One of my clients said to me the other day that she had seen many therapists but no-one like me. While I was still trying to work out whether this was a compliment or not, she clarified this by saying that she has had more contact with me in three months than with others in a year and how do I do this when I am so busy?
True, I am busy but one of the key features of CBT (Cognitive Behavioral Therapy) is the assignment and fulfilling of homework tasks. It would be wrong to confuse homework given in CBT therapy with homework given in school and overseen by parents. Homework, or whatever name a client wants to give it to make it acceptable, is an essential part of CBT therapy. Without it, clients take longer to recover and they would also miss the valuable opportunity of putting the work done in sessions into practice. However, it must be said that many clients feel foolish about these tasks or simply claim to have no time but the setting of homework should take place in a spirit of negotiation with the client who will only complete the task if he truly sees the value in it.
As a therapist, these tasks are very important as it gives you the chance to connect with clients between sessions by reading and giving feedback on the tasks given. I always ask them to send them to me by email and I try to give feedback within twenty-four hours. It also keeps the client focussed on working through the presented problem and the therapist has a chance to be a daily influence on the client, a support and a security net when things don’t go as planned. Given that CBT is seen as a joint effort between therapist and client, this sits well with CBT theory. CBT therapists also place a lot of emphasis on making sure homework is reviewed in session, meaning they take an active part in it. In my experience, the following list contains effective measures that can be used for homework assignments:
1. Bibliotherapy : big word but a simple idea. The client reads and reflects on parts of a book assigned by the therapist. This could be a self-help book or something more technical. It gives the therapist the chance to question and challenge the client on what they discovered. This is maybe the easiest task to set and is usually appropriate for a client new to CBT.
2. Daily Mood Log : A classic for CBT therapists. This method calls for the logging of negative thought, triggers and the emotions that result from these. For the therapist, this produces a mine of information to establish underlying belief systems. Clients often find the second stage very difficult, that is changing the irrational thoughts into more realistic ones. Often these belief systems have been turned into facts and are hard to change. I always set the client this task in two stages. Firstly the logging of negative thought patterns and then as a second stage, trying to change them. It is very important that this exercise is monitored properly by the therapist and properly introduced. It can be overwhelming for a client to see the things troubling them in black and white.
3. Cognitive Exercises : If a client’s irrational belief is concerning some form of behaviour, a homework task could be for a client to put themselves in a position where the irrational belief is challenged. For example, if in a meeting a client is too shy to contribute for fear of feeling foolish, a task could be to ‘just do it’. It makes little sense, however, to force this on a client before sufficient work has been done in session, as this is destined to fail and could make matters worse. An extension of this would be to set assignments outside session in an imagery or emotive fashion. A client could be set the task to actually imagine irrational beliefs disappearing and the steps they took to make it happen. Additionally, encouraging the client to use self dialogue to create a conversation between rational and irrational puts the belief and solution in perspective.
4. Writing in a Journal: It is the practice of maintaining a diary to keep an account of situations that arise in day-to-day life. Thoughts that are associated with these situations and the behavior exhibited in response to them are also mentioned in the diary. The therapist and patient together review the matter written in the journal and find out maladaptive thought pattern. The discussion that takes place between them proves to be useful in finding different ways in which behavior of the patient gets affected. Another twist is the client can write a number of positive happenings that have occurred during the day.
5. Graded Exposure : In CBT is all about getting the client to face their regular or ongoing fears because avoiding actually makes the fear worse (through reinforcing fears each time they are avoided) and the best remedy is therefore to work with the client to help the client confront their fears. The difference with graded exposure is it is carried out much more gradually, taking little steps forward each time. This approach is more commonly used with extreme fears and allows the client to slowly confront their fears over an extended period of time. Graded exposure in layman’s terms is simply letting the client take a series of steps rather than making them take a massive jump.
6. Experiments : Behavioural Experiments are simply a tool similar to an action plan used to help people practice new behaviour changes learnt within therapy or through using a CBT workbook. Wilding & Milne (2008) suggest main purposes this skill can used for: testing validity of thoughts (how accurate are they), discovering what happens if you try option A as opposed to option B and for observing results/outcomes of specific changes to behaviour. In a nutshell, behavioural experiments require us to take on the role of a scientist (just like in Socratic questioning) to try new ways of behaving and to observe what happens as a result.
Dr. Nicholas Jenner is a Counseling psychologist in private practice working with individuals, couples, groups and companies. Apart from seeing clients face-to-face, Dr Jenner also runs a thriving online therapy business bringing help to those who are housebound or located in rural locations where therapy is difficult to find. For more information , follow the link to his website HERE
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