Tipos de lactancia y requisitos exigidos a las nodrizas

The main results of this study showed no relationship between homework benefits and completion, costs and completion, or client beliefs and depression. The lack of relationship between homework and depression was in contradiction with much of the previous research in this area (e.g. Kazantzis et al., 2000; Kazantzis, Deane, Ronan, & Lampropoulos, 2005; Rees et al., 2005). However, while correlational studies have generally found a significant effect for homework, studies investigating the causal relationship have produced inconsistent findings (Kazantzis, Deane, Ronan, & Lampropoulos, 2005; Thase & Callan, 2006). While much of the previous literature has demonstrated a relationship between homework and

95 depression, the current study addressed many methodological limitations in previous research, as described earlier. For example, the current study utilised homework ratings at every session, employed a rating scale rather than dichotomous ratings, and used multilevel analysis to discern individual growth trajectories. Additionally, the current study employed client ratings as a focus rather than the ever-popular therapist ratings (e.g. Burns & Spangler, 2000). Therefore it may be that when investigating homework in detail rather than employing averages, this effect is diminished.

An additional explanation is that there are many other factors that may be more important in terms of enhancing outcome (of depressive symptoms) than homework completion. For example, attributional style, one of the main predictors in this thesis, might be one of the more important factors to consider. Perhaps a more pessimistic individual improves less rapidly in therapy than a less pessimistic individual, regardless of whether they do their homework or not. Indeed, Carr and McNulty (2006) list a pessimistic cognitive style in their discussion of risk and protective factors for depression, a claim which is also strongly supported by the theory and research in chapter 3 of this thesis. The findings of this thesis also support the relationship between attributional style and depression, which will be discussed shortly. Carr and McNulty (2006) also list other correlates of therapy outcome, such as neurotic personality traits, or biological and family factors, that are implicated in the etiology and maintenance of depression. A brief literature search will reveal many more confirmed correlates, such as the widely-researched therapeutic relationship (e.g. Zuroff & Blatt, 2006). A possibility might therefore be that homework may be further down the list of importance than initially thought.

Personal experience as a therapist in the depression study consisting of 22 sessions with four of the clients allows further reflection. Two of the four clients seen personally did not complete their homework on a regular basis while two of the clients did. However all four improved in their depressive symptoms over the course of therapy. The same procedures and similar tasks were followed with all of these clients, and, being the same therapist, competence was likely to be relatively similar. There are several possible reasons why all still improved although homework completion was inconsistent between then. One is that all four clients were still motivated to consistently attend therapy, to complete the full 20 sessions plus two follow ups, to develop strong rapport with their therapist, and to challenge their cognitions. All four clients reported having viewed some situations differently,

96 employing cognitive techniques, and attempting to change their behaviour. They all brought examples from their week into therapy, where the situations were worked through together, and the clients at various times expressed finding particular techniques extremely helpful. Therefore one reason for all four clients improving may be that the other therapy factors, such as rapport, and the fact that clients often integrate their learning into the real world anyway, played important roles in clients‘ improvement. Another reason may be that, as Kazantzis, MacEwan et al. (2005) state, non-completion of homework provides rich grounds for discussion as to why it was not completed. It may be that clients were still unsure about attempting a behavioural experiment, or that they thought the task was not of importance, or they were using the techniques in their head rather than on paper due to finding the task arduous. Whatever the reason, these barriers were able to be discussed in therapy and alternative means for reaching the desired goal were formed. Regardless of whether clients did their homework or not, large amount of time were devoted to discussing the homework tasks and therefore learning may still have occurred without actually doing the tasks.

There are several other possible explanations for the lack of relationship between homework and depression in this study. One is that a small effect might in fact exist, but the strong focus on homework in the depression study meant that clients were overall doing large amounts of homework. This might mean that there were not enough clients regularly not completing homework to compare results to. This is where a randomised controlled study with comparison groups would provide clearer results, although the limitations of these are still significant, in that clients often do tasks on their own even when they are not required to. Therefore testing this hypothesis is difficult, but it might be that all clients in this study were exposed to homework enough so that it still had an effect on their treatment outcome. A comparison of outcomes with a replication of this study minus the focus on homework would be advantageous.

Post Hoc Results Indicate a Quantity - Quality Effect

Despite the above findings, there was an interesting effect produced by the quantity - quality homework interaction on depression scores over time. When measuring pure quantity and quality of completion without taking into account any of the other experiences involved in homework (e.g. pleasure, mastery), changes in depression over time are explained to a small degree. The theory behind completing

97 homework inherently makes sense, and so this finding might serve to demonstrate that the basic principles of homework are important. In addition, it suggests that previous research investigating the effects of quantity alone has been limited; the quality of homework completion is also very important to measure (as suggested by Bryant et al., 1999; Kazantzis, Deane, Ronan, & Lampropoulos, 2005; Rees et al., 2005). However, when pessimism is added to this model, the quantity - quality effect on depression scores disappears, indicating that pessimism moderates this relationship to a degree.

Therapists, Clients, and Independent Observers View Homework Differently

Therapist and client agreement is discussed first. Although there are no universal guidelines for interpreting ICCs, it was clear that the coefficients in the current study were not high between client and therapist ratings. Most could be classed as ‗fair‘ agreement (the second-to-bottom ranking on a five-point scale from Montgomery et al. (2002)). This demonstrates that clients are clearly rating their homework completion from a different perspective to what therapists are. This discrepancy was also reported by Kazantzis et al. (2006). However, from the ICCs reported in Table 10 earlier, it is apparent that clients and therapists generally agree more on some items than others. Agreement is higher when rating quantity and quality of homework completion, obstacles encountered, and pleasure and mastery gained from the task. Clients and therapists agreed less on the difficulty of the task, on the progress made from the task, and on all of the items that compose the client ―beliefs‖ factor (comprehension, rationale, collaboration, specificity, and match with therapy goals). This is particularly interesting, because agreement is higher on items that involve the clients‘ personal experience (e.g. sense of pleasure gained from the task), than it is on behaviours that were experienced and observable in the actual therapy session (e.g. rationale for the task, level of collaborating in designing the task). However, Kazantzis, Deane, and Ronan (2005) describe these in-session items as representing client beliefs because this is where their belief system about their ability to carry out the task is likely to be highlighted. To this end, one possible explanation for the findings (also consistent with the hypotheses of this thesis) might be that clients‘ attributional styles are distorting the objectivity of their ratings. However, post-hoc analyses demonstrated that attributional style did not explain any of the variance in homework scores as rated by clients. Therefore, this hypothesis is not likely. It is still possible, however, that client ratings are influenced by other

98 factors (such as personality type or whether they thought the task was important or not), that were not included in the current study. The depression study did measure some of these variables, however an extensive investigation was beyond the scope of the current study. Further still, it may be that therapist beliefs influenced their (therapists‘) ratings of homework completion. Therapists who are pessimistic about the utility of homework, or their general ability as a therapist, may under-estimate their competence in assisting with these same factors. Therapist beliefs were not measured in the depression study but are a promising avenue for future research to investigate.

ICCs between clients and therapists, and independent observers were also poor. In particular the clients only experienced ‗slight‘ or ‗fair‘ agreement with independent observers, while the therapists fared only slightly better. This indicates that independent observers are likely perceiving homework completion very differently from therapists and especially clients. It is possible that because they are rating via video, they are missing out on important information gained from being in the room with the client. Especially if homework is not verbally discussed in detail or specifically named as ‗homework‘, the independent observers are unlikely to be able to give accurate ratings. It is also possible that independent observers are not able to spend as much time thinking about the homework as they are also rating other scales for the depression study in conjunction with the HRS-II. Another explanation may be that the independent observers do not follow a client consistently over time, and so do not remember the clients‘ previous session from which this homework followed on, and they are also not influenced by factors such as the clients‘ personality as much. Therefore, while independent observers are likely to be objective in this sense, they are also missing out on a lot of information that is only gained from being in the room and following the client consistently over time.