LECTURE 9 HOMEWORK IN CBT

CBT comparativeKevin Standish

Learning outcomes

Explore the benefits of counselling clients undertaking Behavioural Tasks / Homework

Examining the role of Behavioural Tasks / Homework

Describe the skills in employing Behavioural Tasks / Homework

Practice the skills of employing Behavioural Tasks / Homework

Session structure (adapted from J. Beck, 1995)

1. Brief update and mood check2. Bridge from previous session3. Collaborative setting of the agenda4. Review of homework5. Main agenda items and periodic

summaries6. Setting new homework7. Summary and feedback

1. Structure of session – getting going

BRIEF UPDATE AND MOOD CHECK: Very often includes measures such as Beck Depression Inventory (BDI). Some clients may feel discomfort with measures but many will feel pleased that you are taking their symptoms seriously. It is best to regard measures as self-reports subject to some transference effects. Discuss client reservations about them and amend use accordingly.

2. Session structure – moving forward

BRIDGING: Ask if client has any memories or issues with the last session. Usually keep brief.

AGENDA-SETTING: Work collaboratively: get client’s ideas but also be prepared to put forward ideas yourself. Can use agenda to prioritise and manage time - for example, to ensure time is spent both on current symptoms and on more historical and developmental material.

3. Session structure: getting to the heart of things

REVIEW OF HOMEWORK: Don’t forget to do this, as forgetting may reduce client’s motivation to do further tasks. May be helpful for client to keep homework in a ‘therapy notebook’.

MAIN AGENDA ITEMS: Some trainees feel like they are being ‘directive’ by encouraging clients to stick to an agenda of items. This may occasionally be true but check out with clients. Padesky & Mooney (1998) suggest that there may be subtle ‘therapist beliefs’ – ‘If I structure the session, the client will experience me as a bully’, etc.!

4. Session structure: ending the session

SETTING NEW HOMEWORK: Try to keep it simple and doable. Ask the client, ‘Can you see the purpose of it?’ and ‘What might stop you doing it?’ Try to set NO-LOSE tasks.

FEEDBACK: Try to find out what has worked and been learnt and what hasn’t. You need the negative feedback as well as the positive in order to keep the therapy on track

Benefits of Homework in CBT

Homework is recognised as a core mechanism to promote change in cognitive behavioural therapy.

Weekly tasks set by the therapist provide valuable opportunities for the client to put into practice the different tools, skills and techniques they have learned

provides an excellent means of helping the therapist to know whether such skills have been fully understood.

The underlying theoretical foundations of Homework

1. Classical Conditioning 2. Operant Conditioning 3. Generalization of Learning 4. Shaping and maintaining changes Read Chapter 2 Kazantzis, Frank P.

Deane, Kevin R. Ronan and Luciano L'Abate. (2005) Using Homework Assignments in Cognitive Behavior Therapy (in google books)

Benefits of Homework in CBT

one cannot easily apply CBT tools when sat inside the clinic or therapy room so it is only through homework undertaken outside of the therapy setting that one can apply such skills to real life.

The idea is that at the end of therapy the patient is able to carry on using the tools and thus become their own therapist

so if homework has not been a regular feature of therapy it is highly unlikely that the patient will continue to find CBT effective following cessation of treatment sessions

Research findings Homework has been viewed as a key ingredient of

cognitive therapy since its inception, and most of the research has examined the relationships between homework completion and therapy outcome.

In an authoritative meta-analytic review of the literature, Kazantzis, Whittington, and Dattilio (2010) report that the use of homework assignments improves treatment outcome and address a number of conceptual issues in research on homework effects.

Research Findings

Rees et al (2005) Relationship Between Homework Completion and Outcome in Cognitive Behaviour Therapy found that quantity and the quality of homework completed predicted outcome on measures of depression, anxiety and quality of life at post-treatment and at 1-month follow-up. The results were strongest for the amount of homework completed, suggesting that clinicians should encourage patients to complete homework even if the homework content is not entirely accurate. The results of this study highlight the importance of homework as a central part of effective cognitive and behavioural treatment.

Research Findings

Fehm & Mrose (2008) researched patients perspectives on homework and found the patients generally had a positive attitude towards homework and that they accomplished most of the tasks. Results show that the vast majority of

patients view homework positively, they are clearly aware of the beneficial function of

homework assignments. The term ‘homework’, considered problematic by

many practitioners, is accepted by the vast majority study.

The high rate of homework completion supports the generally positive attitude towards homework

Setting homework

As homework is central to CBT, time must be allocated to setting them up, 5 to 10 min at the end of the session

Homework will often follow on directly from major topics that have been part of the discussion in the session

The range of homework is boundless It relies on ingenuity of you and your

client in setting up suitable assignments in a collaborative manner

Setting homework

It include can include some of the following: Reading relevant material Listening to treatment tapes Practising new skills Doing a historical review of the past

It is important that it makes sense to the client and will be useful for subsequent treatment sessions of a particular goal

Practical Examples of Homework for CBT

 thought records (to help identify thinking errors and the link between thought and behaviour), journaling (to record/review learning outcomes), 

experiments (for example as part of a graded exposure approach),

surveys (to discover if others believe or the same in specific circumstances)

timetabling (planning time for rest, work and leisure each day).

Therapy homework needs to be clearly explained prior to the end of the session and then thoroughly reviewed during the following (ideally at the beginning) session.

Overcoming Non-compliance to Homework

The very word or mention of homework can result in many adults having a total mental block as it tends to bring back memories of school. But the research shows homework is not seen as negative.

It is absolutely crucial therefore that the therapist especially at the beginning of therapy as well as regularly throughout treatment highlights the key reasons why it is so effective and crucial to CBT.

Rather than using the word 'homework' — which may carry negative associations — use a term like 'task' or 'practice exercise.'

Leahy (2006) recommends the following approaches to overcoming non-compliance:

making tasks very specific, written instructions, be consistent praise the effort of undertaking each task.

Overcoming Non-compliance to Homework

Homework should follow logically from what happened during the session

The assignment should be relevant to the goals set Bear in mind that your client has a life outside of

therapy It should be planned in detail Make sure that homework cannot be failed Provide relevant resources such as diaries and

reading material and should be written down Homework review should always be included in the

next session. Non-completion of homework should be discussed and explore.

Example of homework explanation

http://cbt-cognitivebehaviouraltherapy.co.uk/why-is-homework-important-in-cbt/

Readings

Leahy, R. (2006) Roadblocks in CBT New York: Guilford Press.

Kazantzis, Frank P. Deane, Kevin R. Ronan and Luciano L'Abate. (2005) Using Homework Assignments in Cognitive Behavior Therapy

Chap 1 & 2 (in Google books)

Assignment due: 04 January 2012NO LECTURE NEXT WEEKTUTORIALS ONLYPLEASE COMPLETE THE MODULE EVALUTION FORMS ON NEW LEARNING