Have you done your therapy homework today?
There was a time when psychotherapy meant reclining on a comfortable sofa, free-associating to a silent “all-knowing” therapist. It may not have done much to treat anxiety disorders, but it was comfortable and risk-free.
If you are serious, however, about treating your anxiety disorder, a very different and much more effective approach is required: Cognitive-Behavioral Therapy (CBT) with an emphasis on Exposure with Response Prevention (ERP). This approach involves taking concrete steps towards changing your thoughts, beliefs, and behaviors in order to lessen your anxiety.
This requires committing yourself to hard and often uncomfortable work in the short term in order to live a more comfortable future. Typically, this means “homework” and lots of it!
Yes. I agree that coming to therapy once a week and getting a pleasant dose of supportive reassurance might (in the short term) be more enjoyable than coming to therapy and doing challenging things like ERP, only to leave with homework assignments for the week. If research showed that the former worked, I’d gladly do that type of therapy.
Research, however, consistently shows that CBT is the non-medical treatment of choice for anxiety disorders. Consequently, if you are serious about managing your anxiety disorder, then challenging yourself with CBT (and the homework that comes along with it) is what gives you your best chance of victory.
The rule-of-thumb with CBT is that you get out of it what you put into it. Ultimately, you are the only one who can make the choice to face your fears and therefore (assuming you have access to appropriate anxiety diagnostic, treatment, and support resources) you are responsible for the success of your treatment.
What types of homework might be expected of me?
Since the types of things people fear are limitless, the content of your homework could be anything. Early on, you will likely be given questionnaires and other “data-collection” tasks to do. Then, you will need to learn about your anxiety through hand-outs, book recommendations, and/or internet information sources (You’re doing that right now…good for you!).
Then, you will be taught specific CBT and ERP skills and will be expected to practice regularly outside of therapy. Some people will also be taught specific social, problem-solving, relaxation, or acceptance-based skills that they will be expected to practice regularly.
How much time will I need to devote to homework assignments?
That depends. With severe anxiety disorders, I typically recommend that clients budget a minimum of one hour daily, six to seven days per week for the first month or so. I know that finding an extra hour for ERP each day is challenging, but here’s the deal—research shows that exposure therapy works best when exposure sessions occur frequently and for longer durations. You will likely make more progress in two weeks if you spend four hours a day, seven days a week doing ERP than spending ten years doing ERP once a week for fifteen minutes.
What are some reasons why people do not do their homework?
Lack of understanding of the importance of therapy homework is the most likely reason (“I’m terrified of dogs. Why on earth would I want to interact with one?”). Everyone who engages in CBT or ERP needs to have a reason to do so that makes sense to them. Do you really want to do something that someone else tells you is a good idea, is very uncomfortable, and makes no sense as to why you ought to do it? I thought not. If you are serious about getting your anxiety disorder under control, ask questions, read appropriate self-help or psycho-educational materials, and if you can, talk to people who have had a similar problem and have treated it successfully. Take charge of your own anxiety by becoming informed.
Some people feel pressured to come for treatment. Perhaps a spouse or parent is giving you an ultimatum—get treatment or else! By coming to therapy, you grudgingly meet the externally imposed mandate and by NOT doing your therapy homework you get to fail at therapy and tell the people who are pressuring you, “See, it doesn’t work”, ensuring that they will get off your back. Change is unlikely without sufficient motivation.
For some, the discomfort they fear they will have with ERP feels too painful for them to undergo. In this case, perhaps they (or their therapist) have set too challenging of a homework task—it happens. This can be resolved by either learning anxiety coping skills prior to ERP or breaking the task up into smaller steps. There is always a micro-step, so find it and repeat it until it is less distressing, and then take the next micro-step. If you are devoting an hour or so to ERP a day, those micro-steps can add up to substantial progress quickly.
Homework usually means changing a problem behavior that may be very automatic. Avoidance is a hard habit to break for many. Genuine ambivalence is common among people contemplating facing their fears. Early and honest discussion of this with your therapist is important in order to reduce the likelihood of being assigned homework that you are not yet ready to undertake. If you are still not sure that you want to make a change, it is not appropriate for you to be sent home from therapy with an ERP action plan for the week. Therefore in these cases, your initial homework is best focused on seeking information and bolstering motivation. If the reasons for making a difficult change does not sufficiently outweigh the reasons for continuing your avoidance then it is likely NOT the right time to treat your anxiety disorder. Better to be honest about this upfront and cease CBT/ERP rather than accumulating a list of half-hearted homework “attempts” and failures and concluding that this treatment doesn’t work for you.
It is common for people with severe anxiety disorders to also be depressed. Depression saps one’s motivation to engage in pleasurable activities so it certainly presents a challenge for completing tasks that might be scary, such as facing a feared situation. Often depression will need to be treated prior to treating an anxiety disorder.
While there may be the hope that your anxiety disorder can be overcome, there may be a stronger belief that it is just not possible to get better, that maybe you are too far gone. This can certainly impact one’s willingness to do ERP. Talk to your therapist about your concerns. It is important for you to know that people CAN learn to manage their anxiety disorder even if it is severe and has gone on for many years. It will, however, take consistent work on your part to make that happen.
While some people are open to trying new things if it seems like it might help them with a problem, there are some people whose personality is greatly defined by resisting help from other people. Some of us tend to be just plain oppositional. If you put someone like that in therapy and ask them to do something differently, they are likely to dig their heels in even deeper. The more they are pushed the harder they resist. If this describes you then your best bet for improving your anxiety is to become an expert in your anxiety. Do it for you and no one else. Don’t go to therapy to get told what to do, but “hire” a therapist with an expertise in your anxiety disorder and utilize them as a consultant in your self-directed treatment. Just be sure to be up front about this so that the therapist understands his or her role.
There are others whose personality is characterized by a more passive, dependent, or avoidant stance. These are people who have a consistent pattern across many facets of their life that revolve around either avoiding unpleasant things or enlisting someone else to do unpleasant things for them (or at least accompany them). If this is your personality, then your anxiety might be managed best if you can push yourself to take on ERP challenges more independently, initially enlist someone as an anxiety coach in the early stages, or enroll in a more intensive treatment program where, at least initially, you could have more one to one time with your therapist while doing exposure activities.
Most people would agree that discomfort is a normal and natural part of life. Some people, however, carry a belief that they “should always be comfortable”. This is a Thinking Trap that propels people towards a never-ending quest for comfort. The more you try to stay always-comfortable, the more your ability to tolerate discomfort diminishes. Chasing comfort, therefore, can make your world quite small and your activities very limited. Discomfort IS normal and building up a tolerance for discomfort is actually part of some anxiety treatment protocols.
For someone with a severe anxiety disorder, treatment needs to be a top priority in order to ensure that sufficient time and attention is devoted to taking those steps needed to get better. In life, however, illnesses, crises, time-consuming work obligations, or other genuine obstacles may present themselves. There are, in fact, worse times to treat anxiety disorders than others. Sometimes other life events DO need to take priority. That’s not to say that you cannot treat your anxiety in the face of other problems or obligations, but being realistic about your time constraints (and competing priorities) is important in deciding when to proceed with treatment and at what level of intensity. If you really are unable to make anxiety treatment a very important priority in your life, discuss this with your therapist and decide together whether to postpone treatment or to briefly shift focus.
There are also therapist issues to consider such as whether they have an expertise in ERP and are willing to work within established CBT treatment protocols. If you are concerned whether the types of homework assignments are appropriate for treating your anxiety disorder, ask questions, read anxiety educational materials, and get informed. If you are working with a therapist who you feel does not understand the problem for which you are seeking treatment, or you simply are not “hitting it off” then discuss this with him or her and look for another treatment provider. It is important that you feel your concerns are being addressed. It is difficult to do therapy homework when you have a poor relationship with the therapist who has recommended your daily ERP tasks.
Some people do not follow-through with therapy homework assignments because of the “secondary gains” they receive from maintaining an anxiety disorder. For example:
- Disability payments
- Additional attention and support from friends and family
- More time with kids, parents, or partners
- More time to pursue other interests (read—not having to work)
- Maintaining a status quo
- Getting out of chores or other obligations
- Avoiding other normal life discomforts
Maintaining an anxiety disorder in order to receive secondary benefits is typically NOT something people are aware they are doing. They may attend therapy for the attention or because they are pressured by others, but taking consistent steps towards real improvement is typically absent because getting better would lead to losing something they do not want to lose. The unfortunate thing is that in many cases the benefits from overcoming their anxiety disorder would greatly outweigh the benefits they are receiving from their secondary gain—they just can’t see it. Sometimes the secondary gain is to relieve pressure from someone else. For example, a child with separation anxiety may refuse to leave home to go to school partly because of unspoken pressure to support a depressed parent’s dependency needs (in other words the parent is meeting one of their needs by having a “sick” child).
What should I do if I cannot get myself to follow through with homework assignments at all?
That depends on a number of factors and I recommend that you discuss this with your therapist. However, here are some possible approaches:
- Explore with your therapist the pros and cons of treating your anxiety
- Work with therapist on problem-solving or decision-making skills
- Treat an interfering condition first
- Put off treatment until you are ready (or seek more supportive treatment first and work on basic motivational issues)
- Find a therapist who has more expertise on treating your problem (for anxiety disorders check www.adaa.org for a list of therapists who belong to the Anxiety Disorders Association of America)
- Work with your therapist to take smaller steps
- Make sure you understand (and agree with) the rationale for doing CBT homework
- Tell supportive people your goals (making it public increases likelihood of follow-through)
- Enlist a friend or family member as an anxiety coach to cheer you along as you complete your homework
- Schedule homework into your day
- Make it a top priority
- Reward yourself after completing your homework (perhaps only watch TV after your homework is done)
- Generate bigger incentive such as taking a vacation if you follow-through on your homework for a month
- Impose a negative consequence for not doing your homework (such as giving money to a charity you despise)
- Consider a more intensive treatment (such as an intensive outpatient IOP program or an inpatient or residential anxiety treatment program) where you will do more of your ERP with a therapist present
- Stop treatment for a set amount of time (teachers might hold off on treatment until they are off of teaching for the summer)
In sum, there is good news and bad news. The bad news is that for many people with an anxiety disorder, they will not get better unless they follow-through with appropriate, but potentially unpleasant treatment assignments. The good news is that with follow-through on these assignments most people will improve their anxiety significantly.
Eric Goodman, Ph.D.