Better Therapy Homework: Evidence-Based Practices for Better Outcomes

Better Therapy Homework: Evidence-Based Practices for Better Outcomes
 

Explore evidence-based practices for homework in therapy 

In this video, Maor Katz discusses the importance of making homework assignments more effective to improve client outcomes. He highlights that while we recognize the importance of homework for therapy clients, we often lack formal training to assign it well.

It is crucial to have an interactive and collaborative relationship between the client and the therapist regarding homework. This means actively involving clients by asking them about the action plans and deciding what to focus on. Explaining the why behind the specific homework is essential so that the client feels invested. Providing a complete description of the task and practicing it together in the session can increase the chances of homework completion.

For example, practice a brief social interaction in the session for a client with social anxiety. Practice the first entry during the session, for homework related to journaling. Thinking about the potential obstacles while completing therapy homework assignments is essential.

The content of homework also matters. It can be categorized into lifestyle/well-being homework, such as improving sleep or exercise, and cognitive homework that directly impacts the therapy process, such as capturing thoughts. For workflow, each session starts with a brief mood survey, followed by a brief review of past homework and a dedicated time towards the end. This dedicated time should be used to plan the next homework assignment collaboratively. The speaker also shared accountability measures, such as using 'mission accomplished' versus 'I stubbornly refused' statements. These steps can help boost client engagement.

This webinar focuses on the purpose of homework that goes beyond therapy sessions and helps the client make progress in their daily life. Watch the entire webinar today.
 

IN THIS VIDEO:

Maor Katz: All right so we're talking about homework today and so what we're talking about is the activities that we ask our patients to do in between sessions and let me tell you kind of how we got here but maybe just before that the Feeling Good Institute which I with a number of friends have started a few years back about 10 years ago. What we do is we train and certify clinicians in TEAM-CBT the approach to therapy that we learned from the wonderful Dr. David Burns. First we started with a certification program to provide a road map to how to advance in this approach and then we created trainings to kind of go through this certification and enhance their skill and a few years ago we started to get kind of assemble a team together that are well versed in this approach to making therapy more effective. And kind of created a clinic out of it and what's special about this clinic is that we want to kind of look at it as kind of like a like an elite athlete would look at getting into a team and so you get pretty good you get into the team and now once you're on this kind of high team of a high scale team how do you continue and improve from there and as I was kind of grappling with that a few years ago as we were kind of setting this up.

I was wondering how what makes therapists better and as I was kind of doing the research and how to make therapists better and continuously better continue to improve kind of was horrified a little bit to realize that we don't get that with time when we get more comfortable in our therapy rooms with time but we don't necessarily get more effective and I kind of took a look at myself and I kind of realized that I wasn't getting better either. I think I was actually a less effective therapist as compared to maybe just a year or two after I graduated my residency program. So I kind of took into reading and kind of dove pretty deep into the literature and to understand what actually are some of the key factors that make therapists better and I was as I was doing this and I was excited to find out some some clues was just by chance approach at the same time by Tony Rousmaniere and Alexandre Vaz who are leaders in the field of deliberate practice of therapy skills kind of looking at therapy skills as a way to or looking at therapy scales the same as as musicians look at playing better same as athletes look at getting better and they suggested why don't we why don't we write a book together about the deliberate practice of TEAM-CBT. And so together with Mike Christensen who heads our program over in Canada we started working together and creating this book and super excited of how It's kind of taking shape we are kind of buttoning it up right now when you expect for it to be out towards the end part of 2023 and as I was working in this book together with with Mike we're trying to think what are some key things that make therapy better make for better therapists but aren't normally taught in our in our schools as in with by our supervisors and as we as we train and become therapists and one of those things was homework.

Now homework is such a key part of what always Dr. Burns who's our teacher says about like making therapy better and we hold our patients accountable to doing homework but we come to realize that we haven't really gotten a lot of training in that and so what I'd like to do is launch right now a poll and ask you guys this kind of question. I'm gonna give maybe like 30 seconds not super long for you to answer the poll about whether you think therapy homework is actually important for better or better outcomes. Give people a chance to to answer here maybe like 10 more eight more seconds and showing the results here and so looks like the vast majority of people I'd say you know, it looks like but 92 of folks think that it's at least moderately if not very much important homework is and so it makes sense that you know we're all in the same boat we all kind of agree that the therapy homework is actually a very important or at least moderately important part of therapy and so given that and and that actually is is very well kind of accepted in the field right so Beck in his book of one of the seminal books about the treatment a Cognitive Therapy of Depression kind of mentions how it's an integral part not just injunctive to therapy and then in a work by by Schmidt from 2018 who created a a list of the Core Competencies of of CBT therapy and he's actually Schmidt is also from the Beck Institute assigning homework and doing homework well or using homework well with therapy considered one of the 11 core competencies of a therapist according to his work and we have our own Dr. Burns who over 20 years ago already kind of answered the question of whether it's whether homework doing homework or compliance with homework engagement with homework is it a predictor of improvement of symptoms or is it just a kind of a result of improvement of symptoms and David Burns was able to show that it's actually a predictor of better outcomes so if you're if your patient engages in homework he they're more likely to get better faster rather than it's because they've got better that they're engaging more in homework. So clearly it's important we all kind of recognize that and so I want to launch a quick second poll here is to your experience with with homework training so how many hours of homework training did you actually get like formal training that people kind of taught you as part of your career in getting to do better homework given that it's clearly so important everybody kind of recognizes that most of us do so it's going to give you again like just 30 seconds to give us a sense if you're all kind of similar to the amount of training that I received which is not very much at all. I'm just going to give maybe like 10 more seconds here as you're kind of thinking about that. All right so I'm gonna show you the results and so we see here it's kind of the inverse relationship between how important it is but how many training we actually all tend to receive in this and so we've had whopping 30 percent of people more than 30 people who receive no training at all in one of the core competencies of therapy and then about an hour is another 30 so very, only just seven percent perceived what would be an adequate amount maybe many hours of training kind of that would be reasonable to get given how important it is. So clearly an important topic that we don't train, don't get enough training in. This is what we're going to talk about today. We're going to talk about these keys to how to improve homework compliance and this is based on me basically diving into the literature and understanding what we know from out there and then adding to it some of my own personal experience so we're going to talk about every each each and every one of these sticks Keys revealing your previous tasks, devoting time and how to kind of make it work within the the session, making the process collaborative and how to do that what do we mean by that how to make therapy homework clear and simple as a key to making increasing the engagement how to make it easy and what do we mean by that and finally we'll talk about some accountability steps that can also help in compliance so this is the last goal and the last poll is going to ask you which do you think is more important reviewing previous sessions homework or assigning this session's homework. Kind of a I'm just gonna looks like it's overwhelmingly in one direction here I'm going to share it with you in maybe just five more seconds because you're getting really good at answering these polls really quickly. So 92 percent of folks believe that reviewing previous sessions homework is more important than assigning this sessions homework and I'm really glad that I gave you this poll because that's exactly what I thought and it's actually not true so what learned from a study done by Conklin in 2018 who reviewed a number of factors related to better engagement and homework and they found that reviewing previous sessions homework is not as important as you'd think and their conclusion is yeah review previous sessions homework check in on it but don't spend too much time on it spend time on assigning next sessions homework that's going to be a time better spent and is more likely to yield a more engagement in the future homework.

My understanding from that the way I kind of get it is like you want to not leave it hanging and kind of unacknowledged but you don't want to dive in and really understand why things didn't work out the way that they that you had hoped not spend too much time on it but actually spent time just checking in on it so it's not ignored and moving on to the the next session's homework kind of based on that and other factors through the homework I'm glad I'm not the only one who thought that that was actually not the case that you needed to spend a lot more time on it. So now let's talk about how to assign therapy homework well and one key part is you want it to be a collaborative process so it's not top down like you want to ask questions like what would be a good way to move forward on this what would be a good action plan, what do you think about focusing on this for homework, what would be a good way for you more good things for you to do before our next session and just asking that kind of collaborative approach can yield already to a more engagement in therapy homework. You want to also explain the rationale for the specific homework, you want to have a buy-in and so you'll want to be able to have the buy-in from the patient and that the the goal or the way to get buy-in is by making it a collaborative process and also by having them understand why is that important have them feel that it is important. You also want to provide a thorough description of the homework that's assigned, let me make sure that they understand exactly what's needed from them I know that for me if I don't know exactly what I'm supposed to do that decreases the likelihood of me doing it tremendously I think that's true for everyone so we don't want to just say like a verbal agreement is enough we want to practice together so ideally when you give a homework instruction homework assignments you figure out a homework assignment for your patient you want to actually practice some of it together in the session. Let me give you some examples so if I'm working with my patient and we're working on social anxiety and they're struggling with a lot of shyness and maybe their homework is to do to to go you know around town or downtown or in a cup shop and just smile and say hello to some people catching people's eyes I'm saying hello it's usually one of the first kind of exposure exercises that we do for social anxiety I would want them to practice this first in the therapy room just to catch my eyes and smile and say hi.

Another example is if you're working on some negative thoughts and you want them to respond to their negative thoughts. Take one of the negative thoughts respond to it in session have them in writing have it in writing so they get a graph and then ask them to do the rest of the negative thoughts on their own. If your homework is just to do journaling, practice the first entry right there in the session so giving them kind of a couple of punches in the punch card so they can kind of feel okay they got this we're going to be able to move forward and the last point about how to assign homework to make it more likely to be engaged and effective is you want to think together about some obstacles to success. You want to ask what would get in the way of you actually completing this. Bringing it to conscious awareness that there will be problems with it, let's try to figure those out. Lastly write it down ask them to write it down. What I a lot of times do nowadays is I actually share a document with my patients and online and then we write it down they write it down in the document on top of it the electronic document and they kind of follow up their their so they know for sure I know I was a terrible homework completer myself all throughout my schooling and I think a big part of it is because I have a little bit of ADHD and I would not write things down. I would think to myself I'm sure I'll just remember this no problem I know exactly what the teacher's asking me to do and then of course it just goes poof out of my head and I don't I just don't remember it so my brain lies to me and says you'll remember it but I don't every time again and again and I think this is another reason why we want to make sure that we write it down, we ask our patients to write it down we're not assuming but they'll remember it. All right so now let's think about the content of the homework itself like what is it that we're assigning how can we help our our patients become more likely of actually completing the homework once once it was assigned, you want to think about doing signing homework that flows into their lives so they don't need to set aside some special time that takes them out of their routine out of their lives in order to do it ideally at least some of your homeworkers much of it as possible, make it such that is just flows into their lives seamlessly. An example of that is for me when I was training with Dr. Burns and he was teaching us how to learn how to do the five secrets of effective communication our approach to empathy training and that's something that we also teach our our patients to do to improve their relationships and communications so David suggested that take a couple of days for each one of those techniques and whenever we are in communication with people in our lives between now and the next time that we meet we just use this one technique to start with and so I was training in empathy and the first technique that I was asked to that that I decided to practice was thought empathy this is when you just repeat what the other person is saying verbatim don't add to it you don't change to it. If I come home and out of my day and I remember my wife was preparing after her day she was preparing some the the dinner finishing up the dinner for for our kids and I was asking her how her day was and she said oh it was good like I'm I'm excited I might I might get to be with my friend Patty in the same room next next semester next year and I said oh that's great you're gonna you're thinking you might get to be with Patty next year and she said yeah and I'm feeling a little torn because I'm not sure if I should be with Patty or maybe I should be with with Pam and and I was like oh you're not sure you're not sure whether maybe you should be with Patty or or with Pam and she said yeah and so that exactly and that went on like that for a little while eventually she was like are you are you doing some psychotherapy kind of practice on me and I said yeah I thought you'd be on to it a lot sooner and she said please continue this is really nice. And so the point is of the story is that just make it flow into the patient's life it makes the whole thing a lot a lot easier and and you can think about it in other things like if it is like things that typically take setting aside some time like reading assignments that we often like to our patients to do then see if you can kind of plan to make it when they read anyway or if it's something that's more like self-care of their bodies and running maybe they they can kind of you can figure out together when can they seamlessly fit it into their day how can they make it easiest to actually kind of follow through and might not make it a big disruption in their day.

So let's think about I want to make sure yeah let's think about time so how to manage time as it comes to homework. This is a big part of therapy if we look at therapy as like a workflow we start to think about how to manage our time in that 15 minutes that we typically have however long we have with our patients each time you want to think about the workflow and how to weave in therapy homework if typically what we do is in the first few minutes of the session we're going to find out how the patient is doing we check for symptoms for moods we do a mood survey before each session so we review the mood symptoms we check in with the patient and then we we take that minute or two like Confluence suggested of reviewing previous sessions homework so how are you doing. We're gonna connect on that first kind of empathy and connection and then how did how did it go with your homework assignments and then we're going to move on from that pretty quickly and we're going to have our bokova hour and what I'm recommending is throughout that hour if something comes up that you're thinking could be a good homework continue to kind of collaboratively use that time to figure out your other homework assignment. But then a moment 40 or 10 minutes before the end of the session you want to start you want to have an internal clock or you want you want to start to feel uncomfortable saying like okay we don't we haven't figured out our clear homework yet let's review the action plan so start moment 40 or so is when you want to start to have that kind of statement, let's review the action plan together what are we doing and then that'll give you enough time to maybe start on doing some of the kind of the initial plan of the of the homework assignments like I suggested to practice first in the session and then without you and between sessions. I'm gonna go just a little bit further deep into what to assign some of you are not familiar with TEAM-CBT and I think there's still some of the I'm going to go pretty briefly about it I think there's still something in it for you guys who are not familiar with TEAM-CBT but very briefly I want you to I'll give a quick synopsis of what is kind of TEAM-CBT to this to this way of thinking it's basically a process it's a process of workflow of how to do therapy in a way that makes it more effective and it creates basically gives a therapist a road map into how to conduct therapy based on it and if you look here in this schematic representation it's you P is for testing so we check symptoms before each session then we do our stuff in session and then we test again and then the patients will do homework and then we'll come again to the next session, we'll see their symptoms again, we're doing we'll do our magic together, check whether how helpful is it was assigning. So that's the that's the flow of things and what we do within session is also pretty clear like there's a pretty clear step-by-step process to what we do but and what we want to do is assign homework that also kind of moves us along the process of therapy and that's what I wanted to kind of share with you so for us we divide homework into kind of two kinds one is more of a lifestyle well-being type of homework and there's some thought and some data behind this kind of approach because the thinking is that what makes all therapies all kinds of schools of therapy would see one thought is what makes all of them kind of effective in a similar to a similar degree if done well is that they all kind of converge into the patient being able to do some of those wellness things that make would make anyone feel better that whether it's at their sleep and wake cycle whether it's to do more exercise or meditation. And so the one of the benefits of therapy is being able to kind of motivate encourage or have the patient be able to kind of start doing some of those more of like lifestyle or well-being wellness type of activities and these are typically behavioral and they go across the board they don't have to be in a particular process in the therapy to to start paying attention to that and that's one kind of therapy homework that we assign.

And then the other kind of therapeutic that we assign is more that one that more kind of moves the therapy process itself forward and that's typically more cognitive in nature and so I'll give you some examples of what we do because I know a lot of you are probably a little bit familiar with with TEAM-CBT so in TEAM-CBT we divide the steps roughly into these kind of places in therapy or steps in therapy where you see here in the left column which is start with testing and lack of empathy of course we always empathize with our patients even in other steps of therapy and then the next kind of shift in the process is when we ask for what we call an invitation so we invite our patient to work on something towards their goals and after that when we figure out what we're working on we're going to start to think about what would be some good reasons actually not to achieve those goals and bring the resistance to change to conscious awareness before we melted away and then the next step would be figuring out what whether the patient is going to be willing and able to whoops to do the work that is required in order to to overcome the problems and finally we're in kind of the method space so if in this process of therapy and we're still kind of in the empathy phase we don't really know exactly where the patient wants to go and what are the goals of therapy then the kind of the homework assignments that we would give would be ones that push us towards that so we would ask the patient to maybe Journal maybe think about their goals for therapy and write them down. Maybe we'll do a bunch of other kind of asking to do some work that helps them understand what their role in therapy would be in order to make it more successful and these will be the kind of assignments, these would be different if we already know what we're working on but we're not really specific so if we if if there's like there's like the invitation is like yes I do want to work on on some problem but we don't know enough about the problem and then so we we'd want our patients to maybe capture moments in time when they're if this is depression maybe that they were feeling more depressed or down and let's start to understand the anatomy of the feelings and thoughts and their sensations when they're feeling down. So this will kind of serve us for the next therapy session to be able to get this data and start working on it and then if we're kind of moving along we would again try to give homework assignments that move the therapy forward. I'm gonna just leave it at that here this is a little bit of a taste for you what kind of how to look at specific homework assignment with TEAM-CBT and I was giving this similar workshop to our team of of therapists a couple months ago we went more and we practiced some of this because it was more more relevant to them and if this kind of stuff interests you then you're welcome to take some of our trainings and kind of learn more about it and the last part that I want to share with you some some tips about how to create better engagement with therapy homework is thinking about accountability steps and anything that builds accountability could be helpful and to some degree maybe just checking previous sessions homework as a form of accountability but also as the ask the patient would you is there someone that you'd want to share that this is your plan with and so they would kind of commit to them to as a kind of accountability buddy. Maybe I'm certainly happy to always offer my patients to send me a text or an email telling me that they're they were able to do their homework just to kind of help them with their own accountability in between sessions and one one language kind of one way of saying this in a way that I think is is pretty cool is to is to use this mission accomplished versus suddenly refused language. So this is very deliberate based on David Burns's kind of work this he came up with this language but the idea is that if they complete the the homework the patient sent us sends us just two words mission accomplished but if they did not complete the homework they send the other words I stubbornly refused and so the idea there is to keep the patient really accountable believing in them they can totally do the homework you really believe in them that they can do this and it was their choice for whatever reason not to do it.

This could be another way of kind of holding folks accountable that you can think of some people don't like the idea of suddenly refused because it feels a little kind of hardlined and I can totally understand that as well so it's not for everyone and finally if you really want to do like a big accountability step you can do with some negative consequences. If they don't do it like if they don't go on their run they wash the dishes for the rest of the day or if they don't wake up on time they do some other chore that they're going to so we can kind of think of different negative consequences if they don't actually complete the homework in that can be a lot of fun to think about like kind of good helpful full negative consequences that don't really harm anyone other than deter you from not doing your homework. So now let's go to you guys so I want to ask you if you can take a moment to think about maybe one step that you can change you can kind of concentrate on in the coming weeks about what would be your your action plan and let's review what we've learned and think about what would be your action plan that you would want to take forward from here. The first is to remember to not forget to review your previous sessions homework but to they'll review it and briefly, so review it briefly that's one thing that's the first step that I took when I kind of got to realize that I'm not perseverating therapy homework. The second that I would suggest is to think about assigning homework that flows into the patient's routine to think about assigning homework that flows into their routine without it being too hard and the next one is to practice in session to make sure they write it down, assign homework throughout the session plus the last 10 minutes or use accountability steps. So maybe we can I can ask you to put in the chat box what would you suggest what would you commit to as your action plan. I'll give you a couple minutes. Very cool so I see that a lot of you have put in their plan thank you for that. I wonder why my screen is showing these Jill maybe you know why.

Jill Levitt: First of all or you should probably read so remember that the chat only went to you and I so no one saw anyone else right so what I would do is make sure that you're sharing with everyone what people are sharing and I have no idea who is writing on your screen or how that could possibly be happening, it's definitely not me but I see what you're talking about and I just don't know what that could be it.

Maor Katz: Looks like someone is realizing this and thank you for erasing item.

Jill Levitt: Yeah anyway all right, yeah good idea.

Maor Katz: So yeah I'm gonna go back to the chat box and read some of the things that people are committing to. So Piper is mentioning considering practicing journaling during session and when to start doing that and another a few are saying how about we practice to plan to practice the homework assignment in session. I love that I think that that that is wonderful. The key to that by the way is to to devote enough time so if you're that's in order for you to be able to do that to practice in session you're going to have to have that discomfort come up at minute 40 you know 10 minutes before the end so you really have the time to practice it a little bit before you actually run out of time and that's going to be that's going to be a key a key part I know that there's like a just gravitational pull to always kind of continue to engage in the session and then you're kind of wanting to really be respectful of the patient and might be going through something and you might be sharing with you or whatnot but the idea is that you want to be able to devote the time that you need in order to get through the practice. Others are mentioning flowing into into their routine and you'll want to be kind of make that part of the collaborative process of how to make it flow into the routine you want to think with them, how can we make it flow into your your life without being too disruptive when I think about it creatively and kind of try to solve that problem of how to make it not too disruptive others are suggesting that the accountability steps.

Yeah the accountability steps are really there could be a lot of fun as well when using accountability steps. The there's a lot of room for accountability steps in therapy not only for homework but for any kind of things are changing of habits then we use a lot of accountability steps in our work when we work with people to to change their habits towards towards a better habits. Let me see there's more that I like to share here so I think that catches a little bit of what people are saying I want to just mention to you a little bit about a Feeling Good Institute so what we have is we have this core group of therapists who practice in this approach of continuously improving continuously getting better and if you want to refer patients to to us through this group it's very simple we want to make it very simple for people to refer to us and so you can ask your patients however wants to to see a a patient's through our program is just go on a website and click on book a free consult we want to make it very simple this will get them to consult to set a time to meet with a clinician always with a clinician not with an admin who can help guide them towards if it's not themselves towards a better the best the best fit for them and I think with that I can I actually kind of got through the material a little bit faster than I expected so this allows for us to have a few minutes for questions so maybe if you can if if anybody has some questions in the chat box happy to to answer those right now.

Q&A Session