While several models have influenced the development of our programs, the Lifestyle Risk Reduction Model has been most central to this development (Daugherty and O'Bryan, 1981, 1987; Thompson, Daugherty, and Carver, 1984; Daugherty and Leukefeld 1998, 2002). The key distinguishing features of this model are:
The identification of alcohol- and drug-related health problems, including addiction, as being in the category of lifestyle-related health problems and thus sharing principles of etiology and prevention with other lifestyle-related health problems such as the most common forms of heart disease, some cancers, and type 2 diabetes.
The central role of both biology and quantity/frequency choices in etiology and prevention.
Specifying that the primary role of psychological and social problems is in influencing quantity/frequency choices.
Identifying Five Conditions that can promote adoption of low-risk choices.
The central role of quantity/frequency choices in this model deserves additional comment. It is no accident that PRI was the first program developer in the United States to offer alcohol low-risk guidelines and to make them a central element in its prevention programming. This is a direct expression of the Lifestyle Risk Reduction Model. For many years this was highly controversial not only on the level of curriculum, but also on the level of model of causation.
On its face, it would seem the importance of alcohol or drug use in the role of developing alcohol or drug use disorders would be obvious. Yet, at the time the Lifestyle Risk Reduction Model evolved, alcohol was widely considered to play no direct role in the development of alcoholism. The idea that people could not "drink their way into alcoholism" was widely held and for some, became synonymous with the disease concept. The thinking for many was that people with alcoholism drank because they had alcoholism, rather than alcoholism resulting—even in part—from the amount they drank. Also, at this time it was fairly commonly believed that some people were born with alcoholism. When the alcoholism and drug addictions fields merged on the conceptual and community program level in the 1980s, this thinking was broadened to include drugs. The argument was a harder sell for drug addictions in that the connection between heroin use, for example, and heroin addiction seems so clear. Yet, a common phrase was that "alcoholics and addicts are born not made," an argument made stronger for some by a misunderstanding of research on genetics and on brain science.
In contrast, the Lifestyle Risk Reduction Model suggests that high-risk quantity/frequency choices are the necessary elements for alcoholism and addiction to develop. Our choices have the power to prevent, the power to destroy, and the power to heal.
The idea that quantity/frequency choices would not be central to etiology may sound odd today, but in the early days of PRI's work, PRI's focus on choices as central to etiology, prevention, and treatment was controversial. In that environment, the importance of staying clearly focused on a model cannot be overstated. Yet, it is no less important today; even though the importance of quantity/frequency choices is widely understood. Competing paradigms still pull alcohol and drug professionals in differing directions. Now, as much as any time in our history as a field, we need ways of thinking that help us make sense of the huge amount of research coming out of multiple disciplines. Perhaps the area providing the greatest challenge today is that of genetics and brain function in addictions. We cannot afford to understate the importance of this body of research. Neither can we afford to overstate it. Being grounded in a model can help us do this.
For PRI the Lifestyle Risk Reduction Model provides this grounding. This paper provides a more in-depth understanding of the model that has guided the evolution of Prime For Life® and Prime Solutions®. Other papers in this section will also look at the important contribution of the Transtheoretical Model in honing our understanding of how people change.
The Essentials of the Model
A set of key concepts derived from the empirical literature are central to the Lifestyle Risk Reduction perspective on both the determinants of alcohol- and drug-related problems and methods for effective intervention. The first concept comes from research indicating that as much as half or more of the risk for alcoholism is genetically determined (Hesselbrock et al.,1999). These researchers note that physiological effects and pharmacokinetics dictate the potential for addiction but do not alone determine which individuals become addicted. Evolving research (e.g., Schuckit, 1998) indicates that this risk lies on a continuum. These findings suggest that each person has a biological threshold for addiction, conceptualized in our programs as a range of distances from a "trigger point.” Persons with increased biological risk start out at a shorter distance from their trigger point, meaning it will take less time and less use to reach it than people born with standard risk. In addition, some people have greatly increased biological risk and they can develop addiction even more rapidly.
How we explain the remaining 50% of risk that is not genetic is where the Lifestyle Risk Reduction Model differs from other approaches. In this model we go first to choice, not to the psycho-social factors that underpin those choices. (Think here of the Formula.) If we go directly to the psycho-social factors the implication is that alcoholism/drug addiction is directly caused by a combination of genetics plus personality and environment. This thinking bypasses the only thing our clients can directly control: their choices. Instead, by focusing simply on Biology plus Quantity Frequency Choices we are saying to the client, "Regardless of your family, your job, your education level, your personality or any other factor, you are in charge of the remaining risk and you exercise your power with every choice you make regarding your alcohol and drug use.” This is the message for prevention, and this is the message for recovery. This focus is not to minimize the very important role in psycho-social factors but to magnify the role and power of choice itself.
In addition to inborn biological risks, then, lifestyle choices also present risk and are ultimately the triggering agent. The concept of a trigger point most directly applies to health problems such as alcohol- or drug-related cirrhosis, cancers, or addiction. The biological threshold for experiencing more immediate impairment problems can best be conceptualized as a “tolerance level,” referring to the point at which impairment occurs.
The concept of risk is operationalized in practical terms by focusing on risks we cannot change (biology) and risks we can change (quantity consumed and frequency of consumption). The Lifestyle Risk Reduction Model further indicates that the combination of biological risk with "how much" and "how often" defines the overall level of risk for each person, implying that people with increased biological risk might require different guidelines about alcohol consumption than do those with lower risk. Each individual must therefore ascertain their personal level of biological risk in order to make low-risk lifestyle choices. In effect, then, the goal is to encourage people to make low-risk choices that do not equal or surpass the level of biological risk. While alcohol research indicates a range of low-risk choices, for other drugs the only low-risk choice we can identify is zero.
Rather than defining alcoholism or addiction as problems of will, personality, social influences, or morality, the Lifestyle Risk Reduction Model focuses on the complex interplay between biological and lifestyle risks at the individual level, thereby helping individuals ascertain their own risks and enabling more reasoned and healthy choice-making. This perspective is consistent with theories of reasoned action (Ajzen & Fishbein, 1980) and planned behavior (Ajzen, 1985). The LRRM also recognizes the impact of each person's proximal (family, friends) and distal (neighborhood, culture) environment, especially with respect to acquisition and maintenance of problem behavior. It draws heavily on traditional social learning theory, with emphasis on role modeling (Bandura, 1986), as well as sociological research that articulates social development processes by which individuals become bonded to important systems in their world (Hawkins & Weis, 1985). Finally, by emphasizing the relationship between thoughts (cognition) and actions (behavior), the LRRM is consistent with the literature on cognitive social learning theory and behavioral self-control paradigms (Bandura, 1986).
Given these assumptions about the determinants and course of alcohol and drug problems, fundamental persuasive messages that drive the Lifestyle Risk Reduction Model are therefore: (1) the need to personalize each individual's beliefs about the potential adverse consequences of their choices such that they derive a more accurate understanding of idiosyncratic dangers and benefits; (2) the need to assess one's immediate and more distal social environment to ascertain sources of support for prospective behavioral change; and, (3) the need to establish sufficient motivation to change, coupled with the belief that each individual has the capacity and skills to make low-risk choices and sustain them (self-efficacy).
Phases of Use
PRI also conceptualizes four Phases of Use to describe the progression of alcohol and drug use ranging from low-risk choices-abstinence from drugs and abstinence or other low-risk choices for alcohol (Green Phase) to high-risk choices without psychological dependence (Yellow Phase), to high-risk choices with psychological dependence (Orange Phase), and to psychological dependence along with physiological dependence/addiction (Red Phase).
From Prevention to Recovery
The implications of this model are no less relevant for recovery than for prevention. In the words of a residential treatment program client receiving Prime For Life as part of the educational component of a treatment experience, "For the first time I understand how I became addicted and why I need to abstain to recover." In the simplest of terms, once a person reaches the trigger point, it becomes very difficult to use just a little bit. So many smokers have experienced this when after years of not smoking they decided to "just smoke one." At this point, though, it is not just altered biology that comes into play. As a person moves closer to addiction the high-risk use begins altering most every aspect of the person's life so they are no longer the same psychologically or socially. Yet choice continues to be at the center.
DiClemente (2003) described this interaction as follows, "Although the processes of conditioning, stimulus generalization, and reinforcement often operate at the threshold of awareness, the addicted individual continues to make choices. These choices interact with the conditioning and reinforcement processes to support engagement in the addictive behavior... It takes choice and commitment to continue to obtain effective access and to seek the addictive behavior when there are negative personal and social consequences that begin to emerge." We would add that the processes of conditioning, stimulus generalization, and reinforcement are happening at the intersection of psychology and biology. Individual high-risk choices are the engine that drives this process—ending in addiction.
Five Conditions for Effective Risk Reduction
Any successful intervention for either prevention or recovery must affect choice and the resulting behaviors. The Lifestyle Risk Reduction Model suggests Five Conditions are essential in order to promote low-risk choices and behaviors.
Condition One — People believe: "It (an alcohol or drug-related problem) could happen to me, and it is my quantity/frequency choices that will determine whether or not I experience a problem." This condition addresses perception of risk about personal quantity/frequency choices. The Lifestyle Risk Reduction Model suggests increased risk perception will increase impact for both prevention and recovery efforts. Since the conditions were developed in 1981, a number of studies supports this. For example, heavier drinkers have lower perceptions of risk and higher expectations of positive outcomes from drinking (Brown et al., 1985; Roizen 1983; Fromme et al., 1997). Increased perception of risk is associated with treatment seeking. (Hingston et al., 1982) Higher perceived risk "If I keep drinking as I have been, I will develop alcoholism" at posttest after PRIME for Life is associated with lower recidivism rates 3-5 years after arrest. (Engen, Richard, & Patterson, 1995). It has also been demonstrated that Prime For Life leads to relatively enduring changes in this risk perception (Marsteller, 1996) Most recently our own evaluations have indicated a significant association between this risk perception and motivation to change.
At the heart of this condition is the belief that people will be more motivated to make changes in how much or how often they drink or use drugs if they feel personal vulnerability—if they believe their choices make a difference in the likelihood of an undesired outcome occurring. This may be facilitated by a belief that anyone—not just certain kinds of people—can develop problems if they make high-risk choices. This is true in many other areas besides alcohol and drug problems. If people do not believe that AIDS could happen to them, they may be less likely to use preventive measures. If they do not believe that skin cancer is likely to happen, they are less likely to limit exposure to the sun. This condition is even relevant to non-health issues such as personal finances. People who do not believe that financial problems could possibly happen to them are not likely to take money management seriously. A variety of attitudes can be targeted to effectively establish this condition with target audiences.
For example, widely held beliefs lead people to conclude that alcohol problems happen because of the kind of person one is (largely psychosocial factors although this may include biological factors), rather than the kind of drinking choices one makes (behaviors). At least unconsciously, then, they conclude their drinking choices do not matter because they are too strong, too together, too immune, and definitely not "that kind of person." Many alcohol education programs unwittingly add to that perception by emphasizing psychosocial factors such as childhood experiences, feelings, or self-esteem instead of choices. Clients often leave alcohol education experiences fortified in their beliefs that they are not "that kind of person," and therefore do not need to worry about their drinking choices. This condition suggests the first task of our education must be to replace the belief, "It happens because of the kind of person you are" with the belief, "It could happen to anyone, including me, and how much and how often I drink or use drugs matters."
This can be equally true for recovery programs. Counselors often find it challenging to overcome clients' "denial" that they do not have a problem. Sometimes this denial is based on the clients' long-held belief that "It can't happen to me because I'm not that kind of person." So, when it does happen, the logical conclusion is that "it has not happened" because "it cannot happen to people like me." How can I have something that I cannot get? If we can help people come to believe that they could develop the problem, they cannot help but wonder whether or not it has happened. The perceived "denial" then often begins to melt.
With good intentions, some prevention and recovery efforts try to bring about this and other changes in belief simply by telling people what they "should believe" or what is "true." The Lifestyle Risk Reduction Model suggests that bringing about changes in belief requires a specific, intensive process grounded in non-coercive but persuasive communications. Programs using this model could use specific information grounded in biological and psychosocial research to help people move through a process of belief change. Once this condition is successfully established, people are ready for Condition Two. They are eager to know the answer to these two questions: "How can I know my own level of risk—where is my trigger point?" and "How do I know what choices are low risk for me?"
Condition Two — People know how to estimate their level of biological risk and what specific quantity/frequency choices are high risk and low risk. People can say: "I know what to do." The terms "risk reduction," "low risk" and "high risk," though rarely used in the field at the time PRI began its work, are now widely-used, and clarification may be helpful. When used by PRI, these terms refer to research-based guidelines on specific quantities and frequencies of drinking. Low-risk choices (which include abstinence) are those choices not associated with increased overall mortality in the general population. High-risk choices are linked to a variety of health and impairment problems. Just as people must know what quantity/frequency choices about diet and exercise will reduce risk for heart problems, they need to know what specific quantity/frequency choices decrease (or increase) risk for alcohol and drug-related problems.
Research on health communications tells us specificity is important. In our field, most efforts to quantify have been vague and counter-productive. To help people understand how much is too much, people have been told things like, "You know you've had too much when you have a problem." That is like saying, "You'll know you've had too much cholesterol when you've had a heart attack!" This is certainly not the kind of prevention advice people have gotten for heart disease. They've benefited from some very specific guidance, such as exactly how long and how often people should exercise aerobically, or how little saturated fat to eat per day. Without this guidance, people may believe more cholesterol and less exercise to be low risk when it is actually not.
People have also heard that, if they choose to drink, they should drink moderately or responsibly. But how much is moderate? How much is responsible? Some may believe it is any amount that is less than their friends are drinking. On today's college campuses, two six packs of beer may seem moderate, but research finds this to be very high risk. Again, guidance needs to be specific and research-based.
These guidelines also provide helpful recovery information by providing a specific ruler against which I can gauge how high-risk my own choices have been; and how likely it is I can follow such guidelines successfully. It is normal in the course of recovery for people to think, "Maybe I can drink/use again now." But as one client said, "I could always rationalize that 8 drinks is moderate. I can never rationalize that 8 is 2." The benefit of knowing low-risk guidelines is much like the advice in Chapter Three of the AA Big Book; "We do not like to pronounce any individual as alcoholic, but you can quickly diagnose yourself. Step over to the nearest barroom and try some controlled drinking. Try to drink and stop abruptly. Try it more than once. It will not take long for you to decide if you are honest with yourself about it." The low-risk guidelines provide even greater specificity but serve the same purpose for many people; answering the question once and for all.
Condition Three — People perceive social support for making low-risk choices. People can say: "The people around me support me in making (age-appropriate) low-risk choices." Many customs, values, policies, and messages influence people's choices. If there is not adequate social support for low-risk choices, then the prevention and recovery professionals can help individuals, groups, and communities find ways to build that support. We could quickly think of dozens of ways our society supports people in making low-risk choices for heart disease. Labeling fat content on foods, making fat-free products available, and encouraging regular exercise are examples. The same thing can, and has already begun, to be done to support low-risk alcohol, tobacco, and other drug choices. Alcohol-free social events, no-smoking policies, and employer drug policies are examples.
However, this condition is not only addressing the reality of support but the perception of support. Often people underestimate the amount of support present for abstaining or making other low-risk choices and overestimate the amount of support for making high-risk choices. In establishing this condition, programs will work to change the social environment, but will also work to change individual perceptions of that support. Simply put, people must perceive support for making low-risk choices, or they are not likely to make them.
Condition Four — People hold attitudes, beliefs, values and motivations that support making low-risk choices. People can say: "I am motivated to make (age-appropriate) low-risk choices." Previous conditions established heightened risk perception, knowledge of what to do, and perception of social support. People are still unlikely to adopt low-risk choices across time unless they value and desire the behavior. Attitudes and beliefs may help establish motivation for either low-risk or high-risk choices. Research indicates that expectations on what alcohol or drugs will do for a person are powerful influences on choice. (Brown, et al., 1980; Wall, et al.,1998) For example, those who believe that use will help a person achieve happiness, popularity, sex, or power are much more likely to use. When Condition Four is in place people will hold beliefs that low-risk choices will help them achieve their goals and high-risk choices will threaten what they value. Professionals working to assist the client in establishing Condition Four may work to change high-risk beliefs such as "high tolerance is protective" to "high tolerance is risky." If someone believes that high tolerance is risky and that high-risk choices will inevitably create high tolerance, the high-risk choices become less likely.
Condition Five — People possess the necessary skills to make and maintain low-risk choices. They can say: "I know how to make (age-appropriate) low-risk choices and I am confident I can succeed." People not only need motivation and support for making low-risk choices; they need to know how to make low-risk choices. For instance, people can learn how to turn down a drink without calling unwanted attention to themselves. Knowing how to live sober, how to socialize, relax, or have fun without alcohol or drugs are all necessary skills. Professional efforts are aimed at developing skills to make age-appropriate low-risk choices that will meet social and emotional needs.
A variety of methods and activities may be used to establish these conditions. The challenge to the prevention or recovery professional is to help the client establish all of the conditions. Only then, is the effort truly comprehensive and systematic. We believe it will typically be helpful to establish Conditions One and Two first. However, this will not always be true. Which conditions the professional seeks to establish first may be determined by how many barriers the person has to Condition Four. When there is little internal support, or when the person has severe emotional problems, that may be the first priority. People without hope, or with very little sense of self worth, for example, might not be motivated to learn how to estimate biological risk or the range of low-risk choices.
Whichever sequence is chosen to establish the Five Conditions, the professional methods used are important. Choices are highly personal. It is essential to gain an understanding of how people respond to external efforts to affect their choices. While not part of the model per se, PRI has, from the inception of the model, encouraged utilizing principles of the central route to persuasion to decrease defensiveness and maximize response to prevention and recovery efforts.
The Lifestyle Risk Reduction Model has been the central model that guides our work. The Transtheoretical Model (TTM) has contributed significant understanding of how people change and Motivational Interviewing has further refined the professional skills that can be used to promote change. We have worked to actively integrate these into our programs with the belief by doing so we can evolve a more effective approach to both prevention and recovery.