Table 3.

Barriers to MRT sustainment

Theme	Sample quotation
Lack of referrals	[VJO] wanted to collaborate with us in the substance abuse treatment program to offer this service to Veterans. But the VJOs are rarely at the hospital to co-facilitate a group. And so the plan that we had to partner with them fell through. So that was how we had hoped to get referrals to the group…We needed folks who were court involved or had recent history of being involved with the courts. And we didn’t get those referrals. [Site ID: 101–Non-adopter] VJO was heavily encouraged by MRT, but not something that was mandated. We didn’t get too many referrals from them, so I would have to say that the receptiveness was there, but the referrals weren’t. [site ID: 206–adopter] I felt supportive in going to the training, but when I came back and I needed to get clients into the group I was not being supported. I didn’t get one referral. I could implement it if I had support from the residential unit; then there would be enough people. [Site ID: 202–Adopter]
Conflicts with in-person attendance	Some of our Veterans don’t drive, so transportation may have been an issue. [Site ID: 206–Adopter] I think transportation is [a barrier]. I am in a very rural area. I can’t get enough people to do a group. I will be able to get one person in the group, but then they’re going to have to drive two hours to the VA to attend a two hour group and drive home two hours. They’re rural, and they’re poor, and they don’t have vehicles, so it gets really hard. [Site ID: 202–Adopter] I had opened it up to outpatient. The scheduling was difficult. There’s so many groups going on here, so trying to find a group time. Sometimes we’d find Veterans that were appropriate, but had conflicting appointments. [Site ID: 208–Adopter]
Low patient engagement	Those few that we got to get the group going were already kind of motivated individuals. We were trained as if [MRT] was held in jail [and] they had a captive audience that they knew would be there and would have to participate. So trying to change it for an outpatient setting with volunteers was kind of tough…. [Site ID: 208–Adopter] I didn’t have anybody being mandated to be there…When you have that type of external motivation for the person to be there it seems to work better. [A veteran who was referred] never showed back up because there was nothing other than just his own motivation driving him because there was nothing external whatsoever other than just being recommended. [Site ID: 209–Adopter]
Insufficient staffing	It probably would have been better to train somebody who’s actually on the main campus, who has access to the substance abuse clinic, or the clinics where they have readily available Veterans there…the girl that was doing it got moved to a different position. So it just dissipated right there. [Site ID: 201–Adopter] I tried to get our SUD coordinator involved a little bit and that didn’t really work well…there’s really not a lot of help. I realized that it was going to be up to me to do this. Everybody’s stretched pretty thin already. I was trying to get somebody else trained right here, so we could have two of us, and it never happened. [Site ID: 209–Adopter] Our VJO had very limited staff. Two social workers from our VJO were at the training also…they were overwhelmed with work already. They couldn’t really add this on to their plate…they did not have time to co-facilitate the group so the model that we had planned could not be implemented. [Site ID: 101–Non-adopter]