assignment cognitive homework in therapy

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Assignment cognitive homework in therapy how to start an essay on a poem

Assignment cognitive homework in therapy

The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].

An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically.

Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.

To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework. In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ].

These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].

Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels including learning or cognitive disabilities. One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ].

A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders.

In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated. There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance.

Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ]. The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ].

Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ].

Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers.

It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance. The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship.

Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use.

While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance. The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised.

For example, as artificial intelligence [ ] or emotional sensing [ ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states. This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review.

The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done.

We would anticipate synergistic effects when homework-compliance apps are used in CBT eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work , but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.

Conflicts of Interest: None declared. National Center for Biotechnology Information , U. Published online Jun 8. Reviewed by Pietro Cipresso and Elisa Pedroli. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding Author: David Kreindler ac.

This article has been cited by other articles in PMC. Abstract Cognitive behavioral therapy CBT is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Keywords: cognitive behavioral therapy, homework compliance, mobile apps. Homework Non-Compliance in CBT Cognitive behavioral therapy CBT is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [ 1 , 2 ].

The Utility of Technology in Enhancing CBT Homework Despite its demonstrated efficacy, access to CBT as well as other forms of psychotherapy remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. Congruency to Therapy Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session.

Psychoeducational Homework While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Modality-Specific Homework Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages short message service, SMS to therapists in bulimia nervosa [ 61 ].

Guiding Therapy Therapists have a number of important roles to play in guiding and motivating clients to complete homework. Population Specificity Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels including learning or cognitive disabilities. Other Considerations There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance.

Discussion The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. Limitations and Future Challenges The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. Conclusion This paper presents our opinion on this topic, supported by a survey of associated literature.

Footnotes Conflicts of Interest: None declared. References 1. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord. Canadian PA. Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry. Am J Psychiatry. Cognitive behavioral group therapy in panic disorder patients: the efficacy of CBGT versus drug treatment.

Ann Clin Psychiatry. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. Cognitive-behaviour therapy and medication in the treatment of obsessive-compulsive disorder: a controlled study. Unresolved issues regarding homework assignments in cognitive and behavioural therapies: an expert panel discussion at AACBT.

Behav change. Cognitive Therapy of Depression. New York: Guilford Press; American Psychiatric Association. Helbig S, Fehm L. Problems with homework in CBT: rare exception or rather frequent? Behav Cognit Psychother. A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. J Consult Clin Psychol. Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: review, preliminary findings, and implications for theory and practice.

Behav Modif. Leahy R. Improving homework compliance in the treatment of generalized anxiety disorder. J Clin Psychol. Garland A, Scott J. Using homework in therapy for depression. Emot Behav Diff. Williams C, Squires G. Relationship between homework completion and outcome in cognitive behaviour therapy.

Cogn Behav Ther. J Cogn Psychother. Thase M, Callan JA. The role of homework in cognitive behavior therapy of depression. J Psychother Integr. Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition.

The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression. Am J Geriatr Psychiatry. The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. Psychother Psychosom. J Anxiety Disord. Homework compliance counts in cognitive-behavioral therapy. Adherence during sessions and homework in cognitive-behavioral group treatment of social phobia.

Behav Res Ther. Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. An open trial of cognitive-behavioral therapy for compulsive hoarding. Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety. A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness.

Specificity of homework compliance effects on treatment outcome in CBT: evidence from a controlled trial on panic disorder and agoraphobia. Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement. Patients' experiences of homework tasks in cognitive behavioural therapy for psychosis: a qualitative analysis. Clin Psychol Psychother. Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons with schizophrenia.

J Contemp Psychother. Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. The role of homework in cognitive-behavioral therapy for cocaine dependence. Homework compliance in a brief cognitive-behavioural and pharmacological intervention for smoking.

J Smok Cessat. Homework assignments in cognitive and behavioral therapy: a meta-analysis. Clin Psychol Sci Pract. The relationship between homework compliance and therapy outcomes: an updated meta-analysis. Cognit Ther Res. Payne KA, Myhr G. Increasing access to cognitive-behavioural therapy CBT for the treatment of mental illness in Canada: a research framework and call for action.

Healthc Policy. Smith A. Smartphone Use in Apr 1, [ Google Scholar ]. Mobile phone ownership, usage and readiness to use by patients in drug treatment. Drug Alcohol Depend. Boschen M, Casey LM. The use of mobile telephones as adjuncts to cognitive behavioral psychotherapy. Prof Psychol Res Pr. Mirani L. Dec 18, []. Dorrier J. Mar 7, []. Tompkins M. Guidelines for enhancing homework compliance. Kazantzis N, L'Abate L. New York, NY: Springer; Santor D, Bagnell A.

Enhancig the effectivencess and sustainability of school-based mental health programs: maximizing program participation, knowledge uptake and ongoing evaluation using Internet-based resources. Adv Sch Ment Health Promot. Proudfoot J. The future is in our hands: the role of mobile phones in the prevention and management of mental disorders. Aust N Z J Psychiatry. A randomized controlled trial of a self-guided, multimedia, stress management and resilience training program.

Mobile mental health: review of the emerging field and proof of concept study. J Ment Health. The use of guided self-help incorporating a mobile component in people with eating disorders: a pilot study. Eur Eat Disord Rev.

Psychol Serv. A controlled study of rehearsal and homework. The British Journal of Psychiatry , 6 , — Clinical Psychology: Science and Practice , 7 2 , — Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30 4 , — Mechanisms of change in cognitive therapy: The case of automatic thought records and behavioural experiments. Behavioural and Cognitive Psychotherapy , 31 03 , — Does homework compliance enhance recovery from depression?

Psychiatric Annals. Clinical Psychology: Science and Practice , 17 2 , — A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. Journal of Consulting and Clinical Psychology , 73 4 , Distinctive activities of cognitive—behavioral therapy: A review of the comparative psychotherapy process literature. Clinical Psychology Review , 22 5 , — The role of homework in cognitive behavior therapy of depression.

Journal of Psychotherapy Integration , 16 2 , The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clinical Psychology Review , 27 1 , 46— Role of exposure homework in phobia reduction: A controlled study. Behavior Therapy , 23 4 , — Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls. The American Journal of Psychiatry , Internet treatment for depression: a randomized controlled trial comparing clinician vs.

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 , — Use and acceptability of unsupported online computerized cognitive behavioral therapy for depression and associations with clinical outcome. Journal of Affective Disorders , 3 , — Guilford Press. The relationship between homework compliance and therapy outcomes: An updated meta-analysis.

Cognitive Therapy and Research , 34 5 , — Relationship between homework completion and outcome in cognitive behaviour therapy. Cognitive Behaviour Therapy , 34 4 , — The role of homework and skill acquisition in the outcome of group cognitive therapy for depression. Behavior Therapy , 21 3 , — Misinterpretation of body sensations in panic disorder.

Journal of Consulting and Clinical Psychology , 65 2 , Examining the effects of thought records and behavioral experiments in instigating belief change. Journal of behavior therapy and experimental psychiatry , 43 1 , — Behavior Modification , 24 2 , — Does psychotherapy homework lead to improvements in depression in cognitive—behavioral therapy or does improvement lead to increased homework compliance? Journal of Consulting and Clinical Psychology , 68 1 , Therapist skill and patient variables in homework compliance: Controlling an uncontrolled variable in cognitive therapy outcome research.

Cognitive Therapy and Research , 23 4 , — The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: Secondary analysis of a randomized trial. Behavior Therapy , 44 1 , — Psychologists' use of homework assignments in clinical practice.

Professional Psychology: Research and Practice , 30 6 , Problems with homework in CBT: Rare exception or rather frequent?. Behavioural and cognitive psychotherapy , 32 03 , — Professional Psychology: Research and Practice , 36 2 , The role of homework assignments in cognitive therapy for depression: Potential methods for enhancing adherence.

Clinical Psychology: Science and Practice, 6 3 , — What works for whom: Tailoring psychotherapy to the person. Journal of Clinical Psychology , 67 2 , — Evidence-based treatment and practice: new opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist , 63 3 , An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy , 37 6 , — Psychotherapy list.

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OJIBWAY TALES BASIL JOHNSTON TYPED ESSAY

For research objective two, multilevel mixed models MLM were applied to examine between- and within-patient variability of HE and TBH over the course of treatment in a nested data set. In two-level models HE and TBH assessed at each of the nine telephone sessions level 1 are modelled within each of the 22 individuals level 2. The inter-individual variability in terms of initial status and growth of HE and TBH are modelled at level 2. For research objective three, MLM was analysed with depressive symptoms measured with PHQ-9 defined as criterion on level 1.

Depressive symptoms were assessed in each session. In total, five stepwise built multilevel models were calculated. First, the null or unconditional model was created, including the intercept and the random term null-model. Second, the null-model was expanded by adding a random slope for time model 1.

Third, one time-varying predictor HE was introduced into the random intercept random slope model model 2. All models were estimated using restricted maximum likelihood RML. Analyses were performed using R software version 6. With regard to psychometric properties of the scales, corrected item-total correlations ranged from.

Internal consistency for StH-A was. Across all telephone sessions and patients, homework activities were assigned in total, resulting in approximately two defined homework tasks per session and per patient on average. In total, Using the item anchors, this value translates to small to moderate difficulties. Most commonly assessed types of difficulties encountered by patients were negative events that impeded homework completion Lack of time 8.

With regard to variation in HE among patients and across treatment, we first ran an unconditional or null model with HE as criterion. The average HE across patients and treatment is 2. With regard to TBH, The initial status of TBH is 2. In order to explore the association between HE and TBH, stepwise multilevel models were built with HE as criterion in a separate model.

TBH was significantly and positively related to HE over the course of treatment 0. Results are displayed in Table 5. After modelling the time slope model 1 , time-varying predictor 1 was entered at level 1 model 2. Time-varying predictor 1 was HE of the current session, since ratings refer to the interval between two sessions. Next, the second time-varying predictor—TBH from the previous session—was introduced into the model at level 1.

TBH was not significantly related to depressive symptoms 0. The last model model 4 included an interaction between the two time-varying predictors, however the model did not converge. Results of the random intercept model model 1 , the random intercept and random slope model with one predictor model 2 , and the random intercept random slope model with two predictors model 3 are presented in Table 6.

The present study describes types and amount of homework assigned and depicts rather high levels of HE in tel-CBT. Results of our study further show that HE decreases slightly throughout the course of therapy and that TBH is related to HE over the course of therapy. Ultimately, results reveal that higher scores on HE are associated with lower levels of depressive symptoms, but that TBH and depressive symptoms are not associated.

The study demonstrates that homework assignments and engagement with homework play a central role in tel-CBT — as could be expected from the guided self-help approach. As expected, we found that homework was overall assigned in most of the therapy sessions. The fact that on average two homework assignments were prepared in each session confirms that contents were employed and implemented as scheduled by tel-CBT.

This treatment format lays special emphasis on this kind of intersession activity. When modelling the status and course of HE and TBH, both variables showed more within-patient variability compared to between-patient variability over the course of the treatment, as indicated by the ICC calculations of variance components and the slopes of the variables in the models. The overall high HE across patients might be explained by sociodemographic and clinical patient characteristics.

The average age of our sample was rather high and the vast majority of patients reported having had previous depressive episodes and psychotherapy experience. It is likely that patients with a history of depression and of undergoing treatment are trying particularly hard to make the most out of therapy. Moreover, older patients might show a sense of self-responsibility when it comes to carrying out therapeutic homework.

Contrary to the belief that adult patients may have reservations regarding homework due to their age, there is evidence that adult patients have positive attitudes towards homework, with the vast majority of patients not perceiving themselves too old for homework Fehm and Mrose HE declined slightly over the course of treatment and visual inspection of the individual courses of HE showed that drops in HE happened in some patients in single sessions.

These variations are expected to be due to specific external factors that have an influence on the patient's HE at a given session. For example, further explorative analyses might scrutinize which external factors regarding homework such as difficulties completing the homework task; lack of resources or time in a given week and session content might be responsible for situations with a drop in HE. In view of previous suggestions that homework compliance might not be linear across treatment of social anxiety disorder Leung and Heimberg , future studies might employ statistical models that are suitable to detect various patterns of HE.

For example, latent growth analysis, which requires much larger samples than the one used in our study, would allow to detect differences in latent factors between groups of patients, and to relate different HE patterns to treatment outcome Collins and Sayer Our study provides empirical support for the association between HE and depressive symptoms throughout the course of tel-CBT in mildly to moderately depressed patients.

Using MLM with repeated measures of predictors and outcome, we found a medium-sized association between HE shown between sessions and depressive symptoms in the subsequent session. In other words, when HE increases by one unit in an interval of two sessions, patient's symptomatology decreases an average of 0. Moreover, the result corresponds to one previous study focusing on a similar conceptualization of HE, which found an immediate effect of HE on symptom outcome in the subsequent session Conklin and Strunk In our study, TBH was not associated with depressive symptoms in the subsequent session.

However, our results indicate that TBH was significantly related to HE over the course of treatment, which corresponds to results of a previous study that found TBH to significantly predict subsequent HE Conklin et al. This means that some aspects of assigning homework that received clinical and empirical support in previous work, were not implemented in our study.

For example, it is recommended to write down homework tasks and instructions Cox et al. Moreover, a recent study provides preliminary support for the importance of designing homework tasks that are congruent with what the patient perceived helpful in the session Jensen et al.

It is likely that therapists—despite strictly assigning the activity types as scheduled in the treatment manual—adequately adapted the different homework types to the patient's individual situation and promoted patient's willingness and ability to engage with homework outside the therapy session.

Our results further suggest that the specific type of homework might not be the only relevant factor for higher HE, as long as therapists assign and review homework in an elaborate, comprehensible, and convincing manner. The present results need to be interpreted in due consideration of several limitations: First, the predictor variables were assessed using two self-constructed rating scales, which have not been validated prior to the study.

We did not use standardized or validated instruments to assess HE and TBH, because no process rating instrument targeting the particular conceptualization of these variables exists. We aimed at expanding on the previously reported Homework Engagement Scale HES by Conklin and Strunk by adding indicators such as intensity of HE or difficulties faced when engaging with homework.

Despite good psychometric properties for both scales with regard to internal consistency and moderate to good properties regarding IRR, the validity of GHES might be constrained: Even though GHES is an objective observer-based rating instrument with a precise rating manual, the items do not always allow a direct observation of facets relevant to HE. The appraisal of each item relies on the patient expressing his or her thoughts and experiences with the homework process.

However, these narratives might not cover all areas of interest in the rating instrument. For example, the rating on the difficulty-item is indirectly inferred from the narratives of the patient about how engaging with homework went. If the patient did in fact face difficulties affecting HE, but not explicitly mention these when talking about how homework activity went, the measurement of difficulties faced in this situation might not be representative of HE.

Second, the StHAR did not specifically target competence or quality of assigning and reviewing homework. Future studies might develop and employ rating instruments that clearly differentiate the extent of TBH shown by the therapist from the competency of these therapeutic actions. Third, our methodology and our analytic strategy do not allow for any causal inferences regarding HE and depressive symptoms, despite multiple assessments of HE in session intervals and the depressive symptoms assessed at the beginning of each session.

Reverse causation cannot be excluded, since patients might have reported about homework more elaborately and positively in the sessions due to an improved mood. Moreover, depressive symptoms were assessed retrospectively for the time period since the last therapy session. Fourth, the study sample was rather small. Therefore, additional exploratory statistical models for our third research question e.

Lastly, selection bias might have occurred as the majority of the patients self-referred to the overarching clinical trial, potentially leading to the inclusion of generally motivated patients who showed rather small variability in HE and therefore also did not require the therapist to intervene in a way that promotes HE or improves depressive symptoms. Even though our results should be regarded as preliminary evidence, the findings add to the body of literature due to several strengths.

A more comprehensive concept of the extent of homework compliance was used in the present study, going beyond commonly used quantitative measures of homework completion or single-item compliance measures.

Several differences between HE and previous operationalizations of homework compliance exist. Another strength of the study is the conceptualization of TBH, which incorporates multiple facets regarding preparing and reviewing homework, informed by clinical recommendations. These aspects were derived from listening to and rating complete therapy sessions with high reliability, as indicated by the IRR analyses.

Moreover, observer-based ratings of both HE and TBH might provide more objective estimations of HE and discussion of tasks in the therapy session compared to client or therapist reports Mausbach et al. Lastly, our study provides insight into the course of HE and TBH throughout the entire treatment, which helps generating hypotheses regarding the nature of HE and its relation to TBH and depressive symptoms.

The study provides evidence that homework is implemented by therapists and patients in tel-CBT. However, on average a slight decrease of HE throughout the treatment was observed and patients, who show high HE, experience lower depressive symptoms on average. TBH was not related to depressive symptoms but showed an association with HE.

Future studies might examine whether TBH moderates the HE-symptom improvement relationship and whether specific homework types require specific therapist skills to assign and review in a meaningful way. Aguilera, A. Homework completion via telephone and in-person cognitive behavioral therapy among Latinos.

Cognitive Therapy and Research, 42 3 , — Bates, D. Fitting linear mixed-effects models using lme4. Journal of Statistical Software, 67 1 , 1— Article Google Scholar. Beck, A. Cognitive therapy of depression. New York: Guilford Press. Google Scholar. Bryant, M. Therapist skill and patient variables in homework compliance: Controlling an uncontrolled variable in cognitive therapy outcome research.

Cognitive Therapy and Research, 23 4 , Collins, L. New methods for the analysis of change. American Psychological Association. Conklin, L. A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits? Behavior Research and Therapy, 72, 56— Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression.

Cognitive Therapy and Research, 42 1 , 16— Article PubMed Google Scholar. Cox, D. Increasing adherence to behavioral homework assignments. Journal of Behavioral Medicine, 11 5 , — Detweiler, J. The role of homework assignments in cognitive therapy for depression: Potential methods for enhancing adherence. Clinical Psychology: Science and Practice, 6, — Dozois, D. Understanding and enhancing the effects of homework in cognitive-behavioral therapy. Clinical Psychology: Science and Practice, 17 2 , — Fehm, L.

Clinical Psychology and Psychotherapy, 15 5 , — Haller, E. Manuscript submitted for publication. Jensen, A. Congruence of patient takeaways and homework assignment content predicts homework compliance in psychotherapy. Behavior Therapy, 51 3 , — Jungbluth, N. Kazantzis, N. Homework in cognitive behavioral therapy: A systematic review of adherence assessment in anxiety and depression — Psychiatric Clinics of North America, 40 4 , — Homework assignments in cognitive and behavioral therapy: A meta-analysis.

Clinical Psychology: Science and Practice, 7 2 , — Assessing compliance with homework assignments: Review and recommendations for clinical practice. Journal of Clinical Psychology, 60 6 , — Handbook of homework assignments in psychotherapy: Research, practice, and prevention. New York: Springer. Book Google Scholar. Cognitive behavioral therapy for older adults: Practical guidelines for the use of homework assignments. Cognitive and Behavioral Practice, 10 4 , — Can between-session homework activities be considered a common factor in psychotherapy?

Journal of Psychotherapy Integration, 16 2 , — Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension: homework assignments and therapy outcome. Quantity and quality of homework compliance: A meta-analysis of relations with outcome in cognitive behavior therapy.

Behavior Therapy, 47 5 , — Kraepelien, M. The effects of component-specific treatment compliance in individually tailored internet-based treatment. Clinical Psychology and Psychotherapy, 26 3 , — Lambert, M. Directions for research on homework. Adhu Ed. Leung, A. Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. Behavior Research and Therapy, 34 5—6 , — Mausbach, B.

An updated meta-analysis: The relationship between homework compliance and therapy outcomes. Cognitive Therapy and Research, 34 5 , — Pinto-Meza, A. Assessing depression in primary care with the PHQ Can it be carried out over the telephone? Journal of General Internal Medicine, 20 8 , — Primakoff, L. Homework compliance: An uncontrolled variable in cognitive therapy outcome research.

Behavior Therapy, 17 4 , — Revelle, W. A considerable body of evidence shows that clients who do homework have better outcomes than clients who do not. Finally, we used the two-column thought record to anticipate additional interfering thoughts that could get in the way of engaging in his action plan for the coming week. Conklin, L. January 01, A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits? Behaviour Research and Therapy, 72, Kazantzis, N.

Handbook of homework assignments in psychotherapy: Research, practice, and prevention. New York, NY: Springer. Beck, MD Judith S. Beck, PhD Employment Opportunities. Beck, Ph. Broder, Psy.

Telephone-based cognitive behavioral therapy tel-CBT ascribes importance to between-session learning with the support of the therapist.

Assignment cognitive homework in therapy Adv Sch Ment Health Promot. Important concepts you are discussing in session can be greatly reinforced when patients read about them in black and white. Videoconference- and cell phone-based cognitive-behavioral therapy assignment cognitive homework in therapy obsessive-compulsive disorder: A case series. The researchers found that, compared to a no-treatment control, both thought records and behavioral experiments were effective in reducing the belief that not washing one's hands after going to the toilet would make oneself ill. An open trial of cognitive-behavioral therapy for compulsive hoarding. At virtually every session, you will help patients modify their inaccurate and dysfunctional thoughts and write down their new data analysis in schools of thinking. Clinical formulation Clinical pluralism Common factors theory Discontinuation History Practitioner—scholar model.
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Essay about goodnight mr tom Beck b. Homework assignments in cognitive and behavioral therapy: a meta-analysis. Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavior therapy supplemented data analysis in schools telephone calls. With the rise of mass-market mobile communication devices such as the iPhone or other kinds of mobile devices with app capabilities smartphonesnew solutions are being sought that will use these devices to provide therapy to patients in a more cost-effective manner. Patient Educ Couns. It reminds them of the drudgery of assignments they had to do at home when they were at school.
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DIFFERENCE BETWEEN FUNCTIONAL AND CHRONOLOGICAL RESUME

The types of homework in the treatment manual were classified as: 1 Psychoeducational homework, including reading materials and case vignettes; 2 behavioral homework, including scheduling and undertaking pleasant activities; 3 cognitive homework, including replacing dysfunctional thoughts; 4 self-monitoring homework, referring to observing and monitoring thoughts and emotions; and 5 relapse prevention homework, including recognizing warning signs and establishing an emergency plan.

We developed an instrument measuring global HE independent of the type of homework assigned. GHES consists of seven items regarding quantitative and qualitative aspects of homework completion. Each item is described in detail and is assessed on a 5-point Likert scale, varying from 0 not at all to 4 considerably. The seven items cover the following aspects of HE: 1 Extent to which patients engaged with homework tasks; 2 whether and to which extent patients carried out homework as agreed upon; 3 whether and to which extent patients applied learnt strategies in difficult times; 4 the intensity of HE; 5 whether and to which extent patients faced difficulties when carrying out homework; 6 whether and to which extent patients could benefit from completed homework tasks; 7 estimated time that patients spent on HE.

Additionally, and similarly to HES by Conklin and Strunk , the scale contains two items which serve as a homework log. In the first log-item, homework that was reportedly completed from the previous session were written down by the raters. For the second log-item, research assistants recorded homework assignments for the next session before the rating procedure started.

This procedure ensured that raters were informed about which previously assigned homework the discussion in a session is referring to. An instrument to assess TBH was constructed for the purpose of this study. The instrument consists of eight items covering the process of assigning the upcoming homework TBH-A and the process of reviewing previously assigned homework TBH-R.

All items are assessed on a 5-point Likert scale, varying from 0 not at all to 4 considerably. Each item is described in detail and contains a verbal anchoring for each item manifestation. The five items covering TBH-A build the subscale StH-A and comprise: 1 providing a rationale for the homework; 2 tailoring the homework to the individual situation; 3 addressing potential challenges of completing the homework; 4 specifying the homework; 5 ensuring comprehension of the homework.

The subscale StH-R includes three items relating to TBH-R: 1 extent of discussing previous homework; 2 drawing conclusions of the homework; and 3 using homework to strengthen self-efficacy expectation of patient. Higher scores indicate a larger extent of TBH. Items from both scales are displayed in Table 1. The German versions of the scales can be retrieved upon request from the corresponding author.

Nine items regarding primary and secondary depression symptoms are assessed on a 4-point Likert scale and build a sum score between 0 and Therapists went through each item of the PHQ-9 right at the beginning of each session as part of the symptom monitoring. Patients had a copy of the PHQ-9 in front of them, answering whether the symptom was available 0 none of the days to 3 almost every day.

Although originally developed as a self-report measure, telephone administration of the PHQ-9 seems to be a reliable and valid procedure to assess depression Pinto-Meza et al. Audio recordings were available for all therapy sessions of the included 22 treatments. All available recordings of per protocol therapy sessions were included in the dataset. We did not include the initial face-to-face appointment, as this was not relevant for the assessed process variables.

From tel-CBT sessions that had taken place within this sample, we were able to rate sessions Deviation of the treatment manual is defined as a session that did not target the planned content. This was the case, when therapists had to react to a crisis situation of the patient. HE and TBH were rated by five independent raters one Doctoral candidate and four Master-level students in clinical psychology.

All raters were blind to treatment outcome of the patients. During a period of 4 weeks, raters received 54 hours of training in the employed treatment manual and the use of the rating instruments. Training consisted of discussing the content of the treatment manual, particularly homework types in the tel-CBT.

Furthermore, defining adequate and competent therapist behaviors regarding assignment and review of homework were discussed. Following the training phase, three successive trial ratings were completed by the raters. Each trial rating was discussed and in case of disagreement, the wording of the items were refined until consensus was reached. Prior to the rating phase, three therapy sessions from two excluded cases were randomly selected and rated by all five raters in order to examine initial inter-rater reliability IRR.

This result indicated that IRR was high, and that formal ratings could start subsequently. Raters were encouraged to take notes while listening to the audio file and rate all items at the end of the session. Of the eligible audio recordings, each rater was randomly assigned between 32 and 38 sessions for the main rating. Session allocation was stratified by therapist, patient, and treatment phase phase I: sessions 1—4; phase II: sessions 5—9.

A subsample of therapy sessions was double-coded in order to establish IRR. Each rater was paired with every other rater an approximately equal number of times. For the double-rated sessions, the average score of the rater pair for each item was used in the final analyses.

As GHES and StHAR are newly developed rating instruments, analyses of the psychometric properties were conducted before turning to the research questions under investigation. In order to meet research objective one, the types of homework assigned as well as types of difficulties faced when completing homework are reported. For research objective two, multilevel mixed models MLM were applied to examine between- and within-patient variability of HE and TBH over the course of treatment in a nested data set.

In two-level models HE and TBH assessed at each of the nine telephone sessions level 1 are modelled within each of the 22 individuals level 2. The inter-individual variability in terms of initial status and growth of HE and TBH are modelled at level 2. For research objective three, MLM was analysed with depressive symptoms measured with PHQ-9 defined as criterion on level 1. Depressive symptoms were assessed in each session.

In total, five stepwise built multilevel models were calculated. First, the null or unconditional model was created, including the intercept and the random term null-model. Second, the null-model was expanded by adding a random slope for time model 1. Third, one time-varying predictor HE was introduced into the random intercept random slope model model 2. All models were estimated using restricted maximum likelihood RML.

Analyses were performed using R software version 6. With regard to psychometric properties of the scales, corrected item-total correlations ranged from. Internal consistency for StH-A was. Across all telephone sessions and patients, homework activities were assigned in total, resulting in approximately two defined homework tasks per session and per patient on average. In total, Using the item anchors, this value translates to small to moderate difficulties.

Most commonly assessed types of difficulties encountered by patients were negative events that impeded homework completion Lack of time 8. With regard to variation in HE among patients and across treatment, we first ran an unconditional or null model with HE as criterion. The average HE across patients and treatment is 2. With regard to TBH, The initial status of TBH is 2. In order to explore the association between HE and TBH, stepwise multilevel models were built with HE as criterion in a separate model.

TBH was significantly and positively related to HE over the course of treatment 0. Results are displayed in Table 5. After modelling the time slope model 1 , time-varying predictor 1 was entered at level 1 model 2. Time-varying predictor 1 was HE of the current session, since ratings refer to the interval between two sessions. Next, the second time-varying predictor—TBH from the previous session—was introduced into the model at level 1. TBH was not significantly related to depressive symptoms 0.

The last model model 4 included an interaction between the two time-varying predictors, however the model did not converge. Results of the random intercept model model 1 , the random intercept and random slope model with one predictor model 2 , and the random intercept random slope model with two predictors model 3 are presented in Table 6.

The present study describes types and amount of homework assigned and depicts rather high levels of HE in tel-CBT. Results of our study further show that HE decreases slightly throughout the course of therapy and that TBH is related to HE over the course of therapy.

Ultimately, results reveal that higher scores on HE are associated with lower levels of depressive symptoms, but that TBH and depressive symptoms are not associated. The study demonstrates that homework assignments and engagement with homework play a central role in tel-CBT — as could be expected from the guided self-help approach. As expected, we found that homework was overall assigned in most of the therapy sessions.

The fact that on average two homework assignments were prepared in each session confirms that contents were employed and implemented as scheduled by tel-CBT. This treatment format lays special emphasis on this kind of intersession activity. When modelling the status and course of HE and TBH, both variables showed more within-patient variability compared to between-patient variability over the course of the treatment, as indicated by the ICC calculations of variance components and the slopes of the variables in the models.

The overall high HE across patients might be explained by sociodemographic and clinical patient characteristics. The average age of our sample was rather high and the vast majority of patients reported having had previous depressive episodes and psychotherapy experience. It is likely that patients with a history of depression and of undergoing treatment are trying particularly hard to make the most out of therapy.

Moreover, older patients might show a sense of self-responsibility when it comes to carrying out therapeutic homework. Contrary to the belief that adult patients may have reservations regarding homework due to their age, there is evidence that adult patients have positive attitudes towards homework, with the vast majority of patients not perceiving themselves too old for homework Fehm and Mrose HE declined slightly over the course of treatment and visual inspection of the individual courses of HE showed that drops in HE happened in some patients in single sessions.

These variations are expected to be due to specific external factors that have an influence on the patient's HE at a given session. For example, further explorative analyses might scrutinize which external factors regarding homework such as difficulties completing the homework task; lack of resources or time in a given week and session content might be responsible for situations with a drop in HE.

In view of previous suggestions that homework compliance might not be linear across treatment of social anxiety disorder Leung and Heimberg , future studies might employ statistical models that are suitable to detect various patterns of HE.

For example, latent growth analysis, which requires much larger samples than the one used in our study, would allow to detect differences in latent factors between groups of patients, and to relate different HE patterns to treatment outcome Collins and Sayer Our study provides empirical support for the association between HE and depressive symptoms throughout the course of tel-CBT in mildly to moderately depressed patients. Using MLM with repeated measures of predictors and outcome, we found a medium-sized association between HE shown between sessions and depressive symptoms in the subsequent session.

In other words, when HE increases by one unit in an interval of two sessions, patient's symptomatology decreases an average of 0. Moreover, the result corresponds to one previous study focusing on a similar conceptualization of HE, which found an immediate effect of HE on symptom outcome in the subsequent session Conklin and Strunk In our study, TBH was not associated with depressive symptoms in the subsequent session.

However, our results indicate that TBH was significantly related to HE over the course of treatment, which corresponds to results of a previous study that found TBH to significantly predict subsequent HE Conklin et al. This means that some aspects of assigning homework that received clinical and empirical support in previous work, were not implemented in our study.

For example, it is recommended to write down homework tasks and instructions Cox et al. Moreover, a recent study provides preliminary support for the importance of designing homework tasks that are congruent with what the patient perceived helpful in the session Jensen et al. It is likely that therapists—despite strictly assigning the activity types as scheduled in the treatment manual—adequately adapted the different homework types to the patient's individual situation and promoted patient's willingness and ability to engage with homework outside the therapy session.

Our results further suggest that the specific type of homework might not be the only relevant factor for higher HE, as long as therapists assign and review homework in an elaborate, comprehensible, and convincing manner. The present results need to be interpreted in due consideration of several limitations: First, the predictor variables were assessed using two self-constructed rating scales, which have not been validated prior to the study.

We did not use standardized or validated instruments to assess HE and TBH, because no process rating instrument targeting the particular conceptualization of these variables exists. We aimed at expanding on the previously reported Homework Engagement Scale HES by Conklin and Strunk by adding indicators such as intensity of HE or difficulties faced when engaging with homework.

Despite good psychometric properties for both scales with regard to internal consistency and moderate to good properties regarding IRR, the validity of GHES might be constrained: Even though GHES is an objective observer-based rating instrument with a precise rating manual, the items do not always allow a direct observation of facets relevant to HE.

The appraisal of each item relies on the patient expressing his or her thoughts and experiences with the homework process. However, these narratives might not cover all areas of interest in the rating instrument.

For example, the rating on the difficulty-item is indirectly inferred from the narratives of the patient about how engaging with homework went. If the patient did in fact face difficulties affecting HE, but not explicitly mention these when talking about how homework activity went, the measurement of difficulties faced in this situation might not be representative of HE.

Second, the StHAR did not specifically target competence or quality of assigning and reviewing homework. Future studies might develop and employ rating instruments that clearly differentiate the extent of TBH shown by the therapist from the competency of these therapeutic actions. Third, our methodology and our analytic strategy do not allow for any causal inferences regarding HE and depressive symptoms, despite multiple assessments of HE in session intervals and the depressive symptoms assessed at the beginning of each session.

Reverse causation cannot be excluded, since patients might have reported about homework more elaborately and positively in the sessions due to an improved mood. Moreover, depressive symptoms were assessed retrospectively for the time period since the last therapy session.

Fourth, the study sample was rather small. Therefore, additional exploratory statistical models for our third research question e. Lastly, selection bias might have occurred as the majority of the patients self-referred to the overarching clinical trial, potentially leading to the inclusion of generally motivated patients who showed rather small variability in HE and therefore also did not require the therapist to intervene in a way that promotes HE or improves depressive symptoms.

Even though our results should be regarded as preliminary evidence, the findings add to the body of literature due to several strengths. A more comprehensive concept of the extent of homework compliance was used in the present study, going beyond commonly used quantitative measures of homework completion or single-item compliance measures.

Several differences between HE and previous operationalizations of homework compliance exist. Another strength of the study is the conceptualization of TBH, which incorporates multiple facets regarding preparing and reviewing homework, informed by clinical recommendations. These aspects were derived from listening to and rating complete therapy sessions with high reliability, as indicated by the IRR analyses.

Moreover, observer-based ratings of both HE and TBH might provide more objective estimations of HE and discussion of tasks in the therapy session compared to client or therapist reports Mausbach et al. Lastly, our study provides insight into the course of HE and TBH throughout the entire treatment, which helps generating hypotheses regarding the nature of HE and its relation to TBH and depressive symptoms. The study provides evidence that homework is implemented by therapists and patients in tel-CBT.

However, on average a slight decrease of HE throughout the treatment was observed and patients, who show high HE, experience lower depressive symptoms on average. TBH was not related to depressive symptoms but showed an association with HE.

Future studies might examine whether TBH moderates the HE-symptom improvement relationship and whether specific homework types require specific therapist skills to assign and review in a meaningful way. Aguilera, A. Homework completion via telephone and in-person cognitive behavioral therapy among Latinos.

Cognitive Therapy and Research, 42 3 , — Bates, D. Fitting linear mixed-effects models using lme4. Journal of Statistical Software, 67 1 , 1— Article Google Scholar. Beck, A. Cognitive therapy of depression. New York: Guilford Press. Google Scholar. Bryant, M. Therapist skill and patient variables in homework compliance: Controlling an uncontrolled variable in cognitive therapy outcome research.

Cognitive Therapy and Research, 23 4 , Collins, L. New methods for the analysis of change. American Psychological Association. Conklin, L. A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits? Behavior Research and Therapy, 72, 56— Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression.

Cognitive Therapy and Research, 42 1 , 16— Article PubMed Google Scholar. Cox, D. Increasing adherence to behavioral homework assignments. Journal of Behavioral Medicine, 11 5 , — Detweiler, J. The role of homework assignments in cognitive therapy for depression: Potential methods for enhancing adherence.

Clinical Psychology: Science and Practice, 6, — Dozois, D. Understanding and enhancing the effects of homework in cognitive-behavioral therapy. Homework is not something that you just assign randomly. You should make sure you: tailor the homework to the patient. Types of Homework Assignments.

Patients will also learn to evaluate their own thinking and practice doing so between sessions. Problem-solving At virtually every session, you will help patients devise solutions to their problems, which they will implement between sessions. Behavioural skills To effectively solve their problems, patients may need to learn new skills, which they will practice for homework.

Preparing for the next session Preparing for the next therapy session. The beginning part of each therapy session can be greatly speeded up if patients think about what is important to tell you before they enter your office. Here are some ways to increase adherence to homework: Tailor the assignments to the individual.

Try to start the homework during the session. This creates some momentum to continue doing the homework. It is better to start with easier homework assignments and err on the side of caution. Covert rehearsal - running through a thought experiment on a situation.

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Many counselors assign their clients work to be done outside the therapy session. But how do you find the right kind of homework for the. Homework is a central feature of Cognitive-Behavioral Therapy (CBT), given its educational emphasis. This new text is a comprehensive guide. Why do homework in CBT? Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect.