This post was written by the 2015 winner of the CFHA Research and Fellowship Award.
For me, one of the most challenging aspects of transitioning from traditional training in specialty mental health to working in a Primary Care Behavioral Health (PCBH) setting was learning ways to deliver interventions in that can be effective in a short period of time. Coming from a tobacco research background, I knew there were evidence-based interventions for tobacco use that could be delivered in just three minutes or less.
Not long into my postdoctoral fellowship I also learned about the evidence base for brief interventions as few as five minutes in length for at-risk alcohol use. I felt encouraged by the evidence that brief interventions for these presenting concerns could be effective, especially at the population level. I regularly started implementing brief alcohol and tobacco interventions into my work with patients in primary care, but research data at the time told us that behavioral health providers in integrated primary care settings were not routinely incorporating brief interventions for tobacco and alcohol use into their clinical work with patients. I wanted to learn more about why these brief interventions aren’t regularly occurring in PCBH appointments.
I was excited to receive the Research Fellowship from the CFHA Research and Evaluation Committee in 2015, which allowed me to begin research to help answer this question. For the fellowship, our study team conducted a national online survey of PCBH providers to better understand the barriers to implementing brief tobacco and alcohol interventions when working with patients using tobacco or drinking above low-risk drinking. We also collected data on the facilitators that could promote the use of these interventions.
We were excited that 265 behavioral health providers across the country volunteered to participate (we know these providers are busy!). The majority of providers were psychologists (48%) and social workers (33%), but we also had representation from other professions including licensed mental health counselors, psychiatrists, nurse practitioners, RNs, and marriage and family therapists. Primary theoretical orientation varied, but the most common (51%) was cognitive-behavioral.
It was encouraging to learn that almost all providers (95%) reported previous training in brief alcohol interventions (when assessed broadly; we included class course, independent reading, online training, supervision, and training workshop). Fewer (but still most respondents; 77%) reported some type of past training in tobacco use interventions. As such, we felt it was unlikely that lack of training is preventing providers from implementing brief tobacco and alcohol interventions.
Participants reported that they are conducting at least a brief tobacco intervention with their patients who use tobacco products approximately a third (32%) of the time. This was somewhat encouraging, but left us feeling like there is a lot of room for growth! We presented participants with a list of potential barriers to conducting brief tobacco interventions and asked them to rate each of these factors on a scale from 0=Not a barrier to 4= A significant barrier. The highest rated factors (i.e., biggest barriers) were: 1) the perception that patients have more immediate needs to address than tobacco use, 2) the patient not being interested in quitting or cutting down, and 3) the patient not identifying tobacco cessation as a treatment goal.
Things that participants said would help them conduct more brief tobacco interventions included 1) the patient identifying tobacco cessation or reduction as treatment goal, 2) having a good relationship with the patient, and 3) getting referrals directly from primary care providers (or other PC staff) specifically for tobacco cessation.
Switching to at risk-drinking, participants reported that they are conducting at least a brief alcohol intervention with their patients who endorse at risk drinking 40% of the time. The same lists of barriers and facilitators were presented as in the tobacco section. Like with tobacco, participants said that the top barriers to incorporating brief alcohol interventions into their regular work were 1) the patient not being interested in quitting or cutting down and 2) the patient not identifying alcohol reduction or abstinence as a treatment goal.
However, with alcohol, the providers said that patients not being motivated to cut down or quit was among the top three barriers. Participants identified the same top three facilitators as they did with tobacco; they reported that the patient identifying alcohol reduction or cessation as a goal, having a good relationship with the patient, and getting referrals directly from primary care providers would increase the rate at which they delivered brief alcohol interventions.
So where do we go from here? We were encouraged to learn that lack of time to deliver brief tobacco and alcohol interventions and lack of training to do so were not among the top barriers identified (as these are often cited as a reason that primary care providers are unable to deliver these types of interventions). In addition, all barriers identified are able to be addressed (e.g., encouraging behavioral health providers to use motivational interview techniques to address concerns such as a lack of motivation or not being interested in modifying these behaviors), and the providers have given us great suggestions for things that would help them deliver more of these interventions.
If you are reading this and working in an integrated primary care setting, hopefully this gave you some food for thought regarding how you might begin incorporating more brief interventions for tobacco use and at-risk drinking into your regular clinical practice! Feel free to check out the provider education tab located at this website for some resources related to conducting brief tobacco and alcohol interventions.
Jennifer Wray, PhD, is a clinical psychologist in the Primary Care-Mental Health Integration Clinic at the Ralph H. Johnson VA Medical Center, located in Charleston, SC. She completed a postdoctoral fellowship at the VA Center for Integrated Healthcare in 2017. Dr. Wray is interested in the process of integrating behavioral health and primary care services, and has specific interests in brief behavioral interventions able to be delivered in the unique setting of integrated primary care.