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. Author manuscript; available in PMC: 2023 Jun 2.
Published in final edited form as: J Subst Use. 2022 Mar 13;28(3):349–354. doi: 10.1080/14659891.2022.2047806

The effects of protective behavioral strategies on heavy drinking following a pure motivational interviewing intervention

Margo C Villarosa-Hurlocker 1, Fillip D Kosorukov 1, Jahailah Graham 1, Melissa Hatch 1
PMCID: PMC10237272  NIHMSID: NIHMS1805216  PMID: 37275205

Abstract

Background:

Protective behavioral strategies (PBS) are cognitive-behavioral strategies that students use to prevent risky drinking. Prior work supports PBS as a mechanism of change following a brief motivational intervention (BMI) among college students. This study investigated the necessity of discussing PBS by examining changes in PBS use and drinking following an alcohol intervention that used the parent method of Motivational Interviewing (MI), or Pure MI.

Methods:

Data came from a pilot study that looked at the effects of Pure MI that targeted risky social drinking behavior. The study comprised 42 college students who endorsed hazardous drinking in the last 2 weeks and social anxiety symptoms. Participants completed measures of safe and heavy drinking behaviors at baseline and one-month follow-up.

Results:

The results showed that PBS use increased from baseline to one-month follow-up. Further, the reduction in heavy drinking in social situations was partially explained by an increase in PBS use from pre- to post-intervention.

Conclusions:

Despite not introducing PBS into discussions during the MI intervention, we found that students who used more PBS reported reduced heavy drinking in social situations. Implications from the study suggest that interventions focused on student motivation rather than knowledge can promote safe and reduce hazardous drinking behaviors.

Keywords: Motivational interviewing, heavy drinking, social anxiety, protective behavioral strategies, college students

Introduction

Risky drinking patterns among college students are prevalent and lead to several negative consequences. Approximately 40% of college students engage in heavy episodic drinking (HED; 4/5 or more drinks in one sitting for women/men) in the past 2 weeks (Hingson et al., 2017) and common negative consequences experienced include driving while intoxicated, unintentional injuries, and alcohol-related deaths (Merrill & Carey, 2016). While this is concerning, college students also tend to engage in behaviors to reduce alcohol-related harm (Sugarman & Carey, 2007). Broadening the student repertoire of behaviors to reduce heavy drinking is a critical avenue to prevent long-term drinking problems. Protective behavioral strategies (PBS) are cognitive-behavioral strategies that students may use to keep themselves safe while drinking (Delva et al., 2004; Martens et al., 2004). More PBS use is related to less heavy drinking, and the PBS commonly endorsed by college students include avoiding shots and going home with a friend (Pearson, 2013). Given their empirical support, PBS have become a common skills component of brief motivational interventions (BMIs) for college students.

Recommended Tier 1 interventions (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2019), BMIs are multi-component interventions that use Motivational Interviewing (MI) as the framework to facilitate safe drinking and to reduce alcohol-related harm (Borsari et al., 2009). MI is an empirically supported intervention that integrates client-centered therapy and behavioral reinforcement strategies to elicit and reinforce a client’s own reasons for behavior change (Miller & Moyers, 2017). More specifically, the theory of MI identifies two active ingredients (relational and technical) to explain how the parent method of MI works (hereafter referred to as Pure MI; Miller & Rose, 2009). Though MI is a major component of many BMIs, there are important distinctions between BMI and Pure MI.

BMIs comprise several empirically supported elements derived from distinct theoretical orientations that the therapist is required to cover in session. For example, personalized normative feedback (PNF) is the most common element of BMIs and involves challenging beliefs that students hold about their drinking behavior in relation to other students (Miller & Rollnick, 2002). PNF has been shown to be an effective component of BMIs (Reid & Carey, 2015). Another common element of BMIs is a discussion and identification of PBS to promote safe drinking. Three prior clinical trials have demonstrated PBS as a mechanism of change in BMIs (Barnett et al., 2007; Larimer et al., 2007; Murphy et al., 2012). Despite the clear benefits of BMIs for heavy drinking college students, BMI has been less effective for students who engage in hazardous drinking and have social anxiety (Terlecki et al., 2011, 2012, 2020).

Social anxiety is a common risk factor for hazardous drinking and alcohol use disorder (Buckner et al., 2013). Social anxiety refers to psychological distress and evaluative fears that typically leads to social avoidance (Buckner et al., 2013). Students with social anxiety tend to report more hazardous drinking and less PBS use than their less socially anxious peers (Schry & White, 2013; Terlecki et al., 2020; Villarosa et al., 2014). Though PBS appear important for these students and PBS discussions are common in BMIs, extant work has found that BMIs are less effective for students with social anxiety (Terlecki et al., 2011, 2020) and that the lack of changes to these students’ normative perceptions, derived from the PNF component of BMIs, predicted more rather than less heavy drinking post-BMI (Terlecki et al., 2012). As such, alternative interventions are needed to adequately reduce heavy drinking in students with social anxiety.

The Motivational Interviewing for Risky Social Drinking (MI-RSD) is a Pure MI intervention that was developed to address the needs of student drinkers with social anxiety. Pilot findings of MI-RSD found initial efficacy on risky drinking and social anxiety symptoms (Hurlocker et al., 2021). MI-RSD embodies the theory of MI (Miller & Rose, 2009) and centers around a conversation about risky social drinking, excluding the structured elements common to BMIs (e.g., PNF, PBS). Such an approach may be optimal for students with social anxiety symptoms, given that discussions on risky drinking may naturally include the role of the social context and related distress. In Pure MI, discussions of PBS are not a required element, but may naturally arise in session for two reasons. First, the emphasis on eliciting and reinforcing student statements toward change may naturally lead to how students can stay safe while drinking. Second, an underlying assumption of Pure MI is that students know how to make positive changes, and the focus in session is to help students address why they may want to change their drinking.

Collectively, prior work has found null or worsening effects of BMI for student drinkers with social anxiety symptoms (Terlecki et al., 2011, 2020) despite the potential value of PBS in mitigating alcohol-related harm (Villarosa et al., 2014). As a secondary analysis of data derived from a pilot clinical trial (Hurlocker et al., 2021), the purpose of the current study was to examine the extent that changes in PBS explained changes in heavy drinking following a Pure MI intervention in a sample of hazardous drinking college students with co-occurring social anxiety symptoms. We predicted that there would be an increase in PBS use from baseline to one-month follow-up and that the increase in PBS use would mediate changes in heavy drinking in social situations.

Materials and methods

A within-subject design was used to evaluate changes in PBS use and heavy drinking in social settings from baseline to one-month follow-up among college students who completed the two-session MI-RSD. Given that a full description of study procedures and of the MI-RSD intervention are detailed elsewhere (Hurlocker et al., 2021), we describe below the features of the project relevant to the proposed study.

Participants and procedures

Participants comprised 42 undergraduate students (Mage = 18.96, SD = .98) from a university in the Southwestern region of the US. Most participants identified as female (85%) and as Hispanic/Latinx ethnicity (66.7%). The racial composition of the sample was 80% White, 7% African American, 7% identified as Other, and 3% were American Indian/Alaska Native. Participants were recruited using an online psychology participant pool (SONA), and deemed eligible if they 1) were at least 18 years old, 2) endorsed at-risk drinking in the last 2 weeks, in accordance with NIAAA standards (NIAAA, 2015), and 3) demonstrated at least moderate social anxiety based on a validated social anxiety screener (score > 4; Connor et al., 2001). Eligible participants were directed to a secure website (Qualtrics) to sign an IRB-approved electronic consent and completed a baseline survey that assessed heavy drinking in social situations and PBS. Participants then completed the two-session MI-RSD intervention and completed 1-month follow-up assessments.

Measures

Drinking context scale

The drinking context scale (DCS) is a 22-item, self-report questionnaire used to measure the probability of heavy drinking in the past month based on the emotional, situational and social context (O’Hare, 1997, 2001). It specifically measures two subscales: convivial (DCS-C; e.g., “When I’m at a bar”), and personal-intimate (DCS-P; e.g., “Before having sex”) settings (O’Hare, 2001) and respondents indicated their likelihood of excessive drinking in each context using a five-point scale (1 “extremely low” to 5 “extremely high”). The DCS has been validated in college student samples (e.g., O’Hare, 1997) and the internal consistency was good with the current sample (a: .77 [DCS-P]; .93 [DCS-C]).

Protective behavior strategy scale

PBS were assessed using the 18-item Protective Behavioral Strategies Scale-revised (PBSS-r; Madson et al., 2013). Participants indicate the frequency of using each strategy using a 6-point scale (1 “never” to 6 “always”). The PBSS-r comprises two subscales: controlled consumption (CC; e.g., “leave party/bar at certain time” and “avoid shots of liquor”) and serious harm reduction (SHR; “use a designated driver” and “know where your drink has been at all times”). The PBSS-r has been previously validated (e.g., Madson et al., 2013) and internal consistency of PBSS total and subscale scores were good with the current sample (as = .89 [total], .90 [CC], .73 [SHR]).

Intervention and therapist training

The focus of the therapist in session was to emphasize particular MI strategies; 1) therapist interpersonal style, 2) client language about change, 3) general strategies a therapist uses to embody MI spirit, and 4) MI skills. The Pure MI intervention was developed in accordance with the theory of MI (i.e., relational and technical components) and focused on the student’s ambivalence around changing their risky social drinking while excluding any structured tasks. Four doctoral-level clinical psychology students served as study therapists and completed a total of 12 hours of MI training, facilitated by the first author. The training consisted of the MI-RSD intervention manual (publicly available at: https://casaa.unm.edu/download/MIRSA%20treatment%20manual.pdf), role-play/real-play practice sessions, guided readings, and experiential exercises. All therapists reached at least beginner proficiency on the Motivational Interviewing Treatment Integrity Code (MITI 4.1; Moyers et al., 2016) before delivering the intervention (see, Hurlocker et al., 2021).

Data analytic approach

Given the pilot sample, descriptive analyses were performed to identify potential outliers, multi-collinearity issues, and/or data non-normality. Paired samples t-tests were performed to examine changes in heavy drinking in convivial and personal-intimate contexts, and in PBS use from baseline to one-month follow-up, and effect sizes were calculated using Hedges g, which adjusts for small sample bias. Finally, to evaluate whether changes in PBS use mediated changes in heavy drinking from baseline to one-month post-intervention, a two-condition within-subject mediation analysis was performed using the MEdiation and MOderation analysis for REpeated measures designs (MEMORE) macro for SPSS (Montoya & Hayes, 2017). This novel analytic procedure permits mediation of repeated measurement data of the same people on all variables in the mediation model. In applying this analytic approach to the current study, the independent variable (X) refers to the passage of time (i.e., two conditions: pre- and post-intervention) with the assumption that changes in the mediator (i.e., PBS) and changes in the dependent variable (i.e., heavy drinking) were influenced by the intervention. This analysis expands on the work by Jude et al. (2001) to propose a path-analytic approach to obtain an estimate of the indirect effect. Specifically, Montoya and Hayes (2017) developed the MEMORE statistical macro to calculate a formal indirect effect and eliminate the use of multiple hypothesis tests, and thus eliminating risks of inferential error (Hayes, 2015). Important features of the path analytic framework include (a) the mediator and dependent variables are represented as the difference between scores at two time points, and (b) the independent variable is not represented in the dataset; rather the independent variable refers to the passage of time and its effect is held in the mediator and dependent variable difference scores (see, Figure 1). Further, bootstrap methods are generated by MEMORE, permitting an estimate of the indirect effect from 10,000 resamples while accounting for data non-normality. Mediation is considered significant if the bootstrap confidence intervals do not include zero. Collectively, the MEMORE macro calculates all path estimates and includes inferential tests for the total, direct, and indirect effects of the independent variable (i.e., passage of time).

Figure 1.

Figure 1.

Open in a new tab

Adapted from Montoya and Hayes (2017) and depicts the path-analytic model of a two-condition (passage of time) within-participant mediation model. The independent variable (“X”) does not exist in the dataset and its effect is carried by the difference scores in the mediator and outcome. As recommended by Curran and Bauer (2007), the triangle in the path model signifies that X is quantified by the regression constants in the equations of the difference in the mediator and the difference in the outcome between the two conditions (i.e., pre- and post-intervention).

Results

Preliminary analyses

Means, standard deviations, and intercorrelations of study measures at baseline and follow-up are presented in Table 1. Examination of study measures at each time period revealed no outliers, multicollinearity, or data non-normality. Paired samples t-tests revealed significant differences in risky drinking in convivial drinking settings (t[26] = 3.08, p < .01, g = .71, 95% CI [1.31, 6.55]), but not personal-intimate drinking settings between baseline and follow-up. In terms of PBS, there were significant differences in PBS total (t[26] = −2.32, p < .05, g = .40, 95% CI [−11.04, −.66]) and controlled consumption (t[26] = −2.28, p < .05, g = .43, 95% CI [−10.65, −.54]) scores, but not serious harm reduction scores between baseline and follow-up. Specifically, participants reported engaging in less heavy drinking in convivial setting and using more PBS and controlled consumption strategies at one-month follow-up as compared to baseline.

Table 1.

Means, standard deviations and intercorrelations of study measures.

1 2 3 4 5 6 7 8 9 10
(1) DCS-Cbaseline .43* .29 –
(1) DCS-Cfollow-up .33 .50** .25 –
(1) DCP-Cbaseline −.21 −.03 .28 .14 –
(1) DCP-Cfollow-up −.08 .30 .06 .36 .44* –
(1) PBS-Tbaseline −.66** −.48* −.38* −.27 −.00 −.15 –
(1) PBS-Tfollow-up .37 −.44* −.11 46* −.07 .02 .60** –
(1) PBS-CCbaseline −.65** −.44* −.35 −.20 .14 −.04 .97** .55** –
(1) PBS-CCfollow-up −.32 −.41* −.07 41* .01 .08 .54** .98** .50** –
(1) PBS-SHRbaseline −.34 −.36 −.28 38* −.49** 45* .53** .45* .30 .36
(1) PBS-SHRfollow-up −.42* −.41* −.23 51** −.30 −.22 .62** .75** .52** .60**
M 30.11 26.19 7.19 7.00 73.63 79.48 41.00 46.59 32.63 32.89
SD 5.36 5.43 2.37 2.79 15.63 13.54 13.87 11.25 4.14 3.37
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DCS = Drinking Context Scale; C = Convivial; P = Personal-intimate; PBS = Protective Behavioral Strategies; T = Total; CC = Controlled Consumption; SHR = Serious Harm Reduction

**

p < .01,

*

p < .05

Mediation analyses

Given that heavy drinking in personal-intimate settings were not significantly different from baseline to one-month follow-up, we ran a within-subject mediation analysis to evaluate whether changes in PBS use explained changes in heavy drinking in convivial situations, but not in personal-intimate settings. Although we found significant differences in controlled consumption PBS use in our preliminary analyses, we chose to focus our mediation analysis on changes in PBS total scores due to our small sample.

Model results demonstrated that changes in PBS significantly mediated changes in heavy drinking in convivial settings. As depicted in Figure 2, participants reported lower rates of heavy drinking in convivial settings one month after completing MI-RSD (c = 3.93, p < .01. 95% CI [1.31, 6.55]). After including the PBS change score (i.e., follow-up PBS minus baseline PBS), baseline heavy drinking was no longer a significant predictor of follow-up heavy drinking (c’ = 2.66, p = .05, 95% CI [−.06, 5.37]) and the PBS change score was a significant, partial mediator (B = 1.27(.94), 95% CI [.03, 3.58]).

Figure 2.

Figure 2.

Open in a new tab

Path estimates are unstandardized regression coefficients obtained through bootstrapping of 10,000 resamples. The range in brackets are the 95% CI of the indirect effect. **p < .01, *p < .05

Discussion

Extant work largely demonstrates that students who use more PBS tend to engage in less hazardous drinking behaviors (Pearson, 2013), and PBS use has been found to mediate the effects of BMI on drinking outcomes. However, these effects have not been demonstrated among student drinkers with co-occurring social anxiety symptoms (Terlecki et al., 2011, 2020). This study used a novel, Pure MI intervention to evaluate the mediating effects of PBS use on heavy drinking in a sample of at-risk students with co-occurring social anxiety. As predicted, there was a decrease in heavy drinking and an increase in PBS use from baseline to one-month post-intervention, and the increase in PBS use predicted decreases in heavy drinking in convivial settings from baseline to one-month post-intervention.

Current findings encourage further exploration of PBS as a mechanism of action in a Pure MI intervention for college student drinkers with social anxiety symptoms. Though the small sample size and lack of control condition are notable limitations, current findings broadly suggest that PBS can increase even when not directly discussed in an intervention. There are several possible explanations for this finding. First, extant work has found that most students use a host of PBS without ever participating in an intervention (Howard et al., 2007; Sugarman & Carey, 2007), demonstrating their preexisting knowledge on how to prevent alcohol-related harm. As such, what may explain student use of PBS is their degree of motivation (or why) to use more PBS during drinking episodes. Second, PBS have demonstrated support primarily in interventions that focus on reducing problematic drinking rather than increasing PBS use (Prince et al., 2013). Relatedly, the null findings in prior PBS-specific interventions were partially attributed to not including a motivational component (Martens et al., 2013).

We argue that student motivation to use PBS, not their ability to use PBS may lead to less heavy drinking. Motivation can be enhanced in many ways, as demonstrated by prior BMI and PNF clinical trials. Though some PNF trials do not include an MI component (e.g., Larimer et al., 2007), normative feedback increases student motivation to change their drinking behaviors by developing discrepancy in perceptions of self versus others drinking. Though one study suggested that a multi-component intervention that includes MI and PNF, at a minimum, is ideal for college students (Walters et al., 2009), these interventions have been less successful for those with comorbid social anxiety (Terlecki et al., 2011, 2020). As such, a Pure MI intervention may be a valuable alternative for these students.

In accordance with MI theory, a Pure MI intervention focuses on how to enhance and reinforce student motivation toward change. Thus, by leveraging the therapeutic process, rather than teaching therapeutic skills, the therapist and client have an opportunity to explore ambivalence around drinking and how drinking fits with the client’s values and lifestyle. A Pure MI approach may be ideal for student drinkers who also are struggling with emotional issues, as discussing the reciprocal nature of drinking and emotional distress can provide insight into how distress contributes to ambivalence toward change. Further, an underlying assumption in MI is that students have ideas on how to make positive changes (Miller & Rollnick, 2013), suggesting that a structured discussion around PBS use may be an unnecessary intervention component.

Contrary to null findings of BMIs for this high-risk population (Terlecki et al., 2011, 2020), the proposed MI-RSD intervention offers preliminary support of the parent method of MI (Pure MI) for students with co-occurring social anxiety symptoms. These findings do not preclude the potential value of adding intervention components to MI that can adequately address both drinking and mental health issues. For example, Whiteside (2010) found reductions in drinking and anxiety/mood symptoms among students who completed a BMI that included a dialectical behavior therapy (DBT) skills module. DBT skills such as emotion regulation can help students overcome the cyclical nature of drinking and emotional issues, and student use of more PBS may be a natural byproduct of acquiring DBT skills.

Limitations

As a pilot trial of a novel intervention, current findings must be interpreted in light of its limitations. First, we did not have a comparison group, which limits our ability to attribute study findings to the intervention versus natural change overtime. A necessary next step is to determine the efficacy of MI-RSD in comparison to traditional BMI. Further, our sample was small and mainly comprised women from a single institution, limiting study generalizability. Future work should test the intervention with a larger and more diverse sample. Finally, our study restricted follow-up to one-month post intervention, limiting our understanding of the sustainability of possible intervention effects. It would be useful to gauge the strength of our intervention by evaluating effects at one-year follow-up.

Conclusion

Given the preliminary effects of PBS on heavy drinking in the current study, it would be interesting to see if a Pure MI intervention affects other theorized mechanisms of action (e.g., coping motives, change talk). Relatedly, the proposed intervention may be helpful for student drinkers with other mental health issues, such as depression, PTSD, or other substance use issues. In addition to evaluating differences between MI-RSD and BMI on mental health, PBS use and drinking outcomes over a year follow-up period, it may be valuable to follow the participants into their adult lives to evaluate the sustainability of intervention gains after leaving the college environment.

Funding

This work was supported by the National Institute on Alcohol Abuse and Alcoholism under grant: [L30-AA0270269]; National Institute on Drug Abuse under grant K23-DA052646. The funding organization had no further role in the study design; in the collection, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Footnotes

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author, MH, upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, MH, upon reasonable request.

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