While research has documented heavy drinking practices and associated negative consequences of college students turning 21, few studies have examined prevention efforts aimed to reduce high-risk drinking during 21st birthday celebrations. The present study evaluated the comparative efficacy of a general prevention effort (i.e., BASICS) and event specific prevention in reducing 21st birthday drinking and related negative consequences. Furthermore, this study evaluated inclusion of peers in interventions and mode of intervention delivery (i.e., in-person vs. web).
Participants included 599 college students (46% male) who intended to consume at least five/four drinks (men/women respectively) on their 21st birthday. After completing a screening/baseline assessment approximately one week before turning 21, participants were randomly assigned to one of six conditions: 21st birthday in-person BASICS, 21st birthday web BASICS, 21st birthday in-person BASICS plus friend intervention, 21st birthday web BASICS plus friend intervention, BASICS, or an attention control. A follow-up assessment was completed approximately one week after students’ birthdays.
Results indicated a significant intervention effect for BASICS in reducing blood alcohol content reached and number of negative consequences experienced. All three in-person interventions reduced negative consequences experienced. Results for the web-based interventions varied by drinking outcome and whether or not a friend was included.
Overall, results provide support for both general intervention and ESP approaches across modalities for reducing extreme drinking and negative consequences associated with turning 21. These results suggest there are several promising options for campuses seeking to reduce both use and consequences associated with 21st birthday celebrations.
Alcohol; alcohol-related problems; college students; event-specific drinking; event-specific prevention; 21st birthday
Theory and empirical evidence suggest that North American-based measures of self-esteem, which measure individualistic positive self-regard, may be less applicable to Eastern cultures. In the present exploratory study, we examined how different conceptualizations of self-esteem, as measured by the Rosenberg Self-esteem Scale and the Collective Self-esteem (CSE) Scale, predicted drinking behavior among three groups of American college students (N = 326) with varying ethnicities: White, Korean, and Chinese/Taiwanese. Hierarchical negative binomial regression was employed to evaluate these relations and ethnic identity was controlled in all analyses. Findings indicated that while global self-esteem was positively associated with drinking for the whole sample, ethnicity moderated this relationship such that global self-esteem was related to drinking for White participants but not for their Chinese/Taiwanese counterparts. In addition, while CSE did not associate with drinking for the whole sample, effects emerged for specific ethnicities. Specifically, private CSE was associated with less drinking for Korean and Chinese/Taiwanese participants. Depending on specific Asian ethnicity, public CSE served as a risk (Korean participants) or a protective factor (Chinese/Taiwanese participants) for drinking. Findings suggest that above and beyond ethnic identity, differential relationships between facets of self-esteem and drinking behavior may exist among White, Korean, and Chinese/Taiwanese young adults. Intervention and prevention programs should develop strategies to help Chinese/Taiwanese- and Korean American young adults to cultivate protective factors within domains of CSE.
Collective self-esteem; self-esteem; alcohol use; young adults; Asian American
Alcohol use is prevalent among college students, including those who are in committed romantic relationships. Individuals’ perceptions of their partner’s alcohol use may have significant effects on how they view both their partner and their relationship. The current study examines the effect of one’s perception of one’s romantic partner’s drinking as problematic on one’s relationship satisfaction and commitment, and whether this varies as a function of one’s partner’s drinking. Both partners in romantic heterosexual relationships (N = 78 dyads) completed an online survey assessing alcohol use and problems, relationship satisfaction and commitment, and the perception that their partner’s drinking was problematic. Analyses using Actor-Partner Interdependence Models (APIMs) revealed a partner-moderated actor interaction, such that partner self-reported drinking significantly moderated the association between the actor’s perception of their partner’s drinking as problematic and actor relationship outcomes. Results indicated that when partners drank at higher levels, perceiving their drinking as problematic did not have an effect. These individuals were less satisfied regardless of their perceptions. However, when partners drank at lower levels, perceiving their drinking as problematic was negatively associated with relationship outcomes. Furthermore, for alcohol consumption, three-way interactions with gender emerged, indicating that this effect was stronger for males. Results extend the literature on drinking in relationships and on interpersonal perception. Implications and future directions are discussed.
alcohol; romantic relationships; relationship distress; relationship satisfaction; interpersonal perceptions
Introduction and Aims
Misperceptions of how members of one’s social group think and act influence behaviour. The current study was designed to extend the research of group-specific normative feedback interventions among salient campus groups with heightened risk. Although not a randomised controlled trial, this research used normative feedback that was obtained using wireless keypad technology during a live session, within sex-specific student athlete groups to extend the proof of concept of using this brief interactive intervention.
Design and Methods
Participants included 660 intercollegiate athletes from all varsity athletic teams at two private, mid-size universities. Intervention data were gathered in vivo using computerised handheld keypads into which group members entered in personal responses to a series of alcohol-related questions. These questions assessed perceptions of normative group behaviour and attitudes as well as actual individual behaviour and attitudes. These data were then immediately presented back in graphical form to illustrate discrepancies between perceived and actual group norms.
Results revealed that at 1 month post-intervention, perceived group norms, behaviour, attitudes and consequences reduced compared with baseline. These reductions were maintained at 2 month follow up. Latent growth modelling suggested that the reductions in perceived norms and attitudes were associated with reductions in individual drinking behaviour and negative consequences.
Discussion and Conclusions
These results are among the first to suggest the effectiveness of a novel, group-based normative alcohol intervention among student athletes. Limitations of the design preclude strong inferences about efficacy; however, the findings support further trialling of such information technology in alcohol treatment research.
normative feedback; student athlete; alcohol intervention; handheld keypad
The Timeline Followback (TLFB) interview has been used extensively in the assessment of alcohol and other substance use. While this methodology has been validated in multiple formats for multiple behaviors, to date no systematic comparisons have been conducted between the traditional interview format and online versions. The present research employed a randomized within-subjects design to compare interview versus online-based TLFB assessments of alcohol and marijuana use among 102 college students. Participants were randomly assigned to receive either the online version first or the in-person interview format first. Participants subsequently completed the second format within 3 days. While we expected few overall differences between formats, we hypothesized that differences might emerge to the extent that participants are more comfortable and willing to answer honestly in an online format, which provides a degree of anonymity. Results were consistent with expectations in suggesting relatively few differences between the online version and the in-person version. Participants did report feeling more comfortable in completing the online version. Moreover, greater discomfort during the in-person assessment was associated with reporting more past-month marijuana use on the online assessment, but reported discomfort did not moderate differences between formats in reported alcohol consumption.
alcohol; marijuana; validity; Timeline Followback; online
There is a growing use of mobile devices to access the Internet. We examined whether participants who used a mobile device to access a brief online survey were quicker to respond to the survey but also, less likely to complete it than participants using a traditional web browser.
Using data from a recently completed online intervention trial, we found that participants using mobile devices were quicker to access the survey but less likely to complete it compared to participants using a traditional web browser. More concerning, mobile device users were also less likely to respond to a request to complete a six week follow-up survey compared to those using traditional web browsers.
With roughly a third of participants using mobile devices to answer an online survey in this study, the impact of mobile device usage on survey completion rates is a concern.
Internet; Brief intervention; Alcohol; College; University; Mobile device
Social Norms; Celebration; Birthday; Alcohol; Hierarchical norms theory
The purpose of the present study was to examine between- and within-person relationships among protective behavioral strategies (PBS), alcohol consumption, and related negative consequences during the 21st birthday week. Participants for the present study included undergraduate college students (N = 1,028) who turned 21 during three academic quarters at a large public northwestern university in the U.S. Students completed a Web-based survey that was comprised of measures of 21st birthday PBS, alcohol consumption, and alcohol-related negative consequences. Between-person findings indicated that participants who employed more manner of drinking PBS and fewer serious harm reduction PBS consumed fewer drinks and reached lower BACs. Results also showed that participants who employed a greater number of limiting/stopping PBS and who used more manner of drinking PBS experienced fewer negative consequences. Within-person findings demonstrated that on days when participants used more limiting/stopping PBS, fewer manner of drinking PBS, and more serious harm reduction PBS than average they also consumed more drinks and reached higher BACs. When examining negative consequences, within-person results showed that on days when participants used more limiting/stopping PBS, fewer manner of drinking PBS, and more serious harm reduction PBS than usual they experienced more negative consequences. Discussion focuses on clarification of the association between PBS and drinking and implications for preventive interventions.
21st birthday drinking; alcohol use; alcohol-related consequences; within-person analysis; event-specific drinking; protective behavioral strategies
The purpose of the current study was to evaluate feasibility and efficacy of two promising approaches to indicated prevention of disordered gambling in a college population.
Randomized controlled trial with assignment to a Personalized Feedback Intervention (PFI), Cognitive-Behavioral Intervention (CBI), or Assessment-Only Control (AOC). PFI was individually delivered in a single session and included feedback regarding gambling behavior, norms, consequences, and risk-reduction tips, delivered in a motivational interviewing style. CBI was delivered in small groups over 4-6 sessions and included functional analysis, brief cognitive correction, as well as identification of and alternatives for responding to gambling triggers.
At-risk or probable pathological gamblers (N = 147; 65.3% male; group assignment: PFI, n = 52; CBI, n = 44; AOC, n = 51).
Self-reported gambling quantity, frequency, consequences, psychopathology, normative perceptions, and beliefs.
Relative to control, results at 6-month follow-up indicated reductions in both interventions for gambling consequences (PFI d = .48; CBI d = .39) and DSM-IV criteria (PFI d=.60; CBI d=.48), reductions in frequency for PFI (d = .48). CBI was associated with reduced illusions of control, whereas PFI was associated with reduced perceptions of gambling frequency norms. Reductions in perceived gambling frequency norms mediated effects of PFI on gambling frequency.
A single-session Personalized Feedback Intervention and a multi-session Cognitive-Behavioral Intervention may be helpful in reducing disordered gambling in US college students.
gambling; college students; brief interventions; cognitive behavioral; prevention
This research evaluated a brief mailed intervention for alcohol use as an adjunct to a brief depression treatment for college students with depression symptoms. The intervention aimed to correct normative misperceptions and reduce students’ drinking and related consequences.
One hundred seventy seven college students (70% Female) with elevated scores on the Beck Depression Inventory were randomly assigned to intervention or control group. Participants in the intervention were mailed feedback and information detailing their reported alcohol use, moderation strategies, and accurate normative information regarding student drinking.
Results indicated no main effects of the intervention on drinking or related problems but students receiving feedback showed significant reductions in their perception of drinking norms compared to the control group. Furthermore, students whose normative perceptions reduced showed significant reductions in total drinks per week and total alcohol related problems compared to those whose norms did not reduce.
Results support the importance of correcting normative perceptions and provide direction for selective prevention of alcohol use and related problems among college students with depressed mood.
Alcohol; Norms; Selective Prevention; College Students
Previous research has shown that social norms are among the strongest predictors of college student drinking and that normative misperceptions of more similar groups’ drinking behavior may be more influential on individual drinking than those groups perceived to be more different. However, limited research has explored the moderating role of ethnicity in this context. The current study examined the differential impact that Hispanic/Latino/a and Caucasian students’ normative perceptions of both typical and same-ethnicity college students’ drinking behavior had on their own drinking. Participants (N = 5,369 students; 60.4% female; 81.4% Caucasian; mean age 19.9 years) from two colleges completed web-based surveys assessing their alcohol consumption, and their perceptions of the drinking behaviors of both the typical college student and the typical same-ethnicity college student at their campus. Results demonstrated that perceived norms were significantly associated with likelihood of drinking regardless of race or ethnicity specificity, but that Hispanics/Latinos/as typically had weaker relationships between ethnicity-specific norms and drinking than general student norms and drinking. The opposite was true for Caucasians such that the relationship between same-ethnicity norms and drinking was stronger than the relationship between general student norms and drinking. Further, Hispanic/Latino/a students with high perceived norms were less likely to have consumed any alcohol than Caucasians with similar normative beliefs. Further, a campus site interaction suggests that the size of the minority population on campus relative to other students may influence the relationship between norms and drinking. Implications and targets for future investigation are discussed.
Social Norms; College Student Drinking; Latino; Latina
Sexual assault and problem drinking are both prevalent in college women and are interrelated. Findings from cross-sectional research indicate that motives to drink to decrease negative affect (coping motives) or to increase positive affect (enhancement motives) are partial mediators of the sexual assault-problem drinking relation. However, no published longitudinal studies have examined these relations. The current study tests a longitudinal model and examines coping and enhancement motives as potential mediators. Participants were 131 female undergraduates who completed baseline measures of self-reported sexual assault victimization and problem drinking. Coping and enhancement motives were measured at three-month follow up; problem drinking was measured at six-month follow-up. Analyses using structural equation modeling (SEM) indicated direct and indirect paths in the sexual assault-problem drinking relation. Zero-order correlations indicated significant, positive relations between among drinking motives, sexual assault, and drinking variables. Longitudinally, mediation was evident for coping but not enhancement motives. Ultimately, findings were most consistent with self-medication hypotheses -- i.e., drinking in order to gain relief from symptoms or problems -- regarding the sexual assault-problem drinking relation.
alcohol; sexual victimization; drinking motives; tension reduction; self-medication
While research has examined factors influencing understanding of informed consent in biomedical and forensic research, less is known about participants’ attention to details in consent documents in psychological survey research. The present study used a randomized experimental design and found the majority of participants were unable to recall information from the consent form in both in-person and online formats. Participants were also relatively poor at recognizing important aspects of the consent form including risks to participants and confidentiality procedures. Memory effects and individual difference characteristics also appeared to influence recall and recognition of consent form information.
consent form; self-determination; recall; recognition; research informed consent
College represents a period of risk for heavy drinking and experiencing unwanted consequences associated with drinking. Previous research has identified specific events including holidays (e.g., New Years), school breaks (e.g., Spring Break) and personally relevant events (e.g., 21st birthdays) that are associated with elevated risk of heavy drinking and negative alcohol-related consequences. The systematic evaluation of relative risk offers insights into event specific drinking and an empirical basis upon which to consider allocation of limited prevention resources. Thus, the purpose of the present study was to provide a comparative index of drinking across a wide range of holidays and compare holiday drinking to 21st birthday drinking. Participants were 1,124 students (55% female) who had turned 21 within the previous three weeks in 2008 and provided 90-day retrospective reports of their drinking using the Timeline Follow-back. Results based on a hurdle mixed model for blood alcohol content (BAC) revealed several holidays that stand out for elevated drinking, including New Year’s Eve and July 4th, whereas other holidays appear more similar to weekend drinking, such as Spring Break (approximately last week of March) and graduation (mid-June). Drinking on holidays or special days was substantially lower than drinking on 21st birthdays. Results are discussed in terms of practical applications for targeted intervention efforts on college campuses toward specific events where elevated drinking is known to occur.
event-specific drinking; 21st birthday drinking; timeline follow-back
Automatic cognitive processes have been shown to be unique predictors of drinking behavior and can be assessed using implicit measures. Drinking motives (e.g., enhancement and coping motives), which are also predictive of alcohol use, have not been studied using implicit measures. Moreover, in the U.S., implicit measures have been studied in samples largely consisting of Caucasian or White Americans. This study adapted the Implicit Association Test (IAT) to examine automatic analogues of enhancement and coping drinking motives and approach/avoid tendencies in 56 Asian-American undergraduates. Enhancement and coping IATs were correlated with self-reported drinking motives and predicted unique variance in drinking frequency and heavy drinking when controlling for self-reported motives. Approach IAT scores were neither associated with self-reported approach/avoid tendencies nor predictive of drinking behaviors. These findings provide initial support for the unique predictive utility of drinking motives in Asian Americans, an understudied population.
alcohol; motivation; drinking motives; implicit cognition; Asian Americans; dual process models
Social norms theories hold that perceptions of the degree of approval for a behavior have a strong influence on one’s private attitudes and public behavior. In particular, being more approving of drinking and perceiving peers as more approving of drinking, are strongly associated with one’s own drinking. However, previous research has not considered that students may vary considerably in the confidence in their estimates of peer approval and in the confidence in their estimates of their own approval of drinking. The present research was designed to evaluate confidence as a moderator of associations among perceived injunctive norms, own attitudes, and drinking. We expected perceived injunctive norms and own attitudes would be more strongly associated with drinking among students who felt more confident in their estimates of peer approval and own attitudes. We were also interested in whether this might differ by gender. Injunctive norms and self-reported alcohol consumption were measured in a sample of 708 college students. Findings from negative binomial regression analyses supported moderation hypotheses for confidence and perceived injunction norms but not for personal attitudes. Thus, perceived injunctive norms were more strongly associated with own drinking among students who felt more confident in their estimates of friends’ approval of drinking. A three-way interaction further revealed that this was primarily true among women. Implications for norms and peer influence theories as well as interventions are discussed.
Attitude certainty; injunctive norms; alcohol; college students
Adolescence is a time in which individuals are particularly likely to engage in health-risk behaviors, with marijuana being the most prevalent illicit drug used. Perceptions of others’ use (i.e., norms) have previously been found to be related to increased marijuana use. Additionally, low refusal self-efficacy has been associated with increased marijuana consumption. This cross-sectional study examined the effects of normative perceptions and self-efficacy on negative marijuana outcomes for a heavy using adolescent population. A structural equation model was tested and supported such that significant indirect paths were present from descriptive norms to marijuana outcomes through self-efficacy. Implications for prevention and intervention with heavy using adolescent marijuana users are discussed.
marijuana; adolescent substance abuse; social norms; social learning theory
The literature on “Sojourner Adjustment,” a term expanding on the acculturation concept to apply to groups residing temporarily in foreign environments, suggests that engagement, participation, and temporary integration into the host culture may contribute to less psychological and sociocultural difficulty while abroad. The present study was designed to establish a brief multi-component measure of Sojourner Adjustment (the Sojourner Adjustment Measure; SAM) to be used in work with populations residing temporarily in foreign environments (e.g., international students, foreign aid workers). Using exploratory and confirmatory factor analyses on a sample of 248 American study abroad college students, we established a 24-item measure of Sojourner Adjustment composed of four positive factors (social interaction with host nationals, cultural understanding and participation, language development and use, host culture identification) and two negative factors (social interaction with co-nationals, homesickness/feeling out of place). Preliminary convergent validity was examined through correlations with established measures of acculturation. Further research with the SAM is encouraged to explore the relevance of this measure with other groups of sojourners (e.g., foreign aid workers, international businessmen, military personnel) and to determine how SAM factors relate to psychological well-being, health behaviors, and risk behaviors abroad among these diverse groups.
Sojourner Adjustment; international students; acculturation
There are a number of evidence-based, in-person clinical inteventions for problem drinkers, but most problem drinkers will never seek such treatments. Reaching the population of non-treatment seeking problem drinkers will require a different approach. Accordingly, this randomized clinical trial evaluated an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as an indicated public health intervention (i.e., targeting the population of non-treatment seeking problem drinkers).
Problem drinkers (N = 1767) completed a baseline population telephone survey and then were randomized to one of three conditions – a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions were sent their respective interventions by postal mail addressed to ‘Check Your Drinking.’ Changes in drinking were assessed post intervention at three-month and six-month follow-ups. The follow-up rate was 86% at three-months and 76% at six-months. There was a small effect (p = .04) in one of three outcome variables (reduction in AUDIT-C, a composite measure of quantity and frequency of drinking) observed for the personalized feedback pamphlet compared to the no intervention control. No significant differences (p>.05) between groups were observed for the other two outcome variables – number of drinks consumed in the past seven days and highest number of drinks on one occasion.
Based on the results of this study, we tentatively conclude that a brief intervention, modified to an ultra-brief, public health format can have a meaningful impact.
Sexually coercive experiences, heavy alcohol use, and alcohol-related problems occur at relatively high base rates in college populations. As suggested by the self-medication hypothesis, alcohol consumption may be a means by which one can reduce negative affect or stress related to experiences of sexual coercion. However, few studies have directly tested the hypothesis that coping motives for drinking mediate the relation between sexual assault and problem drinking behaviors, and no published studies have tested this in men. The current study tested this hypothesis using structural equation modeling in a sample of 780 male and female undergraduates. Results revealed that coping motives partially mediated the relation between sexual coercion and drinking and alcohol-related negative consequences. In addition, direct and indirect paths between sexual coercion and drinking were found for men whereas only indirect paths were found for women. Results provide support for self-medication models of drinking and suggest the importance of exploring gender differences in mechanisms for drinking.
Sexual coercion; drinking to cope; alcohol; consequences
Perceived norms are related to health-related attitudes and behaviors, including body image. The current study examined body dissatisfaction and perceived norms for thinness and muscularity among male and female college students.
Participants included 842 undergraduate students (64.5% female) who completed an online survey assessing body image and other health-related attitudes and behaviors. A series of independent sample and paired sample t-tests were conducted to document sex differences in body dissatisfaction and misperceptions of thinness and muscularity norms.
Based on pictorial ratings, both males and females reported discrepancies between their ideal and actual figures. Females perceived other females as significantly thinner and less muscular than the actual norms. Males perceived other males as significantly heavier than their own figures, but the difference between men’s self-reported muscularity and perceived norm was not significant. Both males and females misperceived opposite-sex attractiveness norms for thinness and muscularity.
Results suggest the importance of evaluating same-sex and opposite-sex perceived norms of thinness and muscularity in the etiology of body dissatisfaction, and this research informs social norms interventions targeting misperceptions of body image norms among both males and females.
Body image; Social norms; Muscularity; Thinness; Gender
The current research examines whether self-consciousness subscales have prognostic value in the relationship between perceived norms and drinking and if that differs among college men and women. Results indicate that self-consciousness moderates gender differences in the relationship between perceived social norms and drinking. A strong positive relationship was found between perceived norms (descriptive and injunctive) and drinking for men relative to women and this was more pronounced among individuals who were lower in public self-consciousness. Similarly, the relationship between perceived injunctive norms and drinking was significantly stronger among men than women and this was more pronounced among individuals who were higher in private self-consciousness or social anxiety. These results highlight the important influence of social factors in salient peer reference groups. This is promising information for future research attempting to identify useful indicators of candidates who would most benefit from social norms interventions. This also underscores the relevance of future norms based interventions using self-consciousness as a potential moderator of intervention efficacy.
self-consciousness; social norms; alcohol use; campus organizations; college students
To preliminarily evaluate telephone-delivered motivational enhancement therapy (MET) in motivating unadjudicated and nontreatment seeking intimate partner violence (IPV) perpetrators, who also use substances, to self-refer into treatment.
124 adult men were recruited via a multimedia marketing campaign and were randomly assigned to the intervention (MET) or comparison group following a baseline assessment. Participants in the MET condition received a personalized feedback report on their IPV and substance-use behaviors, consequences, and social norms beliefs.
Results supported the likely effectiveness of MET in short-term reduction of IPV behavior, increasing motivation for treatment seeking, and changing perceived norms for IPV and substance abuse (SA).
Applications for brief MET interventions to facilitate voluntary treatment entry among substance-using IPV perpetrators are discussed.
IPV perpetration; substance abuse; brief interventions; randomized controlled trials; motivational enhancement therapy; check-up model; voluntary treatment referral
Although voluntary enrollment by abusive men in domestic violence perpetrator treatment programs occurs, most men enter treatment only after they have injured a partner or family member and have been arrested, convicted and sentenced. This leaves a serious gap for those who engage in abusive behavior but who have not been served by the legal or social service systems. To address this gap, the researchers applied social marketing principles to recruit abusive men to a telephone-delivered pre-treatment intervention (the Men’s Domestic Abuse Check-Up—MDACU), designed to motivate non-adjudicated and untreated abusive men who are concurrently using alcohol and drugs to enter treatment voluntarily. This article discusses recruitment efforts in reaching perpetrators of intimate partner violence, an underserved population. Informed by McGuire’s communication and persuasion matrix, the researchers describe three phases of the MDACU’s marketing campaign: (1) planning, (2) early implementation, and (3) revision of marketing strategies based on initial results. The researchers’ “lessons learned” conclude the paper.
Abusive men; Social marketing; Recruitment; Early intervention; Prevention
Research examining intimate partner violence (IPV) has lacked a comprehensive theoretical framework for understanding and treating behavior. The authors propose two complementary models, a treatment approach (Motivational Interviewing, MI) informed by a theory (Self-Determination Theory; SDT), as a way of integrating existing knowledge and suggesting new directions in intervening early with IPV perpetrators. MI is a client-centered clinical intervention intended to assist in strengthening motivation to change and has been widely implemented in the substance abuse literature. SDT is a theory that focuses on internal versus external motivation and considers elements that impact optimal functioning and psychological well-being. These elements include psychological needs, integration of behavioral regulations, and contextual influences on motivation. Each of these aspects of SDT is described in detail and in the context of IPV etiology and intervention using motivational interviewing.