Using Homework Assignments in Cognitive Behavior Therapy

Nikolaos Kazantzis, Frank P. Deane, Kevin R. Ronan, Luciano L'Abate, Nikolaos Kazantzis, Frank P. Deane, Kevin R. Ronan, Luciano L'Abate

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781135936891
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Homework is a central feature of Cognitive-Behavioral Therapy (CBT), given its educational emphasis. This new text is a comprehensive guide for administering assignments. The first part of the text offers essential introductory material, a comprehensive review of the theoretical and empirical support for the use of homework, models for practice, and systems for evaluating client compliance and therapist competence in administering assignments. Part two focuses on the role of homework in cognitive therapy, demonstrating successful methods of integration and discussing solutions to common barriers. Rather than offering one-size-fits-all, pre-designed tasks, this book illustrates application of a model with detailed case study and recommendations for adjusting administration methods for particular problems and specific client populations. Over the last nine chapters, homework administration is described within cognitive and behavioral therapy for anxiety and depression, chronic pain, delusions and hallucinations, obsessions and compulsions, marital and sexual problems, personality disorders, children and adolescents, group and family therapy, and older adults.

Readers are provided with a full range of knowledge to successfully incorporate individualized homework assignments into their practice to maximize the proven long-term benefits of CBT.

CHAPTER 1
Introduction and Overview

NIKOLAOS KAZANTZIS

This book is designed for both beginning and more experienced practitioners of cognitive behavioral therapy. It assumes a basic knowledge of cognitive and behavioral theory, research, and practice as well as the ability to conduct an assessment, construct an individualized cognitive conceptualization, and deliver cognitive behavioral therapy. This book presents focused teaching on the use of homework assignments in the therapy, explaining in detail how the practitioner can design, assign, and review therapeutic homework activities. This teaching is based primarily on the work of A.T.Beck’s (1976) cognitive theory and system of psychotherapy.

Treatments identified as cognitive or cognitive behavioral therapy comprise a number of approaches. Cognitive behavioral therapies share the proposition that cognition is linked with behavior, cognition can be assessed and modified, and behavioral change can occur through cognitive change (Dobson, 2001). The model of therapy developed by Aaron T.Beck for the treatment of depression (A.T.Beck, Rush, Shaw, & Emery, 1979; J.Beck, 1995) has been subject to extensive empirical study since its inception (e.g., DeRubeis, Beck, & Tang, 2001; Dobson, 1989), and is regarded as the “standard form” of cognitive behavioral therapy (Clark, 1995).

Homework assignments are a core feature of the cognitive behavioral therapy process. In pragmatic terms, they represent the opportunity for clients to transfer the skills and ideas from therapy to the everyday situations in which their problems actually occur. To our knowledge, there is no generally agreed upon definition for therapeutic homework assignments in the literature. This conceptual variation is illustrated by the broad range in terminology that has been used to describe homework assignments in published articles, such as “extratherapy assignments” (Kornblith, Rehm, O’Hara, & Lamparski, 1983), “extratreatment practice assignments” (Kazdin & Mascitelli, 1982), “in vivo behavioral practice assignments” (Ingram & Salzberg, 1990), “self-help assignments” (Burns, 1989; Burns, Adams, & Anastopoulos, 1985), “show that I can tasks” (Hudson & Kendall, 2002; Kendall et al., 1997), and “home practice activities” (Blanchard, Nicholson, Radnitz, et al., 1991; Blanchard, Nicholson, Taylor, et al., 1991). However, it is likely that the variation in terminology reflects the negative associations with the term homework that are often held by clients and practitioners (Fehm & Kazantzis, 2004). Drawing on the work of Judith Beck (1995), we have operationalized homework assignments as follows:

Homework assignments are planned therapeutic activities undertaken by clients between therapy sessions. Their content is derived primarily from the empirically supported cognitive behavioral therapy model for the particular presenting problem but is tailored for the client based on an individualized conceptualization. Designed collaboratively, homework assignments are focused on the client’s goals for therapy. Homework assignments represent the main process by which clients experience behavioral and cognitive therapeutic change, practice and maintain new skills and techniques, and experiment with new behaviors. Homework assignments also provide an opportunity for clients to collect information regarding their thoughts, moods, physiology, and behaviors in different situations and to read information related to therapy and their presenting problems.

Reflecting their core and crucial role, homework assignments have received more empirical attention than any other single aspect of cognitive behavioral therapy process (Persons, Davidson, & Tompkins, 2001). Studies of psychotherapy process and outcome have produced evidence demonstrating that cognitive behavioral therapy involving homework assignments produces significantly better outcomes than those from therapy consisting entirely of in-session work (Beutler et al., 2004; Kazantzis, Deane, & Ronan, 2000). This research has also shown that treatment outcome is significantly enhanced when clients complete their homework assignments, and this link continues to be replicated in a variety of applications of cognitive behavioral therapy (Abramowitz, Franklin, Zoellner, & DiBernardo, 2002; Burns & Spangler, 2000; Coon & Thompson, 2003; Neimeyer, Kazantzis, & Kassler, 2005; Schmidt & Woolaway-Bickel, 2000; see also Kazantzis, Ronan, & Deane, 2001).

Practitioners report using homework assignments in their clinical work (Kazantzis & Deane, 1999; Kazantzis, Lampropoulos, & Deane, in press) and consider them important for a wide variety of clinical populations. At the same time, however, survey research has shown that there is a distance between practitioners’ self-reports of homework use and what is described in treatment manuals (Kazantzis, Busch, Ronan, & Merrick, 2005; Kazantzis & Deane, 1999). There are also data to suggest that practitioners hold a range of attitudes regarding homework’s effects on the process and outcome of therapy (Fehm & Kazantzis, 2004; Kazantzis et al., in press).

While there is evidence to support the overall effects of homework assignments in ensuring the outcomes of cognitive behavioral therapy, there are relatively few data to clarify the underlying mechanism for these effects. We know that homework assignments produce an effect in therapy that is distinctive, measurable, and leads to improved outcomes. We also know that clients who complete homework assignments are more likely to experience therapeutic benefits. However, there is very little theoretical or empirical work designed to clarify the factors that lead to client engagement in homework assignments and the extent to which their in-session review and design with the therapist impacts client adherence.

In order to contribute to the existing literature, a team research project was initiated at the School of Psychology, Massey University, New Zealand called the Cognitive Behavior Therapy Homework Project. The core research team comprises Nikolaos Kazantzis (PI) at Massey University, Kevin Ronan now at Central Queensland University, and Frank Deane, now at the University of Wollongong, Australia; it also benefits from the contributions of Luciano L’Abate (Georgia State University) and other international collaborators. This team research project is committed to developing an understanding of the mechanism by which homework produces its effects in cognitive behavioral therapy. Specifically, the project has been designed to address several broad objectives: (a) to conduct conventional and statistical reviews of the empirical literature in order to clarify the current knowledge regarding “homework effects” in therapy, (b) to survey psychologists’ use of homework assignments in clinical practice as a means of determining the necessity and utility of further research, (c) to design a theoretical model and associated treatment manual for the use of homework assignments in therapy, (d) to design conceptually based driven methods of assessing homework completion and therapist competence in using homework and to evaluate their psychometric properties, and (e) to conduct prospective process and treatment outcome research to evaluate the utility of the theoretical model and associated treatment manual. At the time of this writing, our team had achieved the first four objectives for the research program, and it was decided that a resource that outlined the theoretical foundations, reviewed the current empirical evidence, and described the process of integrating homework assignments in cognitive behavioral therapy would be helpful for practitioners.

The resulting volume comprises three distinct parts. Part I consists of three chapters that distill the existing theoretical and empirical work and highlight the methodological issues related to the study of homework assignments. Chapter 2 presents a summary of the theoretical foundations for the use of homework assignments. Chapter 3 focuses on the empirical basis for the use of homework assignments in therapy and discusses research on therapy process and outcome, as well as the findings and implications from surveys of clinical practice. Drawing on the theoretical foundations in Chapter 2 and limitations of prior research discussed in Chapter 3, the measurement of client adherence to homework assignments is discussed in Chapter 4. This includes the description of a new measure designed for use in clinical training, practice, and supervision.

Part II of the book consists of twelve chapters that describe the process of using homework assignments for a range of clinical populations and problems (Chapters 5 to 16). The first five chapters describe the use of homework for different clinical populations, namely children, adolescents, older adults, couples, and families. The remaining seven chapters describe the use of homework assignments for different presenting problems, namely panic and generalized anxiety, depression, substance abuse, delusions and hallucinations, obsessions and compulsions, sexual problems, and borderline personality traits.

As we were proposing a book on cognitive behavioral therapy covering a range of different clinical groups, we decided not to constrain our contributors by asking them to look only at a particular aspect of the process or to be prescriptive in terms of what types of difficulties to discuss or what type of detailed case example(s) to include. Our instructions to authors encouraged them to broadly consider the process of using homework for their particular clinical population, so that an integrated guiding model for practice could be presented in a later section. Thus, we invited primarily clinical chapters including the following:

1. Overview of common barriers to the successful use of homework assignments
2. Strategies for the effective use of homework
3. A brief outline of the types of homework activities within the empirically supported cognitive behavioral therapy model(s)
4. Relevant case studies of cognitive behavioral practice

The final part of the book consists of two chapters designed to summarize and synthesize the two preceding sections. Chapter 17 summarizes the clinical recommendations from previous chapters in the service of presenting a generic “guiding model” for the integration of homework into therapy. Chapter 18 also offers general recommendations for furthering the understanding of the process by which homework produces its effects.

As the reader will note, the field is left with many as yet unanswered questions about the role of homework assignments in cognitive behavioral therapy. In the interest of progressing towards our final research objective, our intention is to utilize the resulting guiding model as the basis for a treatment manual in prospective treatment outcome research.

This book aims to provide readers with focused teaching on how to effectively use homework assignments in cognitive behavioral therapy for different clinical groups. It is also our hope that this book will encourage further conceptual and empirical work on this central aspect of therapy process. We are optimistic that the extension of this knowledge in future research will advance our understanding of the therapist, client, and relationship factors that facilitate client learning through the completion of homework assignments.

References

Abramowitz, J.S., Franklin, M.E., Zoellner, L.A., & DiBernardo, C.L. (2002). Treatment compliance and outcome in obsessive-compulsive disorder. Behavior Modification, 26, 447–463.

Beck, A.T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.

Beck, A.T., Rush, J.A., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.

Beutler, L.E., Malik, M., Alimohamed, S., Harwood, T.M., Talebi, H., Noble, S., & Wong, E. (2004). Therapist variables. In M.J.Lambert (Ed.), Bergin and Garfield’s Handbook of psychotherapy and behavior change (5th ed., pp. 227–306). New York: Wiley.

Blanchard, E.B., Nicholson, N.L., Radnitz, C.L., Steffek, B.D., Appelbaum, K.A., & Dentinger, M.P. (1991). The role of home practice in thermal biofeedback. Journal of Consulting and Clinical Psychology, 59, 507–512.

Blanchard, E.B., Nicholson, N.L., Taylor, A.E., Steffek, B.D., Radnitz, C.L., & Appelbaum, K.A. (1991). The role of regular home practice in the relaxation treatment of tension headache. Journal of Consulting and Clinical Psychology, 59, 467–470.

Burns, D.D. (1989). The feeling good handbook. New York: William Morrow.

Burns, D.D., Adams, R.L., & Anastopoulos, A.D. (1985). The role of self-help assignments in the treatment of depression. In E.E.Berckham & W.R.Leber (Eds.), Handbook of depression: Treatment, assessment, and research (pp. 635–668). Homewood, IL: Dorsey Press.

Burns, D.D., & Spangler, D. (2000). Does psychotherapy homework lead to changes in depression in cognitive behavioral therapy? Or does clinical improvement lead to homework compliance? Journal of Consulting and Clinical Psychology, 68, 46–56.

Clark, D.A. (1995). Perceived limitations of standard cognitive therapy: A consideration of efforts to revise Beck’s theory and therapy. Journal of Cognitive Psychotherapy, 9, 153–172

Coon, D.W., & Thompson, L.W. (2003). The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression. American Journal of Psychiatry, 11, 53–61.

DeRubeis, R.J., Beck, A.T., & Tang, T.Z. (2001). Cognitive therapy. In K.Dobson (Ed.), Handbook of cognitive-behavioral therapies (2nd ed., pp. 349–392). New York: Guilford.

Dobson, K. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 57, 414–419.

Dobson, K. (2001). Handbook of cognitive-behavioral therapies (2nd ed.). New York: Guilford Press.

Fehm, L., & Kazantzis, N. (2004). Attitudes and use of homework assignments in therapy: A survey of German psychotherapists. Clinical Psychology & Psychotherapy, 11, 332–343.

Hollon, S.D. (2003). Does cognitive therapy have an enduring effect? Cognitive Therapy & Research, 27, 71–75.

Hudson, J.L., & Kendall, P.C. (2002). Showing you can do it: Homework in therapy for children and adolescents with anxiety disorders. Journal of Clinical Psychology, 58, 525–534.

Ingram, J.A., & Salzberg, H.C. (1990). Effects of in vivo behavioral rehearsal on the learning of assertive behaviors with a substance abusing population. Addictive Behaviors, 15, 189–194.

Kazantzis, N., Busch, R., Ronan, K.R., & Merrick, P.L. (2005). Mental health practitioners use and perceived importance of homework assignments in psychotherapy. Manuscript submitted for publication.

Kazantzis, N., & Deane, F.P. (1999). Psychologists’ use of homework assignments in clinical practice. Professional Psychology: Research and Practice, 30, 581–585.

Kazantzis, N., Deane, F.P., & Ronan, K.R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7, 189–202.

Kazantzis, N., Lampropoulos, G.L., & Deane, F.P. (in press). A national survey of practicing psychologists’ use and attitudes towards homework in psychotherapy. Journal of Consulting and Clinical Psychology.

Kazantzis, N., Ronan, K.R., & Deane, F.P. (2001). Concluding causation from correlation: Comment on Burns and Spangler (2000). Journal of Consultin...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• About the Editors
• Contributors
• Acknowledgments
• Chapter 1: Introduction and Overview
• Part I: Theoretical and Empirical Foundations
• Part II: Specific Populations
• Part III: Specific Problems
• Part IV: Model for Practice and Conclusions
• Appendix—Clinician Resources