Incident-Specific and Individual Level Moderators of Brief Intervention Effects with Mandated College Students

College students who receive campus alcohol violations are at higher risk for alcohol-related problems than other students (Caldwell, 2002; O’Hare, 1997), and on most college campuses sanctions for these students include mandatory intervention to reduce heavy drinking and associated harm. As alcohol-related sanctions on college campuses increase annually (Porter, 2006) and college budgets shrink, it becomes increasingly important to identify the most effective interventions for this high-risk group of young adults. Different modalities such as computer-delivered, web-delivered, and self-administered interventions are being tested and may be appropriate and even preferred for some students. For example, counselor-administered individual Brief Motivational Interventions (BMIs) have reduced alcohol consumption and alcohol-related problems relative to comparison conditions (e.g., computer-delivered, written feedback; Borsari & Carey, 2005, Carey et al., 2006; White et al., 2007), but in some cases equivalent effects have been found in lower-cost comparison conditions (Barnett et al., 2007; White et al., 2006). Moreover, there is growing evidence that particular characteristics of students and their circumstances may help determine the optimal intervention for students who come to the attention of campus authorities. Gender and problem drinking history have been investigated as moderators of intervention effects with mandated students across several studies. Carey and colleagues found that gender moderated intervention efficacy with mandated students; women showed greater response to a BMI vs. a Computer-delivered intervention (CDI), whereas men showed no intervention group differences (Carey, Henson, Carey, & Maisto, 2009). This indication that women may be more responsive to particular interventions has been reflected in other research with nonmandated samples (Blow et al., 2006; Murphy et al., 2004), but Mun, White, and Morgan (2009) did not find gender moderation when BMI was compared to written feedback. Mun and colleagues did find that number of prior alcohol-related problems moderated intervention outcomes, such that BMI with personalized written feedback was more effective than written feedback alone with students who identified more baseline alcohol-related problems. However, Carey et al. (2009) considered a different indicator of alcohol-related risk (Alcohol Use Disorders Identification Test [AUDIT] of 10 or higher) but did not find moderation effects. Although gender and drinking problems are important to examine as they relate to intervention effects for mandated students, students who receive these interventions also have experienced a specific identifiable and recent event that prompted their referral or sanction. The circumstances of the precipitating event (i.e., the alcohol-related consequences experienced in the incident) and individual reactions to the incident may influence intervention effectiveness. In the only study to evaluate incident circumstances as a moderator, Mun et al. (2009) investigated the seriousness of the precipitating incident and found mandated students who were involved in a serious incident (ones that included medical or police attention) were more likely to be classified as improved on heavy episodic drinking and alcohol problems following a BMI than following written feedback. In addition to event seriousness, there is evidence that having had a recent alcohol-related incident precipitates cognitive and affective reactions that may interact with the intervention. Two such state variables, personal attributions (i.e., feeling responsible) about the incident, and perceived aversiveness of the incident have been found to be positively related to motivation to change following a specific incident (Barnett et al., 2006; Longabaugh et al., 1995), and may be a contributing factor to intervention effectiveness. These reactions have not been evaluated as moderators of intervention with mandated students, but a study conducted with 18–24 year old emergency department (ED) patients found that patients who had lower attributions for alcohol use as the reason for their ED visit benefitted more from a counselor-based BMI than a written feedback condition (Barnett et al., 2010). Patients who had higher attributions about the role of alcohol in their event showed no outcome difference between BMI and written feedback. One interpretation of this finding is that patients who attributed their event to alcohol perceived greater salience of the event and were more motivated to change, and were subsequently able to benefit from either intervention. In contrast, those with lower alcohol attributions seemed to require a more intensive and interactive intervention to show behavior change. The importance of the negative affect generated by an alcohol-related event has been investigated in three studies; in all three a negative affective reaction to a precipitating alcohol-related incident was associated with greater motivation to change drinking (Barnett et al., 2002; Barnett et al., 2006; Longabaugh et al., 2005). Further, Barnett et al. (2010) found aversiveness of the event did not moderate response to BMI vs. written feedback in a sample of young adults in an emergency room. Since that sample was not mandated to intervention, and such mandates can generate considerable negative response from students (Palmer, 2004), evaluation of aversiveness as a possible moderator in mandated student samples is warranted. A final characteristic that has been evaluated as a moderator of intervention efficacy in mandated students and other populations is readiness to change alcohol use. In the studies with mandated students described above (Carey et al., 2009; Mun et al., 2009), neither found that baseline readiness to change moderated intervention outcomes. However, in ED patients, readiness to change moderated intervention outcomes, such that patients with lower readiness to change benefitted more from BMI when compared to a written feedback condition, whereas patients with higher readiness did not show intervention group differences (Barnett et al., 2010). Given the importance of readiness to change as a central construct in Motivational Interviewing (MI; Miller & Rollnick, 2002) theory, defined as a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, p. 25), it is important to evaluate its influence on brief intervention efficacy. The few studies with mandated students that have evaluated moderators have contained one-contact interventions. In the only study to investigate whether an additional (booster) session improved outcomes (Barnett et al, 2007), no main effects of booster condition were detected. Barnett and colleagues (2007) suggested the 25-minute booster may have been too short, or that the timing of the booster (1-month post intervention) was not optimal, however, it is possible that individual and event-related characteristics would identify students who could benefit from additional intervention. Therefore, examining moderators of the booster session might provide information that could lead to a targeted or stepped care approach to the use of these sessions. The objective of this study was to replicate previous findings related to baseline alcohol-related problems, readiness to change, and gender as moderators of two commonly used intervention approaches with mandated college students. Further, the goal was to extend research to examine whether individual responses to a sanctioning incident (incident consequences, attributions, aversiveness) moderate the efficacy of different intervention approaches, and whether they moderate the efficacy of booster sessions. Data were from a randomized controlled trial that compared a BMI to a CDI condition (Alcohol 101), after which participants were randomly assigned to a 1-month booster session (Barnett et al., 2007). The original trial included a 1-year follow up, but because the relative influence of any individual single-event contextual factor (including incident-related variables, treatment, and their interactions) is likely to diminish over time, examining the specific roles of moderators at the earliest follow-up time point offers the opportunity to identify characteristics important for short-term drinking reductions. Therefore, our moderation analyses focused on 3-month outcomes. Findings from the original study identified a significant main effect of time at 3-months with a reduction in number of drinking days and heavy drinking days in the past month for both conditions, but no between group differences. No reductions in alcohol related problems were found for either group. Finally, the main effect of booster condition, 2-way interactions with booster, and 3-way interactions were all not significant. We expected that 1) students with a higher number of alcohol problems, lower number of incident consequences, lower alcohol attributions, lower event aversiveness, and lower readiness to change would show greater response following a BMI relative to those completing a CDI; 2) gender would moderate intervention effects with women reducing drinking following a BMI relative to those completing a CDI, whereas men would not show differential treatment effects. This is the first study exploring moderators and their relationship to completing a booster session, but for the same reasons we would expect those with lower response to the event would benefit from the opportunity to engage with a counselor in a BMI, we expect that those with lower incident consequences, lower alcohol attributions, lower event aversiveness, and lower readiness to change would show greater benefit from a booster session relative to no booster.