At the end of the day all the talking and insight in the world is worth nothing if it does lead to a change in behaviour and a resulting change in outcomes for a client. At some point in time what is learnt, understood or acted out in the therapy room has to generalise to the client’s everyday world.
This translation from therapy room to real life is often done using homework exercises in cognitive behavioural therapy. A frequent complaint I hear in supervision is that the client turns up but hasn’t done their homework. This often generates a sense of frustration in the therapist leading to a label of being resistant used more pejoratively that psychologically.
If a client is not doing their homework but is turning up regularly for therapy it is not in my view useful or accurate to say the client is resistant to change. It is more useful to say the client has conflicting motivations about change. Clients may avoid working in therapy because they fear it will not work and this will reinforce their hopelessness. At the same time client may avoid working in therapy because it will work and then they will have to take responsibility for themselves and get on and have a life which can be scary stuff.
The very fact that they continue to come to therapy suggests that some aspect of them believes in or wants to change. Highlighting this as a conflict and exploring the mixed motivations using a cost benefit analysis technique frequently uncovers a way forward.
Calling it homework often casts in the frame of teacher and pupil with accompany memories of school, sometimes for the worse. It also puts it into a frame that this something the client is doing for somebody else i.e. the therapist rather than for themselves. At the same time I have never been totally comfortable with other descriptions such as activity scheduling or behavioural experiments.At the end of the day I usually come back to calling it homework.
There area number of good books and articles on using homework in a cognitive behavioural framework. Leahy’s great book; Overcoming Resistance in Cognitive Therapy covers homework problems in his chapter on process resistance. There has been a recent book published devoted entirely to homework in CBT whose authors include our own Professor Frank Deane. The book is called Using Homework Assignments in Cognitive Behavior Therapy. Judith Beck has some brief suggestion in her book: Cognitive Therapy: Basics and Beyond
Before exploring client resistance to homework it is useful to check that therapist or delivery issues are not interfering with homework completion. In my view it is always best to start with something small and simple and build on success. Far easier to be able to be positive about a success than it is to re-engage a client who feels like they have fialed you or themselves. Beginning therapists often carry beliefs about homework such as more is better. While compliant and compulsive clients may go off and complete all the homework given there will also be a feeling of resentment that may impact on the therapeutic alliance at a later stage.
Failure to complete the first small and simple homework is often a good indicator that the client has conflicting motivations about homework and this need to be explored as they also often reflect conflicting motivations about engaging in therapy.
Does the client understand the homework?
Tell me in your own words what you think you will doing with your homework over the week
I would just like you to complete the first part of the thought diary so I can see that you understand what you need to do.
Does the client understand the purpose of the homework?
I have asked you to monitor all your negative thoughts when you are in social situations over the week. How do you think this will help you with your therapy?
Be specific about what constitutes completion how often when and where it should occur. Think about using a homework prescription or written contract about what they are to complete. Here is an example of a homework prescription.
Explore ambivalence about completing homework in session. Often a simple way to do this is to ask:
On a scale of 1 to 100 what would be your confidence rating that you would complete this homework?
If the response is less than 70% then this needs to be explored
Cognitive therapy works on building blocks; if the foundations are not in place then effective therapy cannot continue. The purpose of homework is to cement these blocks in place. From this perspective homework must be completed to move onto the next step. If the client is not able to identify negative thoughts in their environment then moving onto to challenging these thoughts is a waste of time.
If homework is not completed then completing homework becomes the goal of the next therapy session. This may involve the need to explore motivationally why the homework was not completed before moving onto to complete the homework to some degree.
The second part of this posting will explore in more depth client resistance issues in homework completion.