The unexpected mental health problem hidden under plain sight
An integral part of Cognitive Behavioral Therapy - the gold standard of mental health therapy (David, 2018), is homework. Between-session assignments have a significant impact on outcome on a range of mental health disorders, according to research (Kazantis, 2017). These assignments range from psychoeducative homework (books, articles or other types of explanatory materials) , self-assessment homework (monitoring of symptoms or other important data-points), to module-specific homework (assignments designated for a specific diagnosis or problem). These assignments bolster therapy by helping patients transfer what they learn during sessions into applicable and concrete real-world skills.
These assignments - essential as they are to both outcomes and remission rates of evidence-based therapy - have astonishingly high rates of non-adherence. An estimated 50% of adolescents don´t do their homework, and about 20-50% of adults won't do theirs either (Kreidler, 2017). Simply put - patients don't do their homework.
And no wonder! Along with simply being depressed or anxious to begin with, patients then have to store and work with often-time paper based forms that are neither graphically appealing or very user-friendly. For someone who might need help just getting up in the morning, asking him or her to fill in a less than appealing PDF to monitor thoughts throughout the week, is hardly a recipe for success. Common reasons for not adhering to homework range from not understanding the purpose of the assignment, being bound to pen-and paper which decreases the flexibility of data gathering, to lack of direct feedback upon completion.
And this poses problems not just for the patient - but for the therapist as well. The problems are multi-layered. Let's assume a patient does his/ her homework, in the form of a simple behavioral activation paper based form. This form first has to be printed, and then delivered to the patient. The results of this activity take until next session to review. This means the analysis of the activity is done during the first few minutes of the next session, or alternatively after the session. This paper form then has to be stored somewhere secure, and the data has to be manually transferred into a medical journal.
Now, let's assume what happens 20-50% of the time - the patient either hasn't done the homework or hasn't done it as it was intended. This means the therapist is faced with an on-the spot analysis of how this divergence from treatment affects the upcoming sessions. Either the same assignment has to be tried again - adding unnecessary hours to therapy - or the therapist chooses to skip or modify this part of the treatment in order to progress to other parts. Time is also devoted to understanding what resistance might be the source of non-adherence. This type of information might be quite useful, but surely doing the homework as intended is a better use of time.
The end problem on both parts, is an increased risk of simply cancelling treatment (Di Bona, 2018), lengthier treatments, paper waste and increased costs for each patient. Therapy simply becomes less effective. Surely there's a better way.
So how is good therapy homework intended to work?
Turns out there are some guidelines for good homework practice (sounds fun, doesn't it?) (Tompkins, 2002). Good homework is first and foremost meaningful and focused on a specific problem. It isn't general in nature - instead it's in line with the clinical conceptualisation of the patients central issues. It is also easy to do, measurable and acceptable both for the patient and the therapist. It is thus not enough that it theoretically adresses the issue - it must also be practically doable in the patients own context, while being socioculturally adjusted, include a clear rationale for usage, and include a back-up plan in case the homework fails to be done.
So how does this translate into better ways of therapy homework? Kreidler & Tang (2017) has suggested some practical guidelines for leveraging technology, in order to solve these problems.
Technological solutions have a wide array of potential benefits within a therapeutic context. The portability and always on-factor of applications, is a good fit in terms of ease of use. The ability of personalizing, modifying and aggregating custom-made modules in a cheap and scalable way, also means therapists gain a potential for solving the user-experience problem of the standard paper-based solutions.
With this in mind, 6 practical guidelines can be identified for developing digital homework solutions.
The 6 essential features of digital homework solutions
Congruency to Therapy
A digital homework need to be congruent to the essential goals of treatment. This means it needs to be able to be seamlessly integrated to the specific part of treatment for which it is assigned - including psychoeducation and a rationale for usage. Zeeds is designed with this in mind. During the usage of the application - the patient gets a CBT-based rationale for planning and defining behaviors along with their values - in the same way as it might be explained in a therapy session. Zeeds is thus easy to integrate into an already existing treatment plan.
Digital homework should make use of the patients ability to adjust his or her experience, in line with progression. This means that the software is responsive to the patients input - adjusting the experience accordingly. Zeeds is highly personalized and user-centric in this aspect. Patients are enabled to reflect on and identify their own values, in as high detail as they like. After doing that, these values are then used to help the patient establish concrete behavioral plans - building on the patients progression. Both values and behaviors are continuously modifiable - enabling the patient and therapist to take on a learning-based and flexible approach.
Zeeds therapist portal easily breaks down and showcases live-data on behaviors, values and mood, in unprecedented detail. This means therapists can adopt a learning-based approach to analyzing both the patients own behaviors, and how these are affected by the treatment, without having to wait for feedback.
Reviewing and modifying homework is a therapeutic process in itself, where both the therapist and the patient get a moment to learn more about real-world applications to the skills that are to be transferred from therapy. A digital homework should be able to be able to fit well with a rationale for treatment, and also be flexible and responsive to changes.
Zeeds intuitive and easy formula for habit formation, can be easily explained and introduced for a patient - in line with in-session work about values - preferably from Acceptance and Commitment Therapy. The work is easy to collaborate around - the therapist gets easy to digest and clear data on progression, and the patient is able to modify values, mood and behavioral plans based on the collaborative analysis of both parts.
The therapeutic alliance is one of the strongest predictors of treatment outcome (Marasinghe, 2012). If the bond between therapist and patient is broken, no amount of theory or flashy assignments will be able to affect the treatment outcome, and a good alliance empower both parts to take a collaborative approach for mutual success.
Zeeds easy to use patient-application along with the therapists own data analysis portal, is joined for collaborative work through the therapists users manual - specifically designed to aid in introduction, follow- up and closure of the process in a session-based approach.
Software solutions have an unique advantage - among many - to paper-based solutions. They enable instant feedback. In-between sessions there is little a therapist can do to encourage and support their patients.
Zeeds is designed with this in mind. Through detailed notification systems the app is able to schedule and help the patient when the therapist isn't around. The gamified reward system of plants growing as the user registers performing behaviors in line with his/ her behavioral plan, means the patient gets an instant reward upon completion, and doesn't have to wait until next session to get some encouragement.
This refers to the technology being able to take into consideration cultural and social factors, tailoring the user experience so it can be adopted by different population segments.
Zeeds uses a graphical interface that appeals to a broad demographic, with illustrations suitable for a global audience. The exercises and modules in the app use general terms and examples throughout.
A new dawn for therapy homework
While the world is increasingly moving to a digital, software-friendly and scalable approach to most types of problems, therapists are surprisingly analogue in their work. It's time for this to change. That is - if we want to really help people.
And that starts with making them do their homework.
Are you reading this as a clinical psychologist, or therapist? Send us a message, so that we can try to help with your adherence problem - at email@example.com.
Nikolaos Kazantzis, Nicole R. Brownfield, Livia Mosely, Alexsandra S. Usatoff, Andrew J. Flighty (2017). Homework in Cognitive Behavioral Therapy: A Systematic Review of Adherence Assessment in Anxiety and Depression. Psychiatric Clinics of North America,
Volume 40, Issue 4. 625-639. ISSN 0193-953X, ISBN 9780323552967,
David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Frontiers in psychiatry, 9, 4. https://doi.org/10.3389/fpsyt.2018.00004
Tang W, Kreindler D. (2017). Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps
JMIR Ment Health 2017;4(2):e20
Di Bona, L Saxon, D Barkham et al. (2014). Predictors of patient non-adherence at improving access to psychological therapy service sites. Journal of Affective Disorders. 169, 157-164.
Marasinghe R, Edirippulige S, Kavanagh D, Smith A, Jiffry MT. (2018). Effect of mobile phone-based psychotherapy in suicide prevention: a randomized controlled trial in Sri Lanka. J Telemed Telecare. 18(3):151-155.