The common trap of setting sub-optimal homework and how to avoid it
This blog was first published in January 2017 and has been updated in 2019 as a reminder of the importance of dose in CBT and Low Intensity CBT and being clear in your mind if the component of treatment you are offering is either scaffolding or change.
We look at the key differences between scaffolding and change© homework to ensure you are setting the right things (at the right time!)
The term scaffolding and change was first developed by Marie Chellingsworth in 2017 to explain the two distinct types of homework and why getting the change method in from the first session is so important to outcome.
At The CBT Resource we like to think of two distinct, but vital, types of CBT homework scaffolding and change© homework. Scaffolding is all the work that is put into setting up the CBT intervention that you plan to use collaboratively with the Patient. For example psycho-education, socialisation to the model, baseline monitoring, any planning worksheets used such as thought capturing diaries or hierarchies. These are vital, but in themselves are not the 'doing' part of the intervention, the 'change method' that the patient undertakes takes in their every day life to bring about their desired goals. Good CBT of course needs scaffolding to begin treatment, it sets up what is going to happen. We think of these as scaffolding as they provide the support the Patient needs to get to the main task and makes it possible. You can't paint all of the exterior of a tall house without having scaffolding in place. But you can begin to paint the bits within reach as you set up the scaffold! Often clinicians (or the material or package they use) spends too long socialising to the model and using scaffolding tasks like hierarchies and other preparatory tasks as homework, without front-loading to add in a change method.
Whether you work as a High Intensity CBT therapist, Low Intensity CBT Practitioner or you incorporate CBT techniques into your every day practice, getting the right results from the intervention you deliver is key. We all know about the importance of homework in CBT from the wide literature on this. Homework allows the Patient to apply the skills they have learned into their daily life and to experience new learning as a result. It has been found time and time again that patients who are more compliant with homework, get better outcomes. When services say their recovery rates are 'good, but could be better', or say that they are struggling with meeting targets, they often ask us for our help. In the consultancy work that we do, we frequently find that the dose effect is at the heart of the problem. The homework dose effect can impact at all steps of care and is a common trap we can all fall into as busy clinicians and services.
A recent quality improvement study by Ewbank et al, (2019) has looked at transcripts of over 90,000 hours of CBT and found that having the change method discussed in the first session was a key indicator of outcomes along with (unsurprisingly) increased change methods being positively associated with reliable improvement. It is easy to forget that the main premise of CBT, at any step of care, is the recognition that the real change occurs for the Patient during what happens outside sessions with us, not inside them. Treatment needs to follow this philosophy to maximise its effectiveness and therefore be built around a clear planning and reviewing cycle in sessions (planning homework, reviewing homework, planning the next homework, and so on in subsequent sessions......). Getting the dose of change method in as homework is key. When we think of 'dose' we usually think about the number of sessions we have with the Patient. What is often left unsaid, is the homework 'dose' needed between sessions the Patient needs to get the outcomes they want; and what tasks should be set to get them.
For example, many CBT interventions need the Patient to carry out their homework tasks for at least 2-3 hours (or more!) a week. We deliver somewhere between 6-24 sessions of support, depending on the step of care and protocol being used. So in an intervention that is recommended to have 12 sessions for example, we should expect that the Patient will be carrying out about 24-36 hours of homework over that time. This needs consideration and planning early in treatment (or when designing a group) to ensure the homework set will optimise results.
A recent example of the dose effect in action was a Low Intensity CBT group package that we were asked to review here at The CBT Resource recently. It had been developed in-house by the Service. Lots of hard work and time had been put in to develop the group. It had 6 sessions and followed NICE principles for the disorder it targeted. So, on the surface it seemed an ideal intervention. The right number of sessions, the right step of care, the right intervention and there was homework set each week...but could the homework set have been better? could it have been designed to bring about greater change and get better outcomes in the time available? Absolutely yes, yes yes!
In the first three sessions of the group, the content focused solely on socialising the group members to the CBT model, sharing other patient examples and psycho-education about the relevant condition. The homework set each week led on from this content. Sessions four and five were then focused on planning and carrying out the main intervention and the final session was given over to relapse management. The homework in those first 3/6 sessions was all planning based. In the first week they created their own vicious cycle and set goals, in the second and they learned more about their condition and in the third and forth they planned their activities they wanted to get back to and built a hierarchy and started this.
That left just 2 sessions in which the patient learned about the main intervention and carried out the change method before relapse prevention, so in all likelihood patients would only be completing only 6 hours of change method 'treatment' homework, at best!. As a result, most Patients would have had little chance of moving to recovery by the end of the group. There was little time left in the sessions to clarify any misunderstandings or help people in the group learn from their experience of using the change method or help to get any setbacks back on track and certainly there was no opportunity for refinement based on the new learning; rendering the relapse management session at that point ineffective for the majority of participants.
In the protocols and group packages and interventions we have designed here at The CBT Resource we make sure we balance the two types of homework and bring in the right change methods early from session 1. If we wait until the Patient has mastered their understanding of CBT, we are teaching them to be a theorist, not to experience it in their own life, applied to their own problems. Remember CBT at its heart is a 'doing' treatment. People learn the most from it, and about it, by putting it into action, repetition and reflection on action. Just like when we learned to be a CBT Therapist or PWP, we learned this through doing, through role-play, self-practice/self-reflection, clinical work and supervision and refining skills as we went along (and hopefully always still reflecting and refining them!). Just like that process, our patients will learn more through the doing of the intervention. In the example above, small tweaks to group content to bring forward the change homework alongside scaffolding from the first session made a huge difference to the outcomes and patient satisfaction.