Journal of Substance Abuse Treatment 34 (2008) 25–35

Special article Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders

Carlo C. DiClemente, (Ph.D.)a,4, Melissa Nidecker, (Ph.D.)a, Alan S. Bellack, (Ph.D.)b

aDepartment of Psychology, University of Maryland, Baltimore County, Baltimore, MD 21250, USA bVISN 5 Mental Illness, Research, Education, and Clinical Center and University of Maryland School of Medicine, Baltimore, MD, USA Received 7 August 2006; received in revised form 11 December 2006; accepted 16 December 2006

Abstract

A complicating factor affecting the treatment of individuals with coexisting substance use problems and serious mental illness is their motivation for change and how these interacting, chronic conditions affect the entire process of intentional change. This selective review explores conceptual and assessment issues related to readiness to modify substance use and readiness to initiate helpful for managing mental illness in the search for a better understanding of patient motivation for change. The recent but limited research on motivation and stages of change among dually diagnosed patients indicates that these individuals appear to access and use an intentional behavior change process. However, it is not completely clear how this process works and what precise adaptations are needed to assess and to access motivation to change to encourage sustained behavior change in this population. Nevertheless, motivation and readiness to change are important dimensions that need to be addressed in treatment and research with dually diagnosed populations. D 2008 Elsevier Inc. All rights reserved.

Keywords: Motivation; Stages of change; Serious mental illness; Readiness for change; Co-occurring disorders; Substance abuse

1. Introduction either or both of these disorders is often characterized by a lack of therapeutic engagement, problematic motivation for Substance misuse by individuals with a chronic and change, and relapse after some initial successful change serious mental illness (SMI) such as schizophrenia or bipolar (Blanchard, 2000; DiClemente, 2003; McGovern, Wrisley, disorder is a pervasive problem with studies showing that & Drake, 2005; Mueser, Drake, Turner, & McGovern, 2006; nearly 50% of all persons with SMI have met the criteria for Oncken & Blaine, 1990). a substance use disorder (SUD) in their lifetime (Barry, Multiple problems always complicate behavior change Fleming, & Greenley, 1995; Kessler et al., 1997; Mueser, and necessitate complex and integrated treatment planning Yarnold, & Bellack, 1992). Substance abuse and depend- (DiClemente, 2003; McLellan, Lewis, O’Brien, & Kleber, ence in persons with SMI are especially detrimental because 2000). Individuals with two or more diagnosable psychiatric of the complex interactions between the two problems and conditions are often differentially motivated with regard to the impact on treatment engagement and outcomes. For the two conditions. They may simply comply with services example, nonadherence with medication, symptom exacer- while hospitalized to resolve some acute problem only to bation, rehospitalization, poor social adjustment, and worse avoid all treatment once discharged (Brady et al., 1996). prognosis are a few of the adverse consequences associated However, the more severe the mental illness and the with dually diagnosed patients (Drake, Mueser, Clark, & substance abuse problems are, the more dysfunctional Wallach, 1996). Moreover, treatment of individuals with thought processes, impaired decision-making skills, and the lack of insight diminish the ability to recognize the need for treatment as well as the individuals’ ability to seek and 4 Corresponding author. Department of Psychology, University of Maryland, Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250, participate in it (Center for Substance Abuse Treatment USA. Tel.: +1 410 455 2415; fax: +1 410 455 1005. [CSAT], 2005; Substance Abuse and E-mail address: [email protected] (C.C. DiClemente). Services Administration, 1995). Motivating these individu-

0740-5472/08/$ – see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2006.12.034 26 C.C. DiClemente et al. / Journal of Substance Abuse Treatment 34 (2008) 25–35 als and engaging them in the process of behavior change are These multiple motivational tasks and the broader particularly challenging and not well understood. phenomenon of intentional behavior change have been Although motivation and readiness to change among described as the Stages of Change in the TTM of change substance-abusing individuals have been examined rather developed by Prochaska and DiClemente (1984). Preaction extensively over the past 20 years (Miller, 1985, 2006; stages focus on the tasks needed to prepare for taking action Prochaska, DiClemente, & Norcross, 1992; Simpson & Joe, including creating concern, goals, intentions, plans, and 1993), motivation and readiness to change among individ- commitment for engaging in a specific behavior change. uals with SMI and SUD have just recently begun to be They include precontemplation, contemplation, and prepa- explored (Carey, Maisto, Carey, & Purnine, 2001; Zeidonis ration stages. Action-oriented stages focus on implementing & Trudeau, 1997; Zhang, Harmon, Werkner, & McCormick, the actual behavior change (quitting cocaine use, taking 2004). Whether motivational considerations and indicators medication as prescribed) and include one stage that is of readiness to change that are important dimensions of related to behavior initiation (action) and one related to change among substance-abusing individuals can also be sustaining that change over time (maintenance). Stage- useful and applicable in a population of individuals with specific tasks need to be accomplished well enough to SMI and substance abuse disorders is an important question support forward movement toward the successful establish- that needs to be answered. ment of new behavior, and often, individuals need to recycle This review describes conceptual and practical consid- through the stages multiple times to accomplish this erations regarding motivation for change among the more (DiClemente, 2003, 2005). The tasks of each of the stages severely disabled of the dually diagnosed individuals, play an important role in what has been described as selectively reviews the growing number of studies exam- motivation to change a behavior. ining applications and challenges related to assessing and What does it take to move through these stages and intervening on patient motivation, and concludes with accomplish the stage tasks? The activities and experiences recommendations for incorporating motivational dimen- that help individuals complete the tasks of the stages and sions into research and treatment of individuals with co- progress through the stages are referred to as Processes of occurring disorders to enhance engagement, adherence, Change. These processes are viewed as the benginesQ that and behavior change. Although any combination of help individuals complete the tasks of each stage and substance use and mental illness complicates change, we include both cognitive/experiential types of activities (i.e., willfocusonissuesandstudieswithrelevancefor consciousness raising, self reevaluation, environmental individuals with SMI. In this article, substance abuse reevaluation, emotional arousal) and also behavioral activ- disorders will include both abuse and dependence because ities and strategies (i.e., self-liberation, , individuals with SMI often have patterns of drug use that, counter conditioning, , and help- although disruptive and problematic, do not meet strict ing relationships). These processes are relevant to the tasks criteria for dependence. Recognizing that there are multiple in different stages and are needed to create the conditions other perspectives on motivation and behavior change, we necessary (a) to meet the task goals of each of the stages, (b) will use constructs and considerations from the Trans- to move through the entire process of change, and, theoretical Model (TTM) of intentional behavior change ultimately, (c) to achieve behavior change outcomes and Motivational Interviewing (MI) to explore how (DiClemente, 2003; Prochaska et al., 1992). In both cross- motivation interacts with treatment and behavior change sectional and longitudinal studies, significant relationships (DiClemente, 2003; Miller & Rollnick, 2002). among stages and processes of change have been found with a variety of addictive behaviors indicating a consistent and orderly relationship among individuals representing differ- 2. Defining motivation and readiness for change ent motivational stages (DiClemente & Hughes, 1990; DiClemente & Prochaska, 1998; DiClemente et al., 1991). Motivation refers to a central mechanism or constellation Although the labels of the processes are derived from of mechanisms that lie at the heart of why and how people theories of , the activities and experiences are change addictive and health behaviors. Being motivated to familiar and used by both natural changers and those who perform a behavior is critical to an individual’s performance attend treatment (DiClemente, 2006). and whether or not a successful outcome is achieved (Bandura, 1986; Miller, 1985). Although there are different 2.1. Relevance of motivation and the process of change to theories about motivation (Miller, 1985, 2006), the concept substance abuse and mental illness broadly includes an individual’s concerns about or interest in the need for change, his or her goals and intentions, the Among substance-abusing individuals, motivation and need to take responsibility and make a commitment to intentions related to the modification of the addictive change, and sustaining the behavior change and having behavior play an important role in the recovery process. adequate incentives for change (DiClemente, Schlundt, & Findings from numerous studies demonstrate a positive Gemmell, 2004; Miller & Rollnick, 2002; Vuchinich, 1999). relationship between motivation for treatment and motiva- C.C. DiClemente et al. / Journal of Substance Abuse Treatment 34 (2008) 25–35 27 tion for change, assessed in multiple ways, and substance Ziedonis, Krejci, & Brandon, 2004). In a pilot study, Daley, abuse treatment outcomes (DeLeon, Melnick, Kressel, & Salloum, Zuckoff, Kirisce, and Thase (1998) found a Jainchill, 1994; Simpson & Joe, 1993). Motivation to motivational-intervention-increased attendance and engage- change substance abuse behavior has been associated with ment and decreased rehospitalization among patients with treatment engagement, quit attempts, reduction of alcohol depressive disorders and cocaine dependence. consumption, treatment retention in cocaine users, sustained abstinence, and better treatment outcomes among individ- 2.2. Understanding the process of change with co-occurring uals diagnosed with alcohol and cocaine dependence disorders (Carbonari & DiClemente, 2000; CSAT, 1999; DiClemente et al., 1991; Joe, Simpson, & Broome, 1998; Project Despite the importance of motivation and indications of MATCH Research Group, 1997; Pantalon, Nich, Frank- its relevance for treatment among substance-abusing indi- forter, & Carroll, 2002; Stotts, Schmitz, Rhoades, & viduals and individuals with SMI, how motivation and the Grabowski, 2001). process of change work with dually diagnosed individuals is Motivational enhancement interventions have often still in question. Motivation, according to the TTM produced improved outcomes compared with control perspective, requires individuals to engage in enough conditions in a range of alcohol- and drug-abusing patients cognitive/experiential activities to move through early (Bien, Miller, & Tonigan, 1993; Miller & Rollnick, 2002; stages and to engage in behavioral activities to initiate and Stotts et al., 2001). Carroll and colleagues (2006),ina sustain the change. This is an arduous and rather cognitively large, recent, multisite effectiveness study, found that complex process. Although studies have demonstrated that integrating MI techniques into intake procedures increased the dimensions of the TTM appear to be relevant for retention but not short-term drug use outcomes. However, changes in substance use among subgroups of smokers, brief motivational interventions prior to treatment have not drinkers, and illicit drug users, as well as with various health always improved treatment engagement and outcomes in behaviors, there are questions and concerns about how the populations of drug-abusing individuals who are poor, process of intentional behavior change and these variables minority, and less educated with multiple problems operate in those with SMI and those with co-occurring (Donovan, Rosengren, Downey, Cox, & Sloan, 2001; disorders (Bellack & DiClemente, 1999; Muesser et al., Miller, Yahne & Tonigan, 2003). 2006). The questions include whether these dually diag- As is true for most medical and mental health problems, nosed individuals can access the intentional process of motivation is also considered an important dimension in the change and make use of decision making, intentionality, treatment of SMI. Adherence to medication regimens, commitment, planning, and experiential and behavioral engagement and participation in medical and psychosocial processes of change when they make changes in their treatments, and use of recommended remediation coping substance-abusing or adherence behaviors. Other questions strategies are problematic for many individuals and even concern whether, or rather how extensively, any cognitive more challenging for those with SMI conditions. Moreover, impairment among individuals with SMI interferes with problems with adherence in psychiatric treatment are making decisions or undermines accurate self-evaluations exacerbated by the presence of substance abuse disorders (e.g., self-efficacy and ability to plan). Many people with and significant problems in other areas of functioning SMI have cognitive impairments that interfere with the (Drake, Brunette, Mueser, & Green, 2005; Mueser et al., ability to develop and sustain a focus on reasonable goals. 2006). Adherence to medical treatments requires an under- Similarly, the neurobiological aspects of illness frequently standing of the adherence burden, specification of the impact on motivation (e.g., avolition) and drive (e.g., behavior change targets, and appreciation of the process of anergia). Some professionals have indicated that the change. Engaging patient motivation is an integral part of behavior change process among individuals with SMI and resolving the adherence problems (DiClemente, Ferentz, & those with co-occurring disorders may be more driven by Velasquez, 2004). external considerations or reinforcers, seems less inten- Similar to the findings in substance abuse, motivational tional, and appears more chaotic than the process among techniques based on MI principles have been viewed as individuals without these problems (Bellack & DiClemente, promising in a systematic literature review of interventions 1999). Finally, there also are concerns about whether we can for improving medication adherence and as superior to more accurately assess motivation for change in dually diagnosed traditional psychoeducational approaches (Zygmunt, Olf- individuals, as well as whether the construct of motivation son, Boyer, & Mechanic, 2002). Swanson, Pantalon, and operates in the same manner as it does with substance- Cohen (1999) found that adding MI techniques to initial abusing individuals who do not have a co-occurring SMI. assessment increased the proportion of patients attending Similar questions have arisen about MI, which was outpatient appointments overall and for a dually diagnosed developed as a set of brief intervention strategies geared to group of patients. Others have found that MI and engaging individuals in earlier stages of change in the type of personalized feedback increased tobacco treatment engage- cognitive and experiential activities that would promote ment and attendance for individuals with SMI (Steinberg, preparedness for change and accomplishment of preaction 28 C.C. DiClemente et al. / Journal of Substance Abuse Treatment 34 (2008) 25–35 stage of change tasks (Connors, Donovan, & DiClemente, sive measures of motivation, like the University of Rhode 2001; Miller & Rollnick, 2002). In his review of the MI Island Change Assessment (URICA) and the Stage of intervention literature, Heather (2005) argues that motivation Change, Readiness, and Treatment Eagerness Scale (SOC- is not all that clients need and that there may be differences in RATES), have been used most often with alcohol- and drug- the adequacy and effectiveness of these motivational abusing individuals because they are sensitive to various techniques depending on the severity of substance depend- types of attitudes and intentions and less vulnerable to social ence and the presence of co-occurring disorders. desirability or simple denial of a problem. However, these types of measures are lengthy, complex, and rely on self- report. The general concern that individuals with SMI 3. Measuring motivation and the change process in cannot accurately evaluate motivation is heightened when co-occurring populations cognitive and complex measures are used.

Any questions regarding the role of motivation in co- 3.1. Evidence of validity and utility of motivational occurring populations can only be addressed if we are able measures to measure motivation accurately and validly. Because individuals with SMI and drug use disorders are disadvan- Several studies have used various measures to assess taged in social and cognitive areas, assessing motivation and motivation to modify substance use and found initial its role in behavior change is a challenge. For instance, we support for their validity and utility, with some exceptions. know that the cognitive impairments that individuals with Velasquez, Carbonari, and DiClemente (1999) assessed the schizophrenia (without SUD) possess make it difficult for central constructs in the process of change model among them to benefit from rehabilitation programs (Bellack, Gold, alcohol-dependent individuals with major depressive dis- & Buchanan, 1999; Silverstein, Schenkel, Valone, & order, schizophrenia, or bipolar disorder. They found Nuernberger, 1998). There have been questions as to acceptable internal consistency (a coefficients) for the whether those same cognitive impairments (e.g., perception, decisional balance scales (i.e., pros, a = .90; cons, a = .91) attention, memory, and reasoning deficits) and the psychotic and for the URICA overall readiness to change score (a = symptoms that can accompany schizophrenia impact the .91). Psychiatric severity was predictive of increases in way these individuals go about changing their drug use reported temptation to drink and of reduced incidences of behavior. The ability to accurately self-report intentions to behavioral coping. In addition, higher scores on psychiatric change a behavior may be compromised by the problems in distress were related to the endorsement of greater self-awareness and abstract thinking that often accompany importance on the bconsQ (i.e., negative aspects) of an SMI. Even if motivational capacities are intact and drinking alcohol and greater endorsement of items in the operational, there is a question as to whether motivation to URICA Maintenance Striving scale, suggesting that they change can be accurately measured in a dually diagnosed were engaging in a struggle to maintain sobriety. Overall, population using readiness-to-change assessments that are the way participants answered change measures regarding used with populations of substance-abusing individuals their drinking problem was similar to patterns found in without SMI (Carey, Purnine, Maisto, Carey, & Barnes, samples of people with alcohol problems who did not have 1999; Project MATCH Research Group, 1997, 1998). In a co-occurring SMI. addition, the negative symptoms associated with schizo- Another study examined decision making using an phrenia could make readiness-to-change measures difficult alcohol decisional balance measure in a sample of individ- to use because these individuals may be unable to exert the uals dually diagnosed with schizophrenia and alcohol abuse thought and effort required to validly complete these and also found similarities between this sample and samples instruments (Carey et al., 2001). Further, many people with of substance-abusing populations without SMI. Hagedorn SMI have problems reading and comprehending the types of (2000) specifically investigated the use of the alcohol abstract questions found on many motivation measures. decisional balance scale (DBS) and added items specific Although a number of studies have looked at the to individuals with SMI (e.g., medication effectiveness, usefulness of readiness-to-change scales among substance- hospitalizations) to determine whether this population abusing populations (Carey et al., 1999), evidence for the considered different pros and cons when changing their utility of one or more of these measures among dually drinking as compared with alcohol-abusing individuals diagnosed patients is supportive but currently limited. There without SMI. Results showed that although there were are many ways to evaluate motivation and assess the stage some unique considerations, the essentials of the decision- status of patients entering treatments. These tools range making measure were similar in relationship and structure to from a readiness ruler (e.g., on a scale of 1 to 10, how ready measures that have been used with substance-abusing are you to change this behavior [quit , stop using samples without SMI (DiClemente, 2003; Hagedorn, 2000). illegal drugs]?), to a series of questions that can be used as A more recent study (DiClemente, Nidecker, & Bellack, an algorithm to assign stage, to more complex multiple- unpublished manuscript) investigated five TTM measures subscale measures (DiClemente et al., 2004). More exten- that have been found to be reliable and valid in populations C.C. DiClemente et al. / Journal of Substance Abuse Treatment 34 (2008) 25–35 29 with SUD and evaluated them for their psychometric retesting and appropriate for populations with SMI who properties with a sample of 241 psychiatric outpatients. may have limited cognitive resources, although it is more Participants met Diagnostic and Statistical Manual of vulnerable to desirability and dissimulation. Similarly, a Mental Disorders, Fourth Edition (DSM-IV) criteria for single-item rating scale, such as the one used in studies of either a schizophrenia spectrum disorder or a nonpsychotic smoking (Abrams, Herzog, Emmons, & Linnan, 2000; affective disorder, along with criteria for either cocaine Biener & Abrams, 1991) and gambling (Pietrzak & Petry, dependence or remission. The measures used to assess stage 2005), may be appropriate to use when assessing and processes of change were shortened versions of motivation to change among people with co-occurring originals and focused on illicit drug use. All measures were disorders. These rating scales typically ask how ready a designed to be read on a sixth-grade reading level and were person is to change this behavior (using illegal drugs, read aloud to participants to ease comprehension of the drinking, smoking, etc.), on a 10-point Likert scale. They scales. Specific TTM measures used were the URICA to are short, easy to understand, and convenient for use and assess readiness to change, the DBS to evaluate perceived have been found to relate to other measures of stage status. pros and cons of cocaine use, the Processes of Change scale Clark, Wells, Peterson, Jackson, and Stanton (2006) and to identify behavioral and cognitive change processes, and Wells, Calsyn, Clark, and Jackson (1998) moved beyond the the Temptation to Use and Abstinence Self-efficacy scales purely verbal self-report and developed a cartoon stage to measure temptation to use and confidence to abstain from assessment to be used with individuals with reading or cocaine use. Each measure was found to have good cognitive deficits. It includes a series of four-panel cartoons reliability and validity within the total sample. When the depicting different attitudes or intentions about using group with schizophrenia and the group with affective substances. The scale includes pictures of a character disorder were analyzed separately, all measures except for (neutral in gender and ethnicity) participating in either illicit the URICA remained psychometrically sound. The URICA drug use behaviors or abstaining behaviors. The subject’s showed some problematic stability in the group with task is simply to indicate whether each panel is like them affective disorder, perhaps due to specific cognitive limi- now or not like them now and which one is most like them. tations common with this diagnosis (e.g., difficulty concen- There are three cartoons for each of the four stages of trating, making decisions). However, the data from patients change, permitting calculation of stage of change scores and with schizophrenia paralleled findings on the various a continuous readiness to change score analogous to the change variables for modifying cocaine abuse in other URICA. Several recently completed studies have used both drug-abusing patients both in terms of the psychometric the more extensive URICA and the cartoon assessment. properties and the expected pattern of relationships across Kinnaman, Bellack, Brown, and Yang (in press) compared the remitted and dependent subgroups. Although their the Wells instrument and the URICA in a large sample of neurocognitive deficits may interfere with some higher people with schizophrenia who met DSM-IV criteria for order cognitive functions and modulate the intentional current cocaine dependence or dependence in remission. change process, this study suggests that patients with The two instruments were positively but only modestly schizophrenia appear to be accessing and using this process correlated (r = .25) on the overall readiness scores. In this in their efforts to modify cocaine use. study, the cartoon measure was more highly related to Some studies have employed simpler assessment tools current drug use and treatment participation than the in an attempt to measure motivation more efficiently. For URICA. The URICA did not prove to be highly valid in example, the short, five-question algorithm often used to this study despite the fact that it was simplified to make it assess readiness to change among smokers (DiClemente et more comprehensible and less abstract for subjects. Sim- al., 2004) is rarely used to examine those with SMI trying ilarly, Bellack, Bennett, Gearon, Brown, and Yang (2006) to change their drug use behavior. However, one study explored URICA scores in a treatment effectiveness trial for showed that this brief algorithm was a reliable measure of patients with drug dependence and SMI and did not find that stage of change regarding substance abuse among individ- baseline scores were highly predictive of treatment partic- uals with schizophrenia, major depression, or bipolar ipation, attrition, or outcomes. In the study previously disorder (Carey, Purnine, Maisto, Carey, & Barnes, described, which compared cocaine-dependent and remitted 2002). There was demonstrated reliability with 75% individuals with schizophrenia or affective disorders, the agreement between endorsed stages over a 1-week period. two measures (URICA and cartoon assessment) were also Another study using the stages of change algorithm modestly correlated (r = .19), with the cartoon assessment examined the motivation for of smokers more related to action markers like temptation and with schizophrenia or schizoaffective disorder, demonstrat- abstinence efficacy and the URICA more related to ing similar proportions in precontemplation, contemplation, preaction stage variables like the cons of drinking. and preparation stages of change as in the general Finally, it may be difficult to obtain consensus on stage population, with a similar percentage making a quit status between provider and patient assessments. Adding- attempt in the past year (Etter, Mohr, Garin, & Etter, ton, el-Guebaly, Duchak, and Hodgins (1999) investigated 2004). The brevity of the algorithm makes it useful for readiness-to-change measures among 39 substance-abusing 30 C.C. DiClemente et al. / Journal of Substance Abuse Treatment 34 (2008) 25–35 individuals with schizophrenia. There was little correspond- Other investigators have examined relationships between ence between subject’s stage of change (as defined by the stages and processes of change throughout the course of clinician and chart data along with an algorithm) and stage treatment in individuals with co-occurring disorders. Finnell defined by two measures: the SOCRATES (Miller & (2003) found differences in some TTM dimensions between Tonigan, 1996) and the Readiness to Change Questionnaire people with coexisting SMI and drug use disorders in (Rollnick, Heather, Gold, & Hall, 1992). However, the small comparison to other drug-abusing populations. Specifically, sample size and questionable stage assignments used in this dually diagnosed individuals appeared to be using more study make the findings difficult to interpret. behavioral processes in the action stage and more experi- In summary, although sometimes difficult to measure in ential than behavioral processes in maintenance, in contrast the co-occurring populations, research to date has demon- to other populations where experiential processes are more strated that motivation (a) can be measured with a variety highly endorsed in earlier stages (i.e., contemplation and of instruments, (b) seems to relate to other process of preparation) and where behavioral processes are endorsed in change measures in a similar way as it does with later stages (i.e., action and maintenance; DiClemente, et al., substance-abusing individuals who are not dually diag- 1991). She speculated that this difference may be a result of nosed, and (c) measures a patient characteristic that seems the need to continue to use cognitive/experiential processes related to engagement in change. However, current studies when symptoms heighten even after they reach sobriety. are limited and inadequate to determine a single optimal However, there have been some studies that found measure. The support for the internal validity of the unexpected relationships between motivation and treatment measures is stronger than the support for the external attendance. Pantalon and Swanson (2003) found that dually validity. In particular, there are conflicting data about the diagnosed individuals with high motivational readiness to utility of more complex measures. Future studies should change as measured by a URICA readiness composite score consider using more brief and simple means of assessing attended fewer clinic appointments than those with low readiness and motivation to change, as well as more motivational readiness. However, this sample included extensive ones to determine which type of measures has individuals with a variety of diagnoses, and participants greater utility in the dually diagnosed population. Assess- were not limited to a single problem in responding to the ment of motivation should also consider the level of motivation measure; therefore, they could be responding to impairment and the goals of the clinician or researcher. the psychiatric disorder, the substance use problem, or both. In another study looking at dually diagnosed individuals 3.2. How motivation affects change and treatment with with schizophrenia and SUDs, higher rates of seeking dually diagnosed individuals treatment were associated with low motivation based on a five-item bstage of change algorithmQ (Zeidonis & Trudeau, In addition to the psychometric evaluations of the 1997). As indicated above, Bellack et al. (2006) found that measures of motivation, a number of studies have examined motivation to change at baseline did not appear to predict how motivation interacts with endorsement of various either attendance or survival in treatment. These findings process measures identified in the TTM and markers of contradict what we would normally expect the impact of change like decision making and self-efficacy, as well as motivation on treatment adherence to be, and it is not clear treatment engagement and outcomes in patients with co- whether these findings are related to problematic assess- occurring substance abuse and psychological disorders. In a ment or represent findings that indicate that motivation number of studies, greater motivation is associated with operates differently. positive indicators of change. Carey et al. (1999) found that dually diagnosed individuals with high motivational read- 3.3. Multiple behavior change targets complicate assessing iness to change substance use reported more cons and fewer and managing patient motivation benefits to using substances, reported more substance abuse problems, took more steps toward changing their behavior, Motivation and the change process are behavior specific. and used substances less than individuals who had lower Therefore, it is critical to be clear about the specific motivational readiness to change. Likewise, Ries and behavior change being considered or sought. Understand- Ellingson (1990) demonstrated that dually diagnosed ing what would constitute action in the action stage is individuals with high motivation had a higher rate of drug critical. Is it taking medication daily, reducing drinking, abstinence when compared to those with low motivation. stopping cocaine use, or no longer sharing needles? For Finally, a study examining 390 individuals with co- example, substance users can be motivated to reduce the occurring alcohol abuse problems and SMI also found that amount of consumption (e.g., reduce alcohol intake) or to motivation, measured by the SOCRATES (Miller & abstain completely (e.g., alcohol abstinence). Individuals Tonigan, 1996), predicted future alcohol use. Specifically, can be motivated to comply with one of a provider’s the more ambivalent patients were about their alcohol use, suggested actions (e.g., taking medications) but not with the more alcohol they consumed at a 9-month follow-up another (e.g., attending group). Motivation to change one (Zhang et al., 2004). behavior does not necessarily imply motivation to change a C.C. DiClemente et al. / Journal of Substance Abuse Treatment 34 (2008) 25–35 31 second even if both are substances of abuse. For example, problems. Although clinicians have recognized this inter- when alcohol-dependent individuals quit drinking, they action for a long time, understanding how multiple often do not quit smoking. Heroin-addicted individuals may problems interfere with motivation and the process of stop the opiate addiction but do not necessarily stop changing behaviors can increase our ability to understand drinking, smoking, or using other drugs such as marijuana. and intervene with multiple behavior change targets. It is critical to understand motivation in terms of the It is also possible to assess multiple problem areas specific behavior that is the target of change and to separately to determine motivation to change in individuals understand that there may be many different behaviors that with co-occurring disorders. For example, a study that individuals need and/or want to change (DiClemente, 2003; compared 132 individuals with both a psychiatric and Heesch, Velasquez, & von Sternberg, 2005; King, Marcus, alcohol disorder on the URICA-Alcohol and a separate Pinto, Emmons, & Abrams, 1996). Readiness for Mental Health Treatment measure found that Individuals motivated to go on methadone are not these patients did indeed have separate levels of motivation necessarily motivated to quit drinking or stop smoking for mental heath and alcohol abuse treatment (Heesch et al., (Haug, Svikis, & DiClemente, 2004; Stotts, Schmitz, & 2005). Motivation for change and motivation for treatment Grabowski, 2003). As Brady et al. (1996) noted, assuming are not identical even for problematic drinking (Freyer et al., that a person with multiple problems is in a single stage of 2005). Identifying the motivational level for each problem change for each problem is presumptuous and often behavior, varying levels of goals, and determining whether erroneous. One criticism of the URICA is that the bproblemQ the motivation is for change or for seeking help in tailoring Q referred to in the measure is not specified. For instance, in interventions to specific patient needs. a study by Pantalon et al. (2002), participants with coexisting cocaine and alcohol problems completed the URICA based on their motivation to change both behaviors. 4. Integrating motivation into adherence and treatment Although the URICA was found to be useful for this programs population, the results may have been stronger if both addictions were considered separately in terms of motiva- Most of the innovative and integrative treatments for the tion and the change processes. Thus, it is not surprising, and dually diagnosed population contain motivational enhance- may even be normative, that a client can be at two different ment components like MI strategies and the use of stages simultaneously in regard to his or her SUD and behavioral strategies that increase engagement and adher- mental illness. Viewing these two client problems as ence (Barrowclough, et al., 2001; Bellack et al., 2006; separate but having parallel treatment needs and under- Carey, 1996; Martino, Carroll, Kostas, Perkins, & Rounsa- standing that both are undergoing their own process of ville, 2002). This integrative approach is mirrored in the change are crucial in the effective treatment of dually efforts of researchers and clinicians to combine treatment diagnosed patients (Brady et al., 1996; DiClemente, 2003). approaches and strategies by blending motivational, cogni- In addition to the two central problems identified by the tive–behavioral, and family-based psychosocial approaches term dual diagnosis, these patients often have multiple other with pharmacotherapy (Miller, 2004; Zeidonis et al., 2005). problems. The entire process of change and progressing A few researchers are beginning to use approaches tailored through the stages for any single, specific behavior can be to participants’ stage of change and motivations for drug use helped or hindered by the presence of associated difficulties and are finding some success (James et al., 2004). and disorders. Contextual problems often surround and MI and current cognitive–behavioral approaches are complicate an attempt to change any behavior (DiClemente, more patient centered and begin with patient engagement 2003; McLellan et al., 2000). Motivation for changing by on their concerns. These approaches emphasize substance abuse behavior waxes and wanes when problems collaborative that recognizes harm reduction in one of the contextual areas (e.g., living situation, and small steps in reaching larger goals. The style and depression, relationship problems) arise. Contextual prob- substance of the patient–provider interaction include recog- lems may exist in the areas of problematic beliefs and nition of personal concerns, values and considerations, lack attitudes, troubled interpersonal relationships, complications of confrontation and excessive pressure, creating personal- in various social systems (legal, employment), and intra- ized planning, finding and providing reinforcers that can personal conflicts and deficits (DiClemente, 2003; McLellan support the accomplishment of the various tasks of the et al., 2000; Prochaska & DiClemente, 1984; Ziedonis et al., treatment stages of change, providing structure and con- 2005). Multiple problems complicate completion of change structive monitoring of the goals and behaviors, and tasks for any single target problem or proposed change. The building skills that are needed to complete the tasks of argument for integrated treatment, aggressive case manage- change. Although there are still too few studies that examine ment, and offering multiple resources simultaneously in and support each of these components to make any firm treating individuals with multiple problems should be as conclusions, there is growing support and consensus for the much about motivation and completing the stage tasks for combination of approaches and the need for integrating the target behaviors as it is about resolving additional treatments (Mueser, Noordsy, Drake, & Fox. 2003) and for 32 C.C. DiClemente et al. / Journal of Substance Abuse Treatment 34 (2008) 25–35 incorporating motivation enhancement as a part of the benefit from outpatient treatment or needs residential care package (Carey, Carey, Maisto, & Purnine, 2002; Drake should not simply be a decision related to the severity of the et al., 2001; Martino, Carroll, Nich, & Rounsaville, 2006). problems or to the setting where the patient is first seen; it should be related to the motivation of that individual with 4.1. Implications for treatment of co-occurring disorders regard to the various problems as well. Individuals in the precontemplation stage for a cocaine abuse problem, who The challenge of motivation and change in the popula- are trying to adhere to medication for schizophrenia, may tion of individuals with co-occurring disorders offers an need some structured residential support and a respite from opportunity (a) to evaluate practitioner beliefs and assump- the streets to stabilize medication adherence and work on tions, (b) to incorporate motivation more completely into motivational tasks related to the cocaine use. Similarly, integrated treatment and decisions about level of care, (c) to individuals in the preparation stage for changing drug use determine level of support needed to promote change, and but in the precontemplation stage for medication compliance (d) to consider more proactive approaches to the treatment for their bipolar condition need assistance to understand the of co-occurring disorders. Although we have focused on co- benefits of medication adherence as part of their plan to stop occurring disorders in individuals with SMI, these consid- using drugs. The change processes as well as the problems erations appear to be as relevant for individuals with non- related to the two conditions interact. SMI conditions as well because the interactions between Amount of structure and use of behavioral reinforcement substance abuse and less severe mental illness can be as also vary depending on the level of motivation and stage problematic and interactive. Although the severity of mental status of the individual. For example, less motivated illness may appear less in individuals without SMI, individuals might benefit more from a structured behavioral substance use and mental illness may be more closely program that provides clear subgoals and rewards partic- connected in terms of self-medication; thus, interactions ipation and engagement. This type of program might be less with motivation can be as complex. important for individuals with more motivation and skills, Many mental health and substance abuse providers have who are further along in the change process either for views about motivation and the dually diagnosed population managing the mental illness or for modifying substance that can interfere with coherent and integrated treatment. abuse behavior. Reinforcements can and have been used Each type of provider underestimates, at times, the capacity successfully in and influencing certain behaviors of these individuals to engage in an intentional change related to treatment attendance and adherence, as well as in process or respond to motivational and cognitive–behavioral assisting to promote behavior changes that can influence the strategies. Often, they resort to medication regimens that are change process (Bellack et al., 2006). Accepting partial or poorly monitored and where adherence is inconsistent. In harm reduction goals while promoting more stable and addition, they use weak forms of education and social complete solutions for recovery can also provide incentives support to manage substance abuse problems and mental to promote change. Mandated treatment also offers an illness. Because both of these disorders tend to be chronic, interesting challenge for incorporating motivation in these and relapse can be complicated by multiple contextual treatments and offers an opportunity to engage an otherwise problems, there is significant discouragement that can fuel elusive patient by shifting motivation from more extrinsic dropout on the part of the patient and burnout on the part of considerations to more intrinsic ones (DiClemente, 2003). the provider. Motivational considerations are central to the Similar issues arise with the use of contingency manage- problem and to the solution. ment in drug abuse treatment where the challenge is to Although there is a growing recognition of the need for engage natural, intrinsic motivation as the contingencies are multidimensional treatment to address both SMI and SUD, phased out. Integrating motivational and behavioral as well as a push for integrated treatment to combat the approaches is an exciting new area for research and negative interactions among the multiple, simultaneously programmatic development. presenting problems, there is still an incomplete under- Clearly, less motivated individuals need more proactive standing of the implications of these conditions on and intense interventions. Case managers have to be more motivation and the process of change. However, it is clear active to prevent less motivated individuals with SMI and that motivation related to either problem area will signifi- SUD from falling through the cracks in the mental health cantly impact engagement, participation, adherence, and care system. There are some very innovative proactive outcomes of patients in either mental health or substance programs reaching out to homeless, drug-abusing individ- abuse settings. In both settings, motivation should be an uals with SMI where treatment providers go onto the streets important part of treatment planning and case management and begin discussions on behavior change using MI to maximize effectiveness and efficiency of treatment principles (Fisk, Rakfeldt, & McCormack, 2006). Although recommendations. Clearly understanding the motivational not always controlled trials, the engagement of some of dimensions for both problems is critical because the these clients into treatment and movement into stable appropriate level of care cannot be well ascertained without housing supports the notion of being proactive in engaging some consideration of motivation. Whether someone can the less motivated patients. C.C. DiClemente et al. / Journal of Substance Abuse Treatment 34 (2008) 25–35 33

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