Homework in psychotherapy is sometimes assigned to patients as part of their treatment. In this context, homework assignments are introduced to practice skills taught in therapy, encourage patients to apply the skills they learned in therapy to real life situations, and to improve on specific problems encountered in treatment.Hundt, N. E., Mignogna, J., Underhill, C., & Cully, J. A. (2013). The relationship between use of CBT skills and depression treatment outcome: A theoretical and methodological review of the literature. Behavior Therapy, 44(1), 12–26. For example, a patient with deficits in social skills may learn and rehearse proper social skills in one treatment session, then be asked to complete homework assignments before the next session that apply those newly learned skills (e.g., going to a social engagement or greeting five people each day).Falloon, I. R., Lindley, P., McDonald, R., & Marks, I. M. (1977). Social skills training of out-patient groups. A controlled study of rehearsal and homework. The British Journal of Psychiatry, 131(6), 599–609.
Homework is most often used in cognitive behavioral therapy (CBT) for the treatment of mood and anxiety disorders, although other theoretical frameworks may also incorporate homework.Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta‐analysis. Clinical Psychology: Science and Practice, 7(2), 189–202.Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., ... & Marlatt, A. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295–305. Some of the types of homework used in CBT include thought records and behavioral experiments.Bennett-Levy, J. (2003). Mechanisms of change in cognitive therapy: The case of automatic thought records and behavioural experiments. Behavioural and Cognitive Psychotherapy, 31(03), 261–277. Patients using thought records are instructed to write down negative cognitions on the thought record form and weigh the evidence both for and against the negative thoughts, with the goal being to come up with new, balanced thoughts in the process. Behavioral experiments are used as homework to help patients test out thoughts and beliefs directly. Studies have shown that homework completion and accuracy predict favorable outcomes in psychotherapy and may help patients stay in remission.Burns, D. D., & Auerbach, A. H. (1992). Does homework compliance enhance recovery from depression? Psychiatric Annals.Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta‐analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17(2), 144–156. However, some therapists are concerned that assigning homework makes therapy too formal and reduces the impact of the individual sessions.Kazantzis, N., Lampropoulos, G. K., & Deane, F. P. (2005). A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. Journal of Consulting and Clinical Psychology, 73(4), 742.
Approaches
Most of the literature published on homework in psychotherapy to date focuses on homework use during CBT, which involves changing patients' thoughts and behaviors to reduce the symptoms of the mental disorders from which they are suffering.Blagys, M. D., & Hilsenroth, M. J. (2002). Distinctive activities of cognitive–behavioral therapy: A review of the comparative psychotherapy process literature. Clinical Psychology Review, 22(5), 671–706. A variety of homework assignments exist in CBT.Thase, M. E., & Callan, J. A. (2006). The role of homework in cognitive behavior therapy of depression. Journal of Psychotherapy Integration, 16(2), 162. These tasks can range from scheduling a daily exercise routine to practicing progressive muscle relaxation five times a day to monitoring and recording one's negative automatic thoughts throughout the day. In practice, these homework assignments are meant to help patients lift their mood, practice and master skills they developed in therapy, and progressively improve between treatment sessions. Research has found that homework compliance positively predicts successful outcomes in therapy, and therapists are now looking for better ways to implement homework, so that more individuals may receive its benefits.
CBT is not the only type of therapy to incorporate homework. Although each therapist makes his or her own choices regarding homework assignments, some of the other therapies that may assign homework include exposure therapy, psychodynamic therapy, and problem solving therapy.Malouff, J. M., Thorsteinsson, E. B., & Schutte, N. S. (2007). The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clinical Psychology Review, 27(1), 46–57.Al-Kubaisy, T., Marks, I. M., Logsdail, S., Marks, M. P., Lovell, K., Sungur, M., & Araya, R. (1992). Role of exposure homework in phobia reduction: A controlled study. Behavior Therapy, 23(4), 599–621. Homework can also be assigned even if therapists are not physically present with the patients being treated. Such cases include therapy delivered over the phone, over video, or over the Internet.Carlbring, P., Bohman, S., Brunt, S., Buhrman, M., Westling, B. E., Ekselius, L., & Andersson, G. (2006). Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls. The American Journal of Psychiatry, 162(12).Titov, N., Andrews, G., Davies, M., McIntyre, K., Robinson, E., & Solley, K. (2010). Internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance. PLoS ONE, 5(6), e10939. Treatment of some disorders, such as major depression, may also be done without therapists at all.Vernmark, K., Lenndin, J., Bjärehed, J., Carlsson, M., Karlsson, J., Öberg, J., ... & Andersson, G. (2010). Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression. Behaviour Research and Therapy, 48(5), 368–376. Although the efficacy of this self-help-like treatment is still under scrutiny, preliminary data suggest that completion of homework is one factor predicting positive treatment outcomes for patients who receive treatment over the Internet.de Graaf, L. E., Huibers, M. J., Riper, H., Gerhards, S. A., & Arntz, A. (2009). Use and acceptability of unsupported online computerized cognitive behavioral therapy for depression and associations with clinical outcome. Journal of Affective Disorders, 116(3), 227–231.
Thought records Thought records (or thought diaries) are among the most commonly used cognitive assignments in CBT.Greenberger, D., & Padesky, C. A. (1995). Mind over Mood: Change How You feel by Changing the Way You Think. Guilford Press. They allow patients in various situations to closely examine "hot thoughts" and cognitive distortions and, after having done so, arrive at a newly synthesized alternative thought that more closely fits the situation. Many thought records accomplish this task by having patients list out in order: the situation they are in; the emotions they are feeling and with what intensity those emotions are felt; what thoughts they are having and what the "hot thought" is; evidence for the hot thought; evidence against the "hot thought"; balanced alternative thoughts; and the emotions they feel after having completed the thought record and the intensity of those emotions.
Example
Jane has social anxiety disorder and was just told at work that she would be giving a presentation in front of an audience of 200 people the following week. This produces a large amount of anxiety for Jane, and she starts filling out a thought record to try to calm herself down. To begin, she fills in the column about the situation she is in with: "I was told that I am going to give a speech in front of a large audience next week." In the next column, Jane writes what emotions she is feeling and with what intensity she is feeling them: "Anxious – 100. Afraid – 90. Sad – 40." She then starts identifying some thoughts that immediately ran through her head when she heard that she would be giving the presentation: "Oh no, I'm going to mess up and choke. Everyone will laugh at me. My boss will fire me. I will never be able to hold a job at this rate. I'm worthless and a failure." Jane identifies "I'm worthless and a failure" as the hot thought, the thought that invokes the greatest amount of negative emotion in her situation.
After that, Jane starts writing in the next column the pieces of evidence that support the hot thought: "I've done terribly on presentations in the past. I remember one time in high school when I had to give a speech in front of my class and I ended up crying in front of everyone instead. I got a C on that speech and barely scraped by in the class. My high school friends and I don't talk as much anymore. They must be starting to get sick of me too. My co-workers don't try to talk to me either." Jane jots down in the next column pieces of evidence against her hot thought: "I think my boss might have meant well when he gave me this presentation assignment. I did one of these presentations on a smaller scale last week and I think I did just fine. Almost everyone who was there even came up to me and told me so afterwards. I think that those audience members do care about me and would be willing to support me if I asked. Also, I'm filling out this thought record just like my therapist told me to. I think that's what she would have wanted from me."
In the next column, Jane writes down her alternative thought: "The presentation ahead may be scary and making me feel anxious, but I think I can handle it as long as I know that there are people who support me." After that, Jane writes the emotions she is now feeling and their intensities: "Anxious – 50. Afraid – 40. Sad – 10. Relieved – 50."
Efficacy
Both the quality and quantity of thought records completed during therapy have been found to be predictive of treatment outcomes for patients with depression and/or an anxiety disorder.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 and Research, 34(5), 429–438. Furthermore, Rees, McEvoy, & Nathan (2005) found that accuracy ratings of patients' thought records mid-treatment was positively correlated with post-treatment outcomes, and that doing homework in CBT was overall preferable to not doing homework in CBT.Rees, C. S., McEvoy, P., & Nathan, P. R. (2005). Relationship between homework completion and outcome in cognitive behaviour therapy. Cognitive Behaviour Therapy, 34(4), 242–247. Completing thought records accurately may also be indicative of overall skill gain in treatment; Neimeyer and Feixas (1990) found that patients with depression who completed thought records accurately were less likely to relapse six months after treatment termination.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(3), 281–292. The researchers hypothesized that this was because the patients who completed thought records accurately had acquired the skills taught in CBT, and that these skills served as valuable coping strategies when the patients were faced with future stressors and needed to act as their own therapists.
Behavioral experiments
Behavioral experiments are collaborative endeavors in which therapists and patients work together to identify a potentially negative or harmful belief, then to either confirm or disprove it by designing an experiment that tests the belief. Like thought records, they are most often used in CBT.
Example