willing to change. This finding indicates that perhaps centers that treat college students for drinking problems should consider having at least one pharmacological option for high-risk students. Kypri et al. (2003) looked at receptiveness to a practitioner-delivered intervention versus a web-based intervention. The web-based intervention included personalized feedback to the individual. The practitioner-delivered intervention included advice from a nurse, counselor, psychologist, or physician. Kypri et al. found that 81% of the students would be receptive to use the web-based intervention if they had a problem versus only 61% indicated they would use the practitioner-delivered intervention. When results from students who were considered hazardous drinkers were filtered out, 82% of these students answered they would use the web-based intervention if they had a problem compared to only 58% who reported they would use the practitioner-delivered intervention. It appears that it is important for treatment services to have a variety of options available for students. In addition, web-based interventions may be particularly popular for students in this electronic/internet era. Types of treatment. While the researchers working on current preventative literature have examined several different types of programs, researchers working on the current treatment

39 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 39 literature are mainly focused on the idea of motivational interviewing (Miller & Rollnick, 2002). Motivational Interviewing is one of the main components of the Brief Alcohol Screening and Intervention for College Students (BASICS), (Dimeff et al., 1999) however, it can also be delivered alone. The following section will take a more extensive look at the BASICS and motivational interviewing. A review of some of the literature that supports these treatments for heavy-drinking college students will follow. Finally, the treatment section will conclude by looking at other interventions that have been used with the college population. The BASICS. Much of the current literature on treatment for problem drinking among college students includes the use of the BASICS. Based on its heavy use in research over the last decade, it appears the BASICS is the primary treatment tool for college students. While the book that introduced the BASICS was written in 1999 (Dimeff et al.), the treatment has been researched much more within the past 6 or 7 years (LaBrie, Pedersen, Lamb, & Quinlan, 2007; LaBrie, Thompson, Huchting, Lac, & Buckley, 2007; Terlecki, Larimer, & Copeland, 2009; Tevyaw, Borsari, Colby, & Monti, 2007). The major principles behind the BASICS as well as an overview of the treatment are discussed in a review of the original book (Barry, 2002). The BASICS is based on principles of harm reduction. Harm reduction treatment includes the goal of controlled drinking; however, the two terms (harm reduction and controlled drinking) are often used interchangeably in the United States (Heather, 2006). Proponents of this treatment approach do not believe that an individual must abstain from alcohol in order to successfully control his or her drinking. In addition, harm reduction builds on the ideas of developing goals for moderate use of alcohol, reducing the negative consequences associated with alcohol use, and using alcohol under safer circumstances. Harm reduction is a controversial topic in the U.S. primarily because the dominant ideology at alcohol treatment centers in the

40 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 40 United States is total abstinence (Heather, 2006). Harm reduction may be particularly appropriate for college students who are likely to fail in abstinence-only treatment due to constant pressures to drink in a college environment. In addition, because many college students are young, they do not reach criteria for dependence because they have not had enough time to become tolerant or to develop withdrawal symptoms. For many college students, their alcohol consumption will likely decline as they mature. Environmental pressures and eventually maturing out of heavy drinking are both reasons why a harm reduction approach such as the BASIC can be successful. The first step of the BASICS is the assessment which was previously described. The intervention portion of the BASICS is the second of two individual sessions about one or two weeks after the original assessment session. As previously noted, the main goals of the first session include orientation to the program, assessing the risk for alcohol-related problems, and having the student commit to self-monitoring his or her drinking habits in the following weeks. The aim of the first session is not specifically to reduce consumption; however, the simple procedure of self-monitoring will likely increase awareness of his or her drinking habits and subsequent risks. This awareness will hopefully help bring about some initial change in a positive direction. The second session includes personalized feedback. An individual s personal drinking habits are reported and compared with student norms. The personalized feedback includes the amount of alcohol consumed, frequency of drinking, and a report on typical and highest blood-alcohol content. The session also includes information about risks that are associated with drinking and some advice about how to drink safely. The two main goals of the intervention are to raise the individual s awareness of his or her risky drinking behaviors and to increase motivation to reduce these behaviors.

41 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 41 The main goal of the counselor is to provide this information and advice without lecturing the student or trying to scare the student. As mentioned earlier, the counselor tries to increase motivation to change using many of the principles of motivational interviewing (MI) including being non-judgmental, being open to the responses and questions of the student, and utilizing opportunities to increase concern and provide the student with accurate information about risks, myths, and norms (Barry, 2002). The BASICS is often a paradigm in which MI is used as a major component, however MI can also be used as a solo treatment. A more detailed discussion on MI will follow. Motivational Interviewing (MI). The main concept behind MI is to work with the client to make apparent the discrepancy between where the client is currently in life and where the client would ideally like to be (Miller & Rollnick, 1991). According to Miller and Rollnick, there are two phases to MI: building motivation for change and strengthening commitment to change. The counselor collaborates with the client so that the client voices his or her own motivation for change, rather than feeling coerced or forced by the counselor. The client is responsible for choosing and implementing change. During the early stages of MI, the counselor has several tasks to complete which will hopefully help to build motivation for change. First of all, any initial resistance is not directly opposed. According to Miller and Rollnick (1991), when clients feel they are being pushed, they are likely to push back and strengthen their resistance and reasons not to change. Absorbing and reflecting the resistance is a more neutral way to respect that the client is ambivalent about the change as well as normalizing the ambivalence. Once it is established that the counselor is not going to fight with the client about change, the counselor can slowly incorporate the awareness of a discrepancy into the conversation. The counselor will inquire about disadvantages of continuing

42 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 42 life as it is, advantages of change, and optimism about change. Asking questions that elicit an awareness of consequences that will occur or have been occurring in the client s current life is important. When the counselor is able to get the client to talk about benefits of change, optimisms of change, and disadvantages of the status quo, this is called change talk. If the client talks about the advantages of the status quo, pessimisms of change, and satisfaction with current life situations, this is called sustain talk (Vader, Walters, Prabhu, Houck, & Field, 2010). Ideally, the more the counselor can elicit change talk, the more likely the client will be motivated to change. Once the client appears to gain some motivation to change, the counselor s next task is to strengthen the commitment to change. A major principle of MI is that the client already has all the resources and strengths needed to change, it is just a matter of eliciting these resources and strengths. Just as the client is in charge of his or her own motivation, the client is also primarily in charge of answers and solutions. The counselor can strengthen the commitment to change by explicitly encouraging hope and affirming any suggestions the client has towards change. When the client states intentions to change, the counselor should work to make the intentions as specific and concrete as possible so that the client is more likely to follow through. The counselor may ask about specific steps that can be taken to achieve the change as well as how and when each step could occur. By the end of the treatment, the client will have hopefully developed his or her own desire to change and to lessen the gap between current life and ideal life. In addition, the client will hopefully know exactly how the change can occur as well as feel confident that his or her own plan will work (Miller & Rollnick, 1991).

43 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 43 The following is a short illustration of MI. A conversation such as this that includes elements of building motivation for change would like take place after initial resistance is absorbed the reflected. Therapist: What worries you about your current situation? Client: Not a whole lot. I like to have fun. I like to party with my friends. This is college and this is what college students do. I do struggle to make it to class a lot of the time, but only the super serious students go to class every day. T: How is missing classes affecting your academic experience? C: In a couple of classes it does not seem to really matter. I can get by with C s as long as I show up for tests and when assignments are due. I have to re-take Business Law because I failed it last semester. I slept through one of the tests and forgot about a paper. T: Will this affect your plans for after graduation? C: Well, my plan is to apply to MBA programs. I am not really sure what these programs look for in terms of grades, but I am guessing they are not going to be too impressed by my C s and failing Business Law. T: Do you think you will be able to get into an MBA program with your current GPA? C: Probably not, but I am only a sophomore so I have time to get my GPA up. T: What would be the advantages of trying to raise your GPA over the next few semesters? C: The best thing would be that my parents would get off my back about my grades. My dad is always hounding me about not putting in enough effort and MBA programs are not going to accept you. I guess it would be nice to be able to show MBA programs that I did a lot better in my classes during junior and senior year.

44 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 44 The therapist would continue to attempt to get the client to recognize the disadvantages of the status quo and the advantages of making a change. The therapist cannot be the one to highlight the advantages and disadvantages; the client needs to recognize these for him or herself. After the discrepancy between current life and ideal life becomes quite clear, the therapist would begin to strengthen commitment to change. Empirical support for BASICS and MI. A study by Terlecki et al. (2009) used the intervention portion of the BASICS to examine the effects of Brief Motivational Intervention (BMI) on heavy-drinking, mandated college students. In past research on the effectiveness of BMI, it has been difficult to determine whether reduced drinking and fewer alcohol-related problems after a disciplinary action paired with BMI was due to the treatment, the discipline, both, or other factors. Terlecki et al. (2009) used control groups in order to determine the true effectiveness of BMI. Researchers also sought to determine whether BMI was as effective for mandated students as it was for students who volunteered for the treatment. Results indicated that mandated students who participated in the BMI in addition to being disciplined by the school decreased their weekly alcohol consumption more than students who only received discipline. In addition, mandated and voluntary high-risk drinkers benefited similarly from BMI. In order to examine the mechanisms behind MI, Vader et al. (2010) studied the language used in motivational interviewing. More specifically, the researchers wanted to examine the relationships between change talk used by counselors and change talk used by clients as well as the connection between client change talk and outcome. As mentioned previously, change talk is language that is consistent with the principles of MI and occurs when clients talk about the benefits of change, optimisms of change, and disadvantages of the status quo. The opposite of change talk is sustain talk which occurs when clients talk about the advantages of the

45 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 45 status quo, pessimisms of change, and satisfaction with current life situations. A hypothesis of the study maintains that when counselors use change talk it results in more change talk for clients. Another hypothesis states that clients who engage in change talk have more positive outcomes, in this case reduction in drinking. The results were consistent with the hypotheses. Counselor change talk was correlated with client change talk. More importantly, client change talk was correlated with improved drinking outcomes. This study not only shows one of the mechanisms for change within MI but also shows the importance of counselor language during the process of MI. Counselor language appears to set off the chain of events that leads to positive drinking outcomes for clients. Some researchers have found that MI can also be effectively used in a group setting (LaBrie, Pedersen, et al., 2007; LaBrie, Thompson, et al., 2007). In one study, (LaBrie, Thompson, et al., 2007) the effects of MI on drinking behavior were looked at in a group of college women. Among the mandated female students, results indicated that drinking was reduced by almost 30% 12 weeks after the MI group session. LaBrie, Thompson, et al. (2007) speculated that addressing gender-specific reasons for drinking within the group may have helped the women in the group engage in more productive change talk along with more motivation to change. LaBrie, Pedersen, et al. (2007) examined using MI in a group setting with male college students. In addition to using MI, two other interventions were added to the group. The students also received social norms feedback and expectancy challenges. Social norms feedback attempted to correct students misperceptions about drinking behaviors among their peers by giving students accurate information about average consumption levels. As previously mentioned in the foundations section, students tend to overestimate the drinking norm. In

46 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 46 addition, positive expectations of the effects of drinking were challenged by providing students with accurate information about the effects of alcohol from research studies. These two interventions are similar to techniques that are used in the BASICS. Overall, the adaptations of motivational interviewing (AMI) used in a group setting were found to decrease alcohol behaviors among the male students. More specifically, the number of drinks per month, the number of drinking days per month, the average number of drinks per sitting, and the maximum number of drinks in a sitting were all significantly reduced from the pre-group assessment to the 1-month follow-up as well as the 3-month follow-up. It appears that MI can be used effectively in the group setting to reduce drinking levels for both men and women. Other treatment options and considerations. Some college campuses are using technology as treatment tools for students who are heavy drinkers (Barnett, Murphy, Colby, & Monti, 2007; Doumas, McKinley, & Book, 2009). In one study, Doumas et al. (2009) examined the effectiveness of a personalized feedback intervention compared to an alcohol education intervention, both of which were delivered to students via the web. Similar to other studies comparing personalized feedback and education interventions, results found that participants in the web-based personalized feedback groups reduced their weekly drinking (40% reduction) significantly more than participants in the web-based educational group (18% reduction). In addition, the web-based personalized feedback group also lowered their peak consumption levels (20% reduction) significantly more than the web-based educational group (5% reduction). Finally, the personalized feedback group lowered their frequency of drinking to intoxication by 18% compared to only a 10% reduction for the educational group. Not all computerized treatments have been found to be effective. Barnett et al. (2007) examined the effectiveness of the use of technology in the treatment of heavy-drinking students.

47 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 47 The participants were broken up into two groups. The participants in the first group received a computer-based education program which takes students to a virtual party. The participants in the second group received their intervention from a counselor. The intervention was based on MI principles and was similar to the BASICS intervention previously discussed. Contrary to other research, Barnett et al. (2007) found that after 1 year, the participants in the computer-based intervention increased the number of drinks consumed per sitting and continued to drink as frequently as before the intervention. In addition, after 1 year, participants in the counselor-based intervention increased the frequency of drinking while number of drinks per sitting stayed the same. Barnett et al. noted that this study had a longer follow-up period (1 year) than many of the other studies on this topic. This may have contributed to lack of success of either the computer-based or counselor-based interventions. Researchers have found that peers have significant influence over one another (Talbott, 2008; Valliant, 1995). With this idea in mind, Tevyaw et al. (2007) examined whether peers could also have a positive influence over friends who are involved in an alcohol treatment program by examining the effectiveness of a brief motivational intervention with the BASICS when the intervention includes the support of a peer. In a study including 72 mandated college students, half of the participants received standard BASICS treatment while the other half received standard BASICS treatment that included the company of a supportive peer. Both types of treatment included aspects of MI. Participants in the peer-enhancement treatment group were able to personally pick the peer that was included in their treatment. The treatment sessions included the mandated participant, the peer, and the interventionist. The main participation of the peer came during the final portion of the treatment. Each peer was asked to actively contribute to the development and implementation of the strategies that the participant was to use

48 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 48 to reduce or eliminate drinking. Results gave further support to the effectiveness of BMI that includes the BASICS as both treatment groups showed a significant reduction in drinking (number of days drinking and number of days of heavy drinking). However, the reduction in drinking was, on average, three times larger in the peer-enhanced group than in the group that did not include peer support (Tevyaw et al., 2007). The majority of treatment research over the past several years has focused on the BASICS and MI or technology driven treatment (Doumas et al., 2009; Labrie, Pedersen, et al., 2007; Terlecki et al., 2009; Tevyaw et al., 2007; Vader et al., 2010). The findings on the BASICS and MI point strongly in a positive direction while findings on technology driven treatment are mixed. Some researchers are quick to point out that in addition to using effective treatments, it is vital that college treatment centers know whether the options will be well received by students. A treatment found to be very effective in the literature is of little use if students refuse to partake in the treatment. However, even for those students who are highly resistant to treatment, MI is a treatment that is designed to work with resistant clients (Moyers & Rollnick, 2002). Research on receptiveness has shown that many students are receptive to individual therapy but may prefer web-based interventions if there is an option. In addition, there may be a small group of students whose treatment needs will be met with the addition of a pharmacological option to treatment centers. Overall, it is important to continue researching both the effectiveness and receptiveness of treatments for college students to attempt to find the treatment options that will be helpful and useful to students with alcohol problems. Cultural Considerations Culture plays a role in the prevalence, assessment, and treatment of almost any type of mental health disorder or condition. In order to effectively design prevention and treatment

49 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 49 programs for college students with alcohol problems, counselors need the knowledge to identify which cultural subgroups are most at risk of developing alcohol-related problems. Also, considering cultural issues that may play a role in the assessment process can help clinicians and counselors develop a good relationship with clients and be able to assess problems accurately. Finally, taking into account cultural considerations may give clinicians and counselors a better chance at selecting an appropriate treatment program for each individual. The following section will begin with a segment about demographic factors that make it more or less likely that a student will develop problems with alcohol. Next, there will be a discussion of general assessment considerations when working with a diverse population of alcohol users and abusers. The final segment will include general treatment considerations when working with a diverse population. The assessment and treatment segments will attempt to tie together the general cultural considerations with a college population of alcohol users and abusers. Demographic Factors Research has indicated that the drinking patterns of younger students differ from those of older students; however, the findings are somewhat inconsistent (Champion et al., 2009; Ford, 2007; Theall et al., 2009; Wechsler et al., 1997, 2000). Some researchers found that younger students were more likely to binge drink than older students (Ford, 2007; Theall et al., 2009; Wechsler et al., 1997). However, the age that divides younger students from older students differs or is unclear in these studies. Wechsler et al. (2000) found that underage students (20 years or younger) were less likely to drink than older students (21 years and older), but when they did drink they drank more in one sitting than older students. In contrast, Champion et al. (2009) found that younger students both drank more often than older students and drank more per sitting than older students.

50 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 50 Male college students drank and binge drank more frequently than female college students (Champion et al., 2009; Kahler et al., 2003; Neighbors et al., 2007; Pedersen, LaBrie, Hummer, Larimer, & Lee, 2010; Wilson et al., 2004). Men also reported consuming more alcoholic beverages per sitting, about five, than do females, about two (Wilson et al., 2004). Why is it that men in college tend to drink more than women in college? Men reported drinking for social reasons more than did women. Male students were also more likely to report that they drank to get high than female students (Wilson et al., 2004). I speculate that men also face more pressure from their peers to engage in heavy drinking behaviors than women. In addition, men may drink more due to socialization factors that have deemed it more acceptable for men to drink heavily than women. Other factors that are associated with increased levels of drinking included being European American (Ford, 2007; Kahler et al., 2003; Pedersen et al., 2010; Rice, 2006; Theall et al., 2009), having never been married (Ford, 2007), having lower grades (Ford, 2007), and binge drinking in high school (Ford, 2007; Theall et al., 2009). Being African American or Asian was associated with decreased levels of heavy drinking compared to European Americans (Champion et al., 2009; Nguyen, Kaysen, Dillworth, Brajcich, & Larimer, 2010; Pedersen et al., 2010; Theall et al., 2009). Being Hispanic was a risk factor in one study (Ford, 2007) but a protective factor in others (Pedersen et al., 2010; Theall et al., 2009). Overall, it appears that young, European American males are most likely to be binge drinkers. Whether a younger student such as this would drink more frequently than an older, European American male is not clear. However, in terms of binge drinking, a young, European American male with low grades, a previous history of binge drinking, and belonging to either a

51 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 51 fraternity or an athletic team seems to have the highest risk of consuming large amounts of alcohol in one sitting. Culture and Assessment When working with a culturally diverse population, it is important that clinicians and counselors consider certain aspects when using alcohol assessment tools. The validity and reliability of certain measurements may vary from culture to culture, especially if the psychometric properties of a measurement were obtained from studies with primarily European American participants (Cremonte, Ledesma, Cherpitel, & Borges, 2010). High validity and reliability with European Americans does not imply high validity and reliability with other subgroups. It is also important to make sure measurements are valid and reliable with both men and women (O Hare & Tran, 1997). A good way to know whether a measurement will be valid and reliable with diverse clients is to determine whether or not it has been tested cross-culturally. For example, scores from the Drinking Motives Questionnaire Revised (DMQ-R) were found to be valid and reliable across multiple cultures (Kuntsche, Steward, & Cooper, 2008). In addition, Schedules for Clinical Assessment in Neuropsychiatry (SCAN) alcohol and drug diagnosis had good to excellent levels of reliability for dependence across different cultural groups (Easton et al., 1997). It is important to consider the fact that scoring on an alcohol-screening measure can vary widely based on how an individual interprets the questions on the measure. Interpretations may be based on one s cultural background (Knibbe, Derickx, Kuntsche, Grittner, & Bloomfield, 2006). For example, an item that questions participants about failure to fulfill role expectations due to alcohol use may be interpreted differently by participants from diverse cultures who have different interpretations of what it means to fulfill role expectations.

52 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 52 If an assessment tool is available in a different language, it is important to know if the translated version of the tool has remained valid and reliable. Scores from the Alcohol-Timeline Followback (TLFB) and the Inventory of Drinking Situations (IDS) were found to be valid and reliable across three different languages (Sobell et al., 2001). However, as Gureje, Mavreas, Vazquez-Barquero, and Janca (1997) and Room, Janca, Bennett, Schmidt, and Sartorius (1996) point out, there will likely be difficulties with translation of key words from alcohol abuse and alcohol dependence criteria that do not have equivalent words in other languages. In addition to problems with translation, culture may play a role in the definition of binge drinking and alcohol abuse or dependence. Drinking behavior that is seen as problematic in one culture may be seen as typical behavior in another culture. For example, while many countries have similar definitions of what constitutes binge drinking, some countries, such as Russia, have a much higher threshold for the term binge drinking. In addition, some cultural views place heavy concern on binge drinking (many countries in Asia), while others view it as a normal part of life (many countries in Europe). This may cause individuals from diverse backgrounds to answer items differently than individuals from the country in which the assessment tools were tested. Ultimately, this would affect the accuracy of the diagnosis. Hasin et al. (1997) examined the diagnostic ability of three instruments designed to assess alcohol-related problems. The results indicated that culture had little influence over the diagnosis, making these instruments valid and reliable cross-culturally. However, other studies have indicated that substantial differences exist in the definition of problematic use of alcohol which suggests that a diagnostic test that is accurate in one culture may not be accurate in another culture (Gureje et al., 1997; Room et al., 1996). Researchers working on the ICD and DSM may need to make criteria for alcohol abuse and dependence more universally applicable

53 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 53 due to the variation in definitions of dangerous drinking behaviors between cultures (Room, 1996). While the above research included general suggestions and findings when assessing alcohol problems with a diverse population, much of the information can also apply to assessing alcohol problems with a diverse population of college students. The cross-cultural value of assessment tools should always be a concern when working with students of color. Having at least a few assessment tools in different languages (Spanish, Chinese, German, etc.) would greatly expand a campus treatment center s ability to make accurate assessments, and it would help all students feel as comfortable and confident as possible. Finally, it appears very important to discuss each student s cultural views on appropriate alcohol use and problematic alcohol use. As cultural definitions of abuse and dependence differ, this information could be vital in formulating an appropriate treatment plan. Culture and Treatment Below I present some general cultural information to consider when treating individuals from diverse backgrounds. Many typical trends and suggestions for cultural subgroups will be discussed, yet it should not be assumed that these trends and suggestions will be appropriate for all members of a particular cultural subgroup. Counselors and clinicians should consider each client individually and use the following as information that may or may not fit with clients understanding of their problems and their treatment. Asian Americans and Pacific Islanders. Asian Americans and Pacific Islanders (AAPIs) with alcohol problems tend to view themselves as immoral, lazy, having a lack of will power, or being unworthy of help (NcNeece & DiNitto, 2005). This may explain why AAPIs underutilize addiction treatment. AAPIs likely do not seek professional help until the problem is

54 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 54 severe. AAPIs may also be reluctant to seek treatment as a result of the fear of bringing shame to their families, having pride in handling their problems alone, or preferring to handle problems within the family. Many AAPIs also see problems as physical (NcNeece & DiNitto, 2005). Therefore, alcohol problems are likely conceptualized as biologically based. This may suggest that AAPIs will respond better to treatment if their alcohol problem is approached from a biological perspective and is treated with medication, such as Naltrexone, from a physician rather than psychotherapy from a counselor. If medication is not an option, psychoeducation will likely be accepted due to the high value that AAPIs place on education. This also reduces the pressure to self-disclose. When AAPIs do communicate with a treatment professional, the communication is likely to be subtle and indirect. They believe confrontation is inappropriate so eye contact may be minimized and they may say what they believe the professionals want to hear. It is important to remember that an AAPI client that is nodding may be doing so out of respect rather than out of agreement. Other considerations when working with AAPIs include remembering that nonverbal communication is very important to AAPIs, personal or intimate questions are considered unprofessional, and discussing health or academic concerns may be a better approach than immediately discussing problematic alcohol use (NcNeece & DiNitto, 2005). AAPIs usually prefer advice from counselors rather than a non-directive approach as it fits with their preference for a quick solution much like they would receive from a medical doctor. Because family honor is so important for AAPIs it may be helpful to frame the completion of treatment and curing the alcohol problems to be a way to restore family honor. Family treatment may even be appropriate if available.

55 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 55 African Americans. For African Americans (AAs), intoxication is generally disapproved and use infrequently turns into abuse when compared with other subgroups (NcNeece & DiNitto, 2005). Some of the biggest factors that may drive AAs to use alcohol are social structural factors such as unemployment or financial struggles and discrimination. These are factors that may be important to address during treatment. In addition, it is important to recognize that AAs with a diagnosis of abuse have more associated problems such as depression, paranoia, and psychosis than do other subgroups. Mental health counseling on top of substance abuse counseling should be a consideration. One of the biggest problems when AAs seek treatment is finding a center that is culturally sensitive to differences from European Americans or other subgroups (NcNeece & DiNitto, 2005). Some important things to consider when treating an AA for alcohol-related problems are that the goals of empowerment and boosting self-esteem should be a focus (NcNeece & DiNitto, 2005). Teaching AAs how to negotiate a European American culture without losing their own culture is vital. Emphasizing strengths and avoiding victim-formulation will help to empower and build self-esteem. Including family in the treatment process will be an important source of support, in addition to focusing on the church community and the power of religion when applicable. Hispanic Americans. A very important factor to consider when treating Hispanic Americans (HAs) is the level of acculturation (NcNeece & DiNitto, 2005). In general, the more acculturated a HA individual is to European American culture, the more likely he or she is to drink heavily. However, if a HA is not fluent in English and primarily communicates in Spanish, this may lead to feelings of disconnect and isolation that can increase the chances of heavy drinking, especially in HA youth.

56 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 56 Addiction is viewed as a moral weakness for HAs and, therefore, religion is often seen as the solution (NcNeece & DiNitto, 2005). Clinicians and counselors may find it difficult to have HAs take responsibilities for their problems with alcohol due to the idea of Fatalism which states that all actions and events are predetermined by a higher power. When working with HAs it is also important to consider the idea of Familismo and Machismo. Familismo is the belief that each family member has a particular role and these roles are usually not flexible. The father has the power while the mother is self-sacrificing. Machismo states that a man s duty is to live with honor and respect and fulfill all of the family obligations. On the other hand, Marianismo is the idea that HA women try to emulate the Virgin Mary in as many ways as possible including duty to the family, purity, self-sacrificing, and passivity. Clinicians and counselors should attempt to work within these roles when working on changing behaviors in treatment. Men may believe that disclosure is a sign of weakness and is unacceptable, so using a strength-based approach for HA men may be ideal so that they can save face and keep their self-esteem intact. A strengthbased approach would be more focused on abilities the man possess that can be used in the future rather than his shortcomings in the past. Women may passively deny problems and suffer in silence instead of seeking help, so emphasizing the Virgin Mary s strength and independence rather than her submissiveness may be important. If this approach with a HA woman is not working, a counselor could reframe successful treatment as an important duty to her family. Working to solve the problem within the family is much more favorable then pushing a HA with assertion or independence from the family unit (NcNeece & DiNitto, 2005). Important treatment considerations include having staff members who are fluent in Spanish, not fighting family unity, and using fatalism to justify treatment acceptance and that they are here for a

57 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 57 reason. Counselors should know that HAs typically prefer warm, supportive relationships and may agree with the counselor to maintain harmony rather than due to actual agreement. Native Americans. Native Americans (NAs) have a high rate of alcohol use (NcNeece & DiNitto, 2005). This high rate may be the result of being caught between two worlds and trying to hold onto NA culture in the face of European American oppression. Drinking is a shared social activity which promotes group solidarity. Refusing a drink may be considered rude. In addition, alcohol use may be an act of defiance against European Americans and used as a way to distinguish themselves from other subgroups. Despite these reasons for high rates of alcohol use, drinking is viewed as adverse because it destroys harmony with nature and the unity of the body, mind, and spirit. It is important for counselors to recognize some of the psychological explanations for alcohol use among NAs (NcNeece & DiNitto, 2005). Alcohol may be used to relieve anxiety and depression caused from poverty and hardships. It may be used to release suppressed or repressed anger that was created from years of oppression. Alcohol could also be used as relief from the pressures due to forced acculturation and loss of their own culture. Other counseling considerations when working with NAs include emphasizing that dealing with alcohol problem is a way to reconnect and revitalize NA culture, giving advice or being told what to do may be perceived as intrusive, and personal responsibility may be unrecognized due to the general view that substance abuse is externally, rather than internally, caused (NcNeece & DiNitto, 2005). Including family, elders, or a tribal network may be a vital component to effective treatment with NAs. Finally, counselors need to be attuned to other conditions that may need to be treated on top of alcohol problems including depression, anxiety, and issues associated with poverty and oppression.

58 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 58 Summary. In the segment above, I discussed general treatment considerations when working with a diverse population for alcohol treatment. There is very little research that specifically looks at cultural considerations for college students in alcohol treatment. The research that is out there that fits culture, college students, and alcohol treatment appears to be very specific, and it would be difficult to generalize. While not specific to a college population, the above segment suggests many considerations to take into account when working with AAPI, AA, HA, or NA students. Ethical Considerations In the following section, two potential ethical issues that could arise when working with college students with alcohol-related problems will be discussed. These topics are client autonomy and confidentiality. Client autonomy is the idea that clients should be able to make their own decisions when it comes to participating in treatment and how to work through their problems (Silber & Silber, 1996). Ethical issues may arise when clients are mandated to be in treatment, are resistant in a treatment session, or do not participate in a collaborative relationship with the therapist. Confidentiality between client and therapist means that any information that is disclosed to the therapist in session will not be disclosed to outside sources. However, the law states that there are some instances when confidentiality must be broken in order to preserve the safety of the client or others. This presents an interesting ethical dilemma for therapists working with college students with alcohol-related issues. In addition, confidentiality also means that others will not know that a particular person is in counseling. Another ethical dilemma is developed when other officials at a university or college require notification of completed counseling sessions. Client autonomy and confidentiality will now be further discussed.

59 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 59 Client Autonomy Ethical issues about client autonomy fall on a continuum. An issue that falls onto the most severe end of the spectrum is working with clients who have been mandated to treatment. In the case of college students, being mandated to treatment by their university or college (Barnett et al., 2007; Terlecki et al., 2010) with the threat of further disciplinary actions if treatment is not completed takes away most of the students autonomy before even entering their first counseling session. One ethical concern related to autonomy is whether students should be required to participate in treatment. One side of the debate is for client autonomy and the other side of the debate is for beneficence. Beneficence is the act of doing good, and in the case of this ethical dilemma, it is an action of good that goes against the client s autonomy (Silber & Silber, 1996). Should clients be forced into treatment if it is deemed that it is for their own good? Or, should clients be able to decide whether they need to seek help for their alcohol-related problems. A related issue is whether the informed consent becomes obsolete when the alternative to treatment basically forces the student into treatment. One of the primary purposes of informed consent is for the client to be fully informed about what to expect in treatment including risks, benefits, and alternative options from the proposed treatment. Extensive information about the treatment is presented to the client so that he or she can make a fully informed decision about whether to participate (Bailey, 2003). The informed consent is designed so that participants do not feel coerced into treatment. However, what happens when the student is mandated to treatment and the only other option is being suspend from school? In most cases, it seems as if students would feel as if they have no other choice but to go to treatment. Are therapists who work with mandated college students treating consenting individuals or coerced individuals?

60 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 60 MacDonald (2002) offers this way of looking at the informed consent debate. For students who choose treatment over other university sanctions, they are consenting to treatment. While the client may have different goals in mind than the therapist (e.g. getting out of trouble with the university vs. reducing dangerous drinking behaviors), consenting to treatment is also consenting to some infringement on autonomy. In this case, the level of justified infringement can usually be based on the amount of freedom that the client had in coming to treatment. For example, if the student had the option of treatment or 5 hours of community service around campus, the student has quite a bit of freedom about choosing whether or not to attend treatment. Therefore, if the student chooses treatment and signs the consent form, infringement is reasonably justified. However, if the student had the option of treatment or being expelled from school, the student has little freedom to decline treatment. In this case, when the student signs the consent form, infringement of autonomy is not justified because consent does not seem to be voluntary. Moving along the continuum of ethical issues concerning client autonomy, a less severe, but still important topic to consider is working with resistant clients. When working with resistant clients, therapists may find themselves using coercion, manipulation, or persuasion in an attempt to elicit change (MacDonald, 2002). The ethical debate elicits the question, Should therapists avoid coercion, manipulation, and persuasion at all costs when working with resistant clients, or is it a viable solution when all else has failed and it is for the client s own good? Clients may be resistant in session for many reasons including not wanting to be in treatment in the first place as mentioned above, believing their drinking is not a problem, or disagreeing with the style or approach of the therapist. Regardless of whether the student is willing to be in

61 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 61 treatment or not, how should therapists deal with clients who are resistant to making changes in their behavior? When working with resistant students, a counselor may find him or herself using paternalism to try to elicit a change (Silber & Silber, 1996). Paternalism involves making decisions for another person to try to meet their needs without giving the other person any responsibility in the matter. There are many problems with paternalism. First of all, it may cause more resistance. During a crucial time of personal development, it takes away the college student s autonomy and growing sense of independence. It sends the message that the counselor s ideas are better than the client s own ideas. Finally, paternalism takes away the opportunity for students to make their own decisions, make mistakes, and learn from their mistakes (Leiden University, 2008). My suggestion would be that paternalism only be used as a last resort when the student has not responded to any other therapeutic attempts (e.g., developing a warm, supportive relationship, motivational interviewing, asking the client to formulate his or her own goals) by the counselor. MacDonald (2002) examined the ideas of working with resistant patients within an eating disorder context. He pointed out that although he was specifically discussing patients with anorexia, the broad topic of ethical decision-making with resistant clients could be applied to the entire clinical field. As such, MacDonald s ideas can shed some light on ethical decisionmaking with college students who are resistant to alcohol-related treatment. Therapists must find a balance between their desires to help the client and their desires to respect the client s independence (MacDonald, 2002). This brings us back to the debate between autonomy and beneficence. Full autonomy includes ability to direct one s own life and to make one s own decisions. MacDonald points out that autonomy includes control over one s own

62 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 62 actions (freedom of constraint) and ability to rationally deliberate about decisions. In the case of students who are resistant to alcohol treatment, they lack both aspects of autonomy. The mandated student does not have full control over his or her actions. If treatment is not completed, there are likely other consequences imposed by the university, which is something over which the therapist also has no control. In addition, in the case of a student with severe drinking problems, he or she seemingly lacks the ability to make rational decisions. Therefore, the student is already lacking autonomy even before coming into the therapist s office. MacDonald raises the argument that by forcing treatment on a student, you are in fact giving some autonomy back to the client because he or she will no longer be under sanction with the university, and treatment may help the client learn more rational decision-making skills. While not everyone will agree with this argument, counselors can consider this point when forming their own opinions on the matter of client autonomy. Another argument to treat the resistant client goes back to the idea of beneficence and the desire to do good and help the client (MacDonald, 2002). Treating a student with a serious alcohol problem, even if initially the treatment is against the student s will, may ultimately lead to better physical and mental health, better academic performance, and possible even a lifesaving experience. The issue of treating students with serious, life-threatening alcohol problems will be revisited later in the confidentiality section. However, I would argue morally that intentions to do good are not sufficient to justify imposing treatment. MacDonald (2002) argues that there needs to be a balance between beneficence and autonomy. Beneficence is justified when it is for the client s own good and the client is already acting in a non-autonomous way (e.g., by losing the ability to make rational decisions seen when a student drinks to the point of needing medical care). However, that brings

63 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 63 up the next question of whether intention to help is enough or whether treatment is only justified if the therapist strongly believes it will help. Perhaps therapists are only justified when they have good reason to believe that the treatment will work for that particular client. When multiple options seem to carry the same amount of benefit, the option that causes the least amount of infringement on autonomy should be selected. MacDonald (2002) states that every action that infringes upon another person s autonomy is ethically significant, though not always ethically wrong (p. 4). Therefore, it is vital to understand the impact of an ethically significant decision that is made when working with a client. It is important for therapists to consider many of the issues above in order to decide whether an infringement on autonomy is in the best interest of the client. Therapists must also consider their obligations to the university or college. Whether they are required by the school to treat mandated students will likely play a large factor in their decision-making. If the school allows the therapist to use his or her own judgment and it is deemed that infringement is not in the best interest of the student, it is safe to say that that infringement is both significant and wrong. If the infringement is deemed to be in the best interest of the client and does no additional harm to the client, the final tool for the therapist to consider is his or her clinical judgment. There is rarely a black and white issue when it comes to ethical decision-making. When a therapist is either required to treat a mandated and resistant student or has deemed it is in the best interest of the student, how should the therapist proceed? Using the technique of Motivational Interviewing (MI; Miller & Rollnick, 2002) may be appropriate for resistant college students. This technique emphasizes collaboration between the client and counselor. The counselor rolls with resistance instead of trying to push back. In addition, the counselor creates an atmosphere in which the client feels empowered and responsible for making

64 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 64 changes. Instead of using force or coercion, counselors work to develop the discrepancy between the client s current life situation and ideal life situation. Using MI may help ease the resistance of the client so beneficial progress can be made (for full description of MI, see treatment section). On the least severe end of the autonomy spectrum is the idea of developing a collaborative relationship between therapist and client. In many situations, therapists should ethically strive for an atmosphere that fosters mutual respect and collaborative ideas so that the student has equal influence over the treatment process. It is important for therapists to understand the reasons why it may be difficult to develop this atmosphere when working with college students. Awareness will hopefully help therapists avoid the potential ethical issue of developing a one-sided relationship with their clients. While most college students are legal adults (age 18 and up), many are still in their adolescence or just recently removed from adolescence. Working with these young adults can produce a unique ethical dilemma that is not found when working with children or adults. The primary issue revolves around the counselor-client relationship (Silber & Silber, 1996). Many college students are used to being in a submissive role in their relationships with older adults, whether it be with parents, teachers, friends parents, or a boss. Thus, many students have not had many opportunities to be equal in an adult relationship, yet they are legally, and often developmentally, old enough to be making their own decisions and dictating their own lives. As Silber and Silber (1996) suggest, counselors should be aware of the fact that students may comfortably fall into a Guidance-Cooperation relationship with their counselors because they do not know any different. This relationship involves the counselor telling the client what to do and the client obeying. From an ethical standpoint, counselors should strive for a Mutual

65 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 65 Participation relationship with clients. This relationship involves the client being an active participant and the counselor finding ways to help the client help him or herself (Silber & Silber, 1996). This is the most ethical option because the client is able to come to his or her own conclusions, allowing him or her to own the solutions, with minimal guidance from the counselor. Values are not imposed and preaching is avoided. Not only should a counselor strive for a Mutual Participation relationship, but the counselor should actively work towards instilling a sense of empowerment in the students to let them know that acting assertively and being responsible for themselves is now an acceptable way to have control over their own lives. Confidentiality In a counseling relationship in which the client chooses to be in therapy, ideally no person outside the counseling agency will know about the therapy unless specified by the client. When a client is mandated to be in counseling, this type of confidentiality becomes an ethical concern. Specifically with college students, if they are mandated to treatment by the university or college, it is likely that someone from the school will need to be notified that the student has completed the necessary counseling. Is this unethical? Is it ethical if the student agrees to the disclosure to a school official? What about if the student is required to agree to the disclosure? As with most other ethical issues, there is no right answer to these questions. A therapist at a university or college may be required, as part of the job, to disclose therapy attendance to a dean or other school official. In this case, in order to keep confidentiality as much as possible, it is recommended that the therapist disclose attendance to as few individuals as possible, notify the student that this disclosure is required and document this interaction, and disclose as little information as possible to the school official. This may be an ethical issue that will be present as

66 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 66 long as students continue to be mandated to treatment. It is the job of the therapist to be aware of these ways to limit breaks in confidentiality. A final ethical topic to discuss, and perhaps the most important, is the issue of confidentiality versus duty to protect with students whose behavior may have life-threatening implications for themselves or others. In terms of confidentiality versus the duty to protect, the Professional Counselor and Clinical Professional Counselor Act states: No licensed professional counselor or licensed clinical professional counselor shall disclose any information acquired from persons consulting the counselor in a professional capacity, except that which may be voluntarily disclosed under the following circumstances: When a communication reveals the intended commission of a crime or harmful act and such disclosure is judged necessary by the licensed professional counselor or licensed clinical professional counselor to protect any person from a clear, imminent risk of serious mental or physical harm or injury, or to forestall a serious threat to public safety. (2011). The important words to consider within this section are clear, imminent risk of serious mental or physical harm or injury and serious threat to public safety. Does drinking with the goal of blacking out constitute a clear, imminent risk of serious mental or physical harm or injury? How about drinking with the goal of needing a trip to the hospital? Does drinking so much that a person cannot make rational decisions about driving constitute a serious threat to public safety? How about being a serial drunk driver? What about a client who has a legal history of drunk driving and injuring him or herself or other people?

67 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 67 These are all questions that can arise when treating a college student for alcohol-related problems. Some of most important things to consider when attempting to make an ethical decision about confidentiality versus duty to protect are past behaviors, the directness of the statement made by the client about a potentially harmful act, and the willingness of the client to work with the counselor to elicit change. Client disclosure about black-outs or trips to the hospital for drinking a large amount would likely rarely lead to a break in confidentiality. In this case, unless the client had a long history of serious medical attention from binge drinking, continued to do so without acknowledging the severe consequences, was unwilling to work towards any bit of change, and was deemed to be putting his or her life in danger from the amount of alcohol consumed, breaking confidentiality would not be encouraged. Drunk driving is a different situation. There are certainly situations involving drunk driving that can cause a clear, imminent risk of serious physical harm or injury or cause a threat to public safety. Again, before acting, it is important that therapists consider the client s past behaviors, the information that the client is giving about the potential drunk driving incident, and whether the client is striving for change. More specifically, unless a client is very direct about participating in drunk driving and specific about when this may occur, it would be difficult for most therapists to support breaking confidentiality. A situation where a client does not make a very direct or specific comment about drunk driving, but has a long history of drunk driving, some of which ended in injury to self or others, may justify a break in confidentiality. In this case, the therapist may disclose the threat to any party that the client identified as being a passenger in the car during the potential drunk driving incident. If the client seems to be the only person that will be in the car, a disclosure to a spouse or other loved ones may be warranted in order to keep the client safe. As with most ethical issues, there is a lot of gray area. Ultimately,

68 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 68 one situation in which there is little gray area and the benefits of duty to protect will likely outweigh the cons of breaking confidentiality is with a client who makes a direct and specific statement about drunk driving and has a history of following through with the behavior. There are many aspects about ethical counseling that do not have a right answer. However, most of these aspects do have a wrong answer. When working with college students with alcohol-related problems, as with any clinical population, decisions should not lead to more harm or distress for the client. When attempting to make the right ethical choices, things to consider are the type of therapeutic relationship that is forming and the impact that the choices will have on the relationship. College students, especially young college students, are at a unique age in which they are transitioning into adulthood, yet some of their relationships keep them in childhood. A closely tied aspect to consider is autonomy versus beneficence. Counselors top goal is to help their clients, but counselors must be careful with this help if it is not well received. Ideally, counselors want their clients to come to their own conclusions and feel empowered to make changes without coercion, manipulation, or high amounts of persuasion. However, there are some instances when beneficence wins out over autonomy because it is mandated or because the client is incapable of being autonomous. Finally, counselors must always be aware of the debate between confidentiality and duty to protect. When working with college students with alcohol-related problems in the absence of another mental health disorder, this debate will rarely arise because clear, imminent risk will be difficult to find. However, when a situation does present itself where serious harm to self or others is clear and imminent, the counselor must ethically act. All in all, a counselor working with college students with alcohol problems will often be required to rely on his or her best clinical judgment. A solid ethical background will be the most beneficial tool.

69 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 69 Future Research Although there is a lot of research about college students with alcohol-related problems there is always room to expand on the existing literature and help counselors better understand this population. The following section includes suggestions for future research in this domain. The suggestions are organized into five subsections as they correspond to the five previous sections in this paper: Foundations of Behavior, Assessment, Treatment, Cultural Considerations, and Ethical Considerations. Foundations of Behavior There are a couple of gaps in the research on factors that influence drinking in college students that would be beneficial for future researchers to examine. First of all, it would be helpful for therapists to learn why college athletes and Greek members tend to consume more alcohol than college students who are not involved in these activities. While the connection between being an athlete or Greek member and high alcohol usage has been consistently made (Ford, 2007; Hildebrand, Johnson, & Bogle, 2001; Park, Sher, & Krull, 2008; Wechsler, 2000), it is unclear whether it is peer pressure, the need to fit in, observational learning, or another factor that contributes to this connection. This information will help therapists be able to target specific factors during treatment. If peer pressure is found to be a major contributor to high alcohol usage among these populations, a therapist may target a client s susceptibility to influence. However, if the major contributor is found to be the need to fit in, a therapist may choose to target self-esteem and self-image. The other major gap in the literature involves the perceived behavioral control portion of the Theory of Planned Behavior (Azjen, 1991). The concept of perceived behavioral control fits nicely into the theory; however, there was no support for connection between perceived

70 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 70 behavioral control and actual behavior in the literature. It should be noted that the connection was not disproved, but rather no research could be found that examined perceived behavioral control and actual behavior. If research findings support this connection, it will help to further therapists understanding of why college students engage in drinking behaviors. This knowledge could help to guide assessment and ultimately treatment planning for students with alcoholrelated problems. Assessment A stated purpose of the SASSI-3 is to be able to determine whether a client is answering questions untruthfully in an attempt to make his or her alcohol problem seem worse or better than the reality of the situation (Myerholtz & Rosenberg, 1998). However, multiple studies have found that the subtle subscales do not have any clinical relevance (Clements, 2002; Feldstein & Miller, 2006). It would be helpful for future researchers to determine whether or not the SASSI- 3 can be used to detect faking with a population of college students. As of now, college counselors should be careful when interpreting the subtle scales from the SASSI-3 because scores may be invalid. If it is found that the subtle scales are not valid with college students, future research should aim to design and test an instrument that, like the MMPI, is valid and reliable in detecting faking. An instrument such as this could be particularly beneficial when working with college students who may be mandated for treatment and could be less than truthful on questions directly related to alcohol use. The research literature on alcohol assessments with college students could benefit if each of the assessments that were described (AUDIT, MAST, SASSI-3, BASICS) received more attention in terms of their psychometric properties with a sample of college students. It is vital

71 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 71 that the MAST receive more research attention in this area as there is currently no research that discusses psychometric properties in any depth with college students. Treatment In the future, researchers should always emphasize finding new treatments that are more effective with a sample of college students. Looking at some specific goals for future research in treatment options, it would be helpful to see more research that focuses on types of prevention that are particularly effective with specific groups within a college population. In other words, alcohol has been widely researched among college students, yet college campuses could be more effective in preventing alcohol-related problems if research was conducted on specific college groups. For example, a prevention strategy that works well for students who are currently abstaining from alcohol use would likely not be effective with students who binge on a regular basis. Prevention programs may need to be specifically geared towards athletes or toward Greek members as their social environments differ from the social environments of the average college student. Incoming freshmen would likely benefit from prevention programs that may or may not be effective with upperclassmen. Students may be affected differently by prevention messages based on their cultural, religious, or economic status background. The more research that is conducted in this area, the more confidence college campuses can have in putting together effective programs for all groups of students. Current research shows mixed results for computer and web-based interventions for college students (Barnett et al., 2007; Doumas et al., 2009). If more research was conducted, it would help college counseling centers to determine whether a computer or web-based intervention should be offered to students. Certain types of computer or web-based programs likely would be found to be effective while others would not. Since the research states that some

72 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 72 college students may be more receptive to a computer interaction than a person interaction when it comes to treatment (Kypri et al., 2003), more research in this area could be very beneficial to clear up the current mixed results. In addition, including a web-based intervention in the alcohol curriculum offered at a college counseling center may be a way to free-up therapists for more work with students who display strongly problematic drinking behaviors. In other words, using a web-based intervention for first-time offenders would allow therapists to have more hours to meet with students who have multiple offenses or show signs of heavy abuse or dependence. As new research continues to surface, continued research on student receptiveness to various treatments likely will be beneficial. Treatments that are found to be effective in the literature but are refused by students in a practical setting are not going to help treat alcoholrelated problems. In the current treatment literature, a study that examines the receptiveness of the BASICS and Motivational Interviewing with a sample of college students would add to the effectiveness and usefulness of these treatment strategies. Cultural Considerations The biggest gap in the cultural literature on alcohol abuse is the lack of cultural research specifically with a college population. There is a lot of research that explains general cultural considerations when working with clients who have alcohol-related problems. Many of these considerations can generalize to working with college students; however, the literature can be improved with more specific studies with college students. It may be found that culture interacts with the young age of most college students and produces unique considerations that should be taken into account when working with college students from diverse backgrounds. Researchers have found that the definition of problematic drinking can vary by culture (Gureje et al., 1997; Room et al., 1996). Since assessment and diagnostic tools developed using

73 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 73 samples of people from the United States may not be reliable and valid with other populations such as international students, it is important for researchers in the future to continue testing existing assessment tools on various cultures. If it is found that many of the tools are not generalizable to other cultures, researchers should design measurements that can be used with students from diverse backgrounds. The literature on drinking patterns of younger versus older college students has been inconsistent (Champion et al., 2009; Ford, 2007; Theall et al., 2009; Wechsler et al., 1997, 2000). More research in this area could help to clarify the inconsistencies. Fully understanding how drinking patterns differ between younger and older students could help college counseling centers design effective prevention programs and interventions that target younger and older students separately. Ethical Considerations There is a lot of gray area in the ethical treatment of college students with alcohol-related problems. Future research that can better assist counselors in making the right ethical decision when treating this population would be very beneficial. For example, researchers who investigate how feelings of infringement and loss of autonomy for college students in alcohol treatment impact the therapeutic relationship may find information that helps counselors decide whether infringement is in the best interest of the student. In addition, research on unique considerations to take into account when working with young adults could be beneficial. Most college students are at an age in which they are no longer children, but in some ways they lack the maturity to be considered adults. In the future, researchers can focus on how working with this population, at a unique developmental stage, impacts the therapeutic relationship. Finally, an ethical area that is up for debate is confidentiality versus duty to protect when dealing with a

74 ALCOHOL MISUSE AMONG COLLEGE STUDENTS 74 college student who discloses information about future drunk driving. A paper that extensively discusses this ethical dilemma would give counselors a resource to turn to if this situation were to arise while counseling college students. Conclusion In this paper I have extensively examined the research literature on the topic of alcohol use and misuse among college students. The aim of the paper was to help counselors better understand all aspects and considerations when working with this population. Counselors now have more information about reasons why a college student may be engaging in problematic drinking behaviors. The assessment and treatment sections reviewed several tools and strategies that can be used, as well as their effectiveness, with college students. The cultural considerations section supplied general information for counselors to keep in mind when working with students from diverse backgrounds. Finally, the ethical considerations section was designed to initiate thought about various gray areas when counseling this population. The final section was aimed at researchers. This section was assembled based on gaps in the literature that were seen throughout the first five sections. Based on the statistics, it is clear that alcohol use among college students is an ongoing problem. It is important for counselors and researchers to continue to pay close attention to all the unique aspects involved in working with this population.

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