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Improving Cognitive-Behavioral Therapy Homework Adherence with Change Talk and Commitment Language: a Cognitive Dissonance Perspective of Behavioral Change Robert J

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Improving Cognitive-Behavioral Therapy Homework Adherence with Change Talk and Commitment Language: a Cognitive Dissonance Perspective of Behavioral Change Robert J Philadelphia College of Osteopathic Medicine DigitalCommons@PCOM PCOM Psychology Dissertations Student Dissertations, Theses and Papers 2014 Improving Cognitive-Behavioral Therapy Homework Adherence with Change Talk and Commitment Language: A Cognitive Dissonance Perspective of Behavioral Change Robert J. Brecher Philadelphia College of Osteopathic Medicine, [email protected] Follow this and additional works at: http://digitalcommons.pcom.edu/psychology_dissertations Part of the Clinical Psychology Commons Recommended Citation Brecher, Robert J., "Improving Cognitive-Behavioral Therapy Homework Adherence with Change Talk and Commitment Language: A Cognitive Dissonance Perspective of Behavioral Change" (2014). PCOM Psychology Dissertations. Paper 299. This Dissertation is brought to you for free and open access by the Student Dissertations, Theses and Papers at DigitalCommons@PCOM. It has been accepted for inclusion in PCOM Psychology Dissertations by an authorized administrator of DigitalCommons@PCOM. For more information, please contact [email protected]. Philadelphia College of Osteopathic Medicine Department of Psychology IMPROVING COGNITIVE-BEHAVIORAL THERAPY HOMEWORK ADHERENCE WITH CHANGE TALK AND COMMITMENT LANGUAGE: A COGNITIVE DISSONANCE PERSPECTIVE OF BEHAVIORAL CHANGE Robert Jay Brecher Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Psychology June 2014 PHILADELPHIA COLLEGE OF OSTEOPATIDC MEDICINE DEPARTMENT OF PSYCHOLOGY Dissertation Approval T) --- '7'"7 This is to certify that the thesis presented to us by k D 6 6 '{L 1 J , biQ E c Gi t::- I<... On the CJo ·t~ day of __, ·lilAr_vl,. 1"'-v,_____ , 20--.:::!_,} l_l in partial fulfillment of the requirements for the degree of Doctor of Psychology, has been examined and is acceptable in both scholarship and literary quality. Committee Members' Signatures: Elizabeth A Gosch, PhD, ABPP, Chairperson Robert A DiTomasso, PhD, ABPP Michael Dolan, PsyD Robert A DiTomasso, PhD, ABPP, Chair, Department of Psychology iii Acknowledgements The present work represents the culmination of an academic journey that would not have succeeded without the help, guidance, and mentorship of teachers and professors who were willing to spend valuable personal time and immeasurable energy to mold the student before them into a student capable of achieving his aspirations: Lisa Downs of Jarrettown Elementary School, who set the tone for me to always seek additional help and support from instructors. Cheryl Hall of Jarrettown Elementary School, who taught me the invaluable skills of organization and academic responsibility. Phyllis Schachter of Temple Sinai, who encouraged me to build on accomplishments. Janet Frazer of Abington Friends Upper School, who taught me foundational skills of academic research and writing. Leela Raja of Abington Friends Upper School, whose mentorship has been invaluable and whose example motivated me to continue to look for mentors throughout my academic career. Stephen Kilianski, Ph.D., of Drew University, whose enthusiasm for research was contagious, and whose mentorship in academic writing set the foundation for my graduate studies. Stephanie Felgoise, Ph.D., whose mentorship throughout my graduate studies matured my understanding of research from a theoretical and practical perspective. Robert DiTomasso, Ph.D., and Michael Dolan, Psy.D., who devoted time and effort to this project. The counsel, guidance, and expertise provided made this work possible. iv Elizabeth Gosch, Ph.D., who devoted countless hours and endless patience to encourage me to draw on all I had learned from each teacher and mentor listed above in order to overcome the obstacles encountered during this project and to produce this work. v Abstract Adherence to homework assigned during cognitive-behavioral therapy (CBT) is an important factor contributing to positive outcomes. However, rates of adherence are poor, limited evidence supporting methods to improve adherence is limited. The current study aimed to develop and test an intervention designed to promote CBT homework adherence based on cognitive dissonance theory. Patients participating in outpatient CBT were randomly assigned to either an experimental or a control condition. In the experimental condition, participants engaged in an induced-compliance procedure eliciting change talk targeting the recommended homework activity. The control condition consisted of treatment as usual. Owing to limited sample size (n = 14), statistical analysis lacked sufficient power to confirm hypotheses; however, notable effect sizes were observed trending in support of the study hypotheses predicting greater rates of homework adherence in the experimental condition. These data, in conjunction with the large body of evidence directly supporting cognitive dissonance theory as an explanation of attitude and behavioral change, invites future studies to continue to explore the use of cognitive dissonance theory in clinical settings to promote attitude and behavioral change. vi Table of Contents List of Tables…………………………………….……………………………...………vii Chapter 1: Introduction…………………………...…………………….…….…..………1 Chapter 2: Review of the Literature………………………………………….….....……8 Non-adherence…………………………………………………………….……..9 Cognitive Dissonance Theory: A Theory of Attitude and Behavioral Change…23 Motivational Interviewing: An Intervention for Behavioral Change…………...57 Homework Assigned in CBT………………………….……………….………..65 Synthesis of the Literature……………………………………………...………..76 Chapter 3: Hypotheses…………………………………………………..………..……...78 Primary Hypothesis………………………………………………...……..……...78 Secondary Hypotheses……………………………………………...……..……..78 Analyses to Rule Out Alternative Explanations……………………...………….79 Chapter 4: Method ……………………………………………………………………..80 Design and Design Justification………………………………………..……...…80 Homework Adherence Measurement Considerations…………………...………81 Dissonance Procedure Rationale…………………………………………...……82 Inclusion Criteria……………………………………………………………..….82 Exclusion Criteria………………………...……………………………………...83 Participants………………………………………………………..………..…....83 Participant Demographics………………………………………………………84 vii Informed Consent…………………………………………….……………....….84 Measures……………………………………………………..………….….........85 Procedure…………………………………………………..…………….……....86 Chapter 5: Results………………………………………………..…………………...….90 Chapter 6: Discussion…………………………………………..………………..….…...94 Limitations of the Current Study……………………………….………………..95 Suggestions for Future Research……………………………….…………….…99 Implications of this Research and Conclusion………………..………………101 References………………………………………………………….…..……………...103 Appendix A: Homework Category Checklist………………………..………………....118 Appendix B: Control Questionnaire………………………………..………………..…119 Appendix C: Experimental Questionnaire/Intervention………….………………….....121 viii Table Table 1. Comparison of Adherence to CBT Homework by Condition……………….93 Running head: IMPROVING CBT HOMEWORK ADHERENCE Chapter 1 Introduction Homework is an essential component of cognitive behavioral therapy (CBT), serving several functions towards the achievement of patient treatment goals that can be broadly categorized across three domains: data gathering, learning, and bridging. Homework serves as data gathering in that it is an opportunity for patients to collect information about themselves and the influence of techniques taught in therapy that can inform future therapy sessions and interventions. Homework also allows the patient to learn more about psychological processes or phenomena, such as engaging in bibliotherapy. Finally, homework bridges the therapeutic session to the rest of the patient’s life by encouraging patients to practice skills taught in therapy and generalize the use of those skills into their daily lives (Beck, 1995, Freeman, 2007; Freeman & Rosenfield, 2002). A growing body of literature suggests that patient adherence to homework is predictive of outcomes, with effect sizes ranging from mild to moderate (e.g., Burns & Nolen-Hoeksema, 1991; Burns, & Spangler, 2000; Kazantzis, Deane, & Ronan, 2000; Kazantzis, Whittington, & Dattilio, 2010; Startup & Edmonds, 1994). Yet, in a survey of clinicians, Helbig and Fehm (2004) reported that only 38.9% of patients complete homework as assigned. In light of these findings, clinicians may look to employ methods to promote homework adherence. Several theorists have suggested guidelines and recommendations to increase homework adherence (Beck, 1995; Freeman, 2007; Freeman & Rosenfield, 2002). However, there are few empirical investigations of these suggestions (Detweiler & IMPROVING CBT HOMEWORK ADHERENCE 2 Whisman, 1999). Furthermore, the empirical evidence that does exist surrounding these suggestions does not support the theorists’ recommendations (Startup & Edmonds, 1994). This evidence suggests a clear need for empirically based interventions that can be employed to increase adherence to CBT homework. Fundamentally, an intervention to increase adherence to homework is an intervention to change behavior. Thirty-two years ago, Prochaska and DiClemente (1982) published the transtheoretical model of behavioral change, or as it is more commonly referred to, the stages of change model. This model was revised by Freeman and Dolan (2001) to include 10 nonlinear stages that describe typical cognitive patterns an individual may experience on a continuum of behavior: noncontemplation, anticontemplation, precontemplation, contemplation, action-planning, action, prelapse, lapse, relapse, and maintenance. Prochaska, DiClemente, and
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