Introduction
Homework assignments have long been considered a central feature of cognitive behaviour therapy (CBT) (e.g. Beck, Reference Beck2011), and homework compliance has been directly associated with treatment outcomes (see meta-analysis by Kazantzis et al., Reference Kazantzis, Whittington and Dattilio2010; Kazantzis et al., Reference Kazantzis, Whittington, Zelencich, Kyrios, Norton and Hofmann2016). However, one in-depth interview identified that clients could struggle in, and between, CBT sessions (Barnes et al., Reference Barnes, Sherlock, Thomas, Kessler, Kuyken, Owen‐Smith, Lewis, Wiles and Turner2013). This was true both for those who did and did not complete therapy. CBT homework can be the biggest challenge to clients (Barnes et al., Reference Barnes, Sherlock, Thomas, Kessler, Kuyken, Owen‐Smith, Lewis, Wiles and Turner2013), and therapists also describe that problems during the assignation as well as during completion of a homework task regularly occur (Helbig and Fehm, Reference Helbig and Fehm2004).
The aim of this study was to examine if perfectionism was associated with homework adherence in CBT, especially the procrastination of homework assignments. Over the past 20 years, research has produced converging evidence that perfectionism has different aspects. In particular, two main dimensions have been differentiated: perfectionistic strivings, i.e. setting high standards and a self-oriented striving for perfection, and perfectionistic concerns, i.e. concerns over mistakes, feelings of discrepancy between one’s standards and performance, and fears of negative evaluation and rejection by others if one fails to be perfect. A meta-analysis revealed that perfectionistic strivings show negative relationships with procrastination, while perfectionistic concerns show positive relationships with procrastination (Sirois et al., Reference Sirois, Molnar and Hirsch2017).
Clinical perfectionism (Shafran et al., Reference Shafran, Cooper and Fairburn2002) suggests that perfectionists’ pursuit of their standards and their fear of failure in meeting them becomes so aversive that they delay beginning tasks (procrastination), abandon them midway, or avoid them entirely. An alternate explanation for the associations of perfectionism to procrastination is that individuals with higher levels of perfectionistic concerns may set goals that are more unrealistic and less attainable than those high in perfectionistic strivings, and that the larger discrepancy created by these differences in goals is what contributes to unfavourable expectancy assessments, and subsequent goal withdrawal or abandonment. As homework compliance may reliably reflect client engagement (Holdsworth et al., Reference Holdsworth, Bowen, Brown and Howat2014), the analysis of the effect of perfectionism on homework will increase the understanding of how perfectionism, as a client belief system, can impact engagement.
In order to examine the relationship between perfectionism and procrastination, the current study employed a brief CBT self-help intervention, given as homework, as the behavioural task. It was expected that perfectionism would be associated with a higher standard of homework setting, but only perfectionistic concern, not perfectionistic strivings, would be associated with procrastination of homework in CBT self-help intervention. This study also examined if homework adherence was associated with improvement in depression.
Method
Participants
The participants for this study were 38 university students (27 females) with a mean age of 21.58 years (SD = 3.73). Participants were recruited through a mixture of opportunity sampling and the university’s research subject pool. Completing the study rewarded participants with participation credits. The inclusion criteria were (1) participant age between 18 and 65 years, and (2) participants were not receiving psychological therapies. Participants were naïve to the experimental objectives and all participants completed the full experimental procedure.
Measures
Clinical Perfectionism Questionnaire
The Clinical Perfectionism Questionnaire (CPQ; Fairburn et al., Reference Fairburn, Cooper and Shafran2003) is a 12-item inventory developed to assess pathological perfectionism at a clinical level. Respondents are asked to select how best a statement describes them, over the course of the past month using a 4-point Likert scale.
Multidimensional Perfectionism Scale
The Multidimensional Perfectionism Scale (MPS; Hewitt et al., Reference Hewitt, Flett, Turnbull-Donovan and Mikail1991) is a 45-item inventory designed to measure three dimensions of perfectionism. Only items relating to self-oriented perfectionism (SOP) and socially prescribed perfectionism (SPP) were selected for use in the current study. Respondents are asked to select how much they agree with a statement about their personal characteristics using a 7-point Likert scale.
Patient Health Questionnaire-9
The Patient Health Questionnaire (PHQ-9; Spitzer et al., Reference Spitzer, Kroenke and Williams1999) was selected for use in this study for assessing depression. Respondents are asked to complete the inventories by considering ‘how bothered’ they had been by symptomatic traits of anxiety disorders over the previous 2 weeks using a 4-point Likert scale.
Material
This study adapted ‘Depression and Low Mood: Your Self Help Guide’, which is a 47-page booklet designed as a self-help pamphlet (retrieved 11 August 2016 from: https://icope.nhs.uk/wp-content/uploads/depression-and-low-mood-your-self-help-guide.pdf). Three short extracts from the booklet were used in the current study: (a) psychoeducation about low mood, (b) exercise of developing your own vicious circle, and (c) a few exercises for behavioural activation (see the online Supplementary Material).
Procedure
Participants were invited to a quiet testing suite and were informed that the study would consist of two sessions, 7 days apart from each other. Once informed consent had been recorded, participants were asked to complete the series of measures. The mean (SD) for PHQ-9 at this stage was 7.82 (5.34). Following this, participants were asked to read the extract from the material to understand how thought, mood and behaviour are linked to each other. After helping participants to identify routine, necessary and pleasurable daily activities, the experimenter assigned ‘homework’ exercises from the material:
Exercise 1: Participants identified a ‘stressful life event’ and completed a ‘vicious cycle’ of their own. They were asked to fill in the date when they started this exercise.
Exercise 2: Participants set activities they wished to complete in the 7 days on a weekly planner.
Exercise 3: Participants crossed off any activity they managed to achieve on the weekly planner.
Exercise 4: Participants were asked to write down their comments, reflections, and insights into the homework exercises. They were asked to fill in the date when they started this exercise.
Participants were asked to do all the exercises and were given the opportunity to ask clarifying questions. A follow-up session, as close to 7 days as possible, was agreed with each participant; this acted as a ‘deadline,’ for the homework to be completed by. They were asked to hand it in to the experimenter at the follow-up session. In the second session, after handing in the homework, participants were asked to complete the second PHQ-9. The mean (SD) for PHQ-9 at this stage was 7.29 (5.40).
Statistical analysis
In order to analyse behavioural procrastination of respondents, the following were calculated: how long it took (in days) to start Exercise 1 (Vicious Circle), how many activities they set (Number of Activities), how long it took (in days) to complete the first activity (First Activity) in Exercise 3, the number of completed activities (Completed Activities), the proportion of completed activities (Proportion), and how long it took (in days) to start Exercise 4 (Comments).
The correlations between perfectionism (i.e. CPQ, SOP and SPP) and those behavioural measures of procrastination were measured. Further analysis was conducted to investigate the relationship between perfectionism and the reductions in depression scores.
Results
Table 1 presents means, standard deviations, and correlations of perfectionism, reductions in depression, and behavioural measures of procrastination. A series of Shapiro-Wilk tests revealed the violation of normality by data collected from behavioural measures of procrastination, therefore Kendall’s Tau-B correlation was employed to test the relationships between variables.
Means, standard deviations, and Kendall’s Tau-B correlations of perfectionism, reductions in depression, and behavioural measures of procrastination
CPQ, Clinical Perfectionism Questionnaire; SOP, Self-Oriented Perfectionism; SPP, Socially Prescribed Perfectionism; PHQ change, reduction in the score of Patient Health Questionnaire-9; Vicious Circle, how long it took (in days), for participants to start the ‘Vicious Cycle’ homework exercise; Number of Activities, the amount of activities the participant set for themselves; First Activity, how long it took (in days) for participants to complete the first planned activity; Completed Activities, number of activities that participants completed; Proportion, the total amount of completed activities as a percentage; Comments, how long it took (in days) for participants to start the Comments homework exercise. *p < .05, **p < .01.
Only clinical perfectionism and socially prescribed perfectionism, but not self-oriented perfectionism, were correlated with most of the behavioural measures of procrastination. Moreover, those perfectionism scales were negatively correlated with the number of planned activities. Reductions in depression were negatively correlated with the proportion of completed activities; the more activities participants completed, the greater the reduction in depression was.
Discussion
Correlations suggest that participants scoring highly on either the CPQ or the SPP subscales, started tasks later and, completed fewer of their planned activities. Scoring highly on the CPQ or the SPP correlated with setting fewer activities in the interim week between sessions. Scoring highly on the SOP subscale had different directions. The current study generally corroborates the claim that negative facets of perfectionism interferes with the participant’s engagement in homework assignments. The association between the reduction in depression and the proportion of the completed activities suggests that it is important for the therapist to help the client to set appropriate homework tasks that are not too demanding to achieve. This is consistent with the importance of constant attention to the client’s belief system in both the selection of homework tasks, and the manner by which they are tailored for the individual (e.g. Beck, Reference Beck2011). For example, a client with extremely high standards as a schema is likely to find it anxiety provoking to be asked to engage in a task.
One of the more pertinent findings from the study is that the greater the SPP and CPQ were, the fewer tasks participants set on the activity planner. Instead of setting quantitatively demanding tasks, individuals who scored highly on SPP and/or CPQ may set qualitatively demanding tasks (e.g. running 10 km rather than walking 3 km). This warrants further research; a replication of the current study using a qualitative analysis of the tasks participants set on the planner, and a qualitative investigation of the adherence.
The limitation of the current study is the relatively low participant number (N = 38). Future research may need to expand the number of participants, the format of the intervention (other than a self-help) and the diversity of the participants (i.e. clinical populations). Moreover, future research should pay more attention to the quality of the completed homework, because that would reflect a client’s engagement more than its quantity. Consideration of this may more closely reveal perfectionists’ unrealistic treatment expectations, and a tendency to misinterpret the therapist’s praise and encouragement. Notwithstanding these limitations, this study was the first attempt to investigate the relationship between perfectionism and procrastination of homework in psychotherapy. Moreover, the use of behavioural measures of procrastination may be considered one of the strengths of this study, as there is a paucity of studies including a behavioural task to measure procrastination. Although there is a good correlation with self-report measures of procrastination, there is a relative lacuna in the use of a behavioural task.
Supplementary Material
To view Supplementary Material for this article, please visit: https://doi.org/10.1017/S1352465819000547
Acknowledgements
None.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
Osamu Kobori, Glen Dighton and Rachael Hunter have no conflicts of interest with respect to this publication.
Ethical statements
This study was reviewed and approved by the Departmental Ethics Committee, Department of Psychology, Swansea University.
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