Professional Documents
Culture Documents
Introduction
Cognitive behavioral therapy (CBT) is widely accepted
as the most effective therapeutic option for anxiety dis-
orders across the life span. CBT is an active treatment
modality that requires participants to practice and im-
Ashley J. Smith plement newly acquired skills in and out of session.
These skills are not always easy to master or effectively
Ashley J. Smith, PhD, and Amy
M. Jacobsen, PhD, are clinical
utilize in the moment when needed. When adherence is
psychologists with a combined low, for any number of reasons, treatment outcomes will
30 years of experience studying be suboptimal. Likewise, if patients evidence behavioral
and treating anxiety disorders. issues (e.g., opposition, noncompliance) in response to
Dr. Smith received her PhD from the
or outside of anxiety, progress will be limited without
University of NebraskaLincoln, and
Dr. Jacobsen received hers from The appropriate behavioral intervention. Frustration with
University of Georgia. Both have served treatment may mount, resulting in premature termina-
as staff psychologists at a nationally tion or, perhaps worse, prolonged yet ineffective treat-
recognized anxiety center and held ment. Monitoring adherence and effectively resolving
various academic appointments
before starting their respective
issues can facilitate better treatment outcomes.
private practices. They have numerous Although there are a number of strategies for increas-
scholarly publications, including a ing adherence, the use of behavioral techniques specifi-
recently released book titled Childhood cally can produce significant results both in and out of
Anxiety Disorders. Both maintain active
session. Unfortunately, many providers do not routinely
involvement in professional and
advocacy organizations and regularly use behavioral strategies to increase adherence, relying
present at local and national levels. instead on appealing to reason or trying to talk individu-
als into motivation. This article discusses factors that
influence adherence and general strategies designed to allow patients to practice newly
for boosting adherence and also addresses acquired skills to promote mastery as well
the rationale for using behavioral strate- as to use newly acquired skills to manage
gies based on operant conditioning princi- symptoms that arise in real time. The goal
ples (i.e., reinforcement and punishment) of CBT is for these skills to become a new
as part of this process. Specific strategies way of life to encourage continued man-
are described with verbal illustrations of agement and extinction of excessive anxiety.
their implementation. These strategies,
while framed within the context of anxi- What Is Adherence, and Why Is It
ety disorders treatment, are applicable to Important?
a wide range of presenting problems and Adherence, the degree to which a patient
diagnoses across ages. follows treatment recommendations, can
have a significant impact on treatment out-
A Brief Overview of Treatment for come. Put simply, treatments do not work
Anxiety Disorders if they are not implemented. In the case of
There are currently two primary empiri- mental health disorders, treatments often
cally supported treatments for anxiety hinge on actionable steps (e.g., take medi-
disorders across the life span: CBT and med- cine, do therapy homework, attend appoint-
ication with a serotonin-based agent, which ments on time, participate productively in
are recommended if lifestyle interventions, session), and active treatments like CBT re-
such as exercise and mindfulness-based quire out-of-session effort to be effective.
stress reduction, are not sufficient (Stein Participating in CBT to alleviate anxiety
& Craske, 2017). Both treatments indi- symptoms is much like pursuing physi-
vidually, as well as in combination, have cal fitness through diet and exercise. Sim-
proven effective for all anxiety disorders. ply talking about fitness will not lead to
A number of variables may impact which improvements; only consistent actions
treatment is chosen at which time as well will do that. Consistently making healthy
as the outcome of those treatments. For the eating choices and engaging in physical
purposes of this article, we will focus on activity are required. Again, consistency
CBT, although many concepts can be gen- is critical. Likewise, consistent practice of
eralized to pharmacological interventions cognitive, relaxation, mindfulness, and ex-
as well. posure skills is required to achieve lasting
CBT is a short-term active treatment improvements in anxiety management.
based on the conceptualization that Adherence issues are not unique to treat-
thoughts, feelings (physical and emotional), ment for anxiety disorders, or even mental
and behaviors are interconnected. An elabo- health disorders more broadly. Adherence
rate description is beyond the scope of this is a consideration in the treatment (or pre-
article; see Smith & Jacobsen (2017) for a vention) of most medical conditions (e.g.,
more detailed explanation. A typical CBT diabetes management, physical therapy to
protocol for anxiety disorders includes as- rehabilitate an injured body part). Even in
sessment, psychoeducation, skill building terms of general healthy lifestyle, we all
(e.g., cognitive restructuring, relaxation know that we should eat well and exercise
training, mindfulness), and/or exposure regularly, yet knowing what we should do
with response prevention (ERP) (i.e., in- and what we actually do are not always the
tentionally encountering and remaining in same. Within the context of anxiety dis-
the presence of anxiety-provoking stimuli orders, this is further complicated by the
to promote management and extinction of fact that patients are in part being asked to
anxiety). A hallmark of CBT is the use of complete activities that trigger discomfort
between-session homework assignments and anxiety.