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You have definitely heard about CBT.
You may not know it, or you may not immediately assign meaning to those three letters placed side by side, but there’s almost no doubt that you have at least a passing familiarity with CBT.
If you’ve ever interacted with a therapist, a counselor, or a clinician in a professional setting, you have likely participated in CBT. If you’ve ever heard friends or loved ones talk about how a mental health professional helped them recognize their fears or sources of distress and aided them in altering their behavior to more effectively work towards their goals, you’ve heard about the impacts of CBT.
CBT, or cognitive behavioral therapy, is one of the most used tools in the psychologist’s toolbox. It’s based on a fairly simple idea which, when put into practice, can have wildly positive outcomes.
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What is CBT?
This simple idea is that our unique patterns of thinking, feeling, and behaving are significant factors in our experiences, both good and bad. Since these patterns have such a significant impact on our experiences, it follows that altering these patterns can change our experiences (Martin, 2016).
CBT aims to change our thought patterns, the beliefs we may or may not know we hold, our attitudes, and ultimately our behavior in order to help us face our difficulties and more effectively strive towards our goals.
The founder of CBT is a psychiatrist named Aaron Beck, a man who practiced psychoanalysis until he noticed the prevalence of internal dialogues in his clients, and realized how strong the link between thoughts and feelings can be. He altered the therapy he practiced in order to help his clients identify, understand, and deal with the automatic, emotion-filled thoughts that arise throughout the day.
Beck found that a combination of cognitive therapy and behavioral techniques produced the best results for his clients. In describing and honing this new therapy, Beck laid the foundations of the most popular and influential form of therapy of the last 50 years.
This form of therapy is not designed for lifelong participation, but focuses more on helping clients meet their goals in the near future. Most CBT treatment regimens last from five to ten months, with one 50 to 60 minute session per week.
CBT is a hands-on approach that requires both the therapist and the client to be invested in the process and willing to actively participate. The therapist and client work together as a team to identify the problems the client is facing, come up with new strategies for addressing them, and thinking up positive solutions (Martin, 2016).
Many of the most popular and effective CBT techniques are applied to what psychologists call “cognitive distortions” (Grohol, 2016).
Cognitive distortions: inaccurate thoughts that reinforce negative thought patterns or emotions.
Cognitive distortions are faulty ways of thinking that convince us of a reality that is simply not true.
There are 15 main cognitive distortions that can plague even the most balanced thinkers at times:
Filtering refers to the way many of us can somehow ignore all of the positive and good things in our day to focus solely on the negative. It can be far too easy to dwell on a single negative aspect, even when surrounded by an abundance of good things.
Polarized Thinking / “Black and White” Thinking
This cognitive distortion is all about seeing black and white only, with no shades of grey. This is all-or-nothing thinking, with no room for complexity or nuance. If you don’t perform perfectly in some area, then you may see yourself as a total failure instead of simply unskilled in one area.
Overgeneralization is taking a single incident or point in time and using it as the sole piece of evidence for a broad general conclusion. For example, a person may be on the lookout for a job but have a bad interview experience, but instead of brushing it off as one bad interview and trying again, they conclude that they are terrible at interviewing and will never get a job offer.
Jumping to Conclusions
Similar to overgeneralization, this distortion involves faulty reasoning in how we make conclusions. Instead of overgeneralizing one incident, however, jumping to conclusions refers to the tendency to be sure of something without any evidence at all. We may be convinced that someone dislikes us with only the flimsiest of proof, or we may be convinced that our fears will come true before we have a chance to find out.
Catastrophizing / Magnifying or Minimizing
This distortion involves expectations that the worst will happen or has happened, based on a slight incident that is nowhere near the tragedy that it is made out to be. For example, you may make a small mistake at work and be convinced that it will ruin the project you are working on, your boss will be furious, and you will lose your job. Alternatively, we may minimize the importance of positive things, such as an accomplishment at work or a desirable personal characteristic.
This is a distortion where an individual believes that everything they do has an impact on external events or other people, no matter how irrational the link between. The person suffering from this distortion will feel that they have an unreasonably important role in the bad things that happen around them. For instance, a person may believe that the meeting they were a few minutes late in getting to was derailed because of them, and that everything would have been fine if they were on time.
Another distortion involves feeling that everything that happens to you is a result of external forces or due to your own actions. Sometimes what happens to us is due to forces we can’t control, and sometimes what happens is due to our actions, but the false thinking is in assuming that it is always one or the other. We may assume that the quality of our work is due to working with difficult people, or alternatively that every mistake someone else makes is due to something we did.
Fallacy of Fairness
We are often concerned about fairness, but this concern can be taken to extremes. As we know, life is not always fair. The person who goes through life looking for fairness in all their experiences will end up resentful and unhappy. Sometimes things will go our way, and sometimes they will not, regardless of how fair it may seem.
When things don’t go our way, there are many ways we can explain or assign responsibility for the outcome. One method of assigning responsibility is blaming others for what goes wrong. Sometimes we may blame others for making us feel or act a certain way, but this is a cognitive distortion because we are the only ones responsible for the way we feel or act.
“Shoulds” refer to the implicit or explicit rules we have about how we and others should behave. When others break our rules, we are upset. When we break our own rules, we feel guilty. For example, we may have an unofficial rule that customer service representatives should always be accommodating to the customer. When we interact with a customer service representative that is not immediately accommodating, we might get angry. If we have an implicit rule that we are irresponsible if we spend money on unnecessary things, we may feel exceedingly guilty when we spend even a small amount of money on something we don’t need.
This distortion involves thinking that if we feel a certain way, it must be true. For example, if we feel unattractive or uninteresting in the current moment, we must be unattractive or uninteresting. This cognitive distortion boils down to:
“I feel it, therefore it must be true.”
Clearly our emotions are not always indicative of the objective truth, but it can be difficult to look past how we feel.
Fallacy of Change
The fallacy of change lies in expecting other people to change as it suits us. This ties into the feeling that our happinessdepends on other people, and their unwillingness or inability to change, even if we push and press and demand it, keeps us from being happy. This is clearly a damaging way to think, since no one is responsible for our happiness except for us.
Global Labeling / Mislabeling
This cognitive distortion is an extreme form of generalizing, in which we generalize one or two instances or qualities into a global judgment. For example, if we fail at a specific task, we may conclude that we are a total failure in not only this area, but all areas. Alternatively, when a stranger says something a bit rude, we may conclude that he or she is an unfriendly person in general. Mislabeling is specific to using exaggerated and emotionally loaded language, such as saying a woman has abandoned her children when she leaves her children with a babysitter to enjoy a night out.
Always Being Right
While we all enjoy being right, this distortion makes us think we must be right, that being wrong is unacceptable. We may believe that being right is more important than the feelings of others, being able to admit when we’ve made a mistake, or being fair and objective.
Heaven’s Reward Fallacy
This distortion involves expecting that any sacrifice or self-denial on our part will pay off. We may consider this karma, and expect that karma will always immediately reward us for our good deeds. Of course, this results in feelings of bitterness when we do not receive our reward (Grohol, 2016).
Many tools and techniques found in CBT are intended to address or reverse these cognitive distortions.
You can download the printable version of the infographic here.
9 Essential CBT Techniques and Tools
There are many tools and techniques used in CBT, many of which have spread from the therapy context to everyday life. The nine techniques and tools listed below are some of the most common and effective CBT practices.
This technique is a way of “gathering data” about our moods and our thoughts. This journal can include the time of the mood or thought, the source of it, the extent or intensity, and how we responded to it, among other factors. This technique can help us to identify our thought patterns and emotional tendencies, describe them, and find out how to change, adapt, or cope with them.
Unraveling Cognitive Distortions
This is a main goal of CBT, and can be practiced with or without the help of a therapist. In order to unravel the cognitive distortions you hold, you must first become aware of which distortions you are most vulnerable to. Part of this involves identifying and challenging our harmful automatic thoughts, which frequently fall into one of the categories listed earlier.
Once you identify the distortions or inaccurate views on the world you hold, you can begin to learn about how this distortion took root and why you came to believe it. When you discover a belief that is destructive or harmful, you can begin to challenge it. For example, if you believe that you must have a high paying job to be a respectable person, but you lose your high paying job, you will begin to feel bad about yourself.
Instead of accepting this faulty belief that leads you to think unreasonably negative thoughts about yourself, you could take this opportunity to think about what makes a person “respectable,” a belief you may not have explicitly considered before.
Exposure and Response Prevention
This technique is specifically effective for those who suffer from obsessive compulsive disorder (OCD). You can practice this technique by exposing yourself to whatever it is that normally elicits a compulsive behavior, but doing your best to refrain from the behavior and writing about it. You can combine journaling with this technique, or use journaling to understand how this technique makes you feel.
This technique is intended to treat panic and anxiety. It involves exposure to feared bodily sensations in order to elicit the response, activate any unhelpful beliefs associated with the sensations, maintain the sensations without distraction or avoidance, and allow new learning about the sensations to take place. It is intended to help the sufferer see that symptoms of panic are not dangerous, although they may be uncomfortable.
Nightmare Exposure and Rescripting
Nightmare exposure and rescripting is intended specifically for those suffering from nightmares. This technique is similar to interoceptive exposure, in that the nightmare is elicited, which brings up the relevant emotion. Once the emotion has arisen, the client and therapist work together to identify the desired emotion and develop a new image to accompany the desired emotion.
Play the Script Until the End
This technique is especially useful for those suffering from fear and anxiety. In this technique, the individual who is vulnerable to crippling fear or anxiety conducts a sort of thought experiment, where they imagine the outcome of the worst case scenario. Letting this scenario play out can help the individual to recognize that even if everything they fear comes to pass, it will likely turn out okay.
Progressive Muscle Relaxation (PMR)
This is a familiar technique to those who practice mindfulness. Similar to the body scan, this technique instructs you to relax one muscle group at a time until your whole body is in a state of relaxation. You can use audio guidance, a YouTube video, or simply your own mind to practice this technique, and it can be especially helpful for calming nerves and soothing a busy and unfocused mind.
This is another technique that is not specific to CBT, but will be familiar to practitioners of mindfulness. There are many ways to relax and bring regularity to your breath, including guided and unguided imagery, audio recordings, YouTube videos, and scripts. Bringing regularity and calm to your breath will allow you to approach your problems from a place of balance, facilitating more effective and rational decision making (Megan, 2016).
These techniques can help those suffering from a range of mental illnesses and afflictions, including anxiety, depression, OCD, and panic disorder, and they can be practiced with or without the guidance of a therapist. To try some of these techniques without the help of a therapist, see the next section for worksheets and handouts to assist with your practice.
You can download the printable version of the infographichere.
Cognitive Behavioral Therapy Worksheets (PDF) To Print and Use
If you’re a therapist looking for ways to guide your client through treatment or a hands-on person who loves to learn by doing, there are many CBT worksheets that can help.
Alternative Action Formulation
This worksheet instructs the user to first list any problems or difficulties you are having. Next, you list your vulnerabilities (i.e., why you are more likely to experience these problems than someone else) and triggers (i.e., the stimulus or source of these problems).
Once you have defined the problems and understand why you are struggling with them, you go on to list coping strategies. These are not solutions to problems, but ways in which you can deal with the effects of these problems that can have a temporary impact. Next, you list the effects of these coping strategies, such as how they make you feel in the short-term and long-term, and the advantages and disadvantages of each strategy.
Finally, you move on to listing alternative actions. If your coping strategies are not totally effective against the problems and difficulties that are happening, you are instructed to list other strategies that may work better.
This worksheet gets you (or your client) thinking about what you are doing now and whether it is the best way forward. You can find it here.
One popular technique in CBT is functional analysis. This technique helps you (or the client) learn about yourself, specifically what leads to specific behaviors and what consequences result from those behaviors.
In the middle of the worksheet is a box labeled “Behaviors.” In this box, you write down any potentially problematic behaviors or other behaviors you wish to analyze.
On the left side of the worksheet is a box labeled “Antecedents,” in which you or the client write down the factors that preceded a particular behavior. These are factors that led up to the behavior under consideration, either directly or indirectly.
On the right side is the final box, labeled “Consequences.” This is where you write down the consequences of the behavior, or what happened as a result of the behavior under consideration. “Consequences” may sound inherently negative, but they are not necessarily negative; some positive consequences can arise from many types of behaviors, even if more negative consequences result as well.
This worksheet can help you or your client to find out whether particular behaviors are adaptive and helpful in striving towards your goals, or destructive and self-defeating. Follow this linkto print out this worksheet and give it a try.
This worksheet helps you address what some CBT therapists call the “5 P Factors” – presenting, predisposing, precipitating, perpetuating, and positives. This formulation process can help you connect the dots between your core beliefs and thought patterns and your present behavior.
This worksheet presents five boxes at the top of the page, which should be completed before moving on to the rest of the worksheet.
- The first box is labeled “Precipitating Events / Triggers,” and corresponds with the Precipitating factor. In this box, you are instructed to write down the events or stimuli that provoke a certain behavior.
- The next box is labeled “Early Experiences” and corresponds to the Predisposing factor. This is where you list the experiences that you had early on, all the way back to childhood, that may have contributed to the behavior.
- The third box is “Core Beliefs,” which is also related to the Predisposing factor. This is where you write down some of the relevant core beliefs you have regarding this behavior. These are beliefs that may not be explicit, but that you believe deep down, such as “I’m bad” or “I’m not good enough.”
- The fourth box is “Old Rules for Living,” which is where you list the rules that you adhere to, whether consciously or subconsciously. These implicit or explicit rules can perpetuate the behavior, even if it is not helpful or adaptive. Rules are if-then statements that provide a judgment based on a set of circumstances. For instance, you may have the rule “If I do not do something perfectly, I’m a complete failure.”
- The final box is labeled “Presenting Problems / Effects of Old Rules.” This is where you write down how well these rules are working for you. Are they helping you to be the best you can be? Are they helping you to effectively strive towards your goals?
Below this box there are two flow charts that you can fill out based on how these behaviors and feelings are perpetuated. You are instructed to think of a situation that produces a negative automatic thought, and record the emotion and the behavior that this thought provokes, as well as the bodily sensations that can result. Filling out these flow charts can help you see what drives your behavior or thought and what results from it.
Below these two charts is the box “Protective Factors.” This is where you list the factors that can help you deal with the problematic behavior or thought, and perhaps help you break the perpetuating cycle. This can be things that help you cope once the thought or behavior arises or things that can disrupt the pattern once it is in motion.
Finally, the last box is “New Rules for Living.” This box relates to the Positive factor, in that it provides you with an opportunity to create new rules for yourself that will disrupt the destructive cycle and allow you to become more effective in meeting your therapeutic goals. Click here if you’d like to try this worksheet.
Dysfunctional Thought Record
This worksheet is especially helpful for people who are struggling with negative thoughts and need to figure out when and why they are most likely to pop up. By learning more about what provokes certain automatic thoughts, they become easier to address and reverse.
The worksheet is divided into seven columns:
- On the far left, there is space to write down the date and time a dysfunctional thought arose.
- The second column is where the situation is listed. The user is instructed to describe the event that led up to the dysfunctional thought in detail.
- The third column is for the automatic thought. This is where the dysfunctional automatic thought is recorded, along with a rating of belief in the thought on a scale from 0% to 100%.
- The next column is where the emotion or emotions elicited by this thought are listed, also with a rating of intensity on a scale from 0% to 100%.
- The fifth column is labeled “Distortion.” This column is where the user will identify which cognitive distortion(s) they are suffering from with regards to this specific dysfunctional thought, such as all-or-nothing thinking, filtering, jumping to conclusions, etc.
- The second to last column is for the user to write down alternative thoughts, more positive and functional thoughts that can replace the negative one.
- Finally, the last column is for the user to write down the outcome of this exercise. Were you able to confront the dysfunctional thought? Did you write down a convincing alternative thought? Did your belief in the thought and/or the intensity of your emotion(s) decrease? To give this worksheet a try, click here.
Fact or Opinion
One of my favorite CBT worksheets is the “Fact or Opinion” worksheet, because it can be extremely helpful in recognizing that your thoughts are not necessarily true.
At the top of this worksheet is an important lesson:
Thoughts are not facts.
Of course, it can be hard to accept this, especially when we are in the throes of a dysfunctional thought or intense emotion. Filling out this worksheet can help you come to this realization.
The worksheet includes 16 statements that the user must decide are either fact or opinion. These statements include:
- I’m a bad person.
- I failed the test.
- I’m selfish.
- I didn’t lend my friend money when they asked.
This is not a trick – there is a right answer for each of these statements. (In case you’re wondering, the right answers for the statements above are as follows: opinion, fact, opinion, fact.)
This simple exercise can help the user to see that while we have lots of emotionally charged thoughts, they are not all objective truths. Recognizing the difference between fact and opinion can assist us in challenging the dysfunctional or harmful opinions we have about ourselves and others.
If you’d like to print out this worksheet to give it a try, click here.
This worksheet employs the use of Socratic questioning, a technique that can help the user to challenge irrational or illogical thoughts.
The top of the worksheet describes how thoughts are a running dialogue in our minds, and they can come and go so fast that we hardly have time to address them. This worksheet aims to help us capture one or two of these thoughts and analyze them.
- The first box to be filled out is “Thoughts to be questioned.” This is where you write down a specific thought, usually one you suspect is destructive or irrational.
- Next, you write down the evidence for and against this thought. What evidence is there that this thought is accurate? What evidence exists that calls it into question?
- Once you have identified the evidence, you can make a judgment on this thought, specifically whether it is based on facts or your feelings.
- Next, you answer a question on whether this thought is truly a black and white situation, or whether reality leaves room for shades of grey. This is where you think about whether you are using all-or-nothing thinking, or making things unreasonably simple when they are truly complex.
- In the last box on this page, you consider whether you could be misinterpreting the evidence or making any unverified assumptions.
On the next page, you are instructed to think about whether other people might have different interpretations of the same situation, and what those interpretations might be.
Next, ask yourself whether you are looking at all the relevant evidence, or just the evidence that backs up the belief you already hold. Try to be as objective as possible.
The next box asks you whether your thought may an exaggeration of a truth. Some negative thoughts are based in truth, but extended past their logical boundaries.
Next, you are instructed to consider whether you are entertaining this negative thought out of habit or because the facts truly support it.
Once you have decided whether the facts support this thought, you are encouraged to think about how this thought came to you. Was it passed on from someone else? If so, are they a reliable source for truth?
Finally, you complete the worksheet by identifying how likely the scenario your thought brings up actually is, and whether it is the worst case scenario.
These “Socratic questions” encourage a deep dive into the thoughts that may plague you, and offer an opportunity to analyze and evaluate them for truth. If you are having thoughts that do not come from a place of truth, this worksheet can be an excellent tool for identifying and defusing them.
For more CBT worksheets and handouts, visit this website.
Some More CBT Interventions and Exercises
Haven’t had enough CBT toolsand techniques yet? Continue on for more useful and effective exercises!
These are related to thought experiments, in that you engage in a “what if” consideration. Behavioral experiments differ from thought experiments in that you actually test out these “what ifs” outside of your thoughts (Boyes, 2012).
In order to test a thought, you can experiment with the outcomes that different thoughts produce. For example, you can test the thought:
“If I criticize myself, I will be motivated to work harder” vs. “If I am kind to myself, I will be motivated to work harder.”
First, you would try criticizing yourself when you need motivation to work harder and record the results. Then you would try being kind to yourself and recording the results. Next, you would compare the results to see which thought was closer to the truth.
These behavioral experiments can help you learn how to best strive towards your therapeutic goals and how to be your best self.
Thought records are useful in testing the validity of your thoughts (Boyes, 2012). They involve gathering and evaluating the evidence for and against a particular thought, allowing for an evidence-based conclusion on whether the thought is valid or not.
For example, you may have the belief “My friend thinks I’m a bad friend.” You would think of all the evidence for this belief, such as “She didn’t answer the phone the last time I called” or “She cancelled our plans at the last minute”, and evidence against this belief, like “She called me back after not answering the phone” and “She invited me to her barbecue next week. If she thought I was a bad friend, she probably wouldn’t have invited me.”
Once you have evidence for and against, the goal is to come up with more balanced thoughts, such as
“My friend is busy and has other friends, so she can’t always answer the phone when I call. If I am understanding of this, I will truly be a good friend.”
Thought records apply the use of logic to ward off unreasonable negative thoughts and replace them with more balanced, rational thoughts (Boyes, 2012).
Pleasant Activity Scheduling
This technique can be especially helpful for dealing with depression (Boyes, 2012). It involves scheduling activities in the near future that you can look forward to.
For example, you may write down one activity per day that you will engage in over the next week. This can be as simple as watching a movie you are excited to see or calling a friend to chat. It can be anything that is pleasant to you, as long as it is not unhealthy (i.e., eating a whole cake in one sitting or smoking).
You can also try scheduling an activity for each day that provides you with a sense of mastery or accomplishment (Boyes, 2012). It’s great to do something pleasant, but doing something small that can make you feel accomplished may have longer lasting and farther reaching effects.
This simple technique can introduce more positivity into your day and help you make your thinking less negative.
Imagery Based Exposure
This exercise involves thinking about a recent memory that produced strong negative emotions and analyzing the situation.
For example, if you recently had a fight with your significant other and they said something hurtful, you can bring that situation to mind and try to remember it in detail. Next, you would try to label the emotions and thoughts you experienced during the situation and identify the urges you felt (e.g., to run away, to yell at your significant other, to cry).
Visualizing this negative situation, especially for a prolonged period of time, can help you to take away its ability to trigger you and reduce avoidance coping (Boyes, 2012). When you expose yourself to all of the feelings and urges you felt in the situation and survive experiencing the memory, it takes some of its power away.
Situation Exposure Hierarchies
This technique may sound complicated, but it’s relatively simple.
Situation Exposure Hierarchies involves making a list of things that you would normally avoid (Boyes, 2012). For example, someone with severe social anxiety may typically avoid making a phone call instead of emailing or asking someone on a date.
Next, you rate each item on how distressed you think you would be, on a scale from 0 to 10, if you engaged in it. For the person suffering from severe social anxiety, asking someone on a date may be rated a 10 on the scale, while making a phone call instead of emailing might be rated closer to a 3 or 4.
Once you have rated each item, you rank them according to their distress rating. This will help you recognize the biggest difficulties you face, which can help you decide which items to address and in what order. It may be best to start with the less distressing items and work your way up to the most distressing items.
A CBT Manual and Workbook for Your Own Practice + for Your Client
If you’re interested in giving CBT a try with your clients, there are many books and manuals that can help get you started. Some of these books are for the therapist only, and some are to be navigated as a team or with guidance from the therapist.
There are many manuals out there for helping therapists apply CBT in their work, but these are some of the most popular:
For clients or for therapist and client to work through together, these are some of the most popular manuals and workbooks:
There are many other manuals and workbooks out there that can help get you started with CBT, but these are a good start.
5 Last Cognitive Behavioral Activities
Before we go, there are a few more CBT activities and exercises that may be helpful for you or your clients that we’d like to cover.
As readers of this blog will likely know by now, mindfulness can have a wide range of positive impacts, including helping with depression, anxiety, addiction, and many other mental illnesses or difficulties.
Mindfulness can help those suffering from harmful automatic thoughts to disengage from rumination and obsession over these thoughts by helping them stay firmly grounded in the present.
This is a somewhat fancy name for a simple idea that you have likely already hear of: breaking up large tasks into small steps to make it easier to accomplish.
It can be overwhelming to be faced with a huge goal we would like to accomplish, like opening a business or remodeling a house. This is true in mental health treatment as well, since the goal to overcome depression or anxiety and achieve mental wellness can seem like a monumental task to those who are suffering from severe symptoms.
By breaking the large goal into small, easy to accomplish steps, we can map out the path to success and make the journey seem a little less overwhelming.
Writing Self-Statements to Counteract Negative Thoughts
This technique can be difficult for someone just beginning their CBT treatment or suffering from severe symptoms, but it can also be extremely effective (Anderson, 2014).
When you (or your client) are being plagued by negative thoughts, it can be hard to confront them, especially if your belief in these thoughts is strong. To counteract these negative thoughts, it can be helpful to write down a positive, opposite thought.
For example, if the thought that you are worthless keeps popping into your head, try writing down a statement like “I am a person with worth” or “I am person with potential.” In the beginning, it can be difficult to accept these replacement thoughts, but the more you bring out these positive thoughts to counteract the negative ones, the stronger the association will be.
Visualize the Best Parts of Your Day
When you are feeling depressed or negative, it is difficult to recognize that there is good in your life as well. This simple technique of bringing to mind the good parts of your day can be a small step in the direction of recognizing the positive (Anderson, 2014).
All you need to do is write down the things in your life that you are most thankful for or the things that are most positive in your day. The simple act of writing down these good things can forge new associations in your mind which make it easier to see the positive, even when there is plenty of negative as well.
Reframe Your Negative Thoughts
It can be all too easy to succumb to negative thoughts as a default setting. If you find yourself immediately thinking a negative thought when you see something new, such as entering an unfamiliar room and thinking “I hate the color of that wall,” give reframing a try (Anderson, 2014).
Reframing involves countering the negative thought(s) by noticing things you feel positive about as quickly as possible. For instance, in the example where you immediately think of how much you hate the color of that wall, you would push yourself to notice five things in the room that you feel positively about (e.g., the carpet looks comfortable, the lampshade is pretty, the windows let in a lot of sunshine).
You can set your phone to remind you throughout the day to stop what you are doing and think of the positive things around you. This can help you to push your thoughts back into the realm of the positive instead of the negative.
You can download the printable version of the infographic here.
A Take Home Message
As always, I hope this post has been helpful. There are a lot of great tips and techniques in here that can be extremely effective in the battle against depression, anxiety, OCD, and a host of other problems or difficulties.
However, as is the case with many treatments, they depend on you (or your client) putting in a lot of effort. I would encourage you to give these techniques a real try, and allow yourself the luxury of thinking they may actually work. When we approach a potential solution with the assumption that it will not work, then it will probably not work. When we approach a potential solution with an open mind and the thought that it just might work, it has a much better chance of succeeding.
So if you are struggling with negative automatic thoughts, please consider these tips and techniques and give them a real shot. Likewise, if your client is struggling, encourage them to make the effort, because the payoff can be better than they can imagine.
If you are struggling with severe symptoms of depression or suicidal thoughts, please call the following number in your respective country:
- USA: National Suicide Prevention Hotline at 1-800-273-8255
- UK: Samaritans hotline at 116 123
- The Netherlands: Netherlands Suicide Hotline at 09000767
- France: Suicide écoute at 01 45 39 40 00
- Germany: Telefonseelsorge at 0800 111 0 111 for Protestants, 0800 111 0 222 for Catholics, and 0800 111 0 333 for children and youth
For a list of other suicide prevention websites, phone numbers, and resources, see this website.
Please know that there are people out there who care and that there are treatments that can help.
Thank you for reading, and please let us know about your experiences with CBT in the comments section. Have you tried it? How did it work for you? Are there any other helpful exercises or techniques that we did not touch on in this piece?
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- Anderson, J. (2014, June 12). 5 get-positive techniques from Cognitive Behavioral Therapy. Everyday Health. Retrieved from http://www.everydayhealth.com/hs/major-depression-living-well/cognitive-behavioral-therapy-techniques/
- Boyes, A. (2012, December 6). Cognitive behavioral therapy techniques that work: Mix and match Cognitive Behavioral Therapy techniques to fit your preferences. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/in-practice/201212/cognitive-behavioral-therapy-techniques-work
- Grohol, J. (2016). 15 common cognitive distortions. Psych Central. Retrieved from https://psychcentral.com/lib/15-common-cognitive-distortions/
- Martin, B. (2016). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
- Megan, R. (2016, August 8). List of CBT techniques – cognitive behavioral therapy. Info Counselling. Retrieved from http://www.infocounselling.com/list-of-cbt-techniques/
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About the AuthorCourtney Ackerman is a graduate of the positive organizational psychology and evaluation program at Claremont Graduate University. She is currently working as a researcher for the State of California and her professional interests include survey research, well-being in the workplace, and compassion. When she’s not gleefully crafting survey reminders, she loves spending time with her dogs, visiting wine country, and curling up in front of the fireplace with a good book or video game.
This study used prospective, observational methods to evaluate six features of therapist behavior as predictors of homework adherence in cognitive-behavioral therapy (CBT) for adolescent depression, with the goal of identifying therapist strategies with the potential to improve adolescent adherence. Therapist behaviors were expected to interact with initial levels of client resistance or adherence to predict subsequent homework completion.
Participants were 50 referred adolescents (33 females, 54% ethnic minority) ages 14–18 (M=15.9) meeting diagnostic criteria for a depressive disorder, and without co-morbid psychotic disorder, bipolar disorder, autism spectrum disorder, intellectual disability, or concurrent treatments. Therapist homework-related behaviors were coded from audiotapes of Sessions 1 and 2 and used to predict adolescents’ homework adherence, coded from audiotapes of Sessions 2 and 3.
Several therapist behaviors were predictive of subsequent homework adherence, particularly for initially resistant or non-adherent adolescents. Stronger homework rationale and greater time allocated to explaining homework in Session 1 predicted greater adherence at Session 2, particularly for initially resistant adolescents. Stronger rationale and eliciting reactions/troubleshooting obstacles in Session 2 predicted greater adherence at Session 3, particularly for adolescents who were less adherent to prior homework.
Strategies such as providing a strong rationale, allocating more time to assigning homework, and eliciting reactions/troubleshooting obstacles may be effective ways to bolster homework adherence among initially less engaged, depressed teens.
Keywords: Adolescent depression, CBT, homework adherence, engagement, therapist behavior
The assignment of homework is considered important in Cognitive-Behavioral Therapy (CBT) as a means to build and generalize new client skills. A growing body of evidence supports homework as an active ingredient in CBT for adults (see Kazantzis et al., 2010, for a meta-analysis). Although only a handful of empirical studies have examined the role of homework in youth treatments (Clarke et al., 1992; Gaynor, Lawrence & Nelson-Gray, 2006; Hughes and Kendall, 2007; Kazdin, Bass, Siegel, & Thomas, 1989), there is some evidence supporting its positive association with outcome. Two studies of homework in CBT for adolescent depression yielded small to moderate correlations between homework adherence and outcome (Clark et al., 1992; Gaynor et al., 2006). In both studies, adolescents completed about half of assigned homework tasks. Initial results, then, suggest homework completion contributes to better depression outcomes, but adolescent adherence is far from optimal. Thus, one way to improve CBT for adolescent depression could be through increased homework adherence.
A small number of studies in the adult treatment literature have examined therapist behaviors thought to be associated with increased homework adherence. These empirical studies have largely focused on four cognitive therapy strategies originally prescribed by Beck, Rush, Shaw, and Emery (1979), which include: 1) providing clear and specific task instructions and custom-tailoring homework tasks to client problems when possible; 2) providing a rationale for the assignment, stressing the importance and the goals of the task; 3) eliciting patient reactions and possible obstacles to completion of the homework, troubleshooting when necessary; and 4) reviewing assignments from the previous session, summarizing progress made or conclusions drawn from the exercise. Each of these strategies has received some empirical support with adults (Bryant, Simons & Thase, 1999; Detweiler-Bedell & Whisman, 2005; Ryum, Stiles, Svartberg, & McCullough, 2010; Shaw et al., 1999).
Despite suboptimal homework adherence among teens, little is known about processes that improve adherence in youth. Beck and colleagues’ (1979) prescribed strategies provide a framework for examining therapist homework-related behavior with adolescents. From a developmental perspective, the strategy of eliciting adolescent reactions and perceived obstacles to homework completion seems particularly important given that a collaborative approach has been shown to facilitate alliance development with adolescents (Diamond, Liddle, Hogue, & Dakof, 1999), who can be reactive to adult prescriptions or requests.
Of course, “adherence-enhancing behaviors” do not occur in a vacuum. Adolescents vary significantly in their readiness to engage in treatment, and prior research has found that adolescents with higher levels of initial resistance showed poorer subsequent involvement in treatment tasks (Jungbluth & Shirk, 2009). Similarly, early homework adherence has been found to predict subsequent adherence (Addis & Jacobson, 2000). Thus, adolescents who have shown high initial resistance or poor adherence to a previous homework task are likely at greater risk for future non-adherence. It is hypothesized that initially resistant or non-adherent adolescents might benefit most from additional therapist use of adherence-enhancing strategies. Specifically, greater therapist attention to specifying homework tasks, providing a strong rationale, and troubleshooting obstacles, as well as the sheer amount of time devoted to assigning tasks, may be especially relevant for adolescents who are initially resistant or non-adherent to previous assignments. These same therapist behaviors may not be as critical for adolescents with good early engagement or strong prior homework adherence. Teens who have been adherent to prior homework tasks may benefit more from different therapist behaviors, such as more extensive homework review and therapist use of praise.
In summary, this study evaluated six features of therapist behavior as predictors of homework adherence in CBT for adolescent depression. Session recordings from a study of individually delivered, manual-guided CBT for adolescent depression were utilized. Therapist behaviors were expected to interact with initial levels of client resistance and adherence to predict subsequent homework completion. Coding and analysis of therapist adherence-enhancing behaviors were limited to the first two sessions of treatment for two reasons: 1) Previous research with adults has linked early homework to treatment gains (Addis & Jacobson, 2000; Fennell & Teasdale, 1987) and later homework adherence (Addis & Jacobson, 2000); 2) Sample size constrained our ability to evaluate complex interactions in later sessions (when therapist behavior may interact with or depend upon factors from all prior sessions, such as the cumulative effects of resistance, prior therapist behavior, and the trajectory of homework adherence).
The data were obtained from an open clinical trial of CBT for depressed adolescents in an urban setting in the Rocky Mountain West (see Shirk, Kaplinski & Gudmundsen, 2009, for a detailed description of study procedures, which were IRB approved prior to initiating the study). Current study participants were 50 referred adolescents (33 females), between ages 14 and 18 (M = 15.9), who met diagnostic criteria for Major Depressive Disorder (n=37), Dysthymic Disorder (n=10), or Depressive Disorder, Not Otherwise Specified (n=3), as assessed with the Computerized Diagnostic Interview Scale for Children (C-DISC; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000). Exclusionary criteria were: diagnoses of co-morbid Psychotic Disorder, Bipolar Disorder, Autism Spectrum Disorder, or Intellectual Disability; concurrent therapy; or medication for depressive symptoms.
Sixty-six percent of the sample met criteria for a comorbid disorder including generalized anxiety disorder (42%), conduct disorder (34%), social phobia (22%), and attention deficit/hyperactivity disorder (12%). Twenty-eight percent of the treatment sample met criteria for three or more disorders. Forty percent reported a lifetime history of attempted suicide.
By self-report, 54 percent of the sample identified as ethnic minority, including 11 African American/Black, 11 Hispanic/Latino, two Native American, two Biracial, and two Other, with some adolescents endorsing multiple categories. Socioeconomic status was indexed by parent occupation on the Hollingshead Index (Hollingshead, 1976), with an average score of 4.1 (SD=2.1), corresponding to skilled manual workers, craftsmen, and small business owners. Fifty adolescents started treatment, with two dropping out before the second session and five more before Session 3. Available sample size varied across primary analyses from 41 to 33 due to client dropout, mechanical audiotape failure, therapist failure to record a session, and, in a small number of cases, insufficient detail on the audiotape for coding of homework adherence, as discussed in greater detail below. Demographic or study variables did not differ across groups with or without missing data.
High school site coordinators identified and referred potential participants for inclusion in the study. Participants completed a computer-administered diagnostic interview (C-DISC) and demographic questionnaires at the pre-treatment interview. Participating adolescents received free treatment and monetary compensation for completion of research interviews.
A twelve-session, manual-guided, outpatient cognitive-behavioral treatment, adapted for adolescents and evaluated by Rossello and Bernal (1999), was delivered by eight therapists. Goals of the first session were to build rapport, gather information, provide rationale and expectations for treatment, provide education about depression, and introduce mood monitoring homework. The second session included education about negative thinking and its link to mood, followed by introduction of a thought monitoring homework task. In session three, therapists continued discussing negative thinking in relation to depressed mood and introduced skills for challenging negative thoughts, which were then assigned as homework. A review of 25 percent of audiotapes selected randomly indicated high therapist fidelity to the treatment manual, with 83 percent of components delivered (Shirk, Gudmundsen, Crisp Kaplinski, & McMakin, 2008).
All eight therapists had doctoral degrees in clinical psychology, attended a daylong workshop, conducted a supervised practice case, and then received 1.5 hours of weekly group supervision by a licensed psychologist with extensive CBT experience.
Weekly homework assignments were described in the manual, and time was allocated in every session for assigning new homework and reviewing the previous session’s homework. Teens also received workbooks and handouts on which to record assignments. Session 1 homework required adolescents to record daily mood ratings and triggers for negative arousal. Session 2 was the same, but included recording automatic thoughts associated with negative mood or events. Specific guidelines for how to assign homework were not included in the manual.
Computerized Diagnostic Interview Scale for Children 4.0 (C-DISC)
The C-DISC (Shaffer et al., 2000) is a highly structured diagnostic interview with good reliability and criterion validity for identifying psychiatric disorders among youth (Shaffer et al., 2000). The mood, anxiety, and disruptive behavior modules were computer administered to screen for inclusion and exclusion disorders and to measure depression severity based on total symptoms endorsed.
Homework adherence was coded from audiotapes of Sessions 2 and 3, in random order, on a seven-point scale (0=“no effort” to 6=“did more than was asked or exceptional effort”). Reliability of homework adherence coding, based on double coding of 30 percent of sessions (n = 25), was good, with a two-way random effects intraclass correlation (ICC) of .72. Of the 91 existing sessions we set out to code, 84 were given homework adherence ratings. The remaining seven sessions (7.7 percent) could not be coded for one of several reasons: 1) mechanical audiotape error, 2) therapist forgot to record the session, or 3) there was insufficient information on the audiotape to determine a rating. Observed adherence ratings ranged from 0 to 6 (Session 2 M=4.51, SD=1.01 and Session 3 M=4.21, SD=1.12 after outlier adjustment).
Behaviors thought to promote homework adherence were measured using the Therapist Homework Adherence Behavior Scale (THABS), an adaptation of Bryant and colleagues’ (1999) measure from CT for depressed adults. The scale includes six items: 1) specification of the task, 2) provision of rationale, 3) elicitation of client reactions and troubleshooting of difficulties, 4) review of previous homework assignment, 5) praise for homework adherence, and 6) total time spent assigning the task. The first five items were rated on a scale from zero (not done) to four (very well done) and anchored to enhance reliability. The sixth item was scored as simply the number of seconds devoted to assigning homework. Two-way random effects intraclass correlations (ICCs), based on double coding of 21 percent of available sessions (n = 19), ranged from .27 to .84 (mean ICC = .67; See Table 1 for item descriptions, ICCs, and descriptive data). Item 4 (review of previous homework assignment) was dropped due to low reliability. Four Session 1 tapes could not be coded because of mechanical tape failure (n = 2) and therapists forgetting to tape the session (n = 2). One Session 2 tape could not be coded because a therapist forgot to tape the session.
Adherence-Enhancing Behaviors: Item Descriptions, ICCs and Descriptive Data
Initial resistance was assessed during Session 1 using six items adapted from the observational Vanderbilt Negative Indicators Scale (Suh, Strupp, & O’Malley, 1986). Observers used audiotapes to code a 15-minute segment for each client, beginning five minutes into Session 1. This early segment was chosen to begin after introductions and initial scheduling concerns were addressed but before the therapist had time to build much rapport, to better capture the client’s contribution to process. Client demeanor was rated using five items covering five dimensions: hostile, frustrated, impatient, intellectualizing, and defensive. A sixth item was used to rate client negative reactions to the therapist. All items were rated on a 5-point scale ranging from 1 (not at all) to 5 (a great deal) and totaled. Internal consistency for the scale was good (Cronbach’s alpha = .89) and a one-way mixed random ICC (using 25% of scores) demonstrated strong inter-rater reliability (ICC = .88). Four Session 1 tapes could not be coded for initial resistance, for reasons listed above. Initial resistance, adherence-enhancing behaviors, and homework adherence were coded by separate sets of coders to avoid bias. Scores ranged from 6 to 25 (M=7.54, SD=1.91, after outlier adjustment).
Outliers were identified for three of the Session 1 THABS items (specifying task: 3 outliers; providing rationale: 5 outliers; time spent assigning: 2 outliers), and both homework adherence variables (Session 2 adherence: 5 outliers; Session 3 adherence: 6 outliers). Outliers were adjusted by bringing them in to 1.5 times the interquartile range beyond the first or third quartile to prevent undue influence. Skew and kurtosis were within acceptable ranges for all variables. Examination of Mahalanobis distance for all interaction model variables revealed no multivariate outliers.
We tested client demographic (age, gender, race/ethnicity) and clinical (initial depression severity) variables as predictors of homework adherence at Sessions 2 and 3. The only predictor was Hispanic/Latino ethnicity (Spearman r = −.31, p = .03), such that adolescents who self-identified as Hispanic/Latino were less adherent for the first homework task. Thus, Hispanic/Latino was included as a control variable in all analyses predicting homework adherence.
As expected, initial resistance showed a small, though non-significant, association with homework adherence at Session 2 (r = −.26, p = .09) and Session 3 (r = −.23, p = .18). Initial resistance was included as a predictor or moderator in all analyses of therapist behaviors in relation to homework adherence.
Analyses were conducted to evaluate the possible influence of therapist effects on homework adherence. Two separate univariate Analysis of Variance (ANOVA) models were run with therapists as the independent grouping factor and Session 2 and Session 3 homework adherence ratings as dependent variables. Results showed no significant therapist effects on these variables (p’s > .4).
Correlations among HWA predictors
Pearson correlation coefficients were calculated to examine the association among the six therapist behaviors, as well as the three other predictor variables (initial resistance, Session 2 homework adherence, and Hispanic/Latino ethnicity) to be evaluated as predictors of HWA. These associations are presented in Table 2. Although several of the therapist behaviors were significantly correlated with one another, no correlation exceeded .52 and most associations were very small and non-significant; thus, the coding system appears to have captured relatively discrete, non-overlapping constructs. Also, therapist behaviors were generally not associated with initial resistance or homework adherence at Session 2, and initial resistance and homework adherence at Session 2 were only associated with one another at a trend level. Hispanic/Latino ethnicity was associated greater therapist provision of rationale at Session 2 (r = .29, p < .05).
Correlations Among Session 1 and 2 Predictors of Homework Adherence
Session 1 therapist behaviors predicting homework adherence in Session 2
Each of the four Session 1 therapist behaviors were entered into separate multiple regressions. In each regression, therapist behavior was entered along with initial resistance, Hispanic/Latino ethnicity, and the interaction term (therapist behavior centered x initial resistance centered) as predictors of homework adherence at Session 2. Results of these regressions are described below and in Table 3.
Multiple Regression Analyses Predicting Homework Adherence at Session 2 from Therapist Adherence-Enhancing Behaviors in Session 1
Initial resistance demonstrated a small to medium effect across regressions (β’s from −.23 to −.40), as did Hispanic/Latino ethnicity (β’s from −.33 to −.44). In addition, interaction effects were observed for two therapist behaviors: As illustrated in Figure 1, and consistent with our hypothesis, provision of rationale in Session 1 predicted Session 2 adherence more strongly for adolescents who were initially more resistant (interaction term β = .31, p = .03). As illustrated in Figure 2, and also consistent with our hypothesis, the positive predictive association between time spent assigning in Session 1 and adherence in Session 2 appeared stronger for adolescents who were initially more resistant (interaction term β = .30, p = .03). (In Figures 1 and 2, initial resistance was dichotomized at the median into high and low groups for the purposes of illustration.) There was also a trend-level main effect for time spent assigning the homework (β = .26, p = .07) predicting Session 2 adherence.
The interaction between initial resistance (IR) and provision of rationale in Session 1 to predict homework adherence at Session 2, controlling for Hispanic/Latino ethnicity.
The interaction between initial resistance (IR) and the amount of time therapist spent assigning homework in Session 1 to predict homework adherence at Session 2, controlling for Hispanic/Latino ethnicity.
Session 2 therapist behaviors predicting clients’ homework adherence at Session 3, considering prior adherence
Next, we examined whether the same four adherence-enhancing behaviors, this time measured in Session 2, would interact with clients’ level of prior homework adherence to predict adherence at Session 3. Each of the four therapist behaviors were entered into separate multiple regressions along with Session 2 homework adherence, initial resistance, Hispanic/Latino ethnicity, and the interaction term (therapist behavior centered x Session 2 homework adherence centered). The dependent variable was homework adherence at Session 3. Results of these multiple regressions are described below and displayed in Table 4.
Multiple Regression Analyses Predicting Homework Adherence at Session 3 from Therapist Adherence-Enhancing Behaviors in Session 2
Initial resistance demonstrated a small to medium effect across regressions (β’s from −.20 to −.47), and Session 2 homework adherence demonstrated a medium effect across regressions (β’s from .34 to .43) predicting Session 3 adherence. In addition, interaction effects were observed for two of the therapist behaviors: Consistent with our prediction, and as illustrated in Figure 3, provision of rationale in Session 2 predicted homework adherence at Session 3 most strongly for those adolescents who had shown poorer adherence to the previous homework task (interaction term β = −.45, p = .01). Also consistent with our prediction, and as illustrated in Figure 4, eliciting client reactions and troubleshooting obstacles to adherence in Session 2 was positively associated with homework adherence in Session 3 for adolescents who had shown poorer prior adherence (interaction term β = −.40, p = .026). (In Figures 3 and 4, Session 2 homework adherence was dichotomized into high and low groups for the purposes of illustration. High adherence reflected scores of “5” or higher, and low adherence reflected scores lower than “5” on the homework adherence scale.)
The interaction between Session 2 homework adherence (HW2) and Session 2 providing rationale to predict homework adherence at Session 3, controlling for level of initial resistance and Hispanic/Latino ethnicity.
The interaction between Session 2 homework adherence (HW2) and Session 2 eliciting reactions/troubleshooting obstacles to predict homework adherence at Session 3, controlling for level of initial resistance and Hispanic/Latino ethnicity.
Contingent praise in Session 2 was also examined as a predictor of Session 3 homework adherence using multiple regression. Of 33 participants with complete data for this analysis, 28 had completed at least some of the first homework assignment and were included. Praise, Session 2 homework adherence, initial resistance and Hispanic/Latino ethnicity were entered as predictors of Session 3 homework adherence. Results showed significant main effects for Session 2 homework adherence (β = .62, p = .002) and initial resistance (β = −.48, p = .008). The praise term was not significant (p = .18).
The current study used prospective, observational methods to examine six therapist behaviors thought to bolster adolescents’ adherence to homework tasks. Consistent with the adult literature, homework adherence was not merely a function of client characteristics, but instead was associated with variations in the way therapists assigned and reviewed homework tasks. Importantly, the positive impact of several therapist behaviors on early homework adherence was conditioned by client behaviors, including early resistance and prior adherence, underscoring the interactive nature of therapy processes.
It was hypothesized that four therapist behaviors—specifying the task, providing rationale, eliciting reactions/troubleshooting obstacles, and amount of time spent assigning—would predict subsequent adherence, with the greatest effects for adolescents who were at risk for poor homework adherence. Adolescents were determined to be at risk for poor adherence if they demonstrated higher levels of initial resistance in Session 1 and if they demonstrated poor adherence on the first homework task, due in Session 2. Consistent with predictions, three therapist behaviors interacted with the risk variables to predict subsequent adherence.
First, adolescents with higher levels of initial resistance and lower levels of initial adherence were more likely to adhere to subsequent homework assignments when therapists provided a strong rationale. This association was not observed with less resistant and initially more adherent adolescents. Greater provision of rationale did not predict adherence with adults (Bryant et al. 1999), but only main effects were examined. Alternatively, provision of a clear rationale may be particularly important for adolescents compared to adults.
Second, the amount of time therapists devoted to assigning homework in Session 1 predicted adherence in Session 2 at a trend level, and this effect was stronger for adolescents who were initially more resistant. This finding suggests therapists may be able to promote greater adherence by setting aside more time in sessions for assigning tasks, especially for relatively disengaged teens. Associations among therapist behavior variables suggest therapists who spent more time assigning homework were also doing a better job specifying the task and providing rationale for it. Time spent in Session 2 did not predict subsequent adherence, perhaps owing to similarity of homework assignments across early sessions.
Third, when adolescents did not show strong adherence to the first homework assignment, therapist efforts to elicit reactions and troubleshoot obstacles in the second session predicted better adherence to the next assignment. This finding converges with three studies with adults indicating positive effects for eliciting reactions and troubleshooting (Bryant et al., 1999, Detweiler-Bedell & Whisman, 2005, & Worthington, 1986). The same therapist behavior, when measured in the first session, did not predict adherence in Session 2, even when initial resistance was considered as a moderator. It may have been easier to identify and address obstacles after they occurred than before.
Another behavior, specifying the homework task, did not predict subsequent adherence in either session, which may reflect that worksheets with clear written instructions were provided. Providing written reminders has been linked to improved medical adherence (Cox, Tisdelle & Culbert, 1988, Stone et al., 2002) and better therapy outcomes for depressed adults (Detweiler-Bedell & Whisman, 2005).
In examining these four therapist behaviors, consideration of context variables (initial resistance and prior adherence) was essential. Contrary to expectations, only one of the four therapist behaviors trended toward a main effect on subsequent adherence. The remaining predictive effects were only significant when considering these moderators, and results begin to address the clinically important question of how to improve low adherence.
There was also an association between Hispanic/Latino ethnicity and adherence to the first homework task; however, this finding is viewed with caution, as Hispanic/Latino ethnicity was not associated with adherence to the second homework task or initial resistance, nor did it predict alliance or outcome in a previous study with the current sample (Shirk, Gudmundsen, Crisp Kaplinski, & McMakin, 2008).
This study had a number of limitations. First, though larger than most prior studies in this literature, sample size was limited. Given power limitations (power for medium effects ranged between .5 and .7) and the exploratory nature of the study, we made no alpha adjustment for the number of analyses conducted; with Bonferroni correction for the main analyses, adjusted alpha would have been .004. Consequently, replication is essential. Second, identified associations were correlational. Future studies should experimentally manipulate therapist behaviors to clarify causality. Third, therapist behaviors were not examined beyond the second session of treatment; thus, current findings may not generalize to middle and later phases of therapy when assignments often become more demanding. Fourth, although standardized homework assignments in the current protocol offered methodological advantages (e.g., variability in adherence across adolescents could not be attributed to variation in homework tasks), this prevented examination of some therapist strategies (e.g., collaborative task generation, individual tailoring) and may have constrained effect sizes for others (e.g., task specification). Similarly, the manual’s specification of homework review likely constrained variation in this behavior. Finally, interrater reliability for therapist praise was suboptimal.
Clinically, therapists faced with depressed adolescents who initially show poor engagement or marginal homework adherence may consider spending more time assigning homework and providing a strong rationale linking homework tasks to recovery. In addition, therapists may be able to improve poor initial adherence by taking time to troubleshoot obstacles that arise. In sum, how therapists address homework relates to how much homework depressed adolescents will do.
Nathaniel J. Jungbluth, Department of Psychiatry and Behavioral Medicine, Seattle Children’s Hospital, Seattle, WA.
Stephen R. Shirk, Department of Psychology, University of Denver, Denver, CO.
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