9B) HW in clinical practice Flashcards
Define homework
- any therapeutic activity that a client may complete outside treatment sessions
- It should be purposeful and be related to therapeutic goals.
What are some other terms to refer to to HW assignments? (7)
- Between-session activities
- Extra-therapy assignments
- extra-treatment practice assignments
- in vivo behavioural practice assignments
- self-help assignments
- home practice
- learning/discovery tasks
What are some theoretical supports for using HW in clinical practice (2; 3)
BT:
* behavioural principle of generalisation where the effects of reinforcement in one environment is spread to another environment (Skinner)
* generalisation of therapeutic improvement = when desired behaviours or skills (e.g., relaxation) are performed to the same extent within both environments (Catania)
CT:
* Long history of use and emphasis on homework both by Beck and Ellis
* HW considered to be a critical component of the active treatment regimen (Beck et al., 1979).
* Increased feelings of self-efficacy = the sense that the client can actually do something to promote successful outcome (Bandura, 1990; Burns, 1989)
What is the rationale for using HW in clinical practice? (8)
- Makes therapy more concrete and specific
- Enhances communication between client and therapist
- Maintains treatment gains after termination
- Continues application & use of skills
- Provides data which can disconfirm negative thoughts and beliefs
- Data shift, from subjective/abstract to objective, realistic & detailed accounts
- Helps therapist relate session to specific tasks therefore avoiding side issues
- Enhanced treatment rationale (Scogin et al., 1998)
Is HW effective?
Yes BUT results restricted to use of homework in CBT approaches and most studies have involved patients with depression and anxiety
What did the Kazantzis et al. (2000) study find?
- Homework compliance is a significant predictor of therapy outcome: r = 0.22
- Effect sizes for Depression & Other problems were greater than for Anxiety
- Type of assignment matters: Exposure based assignments & “Other” types of assignments produced greater effects than Relaxation
- HW assignments produced a positive mean effect size in the medium range ( r = .36).
- CBT with homework produced significantly better outcomes than CBT without homework
- 68% of clients would improve when therapy involved homework compared to only 32% when therapy involved not homework
- Correlational research shows that homework compliance is associated with positive treatment outcome
Why does HW have positive causal effects on changes in depression? (2)
- provides the opportunity to practice skills between sessions
- leads to generalisation of these skills outside therapy
Identify and explain the 4 causal structures that are implicated in the effectiveness of HW with depression.
- Homework has positive causal effects on changes in depression
o Because it provides the opportunity to practice skills between sessions and leads to generalisation of these skills outside therapy - Depression influences the amount of homework completed between sessions
o Because of hopelessness and/or motivational difficulties inherent in severely depressed clients
o (if true, then HW would have no real benefit in practice) - HW and depression have a circular causal effect on each other
o HW lifts depression and improved depression leads to increased HW compliance - Homework and depression are simultaneously influenced by a third variable such as motivation
o More motivated clients improve more rapidly and comply more with HW
What did the Burns & Spangler (2000) study find?
- HW compliance significantly correlated with reductions in depression (r = -.34)
- Baseline levels of depression were not related to HW compliance
o Patients who were severely depressed completed as much HW, on average, as did patients with low levels of depression - HW appeared to have a causal effect on changes in depression
- Substantial theory and related behavioural research support for the principles of generalisation to suggest homework works
- Moderate support from empirical research suggesting homework activities improve psychotherapy outcome
Importance of HW for different client problems: percentage ratings of “Great Importance”
- 80%+ of respondents: Anxiety, Non-assertiveness, Social Skills
- 70-79% of respondents: Obsessions and compulsions, Insomnia
- 60-60%: Depression, Eating disorders, Sexual dysfunctional
- 50-59%: Substance abuse, physical illness
- 40-49%: Learning disorders
- <33%: Sexual abuse, Delusions & Hallucinations
What is involved when designing HW assignments? (11)
- Prepare the client for homework
- Clarify relevance to the treatment goals
- Clear rationale for the homework activity
- Consider client’s ability, e.g., reading or writing ability
- Provide client with a choice of HW activities or options of ways to complete the assignment
o e.g., different forms of problem monitoring - Consider alternative activities for potential difficulties or barriers to homework completion
o e.g., bad weather preventing outdoor activities - Ask client how confident they are that they will be able to complete the homework assignment.
- Modify or adjust assignment if low levels of confidence.
- Model homework or having client role-play homework activity in session
- Give the client a written note that describes the homework activity, and specifies when, where, how often and how long homework should be practiced
- Write down the client’s homework assignment(s) in your session note
What are some best-practice guidelines when it comes to designing HW assignments? (10)
- 1) Make it value-based.
o Check homework assignment makes sense to the client
o Ask them why they think the assignment might help with their problem - 2) Link the recommended homework assignment to the client’s treatment goals.
- 3) Summarise what was discussed or worked on in the therapy session
- 4) Link focus of session to previous sessions when problem has been worked on – bridging work
- 5) Link session summary to the homework assignment
- 6) Graduated program: Start small
o E.g., graded tasks in depression & exposure-based treatments for anxiety disorders
o Guideline: start with assignments that ask clients to do what they already do 30% of the time - 7) Shape approximations to final behaviour.
- 8) Anticipate potential obstacles
- 9) Practice in session
- 10) Wrriten instructions
How can we anticipate potential obstacles when we are in the design phase of HW assignments? (4)
- “Do you anticipate any obstacles?”
- “Have you had any trouble with tasks like this in the past?”
- Use confidence or likelihood ratings 0- 100
- Use covert rehearsal
Imaging going through all the steps in homework assignment using talk aloud
Helps identify environmental obstacles
When should we practice HW assignment task in session? (3)
When client
* Lacks necessary skill and knowledge to do assignment
* Tries assignment for the first time
* Has to perform the assignment in the presence of strong emotion
Why we should we write down instructions for HW assignment task? (6)
- Shown to improve compliance
- Reduce forgetting detail of HW
- Represents a public statement of intent
- Serves as a record of agreement
- Circumvent misunderstandings/disagreements that might erode therapeutic alliance
- Facilitates therapist being clear, concrete and explicit about instructions
