Integrating between-session homework in psychotherapy: A systematic review of immediate in-session and intermediate outcomes

Homework as a driver of change in psychotherapy

BACKGROUND AND OBJECTIVES

The utilization of Between-Session Homework (BSH) holds a longstanding tradition in the field of psychotherapy. Significantly, it serves as a pivotal catalyst for change within behavioral and cognitive-behavioral therapies, and has also garnered endorsement within psychodynamic and humanistic-experiential therapies. While our current conceptualization of BSH is characterized by assimilation and integration, diversity prevails in how BSH is incorporated into the treatment plan, spanning various therapy stages, thus necessitating a customized therapist-client interpersonal dynamic. Far from being a panacea, the employment of BSH emerges as a highly sophisticated and intricate clinical methodology, demanding a high degree of therapist proficiency and competence to facilitate client engagement.

METHODS

In this introductory paper, we present an issue of the Journal of Clinical Psychology: In Session that exemplifies the diverse modalities through which BSH can be integrated into clinical practice across various client demographics and within distinct psychotherapeutic paradigms. We place specific emphasis on the pivotal role of BSH and its interplay with proposed mechanisms of change throughout the course of treatment.

RESULTS

Initially, we provide an overarching view of the subject and expound on empirical research substantiating the efficacy of BSH in psychotherapy. Subsequently, we delve into strategies for adeptly integrating and monitoring BSH within clinical practice.

CONCLUSIONS

Our primary objectives encompass affording readers a more lucid comprehension of (1) the content and nature of homework; (2) the influence of BSH on treatment outcomes; and (3) the ways through which therapists can foster client engagement with BSH. Finally, we introduce the six papers comprising this issue.

Action recommendations review in community-based therapy and depression and anxiety outcomes: a machine learning approach

BACKGROUND

While the positive impact of homework completion on symptom alleviation is well-established, the pivotal role of therapists in reviewing these assignments has been under-investigated. This study examined therapists' practice of assigning and reviewing action recommendations in therapy sessions, and how it correlates with patients' depression and anxiety outcomes.

METHODS

We analyzed 2,444 therapy sessions from community-based behavioral health programs. Machine learning models and natural language processing techniques were deployed to discern action recommendations and their subsequent reviews. The extent of the review was quantified by measuring the proportion of session dialogues reviewing action recommendations, a metric we refer to as "review percentage". Using Generalized Estimating Equations modeling, we evaluated the correlation between this metric and changes in clients' depression and anxiety scores.

RESULTS

Our models achieved 76% precision in capturing action recommendations and 71.1% in reviewing them. Using these models, we found that therapists typically provided clients with one to eight action recommendations per session to engage in outside therapy. However, only half of the sessions included a review of previously assigned action recommendations. We identified a significant interaction between the initial depression score and the review percentage (p = 0.045). When adjusting for this relationship, the review percentage was positively and significantly associated with a reduction in depression score (p = 0.032). This suggests that more frequent review of action recommendations in therapy relates to greater improvement in depression symptoms. Further analyses highlighted this association for mild depression (p = 0.024), but not for anxiety or moderate to severe depression.

CONCLUSIONS

An observed positive association exists between therapists' review of previous sessions' action recommendations and improved treatment outcomes among clients with mild depression, highlighting the possible advantages of consistently revisiting therapeutic homework in real-world therapy settings. Results underscore the importance of developing effective strategies to help therapists maintain continuity between therapy sessions, potentially enhancing the impact of therapy.

Predictors of homework engagement in group CBT for social anxiety: client beliefs about homework, its consequences, group cohesion, and working alliance

OBJECTIVE

Group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) is effective, but little data exist on generic relational components of the therapeutic process, such as group cohesion and therapy alliance, and central CBT-specific components such as homework engagement, beliefs, and perceived consequences. The aim of this study was to investigate the relationships between homework, group cohesion, and working alliance during group CBT for social anxiety disorder.

METHOD

Participants (N = 105) with SAD engaged in 12 sessions of group CBT. Measures of homework, working alliance, and group cohesion were completed at multiple points throughout treatment. Random-intercept cross-lagged panel models were used to evaluate the prospective relationships between measures.

RESULTS

Prospective relationships between the homework outcomes did not vary throughout the treatment period, with the only significant relationships seen between the random intercepts ("trait" levels). Homework beliefs were a significant negative predictor of future group cohesion, but only in mid- to late-treatment. Homework consequences and working alliance were significantly and positively predictive of each other throughout therapy.

CONCLUSION

Early homework engagement is associated with higher engagement throughout therapy. Working alliance and homework engagement are important to bolster early in group CBT.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12616000579493..

Therapist competence, homework engagement, and client characteristics in CBT for youth depression: A study of mediation and moderation in a community-based trial

OBJECTIVE

Prior studies of Cognitive Behavioral Therapy (CBT) have focused on the quantity and quality of clients' homework completion and only rarely have considered the role of therapist competence.

METHODS

The present study examined (a) therapist competence across the entire process of integrating homework into CBT, including the review, design, and planning of tasks; (b) homework engagement, including client appraisals of the difficulty and obstacles encountered in task completion using the Homework Rating Scale - Revised (HRS-II); (c) pre-post symptom reduction as the index of outcome; and (d) considered client factors such as suicide risk in a community-based trial for adolescent depression. Trained independent observers assessed therapist competence and engagement with homework at two consecutive sessions of CBT for N = 80 young people (Mage = 19.61, SD = 2.60).

RESULTS

Significant complementary mediation effects were obtained; there was an indirect mediation effect of HRS-II Beliefs (b = 1.03, SE B = 0.42, 95% BCa CI [0.35, 2.03]) and HRS-II Perceived Consequences on the Competence-Engagement relationship (b = 0.85, SE B = 0.31, 95% BCa CI [0.39, 1.61]). High levels of suicidal ideation were also shown to moderate this relationship.

CONCLUSIONS

The present findings contribute to the growing body of CBT process research designed to examine the complex interrelationships of client and therapist variables, in a manner that reflects the actual process of therapy, and advances beyond studies of isolated predictors of symptom change.