Group Motivational Interviewing (GMI) For Homeless Veterans In VA Services

Anticipated Impacts on Veterans Health Care:

VA set an ambitious goal for ending homelessness among Veterans by 2015. Housing Urban
Development-VA Support Housing [HUD-VASH] and Grant and per Diem [GPD] are two primary VA
housing programs to help Veterans exit homelessness. Substance abuse among Veterans in VA
housing is a major risk factor for worsening psychopathology and housing instability. Despite
recent adoption of a Housing First approach, many VA housing programs lack the staff
infrastructure to manage substance use disorders (SUDs). This is a significant problem as 60%
(conservative estimate) of Veterans in VA housing have SUDs and these Veterans show greater
psychopathology compared to their counterparts without SUDs. These issues warrant substantial
need for SUD programs in VA housing that are efficient to deploy, easily layered onto
existing services, and require minimal staff to operate. The current study addresses this
current void in VA treatment services in that it investigates the effectiveness,
implementation process, and cost estimate of treatment of an adaptation of motivational
interviewing, an empirically supported intervention with strong impact on reducing substance
use and enhancing treatment engagement, in a group format, referred to as Group Motivational
Interviewing (GMI) for Veterans with SUDs in VA housing. Data from this project, if shown to
be promising, will establish the basis of a GMI dissemination and implementation course of
action for highly vulnerable homeless Veterans in VA housing for achieving their greatest
success in attaining housing stability.

Background:

There is a significant need for 'wraparound' treatment services in VA housing for addressing
SUDs. Homeless Veterans with SUDs are vulnerable to treatment dropout, rendering them
susceptible to relapse, while their continuation in outpatient care during their
participation in VA housing leads to improved clinical outcomes. According to systematic
reviews, individual motivational interviewing reduces the incidence of substance use
disorders, when compared to no treatment, but is labor intensive. As VA moves toward a
'Housing First' paradigm where greater numbers of homeless Veterans will continue to use
substances while in VA housing, delivery of GMI (which may be less labor intensive) to these
patients will be important for initiating and maintaining their recovery as well as enhancing
their psychosocial integration and quality of life. In a prior controlled trial conducted by
the Principal Investigator, GMI resulted in significantly higher outpatient treatment
engagement and lower substance use compared to treatment-as-usual among dually diagnosed
Veterans.

Objectives:

Study objectives are consistent with VA housing recommendations focusing on patient recovery,
health services promotion, and treatment implementation evaluation. GMI will be compared to a
control treatment condition (CT) on (Specific Aim I; Five outcomes: (Primary Hypothesis 1):
treatment engagement; (Primary Hypothesis 1): substance use; (Secondary H2): psychosocial
integration (e.g., social support, community participation); (Secondary H3) quality of
life/psychiatric indices; and (Secondary H4): number of days engaging in
structured/productive work activities in the 6-month follow up. Specific Aim II involves a
process evaluation for documenting (A) formative (e.g., developmental), (B) process, and (C)
summative outcomes; and Specific Aim III involves estimation of cost of intervention in terms
of direct costs, indirect costs of staff, costs of capital and workload measures for future
implementation and dissemination research.

Methods:

Randomized controlled trial comparing GMI to control treatment (CT) across five critical
outcomes. 186 Veterans in VA housing services (93 per treatment arm) will be enrolled with a
diagnosis of alcohol or drug abuse/dependence. Recruitment will take place in Charleston VA
Medical Center HUD-VASH & GPD. Participants will be randomly assigned to (1) GMI or (2) CT,
each consisting of 4 sessions, and will be evaluated at 1, 3, and 6 months. Participants with
a non-substance related DSM-V disorder (e.g., major depressive disorder, PTSD) will be
eligible for the study. Analyses will be conducted using generalized linear mixed models
(GLMM) approach.

Significance to Veterans:

Homeless Veterans with SUDs represent one of the largest and most chronic groups of
psychiatric patients treated in the VA Healthcare System. With the ongoing execution of VA's
"Plan to End Veteran Homelessness," Veterans entering housing require interventions that can
be feasibly implemented with minimal reorganization of existing services. GMI is based on
motivational interviewing, an empirically valid treatment that aligns with Veteran-centered
recovery models including Harm Reduction and more traditional treatment philosophies. The
investment in GMI for VA housing may be minimal as it requires only a few staff to operate in
relatively short time (e.g., 4 sessions, 90-min each) with modest (20 hours) staff training.
It can be layered onto existing services with little interruption or reorganization of staff,
and it has potential to be offered to larger numbers of Veterans with SUDs in VA housing who
would otherwise not receive this intervention.

Inclusion Criteria:

- Men and women Veterans currently in Housing Urban Development-VA Support Housing
[HUD-VASH] and Grant and per Diem [GPD]), newly entering the program but not yet
housed, or Veterans on the HUD-VASH interest (wait) list.

- Able to comprehend English.

- Meets DSM-V criteria for a current substance use disorder and have used substances in
the 30 days prior to treatment entry. Participants on medications targeting their
substance use must be stabilized on medications for at least 2 weeks before therapy
initiation.

- May meet criteria a mood, anxiety or other psychiatric disorder. Participants on
maintenance medications for a mood or anxiety disorder must be stabilized on
medications for at least 2 weeks before therapy initiation.

- Able to adequately provide informed consent and function at an intellectual level
sufficient to allow accurate completion of all assessment instruments.

- Willing to commit to 4 group therapy sessions, baseline, 1, 3, and 6 month follow-up
assessments.

Exclusion Criteria:

- Active suicidal or homicidal ideation with a plan as this is likely to require
hospitalization or other interventions that could interfere with study participation.

- Unstable psychiatric condition that is likely to require hospitalization or other
interventions that would interfere with study participation.

- Unstable medical condition or one that may require hospitalization during the course
of the study.