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A review of client compliancy with suggestions for counselors.

One difficulty faced by many counselors in the helping profession is client non-compliancy. Presumably, clients enter into counseling with a desire to change. This article provides a theoretical perspective, and a brief review of the literature on compliance. An operational definition of compliance is offered along with suggestions for counselors on how to better increase client compliancy.

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Nearly two decades ago, Stone (1979) asked an intriguing question directed primarily toward physicians, but equally applicable to counselors: Why would a client who has gone to the trouble and expense of seeking out a helper, of undergoing stressful tests and other diagnostic procedures, and of receiving advice from a professional, then fail to follow the recommendations? The advice of persons who are acknowledged to be experts and who are supposed to develop and disseminate expert knowledge is often ignored; indeed, such "non-compliance" among clients is widespread (Stone, 1979). Based on our reading of the literature on compliance, perhaps a reasonable estimate of those clients who do not complete homework assignments or follow their counselors advice is approximately one-third! Thus, many non-compliant clients may simply not receive the full benefits of their counselor's expertise.

Clearly, variables associated with client compliance are numerous and interrelated (i.e., economic factors, attitudes of family members, nature of the illness, demographic factors such as gender, age, race, education, socioeconomic status, misunderstanding of the counselor's written instructions (Haynes, 1976)). One category of factors, however, that has been consistently found to be related to client compliancy is the quality of the interactions between the client and the counselor. Of course the notion that the quality of the therapeutic relationship - the working alliance - is critical to the counseling process and is often the cornerstone to client change (cf. Rogers, 1951) should come as little surprise to counseling practitioners.

Promoting healthy client change is an important counseling skill. Such a goal implies that the counselor can positively influence the client to alter specific self-defeating opinions, attitudes, and behaviors after the client leaves the session (Heppner & Dixon, 1985). The notion that one person can influence the actions, attitudes, or feelings of another person is the central theme of the interpersonal influence theory (Strong, 1968).

A Theoretical Perspective on Compliance

The theoretical perspective used in this study to explain compliancy is the interpersonal influence process theory by Strong (1968). A comprehensive review of this theory can be found elsewhere (see Heppner & Claiborn, 1989). For those readers unfamiliar with Strong's theory, however, a general overview is presented. Strong (1968) initially conceptualized counseling as an interpersonal influence process, as he. explicitly integrated social psychological concepts (i.e., Festinger's (1957) cognitive dissonance theory) into counseling. The interpersonal influence model stressed that the client's thoughts, feelings, and behaviors result from the interactive forces operating on the client during the actual counseling process. The theory focuses on the "here and now" not the "if and when" or "there and then"; concentration rests solely on the dynamics between two individuals in therapy - the client and the counselor.

Influence is unavoidable according to Strong (1968). Thus, influence theory maintains that the degree to which the client perceives the counselor as an expert, as trustworthy, and as attractive, is the degree to which the client is likely to adhere to an outside assignment suggested by the counselor. Expertness has been defined as the client's belief that the counselor has the knowledge and means of interpreting this knowledge which will allow the client to obtain a valid conclusion about and to deal effectively with his or her problems. More specifically, client perceptions.

of the counselor as a source of expertness can be influence by (1) objective evidence of training and reputation (i.e., diplomas, certificates, titles, awards, room furnishings, attire, office decor), (2) behavioral evidence (i.e., rational and knowledgeable discussion about homework assignments, confidence in presentation, being organized and attentive, use of structuring, making interpretation responses, suggesting specific behavioral treatment approaches, discussing steps involved in problem-solving, reinforcing efforts towards problem-solving), and (3) reputation as an expert (the more prestigious the introduction, the more positive the reputation).

Counselor trustworthiness is a function of the counselor's (1) reputation for honesty, (2) social role as a counselor, (3) sincerity and openness, and (4) perceived lack of motivation for personal gain. In essence, trustworthiness is enhanced when counselors communicate their concern for the client's welfare, assure the client of confidentiality, and pay close attention to the client's statements.

Counselor attractiveness, as defined by Schmidt and Strong (1971), is the client's positive feelings about the counselor, such as liking and admiring the counselor and desiring to gain his or her approval. Strong (1968) proposed that, for the most part, counselor attractiveness was based heavily on the counselor's behaviors within the session such as displays of unconditional positive regard, accurate empathy, self-disclosures, and appropriate nonverbal behaviors.

In the second phase of counseling, the counselor makes appropriate use of his or her influence to encourage the client to make desired changes in their cognitive and behavioral domains. Thus, counselors may use suggestion, advice, urging, role-playing, behavioral enactment and practice, and homework assignments to increase the likelihood of client change.

Definition of Compliancy

Throughout much of the literature, client compliancy and treatment adherence are often used interchangeably (i.e., Barlow, Macey, & Struthers, 1993; Connelly, Davenport, & Numberger, 1982; Frank, Kupfer, & Siegel, 1995; Rudman, Gonzales, & Borgida, 1995). However, one of the most striking differences between the two terms is where they are discussed in the literature. Studies on compliancy are widespread in the psychological literature, whereas most writings on adherence are in the medical and psychiatric literature. Another difference between compliance and adherence was articulated by Meichenbaurn and Turk (1987) and Levy (1987). They maintain that the term compliance connotates a passive approach, whereby the client merely follows advice of the counselor, suggesting that the counselor has some degree of power over a client. Conversely, adherence suggests a more active, voluntary behavior on the part of the client. In general, however, most authors use the two terms interchangeably.

Of the multitude of definitions of client compliancy, most seem to have in common some aspect of behavior which results from a request given by another person. For example, Haynes (1979) described compliance as the degree to which an individual's behavior matched the advised behavior given to that person. Others have defined compliance more in terms of the client/therapist relationship. For example, compliancy has been described as client participation resulting from interactions in the client and helper's relationship (Woody, 1990). Rheiner (1995) defined compliance as the performance of agreed upon actions which the client and helper believe will promote improvement.

For ease of reading, compliancy will be used consistently throughout this paper when discussing client adherence or client conformity. Indeed, some definitions of compliancy include the word adherence (i.e., compliance is the degree to which the patient adheres to the treatment as prescribed (Davidson, 1976)).

Most studies do not actually define compliance. Often the only way to discover how compliance is operationalized in particular studies is to examine its measurement. For instance, the measurement of compliance for pharmacotherapy may be regular serum level measurements leading one to believe that taking medication is a possible definition of compliance. Similarly, assessing compliance through a review of homework assignments at the beginning of sessions implies that completion of homework is another possible definition of compliance (cf, Frank, et. al., 1995). Still other authors have limited their definitions of compliance to session attendance. For example, both Mattson, Seese, and Hawkins (1969) and Taylor and Stansfield (1984), studied suicide attempters and their subsequent compliance to treatment. in these studies, compliance was defined as attendance of at least one session following emergency room attention. Because many studies of compliance do not actually define the term and those that do alternate between using the terms compliance and adherence, it is difficult to put forth one standardized, or consistently used definition of compliancy. Therefore, for the purposes of our paper, compliancy will be operationalized as that behavior which occurs when a client fully participates in the outside-of therapy assignments, both behaviorally and psychologically. These behaviors, which are to be decided upon by the counselor and the client, are those which have been determined to promote psychological growth or alleviate emotional distress. This definition of compliancy requires the client to not only be present at all sessions [unless the helper and the client mutually agree that the absence is necessary], but completing to the best of his/her ability all homework assignments given. If the client and the helper, however, do not mutually agree that the assignment will not promote growth or alleviate distress, then the client cannot be expected to fulfill the assignment.

An Abbreviated Overview of Compliancy

Client compliance has been extensively studied and written about for decades. To illustrate how often compliancy is discussed, it should be noted that even a decade ago there were more reviews of the literature on compliance than actual studies on the subject (Meichenbaum & Turk, 1987). The rate of reviews since then have seemingly not decelerated. Detailed reviews of the literature on compliance can be found elsewhere (cf Levy, 1987; Meichenbaum & Turk, 1987; Stone, 1979). Compliance is seemingly a problem encountered by most health care providers. One difficulty associated with compliancy is how to measure it. No published, standardized psychological measures of client compliancy could be found at the time of this paper. Indeed, there are no consistently used objective clinical measures of compliancy. Most measures vary in both scope and detail. Meichenbaum and Turk (1987) suggest that an array of measures be used simultaneously to assure that compliancy is being properly measured.

Compliance is a multi-leveled construct. There are numerous methods of observing, conceptualizing, and managing compliancy in therapeutic contexts. One of the few designated models of compliance was developed for physical rehabilitation programs (Rheiner, 1995). This model of compliancy appears somewhat applicable to a psychological setting. The model suggests that: (1) the client's readiness to participate; (2) certain barriers to participation (i.e., environmental, program, societal, and financial barriers); and (3) behavioral manifestations of compliance (i.e., does the client complete homework and show-up at sessions) should all be accounted for in researching compliance. Other writers on compliance also agree that the above stated aspects of compliance do exist (Amaral, 1986; Blackwell, 1976; Fleury, 1991; Frank, Kupfer, & Siegel, 1995; Hulka, Cassel, Kuppel, & Burdette, 1976; Levy, 1987; Levy & Carter, 1976). However, items such as readiness to participate may be more problematic in assessing and defining than the other aspects.

Some researchers have broken compliance into parts, including session attendance and homework completion (Hansen & Warner, 1994). Several factors, including educational level and age of the client, have been attributed to whether compliance occurs by examining specifically attendance or homework completion. For example with respect to session attendance, it has been determined that clients with more than 11. 5 years of education attend sessions significantly more than clients with 11. 5 or fewer years of education (Hansen & Warner, 1994). Similarly, in summary of studies of demographic factors, Haynes (1976) also reported that compliance increases with level of education. Hansen and Warner (1994), however, observed no significant difference in rates of homework completion for court ordered vs. not court-ordered clients.

While some studies have found that compliance increases with age (Haynes, 1979), studies have demonstrated that age is negatively related to compliant behavior, more specifically, to homework completion (cf, Hansen and Warner, 1994). In a study of adolescents, those terminated from therapy for noncompliance significantly differed in their ages, with older clients being terminated more. (Piacentini, et. al., 1995). One possibility for this difference lies in the hypothesis that the acceptability of treatment is associated with higher levels of compliance (Elliott, 1986; Kazdin, 1981; Wolf, 1978). Older individuals have been found to evaluate treatments more negatively than younger individuals (Waas & Anderson, 1991). Thus, it is possible that older individuals might be less accepting of a negatively evaluated treatment and be less likely to comply.

The quality of communication between the counselor and the client has also been found to relate to compliance. Counselors should not only clearly communicate any instructions for attendance and any homework which is assigned (Rheiner, 1995), but should also be cautious of how they are perceived by the client. If the client perceives the helper's attitude differently than expected, compliancy is likely to decrease (Hansen, 1986). It is likely that clients who believe they are being treated with respect are likely to be more compliant (Stone, 1979). Additionally, if clients feel that the counselor is providing more personal treatment, as opposed to being "strictly business," then they are also more likely to be compliant (Geersten, Gray, & Ward, 1973).

Additional studies on compliancy have examined the relationship between client personality and compliancy. Using the five factor model of personality, Christensen and Smith (1995) found that "conscientiousness" was the only factor positively associated with compliance. Despite all the investigations of the role of single elements in compliance, it has been suggested that client personality alone is not as descriptive of why compliance occurs. It is instead suggested that there exists a circular system involving the client, the setting of treatment, and the helper which ultimately determines the degree of compliance (Stunkard, 1981).

In summary, compliance is a phenomenon which has received much attention in the literature. There is more than one way to define compliance, and while there are no standardized methods of measuring compliance, most researchers divide compliance into two parts: session attendance and homework completion. Factors which have been found to influence compliance include the educational level and age of the client, as well as the quality of communication between the helper and the client. There appears to be no significant differences in compliance between voluntary and court-ordered clients. Finally, there is some evidence that the current trend in studying the characteristics of the counselor, as well as those of the client, may influence compliance.

Suggestions for Counselors

One of the most thorough and eloquent reviews on the treatment of compliancy and adherence within the helping profession was written by Meichenbaum and Turk (1987). It is their contention that the complexity and multi-determined nature of treatment noncompliance coupled with the heterogeneity of the client population makes the "integrative" approach to interventions most appropriate. Consistent with the theoretical position offered in this paper, most of the suggestions below focus on the dynamics between the counselor and the client, and, specifically, on the counselor's behavior during the counseling session. What follows, then, is an outline of the several guidelines offered by Meichenbaum and Turk (1987) and Worthington (1986) to reduce client noncompliance,

1. Anticipate noncompliance: Concerns about compliance should be part of the entire treatment program starting with the first meeting. Counselors should stress early on the importance of what the client does, not only during the session, but after the session. Assessing the client's sense of helplessness verses self-efficacy as well as life circumstances that might affect compliancy (e.g., financial resources, work schedule) should also be taken into account.

2. Consider the homework assignment from the client's perspective: Counselors should not assume that their clients will perceive things in the same manner as they do. Clients often have other commitments, demands and life situations that may be more critical than their presenting problem. Thus, counselors should involve the client actively in treatment planning and decisions through mutual goal setting to ensure that client priorities are considered. Counselors should discuss cost, risks, and benefits of a given assignment and set realistic goals.

3. Promote a collaborative relationship based on negotiation: Improving the quality of life is generally the overall goal for most clients. Therefore, giving the client some options concerning the timing of the assignment (i.e., try talking to your parents sometime this week, instead of requiring the client to talk with her parents this Saturday) is better than giving no options. Counselors must be flexible, willing to negotiate within reason, and communicate empathy and respect for the client.

4. Be client-oriented: It is important to listen not only to what the client says but to what he or she fails to state. Perhaps the reason a client does not ask questions is because the client was not listening, did not understand the assignment, or does not plan to follow the homework assignment. Counselors should use clear and specific verbal and written communications. Often times asking client to repeat what they are supposed to do is helpful. Also, counselors should provide feedback and positively reinforce clients' efforts even if the homework assignment was not successful.

5. Customize treatment: There is no such thing as a typical homework assignment for a typical client. Whenever possible the counselor should use the simplest possible assignment that is reasonably likely to produce the desired goal. It may also be helpful to provide demonstrations (i.e., role-playing for practice and feedback).

6. Enlist family support (if possible): Make sure family members or other significant people in the client's life understand the goals of the homework assignment so that they can be enlisted as allies, if possible.

7. Provide a system of continuity and accessability: Clients must view the counselor as an advocate who is accessible, nonjudgmental, competent, knowledgeable, respectful, and genuine in his or her desire to cooperate with them. It is important that clients feel comfortable to ask questions, raise concerns, and be willing to admit that they are confused.

8. Repeat everything: Initial compliancy does not guarantee that compliancy will continue; a counselor should expect some degree of dissipation of compliancy over time. Thus, it is critical to monitor compliancy throughout the entire counseling process.

9. Don't give up: It is too easy to give up on noncompliant clients, simply labeling them uncooperative and stubborn. Do not blame the client! Look first at yourself and reevaluate the appropriateness of the assignment.

10. Establish sound relationships: As others have observed (DiMattes & DiNicola, 1982; Stone, 1979), accuracy of client self-report of compliance depends largely on the quality of the counselor-client relationship. Thus, counselors who develop a strong working alliance with their clients are simultaneously increasing the likelihood of their clients completing homework assignments.

11. Don't forget "therapy" variable: Several important therapy variables, as opposed to counselor or client variables, seem to promote client compliancy. Some of these variables include: clear design of the assignment; verbal commitment by the client; monitoring homework assignments (that is, counselors explicitly attending to the homework assigned the previous session); checking the clients attitude prior to assigning the homework; assigning homework during the early stages of counseling; and amount of time clients actually spend in counseling (that is, the longer they remain in counseling, the more likely they will complete assignments).

12. Start slowly: Studies have shown that compliance with a small request and the use of positive labeling can have a powerful impact on client motivation to change in counseling. Thus, counselors should design initial homework assignments modestly with a high probability of success and only then move towards more demanding outside work. The technique of starting clients off with a small homework task and gradually assigning larger homework assignments is referred to as the foot-in-the-door technique (see Sharkin, Mahalik, & Claiborn, 1989).

Client noncompliance should be a concern to all those who practice the art and science of counseling. We hope this article, especially the dozen suggestions offered, will provide useful information to counselors which will ultimately result in a decrease in client non-compliancy.

References

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Mark J. MILLER, PH.D.
WILLIAM E. KELLY, PH.D.
University of Nevada, Las Vegas

JEROME J. TOBACYK, PH.D.
Louisiana Tech University

ADRIAN THOMAS, PH.D.
ERNEST L. COWGER, PH.D.
Louisiana Tech University
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Miller, Mark J.; Kelly, William E.; Tobacyk, Jerome J.; Thomas, Adrian; Cowger, Ernest L.
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Date:Dec 1, 2001
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