Homework Assignments, Agenda Setting and the Therapeutic Alliance in Cognitive Therapy with Cluster C Personality Disorders: Synergetic or Antagonistic Ingredients?

Research indicates that therapist competence in assigning homework may play a prominent role for outcome in cognitive therapy (CT) with various psychiatric disorders, including Cluster C personality disorders. Potentially cofounding factors need to be addressed though, and the present study examined to what extent therapist competence in (a) assigning homework and (b) agenda setting, as well as (c) the quality of the therapeutic alliance, contributes uniquely to a positive outcome in CT with cluster C personality disorders. Twenty-four patients receiving CT were taken from a previously published randomized controlled trial, and a residualized composite score of psychopathology/distress was used as outcome measure. The quality of the therapeutic alliance was rated by patients at session four, whereas therapist competence in assigning homework and agenda setting was assessed by independent raters in an early session (typically session six). Therapist competence in assigning homework was a strong predictor of outcome in CT, even when taking into account potentially confounding factors such as the quality of the therapeutic alliance and therapist competence in agenda setting. Structuring sessions to increase the benefits of homework assignments appear to be important in CT with cluster C personality disorders.