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.
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.
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.
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