Can we confirm our theories? Can we measure causal effects?: Reply to Kazantzis et al (2001).

Correlations between psychotherapy homework (HW) and recovery from depression (DEP) could be explained by 4 models: (a) HW causes reductions in DEP; (b) reductions in DEP lead to HW compliance; (c) HW and DEP have circular causal effects on each other; and (d) HW and DEP are simultaneously influenced by a 3rd variable, such as motivation. In the D. D. Burns and D. Spangler (2000) (see record 2000-13544-005) study of HW and changes in DEP during the first 12 weeks of therapy using structural equation modeling (SEM), only the first model was consistent with the data. Still, one cannot conclude that a model is "true" or definitely confirm a causal effect, even with experimental designs. The authors recommend SEM for naturalistic and experimental designs. Quality of HW should be included in future research, as N. Kazantzis, K. R. Ronan, and F. Deane (2001) (see record 2001-05666-023) suggest. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of homework in cognitive behavior therapy of depression.

Homework is particularly important in the cognitive-behavioral treatment of depression because the pervasive nature of the characteristic cognitive, affective, and motivational disturbances undercut the impact of didactic and supportive verbal interventions. Despite the importance of homework, a relatively small number of studies have quantified the causal relationship between homework completion and symptomatic outcome. Most of these studies have limited power to detect small-to-moderate effect sizes and rely on retrospective or incomplete measurements of homework that do not distinguish between the quantity and quality of the assigned tasks. Nevertheless, there is relatively consistent evidence from correlational studies to conclude that homework adherence is associated with significantly better outcomes. These findings point to new questions for research (i.e., does ongoing use of homework decrease the likelihood of relapse following termination of time-limited therapy?) and have implications for clinical practice. Examples of homework assignments are provided and strategies to improve homework adherence are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of homework in cognitive-behavioral therapy for cocaine dependence.

This study examines the effect of homework compliance on treatment outcome in 123 participants receiving cognitive-behavioral therapy (CBT) for cocaine dependence. Regression analyses revealed a significant relationship between homework compliance and cocaine use that was moderated by readiness to change. Homework compliance predicted less cocaine use during treatment but only for participants higher in readiness to change. For those lower in readiness to change, homework compliance was not associated with cocaine use during treatment. Homework compliance early in therapy was associated with better retention in treatment. Homework compliance was not predicted by participants' level of education or readiness to change. These findings support the use of homework during CBT for substance use disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety.

Belief in one's ability to change is an important cognitive variable related to treatment gains. This study investigated pretreatment expectancy for anxiety change and early homework compliance in relation to initial and total cognitive change in group cognitive-behavioral therapy (CBT) for anxiety. Participants, who met diagnostic criteria for at least 1 anxiety disorder, completed 10 sessions of group CBT. Early homework compliance mediated the relationship between expectancy for anxiety change at baseline and initial change in CBT. In addition, initial cognitive symptom improvement mediated the relationship between homework compliance and posttreatment outcome. These results suggest that expectancy for change is an important cognitive variable that may provide the initial impetus and subsequent momentum for therapeutic involvement and gains. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of homework in behavior therapy for anxiety disorders.

In this article, the authors discuss the role of homework in behavior therapy for the anxiety disorders. First, the authors describe the essential components of behavior therapy that include exposure to feared consequences and cessation of all avoidance behaviors. Then, the authors briefly review the literature on the relationship between homework compliance and treatment outcome. Next, the authors discuss the way that homework is used in terms of self-monitoring and exposure exercises during the course of treatment. Finally, the authors discuss the practicalities of encouraging homework compliance and managing noncompliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of homework compliance on treatment outcomes for participants with myalgic encephalomyelitis/chronic fatigue syndrome.

Purpose: This study examined the relationship between level of treatment engagement through completion of homework on treatment outcomes within nonpharmacological interventions for participants with ME/CFS. Method: A sample of 82 participants with ME/CFS was randomly assigned to one of four nonpharmacological interventions. Each intervention involved 13 sessions over the course of 6 months. Change scores were computed for self-report measures taken at baseline and 12-month follow-up. Homework compliance was calculated as the percentage of completed assignments across the total number of sessions and grouped into three categories: minimum (0–25%), moderate (25.1–75%), or maximum (75.1–100%). Results: Findings revealed that after controlling for treatment condition, those who completed a maximum amount of homework had greater improvement on a number of self-report outcome measures involving role, social, and mental health functioning. There were no differential improvements in physical and fatigue functioning based on level of homework compliance. Implications: Findings from this study suggest homework compliance can have a positive influence on some aspects of physical, social, and mental health functioning in participants with ME/CFS. It should be emphasized that these interventions do not cure this illness. The lack of significant changes in physical functioning and fatigue levels suggests a need for more multidisciplinary treatment approaches that can elicit improvement in these areas. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Client compliance with homework directives during counseling.

Investigated compliance with homework directives in counseling in 61 clients (aged 21+ yrs), with the cooperation of 18 post-master's degree counselors in a community counseling agency for adults. Compliance was examined as a function of counselor variables, client variables, and therapy variables, using rankings of counselor ability and skills, a rating of cases, and data on homework assignments. Neither counselor ability nor specific counseling skills were related to client compliance. Initial severity of client problems was related to outcome but not to compliance. Clients who remained in counseling had better compliance than those who terminated early. Whether clients presented career or personal/emotional problems was unrelated to compliance. Therapy variables that predicted compliance included assignments given early in counseling, a history of compliance, and whether counselors checked their client's attitude about homework and did not stress their own status. It is suggested that variables associated with the conduct of counseling more strongly influence compliance with homework than do either counselor or client variables. (37 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does psychotherapy homework lead to improvements in depression in cognitive–behavioral therapy or does improvement lead to increased homework compliance?

The bidirectional causal relationships between psychotherapy homework (HW) compliance and changes in depression were assessed in 2 groups of depressed outpatients treated with cognitive–behavioral therapy using nonrecursive structural equation modeling techniques. The data were consistent with the hypothesis that HW compliance had a causal effect on changes in depression, and the magnitude of this effect was large. Patients who did the most HW improved much more than patients who did little or no HW. In contrast, depression severity did not appear to influence HW compliance. HW compliance did not appear to be a proxy for any other, unobserved (3rd) variable, such as motivation. Although the causal effect of HW on depression was large, the correlation between HW and depression was small. Some possible explanations, along with suggestions for future studies, are proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does the alliance cause good outcome? Recommendations for future research on the alliance.

Research has consistently documented that the quality of the therapeutic alliance is related to the outcome of diverse psychotherapies. Insufficient attention, however, has been directed at identifying the nature and magnitude of the causal relationship between the alliance and outcome. In this commentary, we discuss the major threats to causal interpretation of alliance-outcome correlations and provide suggestions for future research that would help clarify the extent to which the alliance causes positive outcomes. Assuming the alliance is a causal factor in relation to outcome, we provide recommendations for research on the alliance that would attempt to improve patient care by enhancing the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive and personality factors in the delay of gratification of hemodialysis patients.

Based on W. Mischel's (see record 1985-06679-001) social learning analysis of the process of delayed gratification in children and A. Bandura's (see record 1977-25733-001) self-efficacy theory, the present authors developed a model of delayed gratification in adults and tested it on 53 20–68 yr old dialysis patients who were required to comply with a stringent regimen of fluid-intake to remain alive. It was hypothesized that Ss' self-evaluations of their past compliance and their efficacy expectations would be associated with their actual delay behavior. Underlying these process-regulating cognitions would be stable competencies, such as learned resourcefulness. Ss evaluated their fluid intake compliance, their efficacy expectations, and their health beliefs. Resourcefulness was assessed by a self-control schedule. Actual fluid-intake compliance was reliably assessed by the mean body-weight increase between dialyses during the 3 mo prior to the study and during 2 follow-up periods. Results support the model and show that self-efficacy expectations were related to persistence with the fluid diet and to Ss' self-evaluation of their past adherence behavior and resourcefulness. Although the path model suggested a causal pattern, the correlational nature of the study precluded any conclusions on a cause–effect relationship. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Practice Makes Progress? Homework Assignments and Outcome in Treatment of Cocaine Dependence.

The relationship between treatment outcome and the extent to which participants completed homework assignments was evaluated among 60 cocaine-dependent individuals assigned to cognitive-behavioral therapy (CBT). Homework was assigned in 72% of all sessions and initiated by participants in 48% of the sessions in which it was assigned. Completion of homework was unrelated to participants' baseline characteristics and several indicators of treatment compliance. Participants who completed more homework assignments demonstrated significantly greater increases in the quantity and quality of their coping skills and used significantly less cocaine during treatment and through a 1-year follow-up. These data suggest that the extent to which participants are willing to complete extrasession assignments may be an important mediator of response to CBT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: A structural equation model.

Demonstrated that therapeutic empathy has a moderate-to-large causal effect on recovery from depression in a group of 185 patients (aged 18–75 yrs) treated with cognitive-behavioral therapy (CBT). The authors simultaneously estimated the reciprocal effects of depression severity on therapeutic empathy and found that this effect was quite small. In addition, homework compliance had a separate effect on clinical recovery, over and above the effect of therapeutic empathy. The patients of novice therapists improved significantly less than did the patients of more experienced therapists, when controlling for therapeutic empathy and homework compliance. Ss who terminated therapy prematurely were less likely to complete the self-help assignments between sessions, rated their therapists as significantly less empathic, and improved significantly less. Ss with borderline personality disorder improved significantly less, but they rated their therapists as just as empathic and caring as other patients. The significance of these findings for psychotherapy research, treatment, and clinical training is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Goal consensus and collaboration.

There are differences in the extent to which patient and therapist agree on psychotherapy goals and work together in the helping relationship. This article reviews the empirical research on the relation between psychotherapy outcome and patient-therapist goal consensus and collaboration. Research results suggest that psychotherapy outcome is enhanced when agreement on therapeutic goals and collaborative involvement (often assessed by patient cooperation, role involvement, and homework compliance) are present during the course of therapy. When therapists and patients demonstrate cooperative and affiliative behavior, and when patients are actively involved in the patient role, better outcomes can be expected. We discuss therapeutic practices based on these findings, emphasizing the involvement of therapist and patient in a process of shared decision-making where goals are frequently discussed and agreed upon. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Process of Recommending Homework in Psychotherapy: A Review of Therapist Delivery Methods, Client Acceptability, and Factors That Affect Compliance.

Although the link between homework use and positive psychotherapy outcomes has been established, relatively little is known about the therapeutic processes, or factors, that promote homework compliance. Homework compliance may be viewed as an indicator of client commitment and involvement in psychotherapy. This article presents the results of a systematic review of research, including 16 empirical studies, related to the homework recommendation process. Findings relate to the frequency and type of homework that therapists deliver, factors that promote client acceptability of homework recommendations, and factors that affect compliance. On the basis of these findings, the authors propose a theoretically and empirically based, 6-phase conceptual model of the homework recommendation process. They also propose specific strategies for recommending homework to clients and directions for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Lesson in Assigning Homework: Therapist, Client, and Task Characteristics in Cognitive Therapy for Depression.

The majority of professional psychologists use homework in clinical practice, at least on occasion. Are there ways of assigning and reviewing homework that contribute to better treatment outcomes? If so, are these strategies being incorporated into clinical practice? To help answer these questions, the authors used data from S. D. Hollon et al.'s (1992) Cognitive-Pharmacotherapy Treatment Project. Trained coders rated aspects of discussions between therapists (delivering cognitive therapy) and clients (N = 24) during the assignment and review of homework. The authors found that better treatment outcome was associated with specific therapist behaviors (i.e., setting concrete goals and discussing barriers to completing the homework), characteristics of the homework task (i.e., using written reminders of the homework), and client involvement in the discussion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Modeling the relationship between growth in rapid naming speed and growth in decoding skill in first-grade children.

This study used an extant longitudinal correlational data set (D. L. Compton, 2000) to model the relationship between growth in decoding skill and growth in rapid automatized naming (RAN) in 1st-grade children. During an academic year, 75 1st-grade children were assessed 7 times (once per month) in word reading, nonword reading, RAN numbers, and RAN colors. Results indicated a unique relationship between RAN numbers and early decoding skill. A bidirectional relationship between decoding skill and RAN numbers was supported, with RAN performance prior to the acquisition of decoding skill predictive of future decoding skill and with increased growth in RAN facilitated by the acquisition of decoding skill. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship between behavioral marital therapy outcome and process variables.

This study was conducted to identify therapist and client behaviors with a positive response to social learning-based behavioral marital therapy. A sample of 32 couples receiving treatment was examined. Immediately after each therapy session, the therapist, husband, and wife independently completed process ratings forms that measured therapist and client behaviors during the session. Composite scales, derived from these ratings, were entered into multiple regression equations to examine their relationship with posttherapy marital satisfaction. After controlling for pretherapy marital satisfaction and the other predictor variables, therapists', husbands', and wives' ratings of positive client behavior (i.e., collaboration, active participation, and homework compliance) were positively associated with therapy outcome. Implications for marital therapy and suggestions for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Retrospective revaluation of causal judgments under positive and negative contingencies.

Retrospective revaluation of causal judgments was investigated in a 2-stage procedure. In the 1st stage, compounds of 2 cues were associated with the outcome, whereas in the 2nd stage, a cue from each compound was trained by itself. Associating this cue with the outcome in the 2nd stage had no detectable effect on the causal rating of the other cue from the compound, whereas presenting it without the outcome enhanced the causal rating of the other cue. The retrospective revaluation of the causal rating of these productive cues and also of preventative cues depended on consistent pairing of the cues during compound training, suggesting a role for within-compound associations. These results favor associative accounts of retrospective revaluation that use separate excitatory and inhibitory learning processes rather than a general error-correcting learning algorithm. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abuse and disabuse of the drug metaphor in psychotherapy research: Hold on to the baby as you throw out the bath.

W. B. Stiles and D. A. Shapiro (see record 1995-10433-001) argue that trivial correlations between process variables and treatment outcome point to inherent methodological limitations of correlational designs in process-outcome research. In coming to such a far-reaching (erroneous) conclusion, Stiles and Shapiro are throwing out the baby with the bath. Correlational designs are perfectly appropriate for testing process-outcome correlations if process measures are adequately conceptualized. Examples of case-specific measures of therapist responsiveness are reviewed to illustrate the power of correlational designs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-evaluation maintenance and the mediational role of emotion: The perception of friends and strangers.

Examined the causal role of emotional arousal in self-evaluation maintenance (SEM) processes. In previous work, A. Tesser and J. Campbell (see record 1983-12693-001) found that Ss were most charitable in their perception of another's performance when self-relevance was low and the other was close. If emotional arousal mediated this pattern of behavior, then the pattern of behavior should be replicated when arousal is present but attenuated when arousal is misattributed or low. The misattribution hypothesis was tested in Study 1. Study 2 was a correlational study in which physiological arousal and misattribution were measured. Results supported the prediction that SEM processes would be attenuated when arousal was attributed to external sources. The misattribution effect was particularly pronounced among more highly aroused Ss. Results are discussed in terms of their implications for the SEM model and person perception. (PsycINFO Database Record (c) 2010 APA, all rights reserved)