Results now published for the largest randomized controlled trial for procrastination

Our paper entitled “Internet-based cognitive behavior therapy for procrastination: A randomized controlled trial” is now published in Journal of Consulting and Clinical Psychology (Impact Factor: 5.279).

Postponing the tasks and assignments that need to be performed is a universal phenomenon shared by most individuals. Although sometimes experienced as stressful, delaying a given course of action is seldom associated with any major psychological suffering. However, for a considerable proportion of the population, deferring important commitments can become a persistent behavior pattern that interferes with their daily life and result in various negative consequences (Pychyl & Flett, 2012). Procrastination, defined as to “voluntarily delay an intended course of action despite expecting to be worse off for the delay” (Steel, 2007, p. 66), refers to a common self-regulatory failure that involves stalling the initiation or completion of important duties or responsibilities until the last minute, after a predetermined deadline, or indefinitely (Dryden, 2000). Even though procrastination has much in common with both difficulties in prioritizing and being self-assertive, procrastination requires an active choice between competing activities in which one is being avoided in favor of the other, and is often characterized by the preference for a more immediate reward or the escape from an aversive experience (Pychyl, Lee, Thibodeau, & Blunt, 2000). Procrastination is not only related to complications regarding the task at hand, but is also associated with personal distress and decreased well-being (Stead, Shanahan, & Neufeld, 2010). Severe and chronic procrastinators are at risk of developing and exacerbating physical disorders (e.g., delaying medical check-ups or adherence to a given rehabilitation program), and mental illnesses (e.g., fewer mental health promoting behaviors and increased levels of stress and anxiety) (Sirois, 2004; 2007). Procrastination is also linked to poorer performance in school and at work, particularly with regard to career and financial success, and is related to substantial financial worry (O’Donoghue & Rabin, 1999; Steel, Brothen, & Wambach, 2001; Tice & Baumeister, 1997).

Procrastination has been proposed by Steel (2012) to be a growing self-regulatory failure, possibly related to increased societal demands for self-control, as well as greater availability of immediate gratification through the widespread use of modern information technology. According to the only available research regarding the prevalence of procrastination, approximately one-fifth of the adult population (Day, Mensink, & O’Sullivan, 2000), and at least half of the university students (Harriot & Ferrari, 1996), describe themselves as experiencing significant difficulties initiating or completing tasks and commitments. These numbers are also reported to have increased over time among adults, from approximately 4-5% in the 1970’s to 20-25% today (Steel, 2012). Even though this upsurge in self-reported procrastination does not necessarily correspond to a clinical condition, more and more individuals are assumed having problems managing their everyday commitments because of severe and chronic procrastination (Pychyl & Flett, 2012). Despite this, research on procrastination has mainly involved the investigation of potential predictors, such as, individual differences, task characteristics, as well as sociodemographics (Steel, 2007), while paying less attention to treatment interventions that specifically target procrastination. Although some personality factors have been found to be correlated with procrastination, including, a high degree of impulsiveness (Specter & Ferrari, 2000), low conscientiousness (van Eerde, 2003), low self-control (Tice & Baumeister, 1997), a high degree of neuroticism (Hetterna et al., 2006), and low self-regulation (Wolters, 2003), the results have been inconsistent and the clinical implications are not always clear (Steel, 2007).

From a theoretical perspective, procrastination has been conceptualized as either a state or as a trait (Sirois, 2014). The state perspective highlights the interaction between environmental stimuli and procrastination, such as, distractions, while the trait perspective emphasizes the stability of procrastination over time (van Eerde, 2000; 2003). According to Steel (2007), twin studies indicate that procrastination is partly explained by genetic variables, in particular, impulsiveness, while the test-retest reliability of many self-report measures of procrastination is good over a ten year period, providing evidence for the notion of procrastination as a trait. Hence, procrastination can be regarded as a persistent behavior pattern associated with a characteristic set of cognitions and behaviors that result in the voluntary delay of tasks and assignments (Sirois, 2014). In particular, dysfunctional beliefs, such as, socially prescribed perfectionism, unrealistic expectations, and low self-esteem have been put forward as possible explanations for procrastination, indicating that severe and chronic procrastinators engage in a type of negative thinking that resembles rumination (Pychyl & Flett, 2012; Stainton, Lay, & Flett, 2000). It has also been suggested that the difficulty to perform instrumental behaviors that are in line with completing a given course of action can lead to self-blame and negative emotions, which, in turn causes procrastination as a way of restoring positive mood (Tice, Bratslavsky, & Baumeister, 2001), consistent with so called incompleteness theories of cognition (Gold & Wegner, 1995). In addition, procrastination can be explained using learning theory, in particular, operant conditioning, self-efficacy theory, as well as different theories of motivation (Rozental & Carlbring, 2014). Steel and König (2006) have, for instance, presented an integrated model of procrastination, the Temporal Motivational Theory, which views procrastination-related difficulties as the result of four different variables: the value of an activity, the expectancy of achieving that value, the timing of that value, and the sensitivity to delay. Accordingly, the lack of value related to a given course of action is assumed to cause procrastination due to its effect on extrinsic or intrinsic motivation (Steel, 2007). However, value is also presumed to be closely related to self-efficacy, that is, the expectations to achieve an anticipated outcome (Bandura, 1977). Furthermore, the effect of different schedules of reinforcement is expected to complicate the initiation of tasks and assignments, as long-term goals are of a fixed interval schedule, while most distractions are of a variable ratio schedule (Stromer, McComas, & Rehfeldt, 2000). In addition, the sensitivity to delay is assumed to give rise to individual differences in procrastination as it affects the ability to defer an immediate gratification in order to complete a given course of action (Mazur, 2001). In sum, procrastination may be maintained by both cognitive and behavioral factors, warranting treatment interventions that target both dysfunctional beliefs and the variables influencing motivation (Steel & König, 2006).

In terms of clinical trials examining the efficacy of treatment interventions for procrastination most of the research have consisted of single-case designs (Dryden, 2012; Karas & Spada, 2009; Neenan, 2008), and the evaluation of different group therapies that are primarily intended for university students (van Essen, van den Heuvel, & Ossebaard, 2004; van Horebeek et al., 2004; Tuckman & Schouwenburg, 2004). Although informative from a clinical perspective, the lack of validated outcome measures as well as the absence of randomization obscures the results, making it complicated to explore the nature of the treatment outcome. However, treatment interventions that are often used in cognitive behavior therapy (CBT) have been recognized as suitable for addressing problems of procrastination (Steel, 2007). Behavioral interventions that facilitate time management, increase automaticity, and decrease the number of distractions, have been shown to improve self-regulation and avert procrastination (Mulry, Fleming, & Gottschalk, 1994). Likewise, establishing routines and using timetables and predetermined activities similar to those in behavioral activation for depression are particularly useful for preventing mental fatigue, creating normal diurnal rhythms, and enhancing overall performance (Digdon & Howell, 2008; Jacobson, Martell, & Dimidjian, 2001). Meanwhile, goal-setting techniques can help the individual set sub goals that are perceived as less burdensome than more long-term goals, while graded exposure can assist the individual in exposing and tolerating emotions that often lead to procrastination (Schraw, Wadkins, & Olafson, 2007). Rewards that are contingent on the performance of an intended response can also help increase extrinsic motivation (Eisenberg, Park, & Frank, 1976; Eisenberg, 1992). Similarly, value clarification might increase intrinsic motivation, which, in turn, may promote diligence (Rozental & Carlbring, 2014). Furthermore, cognitive interventions targeting dysfunctional beliefs that result in procrastination are also important, most notably in the case of perfectionism, fear of failure, and self-doubt (Lloyd et al., 2014; Pychyl & Flett, 2012). Cognitive restructuring can aid commitment to goal-directed behavior (McDermott, 2004), especially when accompanied by behavioral experiments that enable the individual to behave more adaptively in relation to the thoughts and emotions that often result in procrastination (Bennett-Levy, 2003). In addition, implementation intentions and mental contrasting have been shown to facilitate memory retrieval and instigate behavior change by generating memory cues and highlighting the steps that are necessary to attain a given outcome (Gollwitzer & Brandstätter, 1997; Oettingen & Mayer, 2002). Moreover, efficacy-performance spirals may be useful in raising self-efficacy by completing commitments with increasing difficulty as well as providing corrective feedback (Lindsley, Brass, & Thomas, 1995).

Because there are so few clinical trials examining the efficacy of treatment interventions for procrastination, further research is needed in order to determine their usefulness. In addition, no randomized controlled trials have previously been carried out, making it uncertain whether the treatment interventions that are often used in CBT are, in fact, helpful for managing severe and chronic procrastination. Moreover, individuals experiencing difficulties associated with deferring their everyday commitments might also suffer from different psychiatric disorders such as depression and anxiety (Pychyl & Flett, 2012). Prior research has yielded moderate correlations with worry, stress, and feelings of guilt, but no consistent relationship has been found with mood (Steel, 2007). As discussed by Klingsieck (2013), this may be due to the fact that self-report measures or a structured clinical interview assessing the occurrence and severity of psychiatric disorders are seldom used when investigating procrastination, and that most research has been performed on student and not clinical populations. Hence, although procrastination in itself does not constitute a psychiatric disorder, it could be associated with personal distress, and in the long run, result in psychological suffering and psychiatric disorders (Rozental, Forsström, Nilsson, Rizzo, & Carlbring, 2014a). Increasing the awareness of the etiology and maintenance of procrastination is therefore important, as is providing treatment interventions that have demonstrated efficacy, particularly as health care providers may not always recognize procrastination as a problem that can cause significant impairment, and because the knowledge of what treatment interventions to use might not be widespread.

Meanwhile, prior research of delivering treatment interventions via the Internet, most notably CBT, has shown promising results for a number of psychiatric disorders, such as depression (Williams et al., 2013), pathological gambling (Carlbring & Smit, 2008), irritable bowel syndrome (Ljótsson et al., 2011), social anxiety disorder (Andrews, Davies, & Titov, 2011), tinnitus (Hesser et al., 2012), panic disorder (Carlbring, et al., 2006), and insomnia (van Straten et al., 2013). Treatment interventions that are delivered via the Internet also offer many advantages in terms of greater cost-effectiveness, enhanced access to evidence-based care, increased opportunity to reach patients living in remote locations, as well as continuous symptom monitoring that tends to improve adherence (Andersson et al., 2013). In addition, Internet-based CBT has been shown to generate positive results both with and without the provision of a therapist, that is, guided self-help and unguided self-help (Berger et al., 2011), and there are some evidence suggesting that the format of delivering guided self-help does not seem to be related to treatment outcome, for instance, via a telephone or email (Lindner, et al., in press). Providing treatment interventions for procrastination via the Internet, in other words, could constitute a suitable alternative to regular health care if it is found to alleviate problems experienced by many individuals. The objective of the current study was thus to examine the efficacy of Internet-based CBT for procrastination in a randomized controlled trial, and to investigate whether it matters if the participants receive guided self-help or unguided self-help in terms of treatment outcome. It is presumed that CBT delivered via the Internet will produce significant improvements in relation to self-reported difficulties of procrastination, compared to wait-list control, and that this also can affect levels of depression, anxiety, and well-being. Participants receiving guided self-help, involving weekly therapist feedback, are also predicted to fare better than those receiving unguided self-help, involving limited contact with the study supervisors, as the guidance from a therapist may help improve adherence and the completion of homework assignments inherent in the treatment interventions (Richards & Richardson, 2013).

Participants (N = 150) were randomized to guided self-help, unguided self-help, and wait-list control. Outcome measures were administered before and after treatment, or weekly throughout the treatment period. They included the Pure Procrastination Scale, the Irrational Procrastination Scale, the Susceptibility to Temptation Scale, the Montgomery Åsberg Depression Rating Scale−Self-report version, the Generalized Anxiety Disorder Assessment, and the Quality of Life Inventory.

Mixed effects models revealed moderate between-group effect sizes comparing guided and unguided self-help to wait-list control; the Pure Procrastination Scale (Cohen’s d = 0.70, 95% CI [0.29, 1.10], and d = 0.50, 95% CI [0.10, 0.90]), and the Irrational Procrastination Scale (d = 0.81 95% CI [0.40, 1.22], and d = 0.69 95% CI [0.29, 1.09]). Clinically significant change was achieved among 31.3-40.0% for guided self-help, compared to 24.0-36.0% for unguided self-help. Neither of the treatment conditions were found to be superior on any of the outcome measures, Fs (98, 65.17 to 72.55) < 1.70, p > 0.19.

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Internet-based cognitive behavior therapy could be useful for managing self-reported difficulties due to procrastination, both with and without the guidance of a therapist.

Read the full paper:
Rozental, A., Forsell, E., Svensson, A., Andersson, G., & Carlbring, P. (2015). Internet-based cognitive behavior therapy for procrastination: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 83(4), 808-824. doi: 10.1037/ccp0000023

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