A common therapeutic struggle is around homework. I’m referring to ACT- related worksheets or questionnaires, exercises such as daily mindfulness practice, and “bold moves” or other applied behavioral commitments— in other words, any agreed- upon behavioral task that is to occur outside the therapy room within a specified time frame, most typically before the next therapy session. Although the word “homework” might never be used, I use that term here to capture the idea that this is work to be done outside of the session, and is intended to facilitate therapeutic progress.
A common challenge therapists face is when a client does not do the agreed- upon homework, or does not complete it. Clients provide many reasons for not fol- lowing through, many of which exemplify the thinking that has kept them stuck in their lives. The most common misstep I have observed therapists make around the issue of homework is to unintentionally collude with the client, supporting behavioral processes that decrease psychological flexibility. This collusion can take many forms, including sensing that the client has not completed the homework and therefore not asking about it, inquiring about the homework then quickly backing off when the client reports it wasn’t done, working to make it okay for the client that the homework was not done, or quietly dropping the entire topic of homework and not bringing it up again for the rest of therapy. I see all these responses as potentially problematic, for reasons that you can probably guess at this point: In essence they can support a costly system, a system that doesn’t ever fully go away and that will continue to threaten value- based behavioral choices. That is, while reason- giving will certainly continue, buying reasons as causal (as in “I need to feel motivated before going to the gym”) in many instances functions as a significant behavioral constraint.
When working on a homework issue with a client, I keep the above points firmly in mind. Chiefly, I remind myself that it will not serve the client well to align with unworkable reason- giving or experiential avoidance. That said, as always in clinical work, other considerations are involved as well— such as whether to fight this par- ticular battle at this point in time. I know of many therapists, myself included on many occasions, who choose not to assign formal (that is, structured or more speci- fied) homework assignments during the therapy for various reasons. While it might be interesting to explore the efficacy of such decisions, the point I want to make here is that if you and the client have made a commitment to do a particular homework assignment—to carry out some behavioral task—it is important to follow through in a way that is consistent with the model (in other words, that supports rather than works against psychological flexibility).
Barriers to Treatment
165
Scenario: The therapist and client have just completed a mindfulness exercise to begin
the session.
Therapist: “So…let’s start with talking about the willingness sheets I gave you at the end of last session— how did that go?”
Client: “You mean those worksheets?”
Therapist: “Yeah, the two willingness worksheets.” Client: “I started to do them… .”
(Therapist waits.)
Client: “I don’t know. I just don’t like doing that sort of stuff very much. Reminds me of school and homework or something.”
Therapist: “Were these sorts of thoughts showing up at the time? Not liking it, the homework thing?”
Client: “Um, well, I was putting it off, then when I picked it up I was noticing how much I don’t like doing that kind of stuff.” Therapist: “I see. So there was that dislike sort of feeling… .Any other
thoughts or feelings that you remember?”
Client: “Just, I remember thinking it was sort of stupid… .Sorry.” Therapist: “What are you sorry for?”
Client: “I don’t know… .I know you’re just trying to help. I’ve just never done well with that type of stuff.”
(Therapist sits quietly, thinking this through.)
Client (smiling nervously): “What are you thinking? Am I a bad client?” Therapist: “I’m just noticing all the stuff that shows up for you around this.
That last question, for example— whether you are a bad client.” Client: “Well, I feel like a kid or something. Like I’ve done something
wrong.”
Therapist: “Yeah, so there’s some more— feeling like a kid, thoughts that you might be a bad client, worry that you’ve done something wrong by stating how you feel about it… .”
Client: “Yeah, see? This is why I hate it!”
166
Advanced ACTClient (pauses, gets in touch with her feelings a bit): “Yes!”
Therapist: “Let’s see if we can bring that awareness even more front and center. In other words, let’s just notice everything going on right now— all the thoughts showing up, the emotions, even physical sensations.”
Client (sits): “Wow, I am really tense. Like I have a big rock in my stomach or something.”
Therapist: “Perfect. Yeah, just notice that— see if you can breathe in around it, sort of hold it gently.”
Client (breathes): “Okay.”
Therapist: “I notice some tension in my body, too. A kind of ratcheting up of energy.”
(Both sit and breathe.)
Client: “So, what now?”
Therapist: “Can you get at what you are after with that question?” Client: “What do you mean?”
Therapist: “When you asked me, ‘What now?’ I wonder if you were trying to get out of the moment a bit.”
Client: “Yeah, I guess so! I feel weird.” Therapist: “Yeah.”
(Both sit.)
Therapist (eventually continuing): “It’s interesting how you sort of looked to me to help get you out of it.”
Client: “What do you mean?”
Therapist: “When you asked, ‘What now?’ I felt pulled to give you an answer. Like I needed to get us moving forward and out of what was going on right then. Was that going on for you?”
Client: “I suppose… .”
Therapist: “I noticed something else here; did you?” Client: “Notice what?”
Barriers to Treatment
167
Therapist: “Well, something funny seemed to be going on around the wholehomework issue. Something about this feels off.” (Considers). “You know, when you were talking about how you felt you were in school or something, and when you apologized to me for not liking it— even now, when you asked if you were a bad client— all that sort of suggests that this was something coming from me. Like I was making you do homework or something.”
Client (thinks it over): “Well, I know you aren’t making me do it. I do feel like it’s something you want me to do, though.”
Therapist: “Hmmm.” (Thinks this over.) “Yeah, that’s fair. I mean, I have found that when clients do these sorts of worksheets outside of session it helps move things forward. So in that sense I’m for it. But I don’t think it will work too well if doing things like that isn’t something you’ve bought into.”
Client: “Yeah. I just don’t like them.” Therapist: “So what do you want to do?” Client: “What?”
Therapist: “So there are the thoughts and feelings you have around them, but those feelings and thoughts aren’t in charge. That is, you could conceivably decide that there was some point to doing them, and choose to do them, even if dislike or whatever showed up.” (The therapist is being very careful not to take responsibility for the client’s choice by asking the client what she wants to do with this, and yet manages to make the important point that the client has the option to make a choice based on something other than the thoughts and feelings associated with doing homework.)
Client (thinks): “Yeah, I guess so.”
Therapist: “I think it’s important to be intentional about this, whatever you decide— that is, to be clear that you are choosing to work on something specific outside of session, or to be clear that you are choosing not to go that route.”
Client: “Okay.” (Pause.) “I think I’d rather not do the homework thing.” Therapist: “Okay. And, if that changes at some point, just let me know.” Client: “Okay.”
168
Advanced ACTTherapist (upon reflection): “You know, I’m realizing that this is something that will come up again, especially as we are further along in the therapy. That is, this therapy is about getting moving in your life. There’s not much point to it if it doesn’t extend to your life outside the session. In that sense, it’s all about the ‘homework.’” Client: “I understand that. I just don’t want to be filling out sheets and
stuff like that.” Therapist: “Got it.”
Although it is quite possible that this sort of direct conversation around home- work might end up with the client opting to continue working with worksheets and the like, I wanted to demonstrate another possibility— that the client could opt out. Again, remembering that this whole therapy/life thing is by choice— the client’s choice— helps therapists refrain from stepping into persuading, arguing, or trying to convince the client. Those approaches pull for clients to fuse with a therapist- provided “should,” which in turn detracts from the ultimate goal of increased psychological flexibility. This is not to say that the therapist needs to somehow be out of the picture. I have consistently found that when therapists allow themselves to claim their own opinions and feelings about what is happening with homework, they are better able to maintain a therapeutic stance around the issue. Some of the tension around homework comes from therapists trying to outmaneuver clients— to somehow get the client to want to do homework while attempting not to convey any sort of personal investment. It can be more effective to go with transparency here. The therapist demonstrates being able to hold it all: her desire for the client to do ACT- related work outside of session, her reactions when assigned homework is not done (or is), and her recognition that clients get to choose what they do with their time.
In short, remaining steadfast within the ACT model will help you refrain from colluding with a client’s avoidance and other unworkable behaviors around homework. Your clinical judgment will continue to guide you as you work with each unique client from within that framework. For example, while in the above scenario the therapist appears to have felt it beneficial to accept (for now) the line the client was drawing around homework, it is also quite possible that an effective move would have been to confront the fusion going on even more directly. The following exchange, using the same situation, demonstrates pressing a bit more.
Therapist: “I think it is important to be intentional about this, whatever you decide— that is, to be clear that you are choosing to work on something specific outside of session, or to be clear that you are choosing not to go that route.”
Barriers to Treatment
169
Therapist: “I want to be careful here not to fall into trying to persuade you,because as we’ve just said, that starts to feel like I’m making you do something, rather than it coming from you. At the same time, there is something to see here that seems important.”
Client: “Okay… .”
Therapist: “On one hand this might not seem like a big deal, whether or not you fill out some worksheets, but on the other, it represents both the trap and the possibility you will encounter your entire life.” (Client seems a bit dubious but is listening.)
Therapist: “It’s not so much about the worksheets. It’s about you buying what your mind is handing you. All the reasons for not doing them. Completing or not completing a worksheet might seem like no big deal, but it’s the same mind— your mind, handing you some of the same reasons, for not living the way you say you want to be living. For not finishing that degree, for not reaching out to that friend, for not applying for that job.”
Client: “Yeah…I know.”
Therapist: “So while doing a worksheet like that might clarify something we’re working on in here, which in this case happens to be exactly what we’re discussing— willingness— the more significant message for you is to see that you have the ability to choose to do it. That because of some larger commitment to yourself, a value around what you’re doing here, you choose to push through, you can push through.”
Client: “Okay. I hadn’t thought of it that way, but I get it.” (Pause.) “Let’s keep doing the homework.”
Therapist: “Of course I’m glad to hear you say that, but I need to check to see if this feels like it is coming from you or if you are doing it because I want you to.”
Client: “Can’t it be both?”
Therapist: “Bravo! Absolutely. In fact, I see that question was me trying to get rid of anxiety I have around being too pushy or something. But yeah, exactly— you might have a bunch of reasons both to do it and not to do it, all sorts of feelings. The bottom line is that you make a choice because you can.”
170
Advanced ACTThe following exchange highlights what has been said many times now: One of the nice things about an acceptance- based therapy is that even when therapists step off the desired path, they can simply acknowledge that, and in so doing step right back on the path, in the direction they wish to be heading.
Therapist: “I want to start by talking with you about something I realized during the week.”
Client: “Okay.”
Therapist: “I realized that at some point in our work together, I completely dropped the homework thing.”
Client: “Yeah, I noticed that you haven’t asked me about it in a while.” Therapist: “When I think about it I realize it started with not bringing it
up— not asking you about homework because I was afraid you hadn’t done it.”
Client: “You would have been right.” Therapist: “What was going on with you?” Client: “Huh?”
Therapist: “Why didn’t you bring it up?”
Client: “Um…probably because I didn’t do it.”
Therapist: “Yeah, looks like we were both big- time avoiding.” Client: “That’s fine with me!” (Laughs.)
Therapist: “I don’t think it’s fine with me. I think I’m doing you a disservice by avoiding something like that in order to be more comfortable. Especially since we’ve been working on living life according to our values. I have a value around what we do here, and skipping over important stuff because it’s uncomfortable doesn’t mesh with that.”
By resisting the pull to avoid an uncomfortable discussion around homework, the therapist tags clinically important behavior and also establishes a productive way to continue work with the issue over the course of therapy.
Scenario: The therapist and client have been working toward the client’s value around
work, specifically his goal to apply for a job. (Completion of this goal has proved to be a bit of an issue so far.) At the conclusion of the previous session the client committed to filling out a particular application and bringing it into the session.
Barriers to Treatment
171
Therapist: “Do you want to start with the job application? We can take alook at it together.” Client: “It’s in the car.”
Therapist: “Do you want to go and get it?” Client: “No, I didn’t do much with it anyway.” Therapist: “Hmmm.” (Sits silently.)
(Client gives a big sigh, shifts, and folds his arms.)
Therapist: “Let’s really bring our attention to this moment.” (Pause.) “What do you notice going on for you right now?”
Client (sighs again, looks angry): “Just…here we are again. I don’t want the session to be about this again. I didn’t come here for this, you know?”
Therapist: “This sounds important— like there’s lots of information here for us. Let’s start with just getting present and noticing.”
Client: “I feel bored. With this whole thing.”
Therapist: “Bored… .You actually look and sound angry— or at least frustrated.”
Client: “I am frustrated. I’m tired of talking about this.”
Therapist: “Yeah, I can tag that going on for me a bit, too. Frustration that we’re here again, worries about whether you’ll get fed up and leave therapy, all that.” (Pause.) “But I also have a larger value around this. I have hopes for what this therapy might offer you, so I’m going to hang in there with you on this and invite you to hang in with me as well.”
Client (a bit more engaged): “I know… .It’s just…when you ask me about it, it just makes me not want to do it even more.”
Therapist: “Yeah. When I ask you about it I feel like a parent or schoolmarm or something, rather than…a comrade in arms.”
Client (sighs, finally looks directly at the therapist): “It’s not your fault. I should just get my ass in gear.”
Therapist: “That’s a good one. How do you do that exactly?” (Both laugh.)
172
Advanced ACTTherapist: “What do you think would happen if we started the session by you bringing up the issue? That is, you initiate the discussion— whether or not you did whatever you committed to do that week.” Client: “I could do that. I’m not sure it would change whether or not I do
it, though.”
Therapist: “I’m thinking more about this dynamic. Whether or not you complete what you committed to doing is one thing, but having it be clearer to both of us that this is coming from you seems important. You’re pursuing therapy for a reason. You committed to some action to take outside of session for a reason. This is your life and you’re in charge of it.”
Client: “I like that.”
Therapist: “Now, one thing I could see happening is you not bringing it up for some reason, like if you didn’t do what you had set out to accomplish.”
Client: “Well, if that happens just remind me.”
Therapist: “That could turn into the same thing. That is, it could function the same way as me asking you about your homework.”
Client: “Yeah, right.” (Thinks.) “Well, let’s try it and see what happens.” Therapist: “You’re on. And if you choose not to do the homework, simply
notice what comes up for you. There’s good information for you there as well.”
This exchange involved an important shift in responsibility from the therapist to the client, culminating in the client’s assertive “Let’s try it and see what happens.” The therapist continued to use language that highlighted that the client is in charge of things here (“you didn’t do what you set out to accomplish,” “if you choose not to do the homework”), keeping the responsibility firmly on the client. Transparency was effectively employed in the service of moving out of an oppositional dynamic to a more collaborative one. (In other words, the therapist’s “realness” forged a more authen- tic, in- the- moment connection with the client.) Finally, key points were established (those “stakes in the ground”) that could prove useful in future discussion if what happens subsequently does, in fact, mirror the original dynamic (if, for example, the client “forgets” to bring it up and is reminded by the therapist). At the very least, both therapist and client have moved out of a power and control dynamic to a more produc-