using homework assignments in cognitive

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Using homework assignments in cognitive

Despite the importance attached to homework in cognitive-behavioral therapy for depression, quantitative studies of its impact on outcome have been limited.

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Phd essay ghostwriter websites Older Adults. BMC Musculoskelet Disord. Patients' perspective on homework assignments in cognitive-behavioural therapy. Showing you can do it: homework in therapy for children and adolescents with anxiety disorders. Cognitive therapy with couples.
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Writing good software engineering research papers mary shaw The future is in our hands: the role of mobile phones in the prevention and management of mental disorders. Beck, A. New York: Appelton. Videoconference- and cell phone-based cognitive-behavioral therapy of obsessive-compulsive disorder: A case series. Google Scholar Kuehnel, T.
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Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered. There are different types of homework in CBT, including 1 psychoeducational homework; 2 self-assessment homework; and 3 modality-specific homework.

Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target [ 48 ]. An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy. Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD.

Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities. While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy.

As psychoeducation is seen as a major component of mobile intervention [ 50 ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ 51 ], anxiety and depression [ 52 ], eating disorders [ 53 ], PTSD [ 54 ], and obsessive compulsive disorder OCD [ 55 ].

The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches. However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ 50 ].

While information collected retrospectively using paper records can be adversely affected by recall biases [ 57 ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ 58 ]. Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ 59 , 60 ], eating disorders [ 61 ], GAD [ 62 ], and OCD [ 55 ].

Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages short message service, SMS to therapists in bulimia nervosa [ 61 ]. Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs.

Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ 64 - 66 ]. Apps that provide elements of biofeedback such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera , have recently begun to be deployed. Doing CBT homework properly requires time and effort.

While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [ 49 , 52 ]. Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ 59 ].

However, the types of homework delivered by these apps are fixed. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ 62 ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety. Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone.

Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan [ 47 ].

Failure to do this has been identified as a barrier to homework compliance. Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ 47 ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ 47 , 70 ]; this can be done during or in between homework assignments, either in-person or remotely ie, via voice or text messaging [ 60 , 71 ].

Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD [ 72 ], OCD [ 55 ], chronic pain [ 59 , 60 ], depression and suicide ideation [ 71 ], and situational stress [ 73 ]. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 74 , 75 ].

The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].

An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically.

Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.

To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework.

In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].

Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels including learning or cognitive disabilities.

One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ]. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders.

In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated. There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance.

Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ]. The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ].

One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ]. Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ].

Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers.

It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance.

The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use.

While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance. The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised.

For example, as artificial intelligence [ ] or emotional sensing [ ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states. This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review.

The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done. We would anticipate synergistic effects when homework-compliance apps are used in CBT eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work , but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.

Conflicts of Interest: None declared. National Center for Biotechnology Information , U. Published online Jun 8. Reviewed by Pietro Cipresso and Elisa Pedroli. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding Author: David Kreindler ac.

This article has been cited by other articles in PMC. Abstract Cognitive behavioral therapy CBT is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Keywords: cognitive behavioral therapy, homework compliance, mobile apps. Homework Non-Compliance in CBT Cognitive behavioral therapy CBT is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [ 1 , 2 ].

The Utility of Technology in Enhancing CBT Homework Despite its demonstrated efficacy, access to CBT as well as other forms of psychotherapy remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. Congruency to Therapy Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session.

Psychoeducational Homework While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Modality-Specific Homework Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages short message service, SMS to therapists in bulimia nervosa [ 61 ].

Guiding Therapy Therapists have a number of important roles to play in guiding and motivating clients to complete homework. Population Specificity Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels including learning or cognitive disabilities.

Other Considerations There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Discussion The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance.

Limitations and Future Challenges The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. Conclusion This paper presents our opinion on this topic, supported by a survey of associated literature.

Footnotes Conflicts of Interest: None declared. References 1. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord. Canadian PA. Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry. Am J Psychiatry.

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Specificity of homework compliance effects on treatment outcome in CBT: evidence from a controlled trial on panic disorder and agoraphobia. Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement. Patients' experiences of homework tasks in cognitive behavioural therapy for psychosis: a qualitative analysis.

Clin Psychol Psychother. Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons with schizophrenia. J Contemp Psychother. Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. The role of homework in cognitive-behavioral therapy for cocaine dependence. Homework compliance in a brief cognitive-behavioural and pharmacological intervention for smoking.

Interventions to enhance homework compliance in the treatment of clients with schizophrenia are outlined. Advanced Search. Privacy Copyright. Title Critical issues in using homework assignments within cognitive-behavioral therapy for schizophrenia. Publication Details Glaser, N. Abstract Presents an overview of the research findings to date and practical guidelines for the use of homework in cognitive-behavioral therapy for schizophrenia.

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