Preface to Motivational Groups for Community Substance Abuse Programs

This guide is a substantive revision of one we developed in 1997 entitled Motivational Enhancement Groups for the Virginia Substance Abuse Treatment Outcome Evaluation (SATOE) Model: Theoretical Background and Clinical Guidelines. That manual was developed to provide a structure for delivering motivational enhancement interventions in a group format in public sector substance abuse treatment programs in Virginia. It was also developed to be evaluated for its efficacy as one part of the Virginia Substance Abuse Treatment Outcome Evaluation Model, more commonly known in our state as the SATOE model. At that time, the manual was the result of a unique collaboration between a university-based group, the Virginia Addiction Technology Transfer Center (VATTC) of Virginia Commonwealth University, and a working group from the public sector's substance abuse services system convened by the Commonwealth's Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS). We had consulted with that group to help guide implementation of motivational counseling services in public sector community agencies across Virginia. We discovered that many of these programs did not have the resources to provide individual counseling services to their substance abuse clients, not even in a brief format. Thus, we agreed to develop a guide to help the programs "meet somewhere in the middle" between a substance abuse education group format already offered at many of the settings, and the MI individual counseling approach with which we were familiar. Our goal was to help bridge the gap between research and treatment and to make practical information regarding "state-of-the-art" treatment available to counselors in the field.

After DMHMRSAS disseminated the "SATOE Manual," as we called it, we continued to conduct training events and provide consultation on motivational counseling. Through that work, we came to realize that our earlier manual could be usefully expanded to include discussion about implementing and integrating motivational groups in community based agencies. Staff of programs across the state requested we revise our guide to more thoroughly address the "nuts and bolts" of implementing motivational services, especially in the group treatment modality that is prevalent in these community programs. We have attempted to meet those requests in this revised guide. It is our intent that this will remain an evolving document that will benefit from further revisions and additions as the field's experience grows.

We have a few concerns about motivational groups and our guide that we wish to mention. As clinical psychologists, we believe in promoting approaches that have been empirically demonstrated to be effective with their target populations and problems. A model of development of treatment approaches that is considered by many scientists to be ideal is as follows: treatment methods are developed in a structured research setting, examined for their efficacy, then later transferred outside of the controlled environment and examined again in the "real world" of non-controlled community practice to determine if they retain their effectiveness. Only after this research has been done and positive results have been obtained is the new clinical intervention recommended for broader use by others, who presumably will also evaluate the new methods for effectiveness in their own settings. This "ideal" academic/scientific model has some drawbacks, however. The primary problem is the lack of efficiency in the process, which may take several years to complete (or, during which, researchers may "move on" to developing other new methods and the "transfer" to the world of community practice may be neglected altogether). In the meantime, clients must still be served with some approach. Our internal struggle was this: if we wrote a guide for the field that was not thoroughly evaluated by the scientific process outlined above, we would take the risk that the suggested methods might not be effective and the guide would thus potentially promulgate ineffective methods. On the other hand, if we waited for the science to establish that motivational counseling groups could be effective, and in the meantime refrain from writing the guide, we would take the risk of withholding a document that might prove beneficial to practitioners in their efforts to help individuals suffering from disruptive and often destructive substance-related problems. Because most comparative clinical intervention studies have shown relative equality of well-performed but differing clinical interventions, it seems reasonable to believe that the approach described is likely at least as effective as other unresearched group approaches currently used in the field.

In weighing the potential risks and benefits, we decided to write this motivational group implementation guide despite the lack of convincing evidence of its effectiveness at this time. Until the time that we have group methods that demonstrate both efficacy and effectiveness, we believe that our approach of encouraging and assisting talented clinicians to adapt methods from promising approaches is more likely to benefit the field than harm it. In the meantime, we and others will pursue scientific validation for motivational group approaches. A few comparative studies have been done on similar approaches with positive results (Baer et al., 1992; Sobell et al., 1995; Sobell and Sobell, 1995, 1998), suggesting that this general approach may result in reductions in drinking and drug use. A closely-related approach (Sobell et al., 1995; Sobell and Sobell, 1995), compared favorably to individual interventions, maintained positive outcomes at the 1-year follow-up point, demonstrated good group cohesiveness, and provided significant cost-savings over an individualized treatment approach. Although we do not claim to be able to transfer these positive findings to the approach we present here, these results are encouraging. We have conducted a preliminary study of a four-session version of our group motivational approach. In that pre-post study, individuals with dependence on heroin and cocaine who participated in the 4 session motivational waiting group at a community agency reliably progressed from lower to higher readiness for change on the URICA (Wagner et al., 1998) and reported satisfaction with the group support, the opportunity to express their current thoughts about their substance using patterns without criticism and the counselors' caring and positive approach.

In any case, we recommend that agencies attempt to evaluate the effectiveness of any interventions used, even if the evaluations can only be done on a limited sample of the total clientele served.