Treatment Compliance in Cognitive Behavior Therapy

Description of the Strategy

A distinctive feature of behavioral and cognitive-behavioral therapies is the emphasis on acquisition of new skills and knowledge. Indeed, cognitive-behavioral therapists attempt to teach patients methods they can use throughout their lives to reduce and/or manage a variety of maladaptive behaviors and cognitions. Learning such strategies implies the importance of active participation in therapy assignments on the part of the patient. Such assignments, conducted both within and between sessions (i.e., as homework), are a cardinal feature of cognitive and behavioral therapies and are considered an essential mechanism of therapeutic change.

Consistent with the idea that cognitive-behavioral therapies are instructive is the assumption that therapy outcome is enhanced when the patient complies with the therapists' directives and assignments. Although the relationship between compliance and outcome is an empirical question, there has been only a limited amount of research in this area, most of which has been conducted on cognitive therapy for depression and cognitive-behavioral treatment for anxiety disorders. Most often, investigators have used correlational methods to examine this relationship. That is, some measure of treatment compliance is correlated with scores of preto posttest change during treatment. This allows researchers to determine whether [Page 601]patients who exhibit greater compliance with therapy assignments achieve better outcomes than do patients who demonstrate less compliance.

A number of studies suggest that compliance with homework assignments in the cognitive treatment of depression predicts higher rates of improvement. Homework in cognitive therapy typically includes (a) behavioral activation, which involves increasing one's daily activity level; (b) cognitive restructuring, which involves keeping a record of situations in which one feels depressed, using worksheets that assist with identifying and modifying underlying cognitive distortions; and (c) “behavioral experiments,” in which patients test out the validity of their modified (functional) beliefs and assumptions. It appears that adherence to instructions to perform specific behavioral experiments may be especially important. However, not all studies have consistently identified a relationship between compliance and treatment outcome in depressed patients.

Researchers have also examined the effects of compliance with behavioral therapy instructions in the treatment of obsessive-compulsive disorder (OCD) using exposure and response prevention (ERP). Therapy assignments in ERP include conducting prolonged and repeated exposure to situations that evoke obsessional anxiety (e.g., entering a public restroom) and resisting urges to perform compulsive rituals (e.g., changing one's clothes in the middle of the day). In addition to in-session practice under the therapist's supervision, patients are given assignments to practice exposure for homework. Studies demonstrate the importance of compliance with ERP both in and outside the treatment session and have shown that both shortand long-term effectiveness of therapy may be affected by compliance. Research on cognitive-behavioral treatment for other anxiety disorders, such as social phobia and panic disorder with agoraphobia, has also indicated that compliance with instructions might be an important variable that influences treatment outcome.

In theory, homework compliance could impact treatment outcome in both specific and general ways. Indeed, the practice of specific treatment procedures is intended to bring about a change in dysfunctional cognition and behavior and develop the patient's skill for modifying such problems. However, nonspecific effects of compliance must also be considered: The completion of any homework assignment may increase a patient's sense of accomplishment and self-worth and decrease their sense of helplessness, contributing to a reduction in psychological distress. Completing homework assignments may also assist the patient in recognizing the extent of their problem (i.e., self-monitoring), which might motivate further compliance. It is also important to be aware that homework compliance (or failure to comply) may elicit deleterious mood states, such as guilt, self-criticism, anxiety, or hopelessness in some patients. Such effects should be assessed in therapy and processed during the subsequent session.

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