Cognitive behavioral therapy (CBT) is known to be a highly effective approach to mental health treatment. One factor underlying its success is the homework component of treatment.
It’s certainly true that therapy outcomes depend in part on the work taking place in each session. But for this progress to reach its full impact, clients need to use what they learn in therapy during their daily lives.
Assigning therapy “homework” can help your clients practice new skills during the week. While many types of therapy may involve some form of weekly assignment, homework is a key component of cognitive behavior therapy.
Types of Homework
Some clients may respond well to any type of homework, while others may struggle to complete or find benefit in certain assignments. It’s important for clients to step outside of their comfort zone in some ways. For example, it’s essential to learn to challenge unwanted thoughts and increase understanding of feelings and emotions, especially for people who struggle with emotional expression.
But there isn’t just one way to achieve these goals. Finding the right type of homework for each client can make success more likely.
There are many different types of therapy homework. Asking your client to practice breathing exercises when they feel anxious or stressed? That’s homework. Journaling about distressing thoughts and ways to challenge them, or keeping track of cognitive distortions? Also homework.
Some clients may do well with different assignments each week, while others may have harder times with certain types of homework. For example:
- An artistic client may not get much from written exercises. They might, however, prefer to sketch or otherwise illustrate their mood, feelings, or reactions during the week.
- Clients who struggle with or dislike reading may feel challenged by even plain-language articles. If you plan to assign educational materials, ask in your first session whether your client prefers audio or written media.
When you give the assignment, take a few minutes to go over it with your client. Give an example of how to complete it and make sure they understand the process. You’ll also want to explain the purpose of the assignment. Someone who doesn’t see the point of a task may be less likely to put real effort into it. If you give a self-assessment worksheet early in the therapy process, you might say, “It can help to have a clear picture of where you believe you’re at right now. Later in therapy I’ll ask you to complete another assessment and we can compare the two to review what’s changed.”
Mental Health Apps
Some people may also find apps a useful way to develop and practice emotional wellness coping skills outside of therapy. Therapy apps can help people track their moods, emotions, or other mental health symptoms. They can provide a platform to practice CBT or other therapy skills. They can also offer structured mindfulness meditations or help clients practice other grounding techniques.
If you’re working with a client who’s interested in therapy apps, you might try using them in treatment. Just keep in mind that not all apps offer the same benefits. Some may have limitations, such as clunky or confusing interfaces and potential privacy concerns. It’s usually a good idea to check whether there’s any research providing support for—or against—a specific app before recommending it to a client.
Trusted mental health sources, such as the American Psychological Association or Anxiety and Depression Association of America websites, may list some popular mental health apps, though they may not specifically endorse them. These resources can be a good starting place. Other organizations, including Northwestern University’s Center for Behavioral Intervention Technologies and the Defense Department of the United States, have developed their own research-backed mental health apps.
You can also review apps yourself. Try out scenarios or options within the app to get to know how the app works and whether it might meet your client’s needs. This will put you in a position to answer their questions and help give them tips on getting the most out of the app.
Benefits of Homework
Some of your clients may wonder why you’re assigning homework. After all, they signed up for therapy, not school.
When clients ask about the benefits of therapy homework, you can point out how it provides an opportunity to put things learned in session into practice outside the therapy session. This helps people get used to using the new skills in their toolbox to work through issues that come up for them in their daily lives. More importantly, it teaches them they can use these skills on their own, when a therapist or other support person isn’t actively providing coaching or encouragement. This knowledge is an important aspect of therapy success.
A 2010 review of 23 studies on homework in therapy found evidence to suggest that clients who completed therapy homework generally had better treatment outcomes. This review did have some limitations, such as not considering the therapeutic relationship or how clients felt about homework. But other research supports these findings, leading many mental health experts to support the use of therapy homework, particularly in CBT. Homework can be one of many effective tools in making therapy more successful.
Improving Homework Compliance
You may eventually work with a client who shows little interest in homework and doesn’t complete the assignments. You know this could impede their progress in therapy, so you’ll probably want to bring this up in session and ask why they’re having difficulty with the homework. You can also try varying the types of homework you assign or asking if your client is interested in trying out a mental health app that can offer similar benefits outside your weekly sessions.
When you ask a client about homework non-compliance, it’s important to do it in a way that doesn’t anger them, make them feel defensive, or otherwise damage the relationship you’re working to develop. Here are some tips for having this conversation:
- Let them know homework helps them practice their skills outside of therapy. In short, it’s helping them get more out of therapy (more value for their money) and may lead to more improvement, sometimes in a shorter period of time than one weekly session would alone.
- Bring up the possibility of other types of homework. “If you don’t want to write anything down, would you want to try listening to a guided meditation or tips to help manage upsetting emotions?”
- Ask about it, in a non-confrontational way. You might say something like, “Is something making it difficult for you to complete the homework assignments? How can I help make the process easier for you?”
The prospect of homework in therapy may surprise some clients, but for many people, it’s an essential element of success. Those put off by the term “homework” may view “skills practice” or similar phrasing more favorably, so don’t feel afraid to call it something else. The important part is the work itself, not what you call it.
References:
- Ackerman, C. (2017, March 20). 25 CBT techniques and worksheets for cognitive behavioral therapy. Retrieved from https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets
- ADAA reviewed mental health apps. (n.d.). Anxiety and Depression Association of America. Retrieved from https://adaa.org/finding-help/mobile-apps
- 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. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939342
- Mental health apps. (n.d.). The American Institute of Stress. Retrieved from https://www.stress.org/mental-health-apps
- Novotney, A. (2016). Should you use an app to help that client? Monitor on Psychology, 47(10), 64. Retrieved from https://www.apa.org/monitor/2016/11/client-app
- Tang, W, & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health, 4(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481663
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