Homework

Summary

Homework is at the heart of CBT, because it is the way of making the change process in therapy vividly present in the patient’s everyday life, and not only during the therapy sessions. The goal of every CBT is to help the patient experience something new in his or her life, and homework is essential to making that happen: trying out new ways of challenging emotional difficulties in precisely the situations of everyday life where they appear.

Principles and practice

A primary, defining feature of all CBT is the use of “homework”. Homework designates some kind of task, construed collaboratively by therapist and patient, for the patient to perform between therapy sessions. In this way, therapy doesn’t stop when the therapy session stops, but rather continues, by the way of homework, throughout the patient’s everyday life.

Homework is at the heart of all CBT because the mechanism of change of all cognitive behavioral therapies is based on helping the patient getting new emotional and personal experiences in his or her life. Some of these new and corrective emotional experiences may of course take place with the therapist in the therapy room. But the majority of them will most probably take place outside of that room, where most of life takes place – while interacting with loved ones and friends, working with colleagues, and in all other parts of life.

Ideally, the homework tasks constitute an extension of the theme worked on in the therapy session. In an exposure therapy for OCD for example, if the patient during the session has worked with the therapist on exposure for things that the patients’ obsessions say are “contaminated” (like for instance the door handle of the therapist’s office, or the doorhandle of the bathroom at that office), the homework could be for the patient to continue to do the same type of exposures for instance at his- or her own workplace. To be able to overcome fear or other strong feelings also in the absence of the therapist, the patient may need the help of a partner, a family member or close friend.

These are one of the things worked through when defining new homework at the end of the therapy session: When can the patient do it? With the help of whom? What difficulties may arise and how can these be handled? This preparation for homework is very important, and it is important that the therapist allocates time at the end of the session (at least 10 minutes) to work through these elements with the patient. Moreover, is often important that the patient writes down what happens during and after the homework: What happened with the anxiety (what was the Subjective Unit of Distress, see separate article)? What conclusions can be drawn? It is often very helpful to provide the patient with a worksheet that includes these elements, so that he or she gets a structure for how carrying out the homework (see separate Clinical tool “Exposure homework worksheet”).

At the start of the next session, it is important that the homework is reviewed (preferably with the notes the patient wrote down in the work sheet he was given). If the patient could do the homework, it is important to work out which conclusions he or she makes and how these new experiences can continue to be present in the patient’s life. If the patient hasn’t been able to do the homework, it is important to work through the reasons for this? Was it too difficult? What could be changed the increases the probability the patient will succeed? What help or support may he or she need, and from whom?