Lisa* checked into her primary care clinic to get treatment for an injured ankle. While at the clinic, she was also seen by Cassie, a social worker who introduced herself as a behavioral health specialist with the program CHOICES.
Cassie asked Lisa a few questions about her drinking habits and whether she used birth control. Lisa explained that she didn’t think too much about those issues because she was dealing with larger problems, including financial difficulties and getting back to school. They developed rapport, however, and Lisa returned for a second visit two weeks later. They talked some more about the risks of drinking while pregnant. At that time, Lisa also talked with her doctor about birth control because, after her initial conversation with Cassie, she wanted to know her options to avoid an alcohol-exposed pregnancy.
Drinking alcohol during pregnancy is a leading cause of birth defects and developmental disabilities in the United States. But every day, women like Lisa choose healthier behaviors that avoid alcohol-exposed pregnancies thanks to CHOICES, a program developed by researchers at the Health Behavior Research and Training (HBRT) institute at The University of Texas at Austin School of Social Work.
CHOICES, which is being disseminated by the Centers for Disease Control and Prevention (CDC) has been implemented in more than 30 sites across the United States, in primary care clinics like the one Lisa visited as well as in ob-gyn practices and substance abuse clinics. CHOICES has also been implemented in Canada, Russia, and South Africa. Recently, CHOICES has been included in the National Registry of Evidence-Based Program and Practices.
CHOICES at work
CHOICES looks deceivingly simple: it consists of four 45-minute sessions with a behavioral health specialist and one counseling visit with a family planning clinician, all done over a twelve- to fourteen-week period.
To get to this point, however, HBRT researchers Mary Velasquez, Kirk von Sternberg, and Nanette Stephens have been working for the past thirteen years, along with colleagues from two other universities and the CDC. They developed and evaluated the program’s curriculum for acceptability and ease of delivery, and then tested it in a variety of settings to make sure it was really effective in changing people’s behavior.
“CHOICES is an evidence-based program,” explains Velasquez. “This means that it has been tested through a series of studies where we had two groups of women, one receiving CHOICES and the other receiving basic information about alcohol-exposed pregnancy. We then did 12-month follow-up interviews, and found that the women receiving CHOICES were at significantly lower risk of an alcohol-exposed pregnancy because they had changed their behavior, by either drinking less, using contraception, or both.”
There is much work and training behind each of the CHOICES sessions.
To a casual listener, Lisa’s conversation with Cassie might sound informal and effortless. But Cassie was actually following the curriculum in the CHOICES manual, and using strategies and techniques she learned during her CHOICES training in Motivational Interviewing, an evidence-based practice in itself that has proven highly successful in helping people change behaviors.
“We train behavioral health specialists in Motivational Interviewing through intensive sessions,” Stephens explains. “We also give our trainees the opportunity to practice their skills with trained actors posing as patients. We observe these sessions and provide immediate feedback. We have also developed a coaching model, in which trainees record their sessions and send them to us. We listen to the recordings and use a coding scheme to measure the extent to which they are really using Motivational Interviewing language and techniques during the session. We then use this to provide very specific feedback that helps trainees to enhance their skills.”
Motivational Interviewing is an important component of other programs that the HBRT has developed to help patients choose healthier behaviors.
For instance, along with colleagues Richard Spence and Tom Bohman, from the School of Social Work’s Addiction Research Institute, the HBRT team developed and supervised the delivery of a brief intervention, called InSight, for Harris Health District in Texas, the fourth largest public healthcare system in the country.
Patients admitted to Harris Health trauma units, emergency rooms, and primary care clinics were screened for alcohol and drug use. Those who screened positive were referred to an InSight behavioral health specialist, who used Motivational Interviewing while further assessing the severity of drug and alcohol use, and recommending possible services. In follow up interviews between 5 and 8 months later, researchers found substantial decreases in drug use and heavy alcohol use.
“The year after InSight was initiated, there was a 4 million dollar reduction in return visits to the emergency room,” says von Sternberg. “These screening, brief intervention and referral to treatment programs, often identified by the acronym SBIRT, are so successful that they have spread across the country. Every level-1 trauma unit in the United States is now required to do a screening and brief intervention for alcohol use.”
CHOICES and today’s healthcare
Programs like CHOICES and InSight, with their focus on modifiable health behaviors and proven effectiveness, are increasingly important in the changing healthcare landscape of the United States.
“Chronic conditions such as heart disease, cancer, and diabetes are not only leading causes of death in our country, but also big burdens to our health care system,” von Sternberg says. “And we know these conditions have a lot to do with our health behaviors: what we eat and drink, whether we smoke, whether we exercise, and so on. In many cases, patients don’t need a costly treatment or a new pill, but someone to help them modify a behavior.”
The current health reform under the Affordable Care Act creates new opportunities for this type of intervention, as it emphasizes the integration of primary care and behavioral health, and requires providers to cover behavioral health treatments at the same level as other types of care. The hope is that a better integration of behavioral health care services into the broader health care continuum will have a positive impact on quality, costs, and outcomes. This trend in healthcare also opens new opportunities for social workers.
“If you look across the country, behavioral health specialist jobs are increasing and becoming very visible,” Velasquez says. “And many of these jobs are held by social workers, along with other professionals like master’s level counselors or psychologists. I think this trend is great for our students and future graduates, but also to show to the wider public that social work goes beyond case managing, that it is actually a clinical degree.”
Training the Next Generation of Social Workers
The HBRT team is now having a direct impact in the education of social workers at UT Austin. Velasquez is one of the co-investigators in a federal grant that the School of Social Work received to train master’s level social work students as integrated behavioral health specialists to be placed in medical settings.
“The integrated behavioral health program at the School of Social Work has given us the opportunity to fully integrate our experience in evidence-based interventions research and training into the social work curriculum,” Velasquez says. “Applying for this grant was a true team effort that included Diana DiNitto, Dean Zayas, Carol Lewis, Anita Prewett and many other wonderful colleagues from our school.”
As part of the integrated behavioral health program, social work students receive the HBRT training in Motivational Interviewing, including practicing with actors posing as patients and going through the coaching sessions. For their field internship, students are placed in primary clinics throughout Austin, where they apply their knowledge with patients, and continue receiving coaching from HBRT.
“Traditionally, the education of social work students has included a focus on the mental health piece, how to work with a client around depression, for instance,” Velasquez explains. “I think it’s equally important to teach them to use evidence-based brief interventions to work with health behaviors like drinking, smoking, diet, exercise… behaviors that have an impact on chronic conditions.”
HBRT team members are enthusiastic about the possibilities of collaboration that the Dell Medical School will bring to the UT Austin campus.
“Being involved in the creation of a medical school from the ground up is a unique opportunity,” Velasquez says. “We are entering a new and exciting time in health care and our School is well poised to meet the growing need for behavioral health programs that are based on sound scientific evidence, and that can be readily implemented in the community settings that our medical school will serve.”
For their next research steps, the HBRT team is building upon the success of CHOICES. They have recently tested with good results a briefer version that includes smoking as a target behavior. And they have now received funding to implement this briefer version of CHOICES, with an added component addressing obesity, in women’s health clinics of the UT Health Science Center-Houston Medical School.
“These are exciting times for us,” Velasquez says. “For the past twenty years, our research has focused on health behavior change, and on how we translate this research into programs that actually have an impact in the community. It’s very satisfying to see this coming to fruition.”
*Names have been changed