Thirty Years of BASICS: Dissemination and Implementation Progress and Challenges

Abstract

The first clinical trial of Brief Alcohol Screening and Intervention for College Students (BASICS; Dimeff et al., 1999) was launched at the University of Washington in 1990 (Marlatt et al., 1998). Since that time, multiple trials have demonstrated efficacy of BASICS and related approaches in a variety of young adult populations (Cronce & Larimer, 2011; Larimer & Cronce, 2002, 2007) and this information has been widely disseminated (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2002; 2019; Nelson et al., 2010; U.S. Department of Health and Human Services, 2016). However, in practice BASICS implementation varies considerably, including formats and mediums (e.g., group, telehealth, written/electronic feedback alone) not studied in the original research. Even if delivered in an individual in-person format, implementation can stray substantially from the original design; these adaptations may be necessary to address campus resource constraints or other barriers to implementation, but can have unknown impacts on intervention effectiveness. Thus, despite wide-scale efforts to disseminate and implement BASICS, challenges remain, and there are several critical research gaps that need to be addressed to support campuses in implementing BASICS successfully. The current manuscript addresses these dissemination and implementation challenges and research gaps, and provides recommendations for best implementation practices as well as future research needed to improve implementation and effectiveness of BASICS going forward.

Introduction and History of BASICS

Within the past 30 years, the practice of high-risk drinking prevention on college campuses has moved from an ineffective paradigm of didactic alcohol education (Gadaleto & Anderson, 1986; Hanson, 1982) that embraced a primarily abstinence-only goal to several scientifically-supported environmental- and individual-focused approaches, many of which are centered in the philosophy of harm reduction. The origin of this sea change can be traced to a large extent to the work of G. Alan Marlatt and his colleagues at the University of Washington in the 1980s and 1990s, which culminated in development of Brief Alcohol Screening and Intervention for College Students (BASICS; Dimeff et al., 1999).

BASICS grew out of the Alcohol Skills Training Program (ASTP), a group-based cognitive behavioral skills-focused intervention first evaluated in 8-session (Kivlahan et al., 1990) and then 6-session (Baer et al., 1992) formats. Baer et al. (1992) evaluated the 6-session ASTP alongside a 1-session personalized individual motivational feedback session, and found the 1-hour individual session achieved similar reductions in drinking as the 9-hour ASTP group; reductions were maintained over 2 years. This led to the individual intervention (BASICS) being evaluated in a separate trial (Marlatt et al., 1998) with a 4-year follow-up (Baer et al., 2001). BASICS incorporates much of the same content as the ASTP but in a highly personalized one-on-one format allowing for greater exploration of an individual’s drinking.

BASICS was designed for college students engaging in alcohol use and experiencing alcohol-related consequences who may benefit from indicated intervention to refine or augment existing skills to drink in lower-risk ways or, if they choose, abstain. As the name implies, BASICS is brief, typically involving less than 2 hours of direct contact with a given student when facilitated by a trained provider, as originally designed (i.e., 1 hour of assessment plus a 1-hour feedback session). BASICS is delivered in the style of motivational interviewing (MI; Miller & Rollnick, 1991). Consistent with the humanistic roots of MI, BASICS is non-confrontational and nonjudgmental, supporting individual student autonomy in setting goals for drinking and harm reduction planning. Motivation for change is evoked through discussion of personalized feedback addressing students’ alcohol use, consequences, beliefs about alcohol, and other contextual factors. Discussion of feedback is supplemented with relevant education (e.g., definition of a standard drink; alcohol’s effects at different blood alcohol concentrations [BACs]) to support protective behavioral skill use (e.g., determining how many drinks can be consumed over what period of time to remain under a desired BAC limit). This use of education both to prompt consideration of change within a motivational framework and to support skill implementation is a key distinction from ineffective education-only approaches.

As noted, BASICS was among the first individual-focused interventions demonstrated to significantly reduce alcohol-related harm among college students (Baer et al., 2001; Marlatt et al., 1998). A manual documenting how to implement BASICS was published over 20 years ago (Dimeff et al., 1999), coinciding with an explosion in evaluations of BASICS and related Brief Motivational Interventions (BMIs) closely patterned after BASICS (i.e., that utilize an MI-style to discuss personalized feedback) from 8 as of 1999 (Larimer & Cronce, 2002) to 75 as of 2017 (NIAAA, 2019). Multiple independent clinical trials have demonstrated efficacy of BASICS and other BMIs in reducing alcohol use, consequences, or both (see Cronce & Larimer, 2011; Larimer & Cronce, 2002, 2007; NIAAA, 2019 for reviews), providing an evidence base to support wide utilization of BASICS and related BMI approaches in the context of campus alcohol prevention and intervention efforts (NIAAA, 2002).

BASICS Dissemination and Adoption

Rogers (1995) noted the process of diffusing an evidence-based innovation (such as BASICS) into widespread use involves steps related to dissemination, adoption, implementation, and maintenance. BASICS was designed from the outset to enable broad dissemination after initial demonstrations of efficacy. Befitting of its roots in publicly-funded research, the BASICS manual (Dimeff et al., 1999) was written to contain all information necessary to implement the assessment, feedback, and educational components of the program. Unlike some interventions that require participation in lengthy trainings to obtain certification, by design, no such process exists for BASICS. As will be discussed later, although training in MI by a qualified individual is necessary for those not already trained in this approach, and training in educational and skill-based elements of BASICS may be beneficial, a facilitator with MI skills should be able to implement BASICS with only the manual. This low-barrier dissemination model, along with national reports starting with the National Institute on Alcohol Abuse and Alcoholism’s Call to Action Task Force Report (NIAAA, 2002) naming BASICS as one of three Tier I strategies with demonstrated effectiveness in reducing alcohol use and consequences among college students, facilitated more rapid and wider dissemination and adoption of BASICS on college campuses than is typical of many interventions.

As a result of the work of NIAAA’s college drinking prevention task force (NIAAA, 2002), research indicates that by 2010 most administrators on campuses in the United States were aware least aware of the Task Force recommendations and were at varying levels of implementing recommended strategies (Nelson et al., 2010). As evaluation and dissemination efforts continued, BASICS was one of eight individually-focused strategies with “higher effectiveness” designated in NIAAA’s (2019) College Alcohol Intervention Matrix (CollegeAIM) and one of two interventions mentioned by name in the Surgeon General’s Report on Alcohol, Drugs, and Health (U.S. Department of Health and Human Services, 2016).

In part as a result of these dissemination efforts, BASICS has been adopted on college campuses both nationally and internationally (e.g., Hanewinkel & Wiborg, 2005; Simão et al., 2008; Wagstaff, 2015). Nonetheless, there remain a number of challenges to broader adoption. For example, some campus administrators may remain unaware of NIAAA’s recommendations (Nelson et al., 2010) despite dissemination efforts. Among those who are aware of the recommendations, barriers to adoption can include conflicting or confusing messages about what is “effective” or “evidence-based,” whether from commercial groups or stakeholders suggesting or recommending one approach over another. NIAAA (2002; 2019) notes a mix of strategies is best, and it is often suggested that BASICS and related BMI approaches be a prominent part of that mix in a campus’s overall alcohol prevention program. Tools like NIAAA’s CollegeAIM (2019) emphasize the importance of research and science informing what campuses adopt or, conversely, discontinue when there is insufficient evidence for an approach. However, in practice campuses may need additional guidance from research regarding which “mix of strategies” including BASICS is best for their students.

Even among campuses reporting use of BASICS, the approach may be adapted in a variety of ways, including both content and delivery, not part of the original efficacy trials (Wagstaff, 2015). While these variations from the original protocol have implications for effectiveness, they may be considered necessary to support delivery in a particular campus context, highlighting the challenges of making the leap from development, efficacy testing, dissemination, and adoption to implementation.

BASICS Implementation and Adaptation

When campuses engage in decision-making regarding how to implement an evidence-based program such as BASICS, important considerations to guide decision-making include the available research evidence, environmental or organizational context in which the intervention will be conducted (e.g., university policies or organizational structures), resources (including practitioner’s expertise), and student/population characteristics, needs, values, and preferences (Satterfield et al., 2009). Consistent with Satterfield’s model, below we address considerations for implementation of BASICS incorporating information addressing each of these domains.

BASICS: Components and Programming Considerations

Key Components of Personalized Feedback

Guiding the conversation with the student is the personalized graphic feedback. Thus, any campus intending to implement BASICS must consider feedback domains for review with their students and determine what information they plan to use for generating the feedback. The original BASICS feedback was one sheet of paper (with details on the front and back). Since that time, feedback has tended to increase in length and complexity, with some feedback profiles over 20 pages long (Ray et al., 2014). This raises the question of how relevant content can be reviewed in a single session in a way that actually allows for a conversation with the student. Some campuses also try to cast a wide net by including as much content as possible when they engage students in alcohol prevention efforts (e.g., alcohol, Title IX, sexual assault and consent, mental health, other drug use, etc.). However, Ray et al. (2014) noted that although BMI that include highly personalized content have a greater impact on reducing alcohol use and consequences when more components are included, less personalized interventions including multiple components can conversely result in the unintended effect of increasing alcohol use such that “more is less”. This highlights the need for caution when addressing multiple issues in one intervention, and speaks to the importance of including highly personalized feedback as part of BASICS implementation regardless of which feedback domains are chosen.

Several studies have attempted to identify specific components in BASICS and other BMI feedback related to efficacy of reducing alcohol use and related consequences (Carey et al., 2012; Ray et al., 2014). Results indicate certain components are observed within all alcohol BMIs; namely, alcohol quantity, frequency, descriptive norms, and alcohol-related consequences. Additional key components in BASICS personalized feedback that are often utilized and recommended for inclusion are alcohol outcome expectancies and engagement in protective behavioral strategies (Borsari & Carey, 2000; Larimer & Cronce, 2007; Murphy et al., 2010, 2012). In this section we review components typically presented within BASICS feedback along with implementation considerations.

Alcohol Use.

BASICS feedback typically begins with presentation of the participant’s drinking frequency (e.g., number of drinking days per week) and quantity (e.g., number of drinks per drinking occasion) of alcohol use to provide opportunity to discuss typical drinking patterns. On top of being a fairly “safe” topic to begin with, it allows the student and facilitator to make sure that what follows in the feedback reflects the student’s actual behavior. The time frame of assessment can vary, but often refers to alcohol use in the past month. We typically use the Daily Drinking Questionnaire (Collins et al., 1985) and quantity-frequency index (Dimeff et al., 1999).

Alcohol-related Consequences.

In addition to alcohol use, the consequences or effects the participant has experienced resulting from their alcohol use are listed. The purpose of this section is to provide an objective review of the personal effects experienced and to highlight various domains in which these may be occurring (e.g., academic or work consequences, social consequences). Consistent with the concept of developing discrepancies within Motivational Interviewing (Miller & Rollnick, 1991), a facilitator can explore what the student values or finds important (e.g., doing well in school) alongside the status quo (e.g., not studying because they chose to drink) as the facilitator seeks to elicit personally relevant reasons for change. Measures used in prior studies include the Rutgers Alcohol Problems Index (White & Labouvie, 1989), used in the initial evaluation of BASICS, or the Brief Young Adult Alcohol Consequences Questionnaire (Kahler et al., 2005). In the original BASICS protocol and many more recent adaptations, review of consequences has tended to occur closer to the end of the feedback session, after discussion of use and contextual factors and building of rapport, just prior to transitioning to discussing potential skills utilization to reduce drinking-related harm. However, no research of which the authors are aware has tested order of feedback components, and in practice BASICS and related BMIs typically allow for facilitator flexibility in moving between sections based on participant questions and responses (Dimeff et al., 1999).

Perceived Norms for Others’ Alcohol Use.

A consistent mediator of intervention effects of BASICS and related BMIs is the change in perceived descriptive norms regarding how much and how frequently others are drinking alcohol (Carey et al., 2010; Reid & Carey, 2015). BASICS incorporates normative feedback in which the student’s perception of normative alcohol use is contrasted with their own alcohol use and the actual normative behavior of a relevant population (e.g., the typical college student). Both the perceived norms and the participant’s behavior are drawn from the initial assessment, often using the Drinking Norms Rating Form (Baer et al., 1991). However, the “actual population norm” will come from other data sources and often is the most challenging piece of information to identify. If local survey data are unavailable, nationally-gathered data allowing comparisons to the “typical college student” such as the Monitoring the Future survey (Schulenberg et al., 2020), may be used. An important consideration is that the three constructs should match in behavior. An illustration would be: (a) “You drink 2 days per week,” (b) “You think the typical college student drinks 3 days per week,” and (c) “The typical college student drinks 1 day per week.”

Since the original BASICS trial, research has evaluated how specificity of the normative reference group and magnitude of the discrepancy between the actual norm and one’s own behavior impact drinking outcomes (Larimer et al., 2009; Lewis & Neighbors, 2007). Provision of women-specific norms may result in greater reductions in alcohol use for women than gender neutral “typical student” norms; this may be due to women’s norms generally being lower and/or to women’s greater identification with the specific reference group (Lewis & Neighbors, 2007). Other research suggests when group-specific norms are higher, provision of the generic “typical student” norms is as good or better at producing drinking reductions (LaBrie et al., 2013; Larimer et al., 2011). These findings suggest magnitude of the normative discrepancy (i.e., providing the lowest accurate norm; lower than participant’s own drinking and/or perceived norm) may be more important than specificity of the reference group. As college campuses have become increasingly diverse it is important to consider the salience of the “typical student” (Larimer et al., 2011). In practice, it is likely that identification with and similarity to the reference group as well as magnitude of the normative discrepancy for that group are all relevant and require further evaluation in more diverse communities of students (LaBrie et al., 2012, 2013; Larimer et al. 2009, 2011).

Alcohol Outcome Expectancies.

College students with stronger beliefs about the positive effects of alcohol (alcohol outcome expectancies) have been found to engage in more high-risk alcohol use (e.g., Patrick et al., 2016; Zamboanga et al., 2010). Feedback typically lists the positive effects of alcohol the student rates as likely and desirable, which is supplemented by psychoeducation on how expectations about alcohol and placebo effects influence social behaviors (e.g., being more outgoing) differentially across people and contexts while alcohol’s actual pharmacological effects are more consistent and emblematic of depressant effects on the central nervous system (e.g, impaired attention/coordination). The Comprehensive Effects of Alcohol Measure (Fromme et al., 1993) is often used to assess alcohol expectancies.

While BASICS and other BMIs often include components focused on alcohol expectancies (primarily positive social-related alcohol expectancies), evidence has been mixed as to whether alcohol expectancies do (e.g., Turrisi et al., 2009; Yurasek et al., 2015) or do not (e.g., Borsari & Carey, 2000) mediate intervention efficacy. A meta-analysis by Scott-Sheldon et al. (2012) found both in-vivo alcohol expectancy challenge interventions and the discussion of expectancy challenge findings in the context of BASICS or BMI reduced positive alcohol expectancies and short-term alcohol use compared to a control group.

Protective Behavioral Strategies.

If a student chooses to drink, increasing the use of protective behavioral strategies—cognitive behavioral skills that can be implemented before, during, and after drinking—has been shown in some studies to be effective in reducing high risk drinking or consequences (Lewis et al., 2010; Martens et al., 2004, 2011; Patrick et al., 2011). At the time BASICS was developed, anything other than abstinence-only messaging was considered cutting edge, particularly when used with students under minimum legal drinking age. Consistent with a harm reduction philosophy, any steps toward reduced risk are considered to be steps in the right direction (Marlatt, 1996a), though facilitators should avoid the mismatch between suggesting “action” stage strategies for changing behavior to people who are ambivalent about what they want to do (in “contemplation”) or are not considering change (in “precontemplation”) (DiClemente & Prochaska, 1998). In the original BASICS trial, harm reduction strategies were discussed at the end of the session or when relevant to the student, and students left with their personalized feedback and a generic list of tips for reducing harm associated with alcohol use. In subsequent studies, BASICS feedback evolved to typically present a list of harm reduction strategies the student already uses to reinforce these behaviors, then offer a menu of other strategies, exploring these with the student to build readiness and commitment to utilize the skills. Strategies are often in the domains of (a) manner of drinking (e.g., avoiding drinking games, drinking slowly rather than gulping or chugging), (b) strategies for limiting or stopping alcohol use (e.g., determining not to exceed a set number of drinks to maintain BAC below .06, drinking water while drinking alcohol), and (c) strategies for reducing serious harm (e.g., eating before or during drinking, avoiding combining alcohol and cannabis), and are often assessed with variations of the Protective Behavioral Strategies Questionnaire (Treloar et al., 2015).

Additional Components.

The five components presented above are the most commonly used in BASICS and BMIs, and have empirical support as mediators of intervention efficacy and/or have been tested as stand-alone components with demonstrated effects on alcohol use or alcohol-related consequences (Cronce & Larimer, 2011; NIAAA, 2019). However, they are not the only components that have been utilized in BMI. Others such as family history of alcohol or drug problems, tolerance, calories consumed from alcohol, and amount of money spent on alcohol have also been included (Murphy et al., 2010, 2012, 2019; Ray et al., 2014). Typically, these and other components that may be integrated as part of adapting BMIs to specific student interests or campus or cultural contexts have not been systematically studied.

In addition to integrating additional feedback components into BASICS, some researchers have utilized BASICS and BMIs as a foundational intervention, and built on this foundation by incorporating other evidence-based supplemental intervention components, usually delivered within an MI approach. For example, Murphy et al. (2012) found initial support for a behavioral economics supplement and subsequently (Murphy et al. 2019) for both behavioral economics and relaxation supplements added to BASICS. An important aspect of this work is the inclusion of a comparative evaluation design. To the extent possible, this type of evaluation helps address questions of the impact of adapted content on real-world outcomes.

Programming and Providing BASICS Personalized Feedback

Beyond choosing the components provided in the feedback, campuses implementing BASICS also need decide how to generate the feedback to provide to their students. The personalized feedback component of BASICS and related BMIs has been developed in various ways over the years, from initial assessments conducted on paper, hand-scored, and entered component by component into a Word Perfect document (e.g., Marlatt et al., 1998) to using technology to automatically integrate responses from a web-based survey into custom programed web-based feedback, which can be shown online or printed to be reviewed in-person (e.g. Lee et al., in press). Identifying the best strategy for producing the personalized feedback is a primary challenge for college campuses implementing BASICS (Wagstaff, 2015).

Although the original feedback content is detailed in the BASICS manual (Dimeff et al., 1999) which can be procured directly from the publisher or various booksellers for under $50, and rudimentary feedback can be created in any word processing software program, many campuses do not have the capacity or resources to create engaging personalized feedback that can be generated automatically (i.e., through a connection with a database that stores students’ responses to assessment) for use with large numbers of students (Wagstaff, 2015). However, if campuses do have the resources to create feedback themselves, they can find all necessary information in the BASICS manual; commercial options are also available (NIAAA, 2019), although may deviate from the original tested BASICS content. Although the desire to create visually appealing feedback and engaging infographics is often of concern in deciding on a feedback strategy, it is unclear whether and to what extent the display of feedback (i.e., the way it “looks”) affects the impact of feedback. Simple feedback produced inexpensively and without detailed or complex graphics may be sufficient without creating a burden on campus resources.

Environmental and Organizational Considerations in Implementing BASICS

Where and With Whom to Implement BASICS.

An important implementation decision campus administrators need to make is whether BASICS will be part of a targeted strategy for individual populations (e.g., mandated students) and/or part of an integrated suite of strategies across various departments or campus units (e.g., housing, judicial, counseling and health centers). Campuses also need to consider a plan and the resources needed to maintain provision of BASICS to its students in the long term. This includes decisions on which students will be provided BASICS and how they will be identified and reached. Some campuses may provide BASICS sessions only to mandated students who have received citations for drinking after policy violations, whereas others may implement BASICS with higher risk groups like student athletes or members of Greek life. Others may offer it to students who arrive at student health centers with concerns about drinking or are referred by faculty, staff or peers. BASICS and related BMIs have been found to be efficacious with each of these high-risk groups (NIAAA, 2019), supporting their use in a variety of contexts where students can be reached.

When campuses are large, there are practical questions about how to best reach students who might benefit from BASICS. Perhaps no statement better captures this challenge than that posed by Fixsen et al. (2010), who said, “[The use of effective interventions] without [implementation strategies] is like serum without a syringe; the cure is available, but the delivery system is not” (p.448). If BASICS is offered to mandated students following a policy violation, which is associated with reduced drinking and consequences (e.g., Terlecki et al., 2015), it is essential that policies be enforced and a campus conduct process serve as the “delivery system” to BASICS. Drug Free Schools and Campus Regulations require documented evidence of consistent policy enforcement and sanctions (i.e., consistency within the “delivery system”).

Resources Considerations

Selection, Training, and Supervision of Providers.

When a campus has chosen the components and decided how and where to provide the feedback and to whom, they must also decide who will deliver BASICS and how providers will be trained. In the initial BASICS trial, therapists included clinical psychology doctoral students as well as experienced doctoral-level clinicians (Marlatt et al., 1998). For many campuses, a dedicated BASICS office and/or professional (or set of professionals) serves students and provides BASICS. Others may utilize paraprofessional staff and/or young adult peers to provide BASICS. Training peers in MI skills and to facilitate BMIs may address implementation barriers related to limited trained staff and engagement or buy-in from young adults. Peer-led BMI have shown reduced drinking behaviors and in some cases peers have been as effective as professionals (Larimer et al., 2001; Mastroleo et al., 2010, 2014). However, special consideration may be needed for supervision and training of peer facilitators. Tollison et al. (2008) indicated peer facilitators may need additional training on how to adapt to the variability that occurs when seeing more students, especially in reflective statements (a key MI skill; Miller & Rollnick 1991). Additionally, as peers graduate or move-on, the need for ongoing training and bringing new providers into the mix is ongoing. Thus, professional supervision and capacity for training and onboarding new peers is important.

Regardless of facilitator credentials (peer or professional), limited data exist on best practices for training and supervision of BASICS providers and considerations of adherence, competence, and therapeutic/programmatic drift from the evidence-based curriculum. As BASICS is delivered in an MI style, principles from the literature on training MI practitioners are instructive. It is clear that to implement BASICS with fidelity, adherence and compliance with MI spirit and strategies is important (Tollison et al., 2008). Further, in many studies evaluating BASICS that necessitated training facilitators (e.g. Larimer et al. 2001), the training emphasized alcohol information relevant to BASICS as well as MI spirit, principles, and strategies. While numerous options exist to receive BASICS and MI training, no certification is required to be a BASICS provider, and no BASICS-specific “train the trainer” curriculum has been evaluated.

Findings from Miller et al. (2004) and Martino et al. (2011) suggest three important things in thinking about BASICS fidelity: (a) staff or students who will be facilitating BASICS need to be trained by an expert in MI—reading the MI book alone will not produce proficiency in MI skills—though, a web-based course may be effective in helping some facilitators reach and maintain proficiency; (b) staff or peers who demonstrate stronger MI-consistent behaviors following initial training may be more likely to continue to demonstrate those behaviors over time; but (c) ongoing feedback and/or coaching on use of MI during BASICS is needed, at least by some, to achieve maximum proficiency and avoid facilitator drift.

In addition to MI skills, BASICS training typically involves teaching facilitators the alcohol-related informational content related to each feedback domain. Facilitators are reminded to resist the temptation to lecture (Dimeff et al., 1999); instead, informational aspects of BASICS content are introduced when of relevance to the student, and always within a motivational framework. Information might be used to prompt thinking about change, develop discrepancies between where a student is and where they would like to be, or set the stage for a specific protective behavioral strategy in the context of their goals.

Number and Duration of Sessions.

The time required to facilitate BASICS can be an important challenge for implementation, since students may be less likely to engage for lengthier or more sessions, or campuses may have limited staff availability and competing demands for staff time (Wagstaff, 2015). While the brevity of the initial BASICS protocol attempted to address these barriers, additional changes to intervention duration may be deemed desirable depending on individual student needs and/or campus staffing constraints.

The original BASICS protocol (Baer et al., 2001; Marlatt et al., 1998) included two sessions. The first consisted of introduction, building rapport, and detailed assessment (the “AS” or “Alcohol Screening” in BASICS) followed by two weeks of alcohol self-monitoring. In the second, the facilitator reviewed the BASICS personalized feedback report and self-monitoring card with the student, utilizing MI strategies to enhance motivation to change (the “I” or “Intervention” in BASICS). Significant changes in available technology have resulted in adaptations to the BASICS format, such as completing the first assessment session online as opposed to in-person. In fact, most extant studies on BASICS describe it as a single session.

Reduction of BASICS from two in-person sessions to one has been assessed, and single-session BASICS has been shown to produce similar reductions in alcohol use to the original (see Samson & Tanner-Smith, 2015 for review), particularly for heavy drinking college students (e.g., Murphy et al., 2001). Nonetheless, in our clinical experience, for students who may be frustrated or resistant the first session can be invaluable to establish rapport, reduce resistance, and build “buy in” for the second session. For this reason, work with mandated students at University of Washington retains the original two-session BASICS format.

In addition to reducing the number of sessions, research has explored reducing the length of a single session. For example, Kulesza et al. (2013) compared a 10-minute BMI to a 50-minute BMI (both adapted from BASICS) and found comparable drinking outcomes at 4 weeks. However, the sustained, longer-term change associated with this shortened BMI is unknown.

In contrast to fewer and shorter sessions, some studies have examined impact of booster sessions or booster material after the primary intervention. Although often neglected in discussion of the original BASICS protocol, Marlatt et al. (1998) provided mailed booster feedback one year after the in-person session as well as telephone/in-person boosters for a subsample of very high risk participants, which potentially augmented the effect of the original BASICS in-person sessions and was not evaluated separately from the overall BASICS impact. In subsequent adaptations of BASICS and BMI boosters, both content and timing of booster sessions have been varied and results have been mixed with beneficial (Suffoletto et al., 2016), neutral (Barnett et al., 2007) and iatrogenic effects (Carey et al., 2018) reported. Together, these results indicate adjustments to the length of BMI sessions and possible boosters need further examination to determine optimal length, number of sessions, and whether there are individual differences that may suggest variations in these factors for the best outcomes.

Mode of Delivery.

Another common method for addressing implementation barriers related to insufficient staffing is to adjust the mode of delivery to a less resource-intensive format. While all deviations from the original BASICS protocol raise questions regarding their impact on effectiveness, changing the mode of delivery is among the most concerning as campuses stray farther from in-person, one-on-one sessions. These shifts in delivery need to be evaluated whenever they represent something other than a direct application of a published BMI.

In-person Group-based Sessions.

Some campuses have sought to utilize group, rather than individual, sessions while attempting to maintain core elements of BASICS feedback and MI style. These group-based BMIs may reduce challenges of having limited facilitators on college campuses trained and available to provide individual BASICS interventions, but also deviate significantly from the original BASICS protocol. Some research has suggested promising results for group BMIs (LaBrie et al., 2008) whereas others showed impacts on potential mechanisms of change but not on long term alcohol outcomes (Cimini et al., 2009; LaBrie et al., 2009) or changes were not significantly different from a control group (Stahlbrandt et al., 2007). Depending on needs of a campus, unless utilizing a tested group BMI with evidence of efficacy (e.g., LaBrie et al., 2008), the Alcohol Skills Training Program (ASTP) is a group-based harm reduction program with demonstrated efficacy (e.g., Baer et al. 1992; Kivlahan et al. 1990; Logan et al. 2015), and may be advantageous relative to untested group adaptations of BASICS.

Telehealth Delivery.

One use of technology that may extend reach and access to BASICS involves providing all material including the face-to-face sessions in a telehealth format, utilizing video conferencing tools (Lee et al. in press). By providing sessions via video conferencing, students can participate in the privacy of their own homes or elsewhere at their convenience, and facilitators may be shared across different campuses to reduce resource barriers. This also opens up BASICS and other BMIs to certain students who may have been underserved. As online and distance learning schools become options for increasing numbers of students, delivery of support services are similarly offered online. During the COVID-19 pandemic, many campuses have had no choice but to rely on virtual instruction and virtual delivery of clinical services. Fortunately, evaluations of telehealth delivery of BASICS have shown efficacy (Lee et al., in press; King et al., 2020), so for students whose work schedule or distance from campus makes an in-person session challenging, or who feel more comfortable discussing their substance use remotely/virtually, a telehealth session can be an alternative.

Web-based, Mailed/Emailed, and Text Message Formats.

By definition, BASICS and related BMIs are delivered in a live, interactive format (typically one-on-one in person), using a MI style and personalized feedback (Cronce & Larimer, 2011). Nonetheless, numerous studies have adapted the original one-on-one in-person BASICS materials to provide personalized feedback alone through mail, e-mail, text-message, or web-based communication. These Personalized Feedback Interventions (PFI) typically show efficacy in reducing alcohol use and/or consequences (Labrie et al. 2013; Larimer et al., 2007; NIAAA, 2019); however, meta-analyses indicate effects are typically not as large or long-lasting as when feedback is presented face-to-face with a facilitator (Cadigan et al., 2015; Carey et al., 2012). Thus, while PFIs are efficacious in their own right (NIAAA, 2019) and may be an important part of an overall campus prevention strategy, they do not substitute for nor are they synonymous with in-person BASICS.

An additional consideration for campuses when considering electronic feedback delivery is the preferred medium of college students. While the internet has increased access to many things that were typically only available in print, from news to text books, research suggests college students still prefer reading material in print versus electronically (Mizrachi et al., 2018). Thus, while improvements in technology have allowed for advances in how feedback is generated and created options for how it is delivered, the best evidence still supports the original BASICS in-person protocol and print feedback if possible.

Student Special Needs and Considerations in Adapting BASICS

Mental Health Comorbidity.

Increasingly, researchers and campus administrators are grappling with how to address a broad range of mental and behavioral health challenges among students (Lipson et al., 2019). Mental health comorbidities can present challenges to BASICS efficacy. For example, research has found higher levels of depression and social anxiety are associated with poorer intervention outcomes (Geisner et al., 2015; Terlecki et al., 2012). Efforts to adapt BASICS by adding mental health components to address comorbidity have met with mixed results. Whiteside (2010) conducted a randomized controlled trial of BASICS with depressed and anxious students with a history of heavy drinking and drinking to cope. Both a BASICS-only intervention and BASICS with a brief Dialectical Behavioral Therapy (DBT; Linehan et al. 1999) component resulted in reduced drinking to cope at 3 months compared to a relaxation control condition. However, enhancing BASICS with a brief DBT component yielded more robust results. In contrast, Pedrelli and colleagues (2020) found inclusion of a BMI based on alcohol content from BASICS resulted in lower efficacy than Cognitive Behavioral Therapy for Depression alone. Some complexities of adding or integrating other mental health or risk behavior components into BASICS include maintaining the brevity of the intervention while targeting multiple risk behaviors, as well as maintaining optimal personalization of the material to avoid the “more is less” phenomenon (Ray et. al., 2014) wherein adding too many components that are not highly personalized can lead to increases in alcohol use. Conrod (2016) has argued for the importance of identifying personality risk factors (e.g., sensation seeking) via a brief personality inventory (e.g., Substance Use Risk Profile Scale (SURPS); Woicik et al., 2009) and tailoring interventions to an individual’s personality. Thus, components of a BMI would be introduced and discussed in personality-specific ways. Personality-targeted interventions hold promise for general populations as well as those with comorbid mental health problems.

Adapting BASICS for Other Presenting Problems.

Beyond integration of BASICS with added components to address mental health comorbidity, BASICS has also been adapted to address other primary problems (with or without alcohol comorbidity). As the “A” in BASICS stands for alcohol, the question of whether applying the approach to issues other than alcohol can be considered an adaptation of BASICS versus a new approach using similar theoretical and practical strategies is legitimate. Nonetheless, the BASICS approach and feedback protocol are often specifically referenced in these interventions. A number of examples illustrate the breadth of behaviors BASICS has been adapted to address. For example, Dunn and colleagues (Dunn et al., 2006) tested a single session of a motivational enhancement therapy (MET) that wedded MI with personal feedback for participants with bulimia or binge eating disorders, finding the intervention increased participants’ readiness to change and abstinence from binge eating when compared to the self-help control. Similarly, Larimer and colleagues (Larimer et al., 2011) applied lessons from BASICS to a disordered gambling intervention, finding a single feedback session worked as well or better than a longer cognitive-behavioral intervention in reducing gambling frequency and consequences. Lee and colleagues (Lee et al., 2013) adapted BASICS to create an intervention targeting marijuana use. The single one-hour session guided by MI principles and personalized feedback resulted reduced quantity of marijuana used at 3-month follow-up (Lee et al., 2013). Last, Geisner and colleagues (2006) found a PFI modeled after BASICS, targeting depression in college students with mailed personalized feedback and coping strategies, resulted in reduced depressive symptoms and hopelessness compared to the control group; males also indicated greater willingness to use coping strategies at 1-month follow-up.

While some of these adapted interventions included alcohol components, none targeted alcohol as the primary presenting issue. Rather, these extensions illustrate the influence BASICS has had on informing approaches for a variety of behavioral domains and the potential for similar approaches to be applied to other topics of interest. This does not imply that BASICS or BMIs are the appropriate tool for every presenting problem nor that the approach should be utilized in isolation from other campus approaches to deal with mental and behavioral health challenges of students. Rather, these approaches should be considered in the context of students’ unique needs, resources, and the best available evidence matching intervention strategies to presenting issues.

Conclusions and Future Directions

Alan Marlatt has appropriately been credited with changing how college student alcohol use was approached on campuses, how successful outcomes were defined, and adding to (if not creating or ultimately inspiring much of) the list of “what works” in individual-focused prevention and intervention efforts, particularly with the Alcohol Skills Training Program and BASICS (Kilmer et al., 2012). As this year marks the 10^th anniversary of Alan’s death on March 14, 2011, it seems fitting to reflect back on the past 30 years of BASICS progress and pay homage to Alan’s continuing influence on the field. Alan’s innovations in college student alcohol prevention and intervention efforts came from recognizing an unmet need—the need to develop and test interventions for college drinking that were based on sound theory and best clinical practice and appropriately tailored to the developmental stage of young adulthood. All the promise and progress of the past 30 years of BASICS stems from this initial commitment to using the best available research and clinical evidence in developing and testing the approach.

Another of Alan’s significant contributions to the addictive behaviors field was his conceptualization of Relapse Prevention, with the groundbreaking book by Marlatt and Gordon (1985) and studies that followed. As researchers attempted to replicate, extend, and add to the taxonomy of relapse precipitants/predictors that Marlatt and Gordon developed (e.g., the Relapse Replication and Extension Project), Alan had the chance to respond by identifying the number of ways in which replication efforts strayed from the original theory and intent, and even discuss differences in how researchers and clinicians approached the issue (Marlatt, 1996b). This allowed for a “course correction” of sorts, and research on and development of Relapse Prevention strategies continued (Marlatt & Donovan, 2005). Why is this relevant to BASICS? In prevention and intervention efforts, practitioners and researchers alike are reminded of the importance of implementing approaches with fidelity, and implementation fidelity has been defined as the degree to which programs are implemented “as intended by the program developers” (Dusenbury, et al., 2003, p. 240). Although the ability to directly get Alan’s input on adjusted session length, feedback components, innovations in delivery, and other adaptations is no longer possible, as we look ahead to the next 30 years of BASICS we can utilize his dual focus on research evidence and practical clinical considerations to consider best practices, remaining needs, next steps, and possible adaptations of BASICS to further facilitate his and our shared mission to reduce alcohol-related harm among college students and young adults.

Perhaps the most straightforward recommendation stemming from the current overview of implementation practices is that campuses would be advised to utilize the original published BASICS protocol whenever possible, and deviate cautiously if at all unless following a tested and published BMI adaptation. Adding or deleting components, reducing the number and length of sessions, or changing the implementation format all have implications for how well BASICS “works” in the real world to help students reduce alcohol-related harm. While the evidence discussed in this overview suggests BASICS is robust to some of these adaptations (such as reducing to a single session or using well-trained and supervised peer providers), considerably less is known about other adaptations, and there is a clear need for ongoing research to address implementation barriers identified on college campuses (e.g., Wagstaff, 2015).

Among the most pressing research and clinical priorities in implementing and adapting BASICS is incorporating the needs and perspectives of students of color in both majority White institutions and within minority-serving institutions (see Cronce et al., 2021, this volume, for more discussion of this issue). After 30 years of research on BASICS and related BMI on college campuses, the vast majority of trials still include primarily White students at 4-year institutions. While the process of culturally adapting BASICS and related BMI in collaboration with diverse communities of students is ongoing, substantially more attention and resources need to be devoted to this critical research and practice gap. In this process, it is important to consider adaptations of content and well as implementation processes, and to partner with diverse communities of students and providers to address historical and structural inequities in access to resources and opportunities that may further constrain campuses from fully implementing BASICS and other efficacious approaches. A key step in pursuing this research and clinical objective is to increase opportunities to recruit and retain diverse scientists and clinicians in the field. It is also important to consider other aspects of diversity such as gender and sexual minority status, ability, military affiliation, or other dimensions that may influence response to BASICS and BMI and require further adaptation and tailoring to meet student needs.

Beyond the urgent need for further research regarding cultural adaptation of BASICS, there are a variety of practical and theoretical questions that remain understudied and lend themselves well to comparative research designs and efficient trial methodologies such as Sequential Multiple Assignment Randomized Trials (i.e., a trial where each individual may be randomized multiple times and the multiple randomizations occur sequentially through time; Murphy, 2005) and other adaptive intervention trial approaches. Relevant research might address whether and for whom adding or removing feedback components, or modifying components to attempt to strengthen proven mediators of BASICS effects, impacts outcomes, and whether the whole is greater (or less) than the sum of the parts. Other questions might include how to most appropriately allocate or sequence different elements of overall campus prevention strategy, and whether and how technological delivery of some BASICS material might replace, augment, or weaken BASICS effects, for whom, and why.

From a clinical and practical standpoint, additional resources dedicated to improving access and reducing costs for training BASICS facilitators and better understanding how characteristics of facilitators and aspects of the training might impact effectiveness of BASICS are warranted. Further research focused on BASICS in the context of mental and physical health comorbidities is needed, and understanding how to appropriately sequence or integrate material addressing comorbid conditions (and when treating comorbid conditions together or separately is most appropriate) would be useful for clinicians in the field.

Although considerable progress has been made in the past 30 years not just in individual-focused alcohol prevention but also in understanding the importance of policy approaches and the ways in which these seemingly distinct approaches to prevention can work in concert (NIAAA, 2019), high risk drinking among college students is still a public health concern. While BASICS has stood the test of time, and implementing BASICS with fidelity to the original protocol remains a best practice recommendation, no intervention can remain static and still address the changing needs of communities. Adaptations of BASICS may occur for a variety of reasons. As researchers in partnership with campus administrators and clinicians we have the opportunity to chart the course of prevention through rigorous evaluation of adaptations while maintaining commitment to fidelity, further enhancing health and reducing harm among an increasingly diverse community of students over the next 30 years. Alan would expect no less.

Public Health Statement:

This paper provides an overview of Brief Alcohol Skills and Intervention for College Students (BASICS) and describes research evidence, practical considerations, and best practices for implementing this evidence-based approach. It also addresses implementation barriers, research gaps, and future directions.