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Homework in psychotherapy
Homework in psychotherapy is sometimes assigned to patients as part of their treatment. In this context, homework assignments are introduced to practice skills taught in therapy, encourage patients to apply the skills they learned in therapy to real life situations, and to improve on specific problems encountered in treatment.〔Hundt, N. E., Mignogna, J., Underhill, C., & Cully, J. A. (2013). The relationship between use of CBT skills and depression treatment outcome: A theoretical and methodological review of the literature. ''Behavior Therapy'', 44(1), 12–26.〕 For example, a patient with deficits in social skills may learn and rehearse proper social skills in one treatment session, then be asked to complete homework assignments before the next session that apply those newly learned skills (e.g., going to a social engagement or greeting five people each day).〔Falloon, I. R., Lindley, P., McDonald, R., & Marks, I. M. (1977). Social skills training of out-patient groups. A controlled study of rehearsal and homework. ''The British Journal of Psychiatry'', 131(6), 599–609.〕
Homework is most often used in cognitive behavioral therapy (CBT) for the treatment of mood and anxiety disorders, although other theoretical frameworks may also incorporate homework.〔Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta‐analysis. ''Clinical Psychology: Science and Practice'', 7(2), 189–202.〕〔Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., ... & Marlatt, A. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295–305.〕 Some of the types of homework used in CBT include thought records and behavioral experiments.〔Bennett-Levy, J. (2003). Mechanisms of change in cognitive therapy: The case of automatic thought records and behavioural experiments. ''Behavioural and Cognitive Psychotherapy'', 31(03), 261–277.〕 Patients using thought records are instructed to write down negative cognitions on the thought record form and weigh the evidence both for and against the negative thoughts, with the goal being to come up with new, balanced thoughts in the process. Behavioral experiments are used as homework to help patients test out thoughts and beliefs directly. Studies have shown that homework completion and accuracy predict favorable outcomes in psychotherapy and may help patients stay in remission.〔Burns, D. D., & Auerbach, A. H. (1992). Does homework compliance enhance recovery from depression? ''Psychiatric Annals''.〕〔Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta‐analysis of homework effects in cognitive and behavioral therapy: A replication and extension. ''Clinical Psychology: Science and Practice'', 17(2), 144–156.〕 However, some therapists are concerned that assigning homework makes therapy too formal and reduces the impact of the individual sessions.〔Kazantzis, N., Lampropoulos, G. K., & Deane, F. P. (2005). A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. ''Journal of Consulting and Clinical Psychology'', 73(4), 742.〕
==Approaches==
Most of the literature published on homework in psychotherapy to date focuses on homework use during CBT, which involves changing patients' thoughts and behaviors to reduce the symptoms of the mental disorders from which they are suffering.〔Blagys, M. D., & Hilsenroth, M. J. (2002). Distinctive activities of cognitive–behavioral therapy: A review of the comparative psychotherapy process literature. ''Clinical Psychology Review'', 22(5), 671–706.〕 A variety of homework assignments exist in CBT.〔Thase, M. E., & Callan, J. A. (2006). The role of homework in cognitive behavior therapy of depression. ''Journal of Psychotherapy Integration'', 16(2), 162.〕 These tasks can range from scheduling a daily exercise routine to practicing progressive muscle relaxation five times a day to monitoring and recording one's negative automatic thoughts throughout the day. In practice, these homework assignments are meant to help patients lift their mood, practice and master skills they developed in therapy, and progressively improve between treatment sessions. Research has found that homework compliance positively predicts successful outcomes in therapy, and therapists are now looking for better ways to implement homework, so that more individuals may receive its benefits.〔
CBT is not the only type of therapy to incorporate homework. Although each therapist makes his or her own choices regarding homework assignments, some of the other therapies that may assign homework include exposure therapy, psychodynamic therapy, and problem solving therapy.〔Malouff, J. M., Thorsteinsson, E. B., & Schutte, N. S. (2007). The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. ''Clinical Psychology Review'', 27(1), 46–57.〕〔Al-Kubaisy, T., Marks, I. M., Logsdail, S., Marks, M. P., Lovell, K., Sungur, M., & Araya, R. (1992). Role of exposure homework in phobia reduction: A controlled study. ''Behavior Therapy'', 23(4), 599–621.〕 Homework can also be assigned even if therapists are not physically present with the patients being treated. Such cases include therapy delivered over the phone, over video, or over the Internet.〔Carlbring, P., Bohman, S., Brunt, S., Buhrman, M., Westling, B. E., Ekselius, L., & Andersson, G. (2006). Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls. ''The American Journal of Psychiatry'', 162(12).〕〔Titov, N., Andrews, G., Davies, M., McIntyre, K., Robinson, E., & Solley, K. (2010). Internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance. ''PloS One'', 5(6), e10939.〕 Treatment of some disorders, such as major depression, may also be done without therapists at all.〔Vernmark, K., Lenndin, J., Bjärehed, J., Carlsson, M., Karlsson, J., Öberg, J., ... & Andersson, G. (2010). Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression. ''Behaviour Research and Therapy'', 48(5), 368–376.〕 Although the efficacy of this self-help-like treatment is still under scrutiny, preliminary data suggest that completion of homework is one factor predicting positive treatment outcomes for patients who receive treatment over the Internet.〔de Graaf, L. E., Huibers, M. J., Riper, H., Gerhards, S. A., & Arntz, A. (2009). Use and acceptability of unsupported online computerized cognitive behavioral therapy for depression and associations with clinical outcome. ''Journal of Affective Disorders'', 116(3), 227–231.〕
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