Therapy Homework Research Articles

Depressed adults’ experiences of listening to their own clinical improvisations at home: A process evaluation of the music therapy homework

ABSTRACT Introduction Depression has a negative impact on millions of people worldwide, necessitating research into appropriate therapeutic methods. The aim of this qualitative study is to investigate how music therapy clients experience listening to their own clinical improvisations at home, as a part of treatment for depression. Method Adults with major depressive disorder were offered 12 individual sessions of bi-weekly integrative improvisational music therapy, as part of a randomised controlled trial. Participants were asked to complete an online diary after listening to their clinical improvisations. Reflexive thematic analysis was performed on diary entries, and content analysis was applied to music therapists’ reports. Results Fourteen of 32 participants submitted a total of 58 diary entries. Participants' experiences were represented by five themes: music (playing, listening, music perception, music parameters), therapy (therapeutic processing, illness, music therapy trial), emotions (positive emotions, negative emotions, other emotions), embodiment (body parts, sensations, actions) and narrative (chronology, symbolic references). Music therapists’ reports indicated that low compliance and negative experiences during the task could be affected by severity of depression, and ease of use of the technological interface. Discussion Participants’ experiences varied from extremely negative to positive in every theme, finding music they produced beautiful or hideous, feeling proud or ashamed of making it, being energised, or exhausted by it, feeling supported or pressured by the music therapist, and recalling happy or terrifying memories. The findings suggest that a homework task can affect the therapeutic process in both positive and negative ways and should be further researched before implementation.

Exploring the Efficacy of an Online Intervention in Processing Experiences of Heterosexism Among Autistic-LGBQ + Individuals.

This experimental study explored the use of online expressive writing interventions to cope with distress from heterosexist events among a sample of autistic-LBGQ + individuals. This study included an open writing condition and an emotion focused therapy guided writing condition. Over 89% of the participants indicated that the writing exercises were helpful in processing the event, with significant decreases for measures of depressive and trauma/stressor symptoms. A thematic analysis identified specific aspects of each condition that were helpful for participants in coping with heterosexist distress, such as the development of insight through the emotion-focused exercises. This low-demand exercise is promising as a solo exercise or as a therapy homework assignment, especially given the accessibility of this online intervention for autistic-LGBQ + people.

Machine Learning Model to Predict Assignment of Therapy Homework in Behavioral Treatments: Algorithm Development and Validation.

Therapeutic homework is a core element of cognitive and behavioral interventions, and greater homework compliance predicts improved treatment outcomes. To date, research in this area has relied mostly on therapists' and clients' self-reports or studies carried out in academic settings, and there is little knowledge on how homework is used as a treatment intervention in routine clinical care. This study tested whether a machine learning (ML) model using natural language processing could identify homework assignments in behavioral health sessions. By leveraging this technology, we sought to develop a more objective and accurate method for detecting the presence of homework in therapy sessions. We analyzed 34,497 audio-recorded treatment sessions provided in 8 behavioral health care programs via an artificial intelligence (AI) platform designed for therapy provided by Eleos Health. Therapist and client utterances were captured and analyzed via the AI platform. Experts reviewed the homework assigned in 100 sessions to create classifications. Next, we sampled 4000 sessions and labeled therapist-client microdialogues that suggested homework to train an unsupervised sentence embedding model. This model was trained on 2.83 million therapist-client microdialogues. An analysis of 100 random sessions found that homework was assigned in 61% (n=61) of sessions, and in 34% (n=21) of these cases, more than one homework assignment was provided. Homework addressed practicing skills (n=34, 37%), taking action (n=26, 28.5%), journaling (n=17, 19%), and learning new skills (n=14, 15%). Our classifier reached a 72% F1-score, outperforming state-of-the-art ML models. The therapists reviewing the microdialogues agreed in 90% (n=90) of cases on whether or not homework was assigned. The findings of this study demonstrate the potential of ML and natural language processing to improve the detection of therapeutic homework assignments in behavioral health sessions. Our findings highlight the importance of accurately capturing homework in real-world settings and the potential for AI to support therapists in providing evidence-based care and increasing fidelity with science-backed interventions. By identifying areas where AI can facilitate homework assignments and tracking, such as reminding therapists to prescribe homework and reducing the charting associated with homework, we can ultimately improve the overall quality of behavioral health care. Additionally, our approach can be extended to investigate the impact of homework assignments on therapeutic outcomes, providing insights into the effectiveness of specific types of homework.

Parsing within & between-person dynamics of therapy homework completion and clinical symptoms in two cognitive behavioral treatments for adults with anhedonia

ObjectiveHomework is a key theoretical component of cognitive-behavioral therapies, however, the effects of homework on clinical outcomes have largely been evaluated between-persons rather than within-persons. MethodsThe effects of homework completion on treatment response were examined in a randomized trial comparing Behavioral Activation Treatment for Anhedonia (BATA, n = 38), a novel psychotherapy, to Mindfulness-Based Cognitive Therapy (MBCT, n=35). The primary endpoint was consummatory reward sensitivity, measured weekly by the Snaith Hamilton Pleasure Scale (SHAPS), up to 15 weeks. Multilevel models evaluated change in SHAPS scores over time and the effects of clinician-reported and participant-reported homework. ResultsBATA and MBCT resulted in significant, equivalent reductions in SHAPS scores. Unexpectedly, participants who completed greater mean total amounts of homework did not improve at a faster rate (i.e., no between-person effect). However, sessions with greater than average participant-reported homework completion were associated with greater than average reductions in SHAPS scores (i.e., a within-person effect). For clinician-reported homework, this effect was only evident within the BATA condition. ConclusionThis study shows psychotherapy homework completion relates to symptomatic improvement in cognitive-behavioral treatments for anhedonia when session-to-session changes are examined within-person. On the contrary, we found no evidence that total homework completion predicted greater improvements between-person. When possible, psychotherapy researchers should evaluate their constructs of interest across multiple sessions (not just pre/post) to allow more direct tests of hypotheses predicted by theoretical models of individual change processes.

Evaluating the relative contribution of patient effort and therapist skill in integrating homework into treatment for posttraumatic stress disorder.

Homework has historically been an integral component of cognitive behavioral interventions for posttraumatic stress disorder (PTSD). Previous studies differ in the measurement of therapy homework, resulting in inconsistent conclusions about its contributions to symptom reduction. Given the methodological burden associated with examining therapist skill within sessions, there has been no research evaluating the impact of both therapist and patient efforts on homework within and outside of the therapy session across protocols. We first examined the relative contribution of four homework-related variables to treatment outcomes of survivors of interpersonal violence (12 sessions; 58 survivors) diagnosed with PTSD and treated with cognitive processing therapy (CPT) in two randomized, controlled clinical trials. We then assessed the moderating effect of therapist competency in the homework element of CPT on these associations by examining therapist skill in 544 therapy sessions scored by independent raters. Perceived helpfulness of assignments emerged as the only significant predictor of PTSD symptom reduction (β = 0.48). Therapist homework competency moderated the relationship between time spent on homework and treatment outcome, such that more time spent on homework was associated with significantly poorer treatment response at low levels of therapist homework competency. Results suggest that patients' understanding of the direct contribution of homework to recovery is critical for increasing the effectiveness of the homework component of therapy. Therapist skill in incorporating homework effectively into the protocol is variable. It is essential that therapists ensure that patients' efforts (e.g., time dedicated to the task) are yielding clear results and perceived as fruitful. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Investigating routine care non-pharmacological treatment for adolescents with ADHD.

To characterize routine non-pharmacological care for youth with ADHD. 76 audio-recorded work-samples were collected from community mental health therapists in a large metropolitan area in the United States and were analyzed for operationally defined practice elements commonly included in evidence-based non-pharmacological treatment for ADHD. Analyses characterized community provider practices and examined predictors of using evidence-based (vs.low-value) practices. Individually delivered social skills training was the most commonly detected practice element (31.6% of practice samples). Parent involvement in routine care was uncommon (53.9% of sessions had no parental presence). Core elements of evidence-based practices were rarely delivered (e.g., organization skills training: 18.4% of tapes; operant reinforcement: 13.2%); when evidence-based content was introduced, it was typically implemented at a very low intensity. Patient and provider characteristics did not predict use of evidence-based practices. Routine non-pharmacological care for adolescent ADHD primarily consisted of low value practices such as youth-directed treatment and social skills training with low parent involvement and only occasional therapy homework. To improve quality of care, efforts to de-implement low value practices should be coupled with efforts to implement evidence-based practices (i.e., parent involvement, measurement-based care, organization skills training, use of operant reinforcement).

Effects of a smartphone app-augmented treatment for children with oppositional defiant disorder / conduct disorder and peer-related aggressive behavior – a pilot study

BackgroundSocial competence training interventions, especially child-focused ones, have proven to be effective in the treatment of children with conduct disorder. Therapy homework assignments implemented between the therapy sessions are essential for practicing strategies developed during treatment sessions and transferring them to everyday life. However, clinical experience shows that patients’ adherence regarding these assignments is often low, thus diminishing the treatment success. One obstacle in this regard is a lack of motivation. The use of smartphone apps in the context of child and adolescent psychotherapy is relatively new, and may provide novel ways to improve the transfer of coping strategies to daily life between treatment sessions. However, only a small number of high-quality studies have analyzed the systematic use of smartphone apps in therapy. The present study will therefore evaluate patients’ homework assignment adherence when using a smartphone app as compared to a paper-and-pencil method.MethodThe study will be conducted as a randomized controlled trial to evaluate the impact of a smartphone app on the adherence to therapy homework assignments (n = 35) in the treatment of children with aggressive behavior aged 6–12 years compared to paper-and-pencil homework assignments (n = 35).DiscussionThis trial is intended as a pilot study and aims to provide a basis for a subsequent multicenter trial. However, the results may already lead to recommendations for the development and use of mental health-related smartphone apps for children and adolescents with aggressive behavior problems.Trial registrationTrial registration AUTHARK: German Clinical Trials Register (DRKS) DRKS00015625. Registered on 15th October 2019.

Mechanisms of rumination change in adolescent depression (RuMeChange): study protocol for a\xa0randomised controlled trial of rumination-focused cognitive behavioural therapy to reduce ruminative habit and risk of depressive relapse in high-ruminating adolescents

BackgroundAdolescent-onset depression often results in a chronic and recurrent course, and is associated with worse outcomes relative to adult-onset depression. Targeting habitual depressive rumination, a specific known risk factor for relapse, may improve clinical outcomes for adolescents who have experienced a depressive episode. Randomized controlled trials (RCTs) thus far have demonstrated that rumination-focused cognitive behavioral therapy (RFCBT) reduces depressive symptoms and relapse rates in patients with residual depression and adolescents and young adults with elevated rumination. This was also observed in a pilot RCT of adolescents at risk for depressive relapse. Rumination can be measured at the self-report, behavioral, and neural levels- using patterns of connectivity between the Default Mode Network (DMN) and Cognitive Control Network (CCN). Disrupted connectivity is a putative important mechanism for understanding reduced rumination via RFCBT. A feasibility trial in adolescents found that reductions in connectivity between DMN and CCN regions following RFCBT were correlated with change in rumination and depressive symptoms.MethodThis is a phase III two-arm, two-stage, RCT of depression prevention. The trial tests whether RFCBT reduces identified risk factors for depressive relapse (rumination, patterns of neural connectivity, and depressive symptoms) in adolescents with partially or fully remitted depression and elevated rumination. In the first stage, RFCBT is compared to treatment as usual within the community. In the second stage, the comparator condition is relaxation therapy. Primary outcomes will be (a) reductions in depressive rumination, assessed using the Rumination Response Scale, and (b) reductions in resting state functional magnetic resonance imaging connectivity of DMN (posterior cingulate cortex) to CCN (inferior frontal gyrus), at 16 weeks post-randomization. Secondary outcomes include change in symptoms of depression following treatment, recurrence of depression over 12 months post-intervention period, and whether engagement with therapy homework (as a dose measure) is related to changes in the primary outcomes.DiscussionRFCBT will be evaluated as a putative preventive therapy to reduce the risk of depressive relapse in adolescents, and influence the identified self-report, behavioral, and neural mechanisms of change. Understanding mechanisms that underlie change in rumination is necessary to improve and further disseminate preventive interventions.Trial registrationClinicalTrials.gov Identifier: NCT03859297, registered 01 March 2019.

Tailored Text Message Prompts to Increase Therapy Homework Adherence: A Single-Case Randomised Controlled Study

AbstractBackground:Psychotherapy homework completion is associated with positive treatment outcomes, but many patients show low adherence to prescribed assignments. Whether text-message prompts are effective in increasing adherence to assignments is unknown.Aims:To evaluate whether tailored daily text-message prompts can increase homework adherence in a stress/anxiety treatment.Method:This study used a randomised controlled single-case alternating treatment design with parallel replication in seven participants. Participants received a five-week relaxation program for stress and anxiety with daily exercises. The intervention consisted of daily text messages tailored for each participant. Phases with or without text messages were randomly alternated over the study course. Randomisation tests were used to statistically analyse differences in mean number of completed relaxation exercises between phases.Results:There was a significant (combinedp= .018) effect of daily text messages on homework adherence across participants with weak to medium effect size improvements. No negative effects of daily text messages were identified.Conclusions:Tailored text messages can marginally improve adherence to assignments for patients in CBT. Further studies may investigate how text messages can be made relevant for more patients and whether text messages can be used to increase homework quality rather than quantity.

Homework compliance among substance using male offenders of IPV

PurposeResearch suggests that homework compliance within cognitive behavioral therapy is associated with treatment adherence and positive treatment outcomes through generalization of learned skills. The purpose of this paper is to determine whether there were differences in aggression and substance use between participants who did and did not complete therapy homework assignments.Design/methodology/approachSecondary analyses were conducted using data from Easton et al.’s (2017) randomized controlled trial of substance abuse domestic violence (SADV) treatment among substance dependent intimate partner violence (IPV) offenders. Analyses of covariance were conducted in order to determine whether homework completion had a significant effect on aggression and substance use. Correlational analyses were conducted to determine the association between quality of homework and outcomes.FindingsParticipants (n=63) who completed at least two homework assignments had fewer days of alcohol use during treatment compared to those who did not complete any assignments, p=0.03. There was not a difference in the number of days participants engaged in violence based on homework completion. Analyses indicated that those who displayed aggression proximal to alcohol use during treatment completed significantly fewer homework assignments compared to those who did not display aggression proximal to alcohol use (p=0.04).Research limitations/implicationsThis research was limited to a sample of male substance using offenders of IPV within the US additional research utilizing a larger sample size in order to investigate differences in homework completion across treatment groups is needed. Further analysis of the barriers to and predictors of homework compliance among this population is recommended.Originality/valueThis research highlights the need for incorporation of homework and further exploration of methods and treatment modalities to ensure homework compliance among substance using male offenders of IPV.

Observational Assessment of Engagement Strategies to Promote Parent Homework Planning in Community-Based Child Mental Health Treatment: A Pilot Study.

Therapy homework includes tasks given to clients to complete outside of session to facilitate new knowledge/skills or to advance treatment goals. Homework completion, an important element of parent engagement in child mental health (MH) treatment, has been associated with improved child outcomes. The current pilot study assessed the design/assign phase of the therapy homework process to examine a) the extent to which therapists implemented engagement strategies with parents and b) whether therapist deployment of engagement strategies in early treatment predicted subsequent parent participation in homework planning. We included an ethnically-diverse sample of 10 therapists and 11 parent/child dyads receiving community-based MH services who participated in a pilot intervention study. Two observational coding systems were developed to code treatment session recordings for the extent to which a) therapists implemented engagement strategies with parents and b) parents contributed to therapy homework planning. Findings revealed low extensiveness of therapist implementation of engagement strategies with parents. As hypothesized, therapist use of engagement strategies (Collaboration, Empowerment, and Psychoeducation) in early treatment significantly predicted subsequent parent homework planning (sharing perspective on homework planning). However, therapist use of Alliance was unrelated to parent homework planning. These preliminary results suggest that therapist implementation of engagement strategies in early treatment may promote parent participation in homework planning, which is an important precursor to homework completion. This pilot study suggests potential future directions for both research on and training for community-based therapists in implementing successful strategies to promote parent homework planning in child MH treatment.

Treatment Adherence in Child and Adolescent Chronic Migraine Patients: Results From the Cognitive-Behavioral Therapy and Amitriptyline Trial.

To examine treatment adherence among children and adolescents with chronic migraine who volunteered to be in a clinical trial using 3 measures: treatment session attendance, therapy homework completion, and preventive medication use by daily diary. Analyses are secondary from a trial of 135 youth aged 10 to 17 years diagnosed with chronic migraine and with a Pediatric Migraine Disability Score over 20. Participants were randomly assigned to cognitive-behavioral therapy plus amitriptyline (CBT+A, N=64) or headache education plus amitriptyline (HE+A, N=71). Therapists recorded session attendance. Completion of homework/practice between sessions was reported to therapists by patients. Patients reported preventive medication adherence using a daily headache diary. Mean session attendance adherence out of 10 treatment sessions was 95% for CBT+A and 99% for HE+A. CBT+A participants reported completing a mean of 90% of home practice of CBT skills between the 10 sessions. Participants reported taking amitriptyline daily at a mean level of 90% when missing diaries were excluded and 79% when missing diaries were considered as missed doses of medication. Our findings demonstrate that youth with chronic migraine who agree to be a part of a clinical trial do quite well at attending therapy sessions, and report that they are adherent to completing home/practice between sessions and taking medication. These results lend further support to consideration of CBT+A as a first-line treatment for youth with chronic migraine and suggest that measurement of adherence when this treatment is provided in practice will be important.

A Questionnaire for Parents of Children Who Stutter Attending a Self-Help Convention

Purpose To examine the attitudes and feelings of parents of children who stutter attending an annual convention for children who stutter. Method A survey consisting of demographic information, 30 questions regarding parents' feelings and attitudes using a 5-point Likert scale, and 3 open-ended questions was created by the authors and completed by 45 parents of children who stutter attending a convention for children who stutter. Results Parents attending the support group convention were comfortable with and knowledgeable about stuttering. Parents reported that they attended the convention to support their children and themselves and to gain information regarding stuttering. Parents were most concerned that stuttering would impact their children's future and hoped that their children would become happy, confident, and effective communicators. New attendees were less comfortable answering a question regarding the cause of stuttering than were returning parents, and fathers were less likely than mothers to work on therapy homework with their child. Conclusions This is the first study of parents who attend stuttering support groups. The results indicated these parents were comfortable and knowledgeable about stuttering. More research regarding feelings and attitudes of parents of children who stutter, and the impact of support groups on parents, is needed.

"Barriers to Cognitive Behavioral Therapy Homework Completion Scale- Depression Version": Development and Psychometric Evaluation.

We conducted a two-phase study to develop and evaluate the psychometric properties of an instrument to identify barriers to Cognitive Behavioral Therapy (CBT) homework completion in a depressed sample. In Phase I, we developed an item pool by interviewing 20 depressed patients and 20 CBT therapists. In Phase II, we created and administered a draft instrument to 56 people with depression. Exploratory Factor Analysis revealed a 2-factor oblique solution of "Patient Factors" and "Therapy/Task Factors." Internal consistency coefficients ranged from .80 to .95. Temporal stability was demonstrated through Pearson correlations of .72 (for the therapist/task subscale) to .95 (for the patient subscale) over periods of time that ranged from 2 days to 3 weeks. The patient subscale was able to satisfactorily classify patients (75 to 79 %) with low and high adherence at both sessions. Specificity was .66 at both time points. Sensitivity was .80 at sessions B and .77 at session C. There were no consistent predictors of assignment compliance when measured by the Assignment Compliance Rating Scale (Primakoff, Epstein, & Covi, 1986). The Rating Scale and subscale scores did, however, correlate significantly with assignment non-compliance (.32 to .46).

The Case of Gabriel: Treatment with Beckian Cognitive Therapy

The case of Gabriel, an anxious and depressed young man struggling with facing and completing his academic requirements, is hypothetically described from within the orientation of Beckian cognitive therapy. In this approach, Gabriel's psychological difficulties are hypothesized to involve schemas of incompetency and entitlement that give rise to maladaptive beliefs, hindering his ability and willingness to study, write papers, and attend classes. In turn, Gabriel's habitual avoidance worsens his views of himself, prevents him from habituating to his anxiety, interferes with pursuing his goals, and keeps him in a state of low self-efficacy. The therapist emphasizes the importance of assessing and modifying Gabriel's problematic beliefs and counteracting his avoidance via self-monitoring, behavioral experiments, exposures to academic tasks, rational responding, and related therapy homework assignments. The criteria for ending treatment and improving maintenance are discussed in light of Gabriel's potential secondary goals, including improving assertiveness, communication skills, and interpersonal relationships.

Integrating Homework Assignments Based on Culture: Working with Chinese Patients

Cognitive therapy as espoused by A. T. Beck (A. T. Beck, Rush, Shaw, & Emery, 1979) is increasingly used as a therapeutic modality and applied to a variety of cultural groups throughout the world. However, the majority of the literature on empirical and clinical practice has been focused on the use of cognitive therapy for Western cultures. In this article, we discuss Chinese patients’ adherence to therapy homework assignments in terms of Chinese cultural values and practices, their customary problem-solving process, and other traditional beliefs. Through the use of a case study, we illustrate how some of these culturally specific beliefs can influence the process of integrating homework assignments into the course of therapy. This resource on supervising practitioners’ treatment of Chinese patients with cognitive behavior therapy is offered as a contribution to the emerging literature on CBT for non-Western cultures.

How to Supervise the Use of Homework in Cognitive Behavior Therapy: The Role of Trainee Therapist Beliefs

Encouraging and facilitating homework completion is a core cognitive behavior therapy (CBT) skill. Consequently, it represents an important part of training practitioners. Oftentimes the process of integrating homework into therapy is rushed, poorly executed, or forgotten, and trainees are surprised to find that some patients do not complete homework. We advocate for increased therapist responsibility in accounting for homework nonadherence. Therefore, problems with the use of homework in therapy are frequently an agenda item in the supervision of trainee cognitive behavior therapists. In our experience, trainee CBT practitioners exhibit a number of interrelated automatic thoughts, assumptions, and in-session behaviors that influence their use of homework assignments. The Cognitive Behavior Therapy Homework Project has proposed a “model for practice” to guide the use of homework in CBT [Kazantzis, N., MacEwan, J., & Dattilio, F. M. (2005). A guiding model for practice. In: Kazantzis, N., Deane, F. P., Ronan, K. R., & L’Abate, L. (Eds.), Using homework assignments in cognitive behavior therapy (pp. 359–407). New York: Routledge]. The present article will draw from those practice recommendations and discuss the role and impact of the therapeutic relationship and therapist beliefs on the use of homework assignments, with reference to the different levels of CBT conceptualization. Clinical examples from the supervision of trainees enrolled in the practicum component of the Massey University Postgraduate Diploma in Cognitive Behavior Therapy are used to illustrate supervising the use of homework assignments.

Measuring Homework Utility in Psychotherapy: Cognitive-Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder as an Example

Homework, or practice of skills learned in treatment, is a critical component of cognitive-behavioral therapy (CBT). However, no matter how much effort clients put into their therapy homework, this effort can only be useful if adherence to homework is related to improvement in symptoms. Although homework adherence (the extent to which clients practice skills learned in therapy outside of sessions) has been studied with respect to psychotherapy outcomes, ‘homework utility’, a potentially important mechanism of action in cognitive behavioral treatments, has yet to be operationally defined as a distinct construct, and it has yet to be studied with respect to psychotherapy outcome. We therefore propose an operational definition of therapy homework utility: the extent to which homework adherence is associated with parallel symptom improvement across time throughout treatment for each individual client. In this capacity, an indicator of homework utility is operationalized as the within subject correlation of session-by-session homework adherence with session-by-session symptom change. We used a sample of clients who underwent CBT for attention-deficit hyperactivity disorder in adulthood as an example to quantify homework utility and examine its association to treatment outcome. Consistent with our hypotheses, homework utility was significantly associated with overall therapy outcome. Homework utility may be an important construct relevant to the mechanism of action of structured psychotherapies, and examining within subject sessions-by-session correlations with symptomatic change may be a useful way to examine other psychotherapy process variables.

Homework compliance: An uncontrolled variable in cognitive therapy outcome research

Although patient compliance with homework assignments is considered a major component of cognitive therapy for depression, research studies have rarely investigated homework compliance as a variable potentially influencing treatment outcome. This paper reviews the literature on outcome studies of cognitive therapy for depression and describes research design problems that result from the failure to assess and control for differential homework compliance. These design problems limit the internal validity of outcome studies and make it difficult to compare studies that included allegedly similar treatments but produced different results. Recommendations for evaluating the role of homework compliance in outcome research on cognitive therapy and other treatment approaches are described. The need for adequate measures of homework compliance and quality is stressed, and potential criteria for use in cognitive therapy homework rating scales are proposed.

The use of covert sensitization and hypnotic procedures in the treatment of an overweight person: a case report.

Abstract A single, 20 year old, female college student was treated for obesity with covert sensitization. As sometimes happens when using covert sensitization, the continuation of therapy was threatened when, after eight treatment sessions, the therapy sessions and homework assignments became aversive. However, since the client indicated that she could accept the negative experiences if “they would happen and I did not have to make myself do it,” hypnotic procedures were added at the ninth treatment session with the rationale that they would make the whole process almost automatic. Posthypnotic suggestions and self-induction were similarly employed for homework assignments. Evidence was obtained suggesting that the hypnotic procedures were effective in maintaining the client in therapy and in continuation of weight loss. An explanation based on Barber's theory of hypnotic behavior was offered.