Does Psychotherapy With CBT Involve Homework?
How to work with the real-life triggers of trauma experiences.
Posted Nov 18, 2019
Psychotherapy for posttraumatic stress disorder (PTSD) routinely ought to include homework. Many evidence-based treatments (EBTs) for other disorders also include homework, and the systematic nature of the homework and the goal of homework to directly improve function are common differences between EBTs and the less-structured types of psychotherapies.
The rationale for homework is quite simple. Homework provides opportunities for patients to take the skills they practiced in offices and employ them in real-life situations. Real-life exposure is where the rubber hits the road. The triggers are more real. The anxiety is more intense. The associated memories, sensations, and images are richer. The automatic negative thoughts that arise may be deeper, different, or more salient than the automatic negative thoughts that arise in office-based exposures. All of these elements allow a deeper dive into symptoms in the context of everyday functioning.
Will Patients Do Homework?
When I first started as a therapist, it felt odd to assign homework for patients. Most of us have a naturally negative vibe about homework because it is associated with school (i.e., it sounds like work). Also, it did not seem in sync with the way psychotherapy is portrayed in movies or the way it is taught in training programs. Wasn’t psychotherapy supposed to be an intense, one-on-one experience in the psychotherapy office where dreams, hopes, disappointments, or self-deception are peeled back layer by layer to find that elusive kernel of what life is all about? Sure, it can be, but for most people that is neither how psychotherapy can proceed nor what they need.
Once I learned another way of doing psychotherapy with structure and direction in cognitive behavioral therapy (CBT), it was not at all difficult to engage patients in homework. In my research study with very young children with PTSD, I kept track (of course) and 100% of patients could complete some homework. In total, they completed 82% of all homework assignments (Scheeringa et al., 2011). My experiences with adolescents and adults are similar. Within the structure and repetition of EBT protocols, homework flows naturally.
What Is Homework?
Exposure therapy for PTSD employs exposure exercises in two types of settings. The setting most commonly discussed is exposure to anxiety-provoking memories in the office, which I described in my last post. The second type of setting is homework, or in vivo exposure conducted outside of the office by patients on their own. In vivo exposure is an important component of PTSD treatment, and can oftentimes be the critical, most important factor. There are eight main steps to good in vivo exposures:
(1) Practice with non-trauma exposures before doing trauma exposures. Before doing the first trauma-related homework, my manuals have patients complete two non-trauma homework assignments, which are exposures to stimuli that will make them slightly anxious but are not related to their trauma experiences. I want to make sure they are comfortable with the procedure and do not get overwhelmed by pushing themselves too far too fast. There will be plenty of time for trauma exposures and there is no need to rush.
(2) The in vivo exposures ought to be highly-planned out ahead of time. The details of the exposure, including the stimulus, location, day, and time of day are written on the homework sheet which patients take with them. One reason for this level of precision is to make the work as user-friendly as possible; the clients take the homework sheets home with them and they have all the details they need to remember on one sheet of paper. Another reason for this is to close a potential loophole of avoidance so that clients cannot come back next week and say they forgot what they were supposed to do.
(3) Make the first in vivo trauma exposure easy. The first one needs to feel successful. One of the worst things that can happen is patients try an exposure that is highly-anxiety provoking and they end the exposure feeling overwhelmed and remain triggered and distressed for hours or days, which would amplify the natural feeling of avoidance and make them feel like failures. Again, there will be plenty of time for trauma exposures and there is no need to rush.
(4) Rate the degree of anxiety. At the beginning of the exposure, patients rate their level of anxiety on a scale of 1-10 on a feelings thermometer.
(5) Keep it short. We tell patients to do the in vivo exposure only once per week and for only 30 seconds if at all possible. This brevity acknowledges that it is natural for patients to have avoidance and we are not aiming for them to be superhuman. But also, quite simply, that is all it usually seems to take. If patients truly have PTSD and are truly triggered by reminders with powerful fear reactions, 30 seconds is actually a good amount of time. In addition, even though the guidance is to limit exposure to 30 seconds, the guidance is often treated as a minimum guideline. Many patients do it longer than that, which allows an added benefit of patients feeling like they surpassed the goal.
The stimuli for in vivo exposure are unique to every trauma. For domestic violence trauma, homework exposure typically involves driving to the house where the domestic violence occurred and sitting in the car a block away. For motor vehicle accidents, this often involves driving to the spot where the accident occurred.
(6) Re-rate the degree of anxiety. On a scale of 1-10, determine if anxiety has increased or not in response to the stimulus.
(7) Use a relaxation skill to manage the anxiety. After 30 seconds of exposure, use one or more of the relaxation techniques, e.g. controlled breathing, muscle relaxation, or happy-place mental imagery. Do this even if there was no increase in anxiety from the exposure.
(8) Final rating of the degree of anxiety. On a scale of 1-10, determine if anxiety has returned near to baseline.
Sometimes clients are not able to do the planned homework exposures because they get too anxious prior to the exposure worrying about becoming anxious. This is called anxiety sensitivity. In such cases, the homework can be shifted so that the exposure is simply getting ready to do an exposure but not actually doing the exposure. Preparation to do the exposure is the exposure.
In my experience, in vivo exposure is the most important type of homework in the treatment of PTSD. Trauma memories stored in the brain are analogous to a frightening tiger locked in a cage. Office-based exposures are like talking about walking up to the cage. In vivo exposures are like actually walking up to the cage. It opens up a whole different level of experience for treatment.
Scheeringa MS, Weems CF, Cohen JA, Amaya-Jackson L, Guthrie D (2011). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52, 8, 853-860. DOI: 10.1111/j.1469-7610.2010.02354.x