Back to school: counseling college substance abusers; Counselors may be wise to eschew traditional treatment approaches.

The association between substance use and college life dates back as far as the origins of higher education itself. One of Harvard College's first construction projects involved building a brewery on campus so that a steady supply of beer could be served in student dining halls. (1) Substance abuse and college life are tied together today through movies, television, and oral histories passed from one student to another. College substance use has become a significant health issue, increasing the chance that clinicians will encounter a client from this population.

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Working with a college student who has acknowledged a substance abuse problem, or one who has been mandated into treatment by the college, presents special challenges for the clinician. College students often feel the rules do not apply to them--that it is a rite of passage to drink. It is critically important for clinicians to be aware of this attitude and to focus in their work on three areas that can help differentiate among use, abuse, and dependence: proper client assessment, including his/her college environment; sound theoretical approaches addressing the student's social and developmental adjustment level; and referrals to appropriate aftercare services and support mechanisms specifically for the recovering college student.

Assessment challenges

It is no surprise that studies have found that college students report drinking more alcohol than nonstudents of the same age. (2) A 2002 study conducted by the National Institute on Alcohol Abuse and Alcoholism's Task Force on College Drinking reported that drinking by traditional-age college students contributes to 1,400 deaths, 500,000 injuries, and 70,000 cases of sexual assault or date rape per year. However, many of these consequences occur to students who do not meet criteria for a diagnosis of a substance use disorder.

College substance use runs the gamut from light to moderate drinking to immersion in illicit drug use. The proliferation of research and media attention on college substance abuse issues, such as binge drinking and designer drug use, actually has created as many problems as solutions in providing effective substance treatment. The "aftertaste" in public perception is that all college students are on their way to being alcoholics and addicts. This is far from the truth.

In 2002, the Harvard School of Public Health's College Alcohol Study reported that 6% of college students met criteria for a diagnosis of alcohol dependence, (3) compared with 13.5% of the general population. (4) Regardless of these numbers, it has been projected that 20% or more of college students present to counseling with some type of substance abuse problem. (5) For this reason, it is essential that clinicians use great care when assessing college students and that they avoid assigning diagnoses based on what may be environmental factors instead of clinical symptoms.

When conducting the assessment, the clinician needs to collect basic information such as the student's personal history of substance use and psychiatric history, along with family history, while also exploring the student's university drinking environment and student classification (i.e., freshman, sophomore, etc.). This information offers much-needed clues to emotional, behavioral, and cognitive development.

Assessing this client population for a substance use disorder should take into account the student's specific social and developmental factors. In addition to life tasks common in the period of late adolescence and young adulthood, such as identity formation and autonomy development, the transition to college adds unique stressors. Separation from family and old friends, introduction to new social networks, more academic choices and demands, and increased independence tempered with less parental support are changes that may forecast future substance abuse problems because they increase stress while lowering social control. (6)

Nonstudents moving out of their parents' house may face the same pressures but often lack the concentrated environmental components that a college campus offers, such as fraternities and sororities, dormitory living, participation in athletic organizations, and increased peer pressure. (7)

The use of standardized assessments and screening tools is helpful when determining the presence of a substance abuse disorder or other disorder. The Substance Abuse Subtle Screening Inventory (SASSI) is particularly helpful when working with a mandated client who is being deceptive about use. The SASSI includes a defensiveness scale that can detect possible dishonest answers by the client. The College Adjustment Scale (CAS) addresses multiple areas of concern including depression, anger, suicidal ideation, and family problems. The CAS was normed on a college population. Both of these tools have quick administration and scoring times. Clients can easily understand them with proper interpretation from the clinician.

The college student as client

Effective counseling techniques used with a college student don't differ from those used with any client. The clinician still must build rapport, be empathic, and develop a genuine and trusting therapeutic relationship. However, some research suggests that certain counseling approaches prove more effective with the college population.

Offering a college student traditional types of substance abuse treatment may not be effective. Confrontational counseling with a heavy emphasis on a 12-Step paradigm may not be the appropriate choice of therapy for an 18- to 20-year-old client whose social and personal insight, already limited developmentally, have been damaged by drug and alcohol use. In a generation of adolescents raised on faster downloads and increased dependency on parental and institutional support, lengthy insight-based therapies can feel cumbersome and overwhelming. Research has shown that in some cases, standard psychotherapy and general alcohol counseling have exacerbated substance use problems for this client population. (5)

Brief and motivational interventions have proven to be the most effective counseling strategies with the college client. (8) This type of supportive counseling is designed to help the client decide what he/she wants from life, and to examine the role that substance abuse is playing in helping or hindering the effort to obtain it. This helps the client see where he/she is and where he/she wants to be. If a significant disparity exists between these two places, the clinician's job is to help the client figure out how to close the gap. Helping the client see abstinence as an option reduces this disparity.

It is also helpful to have the client review the quality and condition of social relationships in his/her life. For students, life on a college campus involves intense pressures to adapt to new living conditions, perform academically, and engage in new interpersonal scenarios not present for nonstudents. Teaching skill sets such as how to cope with social and environmental conditions conducive to relapse will greatly increase this approach's efficacy. Other key ingredients of brief interventions include providing feedback, developing a menu of strategies, using empathy to encourage and support, and discussing the role of responsibility in being successful. (7)

Support and aftercare

Essential to any holistic treatment program is comprehensive follow-up and aftercare. This is the case for a college student new to recovery and facing a return to the environment that might have fueled substance use.

Putting a recovering student back into a traditional dormitory, residence hall, or off-campus apartment after a period of treatment or counseling can be a recipe for disaster. The good news is that aftercare services and programs for these clients are growing, and college administrators and the treatment community are beginning to understand the particular needs of students in recovery. The designation of "wellness residence halls" represents a growing trend on college campuses. These settings do not tolerate alcohol, tobacco, or drug use and promote a healthy and well-balanced lifestyle. Some campuses even provide special housing for students in recovery and offer programs to enhance posttreatment activities.

A good place for follow-up counseling and support is the college's own counseling center. These centers often are staffed by licensed and certified counselors who have extensive knowledge in addiction. Contacting the center as part of discharge planning offers a natural fit for the recovering student.

Another option for the recovering student not ready for traditional college living but wanting to continue his/her education is the off-campus recovery residence. The Higher Education Recovery Option (HERO) House in Atlanta is a recovery house for college students that offers 12-Step recovery support, class registration assistance, and monthly programs and lectures on various life-skill topics. Randy Haveson, director of HERO House, believes that college students in early recovery will do better in school and in their recovery when they live with other college students. They share the stressors of college, which are different from the stressors of those not in college.

In an interview posted on the HERO House Web site (www.theherohouse.org), Haveson says, "I know there are recovery houses that have some residents who are college students, but there's a different dynamic when students live with other young people who are not in college."

Conclusion

As the focus on college substance abuse continues to grow, colleges and universities are becoming more proactive in dealing with students who are substance-dependent. This results in more college clients reaching out to treatment programs and private providers for help. It is therefore essential that providers understand the special needs of this population. With a little patience, understanding, and creativity, clinicians can provide effective treatment to college students dealing with substance abuse issues.

Mark Schwarze, MA, CSAC, is a counselor and Coordinator of the CPARC (Coalition to Prevent Alcohol Related Consequences) Program at the University of North Carolina at Pembroke. The CPARC Program seeks to use environmental management strategies to reduce high-risk drinking on campus. Schwarze is a member of NAADAC, The Association for Addiction Professionals.

Monica Osburn, PhD, LPC, NCC, ACS, is Director of the Counseling and Testing Center at the University of North Carolina at Pembroke. She is a past-president of the North Carolina College Counseling Association and is a member of the American College Counseling Association and the Association for University and College Counseling Center Directors.

To send comments to the authors and editors, e-mail [e-mail].

References

1. Furnas JC. The Life and Times of the Late Demon Rum. New York: GP Putnam's Sons, 1965.

2. Orford J, Krishnan M, Balaam M, et al. University student drinking: The role of motivational and social factors. Drugs Educ Prev and Policy 2004;11:407-21.

3. Knight J, Wechsler H, Meichun K, et al. Alcohol abuse and dependence among U.S. college students. J Studies on Alc 2002;63:263-70.

4. Doweiko H. Concepts of Chemical Dependency. 5th ed. Pacific Grove, Calif.: Brooks/Cole, 2002.

5. Steenbarger B. Alcohol abuse and college counseling: An overview of research and practice. J College Couns 1998;1:81-92.

6. White H, Labouvie E, Papadaratsakis V. Changes in substance use during the transition to adulthood: A comparison of college students and their noncollege age peers. J Drug Issues 2005;35:281-304.

7. Sullivan M, Risler E. Understanding college abuse and academic performance: Selecting appropriate intervention strategies. J College Couns 2002;5:114-24.

8. Miller WR. Increasing motivation for change. Handbook of Alcoholism Treatment Approaches: Effective Alternatives. 2nd ed. Boston: Allyn & Bacon, 1995.

by Mark Schwarze, MA, CSAC, and Monica Osburn, PhD, LPC, NCC, ACS