Current challenges I. : Homework adherence and Skill stransfer
Recent trends
In the past decades there has been a rise in the awareness and the diagnosis of mental health problems, meaning that the number of people who seek help for psychological problems has increased significantly. However, the availability of mental health care does not seem to mirror this development, resulting in a worrying lack of mental health services in most countries.
At the same time, digitalization and technological development seem to be an unstoppable process all around the world. As a consequence various products and services - including psychotherapy - are moved to digital platforms or are used in combination with digital tools, with the aim to make their use and administration more effective. However, because the spectrum of opportunities for how one can use technology is so large, it is difficult to test and evaluate when it makes sense to use digital solutions instead of analogue ones, and when it is just a more complex way of achieving the same.
To address this question in relation to psychotherapy we would like to publish a three part blog series about “Why we need digital tools in psychotherapy”. In this first two posts we are describing four challenges in psychotherapy that could potentially be addressed more effectively with digital instead of analogue tools. And in the third post we will dive deeper into the research findings about the digitalization of one particular treatment module, namely behaviour activation.
Challenges in psychotherapy
Based on our experiences and scientific literature we collected - a non-exhaustive - list of current challenges in psychotherapy, where digital solutions could be a meaningful substitute or complement and increase the effectiveness and quality of treatment: (1) Homework adherence (2) Skill transfer (3) Individualised treatment and (4) Waiting lists.
The Homework Problem
A recent review of several meta-analyses regarding change processes in Cognitive Behavioral Therapy, identified homework assignments, along with patient-therapist alliance, as one of the in-session processes with the strongest evidence, with significant small to medium effect sizes across studies (Kazantzis et al., 2018). However, an estimated 50% of adolescents (Gaynor et al. 2006) and 20-50% of adults do not or only partially adhere to their homework exercises (Helbig and Fehm 2004; Kazantzis et al. 2005). Reasons for non-adherence are numerous and can be both, internal or external. Internal patient factors are often motivational in nature (e.g. lack of motivation for change when faced with negative emotions, a need to see immediate results, disregard for the importance or lack of knowledge about the rationale of homework, Gaynor et al. 2006; Garland and Scott 2002; Leahy 2002). External factors include pen-and paper formats, lack of instructions as well as a failure to plan for environmental obstacles (Bru et al. 2013; Garland and Scott 2002; Williams and Squires 2014).
Even though studies have found a quite wide range of adherence to internet based interventions (e.g. Melville et la, 2010), digital solutions have multiple benefits over paper and pencil exercises that could - when adequately implemented - support patient compliance and make the administration of homework more effective. To name a few (based on Tang and Kreindler, 2017):
Digital assignments can also increase motivation and adherence by giving patient’s direct feedback about their treatment progress eg. showing completion rate of their exercises. This could help them to see even small improvements in their symptoms and give them a sense of achievement, reinforcing the rationale of homework and treatment in general.
Digital forms of psychoeducational tasks can also make information more accessible and portable. In addition, patients could rely on curated and validated online content instead of trying to navigate through the jungle of more or less reliable mental health posts on the internet.
Real life monitoring of patient data by the therapist (e.g. on an online platform) can also guide and enable more focused therapy sessions as therapists can prepare in advance what aspects of their patient’s experiences and behaviour needs to be discussed in session.
And lastly mobile homework assignments also make it easiest for patients to incorporate the tasks into their everyday life. They can complete the exercises exactly in the moment they are most relevant (eg. when logging behaviours or emotions) which provides more valid information about their current state but also supports faster learning.
Skill transfer
Homework and its appropriate integration into everyday life are also important factors when considering how the skills practised and learned during psychotherapy can be transferred into everyday life. Both in the days between two therapy sessions but also after the completion of treatment, when patients get back to their usual everyday routine, without therapist support.
It is clear that homework exercises in general play a crucial role in applying cognitive, emotional and interpersonal skills automatically in relevant situations (and not just when reminded by the therapist). However, the format of homework assignments might also facilitate or hamper this skill transfer. It seems reasonable to assume that the closer the homework assignments are to actual activities, the more likely it is that they will keep doing it even after treatment has ended. This is, because the skills and cognitive or behavioural actions - such as re-evaluation of a situation or the acceptance of thoughts as just thoughts - get tied to the relevant situations and the situation becomes a cue for that action. As described in various behavioural and habit-formation theories (e.g. Garnder and Rebar, 2019). Mobile solutions for skills learning could enable patients to do multiple quick and simple tasks on the go and in moments when they are most relevant. In contrast, paper forms have other prerequisites such as a surface to write on, a pen and the space and time to get it out of one's bag, which makes them harder to perform anywhere and anytime.
Conclusion
Recent trends in mental health care and digitalization make it both necessary and possible to incorporate digital solutions into psychotherapy. Mobile tools seem to have a high potential to facilitate skill acquisition, transfer and retention during and after treatment. As they can increase homework adherence and facilitate learning and habit formation.
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References
Bru, L., Solholm, R., & Idsoe, T. (2013). Participants’ experiences of an early cognitive behavioral intervention for adolescents with symptoms of depression. Emotional and behavioural difficulties, 18(1), 24-43.
Gardner, B., & Rebar, A. L. (2019). Habit formation and behavior change. In Oxford research encyclopedia of psychology.
Garland, A., & Scott, J. (2002). Using homework in therapy for depression. Journal of Clinical Psychology, 58(5), 489-498.
Gaynor, S. T., Lawrence, P. S., & Nelson-Gray, R. O. (2006). Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: Review, preliminary findings, and implications for theory and practice. Behavior modification, 30(5), 647-672.
Helbig, S., & Fehm, L. (2004). Problems with homework in CBT: Rare exception or rather frequent?. Behavioural and cognitive psychotherapy, 32(3), 291-301.
Kazantzis, N., Luong, H. K., Usatoff, A. S., Impala, T., Yew, R. Y., & Hofmann, S. G. (2018). The processes of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 42(4), 349-357.
Kazantzis, N., Lampropoulos, G. K., & Deane, F. P. (2005). A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. Journal of Consulting and Clinical Psychology, 73(4), 742.
Leahy, R. L. (2002). Improving homework compliance in the treatment of generalized anxiety disorder. Journal of Clinical Psychology, 58(5), 499-511.
Melville, K. M., Casey, L. M., & Kavanagh, D. J. (2010). Dropout from Internet‐based treatment for psychological disorders. British Journal of Clinical Psychology, 49(4), 455-471.
Tang, W., & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: essential features of mobile apps. JMIR mental health, 4(2), e5283.
Williams, C., & Squires, G. (2014). The Session Bridging Worksheet: impact on outcomes, homework adherence and participants’ experience. the Cognitive Behaviour Therapist, 7.