Motivation to Quit Using Substances Among Individuals With Schizophrenia: Implications for a Motivation-Based Treatment Model

Transcription

1 Motivatio to Quit Usig Substaces Amog Idividuals With Schizophreia: Implicatios for a Motivatio-Based Treatmet Model by Douglas M. Ziedois ad Kimberlee Trudeau Abstract Although the motivatio to quit usig substaces is a importat progostic ad treatmet-matchig factor i substace abuse treatmet, there is limited iformatio o motivatio to quit amog idividuals with schizophreia. This study used the five-stages-ofchage model to evaluate the motivatioal levels of 497 idividuals with schizophreia or schizoaffective disorder i a outpatiet metal health cliic. Rates of substace abuse, motivatio levels to quit each specific substace, ad correlates to motivatioal levels were evaluated. At least oe substace use disorder was diagosed i 224 of the subjects (45%); however, there was sigificat variability amog the caseloads of the outpatiet divisio teams. The patiets i the triage/acute services ad commuity outreach teams had substace abuse rates of about 70 percet. Most subjects had low motivatio to quit substaces, ad the rates varied accordig to substace (rage of 41% for opiates to 60% for cocaie). Treatmet-matchig strategies are suggested i the motivatio-based treatmet model. Schizophreia Bulleti, 2(2):229-28,1997. Motivatio is a importat progostic ad treatmetmatchig factor i substace abuse treatmet (Stere ad Pittma 1965; Karoly 1980; Miller 1985; Ziedois ad Fisher 1996); however, there is limited iformatio about the motivatio to quit usig substaces amog idividuals with schizophreia (Ries ad Elligso 1990). Specific dual-diagosis treatmet approaches may be more effective whe matched to the eeds of the idividual patiet, icludig the patiet's level of motivatio. Low motivatio is ofte the explaatio for poor outcomes i treatmet, icludig the lack of egagemet i treatmet or reductio i substace usage. Substace abuse treatmet programs use actio-orieted treatmet approaches ad stress a abstiece model. The less motivated patiets i metal health settigs ofte have difficulty egagig i the substace abuse compoet of dual-diagosis treatmet whe cliicias iitially use the actio-orieted treatmet approaches. As i primary medical cliics, patiets with substace use problems seek treatmet i the metal health treatmet settig for o-substace-use problems (i.e., headache or abdomial discomfort) ad do ot wat to quit alcohol use or stop smokig. Patiets eed to be egaged i substace abuse treatmet if it is to be successful. This study aimed to determie the rates of substace abuse ad motivatioal levels to quit each substace i patiets i a outpatiet settig of a urba commuity metal health ceter. Awareess of a patiet's motivatioal level ca help cliicias develop more realistic treatmet goals ad use appropriate treatmet techiques. Kowledge of the rates of motivatioal levels could also help i treatmet service system plaig ad prioritizig. The motivatio-based treatmet (MBT) model matches treatmet to patiets based o their motivatioal levels. Previous research has foud that the five substaces most commoly used by idividuals with schizophreia are caffeie, icotie, alcohol, marijuaa, ad cocaie. The Epidemiological Catchmet Area (ECA) study reported lifetime substace abuse to be 47 percet (Regier et al. 1990), ad cliical settigs report curret substace abuse i the 25 to 75 percet rage (Scheier ad Siris 1987; Miller et al. 1994). The highest rates of dual diagosis are reported i emergecy room, triage, ipatiet, ad outreach teams (Galater et al. 1988; Dixo et al. 1991; Selzer ad Liebema 199). Substace abuse has a dramatic impact o the course of schizophreia (Fischer et al. 1975; Mueser et al. 1990; Sevy et al. 1990; Ziedois et al. 1994), ad udiagosed ad utreated substace Reprit requests should be set to Dr. D.M. Ziedois, Coecticut Metal Health Ceter, Substace Abuse Ceter, 4 Park St., New Have, CT

2 Schizophreia Bulleti, Vol. 2, No. 2, 1997 D.M. Ziedois ad K. Trudeau abuse seems to worse further the course of the psychiatric illess (Hall et al. 1977; Aath et al. 1989). Models of motivatio characterize motivatio either as a state or as a trait Accordig to the trait model, cliets are resposible for their ow level of motivatio, ad umotivated cliets fail i treatmet. If cliets do ot express motivatio, the they are ot tryig hard eough. Furthermore, the trait model implies that the therapist is isigificat to the treatmet process. Rather, treatmet relies o the motivatio (i.e., distress, compliace, ad depedece) of sick ad eedy cliets (Miller 1985). I cotrast, i the state-based model of motivatio, motivatio is perceived as fluctuatig. Idividuals shift betwee motivatioal stages ad ca relapse durig ay stage ad retur to ay motivatioal stage. Therefore, cliicias must reassess motivatio routiely to employ stage-appropriate therapeutic techiques i treatmet. I additio, patiets may have differet levels of motivatio to stop each type of substace. For example, some idividuals may egage i treatmet to stop their cocaie use; however, they do ot recogize their alcohol abuse ad are ot iterested i abstaiig from this substace. Because of the opportuity for early detectio i a metal health cliic, may of these cliets are ofte ot yet motivated to quit; they are therefore difficult to egage i treatmet ad become revolvig-door cliets. The rates of motivatio to quit usig substaces have implicatios for cliical program developmet ad ew ways to coceptualize ad match psychotherapies ad pharmacotherapies. From cliical program evaluatios ad cliical experiece, a set of priciples for dual-diagosis treatmet is developig; however, there have bee few radomized cliical trials to test their efficacy. This study evaluated the motivatio to quit usig substaces accordig to the five-stage model of chage of Prochaska ad DiClemete (198). This model characterizes motivatio as a state. Based o the fidigs i this article, our cliical experiece, ad the eed to help cliicias orgaize treatmet plaig, the MBT model was developed. The MBT model ecourages cliicias to develop realistic ad appropriate treatmet goals that cosider the severity of the patiet's disorder, his or her motivatioal level, ad the type(s) of substace abused. The model also helps orgaize traiig of metal health staff about addictio ad dual diagosis as it focuses o the addictio problem ad how to itegrate substace abuse treatmet techiques ito metal health treatmet. The MBT model has bee applied withi the Coecticut Metal Health Ceter (CMHC) ad the Metal Health Network of South Cetral Coecticut (Ziedois ad Fisher 1996). Methods Data were collected for this survey study i the Outpatiet Divisio of the CMHC from Jauary through March Durig this period, 77 cliicias provided treatmet for approximately 1,400 chroic metally ill outpatiets (about 50% with a psychotic disorder) at the CMHC. The Survey. The survey icluded iformatio o the cliet's psychiatric disorders, substace use, motivatioal level to quit each substace, ad ivolvemet i substace abuse or dual-diagosis treatmet. It was limited i that urie toxicology testig was ot icluded i the assessmet. I fact, the survey revealed that oly 15 percet of all the outpatiets had a urie toxicology scree durig the previous year. Psychiatric ad substace use disorders were determied by the cliicia's assessmet ad chart review usig DSM-HI-R criteria (America Psychiatric Associatio 1987). Motivatioal levels were assessed usig the five-stage "readiess to chage" scale described by Prochaska ad DiClemete (198). The five stages are precotemplatio, cotemplatio, preparatio, actio, ad maiteace. I the precotemplatio stage, the idividual is cotiuig to use the substace, is ot iterested i discotiuig use durig the ext 6 moths, ad deies or miimizes that associated problems are related to substace use. I the cotemplatio stage, the idividual cotiues to use the substace but recogizes that cotiued use is a problem ad expresses a iterest to quit usig the substace sometime durig the ext 6 moths. However, he or she is very ambivalet about quittig use of the substace. I the preparatio stage, the idividual cotiues to use the substace but is ow iterested i makig a commitmet to stop usig durig the ext 0 days ad would beefit from developig a actio pla. The idividual may have eve made a radom ad usuccessful effort to quit usig. I the actio stage, the idividual is actively attemptig to quit usig the substace ad is ready to participate i treatmet. I the maiteace stage, the idividual has bee abstiet for more tha moths but less tha 5 years, ad addictio is still part of his or her idetified metal health treatmet issues (Prochaska et al. 1992). A five-questio "stage of chage algorithm" was used as a guide to determie the idividual's motivatioal stage (Rossi et al. 199; Prochaska et al. 1994). The algorithm was adapted to assess motivatio for quittig each specific substace ad ot whether there was a commitmet to quit all mood-alterig substaces. The questios i this algorithm iclude whether cliets are curretly usig a substace, whether they thik cotiued use is a problem, 20

3 Motivatio to Quit Usig Substaces Schizophreia Bulleti, Vol. 2, No. 2, 1997 what their persoal treatmet goal is (cotrolled use, temporary abstiece, or permaet abstiece), ad whe they pla to quit usig the substace (withi the ext 0 days or 6 moths). The rates of substace use ad motivatioal levels were assessed for 497 idividuals with diagoses of schizophreia or schizoaffective disorder. The primary metal health cliicias facilitated the collectio of the survey iformatio o their ow patiets. The subjects' demographic data were obtaied from the geeral maagemet iformatio system at the CMHC. Data Aalysis. The major outcome variables i this cross-sectioal survey study were the presece of specific substace use disorders (alcohol, cocaie, marijuaa, ad/or opiate abuse/depedece, icludig cliets i the maiteace stage) ad the motivatioal level for quittig each specific substace (precotemplatio, cotemplatio, preparatio, actio, ad maiteace). Two ew variables were created: dual diagosis ad high/low motivatioal level. A patiet with at least oe substace use disorder (alcohol, cocaie, marijuaa, or opiates) was categorized as havig a "dual diagosis." Patiets with low motivatio were i the precotemplatio ad cotemplatio stages, ad those with high motivatio were i the stages of preparatio, actio, ad maiteace. Several descriptive aalyses were udertake to determie substace abuse ad motivatioal level rates. We assessed the associatio of demographic variables geder, marital status (married vs. ot married), educatio (high school graduate vs. less tha high school graduate), race (white vs. owhite), ad age ad cliical variables (psychiatric diagosis, curret treatmet settig, ad curret participatio i substace use or dual-diagosis treatmet) with the categories of dual diagosis ad high/low motivatioal level. The dually diagosed cliets were divided ito groups of treatmet seekers or otreatmet seekers o the basis of their erollmet i ay type of substace use treatmet. Categorical variables were compared for sigificat differeces by usig the chi-square test statistic, ad cotiuous variables were compared usig the /-test statistic. We performed multiple logistic regressio aalyses to evaluate the associatios betwee high/low motivatio ad the demographic ad cliical variables. Subjects. The study icluded 497 subjects diagosed with either schizophreia (6.6%) or schizoaffective disorder (6.4%) at the CMHC Outpatiet Cliic. Fifty-oe percet were male, 57 percet were white, 94 percet were ot married, 60 percet did ot graduate from high school, ad the mea age was 44 years. These subjects received care i three distict outpatiet settigs ad teams: triage/acute services, commuity outreach teams, ad cotiuous treatmet outpatiet teams. Results Substace Use Disorder Rates. I the sample of 497 patiets, 224 subjects (45%) were dually diagosed with at least oe substace use disorder. Amog the dually diagosed patiets, 79 percet had a alcohol use disorder, 46 percet a cocaie use disorder, 2 percet a marijuaa use disorder, ad 8 percet a opiate use disorder. Patters of polysubstace abuse with cocaie, alcohol, ad marijuaa were determied (see table 1). As expected, dual-diagosis rates varied accordig to treatmet settig withi the outpatiet divisio. The rates of substace use disorders were higher amog cliets seekig treatmet i the triage/acute services (85%) ad the commuity outreach settigs (70%) compared with the cotiuous treatmet outpatiet teams (41%). Most patiets i the higher-acuity settigs of triage ad outreach were polydrug abusers. Chi-square aalyses revealed that sigificatly fewer cliets receivig cotiuous treatmet abused alcohol, marijuaa, cocaie, or opiates (all p < 0.05) tha cliets receivig the higher-acuity services. There were sigificatly more cliets with the combiatio of alcohol ad cocaie addictio i the higher-acuity settigs tha i the cotiuous treatmet teams (p < 0.05; see table 2). Motivatioal Levels to Quit Usig Substaces. Rates of motivatioal levels varied accordig to specific sub- Table 1. Patters of polysubstace abuse amog the dually diagosed ( = 224) patiets at the Coecticut Metal Health Ceter Type of abuse Ay substace abuse Ay alcohol Ay marijuaa Ay cocaie Ay heroi Alcohol oly Marijuaa oly Cocaie oly Other substace oly Alcohol ad cocaie Cocaie ad marijuaa Marijuaa ad alcohol Alcohol, marijuaa, ad cocaie %

4 Schizophreia Bulleti, Vol. 2, No. 2, 1997 D.M. Ziedois ad K. Trudcau Table 2. Substace use by types of treatmet ( = 497) Ay substace abuse Total Ay alcohol Ay marijuaa Ay cocaie Ay heroi Patters of substace abuse Alcohol oly Marijuaa oly Cocaie oly Alcohol ad cocaie Cocaie ad marijuaa Marijuaa ad alcohol Marijuaa, alcohol, ad cocaie Note. Other substace oly ( - ). 'p<0.05. Triage 4%, i = (85) (60) (25) (50) (15) (0) (5) (15) (18) (6) (0) (15) Outreach 9%, = (70) (44) (26) (58) (5) 0) (0) (21) (20) (7) () (19) Outpatiet departmet 87%, r1 = (41) (4) (1) (16) () (18) d) (4) (6) (1) (6) (5) Total 100%, = (45) (6) (14) (21) () (17) (1) (6) (7) (1) (5) (7) staces (see table ), with highest rates reported i the precotemplatio ad maiteace levels, the two extremes of high ad low motivatio. I the maiteace level, the cliet ackowledges the substace abuse problem ad reports abstiece for at least moths. Abstiece was ot verified by toxicology testig. For this study aalysis, the motivatioal levels were categorized as low/high motivatioal levels, ad the majority of patiets abusig each type of substace except opiates were i the low-motivatio category (see table 4). The percetage of patiets at the low-motivatioal level (precotemplatio ad cotemplatio stages) varied accordig to the substace of abuse: alcohol (48%), cocaie (60%), marijuaa (51%), ad opiates (41%). Cliets with dual-substace use had sigificatly low motivatio to quit usig both substaces (p < 0.05). Of ote, early twice as may cliets with a alcohol use disorder were at the maiteace level tha those with a cocaie use disorder. Sociodemographic Factors. The sociodemographic factors of sex, age, marital status, race, ad educatio level were compared accordig to dual-diagosis status (see table 5). Males ad owhites were more likely to be dually diagosed tha odually diagosed (p < 0.05). Accordig to chi-square aalyses, there were o sigificat differeces betwee the high versus low motivatio categories accordig to geder, marital status, or educatio. However, differeces were foud accordig to race ad age. Cliets older tha 40 years of age were less motivated to quit usig alcohol (p < 0.05) ad marijuaa (p < Table. Levels of motivatio to quit usig each substace Motivatio stage Precotemplatio Cotemplatio Preparatio Actio Maiteace Alcohol (=178) 82 (46) 4 (2) 11 (6) 6 () 75 (42) Marijuaai ( = 71) 6 (51) 0 (0) 7 (10) 4 (6) 24 (4) Table 4. Motivatioal levels 1or dually diagosed patiets ( = 224) Substace Alcohol ( = 194) Marijuaa ( = 106) Cocaie ( = 121) Opiates ( = 17) Cocaie ( = :10) High motivatioi (52) (49) (40) (59) (56) (4) (9) (5) (26) Opiates ( = 5 17) (41) (0) (24) (6) (0) Low motivatio (48) (51) (60) (41) 0.05) tha cliets youger tha age 40. Nowhite subjects were sigificatly less motivated tha white cliets to quit usig marijuaa (p < 0.05), cocaie (p < 0.05), ad opiates (Fisher's exact test, p < 0.05). Multivariate logistic regressio aalyses further assessed the associatio of low motivatio to quit each 22

5 Motivatio to Quit Usig Substaces Schizophreia Bulleti, Vol. 2, No. 2, 1997 Table 5. Demographics for total sample ( = 497) Demographic variable Male, % White, % Mea age, yrs Umarried, % Mea umber of grades completed 'p<0.05. Dually diagosed ( = 224) Not dually diagosed ( = 27) substace with the predictor demographic ad cliical variables. For alcohol, age cotiued to be a sigificat factor (p < 0.05), but race did ot. Male geder was sigificatly associated with owhite race. There were o sigificat associatios i the model for marijuaa. Low motivatio to quit cocaie use cotiued to be associated with race (p < 0.05; odds ratio of 2.9). Participatio i Substace Abuse/Dual-Diagosis Treatmet Despite their high level of substace use, oly 52 percet of the dually diagosed patiets were erolled i dual-diagosis/substace abuse treatmet ( = 117). The rate of erollmet of the dually diagosed ( = 224) cliets i the differet types of dual-diagosis/substace abuse treatmet were dual-diagosis group therapy (1%), dual-diagosis partial hospital programs (6%), idividual motivatioal ehacemet therapy (5%), Twelve-Step meetigs (15%), ad other dual diagosis treatmet (27%). Notreatmet seekers were sigificatly older tha treatmet seekers (p < 0.05, see table 6). Treatmet seekers ad otreatmet seekers also had sigificatly differet patters of use (see table 7). Cliets diagosed with a cocaie use disorder were more likely to be erolled i substace abuse treatmet tha to ot be i treatmet. We hypothesized that treatmet seekers would be more motivated to quit usig substaces tha those who did ot seek treatmet. However, chi-square aalyses comparig high/low motivatio categories ad treatmetseekig status disproved our hypothesis. I fact, the highmotivatio cliets were ot erolled i treatmet. A further aalysis revealed the reaso for this fidig: The majority of cliets i the maiteace level were ot ivolved i dual-diagosis treatmet. The percetage of the maiteace-level cliets i treatmet were 6 percet of those with abstiece from alcohol ( = 27), 50 percet from marijuaa ( = 12), 41 percet from cocaie ( = 11), ad 40 percet from heroi ( = 2). Iterestigly, treatmet-seekig polydig abusers were sigificatly less Table 6. Demographics for treatmet seekers ( = 117) versus otreatmet seekers ( = 107) Variable Male, % White, % Mea age, yrs Umarried, % Mea umber of grades completed V<u.O5. Treatmet seekers Notreatmet seekers Table 7. Patters of use of treatmet seekers ( = 117) versus otreatmet seekers ( = 107) Substace Ay alcohol (= 178) Ay marijuaa ( = 71) Ay cocaie (= 10) Alcohol oly ( = 86) Marijuaa oly ( = 7) Cocaie oly { = 0) Other substace oly ( = ) Alcohol ad cocaie ( = 4) Cocaie ad marijuaa ( = 6) Marijuaa ad alcohol ( = 25) Marijuaa, alcohol, ad cocaie ( = ) 1 p<0.05. Treatmet seekers (51) (59) (62) (44) (29) (70) (0) (47) (67) (52) (70) Notreatmet seekers (49) (41) (8) (56) (71) (0) (100) (5) () (48) (0) motivated to quit alcohol use tha otreatmet seekers (p < 0.05). Discussio High rates of substace abuse were foud i this sample, with 45 percet of the cliets havig at least oe substace use disorder. Polydrug abuse was commo. The rates of substace abuse varied accordig to specific outpatiet treatmet settig. The higher-acuity settigs (triage/acute services ad commuity outreach) had sigificatly higher rates of substace abuse (75%) tha the cotiuous treatmet teams. Our fidigs suggest that most cliets i a commuity metal health ceter outpatiet program have low motivatio to quit usig substaces. However, the rate of 2

6 Schizophreia Bulleti, Vol. 2, No. 2, 1997 D.M. Ziedois ad K. Trudeau low motivatio did vary accordig to the substace of abuse, the presece of polydrug abuse, ad the treatmet settig. Compared with cliets with alcohol use disorders, cliets with cocaie use disorders were more likely to be erolled i substace abuse/dual-diagosis treatmet, have lower motivatio to quit usig, ad have higher rates of polydrug abuse. These fidigs may reflect the higher probability of a cliicia's idetifyig cocaie use, associatig cocaie use with a cocaie use disorder, ad ecouragig substace use treatmet. I additio, eve mior cocaie use may result i serious legal, fiacial, ad psychiatric cosequeces. Court stipulatio for substace use treatmet was ot determied ad may accout for the icreased ivolvemet of cocaie users i treatmet, despite their lower level of motivatio to quit usig the substace. I additio, cliets with a alcohol use disorder were twice as likely to be i the maiteace level as those with a cocaie use disorder. The triage settig ad the outreach teams both attract cliets who have a high eed for treatmet, so the discovery that the cliets i these two treatmet settigs had high substace use rates was expected. Dual-diagosis cliets are a high percetage of the revolvig-door cliets who preset i the higher-acuity settigs. Age ad race seem to be sigificat predictor variables for low motivatio to quit usig cocaie. Other importat cliical or demographic variables, such as socioecoomic status, may egate these sigificat associatios ad reveal other potetial biases. Severity of psychiatric or substace abuse illess may be a importat cofactor. I additio, earlier detectio (ad therefore low motivatio) may be associated with specific patiet characteristics. Future studies should use structured motivatioal level istrumets ad urie toxicology assessmets to evaluate the motivatio to quit usig substaces i this populatio. The maiteace level might be further subcategorized accordig to the duratio of abstiece ad other quality of recovery characteristics. More research is eeded to determie how motivatio is best categorized ad evaluated for this populatio. The five-stages-ofchage model by Prochaska ad DiClemete (198) was used i this study; however, there has bee limited study of these stages or the stage algorithm i dually diagosed patiets. Aother simple 5-poit scale of curret motivatio for treatmet has bee assessed ad seems to predict the ability to become abstiet amog dually diagosed patiets (Ries ad Elligso 1990). Future surveys might evaluate cliical clues to assessig motivatio, such as the patiet's resposiveess to discuss substace use, the balace of the patiet's aalysis of the positive ad egative aspects of cotiued use, ad his or her follow-through o plas ad commitmets to quit usig (Ziedois ad Fisher 1996). Doig motivatioal assessmets may help cliets use self-motivatioal statemets as they gai a awareess of how their use affects themselves ad others. Icreased psychological awareess may be beeficial to their overall metal health ad stregthe their motivatio to stop usig substaces (Trudeau ad Reich 1995). Furthermore, a motivatioal assessmet ca help ucover sources of potetial exteral motivatio, such as potetial imprisomet or a aticipated loss of housig, fiacial support, employmet, family, or marriage. Exteral levers ca be helpful i elicitig ad maitaiig chage, icreasig iteral motivatio, ad achievig abstiece. Neuropsychological limitatios may be associated with low motivatio or the perceptio of low motivatio. Idividuals with schizophreia report difficulty focusig their attetio ad filterig out distractig ad irrelevat details. They also have trouble cocetratig o aspects of their eviromet or commuicatig with others. Substace use egatively affects the course of treatmet for idividuals with schizophreia, ad ew ways to evaluate ad treat cliets must be cosidered. About 50 percet of the idetified cliets were egaged i a substace abuse/dual-diagosis treatmet program. Cliets i the maiteace stage were less likely to be i a specific substace abuse/dual-diagosis treatmet program tha those i other stages. Cliical programs aimed at treatig the diversity of idividuals i the maiteace level should be evaluated, icludig peer support itervetios. Give the rage of motivatio to quit usig substaces amog cliets, the metal health cliicia ca beefit from a ew perspective o treatig the dually diagosed. Dual-Diagosis Treatmet Usig the MBT Model The MBT model was developed to help orgaize treatmet plaig ad develop realistic treatmet goals for differet motivatioal levels; for example, lower-motivated cliets have harm reductio goals, ad higher-motivated cliets have abstiece-orieted goals. The MBT model focuses o the addictio problem ad how to itegrate substace abuse treatmet techiques ito metal health treatmet. It uses the five motivatioal levels of Prochaska ad DiClemete (198) ad matches each level to specific aspects of motivatioal ehacemet therapy, dual-diagosis relapse prevetio, commuity reiforcemet approaches, modified Twelve-Step programs, the use of medicatio, ad other substace abuse or psychiatric 24

7 Motivatio to Quit Usig Substaces Schizophreia Bulleti, Vol. 2, No. 2, 1997 treatmet strategies, icludig ogoig assessmets, urie/breath toxicology moitorig, psychoeducatio, social skills traiig, vocatioal supports, family therapy, ad peer support couselig (Ziedois ad Fisher 1994). Medicatios. The cliet's motivatioal level iflueces the choice of pharmacotherapy strategy. Although the fudametal cocepts for the maagemet of schizophreia through medicatio retai their primacy, improvig the cliet's compliace with the prescribed medicatio regime is importat. Motivatioal ehacemet therapy strategies may play a useful role i improvig medicatio compliace. Cliets with low motivatio beefit from improvig their compliace with medicatio, thereby ehacig the effectiveess of their schizophreia treatmet. Two importat choices are depot euroleptic medicatio (i.e., haloperidol or flupheazie) or the atypical atipsychotics (i.e., clozapie or risperidol). Ijectable depot euroleptic medicatio is a uderused itervetio that ca guaratee medicatio compliace. It helps reduce the positive symptoms of schizophreia, icrease participatio i opharmacological itervetios, ad reduce rates of psychotic relapse ad rehospitalizatio (Glazer ad Kae 1992). Haloperidol decaoate has the advatages of lower risk of extrapyramidal side effects ad less frequet dosig (every 4 weeks vs. every 2 weeks) compared with flupheazie. The atypical atipsychotics may also play a importat role i treatig the low-motivatio dually diagosed cliet because they stabilize the schizophreia more effectively ad reduce the egative symptoms, which may have a importat etiological or maiteace role i substace abuse. For example, patiets may attempt to self-medicate their egative symptoms of schizophreia through the use of substaces. Buckley et al. (1994) foud substatial reductios i substace abuse at 6-moth followup i the dually diagosed patiets who were switched to clozapie. Similarly, two studies foud substatial reductios i icotie use amog schizophreia patiets who switched from traditioal euroleptics to clozapie (George et al. 1995; McEvoy et al. 1995a, 19956). More motivated cliets are prescribed medicatios that specifically target symptoms of substace use disorders, such as those associated with detoxificatio, cravig, protracted abstiece, ad withdrawal; i additio, some medicatios act as agoist maiteace agets. Ufortuately, there have bee limited pharmacotherapy trials for the substace-abusig idividual with schizophreia. Psychosocial Treatmets. Most psychosocial treatmet approaches focus o egagemet i treatmet, fidig exteral levers to icrease motivatio, case maagemet, ad bledig traditioal substace abuse psychotherapy approaches with metal health treatmet. The cliet's recovery ad rehabilitatio are facilitated by supportive ad optimistic cliicias (Davidso et al. 199; Drake et al. 199). The three primary substace abuse treatmet approaches that have bee itegrated ito dual-diagosis treatmet are motivatioal ehacemet therapy, relapse prevetio (cogitive-behavioral therapy), ad Twelve- Step recovery approaches.' Case Maagemet ad Outreach Ito the Commuity. Active outreach efforts ca help egage the least-motivated cliets ito treatmet. Drake ad colleagues (199) coordiated substace abuse services for dually diagosed patiets through cotiuous treatmet teams. These multidiscipliary outpatiet teams served as the primary cliicia for a small umber of cliets ad did extesive case maagemet i the commuity settig. Similar approaches have bee described as "assertive commuity treatmet teams" (Koedler 1979) ad "commuity cliet protectio systems" (Pepper ad Ryglewicz 1984). The use of motivatioal ehacemet therapy ad the commuity reiforcemet approach is beig evaluated i commuity outreach programs. Motivatioal Ehacemet Therapy Techiques. Motivatioal ehacemet therapy provides the cliicia with specific guidelies ad treatmet approaches that ca target specific motivatioal levels. Motivatioal ehacemet therapy attempts to build a cliet's motivatio for chage ad stregthe their commitmet to chage. The cliicia uses a empathic approach that ecourages the cliet's resposibility ad capability to chage his or her behavior. Therapy is a partership. Cliet characteristics that ifluece egagemet ito treatmet are the level of self-esteem, locus of cotrol, ad severity of eed for treatmet. Therapist characteristics that ifluece the therapeutic relatioship are the level of hostility, expectacy, ad empathy (Miller 1985; Miller ad Rollick 1991; Miller etal. 1992). The treatmet goals for low-motivatio cliets i the precotemplatio stage is to icrease their awareess of the impact of their substace use ad of the possibility of stoppig their use. Cliets may beefit from receivig 'These approaches are described i detail i the Natioal Istitute o Alcoholism ad Alcohol Abuse Project MATCH Motivatioal Ehacemet Therapy mauals that are available free of charge from the Natioal Clearighouse o Alcohol ad Drug Iformatio (NCADI, ). 25

8 Schizophreia Bulleti, Vol. 2, No. 2, 1997 D.M. Ziedois ad K. Trudeau iformatio ad feedback related to their substace abuse. The cliicia must be ope ad ojudgmetal while still beig realistic ad hoest. Ecouragig cliets whe they make self-motivatioal statemets is a importat motivatioal ehacemet therapy techique. Cliicias are ecouraged to refrai from providig advice, makig iterpretatios, or doig immediate problem solvig. Providig feedback o iformatio leared through the assessmet process or i a therapy sessio at the ed of the sessio ca be a effectively timed strategy. I the cotemplatio level, a useful motivatioal ehacemet therapy techique is to do a "decisioal balace" of the pros ad cos of cotiued substace use ad cessatio of use. The cliet discusses his or her ambivalece about quittig, ad the therapist helps tip the balace toward eterig treatmet ad becomig abstiet. The cliicia affirms that chage is difficult for everyoe, ad uses followup letters ad phoe calls i the egagemet process. The goal i the preparatio stage is to develop a chage pla that is acceptable, accessible, appropriate, ad effective. I the MBT model, the preparatio stage sigals the cliicia to shift emphasis from motivatioal ehacemet therapy to dual-diagosis relapse prevetio strategies. Commuity Reiforcemet Approach. A cliet's level of participatio i treatmet is iflueced by both iteral motivatio ad exteral motivators, such as the legal system, work, family, or cotrol of fiacial resources. The use of these levers ca facilitate a patiet's etry ito ad participatio i treatmet. The commuity reiforcemet approach is based o behavioral therapy priciples of cotigecies, ad liks urie testig ad other outcomes to cosequeces or rewards (ofte a voucher system). This behavioral approach uses exteral levers to chage behavior ad icrease iteral motivatio. The maagemet of disability icome provides a real-world mechaism to use the commuity reiforcemet approach. This approach ca iclude lifestyle couselig that focuses o recreatioal ad educatioal eeds ad social skills/assertiveess traiig (Sisso ad Azri 1989). Actio-Orieted Therapy: Dual-Diagosis Relapse Prevetio. The cliet i the actio stage is attemptig to quit usig the substace. I the early actio phase, the goal is to stay abstiet ad focus o curret problems. Motivatio ad commitmet to chage ofte icrease with icreased self-efficacy, which results from chagig of behaviors ad beig able to better maage or avoid triggers to use. Dual-diagosis relapse prevetio is a hybrid behavioral therapy approach that itegrates ad modifies substace abuse relapse prevetio therapy ad psychiatric social skills traiig. The social skills traiig focuses o problem-solvig ad commuicatio skills, maagemet of psychiatric symptoms, ad medicatio compliace. Dual-diagosis relapse prevetio uses the behavioral learig priciples of role playig, modelig, coachig, presetig positive ad egative feedback, ad assigig homework. Role playig helps address cogitive ad social skills deficits. The cotet of dual-diagosis relapse prevetio therapy sessios alterates betwee a emphasis o substace abuse ad a emphasis o psychiatric problems ad cosiders how each problem ca affect the other. Ogoig assessmet of psychiatric ad substace abuse status may ope a widow of opportuity to reiforce the patiet's awareess of the lik amog substace use, medicatio compliace, ad psychiatric symptoms. Cliets idetify triggers ad early warig sigs of abuse ad develop both geeral copig strategies ad specific skills to prevet relapse ad improve everyday fuctioig. Traditioal substace abuse relapse prevetio therapy is modified to address deficits i attetio spa, abstractio, ad social skills of idividuals with schizophreia (Ziedois 1992; Ziedois ad Fisher 1994). Maiteace Stage ad Recovery Approaches. Makig the trasitio from actio to maiteace ad the improvig core areas of oe's life ca be difficult. For the odually diagosed substace abuser, the maiteace stage has bee labeled "Stage II Recovery" (Larse 1985). The focus is o developig a recovery pla to address a broad rage of issues, especially limitig dysfuctioal relatioships ad icreasig healthy relatioships. Cliets attempt to pursue alterative highs, icludig employmet, better relatioships with sigificat others, ad other social outlets with ousers. This pursuit ca be more difficult for the idividual with schizophreia. Participatio i Twelve-Step recovery programs (Alcoholics Aoymous, Alao, etc.) is usually a importat aspect of treatmet for the odually diagosed substace abusers ad provides cliets a map through the higher motivatioal stages. Ufortuately, cliical experiece i referrig idividuals with schizophreia to Twelve-Step programs has bee mixed. The most effective use of such programs seems to occur whe the meetigs are held withi a metal health settig or a commuity settig that is ope ad receptive to idividuals with a metal illess. Itegratig Twelve-Step priciples ad ligo ito dual-diagosis treatmet ca be helpful, ad several attempts at modifyig those priciples for this populatio have bee suggested (Evas ad Sulliva 1990; Hazelde Foudatio 199). 26

9 Motivatio to Quit Usig Substaces Schizophreia Bulleti, Vol. 2, No. 2, 1997 Coclusios Treatmet of the dually diagosed idividuals with schizophreia is most likely to occur i metal health settigs. Cliical programs seem to have better outcomes whe both the substace abuse ad schizophreia problems are addressed simultaeously, ad whe they provide broadbased ad comprehesive services. Treatmet studies should iclude the assessmet of motivatioal levels ad cosider chages i motivatioal levels as a primary outcome measure. Future research will determie the effectiveess of the motivatio-based treatmet model ad of specific itervetios such as motivatioal ehacemet therapy i reducig the legth of time a cliet takes to move from deial to exteded abstiece. Refereces America Psychiatric Associatio. Diagostic ad Statistical Maual of Metal Disorders. rd ed., revised. Washigto, DC: The Associatio, Aath, J.; Vaderwater, S.; Kamal, M.; ad Brodsky, A. Missed diagosis of substace abuse i psychiatric patiets. Hospital ad Commuity Psychiatry, 40: , Buckley, P.B.; Thompso, P.; Way, L.; ad Meltzer, H.Y. Substace abuse amog patiets with treatmet-resistat schizophreia: Characteristics ad implicatios for clozapie therapy. America Joural of Psychiatry, 151:85 89, Davidso, L.; Simsaria, J.; ad Marcus, K. Providig Services to Persos Dually Diagosed With Prologed Metal Illess ad Substace Abuse: A Report. Hartford, CT: Departmet of Metal Health, 199. Dixo, L.; Haas, G.; Weide, P.J.; Sweeey, J.; ad Fraces, A.J. Drug abuse i schizophreic patiets: Cliical correlates ad reasos for use. America Joural of Psychiatry, 148:224-20, Drake, R.E.; McHugo, G.J.; ad Noordsy, D.L. Treatmet of alcoholism amog schizophreic outpatiets: 4-year outcomes. America Joural of Psychiatry, 150(2):28-29, 199. Evas, K., ad Sulliva, J.M. Dual Diagosis: Couselig the Metally III Substace Abuser. New York, NY: Guilford Press, Fischer, D.E.; Halikas, J.A.; Baker, J.W.; ad Smith, J.B. Frequecy ad patters of drug abuse i psychiatric patiets. Diseases of the Nervous System, 6(lO):55O-55, Galater, M.; Castaeda, R.; ad Ferma, J. Substace abuse amog geeral psychiatric patiets: Place of presetatio, diagosis ad treatmet. America Joural of Drug ad Alcohol Abuse, 14:211-25, George, T.P.; Semyak, M.J.; Ziedois, D.M.; ad Woods, S.W. Effects of clozapie o smokig i chroic schizophreic outpatiets. Joural of Cliical Psychiatry, 56(8):44-46, Glazer, W.M., ad Kae, J.M. Depot euroleptic therapy: A uderutilized treatmet optio. Joural of Cliical Psychiatry, 5:426-4, Hall, R.C.W.; Popki, M.D.; DeVaul, R.; ad Stickey, S.K. The effect of urecogized drug abuse o diagosis ad therapeutic outcome. America Joural of Drug ad Alcohol Abuse, 4: ,1977. Hazelde Foudatio. Dual Disorders Recovery Book. Ceter City, MN: The Foudatio, 199. Karoly, P. Perso variables i therapeutic chage ad developmet. I: Karoly, P., ad Steffe, J.J., eds. Improvig the Log-Term Effects of Psychotherapy. New York, NY: Garder, pp Koedler, W. How traiig i commuity livig programs helps its patiets work. New Directios i Metal Health Services, 2:57-66, Larse, E. Stage II Recovery: Life beyod Addictio. New York, NY: HarperCollis, McEvoy, J.; Freudereich, 0.; Levi, E.D.; ad Rose, J.E. Haloperidol icreases smokig i patiets with schizophreia. Psychopharmacology, 119(1): , 1995a. McEvoy, J.; Freudereich, O.; McGee, M.; VaderZwaag, C; Levi, E.; ad Rose, J. Clozapie decreases smokig i patiets with chroic schizophreia. Biological Psychiatry, 7(8): , 1995fc. Miller, N.S., Belki, B.M., ad Gibbos, R. Cliical diagosis of substace use disorders i private psychiatric populatios. Joural of Substace Abuse Treatmet, U(4):87-92, Miller, W.R. Motivatio for treatmet: A review with special emphasis o alcoholism. Psychological Bulleti, 98(l):84-107, Miller, W.R., ad Rollick, S. Motivatioal Iterviewig: Preparig People to Chage Addictive Behavior. New York, NY: Guilford Press, Miller, W.R.; Zwebe, A.; DiClemete, C.C.; ad Rychtarik, R.G. Motivatioal Ehacemet Therapy Maual. Rockville, MD: U.S. Departmet of Health ad Huma Services, Publicatio No. (ADM): , Mueser, K.T.; Yarold, P.R.; Leviso, D.F.; Sigh, H.; Bellack, A.S.; Kee, K.; Morriso, R.L.; ad Yalalam, K.G. Prevalece of substace abuse i schizophreia: Demo- 27

10 Schizophreia Bulleti, Vol. 2, No. 2, 1997 D.M. Ziedois ad K. Tmdeau graphic ad cliical correlates. Schizophreia Bulleti, 16(l):1-56, Pepper, B., ad Ryglewicz, H. The youg adult chroic patiet: A ew focus. I: Talbott, J., ed. The Chroic Metal Patiet: Five Years Later. New York, NY: Grue & Stratto, pp Prochaska, J.O., ad DiClemete, C.C. Stages ad processes of self-chage of smokig: Toward a itegrative model of chage. Joural of Cosultig ad Cliical Psychology, 51():90-95, 198. Prochaska, J.O.; DiClemete, C.C; ad Norcross, J.C. I search of how people chage: Applicatios to addictive disorders. America Psychologist, 47: , Prochaska, J.O.; Welicer, W.F.; Rossi, J.S.; Goldstei, M.J.; Marcus, B.H.; Rabowski, W.; Fiore, C; Harlow, L.L.; Reddig, C.A.; Rosebloom, D.; ad Rossi, S.R. Stages of chage ad decisioal balace for 12 problem behaviors. Health Psychology, I(l):9 46, Regier, D.A.; Farmer, M.E.; Rae, D.S.; Locke, B.Z.; Keith, S.J.; Judd, L.L.; ad Goodwi, F.K. Comorbidity of metal disorders with alcohol ad other drug abuse. Joural of the America Medical Associatio, 264: , Ries, R.K., ad Elligso, T. A pilot assessmet at 1 moth of 17 dual diagosis patiets. Hospital ad Commuity Psychiatry, 41:120-12, Rossi, J.S.; Rosebloom, D.; Moti, P.M.; Rohseow, D.J.; Prochaska, J.O.; ad Marti, R.A. "Trastheoretical Model of Behavior Chage for Cocaie Use." Preseted at the Aual Meetig of the America Psychological Associatio, Toroto, Otario, Caada, August 199. Scheier, F.R., ad Siris, S.G. A review of psychoactive substace use ad abuse i schizophreia: Patters of drug choice. Joural of Nervous ad Metal Disease, 175(11 ): , Selzer, J.A., ad Lieberma, J.A. Schizophreia ad substace abuse. Psychiatric Cliics of North America, 16(2):401^12, 199. Sevy, S.; Kay, S.R.; Opler, L.A.; ad va Pragg, H.M. Sigificace of cocaie history i schizophreia. Joural of Nervous ad Metal Disease, 178: , Sisso, R., ad Azri, N. The commuity reiforcemet approach. I: Hester, R.K., ad Miller, W.R., eds. Hadbook of Alcoholism Treatmet Approaches. New York, NY: Pergamo Press, pp Steme, M.W., ad Pittma, D.J. The cocept of motivatio: A source of istitutioal ad professioal blockage i the treatmet of alcoholics. Quarterly Joural of Studies o Alcohol, 26:41-57, Trudeau, K.J., ad Reich, R. Correlates of psychological midedess. Persoality ad Idividual Differeces, 19(5): , Ziedois, D.M. Comorbid psychopathology ad cocaie addictio. I: Koste, T.R., ad KJeber, H.D., eds. Cliicia 's Guide to Cocaie Addictio: Theory, Research ad Treatmet. New York, NY: Guilford Press, pp Ziedois, D.M., ad Fisher, W. Assessmet ad treatmet of comorbid substace abuse i idividuals with schizophreia. Psychiatric Aals, 24:477^*8, Ziedois, D.M., ad Fisher, W. Motivatio-based assessmet ad treatmet of substace abuse i patiets with schizophreia. Directios i Psychiatry, 16(11): 1-8, Ziedois, D.M.; Koste, T.R.; Glazer, W.M.; ad Fraces, R.J. Nicotie depedece ad schizophreia. Hospital ad Commuity Psychiatry, 45: , Ackowledgmets This work was supported by USPHS grats DA ad DA-019 to Douglas Ziedois from the Natioal Istitute o Drug Abuse. The Authors Douglas M. Ziedois, M.D., M.P.H., is Associate Professor, Yale Uiversity, ad Director of the Dual Diagosis Program, Coecticut Metal Health Ceter; Kimberlee Trudeau, B.A., is Research Assistat at Yale Uiversity ad the Dual Diagosis Program, Coecticut Metal Health Ceter, New Have, CT. 28