Homework Assignments and Self-Monitoring

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 311

14

Homework Assignments and Self-Monitoring Nikolaos Kazantzis La Trobe University, Australia

Frank M. Dattilio Harvard Medical School, United States

Amy Cummins and Xavier Clayton La Trobe University, Australia

Introduction Aaron T. Beck’s (1976) model of psychopathology centers on the role of dysfunctional cognition in understanding emotional distress and impaired behavior. The theory is extended to the practice of cognitive therapy, now commonly referred to as cognitive behavior therapy (CBT), in which therapeutic interventions are aimed at helping patients change the content and process of their thinking, including the ability to question, evaluate, and gain distance from thoughts and to develop flexibility in their beliefs, rules, and assumptions (A. T. Beck, Rush, Shaw, & Emery, 1979). These cognitive skills enable patients to truly engage with each moment and maintain a present focus even during situations that are upsetting or otherwise emotionally challenging. Extensive research has demonstrated the effectiveness of CBT for helping individuals with a wide variety of mental health conditions to lead more fulfilling lives (A. T. Beck & Dozois, 2011). The application of A. T. Beck’s model in CBT requires a great emphasis on the manner in which the therapist interacts with the patient (J. S. Beck, 2005; Kazantzis, Beck, Dattilio, Dobson, & Rapee, in press; Leahy, 2001). Patients’ cognitions are central to understanding their engagement in the therapeutic process, their view of the therapist, their expectations regarding the outcome of therapy, and their engagement with therapeutic techniques between sessions. Of course, it would be misleading to suggest that cognitions are the sole focus of clinical attention in CBT. Cognitive change is also achieved via the acquisition The Wiley Handbook of Cognitive Behavioral Therapy, First Edition. Edited by Stefan G. Hofmann. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. DOI: 10.1002/9781118528563.wbcbt14

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 312

312

General Strategies

of emotional, behavioral, and physiologically focused skills in CBT (Dobson, 2010). The point is that the same patient cognitions that contribute to the development and maintenance of psychopathology are present in the patient’s view of the therapy process. Homework assignments have been considered crucial to the practice of CBT because they serve to strengthen gains made from one session to the next (A. T. Beck et al., 1979; J. S. Beck & Tompkins, 2007). Extending from the initial work with mood disorders (A. T. Beck et al., 1979), homework is now routinely incorporated in CBT formulations for a variety of clinical conditions, including, but not limited to, generalized anxiety disorder (Barlow, Esler, & Vitali, 1998; M. G. Newman et al., 2011; Wetherell, Gatz, & Craske, 2003), posttraumatic stress disorder (Felmingham & Bryant, 2012; Resick, Williams, Suvak, Monson, & Gradus, 2012), panic disorder (Barlow et al., 1998; Gloster et al., 2011; Vincelli et al., 2003), obsessive-compulsive disorder (Simpson et al., 2011), borderline personality disorder (Linehan, 1993), and relapse prevention for alcohol abuse and dependence (Dimeff & Marlatt, 1995).

What Is Homework, and What Is Homework Not? Stemming from the educational model, the extension of therapy to the everyday situations in which the patients’ problems exist reflects a basic principle of learning and skill acquisition, namely, that practice is important for learning (Kazantzis, Arntz, Borkovec, Holmes, & Wade, 2010). Psychotherapeutic homework assignments can encompass a broad range of creative activities or tasks (Lambert, Harmon, & Slade, 2007). In the treatment of CBT for depression, for example, a range of potential homework assignments are frequently assigned and often include self-monitoring sheets, behavioral activation schedules, arousal reduction, and the use of thought records (Thase & Callan, 2006). We can define therapeutic homework as therapeutic activities completed between consultation sessions, which are collaboratively designed by the therapist and patient to assist with progress toward therapeutic goals (A. T. Beck et al., 1979; J. S. Beck, 2011). However, homework is much more than that. It is also an important relational process that draws upon the patient’s and therapist’s efforts to work as a collaborative team to devise empirical tests of the patient’s experience (i.e., through monitoring; see Dattilio & Hanna, 2012). It is through this unique experimentation with specific techniques and ways of relating that change takes place (Kazantzis, Petrik, & Cummins, 2012).

Socializing Patients to Homework One of the challenges for the practitioner in socializing patients during the early phase of CBT is to communicate the learning principle clearly. Homework can be introduced through the notion of “self-practice,” “self-therapy,” or “experiments,” and by distinguishing this from one’s recollection of school homework, which is graded on a pass/fail basis and usually is assigned by a teacher without input

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 313

Homework Assignments and Self-Monitoring

313

from the student (Kazantzis, 2011). If we are practicing CBT in a manner true to the tenets of collaborative empiricism, any result is useful since it provides important information about the patients’ problems and represents “data” for the case formulation. In essence, it becomes “grist for the therapeutic mill.” Moreover, unlike school homework, CBT assignments are not unilaterally assigned, but rather result from a collaboration between therapist and patient, and ultimately the patient may design his or her own tasks. Thus, our first recommendation is that practitioners avoid using the term “homework” with patients. We advocate for a discussion of the patient’s previously rewarding learning experiences, and use their language and metaphors about learning to convey the importance of therapeutic homework. As patients practice therapeutic techniques and find them helpful, they can apply them in different ways to other aspects of their lives. Some patients quickly adapt the homework, or take its central elements or gist, and apply it in a totally unique way. In order for CBT to be helpful to patients in the long term, it should encourage a level of adaptation and generalization with therapeutic assignments in the short term. As one example, John developed skills in monitoring his pleasure and sense of accomplishment through the day, as part of his initial therapeutic work on depression. He found it helpful to ask himself “What is my level of sadness in this situation?” and “How high is my feeling of contentment right now?” This was something that he practiced throughout the course of his therapy. Ideally, we want our patients to take the techniques that they find helpful in therapy, and embrace them as a part of their daily thinking (i.e., to develop complex reasoning about the application of techniques; Kazantzis & Daniel, 2009). In this way, the skills honed through homework practice become a part of the fabric of their general skill base and contribute to their overall well-being. Thus, when socializing patients to CBT, it is important to convey that homework tasks are an extension of the in-session work which will ultimately support patients in maintaining their well-being long after they conclude therapy.

Managing Therapist Expectations and Reactions One challenge for practitioners is that most patients, at least sometimes, do not engage with their therapeutic homework assignments. A larger problem, however, and one that stems from the same source, involves therapists’ expectations of their patients. When we adopt the medical model, we expect our patients to “adhere” or “comply” with homework as planned, and these notions fall short of capturing the complexity of everyday clinical practice, because many patients benefit from partially completed homework, and some patients can complete more homework than was discussed, but only derive a small benefit. A more useful way of evaluating patients’ between-session therapeutic work is to consider the practical difficulty of the task, the situational obstacles to its completion, and the degree of skill gained from the actual activity (Fehm & Mrose, 2008; Schmidt & Woolaway-Bickel, 2000; Simpson et al., 2010; Simpson et al., 2011; Westra & Dozois, 2006). These considerations form a broader concept of engagement which, when adopted in place of achieving compliance, helps therapists to manage their own expectations about what is possible for patients. If a patient has not engaged with the homework, or is only partially

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 314

314

General Strategies

engaged, the therapist should focus on the quality of the work done and the learning that has resulted, being sure to frame all attempts as successes and connecting their verbal praise with work done. Sophie, an experienced cognitive therapist, often experiences disappointment with her patients’ lack of homework completion, despite doing everything that is requested of her as a therapist. She often feels annoyed when she hears the excuse, “I forgot.” When therapists are asked for “adaptive therapist emotions and attitudes” in the use of therapeutic homework during professional workshops on enhancing the use of homework in CBT, the list usually comes sluggishly—“enthusiasm,” “empathy,” and “patience.” These adjectives are among the most commonly identified adaptive experiences. Yet, when therapists are asked what they would hypothesize to be the most commonly identified experiences among CBT practitioners, they produce a much different list: “anger,” “frustration,” “annoyance,” “disappointment,” “anxiety,” “guilt.” Such lists have been remarkably consistent among different practitioner groups in many different countries. Homework noncompliance is a problem for the practice of CBT worldwide, for several reasons it seems. As a self-reflection exercise, it may be helpful to think of a recent experience of a patient who did not engage with a therapeutic homework task. What emotion did you feel? And as you had that emotion, what went through your mind? What did this experience mean to you as a clinician? Despite the potential for such experiences, there are also CBT practitioners who say that they love the role of homework in therapy. They practice creatively, and see the integration of homework as just another expression of their ability to fuse the process of case conceptualization with the specific technique or treatment strategy in a manner suitable for the particular patient sitting in their consultation room. Such practitioners could not imagine using CBT without homework and would consider it foolish to do so. As it turns out, they are right.

The State of Empirical Evidence for Therapeutic Homework Homework assignments have been investigated more than any other therapeutic process in CBT (Persons, Davidson, & Tompkins, 2000), and their effects have been evaluated in several ways. One group of studies contrasted therapy conditions with and without the use of homework assignments and compared their therapeutic outcomes, generally operationalized as symptom reduction. Interestingly, only some of these studies have demonstrated an advantage for the “homework” conditions when reviewing the findings at the conventional p < .05 criterion for statistical significance, which led many researchers through the 1980s and 1990s to debate the necessity of homework in CBT (e.g., Zettle & Hayes, 1987). However, the advent of quantitative review methods afforded some clarification. It turns out that these studies had low statistical power (a 58% chance of detecting a large effect size, a 32% chance of detecting a medium effect size, and only a 9% chance of detecting a small effect size; see Kazantzis, 2000). Meta-analyses also confirmed that when all the studies were aggregated and analyzed, the difference in outcome between “homework” and “no-homework”

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 315

Homework Assignments and Self-Monitoring

315

conditions was actually substantial (d = 0.77 in Kazantzis, Deane, & Ronan, 2000; and d = 0.63 in Kazantzis, Whittington, & Dattilio, 2010). To interpret the more conservative effect size of 0.63, this would mean that if we were to randomly assign 200 patients to comparable therapy conditions, with 100 assigned to therapy with homework, and 100 to therapy without homework, we would expect 63% and 37% of patients to improve, respectively. (This calculation is based on Rosenthal’s [1991] binomial effect size display, but see McGraw, 1991, for its limitations.) Research has also addressed the questions: “Do practitioners actually use homework, and if so, what do they think of it?” These are important questions as there may be many barriers to the implementation of the evidence base (Garland, BrookmanFrazee, & Chavira, 2010). Surveys among practitioners in Australia (Deane, Glaser, Oades, & Kazantzis, 2005), Canada (Carroll, Nich, & Ball, 2005), Germany (Fehm & Kazantzis, 2004; Helbig & Fehm, 2004), New Zealand (Kazantzis, Busch, Ronan, & Merrick, 2007; Kazantzis & Deane, 1999), and the United States (Kazantzis, Lampropoulos, & Deane, 2005) have found that the majority of practitioners surveyed reported that therapeutic homework was “generally” or “almost always” incorporated into their therapy sessions. Interestingly, the use of between-session therapeutic tasks has been reported among those identifying a range of theoretical orientations. For example, Kazantzis et al. (2005) found that in a diverse sample of psychologists, comprised of individuals who identified their primary orientation as CBT (39%) or psychodynamic/analytic (24%), a high proportion (68%) reported regular homework use. The proposition that homework assignments are now incorporated into a range of different therapies is not limited to these data. Experts from a range of therapeutic approaches have outlined how homework facilitates change mechanisms in, among others, acceptance and commitment therapy (Twohig, Pierson, & Hayes, 2007), behavior therapy (Ledley & Huppert, 2007), brief strategic family therapy (Robbins, Szapocznik, & Pe’rez, 2007), client-centered therapy (Witty, 2007), cognitive therapy (J. S. Beck & Tompkins, 2007), emotion-focused experiential therapy (Ellison & Greenberg, 2007), interpersonal psychotherapy (Young & Mufson, 2007), personal construct therapy (Neimeyer & Winter, 2007), and psychodynamic therapy (Stricker, 2007). Another branch of the empirical literature has sought to explore a closely related, but different, research question: “Is there a positive correlation between patient homework ‘compliance’ and treatment outcome?” Answering this research question in the affirmative provides us with valuable information about the relation (or association) between the two variables, but does not enable us to ascertain the direction of causality (Kaplan & Saccuzzo, 2008). Compliance with homework may lead to symptom reduction, but it is equally plausible that symptom reduction may encourage greater compliance with homework. There has been some confusion about what constitutes a causal effect in this research area. For example, Burns and Spangler (2000) reported that homework compliance had a causal effect on treatment outcome, based on an application of structural equation modeling (SEM) to examine the correlation between homework compliance and symptom reduction in the treatment of depression. As Kazantzis, Ronan, and Deane (2001) noted, although this is an exceptional illustration of the utility of SEM, these data were unable to demonstrate

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 316

316

General Strategies

that homework compliance caused symptom reduction. Prospective, experimental research remains the gold standard for determining causality (Urbina, 2004). The relationship between homework compliance and treatment outcome has been examined in the context of CBT for depression (Addis & Jacobson, 2000; Brothers, Yang, Strunk, & Anderson, 2011; Coon & Thompson, 2003; Cowan et al., 2008; Neimeyer, Kazantzis, Kassler, Baker, & Fletcher, 2008; Startup & Edmonds, 1994), anxiety-related disorders (Hughes & Kendall, 2007; M. G. Newman et al., 2011; Westra, Dozois, & Marcus, 2007; Woods, Chambless, & Steketee, 2002), substance use (Carroll et al., 2005; Gonzalez, Schmitz, & DeLaune, 2006; Witkiewitz & Bowen, 2010), psychotic symptoms (Dunn, Morrison, & Bentall, 2002), hoarding (Tolin, Frost, & Steketee, 2007), and body image distress (Cash & Hrabosky, 2003; McMillan, Stice & Rohde, 2011), and is perhaps the most frequently explored research question. This research question has also been investigated in other forms of cognitive therapy, such as mindfulness-based cognitive therapy as a relapse prevention strategy for depression (Murphy & Lahtinen, 2011). Surprisingly, three quantitative reviews have shown that the association between compliance and symptom change is small, in the vicinity of r = .22 (Beutler, Malik, Talebi, Fleming, & Moleiro, 2004; Kazantzis et al., 2000; Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010). This finding makes little sense in the context of a medium effect size resulting from studies that compare therapy with and without homework. It makes little sense unless we consider one thing—that compliance is not always the most important construct of interest. If we can dispense with the word “compliance,” perhaps the term “engagement” would be a less pejorative term that more obviously incorporates a notion of continuum. Engagement can happen to a lesser or greater extent, whereas one is either “compliant” or “not.” This all-or-nothing polarized view of patient homework behavior is a likely culprit for the therapist’s negative emotions identified above. Engagement also allows for the possibility that the activity itself may pose some challenge. This is certainly the case with therapeutic homework assignments, as they are often emotionally charged and are technically/skillfully challenging tasks that require some amount of deliberate effort. Engagement also allows for the reality that change happens constantly, and that environments/situations are therefore difficult to predict. In the example below, Janine and her therapist discuss the experience of carrying out her behavioral experiment of initiating social interaction, and some of the concerns and barriers for the task: What got in the way? For one thing, I realized I didn’t have their phone numbers any more. THERAPIST: As you were checking, how were you feeling—emotionally? PATIENT: I felt a little relieved, because I wouldn’t have to call them. THERAPIST: Anything else? PATIENT: Well, I was thinking that even if I did call them they wouldn’t want to go to the movies with me. So, I felt relieved initially that I wouldn’t have to do it … but, then I felt anxious because I thought you would be angry with me. THERAPIST: I am pleased you told me about that—it sounds like there were two concerns there: What would actually happen with making social contact and how our discussion would turn out—is that right? THERAPIST: PATIENT

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 317

Homework Assignments and Self-Monitoring

317

Yes. Well … please allow me to convey that I do not feel angry or disappointed in any way. In fact, my perspective of these things is that they are a way to generate and explore new ideas. Sometimes practical things get in the way, or maybe the activity itself was too difficult. Knowing this is helpful because we get a better window into your experience … and in learning what works, we often need to find what doesn’t work. PATIENT: OK—that’s reassuring to know. THERAPIST: What did you get from the beginning steps of the experiment? PATIENT: I guess that I adopted my usual avoidance strategy. I could have looked their numbers up or emailed them instead. THERAPIST: Great! That is something we’ve learnt from doing this. What else? PATIENT: That you weren’t angry that I didn’t do it—that surprised me. PATIENT:

THERAPIST:

As illustrated, Janine and her therapist attended to the useful learning from the homework, and the discussion also led to feedback from the patient about the likely response from the therapist. Clearly, if Janine’s therapist had not allowed time for this discussion, then important information for the case conceptualization would have been missed. With this information, Janine’s therapist is better equipped to encourage engagement, to maintain a positive alliance, and to help Janine work with her pervasive beliefs about other people (including her therapist) and the world.

A Focus on Self-Monitoring As a specific between-session therapeutic activity, self-monitoring has received focused attention in research and practice for at least four decades (e.g., Mahoney, Moura, & Wade, 1973). There has been considerable discussion and evaluation regarding the reliability and validity of the information provided by patients through self-monitoring (Ajzen, Timko, & White, 1982; Kazdin, 1974), as well as comparisons of different self-monitoring targets in treatment for depression (e.g., activity vs. mood; see Harmon, Nelson, & Hayes, 1980) and utility in the treatment of anxiety disorders (e.g., Craske & Tsao, 1999) and eating disorders (e.g., Wilson & Vitousek, 1999). There is supportive evidence for the contribution of self-monitoring in psychotherapy for various mental health conditions (e.g., Burke, Wang, & Sevick, 2011), yet where monitoring is used to measure adherence with therapeutic homework, comparisons to objective assessments have led to questions regarding the reliability and validity of resultant “compliance” self-monitoring by patients (e.g., Neimeyer & Feixas, 1990; Taylor, Agras, Schneider, & Allen, 1983). From this point forward, we shift our attention to the role of the therapist and specific therapist behaviors involved in the effective selection, planning, and review of homework assignments. Research suggests that therapist competence in assigning and dealing with homework within the session is essential to patients’ engagement with homework and treatment outcome (Bryant, Simons, & Thase, 1999; DetweilerBedell & Whisman, 2005; Shaw et al., 1999; Weck, Hilling, Schermelleh-Engel, Rudari, & Stangier, 2011).

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 318

318

General Strategies

Understanding Why Patients Engage with Homework If you were asked to take the book you are reading, close it, and attempt to spin the entire volume on a single index finger, similar to the way in which a basketball player spins a ball, you would likely ask the question, Why? It seems that having a reason for a behavior, especially those that require effort, is critical to understanding sustained engagement in that behavior. Theories exist that are predicated upon decades of sound empirical research that attest to the role of beliefs in determining human behavior, and engagement in health behaviors. Attempting to spin a book on your index finger may appeal to those more practiced at spinning objects on their fingers—basketball players, jugglers—but will immediately conflict with others who hold value in the paper versions of practice resources. For example, many colleagues refrain from writing on the pages of their textbooks. They prefer to make their notes elsewhere in order to keep the book in pristine shape, whereas others highlight and write all over the pages, and some fold or tear out pages. Thus, one layer of cognition we need to attend to relates to task-specific cognitions. What does the patient think of the task? Before deciding on the next homework task, the patient should have the opportunity to gain some experiential learning from in-session practice of the task, and to express his or her task-specific thoughts, especially with regard to its relevance, difficulty, and some feedback about how ready and able he or she is to try it. This information can be used in collaboratively designing homework. A further consideration is whether the task seems relevant to the patient’s therapeutic goals and personal values. The patient needs both a short-term and a long-term benefit to the investment of time and energy in therapeutic homework. Behavior theories suggest that situational antecedents are important for triggering the realization that the application of a therapeutic skill is needed. At the same time, intrinsic and environmental reinforcement is needed to generalize and maintain the practice of therapeutic skills. However, what is reinforcing for one person may be punitive for another. Consequently, therapists need to be guided by feedback from the patient about the homework task. This is a fundamental principle of motivational interviewing: There needs to be (from the patient’s perspective) a clear and immediate benefit to the therapeutic “action” that contributes to a long-term goal (Arkowitz, Westra, Miller, & Rollnick, 2008; Dozois, 2010; Rosengren, 2009). A therapeutic activity might only be evaluated as conflicting with a personal value once a patient has tried it and had the opportunity for an in-session experience of the task. Thus, it is important to consider what engaging in the task means to the patient. Many patients will see their performance with therapeutic homework as a marker or gauge of their personal value, or the likely outcome of their therapy. Others will find themselves feeling “controlled” or “told what to do” simply because a plan represents a limited number of options for the extension of therapeutic work through the week (J. S. Beck, 2005; Kazantzis, 2011). Once the patient has articulated the personal meaning of the task, patient and therapist can work together to address any conflicts with personal values, by, for instance, enlisting greater patient input in the design

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 319

Homework Assignments and Self-Monitoring

319

of the task, or by exploring and perhaps modifying the patient’s perception of the conflict. Patients’ coping strategies can also influence their engagement with tasks. A patient with an extreme avoidance pattern is likely to struggle with a homework task that involves experiencing uncomfortable emotions, just as a patient with chronic anger may resent the idea of a task that involves having him or her practicing new ways of responding to triggering situations (C. F. Newman, 2011). Thus, it is important to consider patients’ existing coping strategies when designing tasks. Elizabeth was certain that she “wouldn’t be able to cope” when first introduced to the thought record, and so, together with her therapist, she decided to start with the initial columns of specifying a situation, recording her emotions, and associated unhelpful automatic thoughts, images, dreams, and fantasies. Elizabeth also found it validating to complete a second form that acknowledged her doubts about the task, and her concern about her emotions “spiraling out of control ” because she was focusing on them. The goal in using homework assignments is to empower patients to engage with their emotional experience and to motivate them to try out alternative or refined ways of coping. Without attending to the patient’s personal meaning in this work, there is a risk of triggering and reinforcing his or her negative beliefs. Sigmund felt surprised when he recalled his work as a project manager when attempting an intervention of “evaluating worries.” The activity of focusing on his worries, scrutinizing their likelihood, and identifying them as helpful or unhelpful reminded him of ineffectively addressing the concerns of his team members—he said, “I’m relating this to my team!” Without attending to this memory flashing through his mind, his therapist may have missed an important opportunity to talk about his associated feelings of “tenseness” and being “on edge” when engaging with the cognitive restructuring task. Anna and her therapist discussed a behavioral experiment after some in-session practice with a task. Her therapist initiated some Socratic dialogue to explore Anna’s beliefs about the task, its connection to her personal values, and perceived relevance to therapy goals within the dialogue: So we are talking about opening the door for five people at work this week. How does this fit with your understanding of how to strengthen relationships? PATIENT: I think it’s a simple gesture and it’s definitely a step in the right direction. THERAPIST: What do you think about the task itself—in relation to your personal values? PATIENT: I think I’m generally a courteous and helpful person. Maybe this small gesture will convey that to others too. THERAPIST: What do you predict will happen? PATIENT: People will probably look right through me. THERAPIST: How much do you believe that will happen—on a 0–100% scale? PATIENT: People are not considerate—I am 100% confident that no one will even notice; they’ll just walk on by. THERAPIST: OK, so we have a useful activity on our hands. It is something that reflects your personal value of being courteous and helpful, but it’s also going to help us gauge how others respond to this act of consideration. If we view people in just one way or another, there’s a chance that we miss some exceptions to the rule, or variations among THERAPIST:

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 320

320

General Strategies

people—so this experiment is useful in supporting the collection of “data.” We might find “data” that support your prediction, and some data that don’t. PATIENT: We’re going to see how people respond. THERAPIST: Yes, that’s right! And let’s record how they respond. And how do you feel about proceeding with this task? PATIENT: Interested actually … THERAPIST: I’m interested too; let’s figure out how we are going to record these experiences.

As this example illustrates, we advocate for the use of Socratic dialogue to explore the patient’s associations with the task, how the task connects with his or her assumptions, rules, and personal values regarding (a) self, (b) others and the world including the therapist, (c) the likely outcome of the task (and therapy), (d) distressing emotions, and (e) compatibility and conflict with existing ways of coping. Because imagery is the next best thing to being in situations, it serves as a useful technique for facilitating in-session practice when the immediate environment is not conducive to such exposure (J. S. Beck, 2011; Kazantzis, Arntz, Borkovec, Holmes, & Wade, 2010). After having practiced sensation induction for the treatment of panic through the previous week, Daniel communicated to his therapist that the hyperventilation exercise failed to trigger any fear response as planned. Daniel and his therapist used imagery in the following session to enable him to move into a busy supermarket, cinema theatre, and crowded street to practice his alternative interpretations of any heightened physiology that he may experience, such as “this is my anxiety—and anxiety is normal. It will take me some time to feel entirely comfortable, but if I stay in the situation long enough, I know I will start to enjoy being here. It’s an opportunity to practice my therapy skills!” One way to select homework assignments is to take an existing therapeutic intervention and incorporate it into work with a patient (e.g., monitoring physiology [Clark & Beck, 2010], panic, and worry [Wells, 2009]). Reliance on existing forms for homework may be more useful at the early stages of therapy or when the patient is markedly distressed. For example, Jenny likened having too much choice in therapy to visiting a supermarket with 30 types of mustard while she was rushing to gather the other dinner party items before picking up her children from school. Too much choice can be distressing. In fact, a useful rule of thumb is to consider an inverse relationship between the extent of collaboration, or shared work, in designing homework assignments and the level of patient distress. At the other end of the continuum there is the opportunity to design an intervention from the ground up (to be extended in homework). Behavioral experiments are an excellent example of this form of homework, as therapists and patients have identified thoughts to evaluate and have a process of designing a tailored “empirical test” of the belief through data gathering and/or experimentation with new or adjusted behavior (Bennett-Levy et al., 2004). In summary, consideration should be given to the extent of collaboration in “coauthoring” or designing a therapeutic homework task in the context of each patient’s

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 321

Homework Assignments and Self-Monitoring

321

distress in-session. The therapist should revert to “off-the-shelf” homework when patients are more distressed, and encourage patients to design totally new homework tasks when they are less distressed.

Helping Patients to Plan Their Homework The majority of the therapeutic activities that patients are asked to engage in between sessions involve some amount of self-monitoring. Beyond recording subjective emotions, thoughts, physiology, behaviors, and interactions, there is generally an implicit need to self-monitor in order to know when to use a therapeutic technique. Put simply, most homework assignments demand that patients use their executive functioning abilities. Research on prospective memory and implementation intentions overlap in pointing to the value in having a clear plan in order to reduce the demands (or cognitive load) of the task (Gollwitzer & Sheeran, 2006; McDaniel, Howard, & Butler, 2008). CBT homework assignments often require some prioritization, problem solving of unexpected obstacles, inhibition of other learned responses (or ways of coping), initiating new responses, and shifting, focusing, and dividing attention. Thus, the very least therapists can do is support their patients to arrive at a specific plan that helps them start with the homework activity. Consider environmental prompts such as smartphone reminders, alarms, colorful notes, wearing a watch on a different arm, leaving something unusual out of place, or putting colorful stickers in prominent places. It is then useful to ask the patient to summarize the task and present his or her understanding of how the task contributes to therapy goals. Through collaborative discussion, the therapist takes a questioning approach to decide on when, where, how often, and for how long the homework task should be done. Practitioner surveys have shown that only a small proportion of therapists (25% or less) work with their patients to devise a plan that comprises these components (Kazantzis & Ronan, 2006; Kazantzis & Deane, 1999). This process is initially led by the therapist, but requires the patient to provide the information, as they are the expert on their lives. After a few sessions, the patient can usually take the lead and initiate a specific plan with little contribution from the therapist. Initially, however, arriving at a specific plan may require about 10 minutes of the concluding part of the therapy session. We advocate engaging patients to decide on when, where, how often, and for how long the homework assignment will be done. The same homework can be made more manageable by reducing its frequency. A more structured and therapist-led process is needed when the patient is distressed. However, the goal is to create the conditions under which the patient can put together his or her own plan, especially as the patient takes more of the lead (and as the patient guides more of the collaborative work in CBT; see Kazantzis, Arntz, et al., 2010). Devising a clear plan for the homework with patients often raises likely obstacles and potential environmental barriers, so it is helpful to ask about these specifically. Additionally, therapists are wise to summarize the homework and ask patients to provide feedback about the plan through ratings of their perceived confidence,

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 322

322

General Strategies

readiness, and importance (e.g., using subjective visual analogue scales ranging from 0 = none, to 50 = moderate, to 100 = high). Many therapists are surprised that their patients are less than 70% confident about the homework, even though there has been in-session practice, and the patient has decided on the specific plan for the task. It is vital for therapists to be able to detect and effectively manage early patient reluctance toward tasks, as this has been found to be a strong predictor of engagement and treatment outcome (Westra, 2011). The whole is greater than the sum of its parts, and so it is usually helpful to reconsider some aspect of the homework, such as prioritizing one part by reducing it into manageable chunks. When patients rate very low levels of confidence, questions that may be helpful include: • “What would make you more confident about the task?” • “What would need to happen in order for the score to increase from X to 100?” • “How could the task be changed to increase your confidence? Could we draw on the help of others to aid you?” • “What have you learned from previous tasks?” • “What are the steps you need to take to feel confident to start?” A written summary of the homework that patients can take home with them has been demonstrated to increase rates of engagement significantly (Cox, Tisdelle, & Culbert, 1988), and a variety of summary forms have been recommended in the professional literature to aid with therapeutic homework (e.g., Kazantzis, Dattilio, & MacEwan, 2005).

Building Hope and Resilience through Reviewing Homework If patients are asked to engage in homework assignments, then it follows suit to ask them about their level of engagement and how they felt about the assignment at the next session. Some therapists think, “I should only ask patients about homework if they have done it,” and miss opportunities to gain feedback from patients who have not engaged with the assignment. Therapists want to acknowledge the work the patient has done, as well as what may have inhibited him or her from completing the assignment. The review of homework during each session also conveys to patients that the ultimate benefit of therapy will be dependent on their degree of practice between sessions. If therapy is truly about learning, then the homework review can be focused on what was gained, no matter how small the steps in going forward. Structuring sessions and pacing them appropriately depends on an effective review of therapeutic homework assignments. It is useful to review the practical obstacles to the task, as distinct from thoughts and emotions generated in completing the task. For example, Sasha found substantial relief from practicing strategic withdrawal and arousal reduction in interpersonal interactions where she was arguing and shouting, yet this new strategy was associated with significant guilt and was accompanied by the thought: “All these years that I have argued with people, and been aggressive … I’ve

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 323

Homework Assignments and Self-Monitoring

323

hurt so many because of my selfishness … How could I have given myself permission to treat people with such disrespect?” Without asking about her emotions and thoughts when engaging in this task, Sasha’s therapist may have missed vital information for the session agenda and case conceptualization. Patients also often minimize their accomplishments, or perceive progress as evidence that their overall functioning is substandard, so cognitions activated in the homework are critical to be assessed as part of the review. The input offered to patients about their homework represents important feedback about their progress in therapy. For this reason, it is useful to titrate verbal praise and encouragement carefully so that it is clearly connected to the work done (i.e., concrete evidence to the patient that the praise is accurate), and that it is honest, sincere, and appropriate to what the patient has achieved. It is important to communicate to patients that the skill being learned may be developed or adapted further, which builds hope and optimism. Sharing stories of other patients who have been at a similar stage of skill acquisition may also serve as a means of encouraging patients. Understanding the patient’s worldview through accurate empathy and understanding is central to effective homework review. Acknowledging the difficulties in the task (both emotional and achievement-related) and the importance of persisting despite these challenges communicates to the patient that the therapist believes in his or her abilities to bolster resilience. Therapists should attend to whether their patients expect them to be disappointed for work not done, or not completed “properly” or “adequately,” and take time to discuss their feelings of guilt and shame. Given that homework is therapeutic work, then it makes sense that the process of engagement in homework is therapeutic on multiple levels (i.e., through the direct benefits of the therapeutic task, the patient’s increased appreciation and awareness of his or her potential, and his or her discussion with a therapist who is accepting and encouraging). It should be borne in mind that the conclusions patients reach from their work in engaging with homework directly supports their belief about the likely outcome of their therapy.

Conclusion No guidance on the use of therapeutic homework in CBT would be complete without a homework assignment. Take a few moments to reflect on the ideas shared in this chapter, and ask yourself the following questions: What ideas can I take with me from this chapter, and how can I implement them effectively in my future work with patients? Consider what steps you would need to take to implement this plan effectively, and think about how what you have selected links to your goals as a developing professional. If you were talking to a colleague, what advice would you give him or her about incorporating therapeutic homework into his or her sessions after reading this chapter? Imagine yourself a year from now, if you were sitting down and reflecting on your therapeutic practice; what aspects regarding the use of homework would you like to have developed?

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 324

324

General Strategies

Acknowledgements The authors wish to acknowledge the cognitive therapy teachings, guidance, and mentorship of Aaron T. Beck (FD and NK), as well as Christine Padesky, Judith Beck, Kathleen Mooney, and Cory Newman (NK). Special appreciation is extended to our colleague and valued collaborator Keith Dobson. The authors wish to extend gratitude to the current trainees and alumni of the Cognitive Behavior Therapy Research Unit at La Trobe University for their ideas and collaboration, and to those colleagues from the international CBT community who have shared in discussions and assisted in developing the ideas represented in this chapter (in alphabetical order): Tom Borkovec, David A. Clark, Frank Deane, Art Freeman, Stefan Hofmann, Ken Laidlaw, Robert Neimeyer, Nancy Pachana, Ron Rapee, Kevin Ronan, Gregoris Simos, Mehmet Sungur, Eleanor Wertheim, and Wong Chee-wing. We also extend sincere thanks to Judith Stern for feedback on a previous draft of this chapter, and to all those patients who have worked with us in therapy, since they are our best teachers about what is ultimately useful when enhancing the use of homework in therapy.

References Addis, M. E., & Jacobson, N. S. (2000). A closer look at the treatment rationale and homework compliance in cognitive-behavioral therapy for depression. Cognitive Therapy and Research, 24, 313–326. doi:10.1023/A:1005563304265 Ajzen, I., Timko, C., & White, J. B. (1982). Self-monitoring and the attitude-behavior relation. Journal of Personality & Social Psychology, 42, 426–435. Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (2008). Motivational interviewing in the treatment of psychological problems. New York, NY: Guilford Press. Barlow, D. H., Esler, J. L., & Vitali, A. E. (1998). Psychosocial treatments for panic disorders, phobias and generalized anxiety disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (pp. 288–318). New York, NY: Oxford University Press. Beck, A. T. (1976). Cognitive therapy and the emotional disorder. New York, NY: New American Library/Meridian. Beck, A. T., & Dozois, D. J. A. (2011). Cognitive therapy: Current status and future directions. Annual Review of Medicine, 62, 397–409. doi:10.1146/annurev-med05220-100032 Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press. Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York, NY: Guilford Press. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond. New York, NY: Guilford Press. Beck, J. S., & Tompkins, M. (2007). Cognitive therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 51–63). New York, NY: Springer. Bennett-Levy, J., Butler, G., Fenell, M., Hackmann, A., Meuller, M., & Westbrook, D. (2004). Oxford guide to behavioural experiments in cognitive therapy. Oxford, England: Oxford University Press.

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 325

Homework Assignments and Self-Monitoring

325

Beutler, L. E., Malik, M., Talebi, H., Fleming, J., & Moleiro, C. (2004). Use of psychological tests/instruments for treatment planning. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment (pp. 101–132). Mahwah, NJ: Lawrence Erlbaum Associates. Brothers, B. M., Yang, H. C., Strunk, D. R., & Anderson B. L. (2011). Cancer patients with major depressive disorder: Testing a biobehavioral/cognitive behavior intervention. Journal of Consulting and Clinical Psychology, 79, 253–260. doi:10.1037/a0022566 Burke, L. E., Wang, J., & Sevick, M. A. (2011). Self-monitoring in weight loss: A systematic review of the literature. Journal of the American Dietetic Association, 111, 92–102. doi:10.1016/j.jada.2010.10.008 Burns, D. D., & Spangler, D. L. (2000). 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, 46–56. doi:10.1037//0022-006X.68.1.46 Bryant, M. J., Simons, A. D., & Thase, M. E. (1999). Therapist skill and patient variables in homework compliance: Controlling an uncontrolled variable in cognitive therapy outcome research. Cognitive Therapy and Research, 23, 381–399. Carroll, K. M., Nich, C., & Ball, A. (2005). Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. Journal of Consulting and Clinical Psychology, 73, 749–755. doi:10.1037/0022-006X.73.4.749. Cash, T. F., & Hrabosky, J. I. (2003). The effects of psychoeducation and self-monitoring in a cognitive-behavioral program for body-image improvement. Eating Disorders, 11, 255–270. doi:10.1080/10640260390218657 Clark, D. A., & Beck, A. T. (2010). Cognitive therapy of anxiety disorders: Science and practice. New York, NY: Guilford Press. Coon, D. W., & Thompson, L. W. (2003). The relationship between homework compliance and treatment outcomes among older adult outpatients with mildto-moderate depression. American Journal of Geriatric Psychiatry, 11, 53–61. doi:10.1176/appi.ajgp.11.1.53 Cowan, M. J., Freedland, K. E., Burg, M. M., Saab, P. G., Youngblood, M. E., Cornell, C. E., … Czajkowski, S. M. (2008). Predictors of treatment response for depression and inadequate social support—The ENRICHD randomized clinical trial. Psychotherapy and Psychosomatics, 77 , 27–37. doi:10.1159/000110057 Cox, D. J., Tisdelle, D. A., & Culbert, J. P. (1988). Increasing adherence to behavioral homework assignments. Journal of Behavioral Therapy, 11, 519–522. Craske, M. G., & Tsao, J. C. (1999). Self-monitoring with panic and anxiety disorders. Psychological Assessment, 11, 466–479. Dattilio, F. M., & Hanna, M. A. (2012). Collaboration in cognitive-behavioral therapy. Journal of Clinical Psychology, 68, 146–158. doi:10.1002/jclp.21831 Deane, F. P., Glaser, N. M., Oades, L. G., & Kazantzis, N. (2005). Psychologists’ use of homework assignments with clients who have schizophrenia. Clinical Psychologist, 9, 24–30. doi:10.1080/13284200500048141 Detweiler-Bedell, J. B., & Whisman, M. A. (2005). A lesson in assigning homework: Therapist, client, and task characteristics in cognitive therapy for depression. Professional Psychology: Research and Practice, 36, 219–223. Dimeff, L. A., & Marlatt, G. A. (1995). Relapse prevention. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (pp. 176–794). Boston, MA: Allyn & Bacon.

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 326

326

General Strategies Dobson, K. S. (2010). Handbook of cognitive behavioural therapies (3rd ed.). New York, NY: Guilford Press. Dozois, D. J. A. (2010). Understanding and enhancing the effects of homework in cognitive behavioral therapy. Clinical Psychology: Science and Practice, 17 , 157–161. doi:10.1111/j.1468-2850.2010.01205.x Dunn, H., Morrison, A. P., & Bentall, R. P. (2002). Patients’ experiences of homework tasks in cognitive behavioural therapy for psychosis: A qualitative analysis. Clinical Psychology and Psychotherapy, 9, 361–369. doi:10.1002/cpp.344 Ellison, J., & Greenberg, L. (2007). Emotion-focused experiential therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice and prevention (pp. 65–83). New York, NY: Springer. Fehm, L., & Kazantzis, N. (2004). Attitudes and use of homework assignments in therapy: A survey of German psychotherapists. Clinical Psychology and Psychotherapy, 11, 332–343. doi:10.1002/cpp.419 Fehm, L., & Mrose, J. (2008). Patients’ perspective on homework assignments in cognitive-behavioural therapy. Clinical Psychology and Psychotherapy, 15, 320–328. doi:10.1022/cpp.592 Felmingham, K. L., & Bryant, R. A. (2012). Gender differences in the maintenance of response to cognitive behavior therapy for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 80, 196–200. doi:10.1037/a0027156 Garland, A. F., Brookman-Frazee, L., & Chavira, D. A. (2010). Are we doing our homework? Clinical Psychology: Science and Practice, 17 , 162–165. doi:10.1111/j.14682850.2010.01206.x Gloster, A. T., Wittchen, H. U., Einsle, F., Lang, T., Helbig-Lang, S., Fydrich, T., … Arolt, V. (2011). Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT. Journal of Consulting and Clinical Psychology, 79, 406–420. doi:10.1037/a0023584 Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta-analysis of effects. Advances in Experimental Social Psychology, 38, 69–119. doi:10.1016/S0065-2601(06)38002-1 Gonzalez, V. M., Schmitz, J. M., & DeLaune, K. A. (2006). The role of homework in cognitive-behavioral therapy for cocaine dependence. Journal of Consulting and Clinical Psychology, 74, 633–637. doi:10.1037/0022-6X.74.3.633 Harmon, T. M., Nelson, R. O., & Hayes, S. C. (1980). Self-monitoring of mood versus activity by depressed clients. Journal of Consulting and Clinical Psychology, 48, 30–38. Helbig, S., & Fehm, L. (2004). Problems with homework in CBT: Rare exception or rather frequent? Behavioural and Cognitive Psychotherapy, 32, 291–301. doi:10.1017/S1352465804001365 Hughes, A. A., & Kendall, P. C. (2007). Prediction of cognitive behaviour treatment outcome for children with anxiety disorders: Therapeutic relationship and homework compliance. Behavioural and Cognitive Psychotherapy, 35, 487–494. doi:10.1017/S1352465807003761 Kaplan, R. M., & Saccuzzo, D. P. (2008). Psychological testing: Principles, applications, and issues (7th ed.). Belmont, CA: Wadsworth. Kazantzis, N. (2000). Power to detect homework effects in psychotherapy outcome research. Journal of Consulting and Clinical Psychology, 68, 166–170. doi:10.1037//0022-006X.68.1.166

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 327

Homework Assignments and Self-Monitoring

327

Kazantzis, N. (2011). On becoming a therapist: Helping clients try “My own therapy”. In H. G. Rosenthal (Ed.), Favorite counselling and therapy homework assignments (pp. 205–208). New York, NY: Routledge. Kazantzis, N., Arntz, A. R., Borkovec, T., Holmes, E. A., & Wade, T. (2010). Unresolved issues regarding homework assignments in cognitive and behavioural therapies: An expert panel discussion at AACBT. Behaviour Change, 27 , 119–129. doi:10.1375/bech.27.3.119 Kazantzis, N., Beck, J. S., Dattilio, F. M., Dobson, K. S., & Rapee, R. (in press). Collaborative empiricism as the central therapeutic relationship element in cognitive behavior therapy: An expert panel discussion at the 7th International Congress of Cognitive Psychotherapy. International Journal of Cognitive Therapy. Kazantzis, N., Busch, R., Ronan, K. R., & Merrick, P. L. (2007). Using homework assignments in psychotherapy: Differences by theoretical orientation and professional training? Behavioural and Cognitive Psychotherapy, 35, 121–128. doi:10.1017/S1352465806003328 Kazantzis, N., & Daniel, J. (2009). Homework assignments. In G. Simos (Ed.), Cognitive behaviour therapy: A guide for the practicing clinician (2nd ed., Vol. 2, pp. 165–186). New York, NY: Routledge. Kazantzis, N., Dattilio, F. M., & MacEwan, J. (2005). In pursuit of homework adherence in behaviour and cognitive behaviour therapy: Comment on Malouff and Schutte (2004). Behavior Therapist, 28, 179–183. Kazantzis, N., & Deane, F. P. (1999). Psychologists’ use of homework assignments in clinical practice. Professional Psychology: Research and Practice, 30, 581–585. doi:10.1037/0735-7028.30.6.581 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 , 189–202. doi:10.1093/clipsy.7.2.189 Kazantzis, N., Lampropoulos, G. L., & Deane, F. P. (2005b). A national survey of practicing psychologists’ use and attitudes towards homework in psychotherapy. Journal of Consulting and Clinical Psychology, 73, 742–748. doi:10.1037/0022006X.73.4.742 Kazantzis, N., Petrik, A. M., & Cummins, A. (2012). Homework assignments. Accepted entry in Common Language for Psychotherapy Procedures. www.commonlanguagepsychotherapy.org Kazantzis, N., & Ronan, K. R. (2006). Can between-session (homework) activities be considered a common factor in psychotherapy? Journal of Psychotherapy Integration, 16, 115–127. doi:10.1037/1053-0479.16.2.115 Kazantzis, N., Ronan, K. R., & Deane, F. P. (2001). Concluding causation from correlation: Comment on Burns and Spangler (2000). Journal of Consulting and Clinical Psychology, 69, 1079–1083. doi:10.1037//0022-006X.69.6.1079 Kazantzis, N., Whittington, C., & Dattilio, F. (2010b). Meta-analysis of homework effects in cognitive and behavioural therapy: A replication and extension. Clinical Psychology: Science and Practice, 17 , 144–156. doi:10.1111/j.1468-2850.2010.01204.x Kazdin, A. E. (1974). Reactive self-monitoring: The effects of response desirability, goal setting, and feedback. Journal of Consulting and Clinical Psychology, 42, 704–716. Lambert, M., Harmon, S., & Slade, K. (2007). Directions for research on homework. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research practice and prevention (pp. 407–423). New York, NY: Springer. Leahy, R. L. (2001). Overcoming resistance in cognitive therapy. New York, NY: Guilford.

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 328

328

General Strategies Ledley, D., & Huppert, J. (2007). Behavior therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice and prevention (pp. 19–34). New York, NY: Springer. Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Mahoney, M. J., Moura, N. G., & Wade, T. C. (1973). Relative efficacy of self-reward, selfpunishment, and self-monitoring techniques for weight loss. Journal of Consulting and Clinical Psychology, 40, 404–407. Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy Research, 34, 429–438. doi:10.1007/s10608-0109297-z McDaniel, M. A., Howard, D. C., & Butler, K. M. (2008). Implementation intentions facilitate prospective memory under high attention demands. Memory & Cognition, 36, 716–724. doi:10.3758/MC.36.4.716 McGraw, K. O. (1991). Problems with the BESD: A comment on Rosenthal’s “How are we doing in soft psychology?” American Psychologist, 46, 1084–1086. McMillan, W., Stice, E., & Rohde, P. (2011). High and low-level dissonance-based eating disorder prevention programs with young women with body image concerns: An experimental trial. Journal of Consulting and Clinical Psychology, 79, 129–134. doi:10.1037/a0022143 Murphy, H., & Lahtinen, M. (2011). Understanding the impact of meditative homework on depression in the context of mindfulness based cognitive therapy (MBCT): An interpretative phenomenological analysis. European Psychologist, 26, 659. doi:10.1016/S0924-9338(11)72365-3 Neimeyer, R. A., & Feixas, G. (1990). The role of homework and skill acquisition in the outcome of group cognitive therapy for depression. Behavior Therapy, 21, 281–292. Neimeyer, R. A., Kazantzis, N., Kassler, D. M., Baker, K. D., & Fletcher, R. (2008). Group cognitive behavioral therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition. Cognitive Behaviour Therapy, 37 , 199–215. doi:10.1080/16506070801981240 Neimeyer, R. A., & Winter, D. (2007). Personal construct therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 151–171). New York, NY: Springer. Newman, C. F. (2011). When clients’ morbid avoidance and chronic anger impede their response to cognitive-behavioral therapy for depression. Cognitive and Behavioral Practice, 18, 350–361. doi:10.1016/j.cbpra.2010.07.004 Newman, M. G., Castonguay, L. G., Borkovec, T. D., Fisher, A. J., Boswell, J. F., Szkodny, L. E., & Nordberg, S. S. (2011). A randomized controlled trial of cognitivebehavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies. Journal of Consulting and Clinical Psychology, 79, 171–181. doi:10.1037/a0022489 Persons, J. B., Davidson, J., & Tompkins, M. A. (2000). Essential components of cognitivebehavior therapy for depression. Washington, DC: American Psychological Association. Resick, P. A., Williams, L. F., Suvak, M. K., Monson, C. M., & Gradus, J. L. (2012). Long-term outcomes of cognitive-behavioral treatments for posttraumatic stress disorder among female rape survivors. Journal of Consulting and Clinical Psychology, 80, 201–210. doi:10.1037/a0026602

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 329

Homework Assignments and Self-Monitoring

329

Robbins, M., Szapocznik, J., & Pe’rez, G. (2007). Brief strategic family therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 133–149). New York, NY: Springer. Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. New York, NY: Guilford Press. Rosenthal, R. (1991). Meta-analysis: A review. Psychosomatic Medicine, 53, 247–271. Schmidt, N. B., & Woolaway-Bickel, K. (2000). The effect of treatment compliance on outcome in cognitive-behavioral therapy for panic disorder: Quantity versus quality. Journal of Consulting and Clinical Psychology, 68, 1–18. doi:10.1037/0022006X.68.1.13 Shaw, B. F., Elkin, I., Yamaguchi, J., Olmsted, M., Vallis, T. M., Dobson, K. S., … Imber, S. D. (1999). Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression. Journal of Consulting and Clinical Psychology, 67 , 837–846. Simpson, H. B., Maher, M. J., Page, J. R., Gibbons, C. J., Franklin, M. E., & Foa, E. B. (2010). Development of a patient adherence scale for exposure and response prevention therapy. Behavior Therapy, 41, 30–37. doi:10.1016/j.beth.2008.12.002 Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E. B., & Franklin, M. (2011). Patient adherence predicts outcome from cognitive behavioral therapy in obsessivecompulsive disorder. Journal of Consulting and Clinical Psychology, 79, 247–252. doi:10.1037/a0022659 Startup, M., & Edmonds, J. (1994). Compliance with homework assignments in cognitive-behavioral psychotherapy for depression: Relation to outcome and methods of enhancement. Cognitive Therapy and Research, 18, 567–579. doi:10.1007BF02355669 Stricker, G. (2007). Psychodynamic therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research practice and prevention (pp. 101–111). New York, NY: Springer. Taylor, L. B., Agras, W. S., Schneider, J. A., & Allen, R. A. (1983). Adherence to instructions to practice relaxation exercises. Journal of Consulting and Clinical Psychology, 51, 952–953. Thase, M. E., & Callan, J. A. (2006). The role of homework in cognitive behavior therapy of depression. Journal of Psychotherapy Integration, 16, 162–177. doi:10.1037/1053-0479.16.2.162 Tolin, D. F., Frost, R. O., & Steketee, G. (2007). An open trial of cognitive-behavioral therapy for compulsive hoarding. Behaviour Research and Therapy, 45, 1461–1470. doi:10.1016/j.brat.2007.01.001 Twohig, M., Pierson, H., & Hayes, S. (2007). Acceptance and commitment therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 113–132). New York, NY: Springer. Urbina, S. (2004). Essential of psychological testing. Hoboken, NJ: John Wiley & Sons. Vincelli, F., Anolli, L., Bouchard, S., Wiederhold, B. K., Zurloni, V., & Riva, G. (2003). Experiential cognitive therapy in the treatment of panic disorders with agoraphobia: A controlled study. CyberPsychology & Behavior, 6, 321–328. doi:10.1089/109493103322011632 Weck, F., Hilling, C., Schermelleh-Engel, K., Rudari, V., & Stangier, U. (2011). Reliability of adherence and competence assessment in cognitive behavioral therapy: Influence of clinical experience. Journal of Nervous and Mental Disease, 199, 276–279. doi:10.1097/NMD.0b013e3182124617

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 330

330

General Strategies Wells, A. (2009). Metacognitive therapy for anxiety and depression. New York, NY: Guilford Press. Westra, H. A. (2011). Comparing the predictive capacity of observed in-session resistance to self-reported motivation in cognitive behavioral therapy. Behaviour Research and Therapy, 49, 106–113. doi:10.1016/j.brat.2010.11.007 Westra, H. A., & Dozois, D. J. A. (2006). Preparing clients for cognitive behavioral therapy: A randomized pilot study of motivational interviewing for anxiety. Cognitive Therapy and Research, 30, 481–498. doi:10.1007/s10608-006-9016-y Westra, H. A., Dozois, D. J. A., & Marcus, M. (2007). Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety. Journal of Consulting and Clinical Psychology, 75, 363–373. doi:10.1037/0022-006X.75.3.363 Wetherell, J. L., Gatz, M., & Craske, M. G. (2003). Treatment of generalized anxiety disorder in older adults. Journal of Consulting and Clinical Psychology, 71, 31–40. doi:10.1037/0022-006X.71.1.31 Wilson, G. T., & Vitousek, K. M. (1999). Self-monitoring in the assessment of eating disorders. Psychological Assessment, 11, 480–489. Witkiewitz, K., & Bowen, S. (2010). Depression, craving and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78, 362–374. doi:10.1037/a0019172 Witty, M. C. (2007). Client-centered therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research practice and prevention (pp. 35–50). New York, NY: Springer. Woods, C. M., Chambless, D. L., & Steketee, G. (2002). Homework compliance and behavior therapy outcome for panic with agoraphobia and obsessive compulsive disorder. Cognitive Behaviour Therapy, 31, 88–95. doi:10.1080/16506070252959526 Young, J., & Mufson, L. (2007). Interpersonal psychotherapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 85–100). New York, NY: Springer. Zettle, R. D., & Hayes, S. C. (1987). Component and process analysis of cognitive therapy. Psychological Reports, 61, 939–953.

Further Reading Beck, A. T. (1964). Thinking and depression. II. Theory and therapy. Archives of General Psychiatry, 10, 561–571. Leahy, R. L. (2008). The therapeutic relationship in cognitive-behavioral therapy. Behavioral and Cognitive Psychotherapy, 36, 769–777. doi:10.1017/S1352465808004852

PC4-Galliard c14.tex V1 - 05/17/2013 4:05 P.M. Page 331

Please note that the abstract and keywords will not be included in the printed book, but are required for the online presentation of this book which will be published on Wiley’s own online publishing platform. If the abstract and keywords are not present below, please take this opportunity to add them now. The abstract should be a short paragraph upto 200 words in length and keywords between 5 to 10 words.

Abstract: This chapter outlines the evidence base for therapeutic homework assignments in cognitive behavioral therapy and provides a guide for the implementation of that evidence with rich clinical examples. Self-monitoring, a central part of many applications of cognitive behavioral therapy for different clinical disorders and populations, is used throughout the chapter as a basis for illustrating the effective use of therapeutic homework. The chapter begins with a practitioner-friendly review of the various avenues of research, seeking to understand the role of therapeutic homework in cognitive behavioral therapy, and then incorporates some reflection on the theorized determinants of engagement in homework. The main portion of the chapter, however, is reserved for clinical examples and guidance for practice. The chapter also highlights clinical tips and, at various points, encourages the reader to reflect on his or her own beliefs and practices regarding the role of therapeutic homework in cognitive behavioral therapy. Copyright © 2013 John Wiley & Sons, Ltd.

Keywords: cognitive therapy, cognitive behavioral therapy, homework, homework assignments, self-monitoring, therapist competence