Adapting Homework for an Older Adult Client With Cognitive Impairment

There is growing evidence that psychosocial treatments incorporating behavioral intervention strategies can be effective in the treatment of depression in older adults with cognitive impairment. However, less work with such cases has focused on the use of cognitive interventions in tandem with these behavioral intervention strategies. This case study describes how cognitive behavioral intervention strategies and related homework assignments were tailored and integrated to successfully treat depressive symptoms in an older African American diagnosed with probable Alzheimer’s disease. Examples of the homework strategies utilized are introduced by phase of treatment. We also discuss ways to overcome barriers to homework completion as well as methods to incorporate the client’s sociocultural context and personal history into homework.     

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.     

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.     

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.     

Der Einsatz von Hausaufgaben in der Psychotherapie

Homework is not only an essential part of cognitive-behavioral treatment but is also used in a variety of other therapy approaches. Its positive relation to therapy outcome has been proved. In consequence, patients’ compliance with homework assignments is an important therapeutic goal. In the last years, numerous papers focused on recommendations for enhancing acceptance and completion of homework assignments. The present article provides an overview about existing recommendations. Proposals are summarized and opposed to empirical studies on single homework procedures and their influence on homework compliance. Due to a lack of empirical data, the effectiveness of most recommendations could not yet be proved. General problems in homework study design and possible directions of further research addressing homework use are discussed.     

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.     

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.     

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.     

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.     

Family Focused Treatment for Patients with Bipolar Disorder in Turkey: A Case Series

Family-focused therapy (FFT) is a 9-month, 21-session structured psychoeducational treatment for bipolar disorder. Several US-based studies have documented its efficacy as adjunctive to medication for depression stabilization and relapse prevention. However, FFT has never been applied outside of the United States. The objective of this case series is to explore the applicability of FFT in a non-Western culture. Ten patients with bipolar disorder and their family members attended the 9-month FFT as adjunctive to pharmacotherapy in an outpatient specialty clinic in Izmir, Turkey. Patients improved in Global Assessment of Functioning Scores and Clinical Global Impression Scores from pre- to posttreatment. Case studies are given, which illustrate the differences between Western and non-Western families coping with bipolar disorder. FFT was easily applied to a Turkish sample with few changes in format or focus. Adaptations included substitution of oral for written therapeutic tasks or homework assignments. Randomized controlled trials are needed to test the clinical effectiveness of FFT and other psychosocial interventions in non-Western cultures.     

Show-That-I-Can (Homework) in Cognitive-Behavioral Therapy for Anxious Youth: Individualizing Homework for Robert

Cognitive-behavioral therapy (CBT) has been reviewed and described as an empirically supported treatment for anxious youth. One component of CBT is the use of out-of-session “Show That I Can” tasks (STIC; i.e., homework tasks). STIC tasks vary in content and are to be completed between sessions. We discuss homework in CBT for Robert, a 13-year-old boy with social anxiety. Robert experienced distressing anxiety participating in and giving presentations at school and was fearful of open-ended questions. Robert had difficulty maintaining conversations with peers and reported being preoccupied with a concern that he would say something “weird” or “stupid.” Robert avoided numerous situations, and his social anxiety affected his grades, social interactions, family, and quality of life. Robert’s initial homework tasks entailed (a) journaling and self-monitoring anxious feelings and thoughts, and (b) practicing relaxation skills. During the second half of treatment, Robert’s STIC assignments were exposure tasks, including (a) opinion discussion assignments, (b) participating in class, and (c) initiating conversations with children at the bus stop. The present discussion focuses on how homework was individualized and presented so that it was palatable and sensitive. Issues regarding out-of-session exposure tasks that elicit sufficient anxiety, resistance to high-level exposure tasks, and parent involvement are explored.     

Addressing Dropout From Prolonged Exposure: Feasibility of Involving Peers During Exposure Trials

Posttraumatic stress disorder (PTSD) is a significant problem for combat veterans. Fortunately, effective treatments, such as Prolonged Exposure (PE), are available and widely disseminated in the Veterans Affairs (VA) health-care system. Nonetheless, despite well-documented effectiveness, attrition remains high at approximately 30% across evidence-based interventions. Early studies indicated that dropout was largely related to stigma and logistical barriers (e.g., travel time and cost). However, research demonstrates that eliminating these logistical and stigma-based barriers (e.g., through home-based telemedicine) has little effect on dropout. We surveyed 82 veterans who dropped out of PE treatment regarding reasons for leaving treatment. Approximately half indicated that in vivo homework assignments caused significant problems, and when asked to consider the possibility of peer support during in vivo exposure assignments, 52% indicated that they would consider returning to treatment with such assistance. In response to this feedback, we constructed an in vivo therapy peer support program wherein peers are directly involved with in vivo exposure exercises. The following brief report presents the rationale for, outline of, and initial feasibility data supporting this program to enhance both return to, and completion of, exposure therapy treatment for PTSD.     

Research to Practice: Implementation of Family School Success for Parents of Children With ADHD

“Family-School Success” (FSS) is an efficacious intervention improving the home and school functioning of children with ADHD in grades 2–6. An extension of this intervention designed for a younger population also showed positive effects for kindergarten and first grade students in a pilot study. Following the completion of these trials, FSS was implemented in a fee-for-service tertiary care ADHD center. The implementation process included adapting the manual and treatment procedures to be feasible outside the structure and support of a federally funded randomized control trial (RCT). The current study examines the process of adapting the treatment protocol and examines the acceptability and effectiveness of the adapted FSS, as well as predictors of family treatment response including parent engagement in treatment (as measured by attendance and homework adherence). A case study illustrates the adaptations to the intervention and its implementation in the clinic-based setting. In line with findings from clinical trials, families reported high satisfaction with the adapted FSS intervention and showed significant improvement in parental self-efficacy, child academic homework performance, and reduction in child impairment. Additionally, as in the initial FSS RCT, parental attendance in the adapted FSS program predicted child attention to academic homework, controlling for parental adherence to between-session homework. Furthermore, controlling for attendance at FSS sessions, parent adherence to between-session homework assignments predicted improvements in parent self-efficacy as well as child’s homework productivity. These results replicate those of the original RCT and confirm that both session attendance and between-session homework completed are important for improvement during the program. Overall, this study provides support for the acceptability and effectiveness of this treatment model and suggests that future work toward dissemination to community-based settings would be worthwhile.     

The Obstacle is the Path: Overcoming Blocks to Homework Assignments in a Complex Presentation of Depression

There is increasing evidence to demonstrate that clients who complete homework assignments have a better outcome in cognitive therapy (Kazantzis, Deane, & Ronan, 2000). Most clinicians recognize that enabling clients to effectively utilize homework can be a major task in itself, particularly with disorders such as depression, where individuals find even the simplest daily tasks daunting. This article begins by highlighting the problem of changing any pattern of activity, and then explores the difficulties of engaging clients in homework when they present with persistent depression with secondary anxiety features.     

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.     

Longitudinal evaluation of the importance of homework assignment completion for the academic performance of middle school students with ADHD

The primary goal of this study was to longitudinally evaluate the homework assignment completion patterns of middle school age adolescents with ADHD, their associations with academic performance, and malleable predictors of homework assignment completion. Analyses were conducted on a sample of 104 middle school students comprehensively diagnosed with ADHD and followed for 18 months. Multiple teachers for each student provided information about the percentage of homework assignments turned in at five separate time points and school grades were collected quarterly. Results showed that agreement between teachers with respect to students assignment completion was high, with an intraclass correlation of .879 at baseline. Students with ADHD were turning in an average of 12% fewer assignments each academic quarter in comparison to teacher-reported classroom averages. Regression analyses revealed a robust association between the percentage of assignments turned in at baseline and school grades 18 months later, even after controlling for baseline grades, achievement (reading and math), intelligence, family income, and race. Cross-lag analyses demonstrated that the association between assignment completion and grades was reciprocal, with assignment completion negatively impacting grades and low grades in turn being associated with decreased future homework completion. Parent ratings of homework materials management abilities at baseline significantly predicted the percentage of assignments turned in as reported by teachers 18 months later. These findings demonstrate that homework assignment completion problems are persistent across time and an important intervention target for adolescents with ADHD.     

Do drop-outs differ from successfully treated obsessive-compulsives?

The most common reasons given by patients for dropping out of treatment are: environmental constraints, dissatisfaction with services and that they no longer need help. In this study two groups of patients suffering from obsessive-compulsive disorders are compared. The drop-outs' reasons for terminating treatment are compared with the comments of patients who completed the therapy successfully. Drop-outs differ from successfully treated OCD's in five respects: they appear to be less obsessive-compulsive; they have more discongruent treatment expectations; they are more critical of the therapist; they experience less anxiety in carrying out homework assignments; they less frequently come under pressure from people close to them.     

Therapeutic Factors Contributing to Change in Cognitive-Behavioral Group Therapy for Older Persons with Schizophrenia

The contributions of homework, therapy participation, cognitive insight, and skills acquisition to treatment outcomes in group CBT for schizophrenia were examined. Increased cognitive insight was associated with reduced positive, negative and total symptoms, but not improved psychosocial functioning. Greater participation was associated with increased cognitive insight, reduction in total and negative symptoms, and a trend was found for positive symptoms. Greater homework adherence was associated with greater skill acquisition, but skill acquisition was not significantly associated with change in any outcome. The therapeutic factors contributing to change in CBT for schizophrenia appear different for symptom and psychosocial functioning outcomes.     

A point contingency for homework submission in the graduate school classroom

We explored the effects of points versus no points on the submission of homework assignments and quiz performance in a graduate-level course. Students were more likely to submit homework assignments during points weeks, but quiz scores were relatively unaffected.