He has had enough, and I am still adding to him! It will bother him! 80%
! 90%
The picture describes the vicious circle of countertransference reaction, where automatic thoughts lead to developing negative emotions, bodily reactions and behaviors. Any vicious circle components can alert the therapists that their countertransference reaction is taking place.
Case Vignette –Discussion of Setting Homework During Supervision
Paul is a student in the second year of CBT training. In supervision, he reports the difficulty of assigning homework to an elderly patient suffering from depression after starting to have problems at work. Paul is convinced that the patient has a problem with homework at home due to his depression. Paul understands that he feels depleted and is overwhelmed by the bullying boss at work. During the session, the patient tends to complain about how uncomfortable his superior is and how difficult it is for him to manage these demands. In the session, the Socratic Dialogue alleviated the patient’s catastrophic thoughts about how the work could not last; nevertheless, he did not make other records of automatic thoughts at home. Paul thinks it’s because of depression and exhaustion from work. According to him, the patient no longer has the energy to do homework. Looking at the session video, the supervisor noticed that at the end of Paul’s session, he was giving homework briefly, uncertainly, almost as if he was apologizing, and did not find out how much the patient understood him or explain why the patient should do it. The supervisor and Paul looked at this part of the recording again. Then the supervisor asked Paul to write down a vicious circle of what was happening to him in the homework situation ( ). The elaboration of the vicious circle of one’s experience enabled Paul to conceptualize what was happening to him. He realized that it was similar to homework assignments with other patients. Nonetheless, with this older patient, it was even more difficult. When the supervisor asked him why he had a problem with this, Paul realized that he had a strict father who instructed him not to bother him as a child since he was exhausted from dealing with work issues. The mother also warned him and his sister not to disturb their father while he rested after a long work day. Her father’s mother was absent and disinterested in him. Thus, Paul realized he had a big problem asking for something from older individuals - such as homework or exposure. He has the impression that it is wrong and that it bothers them that they have had enough. He perceives it as disrespectful to them, as he is much younger, a psychologist who only recently completed his education. Similar thoughts and unpleasant feelings appeared to him with older women; nevertheless, he overcame them more easily. If they developed ambivalence or reluctance, they also quickly tended not to be given homework. Now Paul was very much aware of the situation. The record of automatic thoughts that Paul was given for his homework to fill in after the therapeutic sessions, where uncomfortable emotions appear, revealed other negative automatic thoughts. Paul doubted himself in some sessions, especially with elderly or university-educated patients. ‘Bigger problems’ occurred with both authoritarian-looking men and women. Paul often thought that he “cannot handle therapy”, “he cannot do it”, “he’s too soft”, “he’s too urgent”, “I am pushing too hard”, and “I do not believe in it”, “they certainly misinterpret it”. Paul learned to achieve a more balanced view of the situation with the Record of Automatic Thoughts ( ). At the simplest level, awareness gained through guided discovery, Socratic dialogue, or working with the Record of Automatic Thoughts may be sufficient to facilitate cognitive shift, which is then reflected in behavior leading to more promising therapeutic outcomes. In this case, Paul began to spend more time designing and assigning homework to his elderly patients. In the supervision session, he played it with the supervisor in front of the video camera with the help of changing roles. This practice and video feedback increased Paul’s confidence when completing homework, which was nicely seen in the next session recording with the same patient. During the session, Paul evoked an idea of the task and its usefulness to the patient. The result was the successful completion of homework and an improved mood. |
Homework assignments are a common part of supervisory work. These may involve the patient’s management (eg noticing on their recording how often the therapist strengthens the patient and how and if it is rare to clarify where reinforcement would be appropriate), working on oneself (eg clarifying experiences and attitudes that lead to countertransference in a particular patient, awareness of which other patients may also occur) and theoretical study (the supervisor may advise the therapist to read a professional text that can help better understand and work with the patient). 40
The supervisor helps define a specific engagement, discusses specific therapeutic methods, touches on what methods the therapist has used and what else they may consider the role, for the most part, the implementation of strategies whose ability to use in therapy under supervision will be planned, as part of homework.
Homework assigned in supervision usually deals with mapping problems (supplementing the conceptualization of the case, evaluation, vicious circle of the problem with the patient, etc.), monitoring certain behaviors (mostly communication with the patient), or implementing new, behaviors in therapy (usually using therapeutic strategies). 12 Homework teaches the supervisee to work on self-reflection outside the supervision meetings. 41 Discussing the homework properly at the beginning of the session is important. The mentioned home exercises usually concern the work with the supervised case report of the patient. The basic questions concern homework results, discussing the obstacles in solving them and what the supervisee learned in homework. 8 The discussion gives the supervisor case management information and can point to important practice moments.
Before the end of the session, the supervisor and the supervisee agree on a homework assignment. It is optimal when homework arises from a problem addressed in the session’s main part. 8 At the beginning of supervision, proposals for homework assignments usually come from the supervisor and are discussed and recorded in writing. 40 During supervision, the supervisee creates homework assignments, and the content is discussed with the supervisee.
Homework must make sense for the supervisee; otherwise, he will have no motivation to do it. However, it is also important to make sense of the patient or patients and develop the therapist’s skills and competencies. It is desirable to discuss the meaning of homework in supervision.
It is advantageous to discuss the anticipated difficulties in completing homework. This has the advantage that the supervisee can prepare for possible difficulties, consider overcoming them and consult with the supervisor. Discussing difficulties helps the supervisee model and later develops the skill to discuss the patient’s homework difficulties.
In some therapists, there can be reasons for a more complex level of conceptualization. 42 That is important when the therapist repeats certain mistakes even though they have repeatedly discussed them with the supervisor. At a directly accessible level, the situation with the patient can be described using a vicious circle. The deeper “hidden” level refers to the core beliefs and conditional rules activated in a specific situation with the patient. 40 , 43 A supervisor can use the “falling arrow” technique to map core beliefs and conditional assumptions. 43
One such way is the Therapeutic Belief System (TBS). 44 TBS is a theoretical model useful for understanding the specific beliefs, assumptions, and behaviors that therapists and patients commonly experience that could potentially affect the course of therapy. In line with the cognitive model, TBS provides a framework for identifying therapists’ and patients’ beliefs about themselves, each other, the treatment process, the emotions these beliefs can evoke, and typical behavioral reactions. For example, a therapist may see a patient as an “aggressor”, a “helpless victim”, or a “collaborator”. The participant’s own beliefs may supplement these beliefs about himself, such as “victim”, “co-worker”, “carer”, or “rescuer”. Homework assignments may be perceived by both the therapist and the patient as “hopeless”, “productive”, or simply maintaining the status quo and lead to a different emotional and behavioral response. 8 Thus, TBS can be introduced into supervision to guide the supervisee to consider whether he or she identifies with any of the therapists’ typical beliefs and behaviors outlined in the model. A simple awareness of such patterns can be a useful orientation when considering the role of attitudes and beliefs in integrating homework ( Box 4 ).
Case Vignette – Discussion About Supervisee Homework
Ludmila is a third-year student at CBT. She experienced a more intense emotional response as she considered completing her homework for a patient with a social phobia with strong patterns of vulnerability and addiction. The patient showed significant symptoms of social phobia. She has been repeatedly hospitalized, taking antidepressants and attending psychiatric group psychotherapy in daycare twice; nonetheless, social anxiety and avoidant behavior persist. Ludmila and the patient mapped out the conceptualization of problems and began thinking about therapeutic steps that included behavioral experiments and graded exposure to reduce social avoidance gradually. However, in a discussion with the supervisor, she stopped a behavioral experiment, saying it would not work with the patient. When the supervisor asked her what she was going through, she said that anxiety, when evaluating her intensity, it was up to 8 out of 10. When mapping a vicious circle about the situation, she said she was struck by the following: “She’s checking that it cannot work”; “I have never used a behavioral experiment before. I will ruin it and look incompetent in front of the patient!” Using the “falling arrow” technique, the supervisor and Ludmila came to the core belief “I am incompetent” and the conditional rule “I have to do everything perfectly. Otherwise, it’s priceless”: Core belief: “I am incompetent”. Conditional rules: “I have to do everything perfectly. Otherwise, it’s priceless”. “I should always be prepared for everything, or I will be embarrassed!” Behavior strategies related to core beliefs and conditional assumptions: • I read a lot about how to work with patients, and I still go to supervision to find out how not to make a mistake; • I do in therapy those strategies that I know very well, such as working with the vicious circle and cognitive restructuring; • I avoid doing strategies that I have not yet tried, such as behavioral experiments or working with schemes, prescriptions in the imagination and more; • I avoid asking the supervisor to try it when playing roles because I fear the supervisor will understand that I am incompetent. The core scheme and the conditional assumptions showed why Ludmila avoided giving the necessary homework to help the patient with social phobia. When Ludmila realized her attitude through self-reflection, the supervisor asked her to practice a situation she avoided with the patient by playing roles. They first replayed the situation so that the supervisor played Ludmila’s patient, and then they changed roles so that Ludmila could experience the patients’ feelings while building the behavioral experiment. Ludmila then planned her behavioral experiment with the supervisor, which involved testing a more optimistic view of the patient’s resilience and taking the “risk” of homework without being sure of the outcome. Ludmila performed this experiment, and the patient did her homework well. This encouraged Ludmila to try strategies she was less experienced with other patients. She exposed herself to greater uncertainty, gradually increasing her courage and self-evidentness. |
The scheme broadly refers to mental structures that integrate and give meaning to events. 45 Schemes can be positive, negative or neutral. In CBT as a treatment for psychological disorders, we focus on dysfunctional patterns often associated with specific diagnostic presentations (for example, emotional vulnerability patterns are common in anxiety disorders). Schema is generally defined as a ubiquitous topic of cognitive functions, emotions, physiological feelings about oneself, and relations with others. 33
Therapists’ schemes run in specific therapies and do not usually signal mental health problems. 8 Therapists’ schemes are influenced by the following factors: training experiences, such as supervision and training phase, therapy model, peer group, clinical experience, and personal experience. 13 , 40 Once identified, the therapist’s scheme can be used in supervision as a starting point to discuss some of the practitioner’s views that may interfere with therapy. 8 Completing structured questionnaires can identify participants’ schemes, basic beliefs, and assumptions. Some examples of useful questionnaires are the Dysfunctional Attitudes Scale, 46 the Personal Faith Questionnaire, 47 the Young Schema Questionnaire 48 and the Therapists’ Schema Questionnaire. 49 Leahy’s Therapists’ Scheme Questionnaire is a relatively straightforward screening technique for identifying therapeutic patterns that could affect a therapeutic relationship. It consists of 46 assumptions related to the 14 most common therapeutic regimens.
Certain schemes are particularly common in CBT supervisees. These include “demanding standards”, “excessive self-sacrifice”, and “special superior person”. 49 Training therapists who identify with the “demanding standards” scheme have a somewhat obsessive, perfectionist, and controlling approach to therapy. These therapists usually have high expectations for keeping a patient’s homework and may not realize that non-compliance with homework is often part of the learning process. Therapists may expect that there is a “right” way to complete a homework assignment, leading to feelings of frustration when assignments produce different results. This may signify insecurity and a notion that if things break from the planned structure, the therapist will be exposed as “incompetent”. Many therapists identify with the “excessive self-sacrifice” pattern, the most commonly observed pattern in both novice and experienced therapists. 33 Leahy 49 proposes that these therapists overstate the importance of their patient relationships. They may fear leaving or feel guilty that they are or feel better than the patient. As a result, the therapist may engage in therapy-defeating behaviors, such as making the homework assignment to the patient’s various needs, having difficulty with appropriate assertiveness in discussing persistent patient non-cooperation, and having a tendency to avoid techniques. Such as exposure or opening of painful memories for fear that the patient will be upset.
Novice therapists who identify with the “special superior person” scheme see the therapeutic situation as an opportunity to achieve excellent results and have high-performance expectations. There may be a tendency for the patient to idealize or, conversely, to devalue or distance himself from patients who do not improve or do their homework. The presence of a “special superior” scheme can be seen as overcompensation in response to “demanding standards” and “excessive self-sacrifice”, which have the thematic connotations of “not being good enough”. The supervision session sets the supervisee in a situation where the supervisor supervises homework through videotaped therapeutic sessions utilizing a cognitive therapy scale (CTS). 50 Feelings of superiority and exceptionality can, in some cases, be a way of dealing with the feelings of inferiority that they experience, that their use of homework is judged in this way.
In addition to recognizing the general responses to the scheme that most training students encounter, the supervisor should help the supervisor become aware of his or her idiosyncratic beliefs and coping styles, which some patients may trigger ( Box 5 ). The supervisor should encourage the supervisee to pay special attention to the “overlapping patterns” in which the therapist’s scheme and the patient’s scheme overlap, leading to the over-identification of the therapist with the patient. 33
Case Vignette – The Supervisor Advises the Therapist to Work with Core Beliefs and Conditional Rules
Petr works with a patient diagnosed with the obsessive compulsive disorder and social phobia and with a scheme of excessive vulnerability. Difficulties have persisted for many years, and controlling compulsive and avoidant behaviors have become the patient’s basic coping strategy. The patient was engaged in many “healthy” activities, such as “cleanliness”, “healthy eating”, and “healthy sleep”, which she performed ritually. She avoided most of the social and work situations that caused anxiety, which resulted in a very limited lifestyle with many open hours during the day, which she filled with compulsions. The patient felt frustrated by both the compulsions and the limited lifestyle. She also felt paralyzed by her basic beliefs, “I am different and vulnerable”, and other people are “overly demanding, critical, condemning and harshly rejecting”. Her attitude followed her childhood classmates’ refusal because she was overweight. Petr works with the patient for about 12 sessions. Now, he has come to supervise her case for the first time. During this time, he developed a good therapeutic relationship with the patient. The patient was well involved in the therapeutic process. It was also possible to expose her to social situations and reduce excessive hand washing. However, Petr encouraged “healthy cooking and sleeping”, which took several hours a day, because he considered it a proper “healthy lifestyle”. Petr described these several-hour activities as “successes” and did not consider them possible compulsive strategies that can, among other things, make it possible to avoid stressful situations. The patient has repeatedly expressed that healthy eating and going to bed take much time. However, Petr responded to the patient’s self-criticism with reassurance and further praise for the patient’s accomplishments. Because there were only partial changes in compulsive behavior in reducing excessive washing, the supervisor emphasized that the homework assignment revealed a tendency to fill time with compulsive and trivial activities, which the patient herself points out. The supervisor acknowledged Petr and the patient’s progress in developing a good therapeutic relationship and improving social interactions by reducing excessive washing. She then suggested that Peter and the patient should no longer explore healthy cooking and sleeping and how compulsive and beneficial they were to the patient. Supposedly the patient wants to reduce the time devoted to these activities, and Petr should consider how to help her. Peter was irritated by the supervisor’s opinion and began to explain why he did not feel like doing so. He angrily said it was just an interpretation of the supervisor for which he had no evidence. The supervisor noticed a change in their emotional response and asked Peter to say what was going through his head. Peter said he thought healthy cooking and healthy sleep were related to a healthy lifestyle and should be encouraged, not considered compulsive. The supervisor acknowledged that he might be right. She went back to why it made Peter so upset. Petr angrily said that the supervisor did not appreciate their progress with the patient and was looking for something to criticize. They returned to what she had told him, then asked again if anything else had occurred to him, why it was such an emotionally critical situation. Peter calmed down and said he was also trying to sleep soundly and cook healthily, putting much effort into it. As his patient, he was overweight as a child, and his classmates mocked him. He is not overweight now. He carefully checks his condition, exercises, and sleeps regularly. Therefore, he understands the patient’s effort to adhere to the order. The supervisor expressed understanding of Peter’s explanation. She then asked him if he would consider his homework, what core beliefs and conditional rules might play a role, and if his patient did not have something similar. For further supervision, Petr brought homework with the following core scheme and behavior strategies: Core belief: “I am different, ugly and unlovable”. “Others are overly critical and reject the different”. Conditional assumption: “I have to try to be precise and control everything so that I don’t experience reprimand!” Behavior strategies: • daily weight control, healthy eating, regular exercise and sleep • frequent attempts to emphasize its uniqueness and difference • constant efforts to prevent rejection Peter also realized that his beliefs about himself and others were similar to those of his patient and, like his beliefs, had been ridiculed in childhood. He also acknowledged that he identified with the patient’s distress and could risk-taking on the role of “savior” and overemphasize the patient’s diversity and sensitivity. He decided to thoroughly examine “healthy cooking and sleep” with the patient and determine how much it bothers the patient and what she would like to change. |
For supervisors, their supervisors’ training is important. An important part of this training is the practice of self-reflection, which should be requested directly in the meeting and as homework. It can be a task to capture situations in supervision in which they do not feel comfortable using the vicious circle, cognitive restructuring of automatic negative thoughts in these situations, capturing thoughts, emotions, bodily sensations and behaviors in situations where they are aware that they are experiencing countertransference reactions to the supervised therapist. It is also important that in their homework, they reflect on their concentration level during supervision sessions and consider what supervision skills they have used or what they have learned for the next session. A typical complex homework in supervision training is a video recording of supervision sessions and their analysis. The recorded supervision and analysis are then analyzed in the next supervision training meeting.
This article is designed as an overview of views and experiences. Its important element is work samples. This is also a limitation of this article. Assignment of homework in supervision and therapist and supervisor training lacks scientific information about its effectiveness. Nevertheless, assigning homework is an important part of cognitive behavioral therapy. We know quite well about its meaning in prescribing for patients. Less is known about their meaning and effectiveness in supervision. The supervisee encounters problems completing homework assignments for her patients that she brings to the supervisee. Why the patient does not complete the homework may be his problem, but his therapist may also have a part in it his requirements, which include how the homework is assigned, its suitability for the given patient, timing, and complexity. Homework can also belong to the training of supervisors and the supervision of supervision. Here, we do not know any research evidence about their effectiveness in using the most important part of supervision, the patient; however, they are experienced by supervisors and supervisees as useful and meaningful.
Homework in supervision and supervision requires further reflection on their meaning and subsequent research, which should examine their significance for the supervisee’s competence (supervisee) and the ultimate impact on the patient himself.
Homework presents one of the cornerstones of cognitive-behavioral therapy, CB supervision and the training of CBT supervisors. If applied consistently and collaboratively, homework enhances therapeutic outcomes and increases the patient’s self-confidence. Setting and maintaining a fruitful working alliance for homework can be challenging – issues with homework present one of the common reasons to seek a supervisory consultation. Supervision then focuses on examining the specific case and experienced problems, factors in the interaction between the therapist and their patient, and the therapist’s automatic thoughts, schemas, and behaviors that might maintain the issue. There are several ways to address this topic in supervision. Homework is usually part of supervision because of its usefulness. The supervised therapist may be given similar tasks as the patient receives in therapy: to describe the automatic thoughts that occur to him while guiding the patient, to test them and look for a more rational response, to conduct behavioral experiments, to clarify the core beliefs and conditioned assumptions that influence the formation of the therapeutic relationship, experiments with adequate communication with the patient and others. A therapist’s self-experience through practice can help them improve their therapeutic work.
This paper was supported by the research grant VEGA no. APVV-15-0502 Psychological, psychophysiological and anthropometric correlates of cardiovascular diseases.
The authors report no conflicts of interest in this work.
Table of contents, why do homework in cbt, how to deliver homework, strategies to increase confidence.
Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect thoughts, and modify their thinking.
Homework is not something that you just assign randomly. You should make sure you:
Types of homework assignments.
Behavioural Activation | Getting active, depressed patients out of bed or off the couch, and helping them resume normal activity |
---|---|
Monitoring automatic thoughts | From the first session forward, you will encourage your patients to ask themselves, “What’s going through my mind right now?” |
Evaluating and responding to automatic thoughts | At virtually every session, you will help patients modify their inaccurate and dysfunctional thoughts and write down their new way of thinking. Patients will also learn to evaluate their own thinking and practice doing so between sessions. |
Problem-solving | At virtually every session, you will help patients devise solutions to their problems, which they will implement between sessions. |
Behavioural skills | To effectively solve their problems, patients may need to learn new skills, which they will practice for homework. |
Behavioural experiments | Patients may need to directly test the validity of automatic thoughts that seem distorted, such as “I’ll feel better if I stay in bed” |
Bibliotherapy | Important concepts you are discussing in session can be greatly reinforced when patients read about them in black and white. |
Preparing for the next session | Preparing for the next therapy session. The beginning part of each therapy session can be greatly speeded up if patients think about what is important to tell you before they enter your office. |
You should also decide the frequency of the homework should be assigned: should it be daily, weekly?
If your patient does not do homework, that’s OK! Explore as a team, in a non-judgmental way, to explore why the homework was not done. Here are some ways to increase adherence to homework:
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This article contributes a comprehensive model of homework in cognitive behavior therapy (CBT). To this end, several issues in the definition of homework and homework compliance are outlined, research on homework-outcome relations is critiqued, before an overview of classical and operant conditioning along with various cognitive theories are tied together in a c omprehensive model. We suggest engagement represents a more clinically meaningful construct than compliance (or adherence). We describe how established behavior and cognitive theories are relevant for understanding patient engagement and what between-session and in-session processes are useful in a comprehensive model. Our primary conclusion from the review of this literature is that current research has focused on limited aspects of homework and missed theoretically meaningful determinants of engagement. Further, little research has sought to examine the role of the therapist in facilitating these theoretically meaningful determinants. The literature on homework is the most advanced of the process research in CBT; the comprehensive model presented here offers clarity for the practicing clinician and represents a testable model for researchers interested in quantifying determinants of homework engagement and the process of integrating homework into CBT.
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The authors thank Aaron T. Beck and Judith S. Beck for helpful discussions and guidance on the topic of integrating homework into CBT.
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Kazantzis, N., Miller, A.R. A Comprehensive Model of Homework in Cognitive Behavior Therapy. Cogn Ther Res 46 , 247–257 (2022). https://doi.org/10.1007/s10608-021-10247-z
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Table of contents.
Cognitive Behavioral Therapy (CBT) stands as a powerful, evidence-based therapeutic approach for various mental health challenges. At its core lies a repertoire of techniques designed to reframe thoughts, alter behaviors, and alleviate emotional distress. This article explores 20 most commonly used cbt techniques. These therapy techniques are scientifcally valid, diverse in their application and effectiveness, serve as pivotal tools in helping individuals navigate and conquer their mental health obstacles.
This is the most talked about of all cbt techniques. CBT employs cognitive restructuring to challenge and alter negative thought patterns. By examining beliefs and questioning their validity, individuals learn to perceive situations from different angles, fostering more adaptive thinking patterns.
John, feeling worthless after a rejected job application, questions his belief that he’s incompetent. He reflects on past achievements and reframes the situation, realizing the rejection doesn’t define his abilities.
In guided discovery, therapists engage individuals in an exploration of their viewpoints. Through strategic questioning, individuals are prompted to examine evidence supporting their beliefs and consider alternate perspectives, fostering a more nuanced understanding and empowering them to choose healthier cognitive pathways.
During therapy, Sarah explores her fear of failure. Her therapist asks, “What evidence supports your belief that you’ll fail? Can we consider alternate outcomes?” Guided by these questions, Sarah acknowledges her exaggerated fears and explores more balanced perspectives.
Writing exercises like journaling and thought records aid in identifying and challenging negative thoughts. Tracking thoughts between sessions and noting positive alternatives enables individuals to monitor progress and recognize cognitive shifts.
James maintains a thought journal. Between sessions, he records negative thoughts about social situations. He then challenges these thoughts, jotting down positive alternatives and notices a shift in his mindset.
By scheduling avoided activities and implementing learned strategies, individuals establish healthier habits and confront avoidance tendencies, fostering behavioral change.
Emily, struggling with social anxiety, schedules coffee outings with friends. By implementing gradual exposure, she confronts her fear and eventually feels more comfortable in social settings.
CBT incorporates relaxation techniques like deep breathing, muscle relaxation, and imagery to mitigate stress. These methods equip individuals with practical skills to manage phobias, social anxieties, and stressors effectively.
David practices deep breathing exercises when faced with work stress. By incorporating this technique into his routine, he manages work-related anxiety more effectively.
Breaking overwhelming tasks into manageable steps cultivates confidence through incremental progress, enabling individuals to tackle challenges more effectively.
Maria, overwhelmed by academic tasks, breaks down her study sessions into smaller, manageable sections. As she masters each segment, her confidence grows, making the workload seem more manageable.
This technique targets panic and anxiety by exposing individuals to feared bodily sensations, allowing for a recalibration of beliefs around these sensations and reducing avoidance behaviors.
Tom, experiencing panic attacks, deliberately induces shortness of breath in a controlled setting. As he tolerates this discomfort without avoidance, he realizes that the sensation, though distressing, is not harmful.
Encouraging individuals to envision worst-case scenarios helps alleviate fear by demonstrating the manageability of potential outcomes, reducing anxiety.
Facing fear of public speaking, Rachel imagines herself stumbling during a presentation. By playing out this scenario mentally, she realizes that even if it happens, it wouldn’t be catastrophic.
Shaping involves mastering simpler tasks akin to the challenging ones, aiding individuals in overcoming difficulties through gradual skill development.
Chris, struggling with public speaking, begins by speaking to small groups before gradually addressing larger audiences. Each step builds his confidence for the next challenge.
This method utilizes reinforcement and punishment to promote desirable behaviors, leveraging the consequences of actions to shape behavior positively.
To encourage healthier eating habits, Sarah rewards herself with a favorite activity after a week of sticking to a balanced diet.
Role-playing scenarios allow individuals to practice new behaviors in a safe environment, facilitating skill development and desensitization to challenging situations.
Alex, preparing for a job interview, engages in role-playing with a friend. They simulate the interview scenario, allowing Alex to practice responses and manage anxiety.
Addressing the link between depression and sleep problems, this technique provides strategies for improving sleep quality, a critical aspect of mental well-being.
Lisa, struggling with sleep, follows sleep hygiene recommendations. She creates a calming bedtime routine and eliminates screen time before sleep, noticing improvements in her sleep quality.
Encouraging engagement in enjoyable or accomplishment-driven activities serves as a mood enhancer and distraction from depressive thoughts.
After feeling low, Mark engages in gardening (a mastery activity) and then spends time painting (a pleasure activity). He finds joy in these activities, which uplifts his mood.
This technique involves creating real-life experiments to test the validity of certain beliefs or assumptions. By actively exploring alternative thoughts or behaviors, individuals gather concrete evidence to challenge and modify their existing perspectives.
Laura believes people judge her negatively. She experiments by initiating conversations at social gatherings and observes that most interactions are positive, challenging her belief.
Externalizing helps individuals separate themselves from their problems by giving those issues an identity or persona. This technique encourages individuals to view their problems as separate entities, facilitating a more objective approach to problem-solving.
Adam, dealing with anger issues, visualizes his anger as a separate entity named “Fury.” This helps him view his emotions objectively and manage them more effectively.
ACT combines mindfulness strategies with commitment and behavior-change techniques. It focuses on accepting difficult thoughts and emotions while committing to actions aligned with personal values, promoting psychological flexibility.
Sarah practices mindfulness exercises to accept her anxiety while committing to attend social events aligned with her values of connection and growth.
This technique involves mentally visualizing feared or distressing situations, allowing individuals to confront and manage their anxieties in a controlled, imaginative setting.
Jack, afraid of flying, visualizes being on a plane, progressively picturing the experience in detail until he feels more comfortable with the idea of flying.
MBSR incorporates mindfulness meditation and awareness techniques to help individuals manage stress, improve focus, and enhance overall well-being by staying present in the moment.
Rachel practices mindfulness meditation daily. By focusing on the present moment, she reduces work-related stress and enhances her overall well-being.
Similar to exposure therapy, systematic desensitization involves pairing relaxation techniques with gradual exposure to anxiety-inducing stimuli. This process helps individuals associate relaxation with the feared stimuli, reducing anxiety responses over time.
Michael, with a fear of heights, gradually exposes himself to elevators first, then low floors in tall buildings, gradually working up to higher levels, reducing his fear response.
Narrative therapy focuses on separating individuals from their problems by helping them reconstruct and retell their life stories in a more empowering and positive light, emphasizing strengths and resilience.
Emily reevaluates her life story by focusing on instances where she overcame challenges, emphasizing her resilience and strength rather than her setbacks.
Each of these CBT techniques plays a unique role in helping individuals transform their thoughts, behaviors, and emotions. While some focus on cognitive restructuring, others emphasize behavioral modification or stress reduction. Together, they form a comprehensive toolkit empowering individuals to navigate their mental health challenges and foster positive change in their lives.
Explore the concept of trauma-informed care and find out how this method is reshaping the world of addiction treatment.
The availability heuristic is a cognitive bias that affects decision-making based on how easily information can be recalled or accessed.
Uncover effective strategies to address dual diagnosis in adolescents, ensuring early intervention for a brighter and substance-free future.
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Cognitive Behavioural Therapy (CBT) is a very practical therapy that involves homework as a huge part of the therapy process.
You may think of school when they hear the term “homework”, and that's understandable. However, homework in CBT is actually a really good thing. The reason that there is a heavy focus on homework or “between session tasks,” during the therapy process is because it is at this point where you can practice the skills you have learnt in therapy. It also tends to be where the magic happens, new learning takes place and people start to notice a shift in how they are feeling.
Imagine you and a friend want to learn a new language and sign up for Spanish lessons once a week. If you attend the one-hour weekly session but do not practise between sessions, but your friend practises daily in addition to attending the weekly session, who do you think will pick up more of the language? If your answer is your friend, then you are right! CBT is very similar in that those who make the time to practise using CBT skills daily are more likely to recover quicker and benefit more from CBT than those who just attend weekly sessions but do not complete the homework in between therapy sessions.
The goal of CBT is to teach you skills to become your own therapist so you can go on and self-manage your day-to-day symptoms and ultimately oversee your recovery. So, the more you practice mastering the skills outside of your therapy sessions, the better you will become in using those skills on your own and well into the future.
Quite often, us Brits like a quick fix, and many come to therapy expecting to be fixed without really doing anything. Unfortunately, this expectation is unrealistic. Most therapies nowadays involve work on both sides, and CBT is no different.
A typical homework task may be something such as completing an activity during the week that you used to enjoy or tackling something that you have been putting off such as paying a bill or booking a doctor’s appointment. It may also be something like having a conversation with a stranger, making a call to someone, or going somewhere that you have been avoiding, such as the supermarket. All homework tasks are decided together with your therapist and are designed to push you slightly out of your comfort zone. The tasks are always in line with your therapy goals and should be designed with those in mind.
Homework can be hard, especially if we are unmotivated or anxious about completing it. If you are having trouble completing the homework, have a chat with your therapist. Together, you should be able to problem solve it and come up with some solutions to try and make things seem more manageable. For example, it might be setting an alarm for a specific time each day to remind you to complete the task you have set yourself. Or it may be breaking the task down to something smaller that feels less overwhelming and more achievable.
It may also be worth thinking about how the homework task will help you work towards achieving your goals. Doing nothing, although easier, is not going to get you where you want to be and will likely keep you stuck where you are. However, doing the homework task will require effort and time, but it is likely to help you work step by step towards where you truly want to be.
Useful Links
https://laurahanstherapy.co.uk/therapy/what-is-cognitive-behavioural-therapy/
https://babcp.com/What-is-CBT
https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/
The New “Homework” in Cognitive Behavior Therapy | Beck Institute for Cognitive Behavior Therapy
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Back to Journals » Psychology Research and Behavior Management » Volume 15
Authors Prasko J , Krone I , Burkauskas J , Vanek J , Abeltina M , Juskiene A , Sollar T , Bite I , Slepecky M , Ociskova M
Received 18 July 2022
Accepted for publication 5 December 2022
Published 22 December 2022 Volume 2022:15 Pages 3809—3824
DOI https://doi.org/10.2147/PRBM.S382246
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Peer reviewer comments 2
Editor who approved publication: Dr Igor Elman
Jan Prasko, 1– 4 Ilona Krone, 5 Julius Burkauskas, 6 Jakub Vanek, 1 Marija Abeltina, 7 Alicja Juskiene, 6 Tomas Sollar, 2 Ieva Bite, 7 Milos Slepecky, 2 Marie Ociskova 1, 4 1 Department of Psychiatry, University Hospital Olomouc, Faculty of Medicine, Palacky University in Olomouc, Olomouc, The Czech Republic; 2 Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra, The Slovak Republic; 3 Department of Psychotherapy, Institute for Postgraduate Training in Health Care, Prague, The Czech Republic; 4 Jessenia Inc. - Rehabilitation Hospital Beroun, Akeso Holding, Beroun, The Czech Republic; 5 Riga`s Stradins University, Riga, Latvia; 6 Laboratory of Behavioral Medicine, Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania; 7 University of Latvia, Latvian Association of CBT, Riga, Latvia Correspondence: Jan Prasko, Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University Olomouc, University Hospital, I. P. Pavlova 6, Olomouc, 77520, The Czech Republic, Tel +420 603 414 930, Email [email protected] Abstract: The homework aims to generalize the patient’s knowledge and encourage practicing skills learned during therapy sessions. Encouraging and facilitating homework is an important part of supervisees in their supervision, and problems with using homework in therapy are a common supervision agenda. Supervisees are encouraged to conceptualize the patient’s lack of homework and promote awareness of their own beliefs and responses to non-cooperation. The supervision focuses on homework twice – first as a part of the supervised therapy and second as a part of the supervision itself. Homework assigned in supervision usually deals with mapping problems, monitoring certain behaviors (mostly communication with the patient), or implementing new behaviors in therapy. Keywords: supervision, cognitive behavioral therapy, homework, self-reflection
The development of competent clinical supervision is crucial to effectively training new CBT therapists and supervisors and maintaining high therapy standards throughout their careers. 1 Clinical supervision is a basis for CBT training, but there are only a few empirical evaluations on the effect of supervision on therapists’ competencies. Wilson et al 2 in their systematic review and meta-analysis, synthesized the experience and impact of supervision for trainee therapists from 15 qualitative studies. Although supervision leads to feelings of distress and self-doubts, it can effectively support supervisees in personal and professional development. It could similarly harm supervisees’ well-being, clinical work and clients’ experiences. Alfonsson et al 3 published a study to evaluate the effects of standardized supervision on rater-assessed competency in six CBT therapists under protocol-based clinical supervision. This is one of the first investigations showing that supervision affects cognitive behavioral competencies. Although several works have studied the effectiveness of supervision on the therapist’s competence and for the therapist’s work with patients in qualitative studies, 3–7 there is still a lack of studies that dealt with the importance of homework in supervision.
Homework is a vital element of cognitive behavioral therapy (CBT) which distinguishes it from many other psychotherapeutic approaches. 8–10 Patients usually participate in therapy by completing homework assignments and taking responsibility for their course.
Assigning and discussing homework is one of the basic competencies of a cognitive-behavioral therapist and a supervisor in the context of counselling, psychology, therapy, and social work. The manuscript aims to refer to homework in several settings: homework in therapy, supervision of homework in therapy, using the homework by the supervisor for the supervisee, and homework in the training of supervisors.
While specific recommendations for the practical usage of homework have been clearly articulated since the early days of CBT, 11 , 12 practitioners state that they do not follow these recommendations. 13–15 For example, many physicians admit that they forget homework or do not focus on standard specifications when, where, how often, and how long the task should last. Often reported non-cooperation in homework assignments may be due to the practice recommendations being too strict or because students think the amount of homework they can assign is limited. 16
Therapists strategically create homework to reduce patients’ psychopathology and encourage them to practice skills learned during therapy sessions; nevertheless, non-adherence (between 20% and 50%) remains one of the most cited reasons for decreased CBT efficacy. 21 Several reasons for non-adherence to homework might be pointed out –the therapist does not regularly discuss homework with the patient, the patient no longer considers it important and stop doing it. 9 , 22 Discussing homework also allows the therapist to strengthen the patient’s belief in their ability to achieve certain goals. 23 The fact that the patient has completed the assignment must be properly acknowledged, and then therapists discuss the quality of homework separately. 24 Good questions might be, “How did you do your homework? Were there any difficulties in fulfilling them? What kind?” Furthermore: “How can you handle these problems next time? What did you learn while completing your homework? Can it help you cope with other issues?”
An important aspect of CBT is the patient’s independence. 10 , 18 Homework is typically determined by consensus. To increase the likelihood that the patient will complete the homework, the patient and the therapist should document their assignments in writing. Additionally, it is very convenient for the patient to record the homework, typically pre-prepared. 24 These records serve as a basis for discussing homework in the next session and also allow the therapist to assess the changes achieved during therapy (“A month ago, you were able to go out alone for only half an hour and your anxiety level previously reached level ‘9’, while now you were alone outside for more than an hour and your anxiety do not exceed ‘5’ rated subjectively”).
Because the goal of therapy is to help the patient experience success, the patient’s assigned homework must be feasible. 18 , 26 On the other hand, patients should improve their ability to cope with problems and unpleasant conditions during therapy, they need to exert significant effort to overcome certain unpleasant feelings and emotions. 19 , 20
Therefore, therapists do not consider the non-fulfilment of homework a priori as a manifestation of resistance or lack of moral qualities on the patient’s part, then as a problem that must be solved together.
However, if, despite a thorough discussion of homework and agreement on its completion, the patient repeatedly does not even attempt to complete it, does not bring records and fails to justify non-compliance, it is necessary to return to the problem analysis and goal-setting. We need to clarify with the patient whether the problem they are currently dealing with in therapy is really the most important for them, whether the goal they seek to achieve is sufficiently desirable, and whether the therapist offers to achieve is acceptable. 9 , 20
Case Vignette – Discussion About Not Completing Homework with an Anxious Patient |
Kazantzis et al 28 advise examining the therapeutic relationship, which significantly impacts therapy adherence, to better comprehend non-cooperation with homework assignments. Data illustrating the therapist’s homework competence and the therapy outcome 29 , 30 show that the therapist is primarily responsible for their patients’ adhering to or failing to do homework. CBT therapists exhibit many interrelated automatic thoughts, assumptions, and behaviors during sessions that affect homework use in therapy. 8 , 15 In training, common negative attitudes for therapists include: “Homework will make patients feel like school and resent!” “They will feel too controlled and limited!”; “Homework will increase some ps’ sense of vulnerability!”; or “Homework will be even more stressful for stressed patients!” Another widespread belief is that the “structure” of CBT, whose homework is important, reduces spontaneity and worsens the therapeutic relationship. 15
In addition, there is some scientific support for these views of therapists’ attitudes toward homework concerning the therapeutic process. 31 The result of these attitudes is either a complete avoidance of homework assignments in a way that is not effective and consequently maintains these beliefs. 8 For example, common behaviors require supervision, such as rapidly discussing directions at the end of a session, neglecting to repeat homework, or failing to justify while designing homework. 9 The CBT Homework Project proposed a practice model 29 that emphasizes the importance of therapist beliefs, therapist empowerment, cognitive conceptualization, and the therapeutic relationship in enhancing homework practice. 23
Theoretical and empirical support for homework assignments in CBT leads most practicing CBT therapists to at least accept in principle that regular and systematic homework assignments will benefit their patients. 8 As a result, CBT therapists favour assigning homework in therapy. However, many beginning therapists encounter problems when they start designing homework (ie, selecting tasks and discussing them with the patient), assigning homework (ie, collaborating on practical aspects of completing homework), and repeating homework in sessions. 32 Incorporating homework into therapy is often superficial, hasty, poorly done, or forgotten. 16 Therefore, problems with using homework in therapy are a common supervision agenda of practicing CBT therapists.
CBT training students are encouraged to conceptualize the patient’s lack of homework and promote awareness of their own beliefs and responses to non-cooperation in the CBT conceptual framework. 8 Suppose the therapist fails to develop this awareness. In that case, errors in clinical judgment may occur, adversely affecting the therapeutic relationship and course of therapy. 33 Self-exercise (practicing CBT techniques and interventions as a therapist) and self-reflection (ie, process reflection) are concepts developed by Bennett-Levy et al, 34 to operationalize a useful understanding of own processes in working with patients. CBT training students are asked to become accustomed to using self-exercise and self-reflection. In a few qualitative studies, self-exercise and self-reflection have proven to improve the therapist’s self-concept, ie, self-confidence, perceived competence in one’s abilities and belief in the effectiveness of the CBT model. 34–36 Calvert et al 37 study checked the use of meta-communication in supervision from supervisees’ perspectives using the Metacommunication in Supervision Questionnaire (MSQ). There were differences in the reported frequency with which the different types of meta-communication were used. It appears that meta-communication around difficult or uncomfortable feelings in the supervisory relationship occurs less often than other components of meta-communication. 1
Below are examples of self-exercise and self-reflective exercises. The following self-assessment is developed to shape thinking before a preliminary meeting with a supervisor. Earlier knowledge has shown that supervisees and supervisors do not always share common ideas about supervision. Therefore, the supervisee could finish this self-assessment as a homework exercise before supervision. A supervisee might want to identify conversation matters that may enable a supervisor to better comprehend their requirements and needs.
Questions regarding previous and desired experience in supervision.
What background information do you think your supervisor requires to understand you at the start? (This may include a curriculum vitae noting appropriate previous experience). What would be the best method to convey these details? Is there any distinction between what you desire from this placement and what you feel you need? What background details about this placement and this supervisor do you have? How does this make you feel? Exists any more information that you need? What do you want and expect your supervisor to concentrate on during supervision? What roles do you want your supervisor to play with respect to you and your work? What supervisory media do you want to experience (for example, taped, “live”, or reported)? What do you intend to do about your feelings? Consider how you feel about your supervisor evaluating your work at the end of the positioning process.
Difficulties in Previous Supervisions (Adapted According to Scaife 2019 ) |
What are the top three strengths you want your supervisor to uncover as you enter this supervisory relationship?
List 3 points for your development that may or might not be obvious to your supervisor.
Therapists regularly discover face-to-face contact with people labelled by society as coming from a specific sub-group.
Which sub-groups make you feel uneasy for whatever reason? Do you want to address this during supervision? 38
Exploring sources of stress from clinical work.
Check all that resonate for you. 39
❑ Perfectionism ❑ Fear of failure ❑ Self-doubt ❑ Need for approval ❑ Emotional depletion ❑ Unhealthy lifestyle
Which of them seems to have the greatest impact on your stress levels?
What supervisor has most regularly identified as weak points in your clinical work?
When mistakes are processed in ways that lead to reflection, flexibility, and adjustments in how you function, it can result in learning and growth.
Consider a patient you are now working with (or have recently worked with) with whom you have experienced a therapeutic failure.
Favorite techniques.
The following examples from clinical supervision demonstrate how self-exercise and self-reflection can help participants understand their belief system’s impact on homework in CBT.
Case Vignette – Discussion About Patient´s Homework During Supervision |
Case Vignette –Discussion of Setting Homework During Supervision |
Recording of Paul’s Automatic Thoughts |
The picture describes the vicious circle of countertransference reaction, where automatic thoughts lead to developing negative emotions, bodily reactions and behaviors. Any vicious circle components can alert the therapists that their countertransference reaction is taking place. |
Homework assignments are a common part of supervisory work. These may involve the patient’s management (eg noticing on their recording how often the therapist strengthens the patient and how and if it is rare to clarify where reinforcement would be appropriate), working on oneself (eg clarifying experiences and attitudes that lead to countertransference in a particular patient, awareness of which other patients may also occur) and theoretical study (the supervisor may advise the therapist to read a professional text that can help better understand and work with the patient). 40
The supervisor helps define a specific engagement, discusses specific therapeutic methods, touches on what methods the therapist has used and what else they may consider the role, for the most part, the implementation of strategies whose ability to use in therapy under supervision will be planned, as part of homework.
Homework assigned in supervision usually deals with mapping problems (supplementing the conceptualization of the case, evaluation, vicious circle of the problem with the patient, etc.), monitoring certain behaviors (mostly communication with the patient), or implementing new, behaviors in therapy (usually using therapeutic strategies). 12 Homework teaches the supervisee to work on self-reflection outside the supervision meetings. 41 Discussing the homework properly at the beginning of the session is important. The mentioned home exercises usually concern the work with the supervised case report of the patient. The basic questions concern homework results, discussing the obstacles in solving them and what the supervisee learned in homework. 8 The discussion gives the supervisor case management information and can point to important practice moments.
Before the end of the session, the supervisor and the supervisee agree on a homework assignment. It is optimal when homework arises from a problem addressed in the session’s main part. 8 At the beginning of supervision, proposals for homework assignments usually come from the supervisor and are discussed and recorded in writing. 40 During supervision, the supervisee creates homework assignments, and the content is discussed with the supervisee.
Homework must make sense for the supervisee; otherwise, he will have no motivation to do it. However, it is also important to make sense of the patient or patients and develop the therapist’s skills and competencies. It is desirable to discuss the meaning of homework in supervision.
It is advantageous to discuss the anticipated difficulties in completing homework. This has the advantage that the supervisee can prepare for possible difficulties, consider overcoming them and consult with the supervisor. Discussing difficulties helps the supervisee model and later develops the skill to discuss the patient’s homework difficulties.
In some therapists, there can be reasons for a more complex level of conceptualization. 42 That is important when the therapist repeats certain mistakes even though they have repeatedly discussed them with the supervisor. At a directly accessible level, the situation with the patient can be described using a vicious circle. The deeper “hidden” level refers to the core beliefs and conditional rules activated in a specific situation with the patient. 40 , 43 A supervisor can use the “falling arrow” technique to map core beliefs and conditional assumptions. 43
Case Vignette – Discussion About Supervisee Homework |
The scheme broadly refers to mental structures that integrate and give meaning to events. 45 Schemes can be positive, negative or neutral. In CBT as a treatment for psychological disorders, we focus on dysfunctional patterns often associated with specific diagnostic presentations (for example, emotional vulnerability patterns are common in anxiety disorders). Schema is generally defined as a ubiquitous topic of cognitive functions, emotions, physiological feelings about oneself, and relations with others. 33
Therapists’ schemes run in specific therapies and do not usually signal mental health problems. 8 Therapists’ schemes are influenced by the following factors: training experiences, such as supervision and training phase, therapy model, peer group, clinical experience, and personal experience. 13 , 40 Once identified, the therapist’s scheme can be used in supervision as a starting point to discuss some of the practitioner’s views that may interfere with therapy. 8 Completing structured questionnaires can identify participants’ schemes, basic beliefs, and assumptions. Some examples of useful questionnaires are the Dysfunctional Attitudes Scale, 46 the Personal Faith Questionnaire, 47 the Young Schema Questionnaire 48 and the Therapists’ Schema Questionnaire. 49 Leahy’s Therapists’ Scheme Questionnaire is a relatively straightforward screening technique for identifying therapeutic patterns that could affect a therapeutic relationship. It consists of 46 assumptions related to the 14 most common therapeutic regimens.
Certain schemes are particularly common in CBT supervisees. These include “demanding standards”, “excessive self-sacrifice”, and “special superior person”. 49 Training therapists who identify with the “demanding standards” scheme have a somewhat obsessive, perfectionist, and controlling approach to therapy. These therapists usually have high expectations for keeping a patient’s homework and may not realize that non-compliance with homework is often part of the learning process. Therapists may expect that there is a “right” way to complete a homework assignment, leading to feelings of frustration when assignments produce different results. This may signify insecurity and a notion that if things break from the planned structure, the therapist will be exposed as “incompetent”. Many therapists identify with the “excessive self-sacrifice” pattern, the most commonly observed pattern in both novice and experienced therapists. 33 Leahy 49 proposes that these therapists overstate the importance of their patient relationships. They may fear leaving or feel guilty that they are or feel better than the patient. As a result, the therapist may engage in therapy-defeating behaviors, such as making the homework assignment to the patient’s various needs, having difficulty with appropriate assertiveness in discussing persistent patient non-cooperation, and having a tendency to avoid techniques. Such as exposure or opening of painful memories for fear that the patient will be upset.
Novice therapists who identify with the “special superior person” scheme see the therapeutic situation as an opportunity to achieve excellent results and have high-performance expectations. There may be a tendency for the patient to idealize or, conversely, to devalue or distance himself from patients who do not improve or do their homework. The presence of a “special superior” scheme can be seen as overcompensation in response to “demanding standards” and “excessive self-sacrifice”, which have the thematic connotations of “not being good enough”. The supervision session sets the supervisee in a situation where the supervisor supervises homework through videotaped therapeutic sessions utilizing a cognitive therapy scale (CTS). 50 Feelings of superiority and exceptionality can, in some cases, be a way of dealing with the feelings of inferiority that they experience, that their use of homework is judged in this way.
Case Vignette – The Supervisor Advises the Therapist to Work with Core Beliefs and Conditional Rules |
For supervisors, their supervisors’ training is important. An important part of this training is the practice of self-reflection, which should be requested directly in the meeting and as homework. It can be a task to capture situations in supervision in which they do not feel comfortable using the vicious circle, cognitive restructuring of automatic negative thoughts in these situations, capturing thoughts, emotions, bodily sensations and behaviors in situations where they are aware that they are experiencing countertransference reactions to the supervised therapist. It is also important that in their homework, they reflect on their concentration level during supervision sessions and consider what supervision skills they have used or what they have learned for the next session. A typical complex homework in supervision training is a video recording of supervision sessions and their analysis. The recorded supervision and analysis are then analyzed in the next supervision training meeting.
This article is designed as an overview of views and experiences. Its important element is work samples. This is also a limitation of this article. Assignment of homework in supervision and therapist and supervisor training lacks scientific information about its effectiveness. Nevertheless, assigning homework is an important part of cognitive behavioral therapy. We know quite well about its meaning in prescribing for patients. Less is known about their meaning and effectiveness in supervision. The supervisee encounters problems completing homework assignments for her patients that she brings to the supervisee. Why the patient does not complete the homework may be his problem, but his therapist may also have a part in it his requirements, which include how the homework is assigned, its suitability for the given patient, timing, and complexity. Homework can also belong to the training of supervisors and the supervision of supervision. Here, we do not know any research evidence about their effectiveness in using the most important part of supervision, the patient; however, they are experienced by supervisors and supervisees as useful and meaningful.
Homework in supervision and supervision requires further reflection on their meaning and subsequent research, which should examine their significance for the supervisee’s competence (supervisee) and the ultimate impact on the patient himself.
Homework presents one of the cornerstones of cognitive-behavioral therapy, CB supervision and the training of CBT supervisors. If applied consistently and collaboratively, homework enhances therapeutic outcomes and increases the patient’s self-confidence. Setting and maintaining a fruitful working alliance for homework can be challenging – issues with homework present one of the common reasons to seek a supervisory consultation. Supervision then focuses on examining the specific case and experienced problems, factors in the interaction between the therapist and their patient, and the therapist’s automatic thoughts, schemas, and behaviors that might maintain the issue. There are several ways to address this topic in supervision. Homework is usually part of supervision because of its usefulness. The supervised therapist may be given similar tasks as the patient receives in therapy: to describe the automatic thoughts that occur to him while guiding the patient, to test them and look for a more rational response, to conduct behavioral experiments, to clarify the core beliefs and conditioned assumptions that influence the formation of the therapeutic relationship, experiments with adequate communication with the patient and others. A therapist’s self-experience through practice can help them improve their therapeutic work.
This paper was supported by the research grant VEGA no. APVV-15-0502 Psychological, psychophysiological and anthropometric correlates of cardiovascular diseases.
The authors report no conflicts of interest in this work.
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Beyond worksheets in cognitive-behavioral therapy, cbt may start with worksheets but it’s about building lifelong skills..
Posted November 14, 2021 | Reviewed by Lybi Ma
Cognitive-behavioral therapy has a reputation for using a lot of worksheets. These started as hardcopy pieces of paper that led a client through the steps of various cognitive and behavioral techniques. Now, these worksheets take the form of fillable electronic files, phone apps, and even chatbots. However, it’s important to note that worksheets are not the beginning and end of cognitive-behavioral therapy. Worksheets are instead supposed to be a type of scaffolding, providing support when a client feels particularly depressed or anxious (and has trouble concentrating) or when they are new to cognitive-behavioral therapy.
The worksheets in cognitive-behavioral therapy come in many forms. I tend to use a worksheet called a thought record that helps people identify a stressful situation, their emotions, their negative thoughts and then challenge those negative thoughts. Thought records can be very simple with single-word labels in four boxes (situation, emotion , negative thought, new thought). They can be more elaborate with columns including spaces for getting into the nitty-gritty of how to challenge negative thoughts and come up with more realistic thoughts. Other worksheets focus on identifying negative thoughts associated with a trauma that is keeping a person stuck. Worksheets can also be useful for tracking activities to find times for more self-care. They can also help with building a hierarchy of feared situations to conquer in the right order and at the right pace.
Worksheets also have the benefit of making clients write down something. Research has shown that we tend to remember something more when we handwrite it or, at the very least, type it out. Worksheets have multiple uses within cognitive-behavioral therapy. The first is making the skills easier to complete both in session and between sessions and the second is making the content easier to remember.
Successful worksheet completion is not the end goal of cognitive-behavioral therapy, however. The end goal is for a client to feel better (at least less depressed or anxious) and to achieve their individual goals . Ultimately, a successful course of cognitive-behavioral therapy results in clients that are able to use the skills and techniques without the worksheets. The worksheets provide important “training wheels” until they are able to use cognitive and behavioral skills on their own or when symptoms might relapse .
Some people do like to continue to use the worksheets even after therapy has ended. There is nothing wrong with continuing to use the worksheets, of course, particularly if it helps someone remember how to use the skills. But for a lot of clients, the goal is to be able to use the skills in their head whenever it’s needed so they can focus on living their life.
Salene M. W. Jones, Ph.D., is a clinical psychologist in Washington State.
At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.
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Fortunately, the research underpinning CBT homework is moving towards more clinically meaningful studies. Therapist skill in using homework has been shown to predict outcomes 9-10, and recently a study found that greater consistency of homework with the therapy session resulted in more adherence. 11 Our Cognitive Behavior Therapy Research Lab (currently based at the Turner Institute for Brain ...
Cognitive-Behavioral Therapy Worksheets (PDFs) To Print and Use. If you're a therapist looking for ways to guide your client through treatment or a hands-on person who loves to learn by doing, there are many cognitive-behavioral therapy worksheets that can help. 1. Coping styles worksheet.
Cognitive-Behavioral Therapy has "been shown to be as effective as medications in the treatment of a number of psychiatric illnesses" (Tang & Kreindler, 2017, p. 1). ... 2017, p. 1). Homework is a vital component of CBT, typically involving completing a structured and focused activity between sessions. Practicing what was learned in therapy ...
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].It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [3-6].
Practitioners looking to support these clients using homework might start by sending their clients one or two audio meditations via Quenza, such as the Body Scan Meditation or S.O.B.E.R. Stress Interruption Mediation. That way, the client will have tools on hand to help manage their anxiety in stressful situations.
Cognitive behavioral therapy (CBT) is known to be a highly effective approach to mental health treatment. One factor underlying its success is the homework component of treatment. It's certainly ...
use of homework adheres sufÞciently to the tenets of CBT. In many respects, CBT without homework is a misnomer. For example, the Cognitive Therapy Rating Scale (Young & Beck, 1980), used to assess compe-tency in the delivery of cognitive therapy, includes a question on whether the therapist assigns and reviews ÔÔcustom-tailoredÕÕ homework ...
Homework in Therapy. While specific recommendations for the practical usage of homework have been clearly articulated since the early days of CBT, 11, 12 practitioners state that they do not follow these recommendations. 13-15 For example, many physicians admit that they forget homework or do not focus on standard specifications when, where, how often, and how long the task should last.
Explore as a team, in a non-judgmental way, to explore why the homework was not done. Here are some ways to increase adherence to homework: Tailor the assignments to the individual. Provide a rationale for how and why the assignment might help. Determine the homework collaboratively. Try to start the homework during the session.
By Judith S. Beck, Ph.D., and Francine R. Broder, Psy.D. Judith S. Beck, Ph.D. We've stopped using the word "homework" in CBT. Too many clients take exception to that term. It reminds them of the drudgery of assignments they had to do at home when they were at school. So in recent times, we've switched. "Homework" is now called the ...
Homework is both a process and a specific task in therapy. Definitions have varied, but those from integrative and non-CBT modalities agree that the concept of "between-session assignments" are relevant and important for the range of psychotherapy approaches (see special issue in Journal of Psychotherapy Integration, Vol. 16, No. 2). One point of differentiation has been the process for ...
A client's success heavily depends on doing homework between sessions. Too many coaches, counselors, and therapists are too nice when a client doesn't. They too readily let the client off the ...
Cognitive Behavioral Therapy (CBT) stands as a powerful, evidence-based therapeutic approach for various mental health challenges. At its core lies a repertoire of techniques designed to reframe thoughts, alter behaviors, and alleviate emotional distress. This article explores 20 most commonly used cbt techniques.
Homework in CBT. Cognitive Behavioural Therapy (CBT) is a very practical therapy that involves homework as a huge part of the therapy process. You may think of school when they hear the term "homework", and that's understandable. However, homework in CBT is actually a really good thing. The reason that there is a heavy focus on homework or ...
A common feature of CBT is assigning therapy homework. In 7 minutes, Christine A. Padesky, PhD demonstrates ways to turn "homework" drudgery into learning cl...
CBT conditions with and without homework reported that effect sizes for CBT with homework were significantly greater than CBT comprising entirely of in-session work for anxiety and depression (d 5 0.48).18 Conversely, a study by Burns and Spangler19 observed that there was evidence of
A meta-analysis is a statistical summary of a body of research. It can be used to identify the average impact of psychotherapy homework on treatment outcomes across numerous studies. The results ...
The investigations advocate that adding homework to CBT increases its efficacy and that patients who constantly complete homework have better outcomes. The outcomes of four meta-analyses highlight the value of homework in CBT: Kazantzis et al 10 inspected 14 studies that compared results for patients allocated to CBT without or with homework ...
supporting homework is almost wholly derived from dismantling studies that contrast CBT with CBT without homework, or correlational studies of homework adherence and symptom reduction. Findings from our most recent meta-analysis suggest that homework quantity and quality have little difference in their relations with outcome4. As clinicians, we ...
The worksheets in cognitive-behavioral therapy come in many forms. I tend to use a worksheet called a thought record that helps people identify a stressful situation, their emotions, their ...
The Cognitive Triangle. worksheet. The cognitive triangle illustrates how thoughts, emotions, and behaviors affect one another. This idea forms the basis of cognitive behavior therapy (CBT). Perhaps most important to CBT, when a person changes their thoughts, they will also change their emotions and behaviors.
Cognitive Behavioral Therapy (CBT) is a transformative approach that intertwines our thoughts, emotions, and behaviors. At Therapy Now SF, we're firm advocates of CBT's efficacy, and an essential ingredient in this process is the use of homework assignments. ... In Cognitive Behavioral Therapy, homework assignments aren't merely tasks to ...