THERAPIST DIRECTIVENESS AND HOMEWORK COMPLIANCE IN COGNITIVE BEHAVIOR THERAPY

Homework is an essential part of Cognitive Behavior Therapy and research has shown that homework compliance improves the outcome of therapy. However, there is little research on what factors enhance homework compliance. Studies in other areas have shown that directive therapist styles are more likely to elicit resistance and non-compliance, while supportive (low directiveness) styles are more likely to elicit cooperation and compliance. We propose a study that rates therapist behavior while assigning homework in CBT on a scale of directiveness. We predict that more directive therapist styles will be associated with less homework compliance than more supportive styles. Introduction Cognitive Behavior Therapy (CBT) has been shown to be an effective treatment for many disorders, but very little research has been done on a critical component of the therapeutic process: homework. In general terms, CBT seeks to modify problematic thoughts and beliefs that are related to negative emotions and debilitating behavior. Homework is described as between-session activities suggested by the therapist which are designed to help treatment along. It can help the client actualize their desired changes in their day-to-day life and not just in the presence of their therapist. Homework assignments vary depending on the psychopathology of the client, but often consist of keeping thought diaries, trying activities that may have been avoided in the past, relaxation exercises, or other activities deemed helpful by the therapist and/or client, though there is no firm, official definition “homework” in existence (Kazantzis & Ronan, 2006). Assigning homework is a common technique used by practicing therapists, especially in CBT. Kazantzis and Deane (1999) found that an overwhelming 98 percent of the practitioners they surveyed used homework. Additionally, CBT practitioners assigned homework in 66 percent of sessions, compared to 48 percent of sessions of non-CBT practitioners. Most therapists say that they value homework’s important and find homework noncompliance to be a problem (Helbig & Fehm, 2004). We should be cautious in interpreting retrospective data like practitioner surveys, but it can still be worthwhile to examine therapist attitudes and the presence of homework in practice. Studies have shown that homework is a key factor in overall treatment success. Kazantzis, Deane, and Ronan (2000) did a meta-analysis of all the studies on homework they could find since 1980, 27 total, and found that homework completion had significant positive effects on therapy outcome, across all disorders and assignment types. They also found homework completion to be a predictor of therapy outcome across all groups. In addition, the more homework that clients complete, the more they improve (Burns & Spangler, 2000). Yet not much is known about factors that may affect homework compliance. Different factors could be client characteristics, the type of psychopathology, the appeal of the homework assignment, the therapist’s technique in assigning the homework, and more (Tompkins, 2002). If these factors could be identified and appropriately manipulated, homework compliance would increase, thus making therapy far more successful. Review of the Literature There have been studies of homework in clients with various disorders, many of them showing positive correlations between homework and therapeutic outcomes (Abramowitz, Franklin, Zoellner, & DiBernardo, 2002; Edelman & Chambless, 1995). Researchers found that, among other factors, homework completion in clients with depression predicted further change and improvement (Addis & Jacobson, 2000). The incorporation of homework in CBT for schizophrenia helps clients improve at least 60 percent more than those not assigned homework (Glaser, Kazantzis, Deane, & Oades, 2000). Another study of clients undergoing treatment for cocaine abuse (Gonzales, Schmitz, & DeLaune, 2006) found that among individuals with high motivation to change, homework compliance predicted lower levels of cocaine usage during and after the treatment phase. Other researchers reported that homework compliance led to lower social anxiety after treatment for social phobia, especially homework assigned at the beginning and end of treatment (Leung & Heimberg, 1996). CBT is at present the most effective and accepted treatment for Generalized Anxiety Disorder (GAD), but has not as yet yielded strong outcomes (Durham et al, 2004). GAD is considered to be the least CBT-responsive anxiety disorder (Campbell & Brown, 2002). A review of data from six controlled outcome studies of CBT for GAD found an average recovery rate of 40%, with the majority of treatments producing rates of less than 30% (Fisher and Durham, 1999). These numbers have a lot of room for improvement. GAD clients can be a particular challenge to assign homework to because they often have expectations for immediate results, demands for certainty, perfectionist beliefs, and excessive, debilitating worry (Leahy, 2002). It seems reasonable to assume that if homework compliance in treatment for GAD can be increased, stronger outcomes will result. What appears to have a strong influence on client compliance is the therapist’s behavior. Patterson and Forgatch (1985) observed that therapists using directive techniques, which they described as “teach” and “confront” behaviors, elicited more noncompliance from clients compared to therapists using “facilitate” and “support” behaviors. When the therapist used a less directive style, they were less likely to be met with resistance and noncompliance, which is particularly important for homework assignment. In another study, Miller, Benefield, and Tonigan (1993) examined the effect of therapy style on problem drinkers seeking counseling. One group received “directive-confrontational counseling,” another “client-centered counseling,” and a third was a control group. The clients in directive therapy showed more resistance and poorer outcomes one year later than those in the supportive group. Furthermore, a study of patients with psychosis found that a high therapeutic alliance predicted high levels of homework compliance (Dunn, Morrison, & Bentall, 2006). These studies show that therapist style has a significant effect on therapy and its effectiveness, and suggest that a less directive style may be preferable for reducing noncompliance. A method known as Motivational Interviewing (MI, Miller & Rollnick, 1992) has been shown to be effective in increasing motivation to change. It uses a highly non-directive and supportive style and is particularly useful for clients who are resistant to change and who have low motivation. A recent study (Westra, Arkowitz, & Dozois, 2007) found that a combination of MI and CBT achieved better therapeutic outcomes than CBT alone. One group was given a pretreatment of MI before entering CBT, while another group received no pre-treatment, and the first group saw more improvement from the CBT. The MI pre-treatment may have helped the participants become more motivated and comfortable and to figure out their treatment goals. This study, and other data on the efficacy of MI, lends support to the value of a supportive vs. directive style in therapy. The studies reviewed above suggest the hypothesis that a supportive style of assigning homework in CBT will lead to greater compliance than a more directive style. Proposed Future Research Data has been made available to us from a study at York University in Canada, on which Dr. Arkowitz is a co-Principal Investigator (Westra, Arkowitz, & Dozois, 2007). Individuals seeking treatment for Generalized Anxiety Disorder participated in either the combination of MI and CBT or CBT only. Using the CBT only group, we will examine the segment during which the therapist assigns homework, rate them on degree of therapist directiveness, and correlate these ratings with homework compliance. Methods Participants Participants were clients and therapists who participated in a study of an MI-CBT combination vs. CBT only for Generalized Anxiety Disorder. The study was conducted at York University. Measures Therapist behavior while assigning homework will be coded on an author-made seven-point scale of directiveness. Directiveness is defined as the therapist being authoritative and telling the client what to do rather than asking for input in constructing the assignment. A highly directive therapist’s language focuses more on “I” and what they want rather than “you” and what the client wants or could be able to do. The scale of therapist directiveness is presented below. 1 2 3 4 5 6 7 Almost no directiveness Medium directiveness Very directive, instructive Asks for client input Allows for some input but not directly No client input at all Procedure Two undergraduate Psychology students at the University of Arizona will be recruited to code the therapists’ behavior on the directiveness scale. Both will be taught the definition of directiveness, but will not be told the hypotheses of the study. They will watch examples and practice coding until their ratings are not significantly different, and then move on to coding the recordings for the study. Their ratings will be correlated with the therapists’ measures of homework completion. Predicted Results We anticipate finding a negative correlation between therapist directiveness and homework compliance: the more directive the therapist, the lower the homework completion. Discussion If the hypothesis is confirmed, it would suggest that the more supportive a therapist is when assigning homework, the more likely the client is to complete the homework, and will likely see more improvement from the therapy. It would mean that regardless of the clients’ personality, intrinsic motivation, the severity of their anxiety, or the type of homework that was assigned, the therapists’ style of assigning the homework had a significant effect on compliance. Of course, furth