When Dialysis Is Hard to Stick With, Which Therapy Helps Most?

When survival depends on routines you didn’t choose

Hemodialysis keeps people alive, but it also demands a relentless schedule: show up for sessions multiple times a week, take medications correctly, limit fluids, and follow a strict diet—often while feeling exhausted, itchy, nauseated, or emotionally worn down. In this setting, “non-adherence” (not sticking to the treatment plan) is rarely simple laziness. It is more often the end result of stress, low mood, fear, frustration, and the everyday logic of being human: we avoid what feels bad now, even if it harms us later.

This is why the Comparing the effectiveness of emotion regulation therapy and cognitive behavioral therapy on treatment adherence in hemodialysis patients: A randomized controlled clinical trial research paper matters. It doesn’t just ask whether therapy improves mood—it asks whether specific psychological tools help patients follow the routines that protect their bodies. The study directly compared Cognitive Behavioral Therapy (CBT) (a structured approach that targets thoughts and behaviors) and Emotion Regulation Therapy (ERT) (a skills-based approach focused on managing intense emotions) against standard care. In other words: when real-world medical adherence is on the line, which mental health approach moves the needle, and how long do those gains last?

What changed when patients learned new mental “moves”

This randomized controlled trial assigned 90 hemodialysis patients to CBT, ERT, or standard care (30 per group), with some dropout in each group. The researchers tracked adherence in five areas: dialysis attendance, medication use, fluid restriction, dietary regimen, and total adherence, measured before treatment, right after, and again at a 3‑month follow-up.

The headline result is straightforward: both CBT and ERT improved adherence compared to standard care, and the control group tended to worsen over time. But the therapies didn’t help in exactly the same way. CBT produced the strongest immediate jump in overall adherence—total scores rose about 28% after treatment, while ERT rose about 10%. One practical way to picture this: CBT seemed to help people do the hard “behavioral” parts more reliably, like resisting the extra glass of water or sticking to food limits when cravings hit.

CBT’s biggest edge showed up in fluid restriction, where improvements were striking (about a 56% gain versus roughly 8% for ERT). ERT, however, appeared to hold its ground better in at least one meaningful area: medication adherence over time. At follow-up, CBT still led overall, but both groups showed some decline from post-treatment peaks in dialysis-specific adherence—suggesting that staying consistent with appointments may be influenced by obstacles beyond mood and motivation (transportation, fatigue, competing responsibilities).

Why CBT surged early—and why emotions still matter later

To make sense of these patterns, it helps to consider what each therapy trains. CBT is often built around clear problem-solving: identify unhelpful thoughts (“One slip won’t matter”), test them against reality (“My weight gain between sessions affects my heart”), and build concrete plans (“If I crave fluids after dinner, I’ll rinse my mouth and use a measured cup”). It also uses behavioral activation and habit design—small steps that reduce reliance on willpower. In dialysis adherence, this structure can translate quickly into action, which fits the study’s strong post-treatment boost.

ERT focuses more on what happens when emotions run the show: panic, anger, shame, hopelessness, or the numb “why bother” feeling. These states often trigger short-term relief behaviors: drinking more fluid to soothe dryness and anxiety, skipping sessions to avoid discomfort, or disengaging from medication routines when life feels uncontrollable. ERT teaches patients to notice emotional waves earlier, name them accurately, and respond with skills instead of automatic coping. That may explain why ERT looked comparatively steadier in medication adherence—taking pills is a daily, repetitive behavior that can falter when people feel defeated, resentful, or overwhelmed. Learning to tolerate those emotions may protect the routine.

This “CBT for quick traction, ERT for emotional endurance” idea fits broader psychological theory. CBT aligns with research on implementation intentions (“If X happens, I do Y”) and self-monitoring, which reliably improve health behaviors. ERT overlaps with the science of emotion regulation and distress tolerance, skills linked to better long-term coping in chronic illness. Consider a realistic clinic snapshot: one patient can follow the diet in the morning, but after a stressful family argument, they impulsively drink or eat off-plan. CBT can help by planning alternatives in advance; ERT can help by reducing the emotional “temperature” that makes the impulse feel urgent. The study suggests that, in this trial, CBT moved behavior more sharply, while ERT supported a different layer of adherence—staying engaged when emotions make the regimen feel unbearable.

How dialysis teams, families, and workplaces can use this tomorrow

The most practical takeaway from this research paper is that adherence improves when psychological care is treated as part of medical care—not an optional add-on. Dialysis centers could use a stepped approach:

1) Use CBT-style tools for the highest-friction behaviors.
Fluid restriction and diet are “in-the-moment” decisions. CBT can help patients map triggers and build specific alternatives. Example: if a patient drinks excessively during TV time, the plan might include pre-measured bottles, sugar-free gum, and a written “urge plan” posted near the couch. This reduces decision fatigue and makes adherence less dependent on mood.

2) Add ERT-style skills for the emotional bottlenecks.
When patients say, “I’m tired of all these rules,” that’s not merely a thought error—it’s emotional exhaustion. Teaching brief emotion skills (naming the feeling, paced breathing, “urge surfing,” or values-based coping) can prevent a spiral where shame leads to avoidance, and avoidance leads to worse labs, and worse labs lead to more shame.

3) Apply the same logic beyond healthcare.
In families, caregivers can stop framing adherence as “being stubborn” and instead ask: is the barrier practical (needs a plan) or emotional (needs regulation)? In workplaces, managers supporting chronically ill employees can offer predictable scheduling (reduces stress load) and private check-ins (reduces stigma), which indirectly improves medical consistency.

Finally, the study hints at a strategic clinical choice: if a team needs a rapid adherence boost, CBT may be the first-line option; if a patient’s main struggle is emotional collapse, resentment, or panic, ERT techniques may prevent dropout from the regimen. Many patients will need both.

The lasting message: adherence isn’t just discipline—it’s psychology

This trial shows that targeted therapy can change what many people assume is “just compliance.” In the Comparing the effectiveness of emotion regulation therapy and cognitive behavioral therapy on treatment adherence in hemodialysis patients: A randomized controlled clinical trial research paper, CBT delivered the strongest short-term gains, especially for difficult behavior targets like fluid restriction, while ERT offered meaningful improvements and may support adherence where emotions quietly sabotage daily routines. The follow-up dip in some areas is a sober reminder: dialysis adherence lives in the real world, where fatigue, logistics, and life stress don’t disappear after therapy ends.

The most memorable takeaway is simple: if we want patients to stick with life-sustaining care, we must treat the mind as part of the treatment plan. The question for clinics isn’t whether they can afford psychological support—it’s whether they can afford not to, when adherence is the difference between stability and crisis.

Data in this article is provided by PLOS.

Tagged Behavior, Behavioral and social aspects of health, Chronic kidney disease, Clinical psychology, Cognitive psychology, Cognitive science, Diet, Emotions, Medical dialysis, Mental health and psychiatry, Mental health therapies, Nephrology, Neuroscience, Nutrition, Psychotherapy, Public and occupational health, Renal diseases