Homework in CBT

Why do homework in CBT?

Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect thoughts, and modify their thinking.

How to deliver homework

Homework is not something that you just assign randomly. You should make sure you:

  • tailor the homework to the patient
  • provide a rationale for why the patient needs to do the homework
  • uncover any obstacles that might prevent homework from being done (i.e. - busy work schedule, significant neurovegetative symptoms)

Types of homework

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?

Adherence

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:

  • 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. This creates some momentum to continue doing the homework
  • Set up systems to remember to do the assignments (phone reminders, sticky notes
  • It is better to start with easier homework assignments and err on the side of caution
  • They should be 90-100% confident they will be able to do this assignment

Strategies to increase confidence

  1. Covert rehearsal - running through a thought experiment on a situation
  2. Change the assignment - It is far better to substitute an easier homework assignment that patients are likely to do than to have them establish a habit of not doing what they had agreed to in session
  3. Intellectual/emotional role play - “I’ll be the intellectual part of you; you be the emotional part. You argue as hard as you can against me so I can see all the arguments you’re using not to read your coping cards and start studying. You start.”