Critical Issues in Using Homework Assignments Within Cognitive-Behavioral Therapy for Schizophrenia

Presents an overview of the research findings to date and practical guidelines for the use of homework in cognitive-behavioral therapy for schizophrenia. In particular, the article outlines strategies to combat the common difficulties experienced when using homework with clients with schizophrenia and the types of homework assignments that may be most helpful. The empirical evidence suggests that cognitive-behavioral therapy incorporating homework assignments help clients to improve at least 60% more than those in treatment without homework. Despite that most therapy formulations incorporate homework as an integral component of treatment for schizophrenia, prior research has identified that practitioners consider homework to be less helpful for clients with delusions and hallucinations. Interventions to enhance homework compliance in the treatment of clients with schizophrenia are outlined.     

Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition

There is a need to understand the mechanism through which homework contributes to clinically meaningful change in therapy. Theoretically meaningful factors such as willingness to complete therapeutic assignments and cognitive skill acquisition have not been carefully studied in prior research. Depressed outpatients (N = 46) received cognitive behavioural group therapy for a 10-week period and were assigned relevant homework activities. Patient self-report and independent ratings of homework compliance were obtained on a session-by-session basis. Using path analysis, the authors found evidence that willingness to complete homework assignments and mastery of skill in cognitive restructuring helped account for the relationship between homework compliance and reduced symptom severity (R2 = .40). However, paths were only significant when patient self-report of homework compliance was used in the model. The present study highlights the problems in assessing homework compliance and in assuming that independent assessment of compliance is more accurate than patient self-report.     

How to Supervise the Use of Homework in Cognitive Behavior Therapy: The Role of Trainee Therapist Beliefs

Encouraging and facilitating homework completion is a core cognitive behavior therapy (CBT) skill. Consequently, it represents an important part of training practitioners. Oftentimes the process of integrating homework into therapy is rushed, poorly executed, or forgotten, and trainees are surprised to find that some patients do not complete homework. We advocate for increased therapist responsibility in accounting for homework nonadherence. Therefore, problems with the use of homework in therapy are frequently an agenda item in the supervision of trainee cognitive behavior therapists. In our experience, trainee CBT practitioners exhibit a number of interrelated automatic thoughts, assumptions, and in-session behaviors that influence their use of homework assignments. The Cognitive Behavior Therapy Homework Project has proposed a “model for practice” to guide the use of homework in CBT [Kazantzis, N., MacEwan, J., & Dattilio, F. M. (2005). A guiding model for practice. In: Kazantzis, N., Deane, F. P., Ronan, K. R., & L’Abate, L. (Eds.), Using homework assignments in cognitive behavior therapy (pp. 359–407). New York: Routledge]. The present article will draw from those practice recommendations and discuss the role and impact of the therapeutic relationship and therapist beliefs on the use of homework assignments, with reference to the different levels of CBT conceptualization. Clinical examples from the supervision of trainees enrolled in the practicum component of the Massey University Postgraduate Diploma in Cognitive Behavior Therapy are used to illustrate supervising the use of homework assignments.     

Congruence of Patient Takeaways and Homework Assignment Content Predicts Homework Compliance in Psychotherapy

Homework is generally considered an essential part of psychotherapy. The present study tested the hypothesis that patients were more likely to complete homework assignments when the content of the assignments was more congruent with content the patient reported wanting to remember from the session (patient takeaways). The study relied on data collected in 541 sessions of individual naturalistic cognitive-behavioral therapy provided to 41 patients in a private practice setting and who completed a feedback form in each session that recorded the content of the homework assignments for the session, patient takeaways from the session, and homework completion. Congruence was determined by raters who evaluated the match between homework content and patient takeaways. Results of generalized linear mixed modeling showed, as predicted, that congruence between homework assignment content and takeaways was statistically significantly associated with homework compliance. This finding suggests that therapists may be able to improve homework compliance by soliciting feedback about what the client found important about the session and then assigning homework consistent with that information.     

Homework Compliance and Quality in Cognitive Behavioral Therapies for Anxiety Disorders and Obsessive-Compulsive Disorder

Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention.     

Assigning Homework to Couples and Families

Homework assignments, or “out-of-session assignments,” have gained popularity among couple and family therapists due to their potential to solidify the work achieved during the course of therapy and to help clients take responsibility for their own change. Homework assignments also serve as a testing ground in therapy to determine what works and what does not. This article provides an update on some of the empirical literature on homework assignments and its reported effectiveness in the domain of couples and family therapy. It also highlights the need for and the effectiveness of out-of-session assignments during the course of treatment.     

Cognitive Behavioral Therapy for Chronic Pain: Strategies for the Successful Use of Homework Assignments

Presents an overview of the research findings to date, and practical guidelines for the use of homework in psychosocial treatments for patients with chronic pain. Generally, psychosocial treatments incorporating homework assignments help patients to improve more than when treatment is comprised entirely of in-session work. The article outlines common obstacles experienced when using homework with pain patients and strategies to combat these obstacles. The types of homework assignments that may be most helpful, as well as interventions that can be used to promote homework compliance and successful treatment outcome are discussed.     

Integrating Homework Assignments Based on Culture: Working with Chinese Patients

Cognitive therapy as espoused by A. T. Beck (A. T. Beck, Rush, Shaw, & Emery, 1979) is increasingly used as a therapeutic modality and applied to a variety of cultural groups throughout the world. However, the majority of the literature on empirical and clinical practice has been focused on the use of cognitive therapy for Western cultures. In this article, we discuss Chinese patients’ adherence to therapy homework assignments in terms of Chinese cultural values and practices, their customary problem-solving process, and other traditional beliefs. Through the use of a case study, we illustrate how some of these culturally specific beliefs can influence the process of integrating homework assignments into the course of therapy. This resource on supervising practitioners’ treatment of Chinese patients with cognitive behavior therapy is offered as a contribution to the emerging literature on CBT for non-Western cultures.     

Introduction

According to cognitive therapy as espoused by Aaron T. Beck, the transfer and maintenance of behavioral and cognitive skills into practical and sustainable real-life application ultimately determines positive therapeutic outcomes. However, the optimal process for ensuring this transfer and maintenance has not been explicitly studied. This particular series of C&BP adds to the growing body of literature on cognitive therapy for complex and chronic problems. A case conference and supervision recommendations are presented as a resource for cognitive and behavioral practice. The focus of this series is the integration of homework assignments into therapy. Developing a collaborative therapeutic relationship and individualized cognitive conceptualization were part of the original formulation of standard cognitive therapy (A. T. Beck, Rush, Shaw, & Emery, 1979), and are essential foundations to therapeutic work with challenging patient problems (J. Beck, 2005). Therefore, in keeping with the spirit of cognitive therapy, this series of C&BP places emphasis on the therapeutic collaboration and cognitive conceptualization processes that greatly enhance the effective use of homework assignments.     

Hausaufgaben in der Psychotherapie

Homework assignments represent a standard intervention in psychotherapy. Homework provides the unique opportunity to emphasize patients’ responsibility for therapeutic change and to intensify the therapeutic process. Despite these high potentials systematic homework assignment is still rare in practice. Psychotherapy research has just recently focused its attention on homework as an effective therapeutic method. Meanwhile the positive effects of homework use on therapeutic outcome have been demonstrated but little is known about therapeutic strategies to enhance these effects. The present article highlights the functions of homework within the therapeutic process and discusses its theoretical mechanisms of action. The article concludes with suggestions from both an empirical and practical point of view to further assist practitioners’ use of homework assignments.     

Hausaufgaben in der Psychotherapie

Homework assignments are part of many treatment manuals for behaviour therapy. Their effectiveness for treatment success has now been shown. Far less is known about their implementation in everyday clinical practice. To offer topical data concerning the utilization of homework and the attitude towards it, we explored a sample of 140 therapists with different theoretical background and with varying degrees of therapeutic experience. Most of the participants frequently used homework assignments. Behaviour therapists use homework significantly more often than analytical therapists and have a more positive attitude towards them. Interestingly, the degree of experience had no influence on utilization of homework. Nearly all participants are familiar with the problem of unaccomplished assignments. Future directions for research und postgraduate courses are outlined.     

Therapist empathy,homework compliance,and outcome in cognitive behavioral therapy for generalized anxiety disorder: partitioning within- and between-therapist effects

Although client-perceived therapist empathy relates to positive therapy outcomes, including in cognitive behavioral therapy (CBT), little is known about how empathy exerts its ameliorative effect. One possible way is by promoting clients’ subsequent homework compliance, a variable that also predicts positive outcomes in CBT. The present study sought to investigate simultaneously, in the context of 43 therapist–client dyads receiving 15 sessions of CBT for generalized anxiety disorder, (1) the association of early client-perceived therapist empathy (averaged over sessions 1, 3, 5) with mid-treatment client homework compliance (averaged over sessions 6, 8, 10); (2) the association of mid-treatment homework compliance on client posttreatment worry severity; and (3) the indirect effect of early perceived therapist empathy on posttreatment worry through mid-treatment homework compliance. Given that clients were nested within therapists, we examined both within- and between-therapist differences in clients’ ratings of therapist empathy and homework compliance, and tested both of these indices as predictors of the relevant dependent variables in a multilevel model. At the within-therapist level (i.e., differences between clients within a given therapist’s caseload), greater early empathy was associated with greater mid-treatment homework compliance. At the between-therapist level (i.e., differences between therapists across all of their cases), greater between-therapist homework compliance was related to lower posttreatment worry. Finally, homework compliance was not found to mediate the relationship between empathy and posttreatment outcome. The results underscore the importance of parsing client and therapist effects, and are discussed with regard to their training and research implications.     

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive–Compulsive Disorder?

Clinical studies in adults and children with obsessive–compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.     

Effects of the contingency for homework submission on homework submission and quiz performance in a college course

Effects of the contingency for submission of homework assignments on the probability of assignment submission and on quiz grades were assessed in an undergraduate psychology course. Under an alternating treatments design, each student was assigned to a points condition for 5 of 10 quiz-related homework assignments corresponding to textbook chapters. Points were available for homework submission under this condition; points were not available under the no-points condition. The group-mean percentage of homework assignments submitted and quiz grades were higher for all chapters under the points condition than in the no-points condition. These findings, which were replicated in Experiment 2, demonstrate that homework submission was not maintained when the only consequences were instructor-provided feedback and expectation of improved quiz performance.     

Homework Compliance Counts in Cognitive-Behavioral Therapy

Background: Prior research has demonstrated that there is some association between treatment engagement and treatment outcome in behavioral therapy for anxiety disorders. However, many of these investigations have been limited by weak measurement of treatment engagement variables, failure to control for potentially important baseline variables, and failure to consider various treatment engagement variables simultaneously. The purpose of the present study is to examine the relationship between two treatment engagement variables (treatment expectancy and homework compliance) and the extent to which they predict improvement from cognitive-behavioral therapy (CBT) for anxiety disorders. Methods: 84 adults with a DSM-IV-defined principal anxiety disorder took part in up to 12 sessions of CBT or acceptance and commitment therapy. Pre- and post-treatment disorder severity was assessed using clinical severity ratings from a semi-structured diagnostic interview. Participants made ratings of treatment expectancy after the first session. Homework compliance was assessed each session by the treating clinician. Results: Contrary to hypotheses, treatment expectancy and homework compliance were poorly correlated. Regression analyses revealed that homework compliance, but not treatment expectancy, predicted a significant portion of the variance in treatment outcome (10%). Conclusions: The present research suggests that although treatment expectation and homework compliance likely represent unique constructs of treatment engagement, homework compliance may be the more important treatment engagement variable for outcomes. The present research suggests that improvement of homework compliance has the potential to be a highly practical and effective way to improve clinical outcomes in CBT targeting anxiety disorders.     

Homework assignments, consequences, and classroom performance in social studies and mathematics

Elementary school students who frequently answered questions incorrectly in class were given daily homework assignments in social studies and math, but they rarely completed the assignments accurately and their classroom performance in social studies and math was only slightly better than when they did not have homework assignments. However, consequences provided for accurate completion of homework assignments increased the number of students completing homework and the accuracy with which homework assignments were completed. Further, assignments of homework with consequences for accuracy were associated with more accurate classroom performance.     

Relationship between homework completion and outcome in cognitive behaviour therapy

Homework or between-session learning has long been considered an essential aspect of effective cognitive behaviour therapy. However, it has received relatively less empirical attention than other components of cognitive behaviour therapy. In general, studies have found that homework completion is predictive of outcome in psychotherapy. However, the amount of homework completed by a patient represents only one aspect of this important therapeutic component. This study investigated both the quantity and the quality of homework completed during a 10-week group cognitive and behavioural treatment program for anxious and depressed patients. It explored the relationship between various aspects of homework completion and outcomes on several different variables. A total of 94 patients were included in the analysis. It was found that both quantity and 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.     

Conceptualizing Patient Barriers to Nonadherence with Homework Assignments

Nonadherence with homework assignments and, by implication, “barriers” to homework assignments are a frequent occurrence in the practice of standard cognitive therapy (Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press). The clinical examples in this article illustrate some of the ways in which environmental, patient, task, and therapist factors can serve as barriers to homework completion. Although these classes of barriers may be discussed independently, they are actually overlapping processes and are more helpful when discussed in tandem. This article illustrates how the therapist’s ability to conceptualize can serve as the context for making sense of the patient’s perceived ability to undertake an activity, the patient’s beliefs about the specific task, and how our ability to use the conceptualization to anticipate barriers is part of evaluating our own therapeutic skills. Several clinical case examples are discussed.     

Relationship Between Homework Completion and Outcome in Cognitive Behaviour Therapy

Homework or between‐session learning has long been considered an essential aspect of effective cognitive behaviour therapy. However, it has received relatively less empirical attention than other components of cognitive behaviour therapy. In general, studies have found that homework completion is predictive of outcome in psychotherapy. However, the amount of homework completed by a patient represents only one aspect of this important therapeutic component. This study investigated both the quantity and the quality of homework completed during a 10‐week group cognitive and behavioural treatment program for anxious and depressed patients. It explored the relationship between various aspects of homework completion and outcomes on several different variables. A total of 94 patients were included in the analysis. It was found that both quantity and 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.     

Causing Students to Choose More Language Arts Work: Enhancing the Validity of the Additive Interspersal Procedure

Research on the additive interspersal procedure was extended by exposing seventh-grade students to curricula-based (e.g., educationally valid) language arts assignments. In Experiment I, each student was given a control language arts assignment containing 20 discrete target items and an experimental assignment containing 24 equivalent target items, plus eight interspersed briefer items. After working on both assignments for 10 minutes, significantly more students chose a new experimental assignment for homework. Individual analysis showed that 85% of the students preferred or chose the assignment associated with higher discrete task completion rates. In Experiment II, students completed both assignments. Results extended previous research by showing that even after expending more effort to complete the 20% more target items plus the additional interspersed items on the experimental assignments, significantly more students chose an experimental assignment for homework. Applied and theoretical implications are discussed along with limitations of the current study and directions for future research.