homework engagement therapy

Sending Homework to Clients in Therapy: The Easy Way

Successful therapy relies on using assignments outside of sessions to reinforce learning and practice newly acquired skills in real-world settings (Mausbach et al., 2010).

Up to 50% of clients don’t adhere to homework compliance, often leading to failure in CBT and other therapies (Tang & Kreindler, 2017).

In this article, we explore how to use technology to create homework, send it out, and track its completion to ensure compliance.

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This Article Contains:

Is homework in therapy important, how to send homework to clients easily, homework in quenza: 5 examples of assignments, 5 counseling homework ideas and worksheets, using care pathways & quenza’s pathway builder, a take-home message.

Cognitive-Behavioral Therapy has “been shown to be as effective as medications in the treatment of a number of psychiatric illnesses” (Tang & Kreindler, 2017, p. 1).

Homework is a vital component of CBT, typically involving completing a structured and focused activity between sessions.

Practicing what was learned in therapy helps clients deal with specific symptoms and learn how to generalize them in real-life settings (Mausbach et al., 2010).

CBT practitioners use homework to help their clients, and it might include symptom logs, self-reflective journals , and specific tools for working on obsessions and compulsions. Such tasks, performed outside therapy sessions, can be divided into three types (Tang & Kreindler, 2017):

Psychoeducation Reading materials are incredibly important early on in therapy to educate clients regarding their symptoms, possible causes, and potential treatments.
Self-assessment Monitoring their moods and completing thought records can help clients recognize associations between their feelings, thoughts, and behaviors.
Modality specific Therapists may assign homework that is specific and appropriate to the problem the client is presenting. For example, a practitioner may use images of spiders for someone with arachnophobia.

Therapists strategically create homework to lessen patients’ psychopathology and encourage clients to practice skills learned during therapy sessions, but non-adherence (between 20% and 50%) remains one of the most cited reasons for CBT failure (Tang & Kreindler, 2017).

Reasons why clients might fail to complete homework include (Tang & Kreindler, 2017):

Internal factors

Lack of motivation to change what is happening when experiencing negative feelings
Being unable to identify automatic thoughts
Failing to see the importance or relevance of homework
Impatience and the wish to see immediate results

External factors

Effort required to complete pen-and-paper exercises
Inconvenience and amount of time to complete
Failing to understand the purpose of the homework, possibly due to lack of or weak instruction
Difficulties encountered during completion

Homework compliance is associated with short-term and long-term improvement of many disorders and unhealthy behaviors, including anxiety, depression, pathological behaviors, smoking, and drug dependence (Tang & Kreindler, 2017).

Greater homework adherence increases the likelihood of beneficial therapy outcomes (Mausbach et al., 2010).

With that in mind, therapy must find ways to encourage the completion of tasks set for the client. Technology may provide the answer.

The increased availability of internet-connected devices, improved software, and widespread internet access enable portable, practical tools to enhance homework compliance (Tang & Kreindler, 2017).

Clients who complete their homework assignments progress better than those who don’t (Beck, 2011).

Having an ideal platform for therapy makes it easy to send and track clients’ progress through assignments. It must be “user-friendly, accessible, reliable and secure from the perspective of both coach and client” (Ribbers & Waringa, 2015, p. 103).

In dedicated online therapy and coaching software, homework management is straightforward. The therapist creates the homework then forwards it to the client. They receive a notification and complete the work when it suits them. All this is achieved in one system, asynchronously; neither party needs to be online at the same time.

For example, in Quenza , the therapist can create a worksheet or tailor an existing one from the library as an activity that asks the client to reflect on the progress they have made or work they have completed.

The activity can either be given directly to the client or group, or included in a pathway containing other activities.

Here is an example of the activity parameters that Quenza makes possible.

A message can be attached to the activity, using either a template or a personally tailored message for the client. Here’s an example.

Once the activity is published and sent, the client receives a notification about a received assignment via their coaching app (mobile or desktop) or email.

The client can then open the Quenza software and find the new homework under their ‘To Do’ list.

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Quenza provides the ability to create your own assignments as well as a wide selection of existing ones that can be assigned to clients for completion as homework.

The following activities can be tailored to meet specific needs or used as-is. Therapists can share them with the client individually or packaged into dedicated pathways.

Such flexibility allows therapists to meet the specific needs of the client using a series of dedicated and trackable homework.

Examples of Quenza’s ready-to-use science-based activities include the following:

Wheel of Life

The Wheel of Life is a valuable tool for identifying and reflecting on a client’s satisfaction with life.

You can find the worksheet in the Positive Psychology Toolkit© , and it is also included in the Quenza library. The client scores themselves between 1 and 10 on specific life domains (the therapist can tailor the domains), including relationships, career development, and leisure time.

This is an active exercise to engage the client early on in therapy to reflect on their current and potential life. What is it like now? How could it look?

The wheel identifies where there are differences between perceived balance and reality .

The deep insights it provides can provide valuable input and prioritization for goal setting.

The Private Garden: A Visualization for Stress Reduction

While stress is a normal part of life, it can become debilitating and interfere with our everyday lives, stopping us from reaching our life goals.

We may notice stress as worry, anxiety, and tension and resort to avoidant or harmful behaviors (e.g., abusing alcohol, smoking, comfort eating) to manage these feelings.

Visualization is simple but a powerful method for reducing physical and mental stress, especially when accompanied by breathing exercises.

The audio included within this assignment helps the listener visualize a place of safety and peace and provides a temporary respite from stressful situations.

20 Guidelines for Developing a Growth Mindset

Research into neuroplasticity has confirmed the ability of the adult brain to continue to change in adulthood and the corresponding capacity for people to develop and transform their mindsets (Dweck, 2017).

The 20 guidelines (included in our Toolkit and part of the Quenza library) and accompanying video explain our ability to change mentally and develop a growth mindset that includes accepting imperfection, leaning into challenges, continuing to learn, and seeing ‘failure’ as an opportunity for growth.

Adopting a growth mindset can help clients understand that our abilities and understanding are not fixed; we can develop them in ways we want with time and effort.

Self-Contract

Committing to change is accepted as an effective way to promote behavioral change – in health and beyond. When a client makes a contract with themselves, they explicitly state their intention to deliver on plans and short- and long-term goals.

Completing and signing such a self-contract (included in our Toolkit and part of the Quenza library) online can help people act on their commitment through recognizing and living by their values.

Not only that, the contract between the client and themselves can be motivational, building momentum and self-efficacy.

The contract can be automatically personalized to include the client’s name but also manually reworded as appropriate.

The client completes the form by restating their name and committing to a defined goal by a particular date, along with their reasons for doing so.

Realizing Long-Lasting Change by Setting Process Goals

We can help clients realize their goals by building supportive habits. Process goals – for example, eating healthily and exercising – require ongoing actions to be performed regularly.

Process goals (unlike end-state goals, such as saving up for a vacation) require long-lasting and continuous change that involves monitoring standards.

This tool (included in our Toolkit and part of the Quenza library) can help clients identify positive actions (rather than things to avoid) that they must carry out repeatedly to realize change.

We have many activities that can be used to help clients attending therapy for a wide variety of issues.

In this section, we consider homework ideas that can be used in couples therapy, family therapy, and supporting clients with depression and anxiety.

Couples therapy homework

Conflict is inevitable in most long-term relationships. Everyone has their idiosyncrasies and individual set of needs. The Marital Conflicts worksheet captures a list of situations in which conflicts arise, when they happen, and how clients feel when they are (un)resolved.

Family therapy homework

Families, like individuals, are susceptible to times of stress and disruptions because of life changes such as illness, caring for others, and job and financial insecurity.

Mind the Gap is a family therapy worksheet where a family makes decisions together to align with goals they aspire to. Mind the gap is a short exercise to align with values and improve engagement.

How holistic therapist Jelisa Glanton uses Quenza

Homework ideas for depression and anxiety: 3 Exercises

The following exercises are all valuable for helping clients with the effects of anxiety and depression.

Activity Schedule is a template assisting a client with scheduling and managing normal daily activities, especially important for those battling with depression.

Activity Menu is a related worksheet, allowing someone with depression to select from a range of normal activities and ideas, and add these to a schedule as goals for improvement.

The Pleasurable Activity Journal focus on activities the client used to find enjoyable. Feelings regarding these activities are journaled, to track recovery progress.

Practicing mindfulness is helpful for those experiencing depression (Shapiro, 2020). A regular gratitude practice can develop new neural pathways and create a more grateful, mindful disposition (Shapiro, 2020).

Each activity can be tailored to the client’s needs; shared as standalone exercises, worksheets, or questionnaires; or included within a care pathway.

A pathway is an automated and scheduled series of activities that can take the client through several stages of growth, including psychoeducation , assessment, and action to produce a behavioral change in a single journey.

How to build pathways

The creator can add two pathway titles. The second title is not necessary, but if entered, it is seen by the client in place of the first.

Once named, a series of steps can be created and reordered at any time, each containing an activity. Activities can be built from scratch, modified from existing ones in the library, or inserted as-is.

New activities can be created and used solely in this pathway or made available for others. They can contain various features, including long- and short-answer boxes, text boxes, multiple choice boxes, pictures, diagrams, and audio and video files.

Quenza can automatically deliver each step or activity in the pathway to the client following the previous one or after a certain number of days. Such timing is beneficial when the client needs to reflect on something before completing the next step.

Practitioners can also designate steps as required or optional before the client continues to the next one.

Practitioners can also add helpful notes not visible to the client. These comments can contain practical reminders of future changes or references to associated literature that the client does not need to see.

It is also possible to choose who can see client responses: the client and you, the client only, or the client decides.

Tags help categorize the pathway (e.g., by function, intended audience, or suggested timing within therapy) and can be used to filter what is displayed on the therapist’s pathway screen.

Once designed, the pathway can be saved as a draft or published and sent to the client. The client receives the notification of the new assignment either via email or the coaching app on their phone, tablet, or desktop.

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Success in therapy is heavily reliant on homework completion. The greater the compliance, the more likely the client is to have a better treatment outcome (Mausbach et al., 2010).

To improve the likelihood that clients engage with and complete the assignments provided, homework must be appropriate to their needs, have a sound rationale, and do the job intended (Beck, 2011).

Technology such as Quenza can make homework readily available on any device, anytime, from any location, and ensure it contains clear and concise psychoeducation and instructions for completion.

The therapist can easily create, copy, and tailor homework and, if necessary, combine multiple activities into single pathways. These are then shared with the click of a button. The client is immediately notified but can complete it at a time appropriate to them.

Quenza can also send automatic reminders about incomplete assignments to the client and highlight their status to the therapist. Not only that, but any resulting questions can be delivered securely to the therapist with no risk of getting lost in a busy email inbox.

Why not try the Quenza application? Try using some of the existing science-based activities or create your own. It offers an impressive array of functionality that will not only help you scale your business, but also ensure proactive, regular communication with your existing clients.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond . Guilford Press.
Dweck, C. S. (2017). Mindset: The new psychology of success. Robinson.
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.
Ribbers, A., & Waringa, A. (2015). E-coaching: Theory and practice for a new online approach to coaching . Routledge.
Shapiro, S. L. (2020). Rewire your mind: Discover the science and practice of mindfulness. Aster.
Tang, W., & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health , 4 (2).

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Therapist Behaviors as Predictors of Immediate Homework Engagement in Cognitive Therapy for Depression

Laren r. conklin.

a Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus OH 43210

Daniel R. Strunk

Andrew a. cooper.

b Department of Psychology, University of Toronto Scarborough, 1265 Military Trail, Toronto, ON M1C1A4, Canada

Homework assignments are an integral part of cognitive therapy (CT) for depression, though facilitating homework engagement in patients with depression can be a challenge. We sought to examine three classes of therapist behaviors as predictors of homework engagement in early sessions of CT: therapist behaviors related to the review of homework, the assignment of homework, and efforts to help patients overcome obstacles to completing homework. In a sample of 66 depressed outpatients participating in CT, therapist behaviors involved in assigning homework predicted both CT-specific homework engagement and more general homework engagement. Therapist behaviors involved in homework review were not predictive of homework engagement. Our findings are consistent with the possibility that therapists’ emphasis of key elements of the homework assignment process enhances patients’ engagement in homework in early sessions of CT.

Homework assignments are an essential part of cognitive therapy (CT) for depression ( Beck, Rush, Shaw, & Emery, 1979 ). In CT, therapists utilize homework to help patients practice using and integrating CT skills into their lives ( Kazantzis & Lampropoulos, 2002 ). Common homework assignments in CT depression include self-monitoring activities to understand the connection between daily activities and mood; recording one’s automatic thoughts and developing alternative responses; and scheduling and engaging in activities to promote a sense of accomplishment or pleasure ( Beck, 1995 ; Beck et al., 1979 ). Patients are encouraged to regularly practice skills learned in therapy through assigned homework; however, the extent to which they engage in homework varies considerably, often falling short of desirable levels ( Kazantzis & Shinkfield, 2007 ).

Previous research has found that patients’ level of engagement with homework during CT is positively related to improvements in depressive symptoms. This relationship has been observed when symptom improvements were assessed over the duration of treatment ( Kazantzis, Deane, & Ronan, 2000 ; Kazantzis et al., 2016 ; Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010 ) and more immediately (i.e., from one session to the next; Conklin & Strunk, 2015 ). However, there is little empirical evidence regarding which therapist behaviors predict homework engagement, in CT or in other treatments. In this study, we examine therapist behaviors that might serve to predict homework engagement. We assess both general homework engagement and engagement with specific types of homework. We use the term homework engagement to refer to the frequency and extent of any homework activities (see Conklin & Strunk, 2015 , for discussion of this conceptualization). It differs conceptually from compliance, which refers to the proportion of homework completed relative to what was assigned (see Primakoff, Epstein, & Covi, 1986 ). In considering candidate therapist behaviors that could predict homework engagement, we drew from both from the empirical evidence available and expert clinical opinion on the subject.

Empirical Evidence

To our knowledge, two previous studies of cognitive behavioral therapies for depression in adults have examined the relation of therapist behaviors and patients’ homework activities ( Bryant, Simons, & Thase, 1999 ; Startup & Edmonds, 1994 ). In first of these studies, Startup and Edmonds (1994) examined the relation of patient ratings of therapist behaviors involved in promoting homework (i.e., providing a rationale, clear description, anticipating problems, and involving the patient in the process) and weekly therapist-rated homework compliance. In their sample of 25 patients in multimodal cognitive behavioral therapy, they failed to find evidence that any therapist behavior was associated with homework compliance. They suggested that ceiling effects in patients’ ratings of therapists may have limited their ability to detect the effects of interest.

In the second study, Bryant and colleagues (1999) examined observer ratings of therapist homework-promoting behaviors at three recorded sessions widely spaced over early, mid, and late-treatment periods in a sample of 26 patients participating in CT. Observers rated the quality of four therapist behaviors: (1) the review of previous homework, (2) the explanation of a rationale for assignments, (3) the clarity and tailoring of assignments to the patient’s reported problems, and (4) how well the therapist sought reactions to the assignment and helped the patient trouble-shoot possible problems that might affect compliance. They found a non-significant trend suggesting a possible relation of their overall measure of homework-related therapist behaviors and homework compliance ( r = .24). An examination of individual items suggested that therapist’s review of the previous session’s homework was significantly positively associated with compliance ( r = .39). After being dichotomized (due to low frequency), an item assessing therapists’ eliciting of reactions to the assignment and trouble-shooting obstacles also showed an association with compliance ( r = .26).

While the focus of the current study is homework in CT for depression in adults, it is worth considering some important findings from the broader homework literature. One important experimental demonstration among behavioral medicine patients found that providing written instructions of the assigned homework led to higher compliance than verbal instructions alone ( Cox, Tisdelle, & Culpert, 1988 ). In a study of depressed adolescents participating in CT, providing a strong rationale and allocating more time to assigning homework predicted subsequent compliance, particularly for those who were initially resistant. Following the first session, therapists’ rationale and eliciting reactions / troubleshooting obstacles predicted compliance among those who had been low in compliance initially ( Jungbluth & Shirk, 2013 ).

Expert Clinical Opinion

While the empirical evidence reviewed above is limited, expert clinicians have offered numerous recommendations and guidelines for improving homework engagement ( Addis & Jacobson, 2000 ; Beck et al., 1979 ; Detweiler & Whisman, 1999 ; Garland & Scott, 2002 ; Kazantzis et al., 2000 ; Kazantzis, Pachana, & Secker, 2003 ; Shelton & Levy, 1981 ; Tompkins, 2002 ). Among the variety of techniques suggested, we discerned three broad categories: (1) therapist behaviors associated with the review of homework; (2) therapist behaviors associated with the assignment of homework; and (3) therapist behaviors related to overcoming obstacles to completing homework assignments.

Although multiple strategies for using homework successfully have been suggested, experts have varied in the extent to which they have emphasized different strategies ( Scheel, Hanson, & Razzhavaikina, 2004 ). When homework has been previously assigned, therapists are encouraged to review those homework assignments at the next session ( Beck et al., 1979 ; Garland & Scott, 2002 ; Kazantzis et al., 2003 ), reinforce the patients’ efforts with praise, and assess the patients’ perceptions of the helpfulness of homework ( Kazantzis et al., 2000 ; Kazantzis et al., 2003 ; Tompkins, 2002 ). Expert clinicians have also emphasized the value of clearly describing and assigning homework. Specific recommendations include: providing a rationale for the homework, devoting time in session to describing how to complete assignments, delineating clear and specific assignments, using in-session practice as needed, and ensuring that patients have a written reminder of their assignments ( Beck et al., 1979 ; Detweiler and Whisman, 1999 ; Garland & Scott, 2002 ; Kazantzis et al., 2000 ; Kazantzis et al., 2003 ; Shelton & Levy, 1981 ; Tompkins, 2002 ). At the beginning of treatment when homework assignments are new to patients, these recommendations may be particularly important. Finally, some experts have recommended working with patients to identify and overcome potential obstacles that might impede homework engagement ( Kazantzis et al., 2000 ; Tompkins, 2002 ). Therapist behaviors related to these three domains (assignment, review, addressing obstacles) were also identified as important to therapists’ competent use of homework by a panel of six experts in CT (see Schmidt, Strunk, DeRubeis, Conklin, & Braun, 2017 ).

In this study, we sought to identify therapist behaviors that may predict homework engagement in early sessions of CT for depression (specifically, in the first five sessions). We focused on early sessions of CT for three reasons: (1) previous research has suggested that much of the therapeutic progress made occurs early in the course of treatment ( Strunk, Brotman, & DeRubeis, 2010 ); (2) we were interested in initial engagement, as we suspected that it is key to establishing a pattern of high levels of engagement throughout treatment; and (3) our assessments of therapist behaviors and homework engagement were labor intensive and therefore required a focused approach. We also planned to build on previous studies in which the authors assessed the relationship between in-session therapist behaviors and patient homework compliance that occurred prior to the next session ( Bryant et al., 1999 ; Startup & Edmonds, 1994 ) by focusing on immediate consequents of therapist behaviors while utilizing a relatively large sample and leveraging repeated assessments to increase power. Based on our review of the existing literature, we evaluated three classes of therapist behaviors described above (viz., reviewing homework, assigning homework, and overcoming homework obstacles). We examine both general homework engagement and engagement with specific types of CT homework. We hypothesized that therapist behaviors in each of these domains would predict homework engagement as observed in patients’ discussions with therapists at the following session.

Participants

CT sessions utilized in this study were drawn from a naturalistic study of 67 adults with major depressive disorder (MDD; see Adler, Strunk, & Fazio, 2015 ; Conklin & Strunk, 2015 ). Because one patient discontinued participation prior to attending a session, the sample was necessarily reduced to 66. CT was provided by four doctoral students who were supervised by the second author (for more information about therapist training and the competence with which CT was provided, see Adler, Strunk, & Fazio [2015] ). Study inclusion criteria were as follows: a diagnosis of current MDD as assessed by the Structured Clinical Interview for the DSM-IV (SCID; First, Spitzer, Gibbon & Williams, 1994) and agreeing to refrain from adding or modifying the dose of any psychiatric medications currently being used over the course of treatment. Individuals were excluded from the study if any of the following were present: Bipolar I or any psychotic disorder; substance dependence in the six months prior to intake; or a primary diagnosis other than MDD if it was judged to require treatment other than CT.

Of the 66 participants, 37 (56%) were female. The mean age was 36.3 ( SD = 13.4, range: 18–69). The racial/ethnic make-up of the sample was 83% Caucasian ( n = 55), 11% African American ( n = 7), 5% Asian American ( n = 3), and 1% were Hispanic/Latino ( n = 1). A majority of the sample (91%) had at least some college education, and 45% had graduated from a four-year college. Two-thirds of the sample (67%, n = 44) were diagnosed as having at least one prior depressive episode, and 61% ( n = 40) of the sample met criteria for one or more co-morbid anxiety disorders, with generalized anxiety disorder being the most common (33%, n = 22). The majority (79%, n = 52) attended the first five sessions, with the remainder of the patients discontinuing treatment prior to session five. All available data from participants were used in analyses.

Homework-Specific Therapist Behavior Scales (HSTBS)

Based on our review of the literature summarized in the introduction, we developed 16 observer-rated HSTBS items to assess three classes of therapist behaviors that may promote homework engagement: Review, Assignment, and Overcoming Obstacles. The first and second authors reviewed this literature and identified key classes of therapist behaviors thought to promote homework engagement. The first author drafted specific items and the second author, who has extensive experience in research utilizing observer ratings of psychotherapy, provided feedback regarding the degree to which the items covered the relevant therapist behaviors as well as suggesting any revisions to facilitate reliable coding of the behaviors by observers. The items were then revised to address these concerns. On the HSTBS, each scale item is rated from zero (not at all) to four (considerable), and then all items on each scale are averaged to create the scale score. In this study, three raters (drawn from a team of 17 raters; see the “ratings of homework-related characteristics” section below for details) used the HSTBS to evaluate each study session; thus, inter-rater reliability for each scale is reported below.

The Assignment scale consists of seven items assessing therapist behaviors thought to be important when assigning homework. The items assess the extent to which: (1) the therapist discussed the rationale for upcoming homework, (2) described how to do the tasks assigned for homework, (3) practiced the skills needed to do the homework, (4) ensured the patient understood how to perform the homework, (5) assigned specific homework, (6) clarified which activities or recommendations were homework assignments, and (7) ensured the patient had a written record of the homework. The Assignment scale had a median Cronbach’s alpha of .67 across sessions. The intraclass correlation coefficient (ICC; adjusted for three raters; see McGraw & Wong, 1996 ) for the Assignment scale was .75.

The Review scale consists of four items assessing therapist behaviors thought to be important in reviewing homework. These items assessed the extent to which therapist: (1) reviewed the homework, (2) involved the patient in reviewing homework, (3) discussed the helpfulness of previous homework, and (4) praised the patient for working on homework. The Review scale had a median Cronbach’s alpha of .76 across sessions. The ICC (adjusted for three raters) for the Review scale was .86.

Finally, the Overcoming Obstacles scale consists of five items assessing therapist behaviors important in ensuring patients would know how to work around possible obstacles to completing homework assignments. Overcoming Obstacles items assessed the extent to which therapists discussed the following with the patient: (1) obstacles that impeded previous homework progress, (2) the ways identified obstacles could be minimized in future homework, (3) the ways possible obstacles to upcoming homework could be worked around, (4) the ways of helping the patient remember to make time to do the homework, and (5) the ways of challenging thoughts that might interfere with the upcoming homework. The Overcoming Obstacles scale had a median Cronbach’s alpha of .75 across sessions. However, the ICC (adjusted for 3 raters) for the Overcoming Obstacles scale was .43. This low ICC may have been due to restriction of range with many zero scores, which was not evident in the other two scales. Because of the low ICC, we limit our presentation of analyses of this scale to basic descriptive statistics and do not present other analyses involving this scale score.

Homework Engagement Scale—General (HES-General; Conklin & Strunk, 2015 )

The HES-General is a three-item observer-rated measure of patients’ between-session homework engagement. The initial evaluation of the HES-General and the HES-CT (described below) were drawn from the same parent dataset ( Conklin & Strunk, 2015 ) as the current study. Three raters (drawn from a team of 19 raters) used the HES-General and HES-CT to rate each session, and inter-rater reliability is reported for each scale below.

The HES-General scale includes the following items: (1) the estimated amount of time the patients spent on homework (time); (2) the frequency with which the patients reported using CT skills when they were sad or upset (frequency); and (3) the estimated effort the patients put into homework assignments (effort). Items were summed so that the range possible on this measure was zero to twelve, with higher scores indicating greater time, greater effort, and more frequent engagement in homework activities between sessions. The HES-General had a median Cronbach’s alpha of .83 across sessions. The ICC for HES-General was .63.

Homework Engagement Scale—CT-Specific (HES-CT; Conklin & Strunk, 2015 )

The HES-CT is a three-item observer-rated scale that assesses the degree to which patients engage in commonly assigned types of CT homework. The homework assessed includes: cognitive homework (primarily thought records), self-monitoring homework (primarily use of a daily activity log), and behavioral homework other than self-monitoring (e.g., practicing assertiveness, planning activities designed to produce a sense of pleasure or mastery). While the HES-CT items were rated on a zero (no engagement) to six (extensive engagement) scale, screening of the items suggested non-normality due to a high percentage of zero values. This is consistent with conventional CT implementation, in which therapists do not typically assign all three types of homework in every session. To reduce the non-normality of the data, the non-zero ratings were recoded. Scores from one to three were coded as a one and scores from four to six were coded a two, thus resulting in scale items with values ranging from zero to two and HES-CT total scores ranging from zero to six. The ICC for HES-CT was .64.

Ratings of CT

Video (or audio) recordings from the first five therapy sessions were coded for this study. Audio recordings were used on occasions where the video quality was too poor for adequate rating or when a video recording was not available. All available recordings were utilized. A total of 288 sessions occurred between session one and five, and recordings of 282 sessions (99%) were available for coding. No recordings were available for sessions taking place via phone ( n = 4) or when a recording device failed ( n = 2).

Ratings of homework-related characteristics

A total of 36 undergraduates were on one of two CT rating teams, and both teams were equivalent with respect to the duration and extent of training. Raters were trained over 10 weeks prior to beginning the rating of study sessions. Training consisted of weekly meetings with the first author to review rating materials and practice making ratings using recordings of CT sessions drawn from an independent study of CT. After the training, raters made study ratings over a subsequent 10 week period. During this period, raters met periodically to discuss any difficulties that had arisen in making study ratings. They also rated clips of CT sessions not from this study to practice making ratings as a group in an effort to reduce any rater drift.

Each study session was rated by three members of each team, with each member rating no more than one session per patient. The averages of raters’ scores were used in analyses. One team ( n = 17) rated therapist behaviors in sessions one through four using the HSTBS. The second team of raters ( n = 19) rated engagement in sessions two through five using the HES-General and HES-CT. To complete their ratings, both teams of raters needed to know what homework had been assigned in the previous session. To provide this information, the second team of raters created a log of homework assignments. Logs for the prior session were provided to aid raters in making their judgments for the current session.

Overall Analytic Strategy

To model the dependence among repeated measures, we conducted primary analyses using the SAS Proc Mixed without specification of random effects. We evaluated four covariance structures (viz., unstructured, compound symmetry, autoregressive, and Toeplitz) and selected the best-fitting covariance structure for each dependent variable examined. The best fitting covariance structure, decided by Akaike’s Information Criterion (AIC), was autoregressive for both the HES-General and HES-CT.

We used repeated measures regression analyses to examine therapist behaviors at each session as predictors of homework engagement at the next session while controlling for homework engagement at the current session. For each of the analyses, lagged engagement scores (viz., engagement scores from sessions 2–5) served as the dependent variable with engagement scores from the previous session entered as a covariate. Thus, engagement at session two served as a covariate in predicting engagement at session three, engagement at session three served as a covariate in predicting engagement at session four, etc. HSTBS scores at sessions one through four were entered simultaneously as predictors in separate models for each homework engagement variable. To aid interpretation, both predictors and dependent variables were standardized to a mean of zero and a standard deviation of one prior to these analyses.

Descriptive Statistics for Therapist Behaviors and Homework

Therapist behaviors involved in homework review would not have occurred in the first session, as homework was not assigned prior to that session. Across the remaining sessions (2 through 5), the Review scale had an average score of 1.90 ( SD = .82). Across sessions 1 through 5, the Assignment scale had an average score of 2.49 ( SD = .58) and the Overcoming Obstacles scale had the numerically lowest average score of .45 ( SD = .54). Review and Assignment, the two scales included in the primary analyses, were moderately positively correlated on average ( r = .26: range: .12 to .47), but this relationship was only significant at one session. 1

Similar to the description provided by Conklin and Strunk (2015) for a subset of this sample, homework was assigned in 99% of the 230 sessions that were rated between sessions one and four. Among the three types of homework we examined, cognitive homework, consisting predominantly of thought records, was most commonly assigned (73% of the sessions). Self-monitoring, involving use of daily activity logs, was the second most frequently assigned homework type (60%). Finally, behavioral homework, which focused on trying new between session activities, was a common, but less frequently assigned type (45%).

Across sessions two through five, patients reported that they completed homework in 88% of sessions. The average amount of total CT-specific homework completed by patients between each session was 1.93 ( SD = .82) out of a possible 6. Breaking these ratings down by the type of homework completed, the average scores indicated that patients completed “some” of each type of homework, which according to the anchors the raters used was equivalent to a partially completed activity log ( M = 1.03, SD = .65), two thought records ( M = .57, SD = .44), and two behavioral tasks ( M = .33, SD = .31).

When examining ratings of general homework engagement (HES-General), patients received an average score of 4.06 ( SD = 1.56) out of 12 points. Broken down by item and interpreting amount based on the scale anchors, average ratings indicate that patients spent approximately 30 minutes on homework ( M = 1.28, SD = .60), “occasionally” used therapy skills when they felt sad or upset ( M = 1.56 SD = .64), and put “some” effort into completing homework assignments ( M = 1.22, SD = .49).

Homework-Related Therapist Behaviors as Predictors of Session-to-Session Homework Engagement

Using a separate model for each dependent variable, we examined both Review and Assignment as predictors of HES-CT and HES-General. For the model of HES-CT scores, the HSTBS Assignment scale significantly predicted homework engagement, t (93) = 3.41, β = .36, p = .001, but the HSTBS Review scale did not, t (93) = .78, β = .10, p = .43. Similarly, for the model of HES-General, the HSTBS Assignment scale emerged as a significant predictor, t (93) = 3.83, β = .41, p = .0002, whereas HSTBS Review scale did not predict HES-General scores, t (93) = −.28, β = −.04, p = .78.

In this study, we examined specific types of therapist behaviors as potential predictors of patients’ session-to-session homework engagement across early sessions of CT for depression. The consistent finding was that the scale aggregating therapist efforts to assign homework was the numerically strongest predictor of homework engagement. Assigning homework predicted both measures of general and CT specific homework engagement. These findings highlight the importance of therapist efforts to encourage patients to practice new skills through their assignment of homework: by providing a compelling rationale, a thorough description of any homework assigned, and ensuring a clear understanding on the part of the patient.

Contrary to expectation, homework review did not predict subsequent homework engagement, neither in the model assessing predictors of general homework engagement nor the model assessing predictors of CT-specific homework engagement. This is in contrast to two previous studies that found some evidence that the competence with which a therapist reviewed homework predicted next session homework compliance ( Bryant et al., 1999 ; Weck et al., 2013 ). The measures and methods used varied considerably from those of the current study, which we suspect played a role in the differing findings. We consider three key differences between previous studies and the current one. First, there was a difference across studies in which sessions were rated. We rated early sessions, whereas Bryant et al. (1999) and Weck et al. (2013) examined sessions spread out across the course of treatment. It is possible that therapists establish a pattern of reviewing homework more frequently for patients who engage in homework regularly. If so, such patterns in later sessions may have contributed to the stronger evidence of a relation of homework review and compliance in studies that included later sessions than our own study. Second, both Bryant et al. and Weck et al. relied on assessments of the competence of homework review. It is unclear how strongly assessments of competence would correlate with measures of the extent to which a therapist engaged in specific behaviors involved in homework review. Finally, rather than homework engagement, authors of both of these previous studies assessed homework compliance. Unlike our assessments of homework engagement, assessments of homework compliance involve measuring the patients’ homework relative to what was assigned. As we have argued previously, this can sometimes lead to high compliance scores when small amounts of homework were completed and low compliance scores when moderate or even relatively high amounts of homework were completed (see Conklin & Strunk, 2015 ).

Limitations

We wish to acknowledge some limitations of this study. First, the Overcoming Obstacles scale exhibited poor inter-rater reliability and was therefore not used in subsequent analyses. As we mentioned, this may have been due to a restriction of range (i.e., a floor effect) that made it difficult for raters to reliably observe the infrequent occasions when therapists exhibited these behaviors. Informed by this evidence that therapist behaviors related to overcoming obstacles may be relatively less frequent or more difficult to identify suggests the need to refine our measure or bolster rater training in future research. Second, our ability to detect the relations of interest depends on both adequate representation of variability in the constructs of interest in the sample as well as the ability of our measures to capture the range of these behaviors. Insofar as some of our measures were created for this study, it is difficult to assess the extent to which this was present. Insofar as larger number of items may enhance a scale’s reliability and validity, one might expect that the Assignment scale would have an advantage over the Review Scale. Nonetheless, it is worth noting the two prior studies that found relationships between homework review and compliance ( Bryant et al.,1999 ; Weck et al., 2013 ) utilized one-item assessments of homework review. Third, therapists involved in the project were therapists in training. The relations we studied may vary as a function of therapist expertise in providing CT. However, evaluations of therapist competence in this study suggested that competence appeared roughly on par with that observed among clinicians providing CT in clinical trials ( Adler, Strunk, & Fazio, 2015 ). Fourth, our decision to focus on early sessions means we do not know whether our findings would generalize across the course of CT. Finally, and most importantly, it is important to note that this study was not experimental. Therefore, we cannot rule out the possibility that our findings might be accounted for by an unmeasured third variable.

Although the use of between-session homework activities has been a key component of CT for depression since its inception ( Beck, Rush, Shaw, & Emery, 1979 ), clinicians have thus far had to largely rely on expert advice and clinical intuition to determine what elements of the homework process are important to emphasize to increase the likelihood that patients complete homework. Should one spend the majority of effort in session reviewing patients’ previous homework and helping them learn from past experience with the homework? Should one instead emphasize the practicing of new skills and ensure that the homework related to those skills is specific and understandable? How one answers these questions plays a key role in determining session structure and flow. We hope that the findings of this study help to facilitate making such decisions on the basis of empirical evidence.

To provide such evidence, we examined the relation of homework assignment and review-related therapist behaviors to general homework engagement and engagement with specific CT homework assignments. Therapist actions involved in assigning homework emerged as the more robust and numerically stronger predictor of both forms of homework engagement. Therefore, helping patients understand the nature of any homework assignments given (by describing the homework clearly, practicing it, ensuring patients have a written record of the assignments, etc.) appears to be a plausible determinant of session-to-session homework engagement. Our findings suggest that homework engagement could be enhanced when therapists emphasize key elements of the homework assignment process in early sessions of CT for depression.

Acknowledgments

We thank our colleagues for making this research possible. Abby D. Adler, Laren R. Conklin, Andrew A. Cooper, Lizabeth A. Goldstein, and Elizabeth T. Ryan served as cognitive therapists and clinical interviewers. Abby D. Adler served as study coordinator. Daniel R. Strunk provided training in and supervision of clinical assessments and cognitive therapy. Special thanks are also due to those who served as raters of therapist behaviors and homework engagement. Without their hard work and dedication, this research would not have been possible.

Funding Source: This project was supported by Award Number TL1RR025753 from the National Center for Research Resources. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

Conflicts of Interest: Laren Conklin, Andrew Cooper, and Daniel Strunk declare that they have no conflicts of interest.

Compliance with Ethical Standards:

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent: Informed consent was obtained from all individual participants included in the study.

1 To examine the average relationships between the scales, correlations were calculated separately at each session, then r values were transformed to z scores, averaged across sessions, and finally these z scores were transformed back to r values.

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HOMEWORK ENGAGEMENT IN COGNITIVE BEHAVIORAL GROUP THERAPY FOR SOCIAL ANXIETY

May 14, 2024

Dear Colleagues,

The National Social Anxiety Center (NSAC) provides information about relevant and current research in service of disseminating and promoting evidence-based treatment. This month’s summary is written by John Montopoli, LMFT, LPCC, A-CBT, representing NSAC – San Francisco , and examines research conducted by McEvoy, Johnson, Kazantzis, and Egan (2024) looking at the predictors of homework engagement in Cognitive Behavioral Group Therapy (CBGT) for Social Anxiety Disorder (SAD).

Both individual and group CBT are well established treatments for social anxiety disorder. Both treatment modalities achieve similar success in reducing symptoms. [1,2,3]. The current study investigates how elements of the therapeutic relationship, specifically group cohesion and working alliance, are associated with homework engagement during group CBT for social anxiety. Increased homework engagement (quality and quantity adherence) has been linked to improved outcomes in CBGT for SAD (Leung & Heimberg, 1996).

In this randomized controlled trial (RCT), 105 participants completed a 12-session group treatment. The findings revealed that group cohesion and working alliance were not directly associated with homework engagement. However, a previous study by Kazantzis and Miller (2022) emphasized the role of appraisals of homework as correlates of engagement.

The authors propose several useful implications, despite the negative associations between the treatment variables. Namely, individuals who have a clear understanding of the value of homework tasks and derive benefits from them are more likely to engage in homework tasks. Specifically, the importance of the client having a clear rationale for homework, that homework tasks closely align with their treatment goals, and tasks are collaboratively designed and implemented as early as possible in treatment. They also suggest that successful engagement in homework is associated with stronger therapeutic alliance, which, in turn, is associated with higher homework mastery over problems and progress. Additionally, the clients who had less clarity over homework tasks tended to report stronger group cohesion.

For clinicians: Homework engagement shows to improve outcomes. What strategies do you use, both in individual and group CBT, to increase homework engagement?

McEvoy, Peter M; Johnson, Andrew R; Nikolaos Kazantzis; and Egan Sarah J. (2024). Predictors of homework engagement in group CBT for social anxiety: client beliefs about homework, its consequences, group cohesion, and working alliance. Psychotherapy Research , 34(1), 68–80.

John Montopoli, LMFT, LPCC, A-CBT Representing NSAC San Francisco (Pacific CBT)

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Empower Your Clients: Effective Therapy Homework Ideas Unveiled

The power of therapy homework, what is therapy homework.

Therapy homework refers to assignments or tasks that are given to clients by therapists, psychologists, coaches, or practitioners as part of the therapeutic process. These assignments are designed to be completed outside of therapy sessions and are tailored to address specific therapeutic goals and objectives.

Therapy homework can take various forms, depending on the therapeutic approach and the client’s needs. It may involve activities such as journaling, practicing mindfulness exercises, completing worksheets or thought records, engaging in self-reflection, or working on specific skills. The purpose of therapy homework is to actively involve clients in their own healing process and empower them to take ownership of their growth and development.

Benefits of Assigning Therapy Homework

Assigning therapy homework offers numerous benefits for both clients and therapists. Some of the key advantages include:

Continuity and Reinforcement : Therapy homework provides an opportunity for clients to reinforce and apply what they have learned in therapy sessions to their daily lives. It helps to bridge the gap between sessions, ensuring that progress continues beyond the therapy room.
Active Engagement : Engaging in therapy homework encourages clients to actively participate in their treatment. It promotes a sense of agency and responsibility, empowering clients to take an active role in their own healing journey.
Skill Development : Therapy homework allows clients to practice and develop new skills, strategies, and coping mechanisms in real-life situations. It helps to reinforce positive changes and build resilience.
Generalization of Learning : Through therapy homework, clients have the opportunity to generalize the insights gained in therapy to different contexts and relationships. It supports the transfer of therapeutic gains into their day-to-day lives.
Increased Self-Awareness : Therapy homework often involves self-reflection and introspection, which can deepen clients’ self-awareness and understanding of their thoughts, emotions, and behaviors. This increased self-awareness can be a catalyst for personal growth and transformation.
Collaborative Process : Assigning therapy homework fosters a collaborative therapeutic relationship between clients and therapists. It encourages open communication, feedback, and discussion, leading to a more effective and tailored treatment approach.

By incorporating therapy homework into the therapeutic process, therapists can enhance the effectiveness of their interventions and facilitate meaningful change in their clients’ lives.

To explore therapy homework ideas for different therapeutic needs, refer to our articles on therapy homework assignments , therapy homework for anxiety , therapy homework for depression , and many more.

Finding the Right Therapy Homework Ideas

When it comes to assigning therapy homework, tailoring the activities to each individual client is essential for maximizing their engagement and progress. By customizing the homework, therapists can address specific needs and help clients work towards their therapeutic goals. Additionally, incorporating the client’s goals and interests into the assignments can enhance motivation and make the process more enjoyable.

Tailoring Homework to the Client

To ensure the therapy homework is effective, it’s crucial to consider the unique characteristics and preferences of each client. Tailoring the assignments involves taking into account factors such as the client’s age, cultural background, learning style, and personal circumstances.

For example, if a client is struggling with anxiety, it may be beneficial to assign homework that focuses on relaxation techniques, such as deep breathing or progressive muscle relaxation. On the other hand, a client who is working on building assertiveness skills may benefit from practicing role-plays or assertiveness exercises outside of therapy sessions.

By tailoring the therapy homework to the client’s specific needs and challenges, therapists can provide targeted support and facilitate progress towards their therapeutic goals. For more ideas on therapy homework assignments, check out our article on therapy homework assignments .

Incorporating Client Goals and Interests

Incorporating the client’s goals and interests into therapy homework is an effective way to increase motivation and engagement. By aligning the assignments with the client’s aspirations, they are more likely to be actively involved in the therapeutic process.

For example, if a client is working towards improving their self-esteem, therapy homework could involve engaging in self-affirmation exercises or creating a self-compassion journal. If a client is interested in mindfulness, incorporating mindfulness exercises and meditation into the homework can be highly beneficial.

By connecting the therapy homework to the client’s personal goals and interests, therapists can foster a sense of ownership and investment in the therapeutic journey. This approach helps to create a more meaningful and impactful therapeutic experience.

Remember, therapy homework is most effective when it is tailored to the client’s individual needs and incorporates their goals and interests. By taking these factors into account, therapists can empower their clients to actively engage in their own healing process.

Therapy Homework Ideas for Different Needs

When it comes to therapy homework, tailoring the assignments to the unique needs of each client is essential. This ensures that the homework aligns with their therapeutic goals and interests. In this section, we will explore therapy homework ideas for different needs, including Cognitive Behavioral Therapy (CBT) techniques , mindfulness and meditation exercises , journaling and writing prompts , and creative expressive arts activities .

Cognitive Behavioral Therapy (CBT) Techniques

CBT techniques are widely used in therapy to help individuals identify and modify negative thought patterns and behaviors. Assigning CBT-based homework can provide clients with practical tools to challenge unhelpful thoughts and develop healthier coping mechanisms. Some therapy homework ideas for CBT may include:

Thought Records : Encourage clients to keep a thought record where they write down and examine their negative thoughts, identify cognitive distortions, and reframe them with more realistic and positive alternatives.
Behavioral Experiments : Suggest clients engage in real-life experiments to test the validity of their negative beliefs and assumptions, helping them gather evidence to challenge and modify those beliefs.
Activity Scheduling : Encourage clients to create a schedule of activities that promote positive emotions, engagement, and a sense of accomplishment. This can help them break the cycle of negative thoughts and behaviors.

To discover more therapy homework ideas for specific topics or concerns, such as anxiety, depression, self-esteem, or assertiveness, check out our article on therapy homework assignments .

Mindfulness and Meditation Exercises

Mindfulness and meditation exercises can be valuable homework assignments to help clients develop present-moment awareness, reduce stress, and cultivate emotional well-being. Some therapy homework ideas for mindfulness and meditation include:

Breathing Exercises : Encourage clients to practice deep breathing exercises, focusing on their breath as it enters and leaves their body. This can help promote relaxation and reduce anxiety.
Body Scan Meditation : Suggest clients engage in a body scan meditation, guiding their attention from head to toe, paying attention to physical sensations and releasing tension.
Mindful Eating : Encourage clients to practice mindful eating by fully engaging their senses, savoring each bite, and paying attention to the tastes, textures, and smells of their food.

For more mindfulness and meditation exercises, along with guided scripts, consider referring to our article on therapy homework for mindfulness .

Journaling and Writing Prompts

Journaling and writing prompts can be effective tools for self-reflection, emotional expression, and personal growth. Assigning writing exercises as therapy homework allows clients to explore their thoughts, feelings, and experiences in a safe and structured way. Some therapy homework ideas for journaling and writing prompts include:

Gratitude Journal : Encourage clients to keep a gratitude journal, writing down three things they are grateful for each day. This practice can help shift their focus towards positive aspects of their lives.
Letter Writing: Suggest clients write a letter to themselves, expressing self-compassion , forgiveness, or encouragement. This can be a powerful exercise for promoting self-acceptance and self-care.
Emotional Release Writing : Encourage clients to engage in free-writing, allowing their thoughts and emotions to flow onto the paper without judgment or self-censorship. This can be a cathartic exercise for emotional processing.

To explore more journaling and writing prompts for therapy homework, consider referring to our article on therapy homework for journaling .

Creative Expressive Arts Activities

Engaging in creative expressive arts activities can provide clients with a unique and alternative way to explore their emotions, enhance self-expression, and gain insights into their inner world. Some therapy homework ideas for creative expressive arts activities include:

Art Therapy : Encourage clients to engage in art therapy exercises, such as drawing, painting, or collaging, to express their emotions and access their subconscious mind.
Music Therapy : Suggest clients create a playlist of songs that resonate with their emotions and help them process their feelings, or encourage them to engage in music improvisation as a form of expression.
Drama Therapy : Encourage clients to engage in role-playing exercises or create and act out scenes to explore different perspectives and gain insights into their own experiences.

For additional therapy homework ideas for creative expressive arts activities, refer to our article on therapy homework for self-expression .

By incorporating therapy homework ideas that align with the specific needs and interests of each client, therapists can empower their clients to actively participate in their own healing journey and make progress towards their therapeutic goals.

Implementing Effective Therapy Homework

To ensure the effectiveness of therapy homework assignments, it is crucial to follow certain guidelines. This section will discuss three key aspects of implementing effective therapy homework: providing clear instructions , setting realistic expectations , and encouraging accountability and follow-up .

Providing Clear Instructions

When assigning therapy homework, it is essential to provide your clients with clear and concise instructions. Clearly outline the purpose of the assignment, the specific tasks or exercises involved, and any guidelines or resources they may need. Using simple and straightforward language will help ensure that your clients understand what is expected of them.

Additionally, consider providing written instructions or therapy homework worksheets that your clients can refer to as they complete their assignments. This will serve as a helpful reminder and guide, increasing the likelihood of successful completion.

Setting Realistic Expectations

Setting realistic expectations is crucial when assigning therapy homework. Take into account your clients’ individual circumstances, such as their available time, resources, and personal commitments. Tailor the assignments to their specific needs and abilities to ensure they can be realistically accomplished within the given timeframe.

By setting achievable goals, you will motivate your clients and increase their confidence in their ability to complete the assignments. This, in turn, will enhance their engagement and overall progress during therapy.

Encouraging Accountability and Follow-up

Encouraging accountability and follow-up is essential for effective therapy homework. Regularly check in with your clients to inquire about their progress and address any challenges or questions they may have. This demonstrates your support and commitment to their growth.

Encourage your clients to keep a record of their experiences, insights, or reflections related to their therapy homework. This can be in the form of a journal, a digital document, or even a dedicated therapy homework app that allows them to track their progress and thoughts.

By reviewing their completed assignments and discussing their experiences during therapy sessions, you can provide valuable feedback and insights. This feedback will reinforce their efforts and help them integrate their learnings into their daily lives.

Remember to offer encouragement and praise for your clients’ hard work and dedication. Celebrate their achievements, no matter how small, as it will motivate them to continue their therapeutic journey.

As you implement these strategies for effective therapy homework, you will empower your clients to actively engage in their healing process. Providing clear instructions, setting realistic expectations, and encouraging accountability and follow-up will ensure that therapy homework becomes a valuable tool for their growth and progress.

Enhancing Client Engagement

When it comes to therapy homework, client engagement is vital for effective progress and positive outcomes. Building a supportive relationship, offering feedback and encouragement, and addressing challenges and concerns are key elements in fostering client engagement .

Building a Supportive Relationship

Establishing a supportive and trusting relationship with clients is essential for effective therapy. Creating a safe and non-judgmental environment allows clients to feel comfortable sharing their thoughts, emotions, and experiences. Actively listening, demonstrating empathy, and validating their feelings are effective ways to build rapport and foster a strong therapeutic alliance.

By developing a supportive relationship, clients are more likely to engage in therapy homework willingly and openly. They will feel understood, respected, and motivated to actively participate in their therapeutic journey.

Offering Feedback and Encouragement

Providing feedback and encouragement throughout the therapy process can significantly enhance client engagement. Regularly acknowledging their progress, recognizing their efforts, and celebrating their achievements can boost their motivation and self-confidence.

Offering constructive feedback that highlights their strengths and areas of improvement can help clients gain valuable insights. It’s essential to provide feedback in a compassionate and non-judgmental manner, ensuring that clients feel supported and encouraged to continue their growth.

Addressing Challenges and Concerns

Therapy is not always a smooth journey, and clients may encounter challenges or have concerns along the way. As a therapist, it is crucial to address these issues promptly and effectively. Actively listen to their concerns, validate their emotions, and work collaboratively to find solutions.

By addressing challenges and concerns, clients will feel heard and supported, which promotes their engagement in therapy. Whether it’s modifying therapy homework assignments, exploring different strategies, or adjusting treatment goals, adapting the therapy process to meet their specific needs can enhance client engagement and overall therapeutic outcomes.

Remember, client engagement is a dynamic process that requires ongoing attention and effort. By building a supportive relationship, offering feedback and encouragement, and addressing challenges and concerns, therapists can empower their clients and create a collaborative therapeutic environment. This environment promotes active engagement in therapy homework and facilitates positive change.

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Therapist Behaviors as Predictors of Immediate Homework Engagement in Cognitive Therapy for Depression

Affiliations.

1 Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus OH 43210.
2 Department of Psychology, University of Toronto Scarborough, 1265 Military Trail, Toronto, ON M1C1A4, Canada.
PMID: 29527079
PMCID: PMC5839503
DOI: 10.1007/s10608-017-9873-6

Homework assignments are an integral part of cognitive therapy (CT) for depression, though facilitating homework engagement in patients with depression can be a challenge. We sought to examine three classes of therapist behaviors as predictors of homework engagement in early sessions of CT: therapist behaviors related to the review of homework, the assignment of homework, and efforts to help patients overcome obstacles to completing homework. In a sample of 66 depressed outpatients participating in CT, therapist behaviors involved in assigning homework predicted both CT-specific homework engagement and more general homework engagement. Therapist behaviors involved in homework review were not predictive of homework engagement. Our findings are consistent with the possibility that therapists' emphasis of key elements of the homework assignment process enhances patients' engagement in homework in early sessions of CT.

Keywords: cognitive therapy; depression; homework.

Grants and funding

TL1 RR025753/RR/NCRR NIH HHS/United States

Occupational Therapy Practice Guidelines for Autistic People Across the Lifespan

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Kristie K. Patten , Kavitha Murthi , Dora D. Onwumere , Emily C. Skaletski , Lauren M. Little , Scott D. Tomchek; Occupational Therapy Practice Guidelines for Autistic People Across the Lifespan. Am J Occup Ther May/June 2024, Vol. 78(3), 7803397010. doi: https://doi.org/10.5014/ajot.2024.078301

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Importance: Occupational therapy practitioners need evidence to support interventions that promote subjective well-being among autistic people and their families through optimal engagement and participation in occupations.

Objective: These Practice Guidelines are informed by systematic reviews to expand knowledge of interventions that promote access, inclusion, engagement, and optimal participation in occupations that are meaningful to autistic people. Our intent was to foster occupational therapy practitioners’ clinical decision-making and reasoning when working with autistic people and their care partners.

Method: These Practice Guidelines were developed on the basis of four systematic reviews, supporting evidence and literature, along with continued revisions and integration through an iterative and collaborative process.

Results: A total of 98 articles were included in the systematic reviews, which are the foundation for practice recommendations in these guidelines. Forty-eight of the systematic review articles were used to inform the clinical recommendations included in these Practice Guidelines.

Conclusions and Recommendations: Strong to moderate evidence indicates the need for multidisciplinary, goal-oriented interventions to support autistic people in different contexts. Although there is only emerging evidence in the inclusion of autistic people’s strengths, interests, and perspectives to guide occupational therapy interventions, such practices can enhance the delivery of neurodiversity-affirming and trauma-informed practices. In addition, evidence is needed to support participation in activities of daily living (ADLs) for autistic youths. We recommend the use of strengths-based language to describe autistic people and the use of environmental adaptations, care partner education, and coaching to enhance occupational therapy service delivery.

Plain-Language Summary: The literature is sparse regarding neurodiversity-affirming and trauma-informed practices for autistic youths, as well as for participation in activities of daily living (ADLs). These Practice Guidelines provide new information on positive mental health development; self-determination; ADLs, instrumental ADLs, play, and leisure occupations for children, adolescents, and adults; person-centered planning for adolescents and adults; and rest and sleep. Information on health management is also provided.

Positionality Statement: This article uses the identity-first language autistic people. This nonableist language describes their strengths and abilities and is a conscious decision. This language is favored by autistic communities and self-advocates and has been adopted by health care professionals and researchers ( Bottema-Beutel et al., 2021 ; Kenny et al., 2016 ). However, we respect the use of person-first language and have made a conscious decision to include research articles that have used this language.

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Baby born deaf can hear after breakthrough gene therapy

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A baby girl born deaf can hear unaided for the first time, after receiving gene therapy when she was 11 months old at Addenbrooke’s Hospital in Cambridge.

Gene therapy has been the future of otology and audiology for many years and I’m so excited that it is now finally here Manohar Bance

Opal Sandy from Oxfordshire is the first patient treated in a global gene therapy trial, which shows 'mind-blowing' results. She is the first British patient in the world and the youngest child to receive this type of treatment.

Opal was born completely deaf because of a rare genetic condition, auditory neuropathy, caused by the disruption of nerve impulses travelling from the inner ear to the brain.

Within four weeks of having the gene therapy infusion to her right ear, Opal responded to sound, even with the cochlear implant in her left ear switched off.

Clinicians noticed continuous improvement in Opal’s hearing in the weeks afterwards. At 24 weeks, they confirmed Opal had close to normal hearing levels for soft sounds, such as whispering, in her treated ear.

Now 18 months old, Opal can respond to her parents’ voices and can communicate words such as “Dada” and “bye-bye.”

Opal’s mother, Jo Sandy, said: “When Opal could first hear us clapping unaided it was mind-blowing - we were so happy when the clinical team confirmed at 24 weeks that her hearing was also picking up softer sounds and speech. The phrase ‘near normal’ hearing was used and everyone was so excited such amazing results had been achieved.”

Auditory neuropathy can be due to a variation in a single gene, known as the OTOF gene. The gene produces a protein called otoferlin, needed to allow the inner hair cells in the ear to communicate with the hearing nerve. Approximately 20,000 people across the UK, Germany, France, Spain, Italy and UK and are deaf due to a mutation in the OTOF gene.

The CHORD trial, which started in May 2023, aims to show whether gene therapy can provide hearing for children born with auditory neuropathy.

Professor Manohar Bance from the Department of Clinical Neurosciences at the University of Cambridge and an ear surgeon at Cambridge University Hospitals NHS Foundation Trust is chief investigator of the trial. He said:

“These results are spectacular and better than I expected. Gene therapy has been the future of otology and audiology for many years and I’m so excited that it is now finally here. This is hopefully the start of a new era for gene therapies for the inner ear and many types of hearing loss.”

Children with a variation in the OTOF gene often pass the newborn screening, as the hair cells are working, but they are not talking to the nerve. It means this hearing loss is not commonly detected until children are 2 or 3 years of age – when a delay in speech is likely to be noticed.

Professor Bance added: “We have a short time frame to intervene because of the rapid pace of brain development at this age. Delays in the diagnosis can also cause confusion for families as the many reasons for delayed speech and late intervention can impact a children’s development.”

“More than sixty years after the cochlear implant was first invented – the standard of care treatment for patients with OTOF related hearing loss – this trial shows gene therapy could provide a future alternative. It marks a new era in the treatment for deafness. It also supports the development of other gene therapies that may prove to make a difference in other genetic related hearing conditions, many of which are more common than auditory neuropathy.”

Mutations in the OTOF gene can be identified by standard NHS genetic testing. Opal was identified as being at risk as her older sister has the condition; this was confirmed by genetic test result when she was 3 weeks old.

Opal was given an infusion containing a harmless virus (AAV1). It delivers a working copy of the OTOF gene and is delivered via an injection in the cochlea during surgery under general anaesthesia. During surgery, while Opal was given the gene therapy in right ear, a cochlear implant was fitted in her left ear.

James Sandy, Opal’s father said: “It was our ultimate goal for Opal to hear all the speech sounds. It’s already making a difference to our day-to-day lives, like at bath-time or swimming, when Opal can’t wear her cochlear implant. We feel so proud to have contributed to such pivotal findings, which will hopefully help other children like Opal and their families in the future.”

Opal’s 24-week results, alongside other scientific data from the CHORD trial are being presented at the American Society of Gene and Cell Therapy (ASGC) in Baltimore, USA this week.

Dr Richard Brown, Consultant Paediatrician at CUH, who is an Investigator on the CHORD trial, said: “The development of genomic medicine and alternative treatments is vital for patients worldwide, and increasingly offers hope to children with previously incurable disorders. It is likely that in the long run such treatments require less follow up so may prove to be an attractive option, including within the developing world. Follow up appointments have shown effective results so far with no adverse reactions and it is exciting to see the results to date.

“Within the new planned Cambridge Children’s Hospital, we look forward to having a genomic centre of excellence which will support patients from across the region to access the testing they need, and the best treatment, at the right time.”

The CHORD trial has been funded by Regeneron. Patients are being enrolled in the study in the US, UK and Spain.

Patients in the first phase of the study receive a low dose to one ear. The second phase are expected to use a higher dose of gene therapy in one ear only, following proven safety of the starting dose. The third phase will look at gene therapy in both ears with the dose selected after ensuring the safety and effectiveness in parts 1 and 2. Follow up appointments will continue for five years for enrolled patients, which will show how patients adapt to understand speech in the longer term.

In Cambridge, the trial is supported by NIHR Cambridge Clinical Research Facility and NIHR Cambridge Biomedical Research Centre.

Adapted from a press release from CUH

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Baby Opal and mother Jo

Credit: Cambridge University Hospitals NHS Foundation Trust

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The role of homework engagement, homework-related therapist behaviors
Background: Telephone-based cognitive behavioral therapy (tel-CBT) ascribes importance to between-session learning with the support of the therapist. The study describes patient homework engagement (HE) and homework-related therapist behaviors (TBH) over the course of treatment and explores their relation to depressive symptoms during tel-CBT for patients with depression. Methods: Audiotaped ...
A Session-to-Session Examination of Homework Engagement in Cognitive
Cognitive Therapy (CT) has been established as an efficacious treatment for depression (DeRubeis, Webb, Tang, & Beck, 2010).The use of homework is an integral component of CT, with homework assignments serving as a critical way of encouraging patients to practice integrating the skills they learn in therapy into their everyday lives (Beck, Rush, Shaw, & Emery, 1979; Kazantzis & Lampropoulos ...
Sending Homework to Clients in Therapy: The Easy Way
Family therapy homework. Families, like individuals, are susceptible to times of stress and disruptions because of life changes such as illness, caring for others, and job and financial insecurity. ... Mind the gap is a short exercise to align with values and improve engagement. Video. How holistic therapist Jelisa Glanton uses Quenza.
A Comprehensive Model of Homework in Cognitive Behavior Therapy
Aaron T. Beck et al. had conducted various studies of cognitive therapy outcomes during this period, and the first clinician guide "Cognitive Therapy of Depression" emerged placing homework as a core and crucial vehicle of change.Beck's therapy was positioned as requiring a collaborative therapeutic relationship, whereby decisions about the techniques of therapy, including the techniques ...
Homework as a driver of change in psychotherapy
Second, a significant correlational effect has been observed between client engagement with homework and treatment outcomes (Kazantzis et al., 2016; Mausbach et al., 2010), with an r = 0.26 across disorders and types of BSH (see also Wheaton & Chen, 2021). This indicates that the more clients engage with BSH (both in quantity and quality), the ...
Homework
Homework engagement contributes to therapeutic outcomes. ... Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression. Cognitive Therapy and Research, 42 (2018), pp. 16-23, 10.1007/s10608-017-9873-6. View in Scopus Google Scholar.
Homework
The available evidence suggests homework is a contributor to positive therapeutic outcomes in cognitive behavioral therapy. Although therapists play an important role in facilitating clients' engagement with homework as they develop greater facility with CBT skills, little is known about the contributions of specific approaches to promoting ...
Therapist competence, homework engagement, and client characteristics
Objective: Prior studies of Cognitive Behavioral Therapy (CBT) have focused on the quantity and quality of clients' homework completion and only rarely have considered the role of therapist competence. Methods: The present study examined (a) therapist competence across the entire process of integrating homework into CBT, including the review, design, and planning of tasks; (b) homework ...
Supporting Homework Compliance in Cognitive Behavioural Therapy
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].It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [3-6].
Therapist Behaviors as Predictors of Immediate Homework Engagement in
Homework assignments are an essential part of cognitive therapy (CT) for depression (Beck, Rush, Shaw, & Emery, 1979).In CT, therapists utilize homework to help patients practice using and integrating CT skills into their lives (Kazantzis & Lampropoulos, 2002).Common homework assignments in CT depression include self-monitoring activities to understand the connection between daily activities ...
The Role of Homework Engagement, Homework-Related Therapist Behaviors
Background Telephone-based cognitive behavioral therapy (tel-CBT) ascribes importance to between-session learning with the support of the therapist. The study describes patient homework engagement (HE) and homework-related therapist behaviors (TBH) over the course of treatment and explores their relation to depressive symptoms during tel-CBT for patients with depression. Methods Audiotaped ...
Empowerment Through Interaction: The Magic of Interactive Therapy Homework
By empowering clients through interaction, interactive therapy homework creates an environment that fosters engagement, accountability, skill-building, and practical application of therapeutic techniques. This collaborative approach between clients and therapists promotes a sense of active participation and ownership in the therapeutic process ...
Homework Engagement in Cognitive Behavioral Group Therapy for Social
The current study investigates how elements of the therapeutic relationship, specifically group cohesion and working alliance, are associated with homework engagement during group CBT for social anxiety. Increased homework engagement (quality and quantity adherence) has been linked to improved outcomes in CBGT for SAD (Leung & Heimberg, 1996).
Empower Your Clients: Effective Therapy Homework Ideas Unveiled
Active Engagement: Engaging in therapy homework encourages clients to actively participate in their treatment. It promotes a sense of agency and responsibility, empowering clients to take an active role in their own healing journey. Skill Development: Therapy homework allows clients to practice and develop new skills, strategies, and coping ...
Therapist Behaviors as Predictors of Immediate Homework Engagement in
Homework assignments are an integral part of cognitive therapy (CT) for depression, though facilitating homework engagement in patients with depression can be a challenge. We sought to examine three classes of therapist behaviors as predictors of homework engagement in early sessions of CT: therapis …
Introduction to the Special Issue on Homework in Cognitive ...
This article introduces the Special Issue in Cognitive Therapy and Research that presents advances in clinical psychological science for homework in behavior and cognitive behavioral therapies (CBTs). Studies include sophisticated evaluations of homework adherence, moving beyond simplistic assessments of quantity and quality of completion to more complete assessments of engagement (i.e ...
Occupational Therapy Practice Guidelines for Autistic People Across the
Importance: Occupational therapy practitioners need evidence to support interventions that promote subjective well-being among autistic people and their families through optimal engagement and participation in occupations. Objective: These Practice Guidelines are informed by systematic reviews to expand knowledge of interventions that promote access, inclusion, engagement, and optimal ...
Elektrostal
Elektrostal. Elektrostal ( Russian: Электроста́ль) is a city in Moscow Oblast, Russia. It is 58 kilometers (36 mi) east of Moscow. As of 2010, 155,196 people lived there.
PDF The Role of Homework Engagement, Homework‐Related ...
Keywords Telephone-based CBT · Therapeutic homework · Homework engagement · Guided selfhelp CBT · Patient activity · Therapist behaviors Introduction Therapeutic homework in terms of inter-session activity pre-sents a central component of psychotherapy and is particu-larly inherent to cognitive behavioral therapy (CBT; Beck et al. 1979).
Elektrostal
In 1938, it was granted town status. [citation needed]Administrative and municipal status. Within the framework of administrative divisions, it is incorporated as Elektrostal City Under Oblast Jurisdiction—an administrative unit with the status equal to that of the districts. As a municipal division, Elektrostal City Under Oblast Jurisdiction is incorporated as Elektrostal Urban Okrug.
Predictors of homework engagement in group CBT for social anxiety
Objective . Group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) is effective, but little data exist on generic relational components of the therapeutic process, such as group cohesion and therapy alliance, and central CBT-specific components such as homework engagement, beliefs, and perceived consequences.
Moscow Oblast
Moscow Oblast (Russian: Московская область, romanized: Moskovskaya oblast, IPA: [mɐˈskofskəjə ˈobləsʲtʲ], informally known as Подмосковье, Podmoskovye, IPA: [pədmɐˈskovʲjə]) is a federal subject of Russia (an oblast).With a population of 8,524,665 (2021 Census) living in an area of 44,300 square kilometers (17,100 sq mi), it is one of the most densely ...
Baby born deaf can hear after breakthrough gene therapy
Patients in the first phase of the study receive a low dose to one ear. The second phase are expected to use a higher dose of gene therapy in one ear only, following proven safety of the starting dose. The third phase will look at gene therapy in both ears with the dose selected after ensuring the safety and effectiveness in parts 1 and 2.
Elektrostal
Elektrostal , lit: Electric and Сталь , lit: Steel) is a city in Moscow Oblast, Russia, located 58 kilometers east of Moscow. Population: 155,196 ; 146,294 ...

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Therapist Behaviors as Predictors of Immediate Homework Engagement in Cognitive Therapy for Depression

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Homework-Specific Therapist Behavior Scales (HSTBS)

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Therapist Behaviors as Predictors of Immediate Homework Engagement in Cognitive Therapy for Depression

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Study at Cambridge

Baby born deaf can hear after breakthrough gene therapy

A baby girl born deaf can hear unaided for the first time, after receiving gene therapy when she was 11 months old at Addenbrooke’s Hospital in Cambridge.

Read this next

Study unpicks why childhood maltreatment continues to impact on mental and physical health into adulthood

New Cambridge-developed resources help students learn how maths can help tackle infectious diseases

School uniform policies linked to students getting less exercise, study finds

The Vice-Chancellor's Awards 2023 for Research Impact and Engagement

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