What makes group MET work? A randomized controlled trial of college student drinkers in mandated alcohol diversion
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What makes group MET work? A randomized controlled trial of college student drinkers in mandated alcohol diversion.

LaChance H., Feldstein Ewing S.W., Bryan A.D. et al.
Psychology of Addictive Behaviors: 2009, 23(4), p. 598–612.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Feldstein Ewing at sfeldstein@mrn.org. You could also try this alternative source.

US students who broke college drinking rules and were required to undertake an alcohol programme responded better to three hours of group motivational interviewing than six of alcohol education; enhanced confidence that they could resist risky drinking was the key. For colleges it offers an effective but economical response to problem drinkers.

Summary A review of studies of interventions to reduce drinking among college students found these on average worked best when they incorporated elements of motivational interviewing, and also when some techniques often used during this approach were included – specifically, feedback to the student on how their drinking compares to the norm, feedback on what the student expects from drinking or why they drink, and exercises weighing the pros and cons of drinking.

The review also found that face-to-face interventions and those delivered one-to-one had the greatest impacts on drinking. However, such interventions are not always feasible or cost effective. Court-referred or university-based alcohol education and diversion programmes are commonly provided in a group modality, and with some success have adapted motivational interviewing to this setting with consequent drinking reductions. But how they work is poorly understood. Studies to date have highlighted the impact on social and enhancement motives for drinking but found no support for other expected mechanisms such as enhancing readiness to change one's drinking. Knowing more about the mechanisms should enable us to develop more effective interventions and/or training for interventionists.

To explore these mechanisms, at a US university the study successfully They completed baseline assessments and interventions. recruited 206 students required to attend alcohol education classes as one of the sanctions for minor underage drinking infractions of the institution's rules. They were randomly assigned to one of three small-group interventions:
• the university's standard two three-hour interactive alcohol education groups;
• one three-hour motivational interviewing session; or
• one three-hour lecture-format alcohol information session.

Responses from baseline questionnaires were used to create personal feedback handouts for students assigned to motivational interviewing on how their drinking compared to national averages. During the group, exercises conducted along motivational lines involved responses written on board so all the group could evaluate and discuss, and finally help each other develop strategies to alter high-risk drinking, substance abuse, and risktaking. Neither of the other two group options featured individualised information or collaborative harm reduction exercises and discussions.

Follow-ups which re-assessed drinking were completed via the internet three and six months later when responses were received from 80% and 76% respectively of the students.

Main findings

Questionnaires completed before and immediately after the sessions were used to assess whether they had led to the intended changes in the psychological mechanisms thought to account for any impacts on drinking.

Contrary to expectations, readiness to change drinking and estimates of how much students drink "when they party" were unaffected. However, there were differential effects on the students' feelings that they could resist drinking ('self-efficacy') under different circumstances. Whether this was when under social pressure to drink, under stress, or just when the opportunity presented itself, self-efficacy had increased most But not always to a statistically significant degree. after the motivational groups. Assessments of the risks posed by drinking also rose most after these groups, though expectations of the positive effects from drinking weakened equally after motivational or standard education groups.

At both follow-ups, all three measures of drinking risk and problems (AUDIT scores indicative of risky drinking, intensity of drinking on drinking days, and alcohol-related problems) had fallen most steeply after the motivational groups. The impacts of the other two groups were roughly equivalent or somewhat greater after the education sessions than the information lecture. Generally the advantages gained by the motivational sessions were statistically significant and substantial.

With both drinking, and some mechanisms thought to underlie drinking, changing more after the motivational sessions, the question arose whether it could be shown that those mechanisms accounted for the greater impacts on drinking of the motivational sessions. The analysis showed that students who after the interventions had relatively high self-efficacy to resist drinking, lower estimates of what partying students typically drank, and lower readiness to change Perhaps because this measure included awareness of drink problems. their drinking, drank less and less problematically (an amalgam of all three alcohol-related measures) at the follow-ups. However, only self-efficacy combined across the three types of circumstances which might promote drinking accounted at least in part for the greater impact of the motivational sessions on drinking and drink-related problems.

The authors' conclusions

Compared to extended alcohol education or information, at both follow-ups students randomly assigned to a motivational session drank less problematically in terms of symptoms of hazardous drinking, alcohol-related problems, and average drinks per drinking day, strengthening the implication from other studies that group motivational interviewing promises to offer a cost-effective response to students required to attend an alcohol programme.

For several reasons these findings are clinically significant. First, they show (contrary to some studies) that high-risk drinkers can respond well to a single motivational session, including sustained, significant and unusually substantial changes in drinking. Across each of the problem drinking measures, the motivational groups were the only ones to consistently evidence significant reductions. Also they did so in ways critical to reducing alcohol-related risk behaviours and associated problems for high-risk drinkers, changes which should reduce their risk of further infractions of college rules.

Other research has highlighted the critical role of self-efficacy in drinking reductions and its involvement in mediating the impact of motivational interventions. Confirming these findings, the featured study found that college drinkers required to undertake an alcohol programme who completed a single group motivational session developed (over and above the impacts of education or information alone) a significantly stronger sense of self-efficacy to refuse drinks across high-risk situations, including social pressure, stress, and drinking opportunities. This bolstering of self-efficacy was in turn associated with more positive drinking outcomes three and six months later.

Positive, mutually reinforcing interactions in the motivational groups may account for these findings. Unlike students in the other groups, motivational participants were asked to generate creative ideas about how they would avoid excessive drinking in typical college situations. They brainstormed ways to do so which to them were realistic and practical, created by themselves and their peers, and which they could own. They also helped each other find solutions they may not on their own have come up with or felt confident enough to mention. Armed with this real-life expertise and after seeing that fellow students in their position felt the strategies would work, they felt more confident that they could avoid 'doing too many shots', 'chugging' (consuming a whole drink in one go), or 'getting hammered'.

Given these findings, universities hoping to reduce drinking among high-risk drinkers should seriously consider group motivational interventions focused on bolstering students' confidence that they can curb their drinking.

Findings logo commentary The findings exemplify what is the most consistent advantage of interventions based on motivational interviewing – that they achieve results generally at least as good as other approaches but in less time, so potentially more economically.

Economy is also improved by the group format. The risk is that bringing heavy and/or risky substance users together will create social justifications and pressures for continued heavy use and make this seem more, not less 'normal'. But when the participants have a joint reason to collaborate in curbing their substance use – typically when they have voluntarily entered treatment with this objective in mind – in studies which directly compared them, group psychosocial therapies have been found equivalent to individual approaches in retention and substance use outcomes. However, such studies are usually limited to comparing outcomes among clients prepared to be randomised to either treatment. Those with strong preferences or practical reasons for choosing one of the formats have been excluded or excluded themselves.

Last revised 16 January 2012

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