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Increasing Treatment Adherence

to Achieve Better Outcomes


Ashley J. Smith, PhD and Amy M. Jacobsen, PhD

Abstract: Cognitive behavioral therapy is an active


treatment that requires participants to master new, often
challenging skills. When patients are unable, for any
number of reasons, to participate in treatment activities
in and between sessions, outcomes will be suboptimal.
This article addresses adherence concerns, including the
use of behavioral strategies in and out of session. These
strategies, while framed within the context of anxiety
disorders treatment, are applicable to a wide range of
presenting problems across ages.
Amy M. Jacobsen
Keywords: motivation, treatment adherence, treatment
compliance, treatment outcomes

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

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Increasing Treatment Adherence to Achieve Better Outcomes

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.

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Increasing Treatment Adherence to Achieve Better Outcomes

Factors that Affect Adherence result from a number of factors, includ-


There are many factors, both within and ing poor insight, insufficient discomfort
outside of a patients direct control, that or interference in functioning (e.g., the
may affect the degree of adherence. teen with anxiety-related school refusal
who plays video games all day), previous
1. Lifestyle or logistical barriers. Other de- failed attempts to change or respond to
mands for time and energy may pre- treatment, poor self-efficacy, fear, and/
clude the completion of between-session or lack of understanding of the rationale
therapy assignments or prevent regular for treatment.
attendance of therapy sessions, both of 5. Severity of anxiety disorder symptoms.
which present adherence issues. Realistic Individuals with severe to extreme anxi-
constraints may include work or school ety disorder symptoms may feel little
requirements, childcare demands, other control over their symptoms or ability
health activities or appointments, finan- to resist engaging in anxious behaviors
cial constraints, and unreliable transpor- (e.g., compulsions or avoidance) when
tation, among others. Patients may also triggered. Moreover, some individuals
forget about homework assignments, with severe anxiety disorders may lack
especially if they are not in the habit of insight or awareness of the irrationality
completing them or find themselves busy of their fears. When overvalued ideation
with other tasks throughout the week. (i.e., belief in the fear) is high, the will-
2. Misunderstanding of treatment rationale ingness to engage in treatment activities,
or plan. CBT is a collaborative treatment such as exposures, often is attenuated.
approach in which patients are expected Anxiety may also inhibit participation in
to be active participants in the process. If sessions, limiting an individuals ability
patients do not understand the rationale to engage with new material and prac-
for treatment in general or for specific tice new skills (e.g., the young adult
components of the treatment protocol, who attended sessions but could not
their participation may be attenuated. give more than 12-word responses to
Likewise, if they do not have a clear buy direct questions and was unable to pro-
in for completing homework outside of duce spontaneous speech due to severe
session, they may be less likely to com- social anxiety).
plete assignments. 6. Comorbidity, including depression and
3. Lack of clear direction from provider. Pa- externalizing behaviors. Anxiety disorders
tients, particularly anxious ones, need often co-occur with conditions that may
clear guidance from their providers about interfere with effective treatment. For
what to do, when to do it, and the rationale example, depression symptoms, such as
for doing so. Low adherence or failure to low motivation, fatigue, and hopeless-
complete homework assignments may, ness, may hinder an individuals ability
in part, be due to lack of clear guidance to follow through with treatment activi-
and recommendations. ties. Similarly, externalizing disorders
4. Motivation for treatment. Motivation, de- such as attention-deficit/hyperactivity
fined as the desire and willingness to do disorder and oppositional defiant disor-
something, is critical for engagement der (ODD) may also impact adherence.
in the treatment process. Motivation A child who is unlikely to comply with
naturally waxes and wanes over time, routine instructions (e.g., brush your
necessitating consideration of how to teeth) is even less likely to comply with
maintain high levels throughout treat- instructions that may result in increased
ment and/or boost low levels when discomfort or anxiety (e.g., go to school).
needed. Low motivation to change may Any negative behaviors these children

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