Between-session homework and processes of change

Abstract

The introductory quote articulates, in a funny and thoughtful way, some interesting ideas about homework relevant to psychotherapy. Although not explicitly stated, the reader gets the impression that there is something slightly negative about homework, which may resonate with some peoples' experiences with school homework growing up. Homework may, for example, create pressure and evoke anxiety due to fear of evaluation, failure, and control. “Besides homework” in passing at the end of the quote, suggests that homework is neither interesting nor important, and perhaps more than anything else, compulsory, directed, and evaluated, with a potential to be “failed”. While educational experiences vary, and some clients who value performing to a high standard and derive a feeling of satisfaction from it may appreciate the educational link, this is certainly not universal as nesting the process of homework, as with all in-session processes within a case formulation is recommended (Kazantzis et al., 2017, and see previous Journal of Clinical Psychology special feature, Vol. 71,5). At least, homework is not “something to take home to think about”, which is unfortunate, and at least sometimes an unhelpful association for a process in psychotherapy. Clearly, there is something in the quote for everyone working within the helping professions to take home and think about.

In the “Introduction” to this issue of the Journal of Clinical Psychology: In Session, we summarized some of the strongest research support for adopting between-session homework (BSH) into clinical work with clients in psychotherapy (Ryum et al., 2023a; see also recent reviews in Kazantzis et al., 2016; Ryum et al., 2023b, 2023c), and argued that it may be considered a common (Kazantzis & Ronan, 2006) or transtheoretical method (Ryum & Kazantzis, 2023) that is highly relevant for clinical training and practice across treatment approaches. We emphasized that the process of facilitating client engagement with specific tasks relies on productive in-session dynamics and therapist skills and competence in selecting, planning, and reviewing BSH, to ensures a skillful integration. Here, we summarize and comment on the six case studies presented in this issue, with special attention to in-session dynamics and the changing nature of BSH over the course of treatment, and also delve into the question of how BSH ties in with proposed change mechanisms across treatment modalities. In sum, we advocate for the position that BSH is something clients can take home from psychotherapy, not only to think about, but to integrate and generalize into their daily lives in ways that promote symptom improvement, positive change, and growth.

This issue of the Journal of Clinical Psychology: In session provides an excellent showcase of a series of in-depth case studies illustrating the varied application of BSH across treatment modalities and disorders, and we are grateful to all contributing authors for devoting their time and expertise to this endeavor. With an emphasis on the continued integration of BSH over the course of therapy, and the ways BSH ties in with proposed change mechanisms, each case provides valuable insights and ideas on how therapists may enhance the clinical use of BSH. Taken together, the case series offers a Kaleidoscope that illustrate the essentially fluid, dynamic, and oftentimes changing nature of BSH as a core aspect of the therapeutic process, and not as simple “add-on tasks”. Here, we first briefly summarize each case-presentation before delving into a more thorough discussion of in-session dynamics and processes of change.

First, Wachen (2023) presented the case of a female client with longstanding symptoms of posttraumatic stress disorder (PTSD) related to childhood sexual abuse and co-occurring attention deficit hyperactivity disorder treated with cognitive-processing therapy. The case highlights the prominent role of BSH in facilitating change within this approach to PTSD, by writing an “impact statement” on how the trauma has affected beliefs about the self, others, and the world (to identify “stuck points”), and further with the systematic and progressive use of worksheets to identify and challenge dysfunctional cognitions related to the trauma to promote a more balanced set of beliefs. Daily re-reading of completed worksheets to reinforce new and more adaptive beliefs and to encourage expression of natural emotions is suggested to extend the use of core cognitive elements learned in-session to broader life domains to reduce avoidance. Behavioral activities are also proposed as BSH toward the end of treatment to promote behavioral activation and self-care. The author suggests several strategies for promote engagement with BSH, including reiterating the rationale, identifying potential barriers (“stuck points”), as well as modifying tasks (e.g., setting reminders to complete worksheets, simplified BSH, repetition to facilitate learning of new material) in the context of cognitive challenges.

Second, Warwar (2023) presented a case illustrating the use of BSH in emotion-focused therapy (EFT) in the treatment of a male client with major depressive disorder (MDD) related to unresolved childhood trauma and underlying shame. The most essential change process in EFT is oftentimes formulated as “changing emotion with emotion” (Greenberg, 2021), by resolving blocks that hinder the processing of painful feelings such as shame. Warwar illustrates and discusses how BSH is a natural extension of in-session work in EFT, that may help deepen, consolidate, and extend in-session work into clients' daily lives throughout the course of therapy. For example, “safe place” work may help clients regulate their emotions and increase self-soothing capabilities to feel calm and safe (Greenberg & Warwar, 2006; Warwar & Ellison, 2019). Paying attention to feelings between sessions and keeping an emotional diary, reflecting on sessions, or writing about “unfinished business” are other examples of BSH that may help increase awareness, strengthen in-session gains, or introduce novelty (trying out something new). The case illustrates how BSH is well-integrated and used in a systematic manner within EFT, also by personalizing suggested tasks and emphasizing specificity (e.g., when, where, how, etc., to do BSH).

Third, Hammersmark et al. (2023) presented a case of group metacognitive therapy (MCT) for seven clients with generalized anxiety disorder (GAD). The case illustrates how so-called third-wave cognitive behavioral treatment (CBT) deviate from the traditional focus on thought-content in CBT (e.g., examination of negative automatic beliefs), and rather emphasizes perseverative thinking styles (e.g., worry, rumination), threat-focused attentional processes, and maladaptive coping strategies as maintaining factors in GAD. The authors demonstrate how structured and systematic use of BSH, including “trigger thought hunting,” detached mindfulness exercises, testing of positive (increase or decrease worry to assess impact on daily outcomes) and negative metacognitive beliefs (e.g., go crazy experiment), and worry postponement may be adapted and implemented in a group setting. The emphasize on thought processes (rather than the content of worry) and group cohesion is proposed to facilitate the development of a group norm and client engagement with BSH, while the authors also note the greater challenge of identifying and challenging clients' nonengagement with BSH in a group format, compared to individual therapy.

Fourth, Murphy et al. (2023) provided an illustration of the use of skill-enhanced CBT with a male client presenting with MDD and comorbid social anxiety disorder. The authors demonstrate how brief videos demonstrating CBT skills may be used as BSH at the outset of treatment to reinforce the treatment rationale, and further how the development of CBT skills may be facilitated by engaging systematically in BSH with the use of thought records to identify and challenge negative automatic thoughts and beliefs, as well as activity logs to increase pleasure and mastery experiences. To amplify the effect of treatment, the authors suggest that BSH (i.e., practice of skills) should not only be undertaken while responding to day-to-day challenging situations (where core beliefs and negative automatic thoughts are activated), but also by being on the outlook for opportunities to applying the skills in even more challenging (future) scenarios. The authors stress how the approach is individualized, principle driven, and flexible, where clients learn to utilize skills with more independence as treatment progresses with the scaffolding of the therapist, and the practice and use of a CBT skills card may help facilitate client engagement.

Fifth, Church et al. (2023) presented the case of a male client diagnosed with obsessive-compulsive disorder (OCD) and comorbid autism, treated with CBT with exposure and response prevention. While this intervention is considered “the gold standard” treatment of OCD, the case illustrates some important considerations and adaptions needed when working with comorbid autism, and strategies to enhance client engagement with BSH. Specifically, the authors note the need to tailor the rationale (and, more broadly, psychoeducation) by using visual resources (e.g., traffic lights) to identify and report levels of anxiety during exposure, to involve supportive others (e.g., family members) to help generalize treatment effects with between-session exposure, to align BSH with clients' special interests, and to use tangible rewards for completing exposure-exercises as part of BSH. The authors recommend including tracking sheets with quantifiable behaviors to help determine if treatment is moving in the right direction (i.e., treatment efficacy), and caution against relying exclusively on clients' subjective perceptions of treatment progress.

Finally, Magistrale et al. (2023) presented a case exploring the use of BSH within relational psychoanalysis (RP), with a male client presenting with narcissistic personality disorder (PD). The authors note the long-standing “resistance” toward adopting more directive and behavioral interventions in psychoanalysis, but argue for the need to invite clients to experiment with new ways of relating as part of BSH when treating PDs. New and more adaptive interpersonal behaviors may not generalize easily into everyday life (or follow from interpretation and new insight alone), and clients' maladaptive ways of relating may also influence negatively on the therapeutic relationship, as illustrated in the case study, by taking care of and controlling other people. Adopting a curious stance and experimenting with new ways of relating may thus lead to new insights, and, ultimately, more adaptive interpersonal behaviors. The authors conclude that BSH is compatible with the central tenets within RP, and caution against relying exclusively on the therapeutic relationship as a vehicle of change, as clients may become dependent, passive, and powerless if therapists are cast in the role of the all-powerful, omnipotent caregiver.

Taken together, all contributing authors emphasized and agreed on the therapeutic benefits of adding BSH into clinical work, across theoretical models, and we note a range of theoretical models are represented (Kazantzis et al., 2009), and there was diversity in the content and adaption of BSH over the course of treatment across the case presentations. Also (and not surprisingly), several authors noted that the term “homework” should be avoided in clinical practice with clients, and instead used terms such as “experiment” or “something to try out.” Notably, there may be very different uses of homework, perhaps even the same homework task within and across theoretical models, and, therefore, the question of how homework is used is almost as important as which tasks are being discussed.

Moving on, our next aim here is to highlight and discuss some themes that emerged as significant for the in-session process of integrating BSH into clinical practice (including methods of BSH administration). Thereafter, we reflect on and discuss the ways BSH ties in with proposed change mechanisms in psychotherapy across theoretical approaches and models.

There was substantial agreement among authors that BSH is a natural companion and extension to the in-session work, that may enrich the therapeutic process, irrespective of the broader treatment approach utilized (e.g., EFT, CBT, RP, etc.) or target complaints (e.g., MDD, OCD, PTSD, GAD, PD). In fact, based on the case presentations as well as earlier research, it is difficult to conceive of a clinical scenario in which the use of BSH might not be useful. Further, authors were united in positing the need to customize BSH to the individual client in distinct ways that align closely with existing guidelines and research (e.g., Kazantzis et al., 2005; Ryum et al., 2023c), which is remarkable given the heterogenous nature of the clinical material presented.

For example, the case studies demonstrate how a specific BSH task, at a given point in the treatment process, is likely to be most effective when it is informed by the case conceptualization and hypothesis about maintaining factors, build upon material that transpires within the session and clients' needs and strengths (and context), is presented with a credible rationale aligned with treatment goals, and when possible barriers and obstacles to client engagement are discussed. As clients are most likely to engage with BSH that is perceived as helpful and meaningful (compared to BSH that lacks purpose and adds stress), an essential common task is to build positive expectations and motivation for engagement, irrespective of the specific task. In sum, selecting, planning, and reviewing BSH is a highly sophisticated and complex in-session process that relies on relational- and treatment-specific skills and competence among therapists (Kazantzis & Miller, 2022) - it is not simply about identifying concrete tasks for clients to engage in between sessions. This aligns with an increasing body of research linking therapist competence in the use of BSH with client engagement with BSH (Bryant et al., 1999; Conklin et al., 2018; Jungbluth & Shirk, 2013; Weck et al., 2013; Zelencich, Kazantzis, et al., 2020) and symptom improvement (Ryum et al., 2010, 2022; Shaw et al., 1999; Zelencich, Wong, et al., 2020), as discussed in recent reviews (Ryum et al., 2023b, 2023c), although some negative results have also been reported (Startup & Edmonds, 1994; Yew et al., 2021).

Another theme that emerged concerns the level of collaboration that is expected and ideal when integrating BSH. As noted in the “Introduction” (Ryum et al., 2023a), this has been a notably contentious issue with authors advocating for the position that BSH should primarily be initiated (a) by the therapist (Ellis, 1962), (b) the client (Brodley, 2006), or (c) mutually negotiated between therapist and client (Kazantzis et al., 2013). Based on the case studies presented in this volume, it seems to have been a move toward a consensual view characterized by collaboration and egalitarianism across treatment approaches. Authors agreed on the importance of involving clients and soliciting feedback in the process of selecting, designing, and reviewing BSH, which align closely with the research literature on the alliance demonstrating mutual agreement on tasks and goals as important for treatment outcome (Flückiger et al., 2018). The therapist may, for example, invite and engage the client in the process by posing questions such as “How may you, until our next session, practice and carry forward the work accomplished in our session today? What might this look like?”. Further, any specific BSH should be framed as an opportunity to learn something new, even if the task does not go exactly as planned, and the clients' experience of engaging with BSH is always “grist for the therapeutic mill.” Perfectionism is not the goal. As emphasized in the case studies, therapists need to be attuned to the client's experience and the therapeutic process and progress, to propose BSH that is within the client's experiential and developmental grasp (e.g., Warwar, 2023) or tolerable level of anxiety (e.g., Church et al., 2023), through a scaffolding process that over time facilitates increased independence on the client (e.g., Murphy et al., 2023) and progressive internalization of new skills (Wachen, 2023). Hammersmark and colleagues (2023) also demonstrate how clients in group therapy may aid and facilitate each other in designing BSH.

Yet another recurrent theme was the need to devote sufficient time to the process of integrating BSH, to ensure that there is mutual understanding of the task, rationale, and purpose to facilitate client engagement. Numerous strategies were suggested that are commonly recommended; for example, assessing the amount of BSH (e.g., exposure) with measures and not relying only on subjective reports (tracking/worksheets); improving adherence to the treatment manual by involving “supportive others” or other group therapy members; adding specificity (when, where, how long, how often is BSH supposed to be practiced?); In-session practice (e.g., in-vivo, visualization) to help therapists assess clients' understanding of the BSH (rationale); writing down BSH or using a portfolio; use of skills card as a reminder of key BSH features; identifying potential negative and unhelpful beliefs and practical and emotional barriers to engaging with BSH; and confidence-ratings related to specific homework-task. There are always different levels of specificity, and a somewhat more nondirective approach was also proposed (Magistrale et al., 2023), and the case studies also demonstrate how client engagement with BSH may be assessed in a structured fashion (as within CBT and EFT) or a somewhat more informal way (Magistrale et al., 2023; Warwar, 2023). Also, there was substantial agreement among authors that BSH should not only evaluated according to the amount (quantity) of BSH completed, but also the quality (what was learned?) and the sense of pleasure, mastery, and progress toward treatment goals.

The case study on group MCT (Hammersmark et al., 2023) illustrate some important considerations in the use of BSH when shifting from individual- to group therapy. Although GAD typically involves worry that involves different domains (e.g., health, work, fear of making mistakes, etc.), the focus on thinking styles and attentional processes (rather than thought content) facilitates the development of a shared case formulation that promotes group cohesion and a collective understanding of maintaining factors and relevant BSH (e.g., metacognitive beliefs). In-session work (in pairs) to plan how BSH can be practiced between sessions may promote client motivation and engagement, as clients can learn from each other (in addition to the therapist) to help generalize learning effects. Group cohesion may also foster session attendance and engagement with BSH. Compared to individual therapy, it may, however, be more challenging to assess the level of engagement with BSH, as clients may choose to say little or nothing at all when BSH is reviewed.

Several authors commented on potential barriers and obstacles to client engagement with BSH. For example, lack of engagement could be due to limited socialization to the treatment model and frustration, especially in the early phase of treatment (e.g., Hammersmark et al., 2023; Murphy et al., 2023), which highlight the need to have a continuous emphasis on the rationale for the treatment and BSH specifically (Callan et al., 2019). Emotional barriers, such as worry and distress (Hammersmark et al., 2023; Magistrale et al., 2023; Warwar, 2023), or difficulties with identifying emotions and anxiety levels (Church et al., 2023) were other potential barriers. Again, authors recommended devoting sufficient time to ensure that clients had understood the rational underlying a specific BSH, by asking for feedback, in-session practice, discussing potential barriers and difficulties to BSH, and writing down specific tasks and rationale.

Some authors commented on the interplay between techniques and the therapeutic relationship. Magistrale et al. (2023), for example, noted how BSH may sometimes evoke strong submissive- or rebelling behaviors in clients, that may be related to needs for dominance or attachment in the context of giving and receiving help and care (Safran & Muran, 2000), and suggested exploring clients' reactions to the use of BSH when challenges arise. Warwar (2023), on the other hand, noted how the therapeutic relationship always has priority over the achievement of specific therapeutic task (e.g., BSH), consistent with the notion that the therapeutic relationship is a facilitative curative factor within humanistic-experiential approaches. Frustration and resistance on the part of clients related to BSH (including the use of forms and portfolio; “felt like going back to school”) was noted by several authors, in particular in the early phase of treatment (e.g., Hammersmark et al., 2023; Murphy et al., 2023). Clients may need time to realize the importance of BSH, but even then some clients may demonstrate increased resistance toward the use of BSH, despite motivational efforts on the part of the therapist (Hammersmark et al., 2023). Linking BSH with therapeutic goals and the therapeutic contract may be particularly important as well as challenging when working with clients with more severe personality dysfunction, and require continued attention on the part of the therapist to avoid therapeutic stagnation or dropout (Dimaggio & Valentino, 2023).

While the field appears to be moving toward a more assimilative and integrative view of psychotherapy that acknowledges the importance of both techniques (BSH) and the therapeutic relationship as essential for the process and outcome of psychotherapy (Derubeis & Lorenzo-Luaces, 2017; Hofmann & Barlow, 2014; Wampold et al., 2017), the case studies illustrate how their relative importance is of continued interest also when discussing between-session assignments (e.g., McEvoy et al., 2023; Ryum et al., 2022; Yew et al., 2021). Different theoretical approaches tend to emphasize distinct components of the therapeutic relationship— transference, the real relationship, and the working alliance (Gelso & Hayes, 1998). As space prohibits a fuller discussion here, we only note that it could add conceptual clarity and advance our understanding of the interplay between techniques and the therapeutic relationship to define and disentangle these constructs clearly. For example, the quality of the working alliance is a way to characterize therapeutic activity, and not an activity in-itself (Hatcher & Barends, 2006). To the extent the use of BSH is experienced as collaborative, purposeful and productive, we would, however, expect a positive correlation between client engagement with BSH and the working alliance.

In sum, we were mostly impressed by how closely authors align when discussing the process of tailoring BSH to individual clients. BSH is most optimal when it is co-constructed between therapist and client, offered in a tentative, nonimposing manner that sparks interest and curiosity, build upon in-session work and feedback from the client, and is experienced as meaningful by the client. Therapists should also devote sufficient time to address potential obstacles and barriers to BSH engagement. Perhaps more than anything else, the case studies illustrate how a collaborative and productive in-session process is paramount for promoting client engagement with BSH.

We now move on to the question of how clients' engagement with BSH relates to posited change-mechanisms across treatment approaches, and ultimately, symptom improvement, positive change, and growth. Our goal is to provide a tentative answer to the somewhat elusive question of “why” BSH contributes to the process and outcome of psychotherapy, a question that also ties in with the interrelationships between the use of specific techniques, change in maintaining factors, and outcome. We will approach this theme at different levels of abstraction.

Earlier, we noted similarities across treatment approaches related to the in-session process of engaging clients in BSH, while also noting diversity in the specific content and tasks selected both within and across treatment modalities/approaches. Nonetheless, at least two overarching themes were identified that adds clarity to how BSH facilitates the treatment process and outcome in psychotherapy. Specifically, all authors noted how BSH may help clients (1) build awareness or insight (a stance of curiosity toward inner mental life; new perspective on thoughts and though processes, etc.) through specific task such as psychoeducation and sharing of rationale (Church et al., 2023; Hammersmark et al., 2023; Magistrale et al., 2023; Murphy et al., 2023; Wachen, 2023; Warwar, 2023), writing about unresolved feelings toward a significant other (Warwar, 2023), writing an impact statement (Wachen, 2023), using work-/task sheets (McEvoy et al., 2023; Murphy et al., 2023; Wachen, 2023), experimenting with new behaviors (e.g., Magistrale et al., 2023), or experiential tasks (e.g., Hammersmark et al., 2023); as well as (2) change behaviors by extending in-session work and (new) behaviors into clients' daily lives through the practice of new skills (e.g., exposure, activity scheduling, trying out new ways of relating, thought worksheet, etc.; Church et al., 2023; Hammersmark et al., 2023; Magistrale et al., 2023; Murphy et al., 2023; Warwar, 2023). Admittedly, there are various ways of conceptualizing change-processes in psychotherapy (e.g, Castonguay et al., 2019; Hayes & Hofmann, 2018; Ryum et al., 2014; Valen et al., 2011), but the case studies demonstrate how numerous techniques may target similar, general change-process (e.g., increasing awareness; experimenting with new skills, etc.). What constitutes “new insight” or “behavior change” is, of course, at a lower level of abstraction, and will at least partly depend on the specific treatment model and case conceptualization.

Rising to an even higher level of abstraction, we may suggest that the essence of BSH is ultimately to consolidate and generalize new learning and skills from the consultation room and into clients' everyday lives, for example, through practice, rehearsal, mastery, and personal agency. As mentioned earlier, the therapeutic relationship (including the “Rogerian” qualities empathy, positive regard, warmth) is essential for the purpose of therapeutic work, but we believe it should generally not be an ultimate end-goal for the client to only have a secure and trusting relationship with the therapist. Clients' may over time warm to an empathic and competent therapist and demonstrate in-session change that suggest improvement to the therapist, but experience little or no change in his or her daily life. In fact, there is a risk in focusing too much on in-session change at the expense of what happens between-session (including passive reliance on the therapist; e.g., Magistrale et al., 2023), and several authors suggested a key goal in treatment is to help clients “become their own therapist” (e.g., Murphy et al., 2023; Wachen, 2023). In fact, between-session changes (e.g., exposure) may be more important for a positive treatment outcome compared to in-session changes, even for treatments that relies on exposure-based interventions (Ryum et al., 2021). Clients can thus play an important role in their own healing process, in taking active steps that improve on their situation, which instils positive expectations, hope and faith in that change is possible.

To elaborate even further, we may build upon recent work by Kazantzis et al. (2017, 2018) and suggest a more comprehensive model that articulates the interplay between techniques and treatment processes (general and treatment-specific change processes). Here, we may think of BSH as a general clinical method (or strategy), where the use of more specific techniques (e.g., ABC worksheet; detached mindfulness; written diary, exposure-exercises) are selected and used to target treatment processes (maintaining factors such as worry, rumination, negative beliefs, attentional bias, perfectionism, avoidance, etc.) in accordance with treatment goals. A specific technique may be used to target different change-processes, depending on the case-conceptualization, in-session process and therapeutic progress, and client needs, and the rationale for each use needs to be adapted to fit different targets and uses. According to this model, techniques are nested within treatment processes, nested within treatment goals, nested within the in-session process of integrating BSH (as a clinical method), in a manner that resembles Russian matryoshka dolls (Kazantzis, 2018; Kazantzis et al., 2017). The case studies in this volume illustrate how different specific techniques may be used to target various maintaining factors, and how techniques may be modified and adjusted over the course of treatment to fit clients' needs in a fluid and dynamic manner. This allows for a more fine-grained analysis of the interplay between techniques, treatment processes, and outcomes, and the case-studies in this volume illustrate how the use of BSH needs to be individualized, flexible, and principle driven, in a way that aligns closely with recent process-based views of psychotherapy (Hofmann & Hayes, 2018; Kazantzis et al., 2018).

All six case-studies provide valuable insights into how BSH may be integrated into clinical work with clients presenting with various disorders across treatment approaches. Although there was substantial heterogeneity in the specific content of BSH discussed across theoretical orientations, there were also similarities pertaining to the process of integrating BSH into therapy. Authors were united in the view that BSH should flow naturally from the in-session work, be presented with a clear formulation and a rationale linking BSH to current in-session work and treatment goals, and collaboratively designed based on shared input and decision-making including client feedback on those decisions, in accordance with current treatment guidelines (Kazantzis et al., 2005) and reviews of the empirical research (e.g., Ryum et al., 2023b, 2023c). This should caution therapists from thinking (and utilizing) BSH as a therapeutic add-on, as something tangible to give the client while leaving the consultation office. Rather, it is imperative to realize that BSH is a transtheoretical feature that should be firmly integrated within the broader theoretical approach and in-session work.

The case studies also illustrate how various techniques may facilitate beneficial change in a limited number of maintaining factors. With the field moving toward transtheoretical formulations of psychotherapy, and a process-based view of clinical work (Hofmann & Hayes, 2018; Ryum & Kazantzis, 2023), it is perhaps not surprising to note rapprochement between treatment approaches. We hope the case studies presented in this volume has provided clinicians with new ideas on how to adopt and tailor BSH, as a transtheoretical model in clinical practice, to fit their clients' needs in ways that facilitate positive change in their daily lives.