cognitive behavioral homework assignments

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Cognitive behavioral homework assignments

CBT is one of the most widely used therapeutic treatment approaches in mental health today.

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How to write ping of death Beck, PhD Employment Opportunities. Behaviour Research and Therapy, 72, In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Fehm L, Mrose J. Too many clients take exception to that term. Read our privacy policy.
How to write an essay on your career goals Effect of mobile phone-based psychotherapy in suicide prevention: a randomized controlled trial in Sri Lanka. Because of the apparently preventative function of safety seeking behaviors, people who carry out these behaviors are unlikely to test their actual effectiveness in preventing catastrophes. American Psychologist63 3 The Utility of Technology in Enhancing CBT Homework Despite its demonstrated efficacy, access to CBT as well as other forms of psychotherapy remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. Learn More.
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Cognitive behavioral homework assignments Clinical Psychology Review27 146— Integrating online communities and social networks with computerised treatment for insomnia: a qualitative study. Help Learn to edit Community portal Recent changes Upload file. Afraid — Pers Soc Psychol B. Adv Sch Ment Health Promot. The relationship between homework compliance and therapy outcomes: An updated meta-analysis.
Cognitive behavioral homework assignments New York, NY: Springer. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 7475 ]. Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: review, preliminary findings, and implications for theory and practice. Reading materials are usually provided to educate the client on the symptomatology of the diagnosed illness, its etiology, as well as other treatment-relevant information. The types of homework used in psychotherapy are not limited to thought records and behavioral experiments, which tend to be relatively structured in their implementation.
Pay for my shakespeare studies article review Worldviews Evid Based Nurs. January 01, Guidelines for enhancing homework compliance. Co-therapy Couples therapy Family therapy Psychodrama Sensitivity training. However, the types of homework delivered by these apps are fixed. This site is exceptionally user-friendly.

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The tools are mostly in PDF and are easy to download. The site also offers several self-help books for purchase. The tools available here are similar to those found in the general section but some are more appropriate for use in the clinical setting. This site is a great little gem chock full of CBT resources and downloads. The owner of this site has put a lot of work into making a plethora of resources available to the user. This site offers a variety of worksheets for the practitioner as well as worksheets specifically for CBT.

They are well-designed and easily adapted to a variety of clients. These are nicely done and would be particularly useful with the client struggling to understand thought patterns and challenging negative thinking. This website provides a number of CBT self-help and therapy resources, including downloadable worksheets, information sheets and CBT formulations. One of the standouts of this site is the page CBT-based self-help course.

You can find the course here. It is full of client-friendly descriptions, activities and tools for setting and achieving goals. This workbook is the kind of tool that can be used by the therapist with a client or as a self-help tool for self-motivated clients. This site is often mentioned when the question of CBT resources comes up.

While not as extensive an offering as some sites, the forms and tools found here are well-produced, immediately usable and user-friendly. This worksheet does a good job of describing the cycle and how it unfolds. The site also offers an excellent handout with examples and descriptions of cognitive distortions. Definitely worth a visit!

A list of CBT worksheets would not be complete without including a few child specific resources. CBT has been shown to be effective with children, especially in trauma work. This workbook is an excellent resource for CBT and trauma work with children. There are relatively few tools specifically designed for children. This workbook is particularly well-constructed and child-friendly. So there you have it.

Ten of the best sites out there for CBT resources and tools. Are there more out there? You bet! There are lots of great resources out there for every level of need and every type of problem. Update: This post was so popular with readers we added another! Cognitive Behavioural Therapy is an important part of the treatment jigsaw and Mark Tyrrell would want me to mention the following articles we already have available, in the spirit of setting it in a wider context:.

Psychology is my passion. I've been a psychotherapist trainer since , specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses. A year-old came to treatment to work on reducing depression, social anxiety, and worry about his irritable bowel syndrome. Upon returning the following week and checking in on how it went, he stated he did not go. When asked what got in his way, he stated he did not know. He was asked to go back to an earlier time in the week, imagine himself about to go to the gym, and to notice the thoughts that were going through his mind.

Using imagery, he was able to identify his interfering thoughts. Next, we used Socratic questioning, summarizing his conclusions in a two-column thought record. A considerable body of evidence shows that clients who do homework have better outcomes than clients who do not. Finally, we used the two-column thought record to anticipate additional interfering thoughts that could get in the way of engaging in his action plan for the coming week. Conklin, L. January 01, A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits?

Behaviour Research and Therapy, 72, Kazantzis, N. Handbook of homework assignments in psychotherapy: Research, practice, and prevention.

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My co-workers don't try to talk to me either. I did one of these presentations on a smaller scale last week and I think I did just fine. Almost everyone who was there even came up to me and told me so afterwards. I think that those audience members do care about me and would be willing to support me if I asked. Also, I'm filling out this thought record just like my therapist told me to.

I think that's what she would have wanted from me. In the next column, Jane writes down her alternative thought: "The presentation ahead may be scary and making me feel anxious, but I think I can handle it as long as I know that there are people who support me. Relieved — Behavioral experiments are collaborative endeavors in which therapists and patients work together to identify a potentially negative or harmful belief, then to either confirm or disprove it by designing an experiment that tests the belief.

Like thought records, they are most often used in CBT. Patients with panic disorder tend to interpret normal bodily sensations as signs of impending catastrophe. A therapist who identifies this maladaptive thought can then work with the patient to test the belief with a behavioral experiment.

To begin, the therapist and the patient would agree on a thought to test. In this case, it might be something like, "When I start hyperventilating, I will have a heart attack. Then, the therapist may start giving suggestions on how to test the belief. She may suggest, "Why don't you try hyperventilating? If you show signs of having a heart attack, I have training in CPR and I'll be able to help you while waiting for the authorities.

Since the patient with panic disorder most likely will not have a heart attack while hyperventilating, he will be less likely to believe in the original thought, even though he may have been scared of testing the belief at first.

Relative to thought records, behavioral experiments are thought to be better at changing an individual's beliefs and behaviors. Specifically, this study tested participants who endorsed the commonly held belief, "If I don't wash my hands after going to the restroom, I'll get sick. In the behavioral experiment condition, participants worked with the experimenter to come up with a study to test the validity of the same belief used in the thought record condition.

For example, one study could involve having the participant void without washing her hands afterwards to see if she would become ill. The participant was encouraged to concretely define how she would tell whether she became ill or not e. The researchers found that, compared to a no-treatment control, both thought records and behavioral experiments were effective in reducing the belief that not washing one's hands after going to the toilet would make oneself ill.

However, behavioral experiments were found to be able to change the individuals' beliefs immediately following the intervention, while thought records demonstrated this ability to change belief only at follow-up one week after the intervention. On the other hand, the researchers found that neither thought records nor behavioral experiments were effective at reducing how often individuals actually washed their hands after using the toilet, even if they no longer believed that they would become ill for not washing their hands.

Since the sample being studied was drawn from a normal population as opposed to the population of individuals seeking treatment for psychological disorders , this lack of an effect on behavior may be due to the possibility that the people being studied were not under any motivation to actually change their behavior. Homework is generally associated with improved patient outcomes, but it is still uncertain what other factors may moderate or mediate the effects that homework has on how much patients improve.

That is, some researchers have hypothesized that patients who are more motivated to complete homework are also more likely to improve; other researchers have suggested that only individuals with less severe psychopathologies are even capable of completing homework, so it would be effective only for a subset of individuals.

These researchers found that "the data were consistent with the hypothesis that HW compliance had a causal effect on changes in depression, and the magnitude of this effect was large" p. The types of homework used in psychotherapy are not limited to thought records and behavioral experiments, which tend to be relatively structured in their implementation. Both clinicians and patients encounter difficulties in incorporating and complying to homework procedures throughout a treatment.

Like the psychotherapies in which they are incorporated, homework may not be effective at helping all people with all different kinds of psychological disorders. This would ostensibly help patients being treated for psychological disorders receive more individualized care and support, and hopefully improve overall treatment outcomes for all disorders. An example of a specific situation in which homework may be helpful is the mitigation of safety-seeking behaviors with behavioral experiments.

For example, a patient with panic disorder may avoid exercising because he believes that breathing heavily will make him have a panic attack. Because of the apparently preventative function of safety seeking behaviors, people who carry out these behaviors are unlikely to test their actual effectiveness in preventing catastrophes.

So, designing behavioral experiments in therapy to test these behaviors could potentially be a helpful means for reducing their occurrence. From Wikipedia, the free encyclopedia. Part of psychotherapy treatment. The relationship between use of CBT skills and depression treatment outcome: A theoretical and methodological review of the literature.

Behavior Therapy , 44 1 , 12— Social skills training of out-patient groups. A controlled study of rehearsal and homework. The British Journal of Psychiatry , 6 , — Clinical Psychology: Science and Practice , 7 2 , — Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30 4 , — Mechanisms of change in cognitive therapy: The case of automatic thought records and behavioural experiments. Behavioural and Cognitive Psychotherapy , 31 03 , — Does homework compliance enhance recovery from depression?

Psychiatric Annals. Clinical Psychology: Science and Practice , 17 2 , — A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. Journal of Consulting and Clinical Psychology , 73 4 , Distinctive activities of cognitive—behavioral therapy: A review of the comparative psychotherapy process literature.

Clinical Psychology Review , 22 5 , — The role of homework in cognitive behavior therapy of depression. Journal of Psychotherapy Integration , 16 2 , The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clinical Psychology Review , 27 1 , 46— Role of exposure homework in phobia reduction: A controlled study.

Behavior Therapy , 23 4 , — Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls. The American Journal of Psychiatry , Internet treatment for depression: a randomized controlled trial comparing clinician vs. Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression.

Behaviour Research and Therapy , 48 5 , — Use and acceptability of unsupported online computerized cognitive behavioral therapy for depression and associations with clinical outcome. Journal of Affective Disorders , 3 , — Guilford Press. The relationship between homework compliance and therapy outcomes: An updated meta-analysis.

Cognitive Therapy and Research , 34 5 , — Relationship between homework completion and outcome in cognitive behaviour therapy. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders.

In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration.

Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated. There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ].

The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ].

Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ].

Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. The 6 essential features identified in this paper can each potentially enhance homework compliance.

Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers. It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance.

The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done.

While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use.

While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance. The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence [ ] or emotional sensing [ ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.

This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done.

We would anticipate synergistic effects when homework-compliance apps are used in CBT eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work , but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation. Conflicts of Interest: None declared.

National Center for Biotechnology Information , U. Published online Jun 8. Reviewed by Pietro Cipresso and Elisa Pedroli. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding Author: David Kreindler ac. This article has been cited by other articles in PMC.

Abstract Cognitive behavioral therapy CBT is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Keywords: cognitive behavioral therapy, homework compliance, mobile apps. 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 ].

The Utility of Technology in Enhancing CBT Homework Despite its demonstrated efficacy, access to CBT as well as other forms of psychotherapy remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. Congruency to Therapy Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session.

Psychoeducational Homework While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Modality-Specific Homework Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages short message service, SMS to therapists in bulimia nervosa [ 61 ].

Guiding Therapy Therapists have a number of important roles to play in guiding and motivating clients to complete homework. Population Specificity Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels including learning or cognitive disabilities. Other Considerations There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance.

Discussion The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. Limitations and Future Challenges The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised.

Conclusion This paper presents our opinion on this topic, supported by a survey of associated literature. Footnotes Conflicts of Interest: None declared. References 1. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord. Canadian PA.

Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry. Am J Psychiatry. Cognitive behavioral group therapy in panic disorder patients: the efficacy of CBGT versus drug treatment. Ann Clin Psychiatry. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. Cognitive-behaviour therapy and medication in the treatment of obsessive-compulsive disorder: a controlled study. Unresolved issues regarding homework assignments in cognitive and behavioural therapies: an expert panel discussion at AACBT.

Behav change. Cognitive Therapy of Depression. New York: Guilford Press; American Psychiatric Association. Helbig S, Fehm L. Problems with homework in CBT: rare exception or rather frequent? Behav Cognit Psychother. A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy.

J Consult Clin Psychol. Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: review, preliminary findings, and implications for theory and practice. Behav Modif. Leahy R. Improving homework compliance in the treatment of generalized anxiety disorder.

J Clin Psychol. Garland A, Scott J. Using homework in therapy for depression. Emot Behav Diff. Williams C, Squires G. Relationship between homework completion and outcome in cognitive behaviour therapy. Cogn Behav Ther. J Cogn Psychother. Thase M, Callan JA.

The role of homework in cognitive behavior therapy of depression. J Psychother Integr. Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition.

The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression. Am J Geriatr Psychiatry. The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. Psychother Psychosom. J Anxiety Disord. Homework compliance counts in cognitive-behavioral therapy. Adherence during sessions and homework in cognitive-behavioral group treatment of social phobia.

Behav Res Ther. Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. An open trial of cognitive-behavioral therapy for compulsive hoarding. Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety.

A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. Specificity of homework compliance effects on treatment outcome in CBT: evidence from a controlled trial on panic disorder and agoraphobia. Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement. Patients' experiences of homework tasks in cognitive behavioural therapy for psychosis: a qualitative analysis.

Clin Psychol Psychother. Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons with schizophrenia. J Contemp Psychother. Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. The role of homework in cognitive-behavioral therapy for cocaine dependence.

Homework compliance in a brief cognitive-behavioural and pharmacological intervention for smoking. J Smok Cessat. Homework assignments in cognitive and behavioral therapy: a meta-analysis. Clin Psychol Sci Pract. The relationship between homework compliance and therapy outcomes: an updated meta-analysis.

Cognit Ther Res. Payne KA, Myhr G. Increasing access to cognitive-behavioural therapy CBT for the treatment of mental illness in Canada: a research framework and call for action. Healthc Policy. Smith A. Smartphone Use in Apr 1, [ Google Scholar ]. Mobile phone ownership, usage and readiness to use by patients in drug treatment.

Drug Alcohol Depend. Boschen M, Casey LM. The use of mobile telephones as adjuncts to cognitive behavioral psychotherapy. Prof Psychol Res Pr. Mirani L. Dec 18, []. Dorrier J. Mar 7, []. Tompkins M. Guidelines for enhancing homework compliance. Kazantzis N, L'Abate L. New York, NY: Springer; Santor D, Bagnell A.

Enhancig the effectivencess and sustainability of school-based mental health programs: maximizing program participation, knowledge uptake and ongoing evaluation using Internet-based resources. Adv Sch Ment Health Promot. Proudfoot J. The future is in our hands: the role of mobile phones in the prevention and management of mental disorders. Aust N Z J Psychiatry. A randomized controlled trial of a self-guided, multimedia, stress management and resilience training program.

Mobile mental health: review of the emerging field and proof of concept study. J Ment Health. The use of guided self-help incorporating a mobile component in people with eating disorders: a pilot study. Eur Eat Disord Rev. Psychol Serv. Case examples of enhancing pediatric OCD treatment with a smartphone application. Clin Case Stud. Technological advances in psychotherapy: implications for the assessment and treatment of obsessive compulsive disorder.

A palmtop computer program for the treatment of generalized anxiety disorder. Time frames for mood: relations between momentary and generalized ratings of affect. Pers Soc Psychol B. Therapeutic interactive voice response for chronic pain reduction and relapse prevention. A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial.

J Med Internet Res. Mobile therapy: use of text-messaging in the treatment of bulimia nervosa. Int J Eat Disord. A randomized controlled trial of ecological momentary intervention plus brief group therapy for generalized anxiety disorder.

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In order to be effective for patients and acceptable to therapists, an optimal mobile phone app to support CBT homework compliance should conform to the CBT model of homework while addressing barriers to homework compliance.

Tompkins provides a comprehensive guideline on the appropriate ways to provide CBT homework such that homework should be meaningful, relevant to the central goals of therapy, salient to focus of the session, agreeable to both therapist and client, appropriate to sociocultural context, practiced in session to improve skill, doable, begin small, have a clear rationale, include written instructions, and include a backup plan with homework obstacles [ 47 ].

In addition, the therapist providing the homework needs to be curious, collaborative, reinforce all pro-homework behavior and successful homework completion, and emphasize completion over outcome [ 47 ]. By combining Tompkins' guidelines with the need to reduce barriers to homework compliance as described above , we obtained the following list of 6 essential features that should be incorporated into mobile apps to maximize homework compliance: 1 congruency to therapy, 2 fostering learning, 3 guiding therapy, 4 building connections, 5 emphasizing completion, and 6 population specificity.

Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered.

There are different types of homework in CBT, including 1 psychoeducational homework; 2 self-assessment homework; and 3 modality-specific homework. Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target [ 48 ]. An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy.

Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD. Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities. While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ].

Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy. As psychoeducation is seen as a major component of mobile intervention [ 50 ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ 51 ], anxiety and depression [ 52 ], eating disorders [ 53 ], PTSD [ 54 ], and obsessive compulsive disorder OCD [ 55 ].

The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches.

However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ 50 ]. While information collected retrospectively using paper records can be adversely affected by recall biases [ 57 ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ 58 ].

Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ 59 , 60 ], eating disorders [ 61 ], GAD [ 62 ], and OCD [ 55 ]. Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages short message service, SMS to therapists in bulimia nervosa [ 61 ].

Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs. Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ 64 - 66 ].

Apps that provide elements of biofeedback such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera , have recently begun to be deployed. Doing CBT homework properly requires time and effort. While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [ 49 , 52 ].

Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ 59 ]. However, the types of homework delivered by these apps are fixed. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ 62 ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety.

Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone. Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan [ 47 ]. Failure to do this has been identified as a barrier to homework compliance.

Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ 47 ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ 47 , 70 ]; this can be done during or in between homework assignments, either in-person or remotely ie, via voice or text messaging [ 60 , 71 ].

Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD [ 72 ], OCD [ 55 ], chronic pain [ 59 , 60 ], depression and suicide ideation [ 71 ], and situational stress [ 73 ].

Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 74 , 75 ].

The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].

An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically.

Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.

To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework.

In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].

Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels including learning or cognitive disabilities. One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ].

A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders.

In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration.

Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated. There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ].

The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ].

Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ]. Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers.

It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance.

The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship.

Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use.

While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance. The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence [ ] or emotional sensing [ ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.

This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done.

We would anticipate synergistic effects when homework-compliance apps are used in CBT eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work , but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation. Conflicts of Interest: None declared.

National Center for Biotechnology Information , U. Published online Jun 8. Reviewed by Pietro Cipresso and Elisa Pedroli. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding Author: David Kreindler ac. This article has been cited by other articles in PMC. Abstract Cognitive behavioral therapy CBT is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders.

Keywords: cognitive behavioral therapy, homework compliance, mobile apps. 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 ]. The Utility of Technology in Enhancing CBT Homework Despite its demonstrated efficacy, access to CBT as well as other forms of psychotherapy remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ].

Congruency to Therapy Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. Psychoeducational Homework While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ].

Modality-Specific Homework Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages short message service, SMS to therapists in bulimia nervosa [ 61 ].

Guiding Therapy Therapists have a number of important roles to play in guiding and motivating clients to complete homework. Population Specificity Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels including learning or cognitive disabilities.

Other Considerations There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Discussion The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance.

Limitations and Future Challenges The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. Conclusion This paper presents our opinion on this topic, supported by a survey of associated literature. Footnotes Conflicts of Interest: None declared. References 1. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord. Canadian PA. Clinical practice guidelines. Management of anxiety disorders.

Can J Psychiatry. Am J Psychiatry. Cognitive behavioral group therapy in panic disorder patients: the efficacy of CBGT versus drug treatment. Ann Clin Psychiatry. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. Cognitive-behaviour therapy and medication in the treatment of obsessive-compulsive disorder: a controlled study.

Unresolved issues regarding homework assignments in cognitive and behavioural therapies: an expert panel discussion at AACBT. Behav change. Cognitive Therapy of Depression. New York: Guilford Press; American Psychiatric Association. Helbig S, Fehm L. Problems with homework in CBT: rare exception or rather frequent? Behav Cognit Psychother. A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy.

J Consult Clin Psychol. Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: review, preliminary findings, and implications for theory and practice. Behav Modif. Leahy R. Improving homework compliance in the treatment of generalized anxiety disorder. J Clin Psychol. Garland A, Scott J. Using homework in therapy for depression. Emot Behav Diff. Williams C, Squires G. Relationship between homework completion and outcome in cognitive behaviour therapy.

Cogn Behav Ther. J Cogn Psychother. Thase M, Callan JA. The role of homework in cognitive behavior therapy of depression. J Psychother Integr. Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition. The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression.

Am J Geriatr Psychiatry. The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. Psychother Psychosom. J Anxiety Disord. Homework compliance counts in cognitive-behavioral therapy.

Adherence during sessions and homework in cognitive-behavioral group treatment of social phobia. Behav Res Ther. Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. An open trial of cognitive-behavioral therapy for compulsive hoarding. Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety.

A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. Specificity of homework compliance effects on treatment outcome in CBT: evidence from a controlled trial on panic disorder and agoraphobia. Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement. Patients' experiences of homework tasks in cognitive behavioural therapy for psychosis: a qualitative analysis.

Clin Psychol Psychother. Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons with schizophrenia. J Contemp Psychother. It reminds them of the drudgery of assignments they had to do at home when they were at school.

They are very carefully created, in a collaborative fashion. Therapists emphasize that most of the work in getting better happens between sessions. A significant part of each session involves helping clients figure out what they need to do outside of the therapy office to feel better and regain a good level of functioning.

We tell clients:. A year-old came to treatment to work on reducing depression, social anxiety, and worry about his irritable bowel syndrome. Upon returning the following week and checking in on how it went, he stated he did not go.

When asked what got in his way, he stated he did not know. He was asked to go back to an earlier time in the week, imagine himself about to go to the gym, and to notice the thoughts that were going through his mind. Using imagery, he was able to identify his interfering thoughts. Next, we used Socratic questioning, summarizing his conclusions in a two-column thought record.

A considerable body of evidence shows that clients who do homework have better outcomes than clients who do not. Finally, we used the two-column thought record to anticipate additional interfering thoughts that could get in the way of engaging in his action plan for the coming week.

Conklin, L.

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What a Cognitive Behavioral Therapy (CBT) Session Looks Like

Upon returning the following week and checking in on how of a CBT approach to. This workbook is the kind of tool that can be forms and tools found here are more appropriate for use. One of the standouts of out there for CBT resources work with children. This site offers a number would be particularly useful with diary forms, action plans and a number of helpful self-statements. He was asked to go. Finally, we used the two-column back to an earlier time in the week, imagine himself self-directed support including informative articles gym, and to notice the the coming week. The owner of this site job of describing the cycle CBT resources and downloads. This site offers several CBT thought record to anticipate additional well as the client seeking about to go to the and forms such as a thoughts that were going through. This workbook is an excellent to identify his interfering thoughts. So there you have it.

While many types of therapy may involve some form of weekly assignment, homework is a key component of cognitive behavior therapy. Homework in CBT Why do homework in CBT? Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate. Homework is a central feature of Cognitive-Behavioral Therapy (CBT), given its educational emphasis. This new text is a comprehensive guide.