Case Managers' Attitudes Toward the Use of Homework for People Diagnosed With a Severe Psychiatric Disability

Case managers’ Attitudes Toward Homework

This is a copy of the authors final peer-reviewed

manuscript as accepted for publication. The article was

published in the Rehabilitation Counseling Bulletin. This

article may not exactly replicate the final version

published in the journal. It is not the copy of record.

http://rcb.sagepub.com/content/51/1/34.abstract

Please cite:

Kelly, P., Deane, F. P., Kazantzis, N., & Crowe, T.

(2007). Case managers’ attitudes toward the use of

homework for people diagnosed with persistent and

recurring psychiatric disability. Rehabilitation

Counseling Bulletin, 51, 34 – 43.

1

http://rcb.sagepub.com/content/51/1/34.abstract


Running head: CASE MANAGERS’ ATTITUDES TOWARDS

HOMEWORK

Case Managers’ Attitudes Toward the Use of Homework for

People Diagnosed with a Severe Psychiatric Disability

2


Abstract

The study examined mental health case managers’

attitudes towards the use of homework and explored the

relationship between clinician attitudes and systematic

homework administration practices. One hundred and twenty

two Australian mental health case managers completed a

survey examining attitudes towards the use of homework.

Case managers who held more positive attitudes reported

better client responses to homework. Systematic homework

administration was predicted by the degree case managers

felt homework enhanced client outcomes and the importance

case managers placed on the use of homework for severe

psychiatric disabilities. The use of training and

supervision programs to promote systematic homework

administration practice is discussed.

Key words: Homework, case management, mental health,

attitude, survey

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Case Managers’ Attitudes Toward the Use of Homework for

People Diagnosed with a Severe Psychiatric Disability

Homework refers to between session activities that

are designed to help individuals make progress toward

their treatment goals (Shelton & Ackerman, 1974;

Kazantzis & Lampropoulos, 2002). These activities are

usually negotiated between a client and treatment

professional during face-to-face contacts. To date,

homework research has generally focused on the

psychosocial treatment of anxiety (e.g., Schmidt &

Woolaway-Bickel, 2000; Leung & Heimberg, 1996) and

depression (e.g. Burns & Spangler, 2000). Homework has

been shown to have a significant effect on treatment

outcome, with homework compliance also positively related

to improved therapy results (see Kazantzis, Deane &

Ronan, 2000). The process of using homework might be used

as an important clinical adjunct within the broader

context of mental health (Glaser, Kazantzis, Deane &

Oades, 2000; Luboshitzky & Gaber, 2000). However, there

has been limited research describing the use of homework

across a range of mental health professionals or more

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complex psychological disorders (e.g. schizophrenia).

Mental health case managers constitute a mixed

professional group who may see benefit from involving

clients in therapeutic tasks between direct face-to-face

contacts (Glaser et al., 2000). This has particular

relevance for persons diagnosed with severe psychiatric

disability, such as schizophrenia, who are typically case

managed within community mental health teams.

There is variation in the terms used to describe

psychiatric disabilities. For example, in a review of the

literature 17 definitions were identified to describe

severe and persistent mental illness (Schinnar, Rothbard,

Kanter & Jung, 1990). For the purposes of the current

study we will refer to severe psychiatric disability

(i.e. schizophrenia, bi-polar and schizoaffective

disorder) and moderate psychiatric disability (i.e.

depression and anxiety). The grouping of these disorders

is consistent with previous conceptualizations of

disorder duration and severity (e.g., Bedell, Hunter &

Corrigan, 1997).

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There is a growing body of literature advocating the

use of homework for severe psychiatric disorders. For

example, Luboshitzky and Gaber (2000) suggest mental

health occupational therapists could include tasks such

as home management assignments (e.g., cleaning the house

according to predetermined steps), development of self-

care skills (e.g., making a dental appointment) or

promoting engagement in leisure activities (e.g., reading

newspapers to identify local entertainment activities).

Glaser et al. (2000) also described a range of approaches

that used homework in the treatment of schizophrenia and

other severe psychiatric disabilities. These included

assignments such as; activity scheduling, self-

monitoring, behavioral tasks, interpersonal assignments

and family based homework interventions amongst others.

As a component of therapeutic contracting, individual

homework exercises are utilized to promote goal

achievement and generalization of psychological

principles to the individuals living environment

(Heinssen, Levendusky & Hunter, 1995). Homework has also

been recommended for use in CBT for psychosis (Chadwick,

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Birchwood & Trower, 1996; Fowler, Garety & Kuipers, 1995;

Hogg, 1996), family therapy (Anderson, Reiss, & Hogarty,

1986; Barrowclough & Tarrier, 1992; Falloon, Boyd &

McGill, 1984) and social skills training (Halford &

Hayes, 1991; Wixed, Morrison & Bellack, 1988).

Whilst there is evidence that homework is

recommended for severe psychiatric disabilities, there

have been limited studies examining or describing its use

in research or actual clinical practice. For example, in

a meta-analytic review of skills training research for

individuals diagnosed with severe psychiatric disability,

Dilk and Bond (1996) identified homework as a core

technique. However, of the 68 studies included in the

analysis only 30 (45%) specified the use of homework to

promote generalization. With an increasing focus on the

use of homework across a range psychotherapies and

counseling approaches (see Kazantzis & Ronan, 2006), the

current research represents a timely analysis of homework

by a multi-disciplinary group of case managers working

specifically with severe psychiatric disabilities. The

present study represents a further analysis of data

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obtained from a survey distributed to case managers.. The

first study sought to identify whether case managers

routinely used homework and how they went about

implementing it within their clinical practice. That

report identified that most case managers (93%) utilize

homework, but found that systematic administration

practices were not routinely followed (only 15%; Kelly,

Deane, Kazantzis, Crowe, & Oades, 2006). The present

study extends the previous work by (a) describing case

managers’ attitudes towards homework, and (b) exploring

the relationship between their attitudes and homework

administration practices.

There is growing interest in the use of homework by

psychologists (e.g., Kazantzis & Deane, 1999; Fehm &

Kazantzis, 2004; Deane, Glaser, Oades & Kazantzis, 2005),

occupational therapists (Luboshitzky & Gaber, 2000),

psychotherapists (Kazantzis, Busch, Ronan, & Merrick, in

press) and mental health case managers (Kelly et al.,

2006), but there has been limited research identifying

how homework is actually transferred into practice

(Kazantzis, Lampropoulos, & Deane, 2005). One factor

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influencing homework implementation may be attitudes held

by case managers. Practitioner attitudes have been

identified as an important factor influencing the

integration of clinical approaches within treatment

(Addis & Kransnow, 2000; Neimeyer, Fortner & Melby,

2001). For example, clinicians holding more positive

attitudes towards the use of behavior therapy are more

likely to use these approaches within their routine

clinical practice (Corrigan et al., 1998). Attitudes held

by mental health clinicians have also been shown to

influence both the assessment and management practices

used when working with an individual diagnosed with a

long-term psychiatric disability (Conning & Rowland,

1992). Examining case managers’ attitudes towards

homework may partially explain the variability in

homework use.

Previous research on attitudes toward homework was

conducted by Kazantzis et al. (2005) examining a sample

of 827 psychologists practicing in the USA. The survey

incorporated a seventeen-item questionnaire used to

measure clinician attitudes towards the use of homework.

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Two factors were identified within the questionnaire: (a)

Negative Session Impact, which captures negative attitudes

clinicians may hold towards the impact of homework upon

the therapeutic relationship, and (b) Positive Homework Effect

which refers to the ability for homework to facilitate

improved treatment results (Kazantzis et al.). Positive

clinician attitudes were found to be associated with

increased quantity and quality of homework adherence, and

more positive client reaction towards the use of homework

(Kazantzis et al.). Both adherence ratings and client

reaction towards homework were based on therapist global

ratings of their entire caseload. The study did not

examine administration practices used by clinicians when

administering homework. However, given that theory and

research suggests that attitudes influence intentions to

perform behavior (Fishbein & Azjen, 1975; Gollwitzer,

1999), a possible explanation is that psychotherapists

holding more positive attitudes towards homework are more

likely to use administration practices that promote

adherence.

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The use of a systematic approach to homework

administration has been suggested as a means to

facilitate client homework adherence and improve the

quality of the homework completed (Shelton & Ackerman,

1974; Shelton & Levy, 1981). From a research perspective,

systematic homework administration involves guidelines

that specify the frequency, duration and location of

where the homework assignment should be completed, and

providing a written record of the homework task for the

client (Kazantzis & Deane, 1999; Shelton & Levy, 1981).

It is likely that assisting the client to develop a plan

for homework completion facilitates the development of an

implementation intention. There is growing support for

the idea that establishing an implementation intention

(i.e. determining how, where and when the task should be

completed) promotes the completion of goal-directed

behaviors (Gollwitzer & Brandstatter, 1997). Kelly et al.

(2006) provided initial evidence for the relationship

between systematic homework administration and case

manager rated measures of both homework compliance and

the client’s positive response towards the use of

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homework. According to this data, the majority of case

managers use homework within their clinical practice, but

homework is used in less than half of all sessions.

Moreover, only 15% of case managers routinely adhere to

systematic administration practice guidelines. Given that

attitudes towards performing a specific behavior are

theorized to be related to the likelihood of actual task

completion (Ajzen, 1991), it is expected that case

managers who hold more positive attitudes towards the use

of homework will tend to administer homework in a more

systematic fashion.

Another factor that may influence the use of

homework by mental health case managers relates to how

important they consider homework to be for the treatment

of severe psychiatric disabilities. Attitudes that are

considered important to individuals are strongly linked

to their beliefs and values, and are thought about

frequently (Judd & Krosnick, 1989). Individuals are also

more knowledgeable, and more likely to seek out attitude

relevant information where a high importance is placed on

an attitude (Holbrook, Berent, Krosnick, Visser &

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Boninger, 2005). While many interventions promote

homework within the treatment for schizophrenia (see

Glaser et al., 2000), limited data regarding the use of

homework with people diagnosed with a severe psychiatric

disability suggests a number of potential difficulties

are associated with implementation (e.g., memory,

motivation etc., see Dunn, Morrison & Bentall, 2002).

Clinicians consistently place lower importance on the use

of homework for symptoms associated with severe

psychiaric disability compared to other clinical problems

(Deane et al., 2005). For example, one study found 50% of

psychologists reported homework was of little or moderate

importance in the treatment of hallucinations and

delusions (Kazantzis & Deane, 1999). However, in these

studies, the clinicians worked predominantly with

moderate psychiatric disability such as depression and

anxiety and may not have been familiar with homework

activities used in treatments of more severe psychiatric

disabilities (e.g., social skills training, Halford &

Hayes, 1991). Mental health case managers with

considerable experience working with individuals

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diagnosed with severe psychiatric disabilities might be

expected to rate homework use for these disorders as

relatively more important

The current study examines the relationship between

case managers’ attitudes and homework administration

practices. Specifically, it seeks to identify (1) if case

managers’ attitudes towards homework influence their

administration practices? It is hypothesized that more

positive clinician attitudes toward homework, will be

related to administering homework in a more systematic

fashion. While, more negative attitudes towards homework,

will be related to administering homework less

systematically. Additionally this study examines if, (2)

the importance placed on the use of homework for moderate

and severe psychiatric disabilities influences

administration practices? It is hypothesized that case

managers will rate homework for severe and moderate

psychiatric disorders with equal importance. A positive

relationship is also expected between ratings of homework

importance and the use of a systematic approach to

homework administration. Finally, the study seeks to

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examine (3) the factors that predict case managers’

homework administration procedures?

Methods

Participants

A total of 195 Australian mental health workers were

approached to participate in the study. Forty

questionnaires were not returned (20%), 27 clinicians

declined to participate (14%) and another 3 (2%) reported

that they were not currently working in a case management

position. This resulted in 122 (63%) case managers

participating in the study. Clinicians were from public

mental health services in the states of Queensland (QLD),

New South Wales (NSW) and Victoria (Vic) and from non-

government organizations including the Richmond

Fellowship (QLD), Aftercare (NSW), and Psychiatric

Rehabilitation Association (NSW). The three non-

government organizations provided a combination of

residential care, supported housing and day programs

utilizing case management models of client care. These

organizations were all participating in a larger study,

aimed at evaluating the implementation of a recovery-

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orientated approach to case management (Oades et al.,

2005). All case managers were primarily working with

individuals diagnosed with severe psychiatric

disabilities. Case managers were excluded from the study

if their caseload primarily consisted of developmental

disabilities.

Seventy-percent of the sample were women. The

majority of case managers were registered nurses (43%) or

allied health workers (35%, i.e. psychologists, social

workers or occupational therapists). At a minimum, both

the nurses and allied health workers had completed an

undergraduate, university degree and fulfilled the

requirements for registration with their respective

professional body. The remaining clinicians (21%) were

employed as welfare or support workers, having completed

three to four years of polytechnic level training in the

field of welfare at a Technical and Further Education

(TAFE) institution. On average, case managers had worked

in their respective profession for 14 years. Twenty-seven

percent of case managers were part-time, working 30 hours

or less. Both part-time and full-time case managers spent

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approximately one hour at each client contact and

estimated having a minimum of fortnightly contact with

each client. On average, part-time case managers had 9

clients on their case load and full-time workers had 14

clients. The majority (66%) of people they worked with

had been diagnosed with persistent or recurring

psychiatric disabilities (i.e. schizophrenia,

schizoaffective disorder and bipolar disorder).

Survey Questionnaire

A 90-item questionnaire was constructed using

previously developed questionnaires (i.e., Kazantzis &

Deane, 1999; Kazantzis et al., 2005). While terminology

varied slightly (e.g. substituting the term case manager

for psychologist), the content of the items was

identical. The questions broadly surveyed clinicians’:

(a) demographic information and workload, (b) overall use

of homework, (c) use of different homework assignments,

(d) method of integrating homework into visits, and (e)

attitudes towards the use of homework. The present study

focuses on the attitudinal measures and case managers’

implementation of homework.

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For the purposes of this study, between sessions

homework assignments were defined as “any between-session

activity that is tied to a therapeutic goal” (Deane et

al., 2005). Case management was defined as a “means of

coordinating services for mentally ill people in the

community where each individual is assigned at least one

mental health worker who is expected to: (a) assess the

individual’s needs, (b) develop a care plan, (c) arrange

and monitor suitable care to be provided, and (d)

maintain contact with the individual” (Marshall et al.,

2004, p. 4). Both homework and case management

definitions were provided within the survey.

Homework attitudes. Seventeen homework attitude items

were taken from Kazantzis et al. (2005) that were phrased

as positive statements (e.g., “Between-session activities

enhance therapy by facilitating the acquisition of

clients’ adaptive skills in everyday situations”) or

negative statements (e.g., “Regardless of there utility,

between-session activities place unrealistic expectations

on clients”). The Kazantzis et al. attitude questionnaire

consisted of two factors, Negative Session Impact and Positive

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Homework Effect, which were derived from confirmatory factor

analysis of 827 psychologists. The authors reported

Cronbach alpha co-efficients of .84 for the Positive

Homework Effect and .80 for Negative Session Impact scales. Table 1

lists the questionnaire items used in the present study.

Case managers rated their level of agreement on a 5-point

Likert scale ranging from 1 (strongly disagree) to 5 (strongly

agree). In the present study, the Cronbach alphas for the

two factors were satisfactory. The Negative Session Impact

factor had an alpha level of .79 and Positive Homework Effect

had an alpha level of .78.

Clinician Rated Homework Experiences. Case managers were also

asked to rate their experiences using homework on three

separate items. These items were taken from Kazantzis et

al. (2005): (1) “how would you describe your clients’

response to your asking them to engage in a between

session activity relevant to treatment” (1 = very

negative to 4 = very positive), (2) “on average, how

would you describe your clients’ level of compliance with

between-session activities” (1 = no compliance whatsoever

to 4 = high level of compliance), and (3) “on average,

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how would you describe your clients’ quality of

performance with between-session activities” (1 = very

low quality to 4 = very high quality). Following the

procedures of Kazantzis et al., these items were analyzed

separately.

Homework importance for moderate and severe mental disabilities.

Kazantzis and Deane (1999) asked clinicians to rate how

important they thought between session homework

assignments were for a range of disorders (e.g. anxiety

and depression) and symptoms (e.g. hallucinations and

delusions, social skills). For the current research we

used a similar scale, although asked case managers to

rate how important they thought between session homework

assignments were for anxiety, depression, schizophrenia,

bipolar and schizoaffective. A five-point Likert scale

was used ranging from 1 (no importance) to 5 (extreme

importance). For the purposes of the current study we

used the descriptors Severe Psychiatric Disability and Moderate

Psychiatric Disability. To examine possible attitudinal

differences regarding case managers’ use of homework,

mean scores for depression and anxiety disorders were

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calculated to form the Moderate Psychiatric Disability category

(α = .91) and mean scores from schizophrenia, bipolar and

schizoaffective disorders formed the Severe Psychiatric

Disability) category (α = .80; see Table 3).

Systematic homework implementation. The questionnaire

included four items used to provide a rating of case

mangers’ systematic homework administration procedures.

These items were taken from Kazantzis and Deane (1999)

and had a Cronbach alpha of .84. The systematic homework

administration score reported in Kelly et al., (2006) was

also used in the current study to compare clinician

attitudes towards the use of homework. As reported in

Kelly et al. (2006), clinicians were asked to rate on a 5

point Likert scale (1 = never to 5 = almost always) how

often they ‘specify frequency of homework practice’,

‘specify duration of homework practice’, ‘specify

location of homework practice’ and ‘make a written note

of homework for the person’. A mean was taken of these

four items, with a score of 4 or above indicating

consistent systematic homework administration.

Procedure

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Participants were recruited to the study in two

ways. First, questionnaires were distributed through

service management and team leaders to the case managers.

Participants were provided with a copy of the cover

letter, a questionnaire and a reply paid envelope to

return the survey. Second, case managers were approached

prior to completing training conducted as part of the

Australian Integrated Mental Health Initiative (AIMhi) -

High Support Stream project (Oades et al., 2005).

Participants were asked to complete the questionnaire as

part of a study examining the use of homework by mental

health case managers. Each participant was provided with

an information sheet describing the purpose of the study

and informed that participation was confidential and

voluntary.

Data analysis

Data analysis was completed using the SPSS for

windows (version 13) statistical package. To examine case

manager attitudes, means and standard deviations were

obtained for both the Positive Homework Effect and the Negative

Session Impact scales. (1) Non-parametric correlations were

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then conducted between clinician rated homework experiences and

both of the attitude subscales to examine the

relationship between these variables. (2) Due to the non-

normal distribution of the homework importance ratings,

nonparametric Wilcoxon Pairs Signed Rank Test were used

to examine the difference between importance ratings for

Moderate and Severe Psychiatric Disability. Finally, (3) a standard

multiple regression analysis was performed to examine the

factors that predict systematic homework administration.

Results

Table 1 provides the means and standard deviations

of case managers’ agreement on the 17 homework attitude

items, ranked in order from highest degree of agreement

to lowest. Subscale scores were summed for each case

manager, with higher scores on the Positive Homework Effect

factor indicating positive attitudes towards the use of

homework and higher scores on the Negative Session Impact

factor indicating more negative attitudes towards

homework (Kazantzis et al., 2005). In terms of the Positive

Homework Effect the average level of agreement was M = 3.94,

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SD = .44. The average level of agreement for Negative Session

Impact was M = 2.10, SD = .56.

<Insert Table 1 about here>

Do case manager’s attitudes towards homework influence their

administration practices?

Table 2 provides Pearson correlations between the case

managers’ attitudes towards homework and their self

reported experiences using homework within clinical

practice. Those who had more positive attitudes towards

the use of homework reported using a more systematic

approach in their homework administration practices. In

addition, case managers who had more positive attitudes

towards homework tended to report better client response,

higher levels of homework completion and higher quality

of task completion by clients. Case managers with more

negative attitudes towards homework, as measured by the

negative session impact scale, reported administering homework

in a less systematic fashion.


Does the importance placed on the use of homework for Moderate and Severe

Psychiatric Disabilities influence administration practices?

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An evaluation of assumptions found that homework

importance for both Moderate and Severe Psychiatric Disabilities were

not normally distributed. Accordingly, the nonparametric

Wilcoxon Pairs Signed Rank Test was used to compare the

case managers’ importance ratings. The results indicated

that case managers rated Homework Importance for Moderate

Psychiatric Disabilities (M = 3.80, SD = 1.34) significantly

higher than Severe Psychiatric Disabilities (M = 3.60, SD = 1.00),

Z = -2.21, p = .05. However, there was a relatively small effect

(d=.17; Cohens, 1988).

What factors predict case managers’ homework administration procedures?

A regression analysis was performed to examine whether

attitudes and perceived importance by disorder were able

to predict the systematic administration of homework by

case managers. The non-normal distribution for importance

of homework for Moderate and Severe Psychiatric Disabilities were

clustered around low importance (no importance, little importance

and moderate importance) and high importance (great importance

and extreme importance). As such, for the regression analysis

both Moderate and Severe factors were dichotomized (low

importance, high importance). Both dichotomized variables were

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included in the regression. Attitudes were represented by

the mean of Negative Session Impact and Positive Homework Effect. The

dependent variable was the Systematic Administration of Homework.

With the use of a p < .001 exclusion criterion for

Mahalanobis Distance, one outlier was removed. Table 3

presents the results of the standard multiple regression

with attitudes and importance ratings by disorder type

predicting systematic homework administration practices

of case managers. The overall regression equation was

significant and predictor variables as a group accounted

for 19% of the variance in systematic homework

administration, F (4,100) = 5.41, p < .005.

The significant predictors of case managers using a

regular systematic approach to homework administration

were Positive Homework Effect (β = .28) and Homework Importance

for Severe Psychiatric Disabilities (β = .26).


Discussion

Case managers tended on average to agree that there

is a positive effect associated with using homework and

tended to disagree that homework results in a negative

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session impact. This suggests that on average, case

managers tend to hold positive attitudes towards the use

of homework. This is consistent with previous data that

found the majority of case managers use homework within

their clinical practice (Kelly et al., 2006). When

compared to the mean ratings from a large normative

sample (derived from Table 3, p. 756 of Kazantzis et al,

2005), case managers’ attitudes were very similar to

those reported by psychologists working across a range of

clinical areas. Case managers who reported more positive

attitudes towards the use of homework also reported that

individuals diagnosed with a psychiatric disability: (1)

responded more positively towards homework, (2) the

quality of homework completed was of a higher standard,

and (3) there was a greater level of homework adherence.

Whilst a significant difference was observed between

case managers’ ratings of homework importance for Moderate

Psychiatric Disability (i.e. anxiety and depression) and Severe

Psychiatric Disability (i.e. schizophrenia, schizoaffective,

bipolar), this difference was relatively small. This

suggests that early findings from practitioner surveys

27


where homework was considered of relatively low

importance for hallucinations and delusions (e.g.

Kazantzis & Deane, 1999), may not generalize to disorders

where those symptoms may manifest. Alternatively, it

could be that practitioners who work predominately with

individuals diagnosed with severe psychiatric

disabilities see greater relevance for homework

activities.

Findings of the present study have implications for

training and supervision in therapeutic homework

procedures. Positive attitudes and perceived importance

for severe psychiatric disabilities were two factors that

accounted for 19% of the variance in the use of

systematic homework administration procedures. Case

managers with positive attitudes more strongly endorsed

beliefs that homework enhanced the person’s degree of

self-mastery, increased the person’s insight into his/her

individual recovery process and facilitated the

acquisition of adaptive skills to everyday situations.

Both theory (Shelton & Levy, 1981; Kazantzis, Mac

Ewan, & Dattilio, 2005) and emerging research (Helbig &

28


Fehm, 2004; Cox, Tisdelle & Culbert, 1988) suggest that

as homework becomes more systematic, adherence is

enhanced. However, case managers do not routinely specify

the frequency, duration and location of where the

homework assignment should be completed, along with

making a written note of the homework assignment for the

person to take away with them (Kelly et al., 2006).

Given that clients diagnosed with a severe psychiatric

disability typically experience a range of cognitive and

motivational difficulties that are likely to impede their

ability to complete homework tasks (Dunn, Morrison &

Bentall, 2002; Glaser et al., 2000), the use of

administration procedures to promote adherence appears

particularly important.

Suggestions have regularly been made to develop

empirically based guidelines for the administration of

homework assignments. For example Scheel, Hanson and

Razzhavaikina (2004) have proposed a 6-phase

administration process that includes collaborative

homework formulation, providing clients with a clear

rational for the task, discussing barriers to successful

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homework completion prior to assignment, checking client

acceptability of the homework task and comprehensively

reviewing homework at the following meeting. Similarly,

Kazantzis, Macewan and Dattilio (2005) have also provided

a comprehensive model for homework administration. The

development of homework administration guidelines is an

important area of research that holds considerable

promise for mental health care workers. Such guidelines

may also benefit other health care practitioners who

routinely use homework assignments within their clinical

work (e.g., physiotherapists, medical practitioners).

While the magnitude of the predictive model was

small to moderate, the current work provides evidence for

the relationship between clinicians’ attitudes and their

homework administration procedures. Training mental

health workers has been successfully used to promote

attitude change towards working with individuals

diagnosed with a severe psychiatric disability (McLeod,

Deane & Hogbin, 2002). Although further research is

required, it is likely that training and supervision

programs that address clinician attitudes by reinforcing

30


the empirical support for homework (see Kazantzis et al.,

2000) and discuss the relevance and theoretical evidence

for the use of homework for individuals diagnosed with a

severe psychiatric disability will help to influence case

managers’ attitudes towards the use of homework.

Additionally, attitudes represent just one component of

social cognitive explanations of behavior. For example,

it is likely that homework administration is also

influenced by beliefs case managers hold regarding

subjective norms (e.g., managerial, supervisory or peer

expectations) and perceived behavioral control (e.g.,

perceived client factors associated with successful

homework completion, sufficient time to administer

homework). Future research would benefit from examining

clinician homework administration practices in relation

to other variables in social cognitive models of behavior

(e.g. Theory of Planned Behavior). This should

incorporate the assessment of actual clinical use of

homework by case managers, rather than relying on self-

reported use.

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An area for further development is the specific

examination of homework practices by rehabilitation

counselors. Surveys indicate that rehabilitation

counselors receive limited training in areas associated

with psychiatric rehabilitation, behavioral intervention

techniques and skills training for severe psychiatric

disabilities (Lee, Ingraham, Chronister, Oulvey & Tsang,

2005; McReynolds & Garske, 2003). However, increasingly

rehabilitation counselors are providing services to

individuals with severe psychiatric disabilities.

Rehabilitation counselors typically use a range of

specific counseling and skills training interventions

(e.g., Garske, 1999) that would appear to benefit from

the use of between session activities to promote the

generalization or development of skills. The use of

homework assignments by this professional group, to our

knowledge, has not been previously explored.

The interpretation of the findings needs to be

considered in relation to the limitations of the study.

The sample size was modest and the extent to which it

represented the full range of mental health workers in

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case management positions is unclear. The study’s sample

of case managers were predominantly female (70%) and by

professional designation mostly nurses (43%), followed by

allied health professionals (35%). The gender mix is

broadly consistent with Australian mental health

workforce data that indicates, “In 2003, just under two-

thirds of the FTE mental health nurses were female”

(AIHW, 2005, p. 10) and that 71% of psychologists are

female (NSW Health, 2003). However, it is unclear to what

extent our sample represents the broader mental health

case manager workforce particularly given there is little

baseline data from non-government organizations.

Self-report surveys are limited in that they only

provide estimates of actual clinical activities and may

be susceptible to social desirability or other response

biases. Similarly, client responses to homework were case

manager perceptions rather than the views of clients

themselves. Finally, case managers that did not return

the surveys may have held more negative attitudes towards

the use of homework and may not have seen benefit in

completing the homework survey. Thus, it is possible that

33


the valence of attitudes toward homework obtained in this

study may err on the side of being more positive than a

more complete sample might reveal. Whilst there are

inherent limitations with the current research design,

the findings provide a valuable preliminary description

of case manager attitudes toward homework.

34


Acknowledgements

Preparation of this article was supported by the

Australian Integrated Mental Health Initiative (AIMhi)

which was partly funded by the National Health Medical

Research Council (NHMRC, #219327), through the Health

Partnership Grant Scheme and partner organizations. The

authors would like to acknowledge David Kavanagh and

Robert King for comments on an early version of this

article.

35


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Case Managers' Attitudes Toward the Use of Homework for People Diagnosed With a Severe Psychiatric Disability

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