Cognitive and Behavioral Practice 14 (2007) 261--267www.elsevier.com/locate/cabp

The Use of Homework in Cognitive Behavior Therapy: Working with ComplexAnxiety and Insomnia

Arthur Freeman, Philadelphia College of Osteopathic Medicine

1077© 20Publ

Homework, or self-help, is an essential and required part of cognitive behavioral treatment. It offers several opportunities for the therapistto extend and increase therapy contact by having the patient “live” the therapy outside of the consulting room. It can also serve as ameasure of the patient’s motivation for therapy or for change. Homework offers the patient an opportunity to practice what has beendeveloped and discussed in the therapy session. By trying out new behaviors, new ideas, or new emotional responses, the patient canmake “real” what has been an abstraction in the therapeutic dialogue. The homework becomes an opportunity for gathering data.Inasmuch as the homework grows “organically” from the session content, it is relevant and timely. Homework provides continuitybetween sessions. Rather than sessions being discrete moments in time, they are chained together by the homework from the previoussession being included in the agenda for the subsequent session. The homework can be structured to involve significant others. This isessential in many therapeutic situations, and having the significant others involved can substantially aid in relapse prevention.Finally, effective homework helps to build therapeutic collaboration and afford the patient the opportunity for building self-efficacy.Using several case examples, this paper describes the functions and impediments to using homework in CBT.

homework1: an assignment given a student [patient] to becompleted outside the classroom [therapy room]2: preparatory reading or research

—Merriam Webster’s New Collegiate Dictionary

WHEN patients spend time, energy, and effort outsideof the therapy room dealing with the cognitive,

behavioral, or emotional problems or issues that havecreated discomfort or dysfunction for them, they aredoing what can be termed “homework.” Ultimately, theinsights gained in the therapeutic collaboration must beapplied to the individual’s life. In effect, the goal ofpsychotherapy is that the patient will take the gains oftherapy (skills, insights, and motivation) “home” and usethem. When therapy ends, all that the patient does on hisown becomes homework. The patient who does not doindependent therapy work and who requires ongoingtreatment to maintain adaptive function will have a fargreater chance for relapse.

Homework as a therapeutic tool is not new. Oftenconsidered a hallmark of behavioral and cognitive beha-vioral therapies (Beck, Rush, Shaw, & Emery, 1979; Beck,

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Freeman, Davis, & Associates, 2003; Freeman, Pretzer,Fleming, & Simon, 2004; Kazantzis, Deane, Ronan, &L’Abate, 2005), homework was a frequent ingredient inpsychodynamic therapies. For example, when Freud askedpatients to attend to their dreams and to write down thedream content and their emotional responses to the dreamimages, it was, by definition, a homework task. Patients who“forgot” to record the dream content might have beenlabeled “resistant” inasmuch as the dream was seen to bethe “royal road to the unconscious” and therefore anessential ingredient in the analysis.

Individuals who never seek therapy and who cope withthe demands and exigencies of life (to a greater or lesserdegree) are doing their work “at home.” Whether theirefforts fully ameliorate the difficulties that they encounteris not an issue. Most individuals spend their lives doingself-work or homework.

Aspects of Homework

Homework is very broad. It can be used to havepatients examine general and specific beliefs, cond uctdirect tests of these beliefs, and practice hypothesis-testingskills in specific in-session and between-session exercises.By trying out new behaviors, new ideas, or new emotionalresponses, homework becomes the life-practice setting forthe therapy. It offers the patient the opportunity to make“real” what has been largely an abstraction in the

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therapeutic dialogue. Homework offers the patient anopportunity to identify, clarify, and change emotionalresponses. It provides a venue for behavioral change, anda context for modifying one’s thoughts and beliefs. Thereare a number of aspects of homework that make itvaluable for psychotherapy, regardless of the therapist’stheoretical orientation. These include:

1. Homework provides a laboratory experience for thepatient. The therapy session can be likened to the“lecture” aspect of a college course and the homeworkoffers the hands-on laboratory experience. What wasvague and abstract in the session is now translated intothe more challenging venue of life. The therapy offerspatients the opportunity to gain insight into theiractions, identify their automatic thoughts, develop andget feedback on their problem-solving patterns, or toexplore the details and change opportunities of theirschema. The homework allows patients to try on newroles and to act “as if …”. The new behavior(s) can thengenerate new data for testing, exploring, and discussionin the therapy sessions.

2. Homework offers continuity between sessions. No matterthe number of sessions in the ongoing therapy, theindividual sessions have the potential, for a variety ofreasons, to stand as discrete moments in time rather thanas an integrated whole. We can make the case that eachsession should stand as a complete therapy, having abeginning and introduction to the therapy (agendasetting), a mid-portion (the focus of the session andfulfilling the agenda), and a summary/concluding partthat integrates and synthesizes the session content, andexperience. This integrated session-by-session focus is auseful and effective model for treatment, especially whenthere are limited sessions. The homework then providesthe connections from one session to the next.

3. Homework affords practice at skills not easily practiced insession. The range of cognitive, behavioral, and emotivetechniques is limited only by the creativity of the therapist.In-session exercises are used to introduce and train apatient in using a particular technique. The in-sessionpsychoeducation can address any of a number ofproblems and be applied to a broad range of interven-tions. For example, in working with a patient with socialanxiety, the therapist can role-play with the patient aparticular behavior (e.g., a social skill), offer feedback onthe patient’s performance, and have the patient improvetheir in-session execution of the technique. A commonlyused in-session intervention is to learn techniques thatevoke and then allay the social anxiety through breathing,imagery, or other calming actions.

By having the patient practice the social skill in agraded task manner within his or her family, work, orsocial network, the grist for the therapeutic mill isenriched by the unplanned vicissitudes that real-life

situations offer. It is far better to use in vivo experience,when possible.

4. Homework brings therapy into the “real” world. Theconsulting room can also be an insulating room,protecting the patient from the sometimes harsh realitiesand vicissitudes of life. Even when the homework is wellplanned and graded in difficulty, there is no way that thetherapist and patient can forsee what might interfere withthe best-laid plans of mice and men.

A second issue relates more to the therapist in that thetherapist may be reluctant to respond to the patient asangrily, powerfully, or insultingly as might occur in reallife. The patient may then be poorly prepared for lifesituations. The homework can be far more controlled andapproximate the final goals of the therapy.

5. Homework aids in relapse prevention. All therapy needsto have an end-point. That point of termination may wellbe evaluated by how well the patient is able to cope withthe stimuli that led to seeking therapy. After all, whentherapy is finished, everything is homework. The strongerthe patient’s homework tradition and self-help skills, thebetter able the patient will be to cope. Frequent home-work exercises post-therapy can keep the patient’s skillssharp and ready for negotiating life.

6. The homework must emerge organically from sessionmaterial. While it is essential that the therapist develop abroad repertoire of homework assignments that includecognitive, behavioral, situational, physiological, and affec-tive tasks, the use of a particular assignment must beclearly and directly related to the conceptualization, thetreatment plan, and the material generated in a particularsession. Rather than the homework being the “add-on” atthe conclusion of the session, it needs to be generatedduring the session and reiterated at the end of the session.In response to the session material, the therapist can askseveral leading questions, for example, “You have justmade an interesting point. What would happen if youwere to go home and ask your parents that very question?”

7. Homework is a data-collection opportunity. By focusingon homework as an opportunity to collect data, whetherpositive or negative, the homework can be structured forthe patient to be a no-fail experience. If, in thehomework, the patient predicts one reaction and getsanother, it is not seen as a success or failure, but simplydata to be explored, understood, and synthesized. Thehomework can then be reformulated to better accom-modate the data.

8. It is important for the patient to contribute to the design ofthe homework. Helping the patient to take increasinglymore responsibility regarding homework serves toempower the patient. As they understand the limits andboundaries of what they can do in their life circumstance,they also gain self-efficacy. If the homework is simplyassigned by the therapist without the patient being

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explicitly involved in its formulation, the data collectedwill be the therapist’s data and not necessarily integratedby the patient.

9.Homework can be structured to involve significant others as"homework assistants”. This can be a central ingredient forall homework. With children, adolescents, and elders, thismay be an essential part of the therapeutic experience.With these latter groups, unless the significant others areinvolved, therapy may suffer. We cannot take the positionthat significant others (parents, family members, spouses,or friends) are malicious and are going to be hurtful tothe patient. In more cases than not, these individuals arecaring and willing to work with the patient in doinghomework. As noted above, if they are not, thatinformation can become data to be factored in to thetreatment conceptualization.

10.Within reason, ethics, and good sense, almost anything canbe used as a homework experience. Given that the goal of thehomework is data acquisition, the homework can be asinnocuous as asking a stranger for the time of day or traveldirections, or making a phone call. It may be as complexand multifaceted as including travel, confrontation with afeared individual, or pushing the limits on one’s fears.

11. Homework extends and increases therapy contact. Ratherthan therapy being an hour or two a week, homeworkincreases the immersion in therapy. The therapy can thentake place several times a day throughout the week. Forexample, the alcoholic may be confronted by the urge todrink multiple times each day. The individual’s main-tenance of sobriety is an essential part of treatment thattakes place as homework. In situations where weekly orbiweekly sessions are not possible or indicated, thehomework will be the focus of therapy.

12. The willingness to do homework offers a measure of thepatient’s motivation to change. If patients are unwilling towork outside of the session, they are, in fact, decreasingtheir opportunities for change. This lack of willingness isadditional data that can be explored in the session. Thelack of completion of homework is not, in and of itself, asign of resistance, but rather leads to a series of questionsto be explored in therapy. Was the homework within thepatient’s repertoire? Did they understand the goals andpurposes of the homework? Were the patient’s expecta-tions for the homework realistic? Were the therapist’sexpectations equally realistic? Were the homework time-table and instructions clear?

13. Homework helps to build therapeutic collaboration.Therapists and patients should collaboratively set specific,reasonable, desirable, and measurable treatment goals andidentify a clear rationale for each homework assignment.It is vital to reframe each collaboratively generatedhomework assignment as a positive, incremental step onthe road to increasing social skills, mood elevation,anxiety reduction, and other desirable goals. Simulta-

neously, the therapist and patient collaboratively testproblematic thoughts, beliefs, behaviors, situations, sche-mas, and assumptions.

14. A particular homework may be repeated several times atincreasing levels of sophistication and complexity. Having thepatient keep an activity schedule retrospectively may be agood first homework experience. This would allow thepatient to assess what they have done in the past week.They can then use the activity schedule prospectively toplan better time and energy use. The patient can then addto that the prediction and completion of work that bringspleasure or a sense of personal efficacy. The homeworkcan be used to help include others into the patient’sactivities.

15. Regardless of the task, homework assignments should beconcrete. The more concrete or simple the homework, thebetter. The dysfunctional thought record (Beck et al.,1979) and downward arrow technique (Burns, 1980; Becket al., 1985) are homework assignments that can be usedto identify and modify activated schemas that generatenegative cognitions. However, even simpler homeworksuch as activity scheduling, identifying mastery andpleasure tasks, maintaining a food diary, or countingparticular thoughts with a simple wrist counter areextremely useful.

Resistance(s) to Doing homework

To subvert homework nonadherence, the therapistmust identify the patient’s cognitions regarding thehomework assignment and the consequences of change.Cognitive restructuring and graded task assignments canhelp to reduce distorted task-interfering cognitions.Homework nonadherence may reflect perfectionism,shame, or simply a failure to understand instructions.Collaborative exploration of the patient’s idiosyncraticcognitions should elicit task-interfering beliefs. Increasingemotional tolerance and social skills training can furtherreduce avoidance of homework.

Using a homework diary can help to prompt patientcompliance and increase commitment. This will involvewriting down the homework before the patient leaves thesession. Cost-benefit analysis of change is an adroit way toput an oppositional and autonomous patient in theposition to convince the therapist of the desirability ofchange. Because unexpected outcomes lead to greateremotional distress than expected outcomes, another wayto inculcate and maintain motivation is to predictoccasional setbacks in the very first session.

In selecting homework activities we must consider thepatient’s current abilities and readiness to change. Forexample, the patient’s perception of the problem, motiva-tion, distress tolerance, communication skills, and evenreading or writing ability need to be considered. Allowingpatients to select among homework activities that are

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equivalent to their own abilities can further increasecommitment, responsibility, and homework adherence.Merely offering the patient a choice of ways and times tocomplete the assignments can have similar effects.

Once a homework assignment is selected, in-sessioncognitive or behavioral rehearsal can help to shapeadaptive skills, increase the probability of homeworkadherence, and illuminate potential obstacles to complet-ing the task. The therapist may ask patients to indicate, ona 0-to-100 scale, how confident they are that they will beable to complete the homework assignment. If the patientindicates low levels of confidence, the therapist can solicitexpected obstacles, which can then be directly addressed(Kazantzis & Deane, 1999). These obstacles may includedistressing beliefs, cognitive and emotional avoidance, aswell as real-world problems like scheduling, inclementweather, and lack of transportation, among others.

Case Example 1

Irene was a 26-year-old woman who sought therapy forher anxiety. In the first intake session, she discussed herlife circumstance. She was engaged to be married toRalph in 3 months and to then move with her fiancé to acity about 500 miles from her present city. The move wasnecessitated by Ralph’s job opportunity to assume a high-paying managerial position in his company. Her presentcity was where she grew up and had family.

She described a history of panic attacks with agor-aphobia that started when she was a teenager. For about 4months at age 18 she did not leave her home. She soughttreatment at a university-based anxiety disorder clinic andwas treated weekly on an outpatient basis for about 3months. Initially, her mother took her to the therapysessions, but for the final month of therapy she was able totravel by herself. She reported that she was now able toleave her home and to work without difficulty but withoccasional “slight anxiety”.

Irene completed a 1-year training program as alicensed practical nurse. This was done to satisfy hermother, who was a registered nurse. Irene never workedas a nurse subsequent to her training experience.

She had a job that she stated she “loved” working in asmall office as one of the “800” contact number operatorsfor a local appliance firm. She enjoyed the interactionwith the two other operators and the office manager. Shehad held this job for the past 3 ½ years.

In developing a problem list, Irene stated, “I want toget married with a clean slate. I would like to get rid of theremaining problems that I have before the wedding.” Theproblems she listed included:

1. That she “cannot” visit the seaside but can go to alake where she can see the shorelines. The open-ness of the beach vista makes her very anxious, even

if seen in a movie. Interestingly, she reported thatbeach scenes on TV are not anxiogenic. Sheattributed this to the limited size of the screen onthe TV. Irene wanted to get rid of any and allremnants of her agoraphobia. She wanted to beanxiety-free to go where she wanted and when shewanted.

2. She will avoid dining in public. She feared thatothers will see her shaking hands as she broughtfood to her mouth. These people would then thinkthat there was something very wrong with her. If shecould not avoid eating in a restaurant or otherpublic dining facility, she required a corner tablewhere she sat with her back to the room. She hadnever shared with Ralph the extent of her agor-aphobia. It was when Ralph expressed interest in acruise as a honeymoon that Irene tearfully sharedher experience. She reported that Ralph seemedvery understanding of why she would not go on acruise inasmuch as they would have to dine withothers, several times a day, in addition to being on aboat with expanses of ocean all around her.

3. Irene reported that she wanted to rid herself of“disturbing” sexual thoughts and fantasies. Shereported that there were several occasions whenshe was having sex with Ralph that she had fleetingimages of other men. It was not always the sameman, nor was this experience frequent. In fact, sheasked Ralph what he thought about when they weremaking love and he told here that he had nothoughts whatsoever. His mind, he said, was blankand he was just enjoying the experience.

4. She often wondered what previous boyfriendsthought of her. Irene had a sparse dating history.She did not start dating “seriously” until she was 21and had been sexually involved with 4 men,including Ralph. Her sexual activity was within thecontext of long-term relationships. The briefest was6 months and the longest was her present relation-ship, which had extended for 2 years. Irenewondered if these men thought that she was“loose” for having sex with them.

Treatment PlanningIn developing a treatment plan and establishing a

structure for therapy, we had to first prioritize Irene’stherapy goals, identify motivation for treatment, andestablish discrete goals. We could then focus the home-work on each area of concern. But what should be thefocus of treatment? How is that decided? Is it the patient’schoice? The problem that is most intrusive in her life? Theproblem that makes her most maladaptive? Is it a matterof random choice? Is the priority the therapist’s choice?Does the prioritization emerge from the Socratic

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dialogue? Should the initial focus be on the easiestproblem so as to build momentum and value to thetherapy? Should the focus be on the most difficultproblem so as to clear the hard issues whereby what isleft is relatively easier? Or, should all prioritization beabandoned in favor of searching for a single commondenominator to all of the problems?

The therapist’s thinking was as follows: None of theproblems incapacitate Irene. She is, by her report,discomforted more by some of the problems than byothers. She is able to travel, work, have friends, and have aromantic and sexual relationship.

Regarding problem #1: Irene’s inability to be at a beachis not necessarily a problem. She is moving to the city ofMinneapolis. There are many lakes in Minnesota (10,000we are told) but no endless ocean vistas. She can swim in apool or in a lake, so the difficulty may never assert itself.The remnants of her agoraphobia were vague. She hadbeen successful in the earlier treatment of the agoraphobiaand was now symptom free. She maintained anxiety aboutpossibly being anxious. Her goal of being without anyanxiety whatsoever was, in the therapist’s view, unrealistic.

Regarding problem #2: her discomfort with dining inpublic. Irene had already made some coping adjustments.She would always ask for a table in a corner or against awall where she can shield her “shaking” hands from theother diners. She would insist on this, even though itmight mean a longer wait for a table.

Problem #3 is interesting inasmuch as it is a commonoccurrence for many people. The issue then is not thatshe has these images of other men while having sex withher fiancé, but her negative evaluation of herself forhaving them. Her fiancé’s statement that he had nothoughts at all was, in fact, more troubling. He undoubt-edly has thoughts, but his denial makes Irene devalueherself further.

Finally, problem #4 relates to her concern regardingthe evaluation of her behavior by others.

Given the limited time for therapy, the therapist’s ideawas to approach the problems in the order of 3, 4, 2, and1. The rationale for the priority was that 4 and 3 seemed tobe related and within what might be considered a normalreaction. The treatment goal was to help Irene limit hernegative view of herself and to normalize the experience.The therapist’s recommendations were presented toIrene along with the rationale for the prioritization. Sheaccepted the therapist’s prioritization.

The first homework assignment was for her to read MySecret Garden by Nancy Friday (1973). This is one of acollection of women’s sexual fantasies by Friday. Ireneagreed to get the book and read it for the second session.She came to the session and stated that she had never hadthe explicit sexual fantasies that were written in this book.Hers were more vague and formless. The session discus-

sion focused on her view of sexual fantasy and whetherfantasies were “good” or “bad”. The discussion includedwhere she learned about the valuation of fantasies, fromwhom, and to then identify her schema regarding sexualfantasies generally and her own sexual fantasies morespecifically. By the end of the session, she asked, “Is itpossible that my fiancé was not being honest about havingno sexual images?”Once Irene saw sexual fantasy as more“normal”, her anxiety diminished. She did, however, statethat she never wanted to have some of the dramaticfantasies described so vividly in the book. Others that wereless dramatic, she said, were more “interesting”.

The session material could focus on how Irene tendedto maintain a negative view of herself, assuming thatothers would see her “badness”. She could link this with ahypercritical mother and a father that she viewed asfrightened by her mother and who did not support Irenebut rather hid behind a newspaper. When questioned bythe therapist as to whether her father was really afraid ofher mother, Irene reported that on several occasions, asher mother was berating Irene for some infraction, hermother would turn to her father and say, “. . . and you justmind your business and keep your mouth shut!”

As homework for the second session, Irene was askedto make a list of exactly what negative thoughts shebelieved that her former boyfriends had about her. Foreach boyfriend, she was to make a list of what theyactually said (if anything), what she believed they meant,what she believed they were thinking but not saying, andher reaction to their words and her perceived meaning ofspoken and unspoken thoughts. The session was spentlooking at her thoughts and transferring them to adysfunctional thought record (DTR). She was then shownhow to use the DTR as a format for looking at herautomatic thoughts. She was, at first, confused by theform, but by taking her through each column of the DTR,she was able to master it by the end of the session. Herhomework for Session 3 was to use the DTR format onother thoughts that she had, especially those relating toher ideas of what others thought of her.

Session 3 focused on the several DTRs that Irene hadcompleted. Her somewhat obsessive/anxious style couldbe used to the advantage of the therapy.

By Session 4, the issue of dining out came to the top ofthe list. Irene was asked if she would be willing (and if itwere possible) to enlist her fiancé in the homework. Ireneagreed and worked in the session to structure an idealscenario that she could use for homework. The followingscene emerged: Irene and Ralph would discuss, plan, andchoreograph a situation wherein they would go to a busyrestaurant. They would ask to sit in the middle of thedining room. Irene would not order any food. Ralph, onthe other hand, would order soup. As he ate the soup hewould try to make his hand tremble as he brought the

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soup to his mouth. Irene’s job was to subtly observe andnote who is looking at him as he ate. The goal of theexperience was to help her to test her idea that “everyonewill notice”. She could then evaluate her data and use theDTR to assess her thoughts of being noticed and themeaning she attributed thereto.

What Irene discovered in her covert observation wasthat nobody seemed to notice. Or, if they did, she couldnot discern any reaction. She reported that the others inthe restaurant were busy eating, talking, and relating totheir dinner partners. Ralph took the assignment veryseriously and wanted to do it several times to help Ireneover this problem. Before Irene came back for the fifthsession, she and Ralph had gone to restaurants for dinnerfive times. Irene was able to conclude that she may havebeen “a bit off” in her predictions.

The fifth through seventh sessions were focused onhelping Irene build a repertoire of relaxation skills thatshe could use when she began feeling anxious. She wasable to identify a physical reaction that signaled thebeginning of anxiety. This involved her scalp tingling andfeeling “hot”. Using this as a signal, she was able to usestructured breathing and progressive muscle relaxation tointervene before she had started down the road to ananxiety attack.

Sessions 8 and 9 used imaginal exercises that related toher dining in public and also responding to her thoughtsabout what others think of her. The in-session work was anextension of Irene’s homework, rather than the other wayaround.

Case Example 2

Mike was a 57-year-old business executive. He was theowner and CEO of a large electronics supply firm that haddistribution centers throughout North and South Amer-ica and had recently contracted to cooperate with asimilar company in Eastern Europe. He sought therapyafter several attempts to deal with his insomnia. He hadsleep-onset difficulties, middle-of-the-night waking, andearly-morning waking. Of the three, he appreciated theearly-morning waking (4:00 A.M.) because he couldexercise on a stationary bicycle and then be in his officeby 5:30. His typical day in the office was from 5:30 A.M. to6:30 P.M. He would also take work home with him andwork until 9:00 at night. His difficulty in sleeping wascausing him both primary and secondary problems. Theprimary problems revolved around his concern that if hewas not mentally sharp he would be “eaten by dragons.”He was concerned by myriad issues of cash flow, productavailability, and so on.

Mike was married for the third time, his previousmarriages ending in divorce after 3 and 10 years,respectively. He had three children, a son from his firstmarriage and a son and daughter from his second

marriage. His children were grown and were all married.His current wife of 15 years, Barbara, was a 48-year-oldwoman who had been widowed when her husband died ofcancer when she was 30. She had two daughters who wereboth in professional schools (law and medicine). She wasa partner in a law firm. She also brought work home andspent extended time in her office. They had a pattern ofspending an hour or two in the evening watching TV(9:00–11:00) and then going to bed. Mike would then layin bed and stated that it was often 2 to 3 hours before hecould fall asleep. His falling asleep was gauged by the factthat he was not looking at the digital clock as it flashed aminute-by-minute account of his sleeplessness. He wouldsometimes wake for a brief time around 3:00 A.M., fallasleep, and be up an hour or two later.

Mike had sought help in the form of hypnosis, sleepstudies, psychotherapy, and pharmacotherapy. The psy-chotherapy was one session of a psychoanalyticallyoriented treatment that Mike said he was able to standfor only one session, and that it was only with greatrestraint that he did not walk out. The therapist hadwanted to explore his dreams and Mike saw little value insuch “touchy-feely crap.”

The only thing that he stated that worked to get him tosleep was medication. The medication, however, left himfeeling “groggy and hung-over” the next day. He had seenseveral physicians and had tried a number of differentmedications,medication regimens, andmedication dosages.He saw themedication as being the worst choice for him.Hehad read a magazine article about CBT and contacted thetherapist to explore whether CBT could help him.

He listed his problems as being related to work. Helabeled his marriage as “fine,” or “as good as it gets.”Mikereported that his relationship with his children andstepdaughters was “good.” He had few friends, manybusiness associates, but aside from dinner at a countryclub, little time was spent in social activities. He attendedmany business lunches, but the focus of these events wasfar less social and far more business. In the initial session,Mike was clear on his therapy goals. “I need to sleep sothat I can be fresh and clear-headed in the morning whenthere are dragons that need slaying.” He also made itquite clear that he hated the ideas of (1) having to ask forhelp, (2) seeing a “shrink,” and (3) talking about hisproblems with anyone.

The first session was spent in identifying previousinterventions, the value and utility of each of them, andgetting as complete a sleep history as was possible. Mikewas asked to sign release on information forms to many ofhis previous therapists and to a hospital-based sleep studycenter. The initial homework for the next session was forMike to keep a “sleep log” that indicated any and allactivities starting from the time he came home to the timehe got into bed to sleep. For a person as busy as Mike, the

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homework was not seen as a terrible imposition but ratheras the “business” of therapy. Keeping track of time spenton any activity was not uncommon for Mike. There waslittle attempt to build a therapeutic bond (relationship)with Mike, and far more emphasis on the treatmentalliance (the treatment plan). Given that Mike did notwant to be in therapy, the therapeutic work would beframed as a series of consultations, something a successfulexecutive could more easily accept.

In the second session Mike presented his sleep log,which indicated that he went to sleep at about 11:00 P.M.after the news broadcast. He reported that he wouldmonitor the digital clock by his bedside and lastremembered being awake at 2:11 A.M. He then awoke atabout 6:00 A.M. feeling “slightly rested” and started hisday. In this session, Mike was introduced to a small, hand-held device for monitoring galvanic skin response (GSR).The session was spent explaining to Mike to principles ofbiofeedback, the mechanism of the device (GSR-2,Thought Technology), and how he could both increaseand decrease his physiological activity as measured by theGSR-2. At first the audible tone generated by the devicewas broadcast through speakers so that both therapist andpatient could hear it, and then through small earphonesfor Mike. There was also a meter that allowed him to seethe needle go from green (relaxed) to yellow (marginal)to red (aroused). Mike was taught to use relaxation-focused images (being out on a golf course in the earlymorning, drinking coffee on the deck of his sailboat atsunrise, and laying in a hammock in his backyard). He didnot routinely do any of these activities because of his busyschedule.

He was enthralled by the biofeedback device, and evenmore by the fact that it was something that he couldcontrol. The issues that were used as a stimulus for thefeedback exercises were thoughts of business, work,competition, threats to his success, and financial topics.He was also quite taken by the rather quick and clearresponse from theGSR-2 to thoughts of business and work.He was able, rather quickly, to lower the tone and to beable to move the meter from green to yellow, back togreen, up to red, etc.

The device was loaned to Mike and the next session wasset for 2 weeks. It was his “job” to use the device every night.

When he returned for his appointment 2 weeks laterhe reported that he was able to quiet his thinking and tofall asleep rather quickly by himself. He went to bed at11:00, started the GSR-2, used relaxation images, and fellasleep. He still awoke at 6:00 A.M., but now reported thathe was rested. He had ordered a device for himself, andhad described his experience to two colleagues during a

luncheon, both of whom would also try it. Mike was seenfor three more sessions—at 2 weeks, 1 month, and 3months. He was sleeping as much as he wished, and hadreferred several colleagues for treatment/consultation.

Summary

Therapy does not end when the patient leaves thetherapy session and the consultation room. Therapy mustbecome part of the patient’s life. The CBT tasks ofmonitoring automatic thoughts, identifying and examin-ing schema, and behavioral change are essential ingre-dients that must be ongoing.

Homework cannot be an addendum to therapy but anintegrated and focused part of the therapy that isintroduced in the very first session. Homework providesa laboratory experience for the patient, offers continuitybetween sessions, affords practice at skills not easilypracticed in session, brings therapy into the “real” world,aids in relapse prevention, emerges organically fromsession material, is a data-collection opportunity to whichthe patient contributes, and can be structured to involvesignificant others as “homework assistants”. Homeworkassignments should be concrete. A particular homeworkmay be repeated several times at increasing levels ofsophistication and complexity. Within reason, ethics, andgood sense, almost anything can be used as a homeworkexperience. Homework extends and increases therapycontact, offers a measure of the patient’s motivation tochange, and helps to builds therapeutic collaboration.

References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). CognitiveTherapy of Depression. New York: The Guilford Press.

Beck, A. T., Emery, G., & Greenburg, R. L. (19985). Treatment of Anxiety.New York: Basic Books.

Beck, A. T., & Freeman, A., Davis, D. D. & Associates. (2003). CognitiveTherapy of Personality Disorders, (2nded.).NewYork:TheGuilfordPress.

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Address correspondence to Arthur Freeman, Institute for CognitiveTherapy, 10319 Dawsons Creek Blvd., Suite J, Fort Wayne, IN 46825;e-mail: artcbt@aol.com.

Received: June 4, 2006Accepted: October 15, 2006Available online 12 June 2007