Homework in Cognitive Behavioral Supervision: Theoretical Background and Clinical Application

Abstract

The homework aims to generalize the patient’s knowledge and encourage practicing skills learned during therapy sessions. Encouraging and facilitating homework is an important part of supervisees in their supervision, and problems with using homework in therapy are a common supervision agenda. Supervisees are encouraged to conceptualize the patient’s lack of homework and promote awareness of their own beliefs and responses to non-cooperation. The supervision focuses on homework twice – first as a part of the supervised therapy and second as a part of the supervision itself. Homework assigned in supervision usually deals with mapping problems, monitoring certain behaviors (mostly communication with the patient), or implementing new behaviors in therapy.

Introduction

The development of competent clinical supervision is crucial to effectively training new CBT therapists and supervisors and maintaining high therapy standards throughout their careers.¹ Clinical supervision is a basis for CBT training, but there are only a few empirical evaluations on the effect of supervision on therapists’ competencies. Wilson et al² in their systematic review and meta-analysis, synthesized the experience and impact of supervision for trainee therapists from 15 qualitative studies. Although supervision leads to feelings of distress and self-doubts, it can effectively support supervisees in personal and professional development. It could similarly harm supervisees’ well-being, clinical work and clients’ experiences. Alfonsson et al³ published a study to evaluate the effects of standardized supervision on rater-assessed competency in six CBT therapists under protocol-based clinical supervision. This is one of the first investigations showing that supervision affects cognitive behavioral competencies. Although several works have studied the effectiveness of supervision on the therapist’s competence and for the therapist’s work with patients in qualitative studies,^3–7 there is still a lack of studies that dealt with the importance of homework in supervision.

Homework is a vital element of cognitive behavioral therapy (CBT) which distinguishes it from many other psychotherapeutic approaches.^8–10 Patients usually participate in therapy by completing homework assignments and taking responsibility for their course.

Assigning and discussing homework is one of the basic competencies of a cognitive-behavioral therapist and a supervisor in the context of counselling, psychology, therapy, and social work. The manuscript aims to refer to homework in several settings: homework in therapy, supervision of homework in therapy, using the homework by the supervisor for the supervisee, and homework in the training of supervisors.

Homework in Therapy

While specific recommendations for the practical usage of homework have been clearly articulated since the early days of CBT,^11,12 practitioners state that they do not follow these recommendations.^13–15 For example, many physicians admit that they forget homework or do not focus on standard specifications when, where, how often, and how long the task should last. Often reported non-cooperation in homework assignments may be due to the practice recommendations being too strict or because students think the amount of homework they can assign is limited.¹⁶

The Sense of Homework in the Therapy

Patients verify methods and skills they learned during the session in real situations and the natural environment.^9,17 Through homework, patients also test hypotheses that emerged during the session with the therapist (for example, “If I went out on the street alone, I would be so weak that I would pass out or lose control completely”). Homework help that the important part of the therapy takes place between sessions and allows the patients to become independent and manage their problems even after the end of therapy.^10,18 Patients learn how to raise hypotheses and test them in real-life situations. Through completing homework persistently during the therapy, patients gain skills on how to plan their activities and gain new skills, and they also collect a rich source of therapeutic diaries. The investigations advocate that adding homework to CBT increases its efficacy and that patients who constantly complete homework have better outcomes. The outcomes of four meta-analyses highlight the value of homework in CBT:

• Kazantzis et al¹⁰ inspected 14 studies that compared results for patients allocated to CBT without or with homework. The average patient in the homework group reported better results than about 70% of controls.

• Outcomes from 16 studies¹⁷ and an updated analysis of 23 studies¹⁹ discovered that higher compliance led to better treatment results among patients who received homework projects during therapy.

• Kazantzis et al²⁰ studied the relationships between quantity (15 studies) and quality (3 studies) of the homework to treatment results. The effect sizes were medium to large, and these effects remained fairly constant in a 12-month follow-up.

Therapists strategically create homework to reduce patients’ psychopathology and encourage them to practice skills learned during therapy sessions; nevertheless, non-adherence (between 20% and 50%) remains one of the most cited reasons for decreased CBT efficacy.²¹ Several reasons for non-adherence to homework might be pointed out –the therapist does not regularly discuss homework with the patient, the patient no longer considers it important and stop doing it.^9,22 Discussing homework also allows the therapist to strengthen the patient’s belief in their ability to achieve certain goals.²³ The fact that the patient has completed the assignment must be properly acknowledged, and then therapists discuss the quality of homework separately.²⁴ Good questions might be, “How did you do your homework? Were there any difficulties in fulfilling them? What kind?” Furthermore: “How can you handle these problems next time? What did you learn while completing your homework? Can it help you cope with other issues?”

How to Increase the Effectiveness of Homework in the Therapy

Homework is the most effective, and it is most likely to succeed if:^19,25

• Follows logically from the topics discussed during the session and uses the methods that the patient learned during the session;

• they are clearly and concretely defined, so it is easy to determine whether or to what extent the patient has been successful in fulfilling them (eg, “Leaving the house alone for at least 30 minutes every day”, not “Starting to go out alone”);

• the patient clearly understands their meaning (“To verify your belief that you will faint on the street” or “See for yourself whether your anxiety will continue to rise, remain the same or subside after a certain time”), and they believe they can achieve the goals;

• homework is formulated so that failure is impossible because, in any case, the patient will learn something useful that will help them in therapy;

• the therapist anticipates and discusses obstacles that could hinder the fulfilment of homework and plans procedures to overcome them.

An important aspect of CBT is the patient’s independence.^10,18 Homework is typically determined by consensus. To increase the likelihood that the patient will complete the homework, the patient and the therapist should document their assignments in writing. Additionally, it is very convenient for the patient to record the homework, typically pre-prepared.²⁴ These records serve as a basis for discussing homework in the next session and also allow the therapist to assess the changes achieved during therapy (“A month ago, you were able to go out alone for only half an hour and your anxiety level previously reached level ‘9’, while now you were alone outside for more than an hour and your anxiety do not exceed ‘5’ rated subjectively”).

Because the goal of therapy is to help the patient experience success, the patient’s assigned homework must be feasible.^18,26 On the other hand, patients should improve their ability to cope with problems and unpleasant conditions during therapy, they need to exert significant effort to overcome certain unpleasant feelings and emotions.^19,20

Even if therapists follow all these rules, they will unavoidably find that sometimes the patient does not complete assigned homework.^20,23 In this case, it is required to find out why this happened:

• whether the patient understood what the task was and what it meant

• whether mastering this exercise is important and motivated

• whether unforeseen circumstances prevented them from fulfilling it

• whether the assigned exercise was not very demanding for them in their current mental state

Therefore, therapists do not consider the non-fulfilment of homework a priori as a manifestation of resistance or lack of moral qualities on the patient’s part, then as a problem that must be solved together.

However, if, despite a thorough discussion of homework and agreement on its completion, the patient repeatedly does not even attempt to complete it, does not bring records and fails to justify non-compliance, it is necessary to return to the problem analysis and goal-setting. We need to clarify with the patient whether the problem they are currently dealing with in therapy is really the most important for them, whether the goal they seek to achieve is sufficiently desirable, and whether the therapist offers to achieve is acceptable.^9,20

Most practicing CBT therapists report that they use homework and consider homework important for many problems¹⁴ and believe in the role of homework in improving therapeutic outcomes.^24,27 Encouraging and facilitating homework is a basic skill of a CBT therapist; therefore, it is an important part of supervision.^19,20,26 Homework needs to be carefully assigned and discussed (Box 1).

Box 1.

Case Vignette – Discussion About Not Completing Homework with an Anxious Patient

Ms Vera is concerned about her future and relationships (she was diagnosed with a generalized anxiety disorder). She has trouble speaking openly with the therapist. From the beginning of treatment, she often apologizes and explains her behavior, ensuring that she did not make a mistake. However, she missed the last session, arrived late, and did not complete her homework. She apologizes frequently and explains why she did not have time to do it. She is visibly anxious. Therapist: It seems, Vera, that something prevents you from completing your homework and may be related to your need to explain why you did not come to the session last time and arrived late today. Do you think it would be possible to talk more about this? It may help to understand the other things we talked about… It may not be easy. Nonetheless, I’d like you to try it. Patient: I do not understand… Why I am still postponing the task… I was afraid to come without. A friend returned from a long business trip and wanted me to meet with him, so I cancelled the session. I apologize in advance…. I was afraid to come; I was late today because everything took me longer at work… I was worried about what you would tell me… Therapist: I understand… You were afraid to come to the session when you did not have homework. You were afraid of how I would react…. Is there more to talk about? It may be important for you to understand this fear… Patient: I was scared… and still think that you will eventually find out that I do not understand it, and I was ashamed… you may think I am stupid if I do not do it well enough… Therapist: You were ashamed and afraid and thought I would label you as stupid… what does it mean to you if I thought you were stupid? Patient: Well, you condemn me for trying so little… that I could not force myself to do the task… I was still postponing… Therapist: What is it like for you to talk about these feelings? Patient: It suffocates me. Therapist: Um, it’s a suffocating feeling …. Have you ever had similar feelings facing someone who was important to you in your life? Patient: Yes, most often with my mother. She always wanted everything 100% from me. From an early age… if something was not perfect, she was angry at me… and then did not talk to me for a few days until I apologized… she acted like I was invisible… I really wanted her to forgive me… (Tears in her eyes). I felt horrible…… Therapist: Um, it must have been painful. I understand that now you are afraid I could react similarly to you if you do not do something 100%. Do I understand that well? Patient: That’s right. I know you are a professional and very kind. Nevertheless, what if you judge me silently. Then you will think I have to take more responsibility for the treatment… And I am still late… that I do not understand the task… that I have failed again… do not be angry with me… Therapist: What you say is important… I am very happy about how openly you talk about it now… It takes courage… It seems to me… The fear that you did not do something one hundred per cent or well… It only happens with your mom and now with me… or elsewhere… in other relationships? Patient: I still have it with my mom even though I can better understand what is happening… nonetheless it’s still the same feeling… I also have it with my friend… that I still have to work 100% to be perfect. I would not say I like it when he criticizes me… I am afraid that he will be angry at me… so I try to make things easier for him, and I am tense… and he blames me a lot, and if I do not admit that he’s right, he does not talk to me… it’s actually the same as with my mother… Therapist: Um, so you react to him in a way like you do your mother and me? Do you experience it like that? Is that right? Patient: Yes, in some ways… I also sometimes criticize him first… that he is not perfect. When he defends himself… he mostly criticizes me… so I stop talking to him too… I am angry and blame him inside… nevertheless I am still afraid he will leave me… I do not understand it at all… I like him… Therapist: Very well, Vera; thank you for sharing this with me. The things you are talking about have a lot in common – This is the worry about the future and what will happen next. You have experienced this worry in the past as your mom criticized you and then stopped talking to you. In our relationship, you worried about what I might say or how I would interpret your behavior. Perhaps, you did not complete your homework due to that. A similar pattern might emerge in your relationship with your friend as you worry about his expectations of you. Is there a specific rule that could define this worry? Patient: Well, it occurs to me that people have to be perfect; otherwise, they deserve to be criticized, and if they do not apologize or promise to change their behavior, they should not be talked to - is that a rule? Therapist: Some people have that - Do you think this may be the case for you? Patient: Yeah, I tend to overthink how other people will react, then I live in horror that I am not perfect, or I try to be perfect… I have been living like this all my life… even if I do something perfectly, I feel good, nevertheless only for a little while. Even at work…. In fact, I am terribly afraid of the boss finding out I make a mistake… even though he appreciates me… I try not to make any mistakes… Therapist: How nicely you put it together… Do you think that the rule of perfection might have also played in your homework assignment? Patient: Yes, I think I had this idea of either understanding the task 100% or not completing it at all. I have also thought that If I missed something important, you would judge me. Therapist: So now you can see how this rule affected your homework. Let us review the homework assignment again and consider where this rule and worry might interfere with getting things done. We will try to work on it together… I will try to help you with it… and today, you have shown how well you can reflect on how certain rules might affect your life.

Kazantzis et al²⁸ advise examining the therapeutic relationship, which significantly impacts therapy adherence, to better comprehend non-cooperation with homework assignments. Data illustrating the therapist’s homework competence and the therapy outcome^29,30 show that the therapist is primarily responsible for their patients’ adhering to or failing to do homework. CBT therapists exhibit many interrelated automatic thoughts, assumptions, and behaviors during sessions that affect homework use in therapy.^8,15 In training, common negative attitudes for therapists include: “Homework will make patients feel like school and resent!” “They will feel too controlled and limited!”; “Homework will increase some ps’ sense of vulnerability!”; or “Homework will be even more stressful for stressed patients!” Another widespread belief is that the “structure” of CBT, whose homework is important, reduces spontaneity and worsens the therapeutic relationship.¹⁵

In addition, there is some scientific support for these views of therapists’ attitudes toward homework concerning the therapeutic process.³¹ The result of these attitudes is either a complete avoidance of homework assignments in a way that is not effective and consequently maintains these beliefs.⁸ For example, common behaviors require supervision, such as rapidly discussing directions at the end of a session, neglecting to repeat homework, or failing to justify while designing homework.⁹ The CBT Homework Project proposed a practice model²⁹ that emphasizes the importance of therapist beliefs, therapist empowerment, cognitive conceptualization, and the therapeutic relationship in enhancing homework practice.²³

Theoretical and empirical support for homework assignments in CBT leads most practicing CBT therapists to at least accept in principle that regular and systematic homework assignments will benefit their patients.⁸ As a result, CBT therapists favour assigning homework in therapy. However, many beginning therapists encounter problems when they start designing homework (ie, selecting tasks and discussing them with the patient), assigning homework (ie, collaborating on practical aspects of completing homework), and repeating homework in sessions.³² Incorporating homework into therapy is often superficial, hasty, poorly done, or forgotten.¹⁶ Therefore, problems with using homework in therapy are a common supervision agenda of practicing CBT therapists.

Personal Training and Self-Reflection of the Therapist as a Supervision Intervention

CBT training students are encouraged to conceptualize the patient’s lack of homework and promote awareness of their own beliefs and responses to non-cooperation in the CBT conceptual framework.⁸ Suppose the therapist fails to develop this awareness. In that case, errors in clinical judgment may occur, adversely affecting the therapeutic relationship and course of therapy.³³ Self-exercise (practicing CBT techniques and interventions as a therapist) and self-reflection (ie, process reflection) are concepts developed by Bennett-Levy et al,³⁴ to operationalize a useful understanding of own processes in working with patients. CBT training students are asked to become accustomed to using self-exercise and self-reflection. In a few qualitative studies, self-exercise and self-reflection have proven to improve the therapist’s self-concept, ie, self-confidence, perceived competence in one’s abilities and belief in the effectiveness of the CBT model.^34–36 Calvert et al³⁷ study checked the use of meta-communication in supervision from supervisees’ perspectives using the Metacommunication in Supervision Questionnaire (MSQ). There were differences in the reported frequency with which the different types of meta-communication were used. It appears that meta-communication around difficult or uncomfortable feelings in the supervisory relationship occurs less often than other components of meta-communication.¹

Below are examples of self-exercise and self-reflective exercises. The following self-assessment is developed to shape thinking before a preliminary meeting with a supervisor. Earlier knowledge has shown that supervisees and supervisors do not always share common ideas about supervision. Therefore, the supervisee could finish this self-assessment as a homework exercise before supervision. A supervisee might want to identify conversation matters that may enable a supervisor to better comprehend their requirements and needs.

Before Starting

Questions Regarding Previous and Desired Experience in Supervision

What background information do you think your supervisor requires to understand you at the start? (This may include a curriculum vitae noting appropriate previous experience). What would be the best method to convey these details? Is there any distinction between what you desire from this placement and what you feel you need? What background details about this placement and this supervisor do you have? How does this make you feel? Exists any more information that you need? What do you want and expect your supervisor to concentrate on during supervision? What roles do you want your supervisor to play with respect to you and your work? What supervisory media do you want to experience (for example, taped, “live”, or reported)? What do you intend to do about your feelings? Consider how you feel about your supervisor evaluating your work at the end of the positioning process.

More Specific Questions

• What specific activities during supervision do you recall as being helpful?

• What conditions would be most convenient for you?

• What would you personally anticipate getting from being supervised?

• However, what would you want to receive from supervision prepared that will not be on offer?

• What could you do about this?

Several possible tough issues can appear in supervision. The following list includes concerns the supervisee might consider (Table 1).

Table 1.

Difficulties in Previous Supervisions (Adapted According to Scaife 2019³⁸)

Difficulties in Previous Supervision	Yes/No
Having too much to do
Having too little to do
Having unclear guidance as to what is required
Having too little autonomy to plan and carry out work
Feeling constrained throughout supervision by the fact that a supervisor is also your assessor
Receiving too much unfavorable criticism during supervision
Receiving too little important appraisal from a supervisor
Not getting enough time from a supervisor for sufficient guidance
Being given too few chances to see your supervisor working
Being pushed repeatedly to be observed at work by your supervisors
Disagreeing with your supervisor on how to continue with some aspects of the work
Disagreeing with your supervisor on how some elements of guidance should proceed
Holding values concerning the function of a professional assistant that appears incompatible with those of your supervisor
Having to deal with various styles of work and supervision from your supervisor compared to previous supervisors
Feeling that your supervisor is too formal with you
Feeling that your supervisor is too informal with you
Having more than one supervisor causes problems in the supervision
Add in any other problems that concern you

In the next step:

1. Recognize the two issues which seem to be the most important ones for you.

2. What steps can be taken now to minimize the chances that these two concerns will seriously disrupt your cooperation?

Reflection on the Strengths

What are the top three strengths you want your supervisor to uncover as you enter this supervisory relationship?

List 3 points for your development that may or might not be obvious to your supervisor.

Reflection on Difficulties

Therapists regularly discover face-to-face contact with people labelled by society as coming from a specific sub-group.

Which sub-groups make you feel uneasy for whatever reason? Do you want to address this during supervision?³⁸

Examples of Self-Assessment in the Supervision Process

Exploring Sources of Stress from Clinical Work

Check all that resonate for you.³⁹

❑ Perfectionism ❑ Fear of failure ❑ Self-doubt ❑ Need for approval ❑ Emotional depletion ❑ Unhealthy lifestyle

Which of them seems to have the greatest impact on your stress levels?

What supervisor has most regularly identified as weak points in your clinical work?

Processing Mistakes

When mistakes are processed in ways that lead to reflection, flexibility, and adjustments in how you function, it can result in learning and growth.

Consider a patient you are now working with (or have recently worked with) with whom you have experienced a therapeutic failure.

Answer the following questions while keeping this experience in mind:

• What are the signs of a therapeutic failure? How can you be certain that what you are doing is not beneficial on some level? What benefits might your patient derive from failure? When did things begin to deteriorate? Which initiatives have been most effective so far, and which have been least effective? How have you been careless?

• Examine your intervention choices as well as how they were carried out:

• What concerns or considerations did you overlook? What is impeding your ability to be more effective? How has your empathy and compassion for this individual been harmed? How can you use this experience to help you grow?

Reflection of Therapeutics Mastery Skills

Favorite Techniques

• Explain three things you have put off in your career or life because they appear risky—you have something to lose and gain.

• Which therapeutic strategies or interventions stimulate you the most?

• What would you call your “hidden weapon”?

• What kind of patients or presenting difficulties interest you the most?

• What would it take to incorporate more of the pleasure and satisfaction you receive when applying the strategies mentioned earlier into other aspects of your work?³⁹

The following examples from clinical supervision demonstrate how self-exercise and self-reflection can help participants understand their belief system’s impact on homework in CBT.

Supervision of Homework in Therapy

Supervision is classically mandatory for students in cognitive behavioral training and plays a crucial part in therapist development.² The typical structure of continuous supervision of one patient includes discussing questionnaires or scales used to measure the severity of the problem (like the Beck depression inventory), homework, events in therapy since the last session, and then discussing the agenda of the current supervision meeting (what will be done in the session, which problem will be addressed), work on a selected issue or problems, homework assignment, session summary and its evaluation by the supervisor. The supervision focuses on homework twice – first as a part of the supervised therapy and second as a part of the supervision itself (Box 2).

Box 2.

Case Vignette – Discussion About Patient´s Homework During Supervision

Therapist: I have a patient, Mr V, who is depressed, and the problem is that he does not do his homework. Even though I discuss why and how he has to do the task making sure we also cover possible obstacles. Nevertheless, he always finds a way to talk me out of this. For example, he tells me, “You know, doctor, I know I should do it. It’s good for me. Nonetheless, I always put it off; somehow, I cannot force myself”. After this, I always urge him to explain why he cannot force himself. Supervisor: I understand that. You try to help him, think about how to make it easier for him to handle it, explain the meaning of the task, and ask about possible obstacles in the performance, and he promises to do it. Then he does not do the task, and he seems helpless. I am not surprised you are dissatisfied and seem even a little upset. (The supervisor supports the supervisee and gives positive feedback on the various specific competencies of the supervisee regarding homework) Therapist: Sometimes, I wonder if I should not give up on his homework. I push him unnecessarily, and then I am just upset, which does not matter. (The therapist feels safe enough in a therapeutic relationship to reveal her scepticism about continuing an important part of the therapeutic plan.) Supervisor: That’s also possible… Let us map out what’s happening with that patient before you decide. What makes him unable to do those tasks? What’s stopping him? Does he have any attitudes or expectations that may be related? Does he believe he can handle it? Or is something else preventing it? Let us hypothesize about schemas that may affect his behavior that hinders this part of therapy. (The supervisor offers an alternative strategy that requires the therapist to use conceptualization skills and specific competence to work with schemas in conceptualizing a case). Therapist: I have discussed this with him before; I offered him the hypothesis that maybe some thoughts prevent him from completing so when he wants to do homework and that it activates his feelings of incompetence, which also appear in other situations. When I asked him what he thought about it, he said, “I don’t know, you’re an expert on that”, and he got me again! (The therapist tried to use conceptualization to understand the patient’s non-cooperation. Nevertheless she still felt stuck. There are also signs of countertransference.) Supervisor: What do you say we try to brainstorm everything we can to change this situation? Otherwise, I want to say that I also have experience when I ask some patients who are very shy or depressed why they do not do their homework, they usually tell me that they “do not know” or that “they do not have the strength” or that “it still does not make sense”, and then I feel helpless for a while. The question is, what to do in such a situation? It occurs to me that we could work together to let the patient not feel as guilty while feeling more like an “expert” when answering. What do you think? Therapist: You are right; I am asking him why he did not do it, and he might feel like he’s in front of a school teacher. I did not get it. At the same time, his mother was a teacher who constantly pushed him to do many tasks and continuously criticized him. I can act like a mother to him - I hope not (laughs). He may feel helpless when he sits down for tasks. I did not discuss his feelings with him. I immediately expected him to make excuses. I also did not discuss his thoughts when I gave him homework. What happens to him when he promises everything? Maybe, he is afraid to tell me there’s too much? Maybe, he is afraid to ask when he does not understand something. When he had such an experience with his mother, I hope we will find some way to encourage him more in brainstorming. I must admit that I doubt myself when I am with him. Am I even in charge of doing therapy? I am often impatient with him; sometimes, I do cognitive reconstruction for him when he does not say anything. I comfort him when he says he’s not worth anything and does not come up with anything. At times, I “save” him. Nevertheless, I am annoyed that he did nothing himself, and he still uses it to wipe my eyes: “Look how incompetent I am”. Then I am helpless, and I do not help anyone. (The therapist discovered some of the countertransference patterns she noticed in her reactions to the patient, thus demonstrating the basic competence of self-awareness.) Supervisor: Very nice self-reflection! You surprised me with how good it is. Especially when I know you are in your second year of training. Just go on! You also asked some important questions straight away. What happens to the patient when he promises to complete the tasks, and what happens to him when he sits down for the tasks? A more thorough mapping of his thoughts, emotions, and behaviors in these situations could help him understand more. Maybe you could also deal with your self-doubts a bit. Perhaps you could find some rational answers that you could use to reduce your self-doubt. I think you have what it takes to do well. (The supervisor used the basic skill to build a supervisory relationship - reinforced the therapist’s basic skill - self-reflection. The supervisor also led the therapist to try a specific CBT skill - cognitive reconstruction - to change her self-doubts about patients such as Mr V.) Therapist: Do you think I should say the pros and cons of managing my therapeutic work? (laughs) I manage it mostly, only sometimes, like now, I cannot do something. Then I fail into unnecessary self-doubt. Fortunately, always only for a while, then I will overcome it. I tell myself that solving a problem is better than pondering my mistakes. You are right; it has to do with my attitude towards myself, which I should still work on. I wonder if I should also record a session with Mr V to listen to me working with him directly? Would you have time to listen? (The therapist responds to the supervisor’s support by mobilizing her basic rational response skills and applying them to herself.) Supervisor: I’d love to listen to a session recording with Mr V to give you more specific feedback. However, it is necessary to have his signed informed consent. It must also be clear to you that you are willing to expose yourself to such exposure and that we will listen together to what you are saying to the patient. Nevertheless, I like it, and it shows your courage and straightforwardness. These are qualities that I have noticed about you before. (The supervisor decided to work directly on recording the supervision session, pointed out the ethical side of things and appreciated the therapist for coming up with this idea.)

Whether and how the patient completes homework is a common supervisory issue (Box 3). The therapist often complains that the patient refuses to do homework or rarely does it.^8,16

Table 2.

Recording of Paul’s Automatic Thoughts

Situation	Thoughts (I Believe on %)	Emotion (Intensity 1–10)	Behaviour	Facts for Automatic Thought	Facts Against the Automatic Thought	Alternative View (I Believe on %)	Outcome Action
I give the patient homework	I cannot push him! 80% He has had enough, and I am still adding to him! It will bother him! 80% It’s inappropriate, and I cannot give my older patient homework. I am not a teacher! 90%	Anxiety 7 Helplessness 8	Quickly enter your homework in a quiet voice, apologize for the assignment and reduce the importance of the task in front of the patient	He looks annoyed when I want him to do something at home and says he cannot do it. He has not brought any homework yet.	He tries to work together in a session. The tasks belong to CBT and help outside the meeting, and tasks are not graded. So far, I have partially avoided assigning homework.	If I explain it to him properly and start working on his homework in a session, he will cooperate. 80% He needs homework. 100% He is not my dad but a patient who needs to work on himself between sessions. 100%	Anxiety 3 Helplessness 3 I will practice assigning homework. I will keep my homework longer at the end of the session.

Figure 1.

The picture describes the vicious circle of countertransference reaction, where automatic thoughts lead to developing negative emotions, bodily reactions and behaviors. Any vicious circle components can alert the therapists that their countertransference reaction is taking place.

Box 3.

Case Vignette –Discussion of Setting Homework During Supervision

Paul is a student in the second year of CBT training. In supervision, he reports the difficulty of assigning homework to an elderly patient suffering from depression after starting to have problems at work. Paul is convinced that the patient has a problem with homework at home due to his depression. Paul understands that he feels depleted and is overwhelmed by the bullying boss at work. During the session, the patient tends to complain about how uncomfortable his superior is and how difficult it is for him to manage these demands. In the session, the Socratic Dialogue alleviated the patient’s catastrophic thoughts about how the work could not last; nevertheless, he did not make other records of automatic thoughts at home. Paul thinks it’s because of depression and exhaustion from work. According to him, the patient no longer has the energy to do homework. Looking at the session video, the supervisor noticed that at the end of Paul’s session, he was giving homework briefly, uncertainly, almost as if he was apologizing, and did not find out how much the patient understood him or explain why the patient should do it. The supervisor and Paul looked at this part of the recording again. Then the supervisor asked Paul to write down a vicious circle of what was happening to him in the homework situation (Figure 1). The elaboration of the vicious circle of one’s experience enabled Paul to conceptualize what was happening to him. He realized that it was similar to homework assignments with other patients. Nonetheless, with this older patient, it was even more difficult. When the supervisor asked him why he had a problem with this, Paul realized that he had a strict father who instructed him not to bother him as a child since he was exhausted from dealing with work issues. The mother also warned him and his sister not to disturb their father while he rested after a long work day. Her father’s mother was absent and disinterested in him. Thus, Paul realized he had a big problem asking for something from older individuals - such as homework or exposure. He has the impression that it is wrong and that it bothers them that they have had enough. He perceives it as disrespectful to them, as he is much younger, a psychologist who only recently completed his education. Similar thoughts and unpleasant feelings appeared to him with older women; nevertheless, he overcame them more easily. If they developed ambivalence or reluctance, they also quickly tended not to be given homework. Now Paul was very much aware of the situation. The record of automatic thoughts that Paul was given for his homework to fill in after the therapeutic sessions, where uncomfortable emotions appear, revealed other negative automatic thoughts. Paul doubted himself in some sessions, especially with elderly or university-educated patients. ‘Bigger problems’ occurred with both authoritarian-looking men and women. Paul often thought that he “cannot handle therapy”, “he cannot do it”, “he’s too soft”, “he’s too urgent”, “I am pushing too hard”, and “I do not believe in it”, “they certainly misinterpret it”. Paul learned to achieve a more balanced view of the situation with the Record of Automatic Thoughts (Table 2). At the simplest level, awareness gained through guided discovery, Socratic dialogue, or working with the Record of Automatic Thoughts may be sufficient to facilitate cognitive shift, which is then reflected in behavior leading to more promising therapeutic outcomes. In this case, Paul began to spend more time designing and assigning homework to his elderly patients. In the supervision session, he played it with the supervisor in front of the video camera with the help of changing roles. This practice and video feedback increased Paul’s confidence when completing homework, which was nicely seen in the next session recording with the same patient. During the session, Paul evoked an idea of the task and its usefulness to the patient. The result was the successful completion of homework and an improved mood.

Homework in Supervision

Homework assignments are a common part of supervisory work. These may involve the patient’s management (eg noticing on their recording how often the therapist strengthens the patient and how and if it is rare to clarify where reinforcement would be appropriate), working on oneself (eg clarifying experiences and attitudes that lead to countertransference in a particular patient, awareness of which other patients may also occur) and theoretical study (the supervisor may advise the therapist to read a professional text that can help better understand and work with the patient).⁴⁰

The supervisor helps define a specific engagement, discusses specific therapeutic methods, touches on what methods the therapist has used and what else they may consider the role, for the most part, the implementation of strategies whose ability to use in therapy under supervision will be planned, as part of homework.

Homework assigned in supervision usually deals with mapping problems (supplementing the conceptualization of the case, evaluation, vicious circle of the problem with the patient, etc.), monitoring certain behaviors (mostly communication with the patient), or implementing new, behaviors in therapy (usually using therapeutic strategies).¹² Homework teaches the supervisee to work on self-reflection outside the supervision meetings.⁴¹ Discussing the homework properly at the beginning of the session is important. The mentioned home exercises usually concern the work with the supervised case report of the patient. The basic questions concern homework results, discussing the obstacles in solving them and what the supervisee learned in homework.⁸ The discussion gives the supervisor case management information and can point to important practice moments.

Homework Assignment

Before the end of the session, the supervisor and the supervisee agree on a homework assignment. It is optimal when homework arises from a problem addressed in the session’s main part.⁸ At the beginning of supervision, proposals for homework assignments usually come from the supervisor and are discussed and recorded in writing.⁴⁰ During supervision, the supervisee creates homework assignments, and the content is discussed with the supervisee.

The Meaning of Homework

Homework must make sense for the supervisee; otherwise, he will have no motivation to do it. However, it is also important to make sense of the patient or patients and develop the therapist’s skills and competencies. It is desirable to discuss the meaning of homework in supervision.

Possible Difficulties When Completing Homework

It is advantageous to discuss the anticipated difficulties in completing homework. This has the advantage that the supervisee can prepare for possible difficulties, consider overcoming them and consult with the supervisor. Discussing difficulties helps the supervisee model and later develops the skill to discuss the patient’s homework difficulties.

The Impact of the Therapist’s Belief System

In some therapists, there can be reasons for a more complex level of conceptualization.⁴² That is important when the therapist repeats certain mistakes even though they have repeatedly discussed them with the supervisor. At a directly accessible level, the situation with the patient can be described using a vicious circle. The deeper “hidden” level refers to the core beliefs and conditional rules activated in a specific situation with the patient.^40,43 A supervisor can use the “falling arrow” technique to map core beliefs and conditional assumptions.⁴³

One such way is the Therapeutic Belief System (TBS).⁴⁴ TBS is a theoretical model useful for understanding the specific beliefs, assumptions, and behaviors that therapists and patients commonly experience that could potentially affect the course of therapy. In line with the cognitive model, TBS provides a framework for identifying therapists’ and patients’ beliefs about themselves, each other, the treatment process, the emotions these beliefs can evoke, and typical behavioral reactions. For example, a therapist may see a patient as an “aggressor”, a “helpless victim”, or a “collaborator”. The participant’s own beliefs may supplement these beliefs about himself, such as “victim”, “co-worker”, “carer”, or “rescuer”. Homework assignments may be perceived by both the therapist and the patient as “hopeless”, “productive”, or simply maintaining the status quo and lead to a different emotional and behavioral response.⁸ Thus, TBS can be introduced into supervision to guide the supervisee to consider whether he or she identifies with any of the therapists’ typical beliefs and behaviors outlined in the model. A simple awareness of such patterns can be a useful orientation when considering the role of attitudes and beliefs in integrating homework (Box 4).

Box 4.

Case Vignette – Discussion About Supervisee Homework

Ludmila is a third-year student at CBT. She experienced a more intense emotional response as she considered completing her homework for a patient with a social phobia with strong patterns of vulnerability and addiction. The patient showed significant symptoms of social phobia. She has been repeatedly hospitalized, taking antidepressants and attending psychiatric group psychotherapy in daycare twice; nonetheless, social anxiety and avoidant behavior persist. Ludmila and the patient mapped out the conceptualization of problems and began thinking about therapeutic steps that included behavioral experiments and graded exposure to reduce social avoidance gradually. However, in a discussion with the supervisor, she stopped a behavioral experiment, saying it would not work with the patient. When the supervisor asked her what she was going through, she said that anxiety, when evaluating her intensity, it was up to 8 out of 10. When mapping a vicious circle about the situation, she said she was struck by the following: “She’s checking that it cannot work”; “I have never used a behavioral experiment before. I will ruin it and look incompetent in front of the patient!” Using the “falling arrow” technique, the supervisor and Ludmila came to the core belief “I am incompetent” and the conditional rule “I have to do everything perfectly. Otherwise, it’s priceless”: Core belief: “I am incompetent”. Conditional rules: “I have to do everything perfectly. Otherwise, it’s priceless”. “I should always be prepared for everything, or I will be embarrassed!” Behavior strategies related to core beliefs and conditional assumptions: • I read a lot about how to work with patients, and I still go to supervision to find out how not to make a mistake; • I do in therapy those strategies that I know very well, such as working with the vicious circle and cognitive restructuring; • I avoid doing strategies that I have not yet tried, such as behavioral experiments or working with schemes, prescriptions in the imagination and more; • I avoid asking the supervisor to try it when playing roles because I fear the supervisor will understand that I am incompetent. The core scheme and the conditional assumptions showed why Ludmila avoided giving the necessary homework to help the patient with social phobia. When Ludmila realized her attitude through self-reflection, the supervisor asked her to practice a situation she avoided with the patient by playing roles. They first replayed the situation so that the supervisor played Ludmila’s patient, and then they changed roles so that Ludmila could experience the patients’ feelings while building the behavioral experiment. Ludmila then planned her behavioral experiment with the supervisor, which involved testing a more optimistic view of the patient’s resilience and taking the “risk” of homework without being sure of the outcome. Ludmila performed this experiment, and the patient did her homework well. This encouraged Ludmila to try strategies she was less experienced with other patients. She exposed herself to greater uncertainty, gradually increasing her courage and self-evidentness.

The scheme broadly refers to mental structures that integrate and give meaning to events.⁴⁵ Schemes can be positive, negative or neutral. In CBT as a treatment for psychological disorders, we focus on dysfunctional patterns often associated with specific diagnostic presentations (for example, emotional vulnerability patterns are common in anxiety disorders). Schema is generally defined as a ubiquitous topic of cognitive functions, emotions, physiological feelings about oneself, and relations with others.³³

Therapists’ schemes run in specific therapies and do not usually signal mental health problems.⁸ Therapists’ schemes are influenced by the following factors: training experiences, such as supervision and training phase, therapy model, peer group, clinical experience, and personal experience.^13,40 Once identified, the therapist’s scheme can be used in supervision as a starting point to discuss some of the practitioner’s views that may interfere with therapy.⁸ Completing structured questionnaires can identify participants’ schemes, basic beliefs, and assumptions. Some examples of useful questionnaires are the Dysfunctional Attitudes Scale,⁴⁶ the Personal Faith Questionnaire,⁴⁷ the Young Schema Questionnaire⁴⁸ and the Therapists’ Schema Questionnaire.⁴⁹ Leahy’s Therapists’ Scheme Questionnaire is a relatively straightforward screening technique for identifying therapeutic patterns that could affect a therapeutic relationship. It consists of 46 assumptions related to the 14 most common therapeutic regimens.

Certain schemes are particularly common in CBT supervisees. These include “demanding standards”, “excessive self-sacrifice”, and “special superior person”.⁴⁹ Training therapists who identify with the “demanding standards” scheme have a somewhat obsessive, perfectionist, and controlling approach to therapy. These therapists usually have high expectations for keeping a patient’s homework and may not realize that non-compliance with homework is often part of the learning process. Therapists may expect that there is a “right” way to complete a homework assignment, leading to feelings of frustration when assignments produce different results. This may signify insecurity and a notion that if things break from the planned structure, the therapist will be exposed as “incompetent”. Many therapists identify with the “excessive self-sacrifice” pattern, the most commonly observed pattern in both novice and experienced therapists.³³ Leahy⁴⁹ proposes that these therapists overstate the importance of their patient relationships. They may fear leaving or feel guilty that they are or feel better than the patient. As a result, the therapist may engage in therapy-defeating behaviors, such as making the homework assignment to the patient’s various needs, having difficulty with appropriate assertiveness in discussing persistent patient non-cooperation, and having a tendency to avoid techniques. Such as exposure or opening of painful memories for fear that the patient will be upset.

Novice therapists who identify with the “special superior person” scheme see the therapeutic situation as an opportunity to achieve excellent results and have high-performance expectations. There may be a tendency for the patient to idealize or, conversely, to devalue or distance himself from patients who do not improve or do their homework. The presence of a “special superior” scheme can be seen as overcompensation in response to “demanding standards” and “excessive self-sacrifice”, which have the thematic connotations of “not being good enough”. The supervision session sets the supervisee in a situation where the supervisor supervises homework through videotaped therapeutic sessions utilizing a cognitive therapy scale (CTS).⁵⁰ Feelings of superiority and exceptionality can, in some cases, be a way of dealing with the feelings of inferiority that they experience, that their use of homework is judged in this way.

In addition to recognizing the general responses to the scheme that most training students encounter, the supervisor should help the supervisor become aware of his or her idiosyncratic beliefs and coping styles, which some patients may trigger (Box 5). The supervisor should encourage the supervisee to pay special attention to the “overlapping patterns” in which the therapist’s scheme and the patient’s scheme overlap, leading to the over-identification of the therapist with the patient.³³

Box 5.

Case Vignette – The Supervisor Advises the Therapist to Work with Core Beliefs and Conditional Rules

Petr works with a patient diagnosed with the obsessive compulsive disorder and social phobia and with a scheme of excessive vulnerability. Difficulties have persisted for many years, and controlling compulsive and avoidant behaviors have become the patient’s basic coping strategy. The patient was engaged in many “healthy” activities, such as “cleanliness”, “healthy eating”, and “healthy sleep”, which she performed ritually. She avoided most of the social and work situations that caused anxiety, which resulted in a very limited lifestyle with many open hours during the day, which she filled with compulsions. The patient felt frustrated by both the compulsions and the limited lifestyle. She also felt paralyzed by her basic beliefs, “I am different and vulnerable”, and other people are “overly demanding, critical, condemning and harshly rejecting”. Her attitude followed her childhood classmates’ refusal because she was overweight. Petr works with the patient for about 12 sessions. Now, he has come to supervise her case for the first time. During this time, he developed a good therapeutic relationship with the patient. The patient was well involved in the therapeutic process. It was also possible to expose her to social situations and reduce excessive hand washing. However, Petr encouraged “healthy cooking and sleeping”, which took several hours a day, because he considered it a proper “healthy lifestyle”. Petr described these several-hour activities as “successes” and did not consider them possible compulsive strategies that can, among other things, make it possible to avoid stressful situations. The patient has repeatedly expressed that healthy eating and going to bed take much time. However, Petr responded to the patient’s self-criticism with reassurance and further praise for the patient’s accomplishments. Because there were only partial changes in compulsive behavior in reducing excessive washing, the supervisor emphasized that the homework assignment revealed a tendency to fill time with compulsive and trivial activities, which the patient herself points out. The supervisor acknowledged Petr and the patient’s progress in developing a good therapeutic relationship and improving social interactions by reducing excessive washing. She then suggested that Peter and the patient should no longer explore healthy cooking and sleeping and how compulsive and beneficial they were to the patient. Supposedly the patient wants to reduce the time devoted to these activities, and Petr should consider how to help her. Peter was irritated by the supervisor’s opinion and began to explain why he did not feel like doing so. He angrily said it was just an interpretation of the supervisor for which he had no evidence. The supervisor noticed a change in their emotional response and asked Peter to say what was going through his head. Peter said he thought healthy cooking and healthy sleep were related to a healthy lifestyle and should be encouraged, not considered compulsive. The supervisor acknowledged that he might be right. She went back to why it made Peter so upset. Petr angrily said that the supervisor did not appreciate their progress with the patient and was looking for something to criticize. They returned to what she had told him, then asked again if anything else had occurred to him, why it was such an emotionally critical situation. Peter calmed down and said he was also trying to sleep soundly and cook healthily, putting much effort into it. As his patient, he was overweight as a child, and his classmates mocked him. He is not overweight now. He carefully checks his condition, exercises, and sleeps regularly. Therefore, he understands the patient’s effort to adhere to the order. The supervisor expressed understanding of Peter’s explanation. She then asked him if he would consider his homework, what core beliefs and conditional rules might play a role, and if his patient did not have something similar. For further supervision, Petr brought homework with the following core scheme and behavior strategies: Core belief: “I am different, ugly and unlovable”. “Others are overly critical and reject the different”. Conditional assumption: “I have to try to be precise and control everything so that I don’t experience reprimand!” Behavior strategies: • daily weight control, healthy eating, regular exercise and sleep • frequent attempts to emphasize its uniqueness and difference • constant efforts to prevent rejection Peter also realized that his beliefs about himself and others were similar to those of his patient and, like his beliefs, had been ridiculed in childhood. He also acknowledged that he identified with the patient’s distress and could risk-taking on the role of “savior” and overemphasize the patient’s diversity and sensitivity. He decided to thoroughly examine “healthy cooking and sleep” with the patient and determine how much it bothers the patient and what she would like to change.

Homework in Supervisor Training

For supervisors, their supervisors’ training is important. An important part of this training is the practice of self-reflection, which should be requested directly in the meeting and as homework. It can be a task to capture situations in supervision in which they do not feel comfortable using the vicious circle, cognitive restructuring of automatic negative thoughts in these situations, capturing thoughts, emotions, bodily sensations and behaviors in situations where they are aware that they are experiencing countertransference reactions to the supervised therapist. It is also important that in their homework, they reflect on their concentration level during supervision sessions and consider what supervision skills they have used or what they have learned for the next session. A typical complex homework in supervision training is a video recording of supervision sessions and their analysis. The recorded supervision and analysis are then analyzed in the next supervision training meeting.

Discussion

This article is designed as an overview of views and experiences. Its important element is work samples. This is also a limitation of this article. Assignment of homework in supervision and therapist and supervisor training lacks scientific information about its effectiveness. Nevertheless, assigning homework is an important part of cognitive behavioral therapy. We know quite well about its meaning in prescribing for patients. Less is known about their meaning and effectiveness in supervision. The supervisee encounters problems completing homework assignments for her patients that she brings to the supervisee. Why the patient does not complete the homework may be his problem, but his therapist may also have a part in it his requirements, which include how the homework is assigned, its suitability for the given patient, timing, and complexity. Homework can also belong to the training of supervisors and the supervision of supervision. Here, we do not know any research evidence about their effectiveness in using the most important part of supervision, the patient; however, they are experienced by supervisors and supervisees as useful and meaningful.

Homework in supervision and supervision requires further reflection on their meaning and subsequent research, which should examine their significance for the supervisee’s competence (supervisee) and the ultimate impact on the patient himself.

Conclusion

Homework presents one of the cornerstones of cognitive-behavioral therapy, CB supervision and the training of CBT supervisors. If applied consistently and collaboratively, homework enhances therapeutic outcomes and increases the patient’s self-confidence. Setting and maintaining a fruitful working alliance for homework can be challenging – issues with homework present one of the common reasons to seek a supervisory consultation. Supervision then focuses on examining the specific case and experienced problems, factors in the interaction between the therapist and their patient, and the therapist’s automatic thoughts, schemas, and behaviors that might maintain the issue. There are several ways to address this topic in supervision. Homework is usually part of supervision because of its usefulness. The supervised therapist may be given similar tasks as the patient receives in therapy: to describe the automatic thoughts that occur to him while guiding the patient, to test them and look for a more rational response, to conduct behavioral experiments, to clarify the core beliefs and conditioned assumptions that influence the formation of the therapeutic relationship, experiments with adequate communication with the patient and others. A therapist’s self-experience through practice can help them improve their therapeutic work.

Disclosure

The authors report no conflicts of interest in this work.