Homework Assignments in Brief Psychotherapy

Homework Assignments in Brief Psychotherapy

Norman Macaskill

ABSTRACT: A rationale is offered for the use of homework assignments in brief therapy.It is argued that such assignments help maintain a therapeutic focus, strengthen the thera-peutic alliance, enhance motivation and can reduce termination difficulties. The analysisof resistance to carrying out homework is also discussed and it is suggested that it can bea potent tool in clarifying motivational problems and blocks to the generalisation of thera-peutic gains into the patient's daily life. Problems for therapists and patients in using suchtechniques are also briefly discussed. An extended case example is included to illustratethe practical application of homework assignments.

Introduction

Homework assignments are central components of behavioural and cognitivepsychotherapy treatment programmes. These assignments consist of a variety of data-gathering, problem solving and behaviour-changing tasks carried out by the patientbetween treatment sessions. These assignments are reviewed subsequently in therapysessions, problems over their completion analysed and new assignments devised tomaintain therapeutic impetus. There is evidence, Cohen, et al (1984), Maultsby (1971),that successful treatment by behavioural or cognitive methods is dependent on regular andsuccessful completion of homework assignments. In contrast, such techniques havereceived very little attention in psycho-dynamically oriented psychotherapy. Wolberg (1980) suggests homework assignments are of value in short-term therapy, Ryle (1983)discusses some uses for written communications between patient and therapist, andShelton and Ackerman (1974) describe the use of a number of homework tasks incounselling and psychotherapy. Davanloo (1980), observes, in passing, that patients whowork on their problems between sessions have the best outcomes. This observation echoesthe experience of many psychotherapists; however, no attempt has been made todetermine whether prescribing work between sessions can affect treatment outcome. Itseems plausible that this neglect results partly from the absence of a clear psycho-dynamicrationale for the use of such techniques in therapy and partly from psychodynamically-based objections to such active techniques.

This paper will attempt to provide such a rationale and to address the potentialobjections which are indicated below.

Norman Macaskill is a Consultant Psychiatrist at the Whiteley Wood Clinic, Woolindin Road,Sheffield S1O 3TL.

British Journal of Psychotherapy, Vol 2(2), 1985© The Author

Norman Macaskill 135

1. Prescribing homework puts the therapist in an active, directive, advicegiving role,and undermines his main role as reflector and interpreter.

2. Homework task-setting emphasised the 'doing-to' over the `being with' function ofthe therapist, and is therefore detrimental to the development of the therapeuticprocess.

3. Task-setting emphasises the patient's reality-situation to the neglect of his intra-psychic state and mental mechanisms.

4. The development of a transference neurosis is impeded by the regular setting ofreality-based homework assignments.

Brief therapy

The above mentioned objections have some validity if long-term analytically-orientated psychotherapy is seen as the only context for discussing homeworkassignments. Borderline and narcissistic patients, who generally require such longtermtherapy, often react adversely to 'doing-to' relationships and require sustained `holding'and 'being-with' (Winnicott (1965), Macaskill (1982). High levels of activity anddirectiveness on the part of the therapist can be experienced as overwhelmingly intrusiveby such patients. However, many less disturbed patients can benefit from briefpsychotherapy (Malan (1963), Sifneos (1972), Davanloo (1980)), and it is with this groupof patients that homework assignments can be a valuable adjunct in therapy. Thispossibility arises because the central principles of brief therapy, outlined below, areenhanced by the use of homework assignments and motivational problems quickly broughtinto focus. Malan (1963) and Flegenheimer (1982) have indicated that brief psychotherapyrequires substantial modifications in the therapist's technique from those appropriate forlong-term therapy. The main modifications are

1. The selection and maintenance of a limited focus for therapuetic work.2. Avoidance of the development of a transference neurosis.3. Early attention to termination.To achieve this the therapist must be active, often confronting, and rapidly establish a

strong therapeutic alliance and high levels of motivation if the patient is to remain intherapy and make substantial changes in the short time span available. The mechanismsthrough which homework assignments may enhance key aspects of brief therapy will nowbe outlined.

Maintaining a focus

All brief therapies converge on the importance of selecting and maintaining a focus fortherapeutic work. A workable, mutually agreed problem or core conflict must beestablished early in therapy for brief therapy to be effective (Malan (1963)).

Homework assignments are an explicit method of focussing during and betweensessions as well as over the course of therapy. Home-based tasks, arising from the contentof therapy sessions, encourage the patient to pursue a selected therapeutic issue duringnon-therapy days and this work is held in focus by the therapist

136 British Journal of Psychotherapy

reviewing the asssignment at the beginning of the following session. Particularly in theearly stages of therapy, homework assignments may consist of reviewing therapysessions, possibly tape-recorded, with the aim of clarifying the key issues to be dealt within therapy. Carrying out therapeutic work between sessions often helps underline thattherapy is a major focus in the patient's current life, and so lessens the possibility of hisperceiving therapy as a separate or peripheral part of his daily experience. Because eachhomework assignment is the end result of a process of problem-selection by the patientand therapist in each session, there is clear prioritisation of problems, ensuring the keyareas are worked on and others noted, but set aside for later attention. Failure to reporthomework or beginning sessions with topics other than those directly related to theprevious homework assignment, i.e., loss of focus, may alert the therapist to problemsand resistances in therapy and call for prompt attention.

Therapeutic alliance

In brief therapy, time does not allow for the systematic analysis and working throughof major transference problems which block the development of a collaborativetherapeutic relationship. A variety of preparatory techniques can help strengthen thetherapeutic alliance. The setting of treatment goals within sessions and over the course oftherapy enhances the therapeutic alliance and vice versa.

Homework assignments provide an ideal method of ensuring therapist and patientmake explicit goals, and evolve realistic short and longer term therapeutic tasks. Enlistingthe patient's participation in constructing assignments facilitates a collaborative ratherthan dependent relationship and often serves to sensitise the therapist to the issues andneeds that are most immediately relevant to the patient.

Motivation

Sifneos (1973) and Malan (1963) indicate that motivation, in this context, meansmotivation to change, take risks, face anxiety and repeatedly confront problems, ratherthan motivation merely to reduce symptoms and distress. Some patients bring this qualityto therapy, while others can be helped to increase their motivation over the first fewsessions of therapy, through the establishment of a good therapeutic alliance, the use ofhomework assignments and by appropriate goal setting.

Homework setting can provide the therapist with a method of enhancing motivationand an invaluable indicator of resistance to change. In the author's experience,dependency conflicts ('I'm, here to be nurtured and cared for'), narcissistic problems ('Ishouldn't have to work hard at changing, it should happen magically'), self esteem issues ('I don't want to try in case I fail'), and egoweakness problems ('I can't stand the pain ofchanging and the sustained effort required'), quickly emerge when the therapist focusseson problems in carrying out homework assignments. These issues, if they are not alreadythe focus of therapy, then become the issues to be worked at.

Sometimes patients acquire insight in therapy, relate in a more self-accepting andself-disclosing manner to their therapist without generalising these gains to


their daily living situation. Homework assignments can alert the therapist to the existenceof this compartmentalised form of change and ensure that adequate attention is then paidto this phenomenon. Here again analysis of problems or resistances to carrying out suchassignments can be very revealing of previously concealed or overlooked problems thatneed to be dealt with.

Therapist activity and the transference

The brief therapist has to be active, maintain the focus of the therapeutic work andprevent the development of a transference neurosis. Vigorous early interpretation oftransference manifestations controls the transference and limits regression (Malan (1963)). As homework setting is an active, structured, realityorientated technique, it reinforcesthe therapist's efforts to manage regression and control the transference.

Termination

Short-term therapy is often effective because of the extended working-through ofproblems that can occur after therapy has finished (Wolberg 1980). The use of regularpost-therapy self-constructed homework assignments is a means of optimising thispotential. For many patients, acquiring the ability to self-monitor and self-analyseproblems during therapy via homework assignments gives them the confidence withwhich to face further problems once therapy is terminated. For some patients, this greatersense of mastery and control over their problems reduces their dependence on thetherapist and, as a result, reduces their sense of ambivalence and loss at termination. Thisreduction of termination difficulties is most likely when the therapist has been careful toensure that, as therapy progresses, the patient has been coached to become increasinglyindependent in constructing and monitoring his homework tasks. This often leads tosome anxiety, symbolically equivalent to the final termination anxieties, as patients facebecoming responsible and autonomous. In some respects, the skills of designing andmonitoring homework assignments when utilised post-therapy bind anxiety and providesecurity by acting as a transitional object, reminding the patient of the therapist and thetherapy setting. Patients describe the process as akin to having their therapist perched ontheir sholder when they face problems and carrying out therapeutic work coached by aninternal dialogue with him.

Problems and limits

Therapists who are trained in long-term therapy can find it difficult to alter theirattitudes, style and techniques to those necessary for successful short-term therapy. Tosome extent, short-term therapists may also have difficulty. Emotionally, they may havereservations about employing active techniques, or the task-orientated emphasis, and theymay experience a sense of loss as some of the `being with' qualities of the therapyrelationship are diluted. The emphasis on systematic analysis of resistance to carrying outassignment may also feel to the novice therapist as a relentless pursuit of the patient.

Learning difficulties are frequently present in addition. Novice therapists often find itdifficult to design assignments in a sensitive and collaborative manner.


Frequently, they fail to ensure these tasks are clear, understandable and manageable,so that patients may fail to carry out tasks. Therapists often initially fail to follow-throughon reviewing tasks, and when they do, fail to use this opportunity to underline success oranalyse resistance and reasons for failure. Consequently, supervision often has to focus onthese emotional and learning problems until the therapist is familiar and comfortable withthese techniques. Supervision is also essential to ensure that homework assignments donot become a vehicle for counter-transference; for example, the therapist may use task-setting as a method of avoiding emotional contact with patients.

Patients also may have problems adjusting to the use of homework techniques. Theirculturally-based expectations may be of a more passive insight-orientated therapy, slightlyset apart from the day-to-day realities of their lives. For this group of patients, the problemcan often be circumvented by careful explanation and preparation prior to the onset oftherapy.

More problematic are those patients who, for characterological reasons, resist thesetting and carrying out of homework tasks. These patients with marked problems ofnarcissism, ego-weakness, dependency or severely damaged selfesteem are probably notsuitable for brief therapy and would in most instances be excluded following initialassessment. However, for those who do slip through this screening process, the settingand carrying out of homework tasks quickly bring to the surface their core problem andrecognition of this should lead to consideration of more long-term therapy.

Practical application of homework

Three main factors need to be considered in planning homework assignments. Theseare: the type of brief therapy being utilized; the psychological sophistication of thepatient; and the stage of therapy the patient is predominantly working at. These pointswill be illustrated in the following case example.

KateKate was a single, 33 year old secretary who presented with a nine year history of

frequent, brief episodes of depersonalisation which had become more severe following thebreak-up of a two year heterosexual relationship. She gave a history of being emotionallyneglected by her mother and a long-standing pattern of perfectionism at work. She had noprevious experience of psychotherapy and during the assessment session she was assessedas being quite psychologically unsophisticated and ignorant of the structure and processof psychotherapy. Therapy, once a week for twenty sessions, was offered along the linesof Wolberg (1980).

Stage I - Preparation (Sessions 1-3)It was apparent that substantial educative input was needed to prepare her for

psychotherapy and consequently at the end of the first session she was given a standardpreparatory booklet, explaining the practical and procedural aspects of psychotherapy andher role in the process. She was asked to read this and bring it back to the second sessionwith any questions she might have regarding this; it was


also suggested that we tape the first few sessions so she could review these at her leisure.She found these assignments lessened her anxiety and confusion about therapy and gaveher the feeling it was not, as she assumed, a mysterious and selfindulgent process.

Stage II - Analysis (Sessions 4-9)Throughout therapy, because of her lack of psychological sophistication, Kate

required substantial educative work, paralleling the process of therapy. As she began tofocus on her feelings and thoughts during the sessions, she was helped to consolidate thiswork by two types of homework assignments. Firstly, she was enabled to be more awareof her thoughts and feelings by keeping a daily diary in which she noted events which ledto unpleasant emotions and then began to recognize that this anxiety was frequentlytriggered by situations in which she felt her self-worth was challenged. Secondly, she wasgiven specific chapters from selftherapy books which related to the insight she wasacquiring in her therapy and homework.

Stage III - Working Through (Sessions 10-18)The above analytic work brought with it some lessening of her symptoms but led to

recognition of anger towards her mother over her perceived unfairness, and consequentguilt. Over several sessions, the guilt lessened but left her with an uncomfortable highlevel of anger towards her mother. Because she had infrequent contact with her mother, itwas evident she could not work extensively in real life on this issue. Consequently, shewas encouraged to practise visualizing conversations with her mother several times eachday for a period of two weeks, rehearsing what she wished to say and trying to view hermother from a more empathic perspective. She was initially sceptical about the value ofthis but returned the following week to say she had spoken to her mother over the 'phoneand had been able to express herself amicably to her without feelings of resentment.

The main thrust of working through her problems, however, was on the link betweenher self-worth, performing well at work and the value of work as a compensation for thelack of her mother's love. Kate was repeatedly encouraged to question her conditionaldefinition of self-worth, firstly, by writing an essay on the worth of others, and secondly,by reading and arguing against written material related to the concept of self-worth. Asshe began to accept this different view of her self-worth, she was encouraged to use this inher daily life by challenging the self-critical thoughts which, she recognised, repeatedlyled to anxiety at her work. Because there was no objective evidence that she was beingcriticized at work, she was encouraged to submit several pieces of shoddy work. Thisproduced mild criticism but not the catastrophe Kate expected. She found she was able,with some effort, to maintain her view of her own self-worth throughout this and felt aconsiderable sense of freedom as a result.

Stage IV - Termination (Sessions 18-20)As therapy came towards the end, Kate experienced a sense of disappointment and

some sense of failure. She was asked to continue monitoring her thoughts in


her daily diary and was able to recognize the repeated thought that while therapy hashelped her, she was not totally cured, which she construed as a personal failure. Kate wasencouraged to recognize this as a further opportunity for her to work on her problem oflack of self-acceptance and at follow-up six months later, reported that the sadness hadgradually disappeared, leaving her feeling stronger and more content.

In the case example above, the type of brief therapy utilized was that of Wolberg (1980). This broad-spectrum psychodynamic approach is applicable to a wide variety ofpatients and the type of homework assignment utilized is fairly typical. Malan's (1963)brief therapy is probably not applicable to such a wide population but the homeworkassignments can be similar to those described above. The only major addition utilized bythe author when short-term therapy focusses substantially on transference interpretations,is that the patient utilize this framework in analysing the contents of the daily diary.

In addition to the type of brief therapy utilized, the phase of therapy plays a major rolein deciding the relevant type of homework assignment. In the initial preparatory phase,most patients, irrespective of their level of sophistication, benefit from homeworkassignments designed to increase their understanding of the psychotherapy process.Preparatory booklets and reviewing tapes of sessions are valuable at this point. In theanalytic phase, a daily diary, linking events to emotions and thoughts, is generallyvaluable and can be supplemented by reading from selected chapters from self-therapybooks. Homework assignments in the working through phase are generally more active,attempting to generalize the insights gained in therapy into behavioural change in thepatient's life. Here shame-attacking exercises (Ellis and Abrahams (1978)) (as in Kate'scase), practice in assertion training and social skills and tasks involving facing anxiety-provoking situations are helpful. Cognitive rehearsal (as in Kate's work on her anger withher mother) can, if practised, frequently compensate for limited opportunities of workingthrough problems in real life situations.

Conclusion

For the reasons outlined in this paper, the author would suggest that homeworkassignments are conceptually and technically consistent with current models of briefdynamic psychotherapy and, furthermore, that setting homework assignments offerssubstantial therapeutic benefits in terms of maintaining a focus, evolving a soundtherapeutic alliance, enhancing motivation and reducing termination difficulties. A majoradvantage of such task-setting lies in the analysis of resistance to carrying out such tasks.The therapist is thereby offered a potent tool for clarifying and working throughmotivational problems and blocks to the generalisation of change from the therapy settingto the patient's life situation.

Empirical research supports the value of such techniques in behavioural and cognitivetherapies and clinical experience with the technique in brief dynamic therapy wouldsuggest that research in dynamic psychotherapy ought to address this issue.


References

Cohen, S. D. Monteiro, W. and Marks, I. M. (1984) Two-year follow-up of agoraphobics afterexposure and Imipramine. In British Journal of Psychiatry Vol. 144, pp.276-81.

Davanloo, M. (Ed) (1980) Short-term Dynamic Psychotherapy Jason Aronson. New York.Ellis, A. and Abrahams, E. (1978) Brief Psychotherapy in Medical and Health Practice. New York:

Springer.Flegenheimer, W. V. (1982) Techniques of Brief Psychotherapy Jason Aronson. New York and

London.Macaskill, N. D. (1982) The Theory of Transitional Phenomena and its Application to the

Psychotherapy of the Borderline Patient. In British Journal of Medical Psychology, Vol. 55, pp.349-60.

Macaskill, N. Macaskill, A. (1983) Preparing Patients for Psychotherapy. In British Journal ofClinical and Social Psychiatry Vol. 2, pp. 80-84.

Maultsby, M. C. (1971) Systematic Written Homework in Psychotherapy. In Psychotherapy: Theory,Research and Practice, Vol. 8, pp. 195-98.

Ryle, A. (1983) The Value of Written Communications in Dynamic Psychotherapy. In BritishJournal of Psychiatry Vol. 138, pp. 185-93.

Shelton, J. L. Ackerman, J. M. (1974) Homework in Counselling and Psychotherapy Charles C.Thomas. Springfield, III.

Sifneos, P. (1972) Short-term Psychotherapy and Emotional Crisis Cambridge, MA: HarvardUniversity Press.

Winnicott, D. W. (1965) The Maturational Process and The Facilitating Environment New York.International Universities Press.

Wolberg, L. R. (1980) Handbook of Short-term Psychotherapy Theme-Stratton. New York.

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Homework Assignments in Brief Psychotherapy