The Effects of Therapist Competence in Assigning Homework in Cognitive Therapy With Cluster C Personality Disorders

newstudy-graphic-66x60.jpgThis study examined the effects of therapist competence in assigning homework on the outcome of CT (cognitive therapy) in patients with Cluster C personality disorders. 25 participants underwent 40 weekly, 50 minute, CT sessions that followed the Beck and Freeman treatment manual for personality disorders. The six treating therapists employed three primary techniques: guided imagery, homework assignments that led the patients to try new adaptive responses, and cognitive, behavioral, and emotion-focused techniques to develop new, more adaptive beliefs to replace the pathological beliefs.

The researchers used the Global Severity Index of the Symptom Checklist 90 Revised to measure symptom distress, the mean scores of the 127-item version of the Inventory of Interpersonal Problems to evaluate interpersonal problems, and the Millon Clinical Multi-axial Inventory to measure personality pathology, as prescribed by the personality disorder scales of avoidant, dependent-submissive, compulsive-conforming, and passive-aggressive. Additionally, they tracked initial symptom improvement after the fourth session using the Helping Alliance Questionnaire. The researchers measured therapist competence in assigning, monitoring, and reviewing homework with the homework assignment subscale of the Cognitive Therapy Scale. This rating is based on the extent to which the therapist reviewed previous homework and summarized progress and conclusions, provided rationale for the assignment and the intended goals, tailored the assignment to the patient’s specific needs, and asked for reactions and feedback from the patient. The researchers also measured therapist competence in agenda setting.

Higher ratings of therapist competence in assigning homework were related to statistically significant improved outcomes on all measures at mid and post-treatment. Therapist competence in agenda setting, however, did not predict treatment outcome at either time. This study is the first to examine the relationship between therapist competence in assigning homework and treatment outcome in patients with Cluster C personality disorders, and the first to find that higher ratings of therapist competence in assigning homework predict greater positive change in symptoms, interpersonal problems, and Cluster C personality pathology.


I often tell therapists and patients that the way people get better is to make small changes in their thinking and behavior every day. That’s why it’s important for patients to do homework – just talking to a therapist for an hour a week is unlikely to be of much help to most people with psychiatric disorders. Homework frequently involves having patients change their distorted thinking so they see reality more clearly, doing “experiments” to change their behavior in small ways to see what happens, and implementing solutions to problems they’ve discussed in session.

I set up homework assignments very carefully and make sure patients are overwhelmingly likely to do them. When an Australian graduate student contacted me a few weeks ago about the role of homework in cognitive therapy, I told him that I think the reason some patients fail to do homework is because of mistakes their therapist makes. Read more