As part of our research and development process, we conducted a focus group interview with both ex-patients in Cognitive Behavioral Therapy, and licensed psychologists in December 2022, in which we asked them to reflect on their previous experiences with homework in psychotherapy. Thanks to this in-depth feedback provided to us, we learnt a lot about the challenges and potential for homework in psychotherapy, as well as how to adapt our value proposition. Below we share our general conclusions.
Patients and psychologists were segmented into separate groups. Each session started with open-ended questions about previous experiences of prescribing or receiving homework in psychotherapy. Discussion amongst participants were encouraged. Thereafter, a video about our solution, and a clickable prototype was demonstrated. After the demonstration, participants gave feedback to our solution in relation to previous homework experiences. The groups took in total approximately 2 hours each.
Previous experience with Homework in Psychotherapy
Patient Perspectives on Homework Adherence
All patients reported using paper-and pencil format for their homework assignments. Exercises mainly consisted of keeping diaries of emotions or behaviors. Patients reported both internal and external factors contributing to adherence to their assignments. In relation to internal factors, patients reported difficulties in understanding the purpose of assignments - reporting feelings of irrelevance or unimportant. Patients also felt tasks were unrewarding in their nature. In relation to external factors, patients reported the tasks as being burdensome to complete, and that they rarely felt they had the time or energy to do so. Commonly, patients forgot to complete the tasks.
“When I fill in those diaries or forms (...) the therapist looks at it and well… so what? What's after that? I want to know. It’s not like, “okay let's continue with the next assignment”, But what about the last one? Why did I do that? And should I keep doing it?”
“(It’s important to) see a progress bar. You need to see that I’ve been here, now I’m here and my final goal is there. You can watch the progress, you can follow it. Seeing that I’m paying so much money for something that helps. Otherwise it seems useless sometimes.”
Patient Suggestions on Improvements
Patients mentioned that assignments with a narrow and simple focus would have been helpful for the completion of their assignments. The issue of relevance was also mentioned, wherein patients would want the relevance of the task to be both explained clearly before handing out the assignment, as well as reflected upon by the therapist afterwards. Importantly, patients also would have liked therapists to explain how the assignment related to their overall treatment goals. Such an evaluation might give patients a better sense of their therapy progress and put the different tasks in context, which would further increase their motivation in the future.
Psychologist Perspectives on Homework Adherence
Interestingly, the main points of our psychologist focus group was in line with the patient perspective. Psychologists indicated the exclusive usage of paper-form assignments and difficulties with patient non-adherence to these assignments. Commonly, non-adherence seemed related to patients not feeling as if they had enough time or energy to complete their assignments. Other reasons for non-adherence included losing the forms, not seeing the purpose of the assignments or not understanding how to practically perform them. A significant proportion of time was spent both discussing the assignments in sessions, as well as documenting the activities after sessions.
“They just said that they didn't have time, they had to do this and this and this instead of doing the homework, they just lost the papers, they got so many papers, documents, they had no idea where they put the homework. They had different therapies during the week and they just got confused, because they didn't take any notes. I think they were a bit overwhelmed as well.”
Psychologist Suggestions on Improvements
Also aligned to the patient perspectives, putting more emphasis on the rationale of the assignment was mentioned as one potential improvement. Digital tools were also mentioned as being helpful for younger audiences.
Feedback on Zeeds
Patients reported liking the colourful design of the application. The growth of trees as indicators for progress was positively received. Furthermore, patients commented upon the structure of the application as being helpful, with clear checkmarks and tasks for the activity in the application. Notification reminders were also seen as useful. Overall, patients overall preferred the application over their previous homework experiences. They also gave suggestions for improvements. Two concrete features were free-writing sections within the application for simple reflections not directly related to the task at hand, as well as options for audio input to further decrease the friction in data input.
“I thought it’s cool that for people with anxiety and depression they really lack structure and foundation in their life. When you give them something like that, it can help them get back to being more stable. Especially when you structure everything like that. It’s a lot easier to stick to it.”
Psychologists favourably rated the design of the application. The structure of the application was also seen as helpful for patients, with easy prompts to register activities in an orderly fashion. They also commented upon the color scheme as being uplifting and positive in nature, which was seen as helpful for patients. Furthermore, the level of detail within the patient data is much broader than normally captured within a paper-form, which makes the tool administratively practical. This was seen as especially interesting for younger populations, owing to the colourful gamified nature of the application. Reflecting on documentation, psychologists emphasised the system as being able to decrease time needed to discuss activities within the session as well as documenting these thereafter owing to the level of data already stored in the web portal prior to sessions, as well as reducing the amount of notes needed within sessions. Reflecting on improvements, flexibility was noted as one potential issue. The content of the assignment should be responsive to the profile of the patient, and it should be able to be easily integrated into other therapeutic modules.
“As a therapist if you don’t have someone to help you to type, and you're not as skilled to type with light speed (during the sessions) then you really have to concentrate: what was in the homework, what did the person say. Just the most important things. And then first you have to find this out, then type it in and Then put it in the system. I think it (Zeeds) can help you to keep eye contact. And then you are there for the patient. And then, afterwards when you do the documentation you can just open the portal, see what the person wrote and compare with your notes. This could help to make a more precise documentation of the homework.”
Both patients and psychologists shared similar experiences of homework assignments within therapy. In relation to our solution, feedback was positive in relation to previous experiences of paper-and pencil formats but suggestions were also made for future improvements.
Are you a clinical psychologist interested in seeing our solution? Feel free to book a demo here.