By Bernard Schwartz, PhD, author of How to Fail as a Therapist
This is the part 2 of "Three Main Reasons Clinicians Fail Their Clients."
3. The Homework Assignment Trap
Providing clients with opportunities to apply what they have learned in therapy is one of the keys to therapeutic effectiveness. This makes good sense, given that clients spend only an hour or two per week in therapy. So it would stand to reason that most therapists would regularly utilize out-of-session activities as part of their therapeutic arsenal. However, the sad truth is that most therapists report never using such assignments. Why would there be this disconnection between what the research shows and what most therapists do?
What the research doesn’t show is that creating homework assignments that clients comply with is a tricky business—and there are a multitude of therapeutic errors that can interfere with the process.
A case history will help illustrate:
Dr. Bloom was working with Sabrina, whom he diagnosed as socially phobic. Sabrina had difficulty in her college classes, worrying excessively about bringing attention to herself. To avoid the possibility of embarrassment, she always arrived early to class, sat in the last row, and never raised her hand. After several weeks of therapy in which he gave her no assignments, Dr. Bloom decided it was time for action and suggested that Sabrina arrive five minutes late to her next class meeting. At her next session, Sabrina at first told her therapist that she forgot to do the assignment but later admitted that she could comply with the first part of the assignment—being late—but could not muster the courage to enter the classroom, so she ended up cutting class.
Was Sabrina’s case just another example of client resistance, lack of commitment, or lack of readiness to change? In fact, a careful analysis of the approach the therapist used reveals several therapeutic errors that greatly decrease the likelihood of compliance.
Unilateral Assignments (“Here’s what you need to do…”)
For starters, Dr. Bloom decided on his own, without input from his client, that it was time for action, and then he chose what that action should be. This one-sided approach helped guarantee noncompliance. Just as the entire therapeutic process should be collaborative, each assignment needs to be arrived at by a joint meeting of the minds. Thus, the term “assignment” is not appropriate because it connotes one person doing the assigning and the other person complying. Far better are concepts such as “experiments,” “activities,” or “tasks.” Therapists certainly can take the lead in developing possible strategies, but clients must be encouraged to provide their input and feedback as the tasks are developed. Clients who feel they have participated in the process of generating the activity are more likely to attempt it, complete it, and maintain whatever they have learned from it. Leaving the client out of the decision-making process increases the likelihood that the task may be beyond the reach of the client’s capabilities. In this case, suggesting the client arrive late to class was an attempt to hit a home run with one pitch instead of moving gradually toward the goal.
Failing to Prepare Clients for the Assignment
All too often, clinicians employ a “take two aspirin and stay out of drafts” approach to therapy. That is, they act as if mental health work is identical to the medical model in which clients ask the all-knowing physician for a diagnosis, prognosis, and treatment recommendations. Most therapy clients need information about the efficacy of specific interventions. During Dr. Bloom’s assignment-giving, he neither sought Sabrina’s input nor gave her even a clue what this fear-inducing activity was supposed to accomplish. What might have seemed obvious to the therapist was probably not at all clear to the client. For those with phobias such as Sabrina’s, education about the efficacy of gradual exposure should have preceded any specific homework recommendations.
Failing to Provide Backup Support to Increase Compliance
As any therapist quickly learns, just because clients say they will perform an activity outside of session, this does not mean they will follow through with the commitment. Getting clients to comply with homework (even those assignments they have helped design) is about as difficult as getting students to complete school assignments on time. Understanding this, successful therapists utilize a wide array of approaches designed to overcome the numerous obstacles to completing out-of-session activities.
Use Post-it notes. At the end of a session, suggest that the client write down the assignment and then post it at home in a convenient location. The therapist should also make a note of the assignment so it can be reviewed at the next session.
Encourage the client to tell a trusted individual about the task, asking the friend to check back and see how the assignment is going. This person should not be a guilt inducer or have any vested interest in the activity other than the welfare of the client. Typically, spouses, children, and parents are not useful choices.
Determine whether the client has a buddy who is also willing to engage in the desired activity. This can be especially helpful with assignments such as increased exercise or attending classes or support groups.
Frame the assignments to learn about oneself while trying new things. Emphasize the possibility of enjoying the opportunity to develop new skills that could be beneficial for a lifetime.
Leave little or nothing to chance by carefully clarifying the how, the when, and the where components of the assignment.
Do a thorough assessment of any obstacles that might prevent the client from following through. Make no assumptions. For example, one client committed to doing an online search for employment during the week. However, an inspection of barriers revealed that the client had never used the internet and in fact did not even have an internet connection for his computer.
Of course, no matter how cautious we are, some clients will inevitably drop out of therapy. However, we can avoid a high percentage of early terminations by reminding ourselves that we aren’t all-knowing, that we might on occasion need consultation, that, on occasion, we might even need to apologize for being judgmental or insensitive. Most importantly, we need to assess our clients regularly to determine if we are on the right track and on the same page.
Bernie Schwartz, PhD, is a licensed clinical psychologist who was the founder and director of the Student Psychological Services at Santiago Canyon College in Orange, California, where he worked for over thirty years. He is the author of How to Fail as a Therapist. In addition to his teaching and clinical work, he has performed over a thousand child custody evaluations for Superior Court of Orange County.