Schizophrenia Bulletin vol. 42 no. 2 pp.

327–334, 2016
doi:10.1093/schbul/sbv143
Advance Access publication September 29, 2015

Motivational Interviewing to Increase Cognitive Rehabilitation Adherence in

Schizophrenia

Joanna M. Fiszdon*,1,2, Matthew M. Kurtz2,3, Jimmy Choi4, Morris D. Bell1,2, and Steve Martino1,2
Department of Psychology, VA Connecticut Healthcare System, West Haven, CT; 2Department of Psychiatry, Yale University School of
1

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Medicine, New Haven, CT; 3Department of Psychology and Program in Neuroscience and Behavior, Wesleyan University, Middletown,
CT; 4Olin Neuropsychiatry Research Center, The Institute of Living, Hartford Hospital, Hartford, CT
*To whom correspondence should be addressed; Psychology Service (116B), VA Connecticut Healthcare System, 950 Campbell Ave.,
West Haven, CT 06516, US; tel: (203) 932-5711, ext. 2231, fax: (203) 937-3542, e-mail: Joanna.fiszdon@yale.edu

Adherence to treatment in psychiatric populations is noto-
riously low. In this randomized, controlled, proof-of-con-
cept study, we sought to examine whether motivational
interviewing (MI) could be used to enhance motivation for,
adherence to, and benefit obtained from cognitive reha-
bilitation. Dual diagnosis MI, developed specifically for
individuals with psychotic symptoms and disorganization,
was further adapted to focus on cognitive impairments and
their impact. Sixty-four outpatients diagnosed with schizo-
phrenia spectrum disorders completed baseline assessments
and were randomized to receive either the 2-session MI
focused on cognitive functioning or a 2-session sham con-
trol interview focused on assessment and feedback about
preferred learning styles. Next, all participants were given
4 weeks during which they could attend up to 10 sessions of
a computer-based math training program, which served as
a brief analog for a full course of cognitive rehabilitation.
As hypothesized, MI condition was associated with greater
increases in task-specific motivation along with greater
training program session attendance. Moreover, postinter-
view motivation level predicted session attendance. There
were no significant differences in improvement on a mea-
sure of cognitive training content, which may have been due
to the abbreviated nature of the training. While the litera-
ture on the efficacy of MI for individuals with psychosis
has been mixed, we speculate that our positive findings may
have been influenced by the adaptations made to MI as well
as the focus on a nonpharmacological intervention.
Key words: psychosis/cognitive remediation/compliance
/treatment/motivation
Introduction
Schizophrenia is characterized by substantial and persis-
tent reductions in motivation (Bleuler, 1911; cf Moskowitz
and Heim1), which in turn hamper attempts to engage
individuals in psychosocial rehabilitation and directly
impact the efficacy of any such treatments.2–5 At pres-
ent, multiple efforts are under way to better understand
these motivational impairments and develop treatments
to lessen their impact.6–8 Herein, we describe the adap-
tation and evaluation of motivational interviewing (MI)
as a method of enhancing treatment-specific motivation
and increasing adherence to cognitive rehabilitation in
individuals with schizophrenia spectrum disorders.
With the well-established link between cognition and
functional outcomes in individuals with schizophrenia,9
interest has flourished in developing and validating cog-
nitive rehabilitation interventions for this population.
While laboratory-based studies indicate efficacy along
with high treatment adherence,10,11 the real-world effec-
tiveness of this and other treatments is compromised by
poor treatment engagement and adherence. For example,
in an intensive community outpatient psychosocial reha-
bilitation program offering cognitive rehabilitation along
with other psychosocial interventions, 37% of those
enrolled (47 of 127) dropped out within the first month
of treatment.12 Other reports based on general psychiatric
samples indicate nonpharmacological treatment nonad-
herence rates ranging from 25% to 75%.13–16 These reports
are quite troubling, given the link between adherence and
outcomes,17–19 and suggest that beyond developing effec-
tive psychosocial interventions, more focus is needed on
ensuring that these interventions are accepted and fully
utilized by individuals for whom they are developed.
Often treated as a unitary construct, there are in fact
many different aspects of motivation, each with sepa-
rate theoretical underpinnings.20 Likely the best known
distinction is that between extrinsic and intrinsic motiva-
tion,7 however further demarcations can be made between
global trait motivation, global state motivation, and

Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center 2015.

327
J. M. Fiszdon et al
task-specific (aka intrinsic) motivation.21 Importantly,
these motivational processes are at least in part distinct,
and some may be more amenable to intervention. In our
own work, for example, we found that individuals with
psychosis who were not motivated for general, everyday
activities could still exhibit motivation for specific tasks,
such as cognitive training.3,21 More so, this task-specific
motivation is malleable,3 suggesting that it may be an
appropriate target for manipulations aimed at increasing
adherence to specific psychosocial treatments.
A complementary line of research on MI22 and related
interventions also indicates that treatment-specific moti-
vation can be enhanced.23–28 Until now, the bulk of this
research has examined the efficacy of this approach in
either general psychiatric, substance-using, or nonpsychi-
atric samples. A number of researchers have also adapted
this approach to targeting medication adherence in indi-
viduals with psychosis,29,30 though the results of these tri-
als have been equivocal. We are aware of only one study
that focused on psychoeducation to increase insight into
cognitive impairment; however, this very brief interven-
tion did not improve self-reported receptiveness to cogni-
tive rehabilitation.31
In the current randomized, controlled proof-of-con-
cept study, we sought to examine whether MI could be
used to enhance motivation for, adherence to, and benefit
obtained from cognitive rehabilitation (CR). A brief cog-
nitive rehabilitation analog was used in lieu of a full course
of cognitive training. We hypothesized that compared to
sham control interviews (CI) matched for duration and
interaction with a clinician, individuals randomized to 2
sessions of MI would evidence: (1) greater adherence to
the CR program as demonstrated by number of training
sessions attended, (2) higher levels of intrinsic motivation
for CR both immediately after the MI sessions and after
a brief program of CR, and (3) greater content acquisi-
tion of skills taught in the CR program. Additionally, we
sought to evaluate the role of motivation level in adher-
ence to CR and hypothesized that postinterview motiva-
tion level would predict number of sessions attended.
Methods
Participants
Adults with schizophrenia spectrum disorders were
recruited by flyer and word of mouth from outpatient VA
Medical Center clinics and community settings. Inclusion/
exclusion criteria were: DSM-IV diagnosis of schizophre-
nia or another psychotic disorder, including affective dis-
order with psychotic features and psychosis not otherwise
specified; not meeting criteria for substance dependence
in past 30 days; psychiatric stability as evidenced by mini-
mum of 30 days since last psychiatric hospitalization and
minimum 30 days since last change in psychiatric medi-
cations; no evidence of developmental disability in chart
or on baseline assessment; no diagnosis of any medical
328
or neurological illness known to impair brain function
including dementia, history of head trauma with loss of
consciousness > 1 hour, or clear cognitive sequelae from
other illness or injury, per medical chart review; no audi-
tory or visual impairment that would impact ability to
participate in computerized training; ability to provide
legal written informed consent (ie, the participant does
not have a legally authorized representative/conservator);
and not currently enrolled in another trial targeting treat-
ment engagement or cognitive performance. Recruitment
occurred between June 2013 and May 2014.
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Study Design
This was a randomized, controlled, proof-of-concept
trial using a math-learning program as an analog for
learning that occurs during a full course of cognitive
rehabilitation. Upon completing baseline assessments,
participants were randomized to receive either a 2-ses-
sion MI focused on cognitive functioning or a 2-session
sham CI focused on assessment and feedback about pre-
ferred learning styles. Session length was 30–45 minutes,
and both sessions were conducted within a week’s time of
each other. To preserve equipoise, both interviews were
presented to participants as different methods of helping
people learn new information. All interviews were admin-
istered by the same therapist and videotaped to allow for
subsequent fidelity ratings. Next, all participants were
given 4 weeks during which they could attend up to 10
sessions of the cognitive training analog (math-learning
program). Participants were provided with multiple time
slots each day during which training could be completed.
No payment was offered for attending the math-learning
sessions, though payment was offered for study assess-
ments. The study was approved by local IRB committees.
All participants provided written informed consent.
Experimental Interventions
Motivational Interview
Dual Diagnosis Motivational Interviewing (DDMI23,32,33),
a 2-session intervention targeting substance misuse in
individuals with psychotic disorders, was used as a start-
ing point for the current MI intervention. DDMI was
specifically designed for individuals with psychosis who
may exhibit negative or disorganized symptoms and
includes accommodations for cognitive impairments,
including the following: asking questions and reflecting
in simple and concise terms, repeating information and
summarizing session content, providing greater structure
during interview, being sensitive to emotional material,
using simple, concrete materials, presenting information
in multiple modalities including using visual aids and
writing things down, frequent restating, slower inter-
view pace, and pauses to allow participants to process
material. These modifications are consistent with some
of the suggestions made by experts in rehabilitation for

individuals with serious and persistent mental illness.34,35
For the current trial, DDMI was further adapted to
focus on the problem area of cognitive impairment and
its consequences. The first session focused on exploring
the participant’s views about his or her cognitive func-
tioning, providing personalized feedback about cogni-
tive function (based on baseline cognitive performance),
providing information on how cognition can be improved
through cognitive training, and conducting a decisional
balance activity to weigh the pros and cons of pursuing
a goal and to build motivation for change. In the second
session, content from the first session was summarized,
including stated reasons for change. Next the participant
and therapist developed and discussed a change plan for
improving cognitive functioning, including the option of
participating in the cognitive training analog. The cogni-
tive training analog was also demonstrated.
Control Interview
During the first session, achievement motivation and
learning style were assessed by collaboratively filling out 2
inventories, the Achievement Motivation Profile (AMP36)
and the Learning Styles Inventory (LSI37). The AMP is a
140-question, Likert-format assessment of motivational
factors that contribute to underachievement and which
also provides specific recommendations for improvement.
Scale items produce information on 4 domains: moti-
vation for achievement, inner resources, interpersonal
strengths, and work habits, which themselves contain
additional subscales. The LSI is 30-item, multiple choice
measure of general learning preferences, which provides
information on preferred conditions for learning, areas
of interest, modes of learning, and expectations for per-
formance. Participants received detailed feedback about
their pattern of scores on the 2 inventories during the
second session, at which time they were also familiarized
with the cognitive training analog.
Cognitive Rehabilitation Analog
A brief, computerized math-learning program was used
as an analog for a full course of cognitive rehabilita-
tion. This particular arithmetic-learning paradigm has
been successfully used in past studies3,4 and is sensitive to
motivational manipulations. Similarly to full-length CR
interventions, it requires the use and practice of several
cognitive skills, including attention, working memory,
and mental flexibility, and allows for direct domain-spe-
cific assessments of learning (arithmetic test) that can
quantify the degree of material absorption. Skills taught
during the training include single-digit subtraction,
division, multiplication, use of parentheses, and order
of operations. The task is delivered as a computerized
“math game,” the object of which is to advance a token
from the start line (1) to the finish line (60). In order to
advance the token, the participant must attempt to com-
bine 3 numbers generated by the computer into a valid
MI for Cogrehab
arithmetic expression using operations of addition, sub-
traction, division, multiplication, and parentheses. The
resulting value of the created expression is the number of
spaces the participant can advance on the board game. If
the participant cannot provide a valid arithmetic expres-
sion using the generated numbers, the computer provides
instructional feedback and offers the correct answer. The
participant is not allowed to advance unless s/he pro-
vides a correct answer. For additional information about
the math-learning program, please refer to Choi and
Medalia.3 In the current trial, the standard version of the
math-learning program was used.
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Measures
Baseline assessment consisted of demographic, psy-
chiatric, cognitive, arithmetic skill (trained during CR)
and task-specific intrinsic motivation evaluations. Task-
specific intrinsic motivation was assessed again immedi-
ately after the second session of MI or CI, and once again
at the end of the study, once participants either finished
all 10 training sessions or 4 weeks from the end of MI/CI
interviews had elapsed. Assessments were conducted by
personnel blind to condition assignment.
Task-Specific Motivation
The Intrinsic Motivation Inventory for Schizophrenia
Research (IMI-SR38), a 21-item self-report, Likert-format
measure, was used to assess domains related to motiva-
tion for cognitive training: interest/enjoyment, perceived
choice, and value/usefulness. The IMI-SR has been
designed to assess the subjective experience of a learn-
ing activity specifically in an experimental setting and has
been shown to have good internal consistency and test-
retest reliability.38 It has also been shown to be associated
with treatment attendance and treatment efficacy, as well
as to be sensitive to motivational manipulation.38 Scores
for each of the 3 subscales can range from 7 to 49, with
full IMI scores ranging from 21 to 148 and higher scores
reflecting greater motivation. A measure of internal reli-
ability for the scale was in the excellent range (Cronbach’s
alpha = .907).
Additional Measures
At baseline, schizophrenia spectrum diagnoses were
confirmed using the Structured Clinical Interview for
DSM-IV,39 administered by the first author (J.M.F.).
Positive and Negative Syndrome Scale (PANSS40) was
used to characterize participants by assessing the presence
and severity of positive, negative, and general psychiatric
symptoms. Premorbid intelligence was assessed with the
Wechsler Test of Adult Reading (WTAR41). Additional
baseline measures included the Brief Assessment of
Cognition in Schizophrenia (BACS42,43), a battery assess-
ing working memory, motor speed, attention, execu-
tive functioning, and verbal fluency, and the Medication
329
J. M. Fiszdon et al
Management Ability Assessment (MMAA44), a proxy
measure of functioning that has been shown to correlate
highly with cognitive ability.45 These latter 2 measures
were used to provide personalized feedback during the MI
sessions. Arithmetic skill was assessed with the Columbia
University Teacher’s College arithmetic test, administered
before and after CR. Alternate versions of the measure
were used for pre and post-CR assessments. Adherence
was defined as total number of sessions attended.
Treatment Fidelity
Therapist adherence to and competence in strategies con-
sistent or inconsistent with the delivery of motivational
interview (eg, reflective listening vs closed-ended questions)
was assessed by blind ratings of 20% of the videotaped ses-
sions, using an adapted version of a fidelity measure pre-
viously developed for DDMI fidelity ratings (see Chen16).
Previous research using this fidelity scale indicated high
(intraclass correlation coefficient [ICC] > 0.80) rater agree-
ment on items assessing therapist adherence to and com-
petence in delivering the treatment. Separate ratings were
computed for adherence and competence for each of the
rated domains and averaged for subjects in each condition.
Prior to making any ratings, our blind rater was trained
and calibrated to our gold standard MI master trainer
(author S.M.), with ICCs >0.90 for adherence to MI con-
sistent items. Average adherence and competence were
calculated for the following types of items: MI-consistent
(ie, open-ended questions, reflective statements, etc.),
MI-inconsistent (unsolicited advice, asserting authority,
etc.), and general interview components (ie, expected to be
presented in both conditions, such as providing a descrip-
tion of cognitive training principles and hands-on demo).
Ratings were made on a 1–7 Likert scale, with higher scores
reflecting greater adherence and competence.
Data Analysis
We applied an intent-to-treat analysis to our study, includ-
ing data from all participants who were randomized to the
MI or sham condition. The distribution of scores for each
variable in each group was inspected for normality and
compared to relevant comparison groups for homogene-
ity of variance. In instances in which dependent measures
were not normally distributed (ie, attendance data from
CR sessions), relevant nonparametric tests were substi-
tuted. First, the 2 groups were compared at baseline on
clinical, demographic, and neurocognitive variables using
independent sample t tests or chi-square consistent with
the nature of the dependent measure. Second, treatment
fidelity was assessed by conducting between-group t tests
for mean adherence and competence ratings of MI con-
sistent strategies, MI-inconsistent strategies, and session
content that should be common to both interview condi-
tions. Third, to assess the impact of the MI intervention
on motivation, we compared all clients on a measure of
330
intrinsic motivation (IMI) before administration of the MI
intervention, immediately after the MI intervention, and
at a follow-up after administration of the 1-month, 10-ses-
sion CR program in a mixed design 2 (group) × 3 (time)
ANOVA. The 2 groups were also compared on number of
sessions attended in CR using the nonparametric Mann-
Whitney U test. To assess acquisition of math skills (arith-
metic test) taught in the CR intervention we used a mixed
design 2 (group) × 2 (time; before and after CR) ANOVA
on arithmetic scores. Cohen’s effect sizes were computed
for between-group effects when evident. To examine the
impact of motivation level on session attendance, we com-
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puted Spearman correlations between postinterview IMI
scores and number of sessions attended. All statistical tests
were 2 tailed and alpha was set at .05.
Results
Participant Characteristics
Four participants dropped out of the interviews (n = 1
MI condition and n = 3 CI condition) and none of these
participants completed any assessments after the inter-
view (see CONSORT diagram, figure 1). There were no
significant differences between the MI and sham inter-
view groups on any variables at baseline (see table 1), with
the exception of the summary composite t score from the
BACS (t(62) = −2.11, P < .05). The MI group showed
better performance on this summary neurocognitive mea-
sure. Hence, baseline cognitive performance was used as a
covariate in subsequent analyses, as appropriate.
Treatment Fidelity
MI tapes were rated significantly higher than CI tapes
on MI-consistent strategy adherence (6.05 [0.33] vs 2.58
[1.91], t = −4.39, P = .001) and MI-consistent compe-
tence (4.48 [0.26] vs 3.66 [0.52], t = −3.45, P = .006).
Both MI and CI tapes were rated low on MI-inconsistent
adherence (1.00 [0] vs 1.11 [0.17], t = 1.58, P = .18). As
there were no rated instances of MI-inconsistent strate-
gies in the MI condition, a comparison of competence
ratings on these strategies was not possible. As should be
the case, there were no significant differences between MI
and CI tapes on common, general interview components
adherence (6.33 [0.70] vs 5.56 [0.72], t = −1.90, P = .09) or
competence (4.11 [0.27] vs 3.94 [0.14], t = 1.34, P = .21).
Between-Group Analyses
The mixed-design ANCOVAs for the IMI and math test
scores revealed main effects for time on the IMI only
(F[2, 114] = 4.12, P < .05), suggesting participants pooled
across both conditions showed improved motivation dur-
ing the trial. Main effect of time was not significant for the
math test (F[1, 56] = 0.48, P = .49). With respect to differen-
tial effects of the interview condition on intrinsic motivation
levels, the ANCOVAs for the IMI revealed improvements
 MI for Cogrehab

Consented (n=69)

Excluded (n=4)
• Self-withdrew (n=2)
• Not meeting inclusion criteria
(n=2)

Baseline tesng (n=65)

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Paral tesng (n=1)

Randomized (n=64)

Allocated to MI (n=33) Allocated to control (n=31)

• Participated in interviews (n=32) • Participated in interviews (n=28)
• Self-withdrew (n=1) • Self-withdrew (n=3)

Post testing (n=32) Post testing (n=28)

Analyzed (n= 32) Analyzed (n= 28)

• Excluded from analysis (give • Excluded from analysis (give
reasons) (n=0) reasons) (n=0)

Fig. 1. CONSORT flow diagram.

for participants in the MI condition compared to the sham

Table 1. Participant Demographics intervention with a significant condition × time interaction
MI Condition CI Condition (F[2, 114] = 13.21, P < .001). Please refer to figure 2 for a
Variables (n = 33) (n = 31) graphical representation of motivation change over time.
Cohen’s effect sizes comparing the MI condition to the
Age 46.52 (9.96) 49.26 (11.23)
sham intervention were in the large range immediately after
Education 13.06 (1.92) 12.42 (1.89)
Gender (% male) 48% 65% the interviews, d = 1.49, and after the CR training 1-month
WRAT Reading t score 43.03 (9.45) 42.03 (8.73) later d = 1.19. For the MI condition, within-group Cohen’s
WASI IQ 90.12 (14.88) 88.74 (15.28) effect size (d) was 0.91 for pre-post interview IMI scores
Age of onset 23.27 (12.84) 21.23 (7.58) and 0.83 for pre to end of training scores. For CI condition,
Schizophrenia (%) 70 87
No. hospitalizations 11.24 (13.15) 8.19 (9.49)
pre-post effect size was −0.27, decreasing to −0.14 when
GAF 41.72 (11.05) 40.30 (8.75) examining pre to end of training scores.
PANSS 49.88 (12.37) 51.27 (12.89) With respect to attendance in CR, there was a sig-
IMI Total 114.58 (23.10) 105.71 (21.80) nificant difference between conditions in number of ses-
BACS t score* 35.25 (10.89) 29.17(14.65) sions attended; participants in the MI condition attended
Note: BACS, Brief Assessment of Cognition in Schizophrenia; more sessions than those assigned to the sham interview
GAF, Global Assessment of Functioning; IMI, Intrinsic (Mann-Whitney U = 3.75; P < .001, d = 1.10). Please
Motivation Inventory; PANSS, Positive and Negative Syndrome refer to figure 3 for graphical representation of this effect.
Scale; WASI, Wechsler Abbreviated Intelligence Scale; WRAT, Lastly, the condition × time interaction for arithmetic
Wide Range Achievement Test.
*t(62) = −2.11, P < .05.
scores was not significant (F[1, 56] = 0.70, P = .41).

331
J. M. Fiszdon et al
Fig. 2. Intrinsic Motivation Inventory total score, over time.
6 Though our study was a rigorous randomized con-
5.06 (4.61)
5 trolled trial with a reasonable sample size, it was a proof-
4 course of CR and will require replication with a full
CI
3 course of cognitive rehabilitation, as we have just begun
MI
2
0.96 (2.25)
1 ficient, and booster sessions may be necessary, though
0
CI MI
Fig. 3. Mean number of sessions attended and SD, by condition.
Motivation Level and Session Attendance
The Spearman correlation between postinterview total
IMI score and number of sessions attended was significant
(rho = 0.59, P < .001). Individual correlations between
attendance and each of the IMI subscales were also sig-
nificant (all P < .05) and ranged from 0.33 (IMI Perceived
Choice) to 0.47 (IMI Perceived Value) to 0.68 (IMI Interest).
Discussion
This is the first study, to our knowledge, to adapt MI for
application with CR in a sample of people with psychosis.
Our findings indicate that MI, adapted for use with indi-
viduals with schizophrenia spectrum disorders and cogni-
tive impairments, can be used effectively to increase both
task-specific motivation and adherence to cognitive train-
ing. While the literature on the efficacy of MI for psychosis
has been mixed,46 we speculate that our positive findings
may have been influenced by the adaptations made to MI
as well as the focus on a nonpharmacological interven-
tion, where risk for side-effects and adverse events is low.
The observed relationship between postinterview motiva-
tion level and session attendance suggests that motivation
likely was the key factor driving adherence, a finding con-
sistent with expert opinion and prior research,3,47 and we
will examine the degree to which MI-related increases in
intrinsic motivation mediate session attendance in a future
332
report. Baseline motivation levels, which were somewhat,
though not significantly higher for individuals in the MI
condition may have also had some impact on the efficacy
of MI and should be further examined.
While we did not find a significant difference in improve-
ment on our measure of cognitive training analogue
between the 2 experimental groups despite marked differ-
ences in attendance, we expect this was likely due to the
abbreviated training and nature of the analogue exercise.
Those in the MI condition attended on average only 5 ses-
sions, which is considerably lower than the 2–5 sessions/wk
over a standard course of a 3- to 6-month CR. Moreover,
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the arithmetic program is not designed to improve cogni-
tive functioning3 but serves as merely a proxy of learning,
where improvements have been noted in past studies when
attendance reached a threshold of 10 sessions.
of-concept trial with brief math training in lieu of a full
to do in a new trial. Given a longer treatment timeframe,
2 brief sessions of MI delivered at start may not be suf-
that will also require evaluation. Additionally, while our
MI intervention included feedback on cognitive perfor-
mance, feedback is not always a component of MI. Our
current design did not allow us to disentangle the impact
of just the feedback to that of feedback presented in the
context of motivational enhancement, and additional
trials would be needed to answer this question. Finally,
while we did not collect pre-post interview ratings of
insight, this variable has previously been linked to treat-
ment adherence.34 Future trials could examine whether
MI leads to any changes in insight, and if so, the overlap-
ping and unique contributions of motivation and insight
on treatment adherence.
MI is a low-tech, fairly easy to disseminate intervention
that can be adapted to address a range of problem behav-
iors. If found efficacious in improving CR adherence in
people with schizophrenia spectrum disorders, it could eas-
ily be incorporated into existing CR programs, and perhaps
into other behavioral interventions and programs, leading
to greater participation in treatment, and hence better out-
comes for individuals with this disabling, chronic illness.
Funding
This study was supported by grant from Department
of Veterans Affairs Rehabilitation Research and
Development Service (1I21RX000598-01A1 to J.M.F.).
Acknowledgment
The authors have declared that there are no conflicts of
interest in relation to the subject of this study.

References
1. Moskowitz A, Heim G. Eugen Bleuler’s Dementia praecox or
the group of schizophrenias (1911): a centenary appreciation
and reconsideration. Schizophr Bull. 2011;37:471–479.
2. Choi KH, Fiszdon JM, Bell MD. Beyond cognition: a
longitudinal investigation of the role of motivation dur-
ing a vocational rehabilitation program. J Nerv Ment Dis.
2013;201:173–178.
3. Choi J, Medalia A. Intrinsic motivation and learning in a schiz-
ophrenia spectrum sample. Schizophr Res. 2010;118:12–19.
4. Choi J, Fiszdon JM, Medalia A. Expectancy-value the-
ory in persistence of learning effects in schizophrenia: role
of task value and perceived competency. Schizophr Bull.
2010;36:957–965.
5. Medalia A, Saperstein A. The role of motivation for treat-
ment success. Schizophr Bull. 2011;37(suppl 2):S122–S128.
6. Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT.
Randomized trial to evaluate the efficacy of cognitive therapy
for low-functioning patients with schizophrenia. Arch Gen
Psychiatry. 2012;69:121–127.
7. Silverstein SM. Bridging the gap between extrinsic and intrin-
sic motivation in the cognitive remediation of schizophrenia.
Schizophr Bull. 2010;36:949–956.
8. Choi J, Medalia A. How to enhance intrinsic motivation
within the setting of a cognitive remediation program.
Schizophr Bull. 2009;35(suppl 1):284.
9. Green MF, Kern RS, Heaton RK. Longitudinal studies of
cognition and functional outcome in schizophrenia: implica-
tions for MATRICS. Schizophr Res. 2004;72:41–51.
10. Keefe RS, Vinogradov S, Medalia A, et al. Feasibility and
pilot efficacy results from the multisite Cognitive Remediation
in the Schizophrenia Trials Network (CRSTN) randomized
controlled trial. J Clin Psychiatry. 2012;73:1016–1022.
11. Wykes T, Huddy V, Cellard C, McGurk SR, Czobor P. A meta-
analysis of cognitive remediation for schizophrenia: method-
ology and effect sizes. Am J Psychiatry. 2011;168:472–485.
12. Kurtz MM, Rose J, Wexler BE. Predictors of participation in
community outpatient psychosocial rehabilitation in schizo-
phrenia. Community Ment Health J. 2011;47:622–627.
13. Cohen K, Edstrom K, Smith-Papke L. Identifying early
dropouts from a rehabilitation program for psychiatric out-
patients. Psychiatr Serv. 1995;46:1076–1078.
14. Falloon IR, Lindley P, McDonald R, Marks IM. Social
skills training of out-patient groups. A controlled study of
rehearsal and homework. Br J Psychiatry. 1977;131:599–609.
15. Chameides WA, Yamamoto J. Referral failures: a one-year
follow-up. Am J Psychiatry. 1973;130:1157–1158.
16. Chen A. Noncompliance in community psychiatry: a review
of clinical interventions. Hosp Community Psychiatry.
1991;42:282–287.
17. Ascher-Svanum H, Faries DE, Zhu B, Ernst FR, Swartz MS,
Swanson JW. Medication adherence and long-term func-
tional outcomes in the treatment of schizophrenia in usual
care. J Clin Psychiatry. 2006;67:453–460.
18. Cook J, Razzano L. Discriminant function analysis of com-
petitive employment outcomes in a transitional employ-
ment program for persons with severe mental illness. J Vocat
Rehabil. 1995;5:127–139.
19. Harding B, Torres-Harding S, Bond GR, Salyers MP, Rollins
AL, Hardin T. Factors associated with early attrition from
psychosocial rehabilitation programs. Community Ment
Health J. 2008;44:283–288.
MI for Cogrehab
20. Trémeau F, Goldman J, Antonius D, Javitt DC. Inpatients
with schizophrenia report impaired situational motivation
but intact global and social motivation. Psychiatry Res.
2013;210:43–49.
21. Choi J, Choi KH, Felice Reddy L, Fiszdon JM. Measuring
motivation in schizophrenia: is a general state of motiva-
tion necessary for task-specific motivation? Schizophr Res.
2014;153:209–213.
22. Miller WR, Rollnick S. Motivational Interviewing: Helping
People Change. 3rd ed. New York: Guilford Press; 2013.
23. Martino S, Carroll KM, O’Malley SS, Rounsaville BJ.
Motivational interviewing with psychiatrically ill substance
abusing patients. Am J Addict. 2000;9:88–91.
Downloaded from https://academic.oup.com/schizophreniabulletin/article/42/2/327/2518960 by guest on 20 July 2022
24. Burke BL, Arkowitz H, Menchola M. The efficacy of moti-
vational interviewing: a meta-analysis of controlled clinical
trials. J Consult Clin Psychol. 2003;71:843–861.
25. Hettema J, Steele J, Miller WR. Motivational interviewing.
Annu Rev Clin Psychol. 2005;1:91–111.
26. Carroll KM, Ball SA, Nich C, et al.; National Institute on
Drug Abuse Clinical Trials Network. Motivational interview-
ing to improve treatment engagement and outcome in indi-
viduals seeking treatment for substance abuse: a multisite
effectiveness study. Drug Alcohol Depend. 2006;81:301–312.
27. Kemp R, Hayward P, Applewhaite G, Everitt B, David A.
Compliance therapy in psychotic patients: randomised con-
trolled trial. BMJ. 1996;312:345–349.
28. Lundahl BW, Kunz C, Brownell C, Tollefson D, Burke BL. A
meta-analysis of motivational interviewing: twenty-five years
of empirical studies. Res Soc Work Pract. 2010;20:137–160.
29. Barkhof E, Meijer CJ, de Sonneville LM, Linszen DH, de
Haan L. The effect of motivational interviewing on medi-
cation adherence and hospitalization rates in nonadherent
patients with multi-episode schizophrenia. Schizophr Bull.
2013;39:1242–1251.
30. Drymalski WM, Campbell TC. A review of motivational
interviewing to enhance adherence to antipsychotic medica-
tion in patients with schizophrenia: evidence and recommen-
dations. J Ment Health. 2009;18:6–15.
31. Medalia A, Saperstein A, Choi KH, Choi J. The efficacy of a
brief psycho-educational intervention to improve awareness
of cognitive dysfunction in schizophrenia. Psychiatry Res.
2012;199:164–168.
32. Martino S, Carroll K, Kostas D, Perkins J, Rounsaville B.
Dual Diagnosis Motivational Interviewing: a modifica-
tion of Motivational Interviewing for substance-abusing
patients with psychotic disorders. J Subst Abuse Treat.
2002;23:297–308.
33. Martino S, Carroll KM, Nich C, Rounsaville BJ. A rand-
omized controlled pilot study of motivational interviewing
for patients with psychotic and drug use disorders. Addiction.
2006;101:1479–1492.
34. Rüsch N, Corrigan PW. Motivational interviewing to improve
insight and treatment adherence in schizophrenia. Psychiatr
Rehabil J. 2002;26:23–32.
35. Bellack AS, DiClemente CC. Treating substance abuse among
patients with schizophrenia. Psychiatr Serv. 1999;50:75–80.
36. Friedland J, Mandel H, Marcus S. Achievement Motivation
Profile. Los Angeles, CA: Western Psychological Services; 1996.
37. Canfield AA. Learning Styles Inventory. Los Angeles, CA:
Western Psychological Services; 1988.
38. Choi J, Mogami T, Medalia A. Intrinsic Motivation
Inventory: an adapted measure for schizophrenia research.
Schizophr Bull. 2010;36:966–976.
333
J. M. Fiszdon et al
39. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured
Clinical Interview for DSM-IV Axis I Disorders–Patient
Edition (SCID-I/P, Version 2.0). New York: Biometrics
Research Department, New York State Psychiatric Institute;
1996.
40. Kay SR, Fiszbein A, Opler LA. The positive and negative
syndrome scale (PANSS) for schizophrenia. Schizophr Bull.
1987;13:261–276.
41. Wechsler D. Wechsler Test of Adult Reading. San Antonio,
TX: The Psychological Corporation; 2001.
42. Keefe RS, Goldberg TE, Harvey PD, Gold JM, Poe MP,
Coughenour L. The Brief Assessment of Cognition in
Schizophrenia: reliability, sensitivity, and comparison with a
standard neurocognitive battery. Schizophr Res. 2004;68:283–297.
43. Keefe RS, Harvey PD, Goldberg TE, et al. Norms and
standardization of the Brief Assessment of Cognition in
Schizophrenia (BACS). Schizophr Res. 2008;102:108–115.
334
44. Patterson TL, Lacro J, McKibbin CL, Moscona S, Hughs
T, Jeste DV. Medication Management Ability Assessment:
results from a performance-based measure in older out-
patients with schizophrenia. J Clin Psychopharmacol.
2002;22:11–19.
45. Heinrichs RW, Goldberg JO, Miles AA, McDermid Vaz
S. Predictors of medication competence in schizophrenia
patients. Psychiatry Res. 2008;157:47–52.
46. Martino S. Contemplating the use of motivational interview-
ing with patients who have schizophrenia and substance use
disorders. Clin Psychol Sci Pract. 2007;14:58–63.
47. Velligan DI, Weiden PJ, Sajatovic M, et al.; Expert
Consensus Panel on Adherence Problems in Serious and
Downloaded from https://academic.oup.com/schizophreniabulletin/article/42/2/327/2518960 by guest on 20 July 2022
Persistent Mental Illness. The expert consensus guideline
series: adherence problems in patients with serious and
persistent mental illness. J Clin Psychiatry. 2009;70(suppl
4):1–46; quiz 47.