Conversation with Connie Weisner


graphic

In this occasional series, we record the views and personal experiences of people who have especially contributed to the evolution of ideas in the Journal's field of interest. Connie Weisner holds the posts of Professor of Psychiatry at the University of California, San Francisco and Associate Director of Health Services Research at the Division of Research, Kaiser Permanente, part of the largest integrated health-care delivery system in the United States.

Early days and schooling

Addiction (A)

I am curious about your early life, where you grew up, and what your family was like.

Connie Weisner (CW)

I am fortunate that I came from a happy family. I was the oldest of five children. My father was a Lutheran Minister and we moved around a great deal. That was a part of my childhood I did not like very much, but it probably helped me develop coping skills. We lived in Iowa, Nebraska, and for the longest in Wisconsin. My mother had been a teacher before she married. She was a wonderful, kind person. Both of my parents recently passed away in their 90s. My siblings are very close, so I feel very lucky. My husband's parents and family have also had a major impact on me—I was very close to his parents. They were Jewish and both died in their 50s due to Holocaust-related health conditions. That loss had a huge impact on our family, and makes me value my time with my family even more. I did not grow up having a family member who had an alcohol problem, as did many people in our field; but my father, as a minister, dealt with many people who had alcohol-related problems and that left an impression on me. It was a time in small Midwestern towns when people were more likely to go to their ministers with problems. I learned how stigmatizing alcohol problems were—such an embarrassment to their families. Alcoholism was a predominant issue that people came to talk to him about. In my younger years, when we were living in Iowa, unemployed men, whom everyone assumed were ‘alcoholics’, would come through small towns on the railroad. They would stop at the churches in the winter to shovel snow or in the summer to do other jobs. I would sometimes get up to find a couple of strange men at our breakfast table. I thought they were people who had interesting lives.

‘… my father, as a minister, dealt with many people who had alcohol-related problems and that left an impression on me’.

A

What was it like being a minister's daughter in a small town?

CW

I learned the term ‘PK’ (‘preacher's kid’), which was not a compliment. In the smallest towns we lived in my father was usually one of the most educated people in town, but I did not like being a minister's daughter. On the other hand, as I got into high school, my parents' philosophy was that ‘as long as you do not get into trouble, you make your own decisions—we trust you’. My friends used my being able to do things as a way to gain permission from their parents as well. Financially, times were hard. I made my way much on my own, and always had a couple of jobs during high school and college; but it was a good life.

A

You went to Wartburg College for your undergraduate education. What were your experiences at Wartburg?

CW

It is a small Lutheran college in Iowa, and I went there because I gained a scholarship. Both my grandparents on both sides of the family lived in the same town as the college. They had each lost their farms during the Depression, and my grandfather was the janitor in my college dorm. Although I was initially embarrassed I learned a great deal about humility, because he was everybody's favorite person—for example, he would fix toasters that were not supposed to be in the rooms, and so forth. It was not my first choice of college, because I was so eager to get out of small Midwestern towns, but because it was a small school and I was motivated, I had many opportunities not available in a larger university. Wartburg had an exchange program with the University of Bonn, for which two people were selected every year. I switched from studying Latin to German and, after a great deal of cramming, was selected to go. My year in Bonn changed my life. I was excited by the languages, the sophistication and international atmosphere. I hitch-hiked with a girlfriend all over Europe—you could do that in those days. Those experiences broadened my world-view. I also had an opportunity to participate in state and national debating during college, and had some excellent professors.

A

You majored in psychology and social work?

CW

Right, because in those small towns, before opportunities in academia opened doors for women, I knew very few women in high school or college who did not become a teacher, a nurse or a social worker. That was it. I never thought beyond that.

‘I knew very few women in high school or college who did not become a teacher, a nurse or a social worker. That was it’.

Training and early career in social work

A

You then went to the University of Minnesota and gained a master's degree in social work.

CW

Yes, in community organization and case-work. It was a great school and experience. My professors included Gisela Konopka and Tom Walz; people in the social work community will know those names. I had great fieldwork instructors and was able to write my master's thesis in Honduras jointly with a fellow student, who later became my husband.

A

What attracted you to the field of social work?

CW

It was probably a little of the minister's daughter in me, but it seemed broader and more interesting than the alternatives at the time. It expanded the way in which I saw the world. I am happy that I studied social work because it provided a conceptual framework and set of values for my work that made, and continues to make, a great deal of sense to me.

A

Speaking of expanding worlds, after you got your master's degree you had social work positions in the United States, India and Africa. What were your experiences in those positions?

CW

The traveling and working abroad were mind-opening. This was in the late 60s and early 70s, and it was a very good time to be young. The economy was good and there were opportunities for international jobs and travel. My husband Stan had a research position in Kenya. We interviewed social workers all over the country for an evaluation of the Kenya School of Social Work. I also helped to develop a sewing cooperative in Mathari Valley, a shantytown in Nairobi. When we lived in India for a year-and-a-half, while he was collecting data for his dissertation I worked with the School of Social Work at Jamia University, a Muslim university, and developed course materials for the cooperatives that the school was running in the community. In each of those countries, I found it fascinating to see how mental health and alcohol and drug problems were handled differently from in the United States. When I look back on those experiences, I see that noticing the different ways in which communities and cultures handle problems has been a thread throughout my career.

‘… noticing the different ways in which communities and cultures handle problems has been a thread throughout my career’.

A

Your first professional social work position in the United States was working with individuals in San Francisco's Skid Row.

CW

Yes, it was called ‘New Start Center’, and in many ways was an early attempt at a medical home. It was staffed with social workers, a doctor and nurse and a welfare worker. It had a detox unit on one floor of an old hotel, and another floor had supervised housing for individuals who could not stop drinking. It also provided out-patient counseling for the larger community. These clients had severe and chronic alcohol, drug and often psychiatric problems, so we networked with other community agencies. I was able to use my clinical and community organization skills. Another social worker and I helped to organize our clients to work on social and economic issues that were affecting them. The group named itself COSMOS (Committee of Sober Members of Society—I had nothing to do with selecting that name!). With the help of Neighborhood Legal Assistance, they improved access to health services for people receiving general assistance (rather than having to rely on emergency room use), stopped housing evictions by hotel owners, stopped arrests of some individuals who would be arrested to be ‘trustees’ in the county jail and got the welfare department to redefine ‘having a kitchen’ as ‘having a can opener’ for eligibility for food stamps. That was an exciting time. We all noted that people were remaining sober for longer while involved in these activities. It brought together my clinical and community organization skills and impressed me with how important client empowerment is, and that activation is possible for even those with the most chronic alcohol and drug problems. That realization has stayed with me throughout my career; part of my current research, which I have wanted to do for a long time, focuses on empowerment and activation.

Alcohol Research Group (ARG) and the move into public health research

A

Later you began working at the ARG as a research assistant.

CW

Right. I had been directing an alcohol program in the Haight-Ashbury area of San Francisco when my son, Aron, was born. I wanted to step back a little from what, in the mid-70s, was a chaotic, political environment. So, totally thinking of it as a diversion and having no idea that it would lead a career in a different direction, I applied for a job at the ARG as a research assistant. My daughter, Stephanie, was born during that time, and the job had the benefit of allowing me to work from home a good deal.

A

You then went to graduate school and received your DrPH (doctorate in public health) at University of California–Berkeley. What made you decide to go back to school and why did you decide to study public health?

CW

I credit ARG Director Robin Room for that decision. Robin encouraged me, even pushed me, to do it while I was at ARG. It was an extremely stimulating environment and I was helped by how open Robin and others were to allowing people without a doctoral degree to participate in the intellectual life of the Center—and if one's ideas were good enough and one showed ability, one could take on projects. Also, public health fitted well with my formative social work background. I was interested in the kinds of questions that could be studied from a public health perspective. I wanted to strengthen my research skills and study alcohol and drug problems and treatment in a larger context. I was drawn to understanding the interaction of individuals and systems. I learned there that alcohol is an ideal medium through which to study social problems, because it is used so commonly and can be problematic, and provokes such different cultural and political responses. It is also an ideal medium through which to study health problems, because it is a risk factor affecting the course of many chronic diseases.

A

Did you continue to work at the ARG while you were in the graduate program?

CW

I did—and before I officially started the degree I took my statistics courses one at a time, so it was a long process. I collected the data that started the Community Epidemiology Laboratory project as part of my dissertation while I was working there.

The Community Epidemiology Laboratory Project

A

Can you talk a little about that project?

CW

Yes, that was a formative experience for me. I had been a research assistant at ARG on several projects. ARG focused on studying drinking patterns and norms in general populations. There was no treatment research agenda, but Robin and the other senior staff were open to new ideas. To digress a little, I was interested in asking some of the same sociological questions they were asking, but also about how policy changes, norms, etc. affected treatment systems. That was partly because of my clinical experience, in which I saw big changes in treatment agencies and in the way alcohol and drug problems were treated when policies changed. As an example, I had been a social worker in San Francisco during the de-institutionalization of mental health and substance use treatment. Substantial changes occurred in what, where and how we could provide for our clients, and that fascinated me. I think that I made a strong case for understanding how communities addressed alcohol problems and the factors that influenced this. I proposed a study of a population entering all the alcohol treatment programs in a nearby county. The goal was to understand the treatment entry process. The clients had many types of problems, such as medical and mental health problems. I had noticed that many people had alcohol problems in all my earlier internship and work experiences, and I wanted to know how they were triaged across community institutions and what affected that process. I talked the leadership of ARG into letting me propose that study as a component in the Center Grant, and that became the first part of the Community Epidemiology Laboratory (CEL) [1].

A

How did that project expand over time?

CW

When we surveyed individuals entering alcohol treatment and asked them about their service histories, we found they had been in many different service settings before finally getting to treatment, so we conceptualized a study in which we would interview people in all the agencies in the county that were providing services to people with alcohol problems. We wrote grants one at a time, and as part of the NIAAA (National Institute on Alcohol Abuse and Alcoholism) center grant for ARG. We conducted a general population study as well as probability studies of individuals entering welfare, primary care, mental health, criminal justice and other health-care settings. Laura Schmidt, Cheryl Cherpitel, Denise Herd, Ron Roizen and I directed those studies. We found that few people were in alcohol treatment agencies, or had been in treatment during the prior year or even during their life-times [2]. That project formed the beginning of a research agenda to study alcohol and drug problems in different health and social service agencies. The general population and alcohol treatment studies in the project became part of a World Health Organization (WHO) project across several countries called ‘The Community Response to Alcohol Problems’ [3, 4], which put me into contact with WHO for the first time. I was also greatly influenced by Robin Room's paper on the ‘two worlds of alcohol problems’—treated and untreated [5].

A

So, over time, you had data to see where people with alcohol problems were obtaining help and some sense of how people might or might not end up in specialty treatment. What were some of the other findings from that project?

CW

We saw empirically that the health-care system was where one finds the most people with alcohol and drug problems and dependence. The criminal justice system was another setting in which many people with alcohol and drug problems were found. We also found that there was very different triaging of people across the community agencies based on gender, age and race, which has become an important part of my research. Basically, I came to the conclusion that those were the places where I would like to find ways to intervene, and that became my primary research interest.

A

How do you think the CEL project reflected your interests in social work and public health?

CW

It brought those interests together. Conceptually, it focused on the philosophy of the ‘whole person’ and the kinds of services they needed, which came from social welfare, as well as the need to intervene early wherever people are, a public health perspective. Also, the research skills that I acquired in UC–Berkeley's School of Public Health really informed that program of research. The project brought my interests together and set the stage for my ongoing research agenda. I was fortunate that I was able to conduct a study that captured my excitement and brought my clinical and research interests together so early in my career.

‘I was fortunate that I was able to conduct a study that captured my excitement and brought my clinical and research interests together so early in my career’.

A

How did your career at the ARG evolve over time? I know you had multiple research projects, but you also assumed different leadership positions.

CW

I was there and at the School of Public Health for a long time. I think the fact that I was able to develop a treatment studies niche and a fundable research program helped me to find a role. I wrote the next ARG NIAAA training grant and then became a more senior staff person, so when each of our directors left, Robin, and then Raul Caetano, I took on the Acting Directorship and searched for a new director. However, I was not interested in the directorship on an ongoing basis. I did not feel comfortable in that role, and probably was too junior for it. I was more excited about developing my research program.

A

How did that research program evolve?

CW

The next step was conducting a second study in the general population in that same California county of people who had alcohol and drug problems but who were not treated. We also conducted another study of people entering treatment in all the public and private alcohol and drug treatment agencies in the county [6]. That was the first time I worked with Lee Kaskutas, who directed that study, and with whom I continue to collaborate. We have followed the people in both samples for many years now and have tried to also answer questions about what happens to people over time who are not treated. Lee has used the study to develop research on 12-Step utilization and effectiveness, as well as an affiliation scale that is often used [7, 8]. That study is what first brought me into contact with the alcohol and drug clinics in the Kaiser Permanente health system.

Kaiser Permanente and the University of California

A

So you left the ARG in 1999 and came to Kaiser Permanente's Division of Research and the University of California–San Francisco (UCSF). What prompted that move?

CW

I was at a point in my career where I wanted to study how alcohol and drug treatment services were changing, and how those services could be moved into mainstream health care, rather than focusing on specialty clinics. I wanted to see if we could improve the delivery of services and health care. In working with the alcohol and drug clinics, I was constantly struck by the severity of people's problems; but when working with other agencies I saw many people whose alcohol problems were less severe, who were not receiving services. I wanted to do something to intervene earlier and to integrate services. In working with the Kaiser clinics from the outside, I found that the organization was very open to testing new ideas. I was fortunate to gain a joint faculty position in the Department of Psychiatry at UCSF and Kaiser Permanente's Division of Research.

A

In coming to UCSF and Kaiser, what did you want to accomplish? What research opportunities opened up (you have mentioned some of them already)?

CW

I thought it was important to look at an entire health ‘system’, understand what the medical and other needs of patients are, think about cost issues and understand how to impact integration—the full context of early screening and intervention, strong specialty care when needed and then, importantly, back to primary care when needed. This has evolved from the work and ideas of others on our team, and has also been influenced by research on disease management programs for other health conditions. As changes are occurring in the larger health-care system, we have been able to anticipate them to test interventions and look at cost-impacts. We are also finding that the approach is generalizable to other health-care settings, particularly Federally Qualified Health Centers, as health reform takes hold in the United States. When the ‘medical home’ or ‘health home’ concept became popularized, I was very excited.

Advisory work

A

You have served on a number of prestigious advisory and policy committees. What perspectives did you provide to those committees and what have you learned from your service on them?

CW

I have been pleased to be on some Institute of Medicine (IOM) committees, and have learned more than I contributed. I have learned from the process of people from different disciplines and perspectives coming together to address an important question. The first one was the 1990 Broadening the Base of Alcohol Problems committee. I think my background in CEL played a part in my being able to provide a perspective on alcohol problems that was broader than one finds typically in the US alcohol treatment system. The study on Managing Managed Care taught me a great deal about the use of performance measurement. More recently, I was fortunate to be on the committee that was the mental and addiction counterpart to the Crossing the Quality Chasm report [9] on health care. Serving on that committee was informative in terms of trying to bring our field into line with treatment for other medical conditions and to improve the quality of care. Again, my role was to integrate the treatment of alcohol and drug problems within health-care systems. It is a very difficult issue, because in the United States our field has grown up with freestanding specialty treatment programs and they are a huge part of our system of care. Therefore, it is important to determine how to integrate something outside the health-care system with how other health conditions are treated. There are many vested interests in the field on both sides, so thinking about it conceptually, as well as about some of the structural barriers to integration, was a challenge. That was also an important issue in the recent IOM committee on substance use problems in the US armed forces. For the past several years I have also been fortunate to be a member of the WHO's International Advisory Committee on Drug and Alcohol Problems. It has been wonderful and enriching to have this international perspective. Working on projects with people from countries that do not have the resources for a well-developed specialty treatment system such as we have in the United States has taught me a great deal. Many countries have actually been considerably more creative than we have in putting services into primary care, so I have learned much from them. We have also had a couple of studies in South Africa in primary care clinics, where we have had great collaborators and have learned more about the role of non-physician providers.

‘Working on projects with people from countries that do not have the resources for a well-developed specialty treatment system such as we have in the United States has taught me a great deal. Many countries have actually been considerably more creative than we have in putting services into primary care, …’

A

What do you think about the willingness of primary care physicians to deal with substance use problems?

CW

That is a huge issue. Part of the problem is that physicians in primary care are very busy, especially as health care moves more toward a medical home model. They have more patient responsibilities than they can handle. The issue of stigma in our field is also problematic. However, what has made a huge difference in physicians' willingness to address substance use problems is a sea-change in thinking about alcohol use as a risk factor—how unhealthy alcohol use relates to other chronic health conditions. However, it has been difficult to encourage clinicians not to think about alcohol or drug use as a primary problem only. Obviously, people who have severe dependence should have their dependence addressed; but once the issue is framed as unhealthy use for people who are on medications, have hypertension and so on, it is much easier to encourage physicians to talk to patients about how much they drink. I am very excited about this approach, because it is making a huge difference in the openness of physicians to address substance use problems.

Integration of treatment with mainstream health care

A

Where do you think the treatment field is heading?

CW

I think that the treatment field is broadening to encompass the whole continuum of alcohol and drug problems. Health care reform via the Affordable Care Act (ACA) in the United States will have a major impact on mainstreaming treatment in health care. It is such a propitious time with the advent of available medications, earlier interventions and also integration with behavioral care more broadly. Our work with adolescents has shown that it is even more the case that alcohol and drug problems do not occur in isolation from other issues [10]; they cannot be addressed in isolation; but if we are looking at early intervention and secondary prevention, then screening for exercise, nutrition and smoking is less stigmatizing for people with alcohol and drug problems, bringing us closer to a model where problems can be addressed earlier. That is not to forget the people who have severe problems, but hopefully we will not think any more of a treatment episode as a magic bullet that is going to make a major difference. Our field will continue to develop a continuing care or chronic disease orientation as well.

A

How is your research moving in the direction of integration?

CW

Our first randomized trial in Kaiser clinics that addressed integration was one that put medical services inside specialty treatment [11]. That was an exciting study, and through it we identified the large prevalence of medical problems in alcohol and drug patients [12]. We conducted many observational studies using the health plan databases, as well as data from several of our treatment studies, to suggest what interventions might look like. We are also studying family members of individuals with alcohol and drug problems, finding high rates of medical and psychiatric comorbidities and reduced emergency room and hospital costs when the family member with a problem is treated successfully [13]. We hope that will stimulate earlier screening. A current study I am very excited about which emerges from these studies [14, 15] is our Medical Home study—linking patients with primary care while they are in specialty alcohol and drug treatment, so they will continue to be monitored in primary care. This study substitutes a curriculum on patient activation and empowerment for part of a traditional medical curriculum. In some ways, this brings me back to my early social work clinical and community organization days where activation seemed related to good outcomes.

Family support

A

You mentioned your husband earlier. Could you talk a little about your family and how they have supported you throughout your career? How has having children impacted your career?

CW

They have been very supportive! I have been so fortunate that my husband shares similar values and career interests. We met in graduate school, and he has spent most of his career at UC–Berkeley. We enjoy talking about each other's work and have given each other ideas over the years, and that has been important. My children have definitely influenced my career, first of all by keeping my priorities in place. When I went to graduate school, later in those days than did most people, I would have to take my oldest daughter to a friend's house at 7:00 a.m. in the morning, to be taken to school later. My youngest daughter, Julia, was born as I finished the doctoral program. They and my son grew up while I was in school and developing my career. I always say that I owe them any frequent flyer miles I have. Now, as adults, they are all carrying out interesting work and I gain a great deal of sustenance and intellectual stimulation from talking with them about their work and seeing the world through their eyes. They are in related fields, so I am continually reminded from my daughter, who works with foster children and other adolescents, how substance use fits into that. My other daughter is studying health law, and has worked in a community court and seen the role of alcohol and drugs in many people' legal problems. My son works on affordable housing and public policy, including sometimes housing for these populations. My daughter-in-law is in the legal field and has conducted work in health; and I now have a wonderful grandchild, all of which keeps that side of my life full and rewarding.

A

How was it being a woman researcher in a new field such as health services research? Did you think that was a barrier at times?

CW

Actually, I was in a unique period and set of circumstances in which being a woman was probably helpful. Health services research was a new field, and there were not many women involved in it. I think I learned a good deal of assertiveness while helping to develop the field—I think it was a benefit, rather than a distraction or detriment. However, I have seen very clearly that this has not been the case for other women.

Looking ahead

A

What do you see yourself doing in the future?

CW

I see myself continuing to work on the issues I feel are most important: implementation and dissemination research, building our field using the laboratory that I have in this health plan, and continuing to work with the younger generation of researchers and watching them take over. I have been very lucky to find some exceptionally talented people to work with who have developed their own niches within our larger program of research and greatly enriched it. Jennifer Mertens has developed the work on clinical epidemiology and primary care, and Sujaya Parthasarathy has developed our health economics research. Stacy Sterling has developed our work with adolescents in pediatrics and in specialty alcohol and drug treatment, and she leads our dissemination work. Cynthia Campbell has added prescription opioids, drug abuse and organizational studies to our portfolio. Derek Satre has added studies on aging, HIV and comorbidity. I would like to see more of the research that we are conducting here move to other settings, such as Federally Qualified Health Centers, which we are starting to do. I would like to help convince policy-makers and health systems that addressing alcohol and drug problems earlier is a good and cost-effective approach. Also, we do not give our field enough credit for a lot of innovations that were developed in alcohol and drug treatment; for example, the self- and mutual-help approaches that are now being borrowed and adapted to other disease management programs. It is an exciting time. This is a period when many of the things that I have hoped would happen are happening, producing many new opportunities. When I think back on it, my career has been divided between the earlier ‘on the ground’ clinical work and later research, but with a continuity in the concepts that have guided my research. The people I am working with now also work closely with clinicians. We have found that many of the important issues to study come from those clinicians. I know that, as it expands, the research program will stay relevant to the needs of the people we care about. I feel very good about that—what more could someone ask of her career?

A

Finally, what advice would you give to a young researcher just beginning a career in addiction science?

CW

‘Staying power’ is important, and for that I think it is necessary to have a driving interest in a particular research agenda that can sustain one's interest over time. Also, although it is a difficult time to compete for research funding, a growing societal interest in the role of alcohol and drug problems and the increased receptivity of the health-care system also provide research opportunities. I think that the new generation of researchers needs to have a broader knowledge about the alcohol and drug field than we have had in the past, including at least a conversational knowledge of genetics, neurobiology, pharmacology and clinical and dissemination research, as well as an understanding of the treatment system. I know that is a tall order, but in the past everyone (including the training grant I directed) focused only on one of those areas. It is not possible to become an expert in multiple areas, but it is important to understand how one's research fits with the larger field and also with other health and psychiatric conditions. It will make one's own research more relevant. I would look for those kinds of collaborations—that is the direction in which the National Institutes of Health seem to be going, and I think it is a good one.

Note

The opinions expressed in this interview reflect the views of the interviewee and are not meant to represent the opinions or official positions of any institution or organization the interviewee serves or has served.

Ancillary