Using Homework in Psychotherapy: Strategies, Guidelines, and Forms - Softcover

Tompkins, Michael A.

Softcover

ISBN 10: 1593850492 ISBN 13: 9781593850494

Publisher: Guilford Press, 2004

Synopsis

A step-by-step guide for therapists who want to start implementing homework or to increase the effectiveness of assignments, this hands-on book is ideal for clinicians from any theoretical orientation. Presented are creative strategies for developing meaningful homework assignments, enhancing compliance, and overcoming typical homework obstacles. Nearly 50 reproducible forms are featured along with detailed recommendations for using them to accomplish five broad therapeutic goals: increasing awareness, scheduling activities, improving emotion regulation and interpersonal effectiveness, and testing assumptions. Also provided are tips for working with special populations, including adolescents, older adults, couples, and clients with severe depression or anxiety. Bursting with helpful tools, tips, and examples, the volume is designed in a convenient 8 1/2 x 11 format with lay-flat binding for ease of photocopying.

About this title

About the Author

Michael A. Tompkins, PhD, is the Director of Professional Training at the San Francisco Bay Area Center for Cognitive Therapy, Assistant Clinical Professor at the University of California, Berkeley, and a Founding Fellow of the Academy of Cognitive and Behavioral Therapies. He is in private practice in Oakland, California.

Excerpt. © Reprinted by permission. All rights reserved.

Using Homework in Psychotherapy

Strategies, Guidelines, and FormsBy Michael A. Tompkins

The Guilford Press

Copyright © 2004 The Guilford Press
All right reserved.
ISBN: 1-59385-049-2

Introduction

Practice is the best of all instructors. -Publilius Syrus

Jessica is a 47-year-old bus driver in treatment for depression. As homework, her therapist asked her to call a friend once each week and chat for 10 minutes. After a few weeks of following through with the assignments, she felt less isolated and depressed. At today's session, she tells her therapist that after chatting with her friend, they went to a movie together on Friday night, and afterward she felt much better through the rest of the weekend. Jessica is surprised that small homework assignments like these are helping her to feel better so quickly. Alfonso is an accountant and lifelong worrier who cut back his hours at work because he couldn't tolerate the anxiety his job caused him. He tells his therapist that the breathing exercises help him feel less anxious in general, but that what have helped most are the homework assignments to practice the breathing exercises in settings and situations that have made him anxious in the past, such as in the conference room at work or before he answers his office telephone. Marcel and Nora tell their couple therapist that while the homework assignments in general have been helpful, the fact that they have been able to work through their differences about a homework assignment and follow through with it has made them more hopeful that the therapy will improve their relationship.

As these cases illustrate, homework can often accelerate clients' progress in therapy, as well as help them generalize their newly acquired skills to the real-life situations that trouble them. In addition, successfully completing psychotherapy homework-or overcoming the difficulties that invariably arise in setting up or carrying out homework assignments-can improve clients' confidence in themselves and in their therapists.

In this introductory chapter, I describe what is meant by "psychotherapy homework" and outline the many benefits of homework to clients and psychotherapists. I close the chapter with a description of the approach of this book, which encourages therapists to first consider what they can do to improve a client's ability to complete psychotherapy homework before assuming that homework problems are solely due to the client's psychopathology.

WHAT IS PSYCHOTHERAPY HOMEWORK?

Imagine what it would have been like to learn your multiplication tables if you had practiced them only in school. Consider how long it would take to perfect your tennis serve if you could practice only once a week during your lesson. What do you think those pen-and-ink drawings would look like if you only painted or sketched while you were in art class? Homework is a key ingredient of any effort to learn a new skill. Homework enables us to practice newly learned skills and thereby to increase our confidence and mastery. Through homework, we also learn discipline, follow-through, and the benefits of working hard to reach a goal.

Homework is one of a handful of clinical strategies common to many different psychosocial treatments (Goldfried, 1980; Marmor, 1980; Shelton & Levy, 1981), and although the homework assignments are derived from different conceptualizations of a clinical problem, the tasks themselves look much the same. For example, a gestalt therapist might ask an unassertive depressed woman who is intimated by her supervisor at work to practice looking at herself in the mirror while repeatedly saying or shouting "No!" (Polster & Polster, 1973). A strategic therapist might direct an unemployed man who is afraid to apply for a job to interview at a business where he wouldn't take the job if he got it, giving him the chance to practice in a less pressured situation (Haley, 1987; Madanes, 1984). Or, in an effort to strengthen the parental subsystem, a family therapist might instruct the parents of an oppositional 12-year-old boy to enforce a reasonable bedtime hour (Carr, 1997; Nelson, 1994), just as a behavior therapist might do. Psychoanalytic models have also included homework assignments-typically tasks that a client has previously avoided or has been unable to perform and are salient to the focus of treatment (Alexander & French, 1946). In particular, behavioral and cognitive approaches have included homework from their conception (Beck, Rush, Shaw, & Emery, 1979; Ellis, 1962; Shelton & Ackerman, 1974), so that today homework is considered an integral component of cognitive-behavioral forms of treatment.

Psychotherapy homework assignments, in general, share certain features. First, clients carry out psychotherapy assignments outside the therapy session, either alone or in collaboration with someone else. A widower with diabetes who is depressed because he can no longer fish with his friends or have Sunday breakfast at the diner around the corner might agree to a homework assignment to telephone several friends during the week to chat, or to invite a friend to pick up breakfast at the diner and come to his place one Sunday morning. Second, homework assignments are planned by the therapist in consultation with the client, emerge from the focus of the therapy session, and are tied to the overall goals of the treatment. Partners who agree that their problems as a couple are largely due to their inability to effectively resolve conflict might agree to a homework assignment to practice a communication skill, such as rephrasing periodically what each partner has heard the other say. Finally, homework assignments direct clients either to collect and report basic information about their experience in natural settings, or to interact with their environment-usually in different ways-in order to extend and generalize their new skills to real-world situations. For example, a young salesman who is depressed because a coworker is calling his clients to try to get them to jump accounts can learn to be assertive in session with his therapist, but this is of little use to him unless he can tell this coworker to back off. Homework assignments can help him practice his new assertiveness skills when he is highly anxious or angry (as he is likely to be when he speaks to his coworker), as well as practice these skills with others in his life. In summary, "psychotherapy homework" is defined as any task that is to be practiced outside the therapy session, is collaboratively devised by the therapist and client, and is intended to facilitate the learning and practice of a new skill in natural settings over time (Persons, Davidson, & Tompkins, 2001).

I use the term "homework" or "homework assignment" when referring to these planful therapeutic activities, although many other terms have been used: "behavioral experiment," "behavioral assignment," "extra therapy," "extra treatment," "home practice," "behavioral practice," "in vivo practice," "generalization practice," "personal practice," "exercise," "between-session tasks," and "self-help assignments." For some clients the term "homework" will matter, especially if the word holds a particular meaning. For clients for whom homework is associated with relentless battles as children with their parents, or with a series of frustrating reminders that they were stupid and couldn't learn, the term can be loaded. However, clients who balk at the word "homework" might not be satisfied with a repackaging of the term. Even young children are not fooled when their therapist asks them to "practice" something at home. Little Jack and Jane figure out quickly that, no matter what the therapist calls it, it's homework because they're being asked to do something that might not be much fun.

This was the case with Maya, a 12-year-old girl who was frightened when separated from her parents and who had recently started refusing to go to school. In addition, Maya had significant expressive learning difficulties that caused homework to be pure torture for her. When Maya's therapist mentioned that she would be asked to do therapy homework tasks such as listening to a progressive muscle relaxation tape every night before bed or writing down what was going through her head when she was feeling scared, Maya crossed her arms, scrunched her nose, and said she wasn't doing any homework, period! The therapist explained that the kinds of things Maya would be asked to do at home would not be the kinds of things her teacher asked her to do. This reassured Maya a bit, but what helped more was when the therapist said that he would work with her parents to see that she was rewarded for doing the therapy homework. At this, Maya smiled and agreed to give it a try.

In other cases, careful wording can help. For example, it is often useful when working with anxious clients to describe homework as "practice," in that it lowers their anticipatory anxiety about the homework itself. The term "practice," unlike "homework," sets an expectation that failure is okay and that performing a task perfectly is neither required nor necessarily helpful.

BENEFITS OF PSYCHOTHERAPY HOMEWORK

Most psychologists now report that they use homework assignments in their clinical practices (Kazantizis & Deane, 1999), and the ability of therapists to increase a client's compliance with therapy homework may be one of the crucial therapeutic skills that determine the success of psychosocial interventions in real-world clinical settings (Addis & Jacobson, 2000).

There are a number of benefits, for both clients and therapists, to the use of homework assignments in psychotherapy. First, homework assignments can help clients become better faster and remain well longer (Burns & Auerbach, 1992; Edelman & Chambless, 1993; Kazantizis, Deane, & Ronan, 2000; Whisman, 1999). In addition, the growing demand for more effective and briefer psychosocial treatments has encouraged therapists to look for ways to make use of the many hours of the week when clients are not in the therapists' offices. Homework can meet this demand, as it is designed to help clients consistently practice skills that would take many months to master if they could only practice once each week in their therapy sessions. The proven effectiveness of brief treatment models, such as cognitive-behavioral therapy, may be due in part to the use of therapy homework (Kazantizis et al., 2000; Whisman, 1993).

Second, homework assignments, because they are carried out in a variety of settings and situations, help clients generalize what they have learned to solve similar (but not identical) problems that can arise at any time and at any point in their lives. For example, a client who came to therapy to overcome his fear of speaking at an annual conference can learn, through homework assignments, that these same strategies can help him feel less anxious when meeting with his boss or when chatting with a colleague at a party. Similarly, a client who sought treatment for depression following the death of her husband can learn, through homework, that these same strategies can help her get through other losses, such as the death of a pet or her daughter's departure for college.

Third, homework helps clients gain confidence in their ability to manage their problems on their own without the assistance of a therapist. When clients are more confident about their ability to manage future occurrences of their problems, they are somewhat protected against them. For example, the lower relapse rates seen with cognitive therapy (an approach that includes homework assignments) than with medication for the treatment of depression can be due to the effects of homework. Clients who have learned and practiced self-management skills through therapy homework are more likely to use these skills to ameliorate future downturns in their mood, which in the past could have resulted in a full-blown clinical episode (Simons, Murphy, Levine, & Wetzel, 1986).

Fourth, homework can help clients better understand the roots of the problems for which they have sought help; the effects of the problems on themselves and others, and the contribution their environments make to the form, intensity, and frequency of the problems. For example, an auto mechanic who was ordered by his supervisor to come to therapy to learn how to manage his anger problem tended at first to minimize how angry he becomes, as well as the consequences of his anger on others. As a homework assignment, the therapist asked him to record on a form when he feels angry, how intensely he feels angry (on a 0-10 scale where 10 is "extremely"), and how others respond to him when he feels angry (e.g., looked fearful, walked away, yelled back). Similarly, a young product specialist for a semiconductor manufacturing company who recently delivered her second child started to pull her hair. For several weeks now, she has been monitoring the frequency and duration of her pulling episodes, as well as what goes through her head afterward. Based on these data, she and her therapist have established that she is highly self-critical after a pulling episode. The therapist would like to help her client see that this can aggravate her hair pulling. As a homework assignment for the coming week, the client agrees to continue recording the duration of each pulling episode; however, this time she is to try to be less self-critical by using more supportive self-talk, as well as other strategies (such as calming breaths and distraction).

Fifth, homework offers clients direct opportunities to test the validity of underlying assumptions and beliefs (Beck et al., 1979). Although testing the validity of underlying assumptions occurs in session and is helpful, there are benefits to expanding this work outside the therapy session. Often it is difficult to work on a problem in session, because the therapeutic situation is not a salient trigger of the underlying maladaptive belief. For example, a software test engineer who believes that others are critical and rejecting may come over time to believe that his therapist is an exception to this rule, and therefore to act more assertively with his therapist in session. In this case, the therapist is no longer a significant trigger of the client's underlying maladaptive belief that others are critical and rejecting. For this reason, no matter how often the client practices being assertive with the therapist, he may still have difficulty being assertive with his supervisor. Homework enables the therapist to set up situations (perhaps graded from least to most difficult) in which the client can practice being assertive with the people in his life with whom he must interact. At other times, clients may find it difficult to recall details or to retrieve thoughts or associations about an event or situation that occurred days before the therapy session. A homework assignment that places clients in the actual situation, with the recommendation that they observe and record their experiences, can solve this problem.

Continues...

Excerpted from Using Homework in Psychotherapyby Michael A. Tompkins Copyright © 2004 by The Guilford Press. Excerpted by permission.
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Edition details

• Publisher: Guilford Press
• Publication date: 2004
• Language: English
• ISBN 10: 1593850492
• ISBN 13: 9781593850494
• Binding: Paperback
• Edition number: 1
• Number of pages: 286