Cognitive Interventions for Anxiety 199
monitoring homework. Many clients do not like filling in forms or writing about their
anxious thoughts and feelings. Even though there is mounting empirical evidence of
an association between treatment improvement and homework compliance (Kazantzis,
Deane, & Ronan, 2000), many clients still have great difficulty engaging in homework.
This problem has been addressed in a number of recent volumes on cognitive therapy,
and various suggestions have been offered for improving homework compliance (see
J. S. Beck, 2005; Leahy, 2001; Kazantzis & L’Abate, 2006). In the present context
the therapist should deal with any misconceptions or difficulties the client may have
about homework. The importance of homework and learning to identify anxious think-
ing should be emphasized as an essential skill that must be acquired before utilizing
the other cognitive and behavioral strategies for reducing anxiety. Homework should
be assigned in a collaborative fashion with instructions written for client convenience.
However, if an individual persists in refusing to engage in homework, termination of
further treatment may be necessary.
There is one reason for homework noncompliance that may be specific to the anxi-
ety disorders. Sometimes clients are reluctant to engage in any self- monitoring of their
anxious thoughts and symptoms because they are concerned it will make the anxiety
worse. For example, a 33-year-old man with abhorrent obsessions about pedophilic
sex was afraid that writing down the occurrence and accompanying appraisals of the
thoughts would not only make them more frequent and raise his anxiety level, but these
thoughts were also a violation of his moral values. He was also concerned that draw-
ing even more attention to the thoughts would erode what little control he had over
the obsessions. In this example concerns about escalating anxiety, the repugnant and
immoral nature of the obsessions, and fear of losing control all contributed to reluctance
to engage in self- monitoring his anxious thoughts.
A number of steps can be taken to address this situation. First, it is important to
make homework noncompliance a therapeutic issue. The faulty beliefs contributing to
reluctance to self- monitor anxious thoughts should be identified and cognitive restruc-
turing can be utilized to examine these beliefs and generate alternative interpretations.
Possibly the homework assignment could be broken down into less threatening steps
such as asking the client to experiment with self- monitoring thoughts on a certain day
(or period within a day) and record the effects of the monitoring. This would be a direct
behavioral test of the belief that “writing down my anxious thoughts will make me
more anxious.”
The cognitive therapist should spend time during the educational phase introducing
the importance of homework and then periodically throughout treatment reminding the
client of the role that homework plays in the success of cognitive therapy. The following
is one way to explain homework to anxious clients:
“Homework assignments are a very important part of cognitive therapy. Approxi-
mately 10–15 minutes toward the end of each therapy session, I will suggest that
we summarize the main issues we’ve dealt with in the session and then decide on
a homework assignment. We will discuss the assignment together and make sure
it is something that you agree is doable. I will write the assignment down so we
are both clear on what needs to be done. From week to week I will also be giving
you different types of forms on which to record the results of the assignment. The
assignments will be short and not involve more than a few minutes out of your day.