How do I get patients to do their therapeutic homework?

Why is therapeutic homework useful in behavior therapy?

In behavior therapy, therapeutic homework is defined as activities that patients carry out between therapy sessions. They are selected jointly by the patient and therapist, carried out independently by the patient, and then discussed together and adjusted if necessary. Homework can thus support the achievement of therapy goals. 

In order to prevent unfavorable associations with school experiences, it is discussed among therapists to avoid the term "homework" in patient:patient contact and to use alternative terms such as "therapeutic exercise tasks". 

Homework should be used early in the therapy process to systematically transfer therapy progress and behavioral changes from the therapy room to the patient's everyday life. In this way, therapy successes can be implemented and secured in the long term. In addition, homework helps to intensify and deepen the therapy: Patients can become aware of problematic cognitions and behaviors through self-observation. In addition, they can learn to apply and practically implement the helpful thoughts and functional behaviors developed in therapy in their familiar environment. Through repetition, new patterns of behavior, thinking, and relating become solidified and stabilized. The experiences gained in everyday life can in turn be incorporated into the therapy process and contribute to further therapy planning. The exercises and homework become more important as the therapy progresses; patients should increasingly implement exercises independently in their everyday lives and transfer successes to other situations and areas of life. In this way, patients actively contribute to shaping the therapy and gain increasing control over the therapy process. 

The application of homework is based on the approach of self-management of the patients, whereby they take over a significant part of the responsibility of the therapy process. This can promote therapy motivation and strengthen the patient's experience of self-efficacy.

Scientific studies have shown that therapies with homework were more successful than therapies without homework. According to this, homework can increase the patient's adaptability and (problem) awareness in everyday situations, promote long-term benefits of therapy, and enhance the patient's experience of success, control, and self-efficacy. In addition, therapists can better assess the degree to which patients are involved in therapy.  

What are the known reasons for not implementing therapeutic homework?

Surveys showed that homework is often not implemented at all, incomplete or modified. Therapists reported homework-related problems in 74% of the cases, for example in setting tasks or implementation. This shows that often the full potential of behavior therapy cannot be used. In order to enable patients to do this, it is first important to understand what exactly causes the problems. 

With regard to the task, a study by Helbig and Fehm (2004) showed that a large proportion of patients doubted that they did not have the necessary coping skills, and some were concerned about the difficulty of the tasks. A small number of patients were dissatisfied with the extent of the task or were not prepared to implement it. Looking at the actual implementation, it was found that only 38% of the homework was fully implemented. Reasons given for non-implementation were too high a level of difficulty, no opportunity to implement, fear or avoidance of the task, or a general refusal to implement. Further studies could show that patients are often not aware of the clinical relevance of homework.

How do I increase the likelihood that my patients will do their therapeutic homework?

Based on the described difficulties, approaches for a more successful implementation of homework could be developed, which therapists should consider when planning and assigning homework. 

Beck et al. (1979) described four basic procedures for this: Homework should be clearly and specifically described, the task should be comprehensible to the patient in the context of the therapy goals, the patient's reaction should be taken into account to prevent possible difficulties, and the patient's progress should be summarized when debriefing the homework. 

For the concrete implementation of the planning and preparation of homework, this means that therapists and patients should define the tasks together. It is important to ensure that both sides have the same understanding of the benefits and implementation of the homework. The task should always fit the individual therapy goals and be clear and specific. It is advisable to provide patients with written instructions for the task and to specify a concrete situation, time, space and place. Consideration of how to remind patients of the homework is often useful and increases the likelihood of implementation. If therapists anticipate hurdles that may arise from the patient's perspective (such as "If I put myself in fearful situations, my fear will get worse"), they can address and counteract them in preparation. Therapists should also convey to their patients that it is not so much the achievement of a goal that is significant, but rather the process and the efforts. In addition, it is the therapist's task to ensure that the patient has the appropriate resources and skills to complete the tasks and that they match the patient's cultural background. The level of difficulty should be adjusted individually so that neither under- nor overload occurs. Over the course of therapy, the difficulty level of the tasks should gradually increase. 

Just like the preparation of the homework, the follow-up should also have an appropriate space in the therapy session. Since patients are required to invest time in completing homework, it is important that therapists also take time to address the issue and appreciate the effort. Otherwise, patients may lose motivation for future homework. In addition, possible difficulties can be identified here and tasks can be optimized and adapted if necessary. Regardless of the outcome of the homework assignment, it is important to let patients reflect on what they have learned in relation to the assignment. Patients should also be positively encouraged for their efforts and motivated to do further exercises. 

What contribution can elona therapy make to homework implementation?

As a digital health application, elona therapy supports outpatient psychotherapy for depression and anxiety disorders by promoting the transfer of therapy content into patients' everyday lives. This means that therapists can activate suitable exercises from over 400 multimedia-based manual and guideline-based contents for their patients to assign homework. Patients thus receive exercises with written instructions that match the session topics and therapy goals. They always have these at their fingertips via their smartphone in everyday life - exactly where they are needed. In addition, elona therapy can remind them of tasks and exercises, thus increasing the likelihood of completion. Any ambiguities, difficulties or insights that arise can be noted directly in the app and thus incorporated into the next therapy session.

Our conclusion

Therapeutic homework is an important instrument in behavior therapy for transferring therapy content to the patient's everyday life and thus consolidating therapy successes in the long term. They promote the patient's self-management and sense of self-efficacy and enable them to actively participate and take responsibility in the therapy process. 

Nevertheless, there are different difficulties in planning, preparing and implementing homework. These are often related to the level of difficulty or general ambiguity of the task. To increase the likelihood of implementing homework, therapists should adapt the tasks individually to the patients and their therapy goals and explain the benefits to them in a comprehensible way. Furthermore, tasks should be described specifically and clearly, ideally also in written form, and the patient's reactions to the task should be taken into account and addressed if necessary. Follow-up, like preparation, should be given a space in the therapy session to reflect on implementation, difficulties, and significance for the therapy process. 

elona therapy can make an important contribution to the planning and implementation of therapeutic homework by giving patients access to the tasks at any time via their smartphone.

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