Discuss Substance abuse and dependence in persons with SMI are especially detrimental because of the complex interactions between the two problems and the impact on treatment engagement and outcomes.

Motivation and the stages of change among individuals with severe mental illness and substance abuse disordersAuthor links open overlay panelCarlo C.DiClementePh.D.aMelissaNideckerPh.D.aAlan S.BellackPh.D.bhttps://doi.org/10.1016/j.jsat.2006.12.034Get rights and contentAbstractA 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 behavior change. This selective review explores conceptual and assessment issues related to readiness to modify substance use and readiness to initiate behaviors 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.Previous article in issueNext article in issueKeywordsMotivationStages of changeSerious mental illnessReadiness for changeCo-occurring disordersSubstance abuse1. IntroductionSubstance misuse by individuals with a chronic and serious mental illness (SMI) such as schizophrenia or bipolar disorder is a pervasive problem with studies showing that nearly 50% of all persons with SMI have met the criteria for a substance use disorder (SUD) in their lifetime (Barry et al., 1995, Kessler et al., 1997, Mueser et al., 1992). Substance abuse and dependence in persons with SMI are especially detrimental because of the complex interactions between the two problems and the impact on treatment engagement and outcomes. For example, nonadherence with medication, symptom exacerbation, rehospitalization, poor social adjustment, and worse prognosis are a few of the adverse consequences associated with dually diagnosed patients (Drake, Mueser, Clark, & Wallach, 1996). Moreover, treatment of individuals with either or both of these disorders is often characterized by a lack of therapeutic engagement, problematic motivation for change, and relapse after some initial successful change (Blanchard, 2000, DiClemente, 2003, McGovern et al., 2005, Mueser et al., 2006, Onken & Blaine, 1990).Multiple problems always complicate behavior change and necessitate complex and integrated treatment planning (DiClemente, 2003, McLellan et al., 2000). Individuals with two or more diagnosable psychiatric conditions are often differentially motivated with regard to the two conditions. They may simply comply with services while hospitalized to resolve some acute problem only to avoid all treatment once discharged (Brady et al., 1996). However, the more severe the mental illness and the substance abuse problems are, the more dysfunctional 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 participate in it (Center for Substance Abuse Treatment, 2005, Substance Abuse and Mental Health Services Administration, 1995). Motivating these individuals and engaging them in the process of behavior change are particularly challenging and not well understood.Although motivation and readiness to change among substance-abusing individuals have been examined rather extensively over the past 20 years (Miller, 1985, Miller, 2006, Prochaska et al., 1992, Simpson & Joe, 1993), motivation and readiness to change among individuals with SMI and SUD have just recently begun to be explored (Carey et al., 2001, Zeidonis & Trudeau, 1997, Zhang et al., 2004). Whether motivational considerations and indicators of readiness to change that are important dimensions of change among substance-abusing individuals can also be useful and applicable in a population of individuals with SMI and substance abuse disorders is an important question that needs to be answered.This review describes conceptual and practical considerations regarding motivation for change among the more severely disabled of the dually diagnosed individuals, selectively reviews the growing number of studies examining applications and challenges related to assessing and intervening on patient motivation, and concludes with recommendations for incorporating motivational dimensions into research and treatment of individuals with co-occurring disorders to enhance engagement, adherence, and behavior change. Although any combination of substance use and mental illness complicates change, we will focus on issues and studies with relevance for individua