Homework is the missing hallmark of CBT In routine practice. Inspection of Improving Access to Psychological Therapies (IAPT) records provides scant evidence of agreed homework assignments. Rarely do they specify the behaviours that the client is to engage in, the coping strategy to be employed and the monitoring strategies. But given that client’s commonly have impaired concentration written specification is a must and helps to ensure compliance with homework [Cox 1988 Cox, D. J., Tisdelle, D. A., & Culbert, J. P. Increasing adherence to behavioral homework assignments. Journal of behavioral medicine, 11(5), 519–522. https://doi.org/10.1007/BF00844844].
Beck [Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press] suggested that homework should be a) clear and specific b) include a cogent rationale c) client reactions should be elicited to troubleshoot difficulties and d) progress should be summarised when reviewing homework. Homework provides a link between sessions. Meeting criteria a) to d) in a low intensity intervention is a tall ask and in the absence of written evidence to the contrary, it must be assumed that this active ingredient in CBT treatment is missing [Kazantzis, N., Whittington, C. J., & Dattilio, F. M. (2010). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17, 144–156]. Whilst it is likely the case that the skilful assignment of homework will relate to outcome Kazantis (2021) [ Introduction to the Special Issue on Homework in Cognitive Behavioral Therapy: New Clinical Psychological Science. Cogn Ther Res 45, 205–208 (2021). https://doi.org/10.1007/s10608-021-10213-9], such considerations are of little consequence if routine therapy is constructed in such a way that homework has difficulty thriving.
It is interesting to ponder that if a Civil Court Case was mounted on the basis that a supposed CBT treatment had not in fact happened, leaving ongoing debility, would a claim for compensation succeed? As an Expert Witness I would ask to see the treatment records and in over 25 years in this capacity I can think of few cases were I could be sure, on the balance of probability, that the said treatment had been delivered. Part of this evidence would be no evidence of homework assignment. IAPT has tried to keep out of the legal domain by asserting that its’ therapists do not make diagnosis. But a Judge might ask where is the accountability in this matter. A Nurse may be called to task for not following an evidence based medical procedure even though overall responsibility may rest with a Consultant. There can be no certainty that IAPT would not find itself in the dock. Its’ defence would likely be that its’ practitioners were only doing, say what most BABCP members do, but this would be skating on thin ice.
Dr Mike Scott