Using Homework in CBT
The October, 2010 edition of Advances in Cognitive Therapy (the newsletter of the Academy of Cognitive Therapy and the International Association of Cognitive Psychotherapy) is a special issue on homework in CT. Here are a few highlights:
- Homework assignments are a core feature of Beck’r CBT but some studies have found weak correlations between homework compliance and treatment outcome. This has led some to question the importance of homework and even recommend that it be removed from CT. Kazantzis and Petrik (2010) discuss the available evidence and conclude a) many of the studies finding weak relationships between homework compliance and treatment outcome are hampered by small sample sizes, b) quality of homework may be more important than quantity of homework completed, and c) meta-analysis provides evidence of a medium-sized relationship (d=.48) relationship between homework compliance and treatment outcome.
- A variety of suggestions are made for improving homework compliance: Tomkins recommends giving a clear rationale for the assignment, making the assignment doable, and providing the client with written homework instructions. Callan et al., recommend using technological interventions (email reminders, alarms, apps on cell phones, etc.) to promote homework adherence. Brodman and Kendall emphasize the importance of collaboration, recommend not calling it “homework” especially with kids, responding to non-compliance with discussion and problem-solving, and rewarding compliance. Kassler et al., recommend using the principles of Motivational Interviewing and using principles of collaboration and collaborative empiricism in selecting, planning, and reviewing homework assignments.
I’d add that clients are much more likely to follow through on homework if:
- Assignments are clearly relevant to goals that are meaningful to the client.
- The therapist asks the client what is likely to interfere with their completing the assignment and then helps plan ways to overcome those impediments.
- The therapist makes a point of remembering what the assignment was, reviews it at the next appointment, and makes sure that the client recognizes how completing the assignment was useful in working towards their goals.
Also, the “Action Plan” and “Behavioral Experiment” forms from Mind over Mood can be very useful.
- Avoid the term “Homework” (except with individuals who like homework and do it consistently).
- Watch for counterproductive attitudes (yours or theirs).
- Provide a clear rationale that they can relate to (such as learning a sport, learning to play an instrument, or learning to cook).
- Develop assignments collaboratively.
- Tailor assignments to the individual.
- Make sure that they see a clear connection between the assignments and their goals.
- Keep assignments realistic and manageable.
- Anticipate impediments and plan how to deal with them.
- Consider using the Action Plan form, setting up reminders, and/or involving significant others.
- Describe, demonstrate, do, and discuss.
- Ask if they have any objections and take any objections seriously.
- In the next session remember the assignment, find out if they did it, what the results were, and what conclusions they draw from it.
- If they didn’t do the assignment, pick a time when they thought of doing the assignment but ended up not doing it.
Have them describe the situation, what led up to it, and how they were feeling, then ask what thoughts went through their head.
Notice what stopped them from completing the assignment.
Jointly figure out what changes to make so that they’ll be successful in completing the assignment.
At the end of the session, make sure they remember what the assignment is and what the point to it is. Make sure that they are willing to complete the assignment and feel capable of doing so. If not, revise the assignment