When Christina Lee, PhD, a licensed psychologist, joined BUSSW as an associate professor in 2019, she brought with her a clear expertise in intervention science, addiction psychology, and health disparities research.
As the first director of the Research Core at BUSSW’s Center for Innovation in Social Work and Health, she continues her pioneering work on immigrant health and the reduction of risky behaviors by tailoring evidence-based interventions that advance the science of treating substance use disorders and improve mental health outcomes for culturally diverse populations.
Learn more about the arc of her research in the Q&A below:
Q: What prompted the path you’ve taken with your recent research?
When I started this work nearly 2 decades ago, “health disparities” was not a commonly used term and the value of adapting treatment to meet the needs and priorities of diverse groups was doubted. But, as a post-doctoral fellow, I was not satisfied with the status quo. I had to know if standardized treatment protocols were helpful for different populations, particularly those from marginalized and oppressed backgrounds.
From the beginning, I believed that our clients were influenced by their social and cultural contexts. While this was widely accepted in social work, it is less common in other disciplines. Recent work on assessing structural determinants of health in medical settings and the revised SAMHSA definition of culture that includes experiences of immigration and discrimination are consistent with my foundational assumption.
My early qualitative work demonstrated that the stress involved in immigration and acculturation could lead to unhealthy alcohol and drug use. For example, drinking heavily and alone to relieve missed social bonds and experiences, or in response to a harsh discriminatory experience, was a common behavior among my clients.
Q: How have you utilized motivational interviewing?
Motivational interviewing (MI) is a client-centered and directive style of counseling with roots in humanistic psychology and cognitive behavioral theory developed by Dr. William Miller to help people who use substances to address ambivalence about change. As a MI trainer, I fully appreciate its underutilized potential to reach marginalized groups who may be mistrustful or uncomfortable around health care providers or “authorities.” Working with my research team, I developed a version of MI that capitalized on this potential. My central hypothesis was that identifying, and then discussing, sensitive events where clients experienced discrimination or shame that prompted drinking, might help to disrupt the stress/heavy drinking association.
Results from the first clinical trial demonstrated that a version of MI which addressed social stressors had positive effects. Heavy drinkers who reported high levels of discrimination reported significantly fewer problems with alcohol if they received our intervention, compared to those who received a more basic MI approach that did not address personal experiences of discrimination and intolerance. Clients also reported significant reductions in anxiety and depressive symptoms up to one year after a single one-on-one session which lasted an hour and fifteen minutes.
Q: Does racism affect health behaviors?
I’ll never forget when I played a tape from this clinical trial for an audience of health care providers (white) and community health workers (Latinx and Black) at a community health center. A client talked about drinking in response to being discriminated against. I was surprised to hear a white clinician say that “something else must have happened to tip that person towards drinking.” The Black and Latinxs community health workers (CHW) replied, almost in unison, “No, that is ENOUGH.” These CHWs began sharing how frequently their sons were stopped by the police; so frequently that one would open his backpack every day on his walk home as though he was expecting this routine procedure.
I am hopeful that our work might alleviate the pernicious effects of racism on health by decreasing alcohol use. In 2019, the National Institutes of Health (NIH) invited me to give a talk at the meeting of the American Society of Addiction Medicine (“Problem Drinking among Medically Underserved Women”). At the conclusion of my talk, an attendee who identified herself as a medical doctor raised her hand and asked, “Dr. Lee, should we be asking about discrimination as part of our health care?” The answer is yes. Racism and discrimination add other sources of stigma to marginalized populations already burdened with so many societal misconceptions and negative attitudes.
Q: How have you determined which aspects of your research have been most effective and where do you go next?
In another study, I explored why this first trial of culturally adapted MI had such positive effects by searching for the active ingredients. I’m proud to have gathered several strong Spanish–speaking therapists and community leaders (Liliana Torres-Bonilla, East Boston Neighborhood Health Center at South End; Zulma Montanez-Liriaño, Lawrence Family Development; Victor Figuereo, Boston Medical Center) to join me in this investigation by listening to the clinical tapes from the original trial and dissecting the intervention using a newly devised coding system our team has developed.
The next step in this process is how to optimize MI treatment in the real world. In another NIH- funded project, in collaboration with UCLA, I trained CHWs from two community health centers in Los Angeles on how to use this optimized MI intervention. In this bilingual study, as clients respond well, I believe it is because we are optimizing MI in a way that helps people become more open to hearing health information.
One client said he stopped drinking when he learned that drinking reduced the effectiveness of his HIV medication. Another said she went from drinking 2 bottles of wine to “one cup,” after “being heard” when she related her experiences as a first-generation college student and her struggle to be a perfect parental caretaker in a family that emphasized traditional gender roles.
The National Institutes of Alcohol Use and Addiction (NIAAA) recently awarded a $3.3 million dollar grant to Boston University (2020-2025) so that we can continue this work. This hybrid-implementation study aims to reduce alcohol-related health harms among Latinx individuals who use substances. It is a five-year collaboration between the Center for Innovation in Social Work and Health (CISWH) and Boston Medical Center (BMC).
Q: How does your work illustrate the intersection of social work and health innovation?
We are grateful for the support CISWH can provide with this new grant since it highlights the crucial connection between social work and community health workers by examining the roles and contributions of social work faculty who train CHWs – tying into the Center’s mission to conduct work that is anti-racist in spirit.
The goal of the study is to test interventions that can be offered widely in primary care settings and to examine the cost effectiveness of doing so. We know that reducing consequences and use is just the start. I am interested in how interventions can address the lasting difficulties of immigration as a social determinant of health. This is a new direction for me and there are few satisfactory models to follow. I’m grateful to be at a school of social work where people are accustomed to making public policy that serves as an intervention and acknowledges the importance of structural determinants and systematic racism on health outcomes. I learn something new every day from my colleagues in this academic community.
Q: What are you looking forward to next?
I’ve learned so much from our study participants and the community health workers who have generously shared their lives with us. Recently, I was able to share my last study results with the participants and thank them through digital ads in El Planeta, (Boston’s Latino daily news site) that linked to the study’s results. I admire the resilience in our study participants, but it’s critical to note that policies are needed to support the health of Latinxs who contribute to our society and to their home countries. These family bonds motivate them. We are hoping to augment these bonds as we continue our work. We want to promote awareness of how discrimination and racism really do harm health and help minimize health inequities by reversing racism.
Read more here.