He has had enough, and I am still adding to him! It will bother him! 80%
! 90%
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.
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 ( ). 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 ( ). 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 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.
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.
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.
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.
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 ).
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 Questionnaire 48 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 Leahy 49 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
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. |
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.
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.
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.
This paper was supported by the research grant VEGA no. APVV-15-0502 Psychological, psychophysiological and anthropometric correlates of cardiovascular diseases.
The authors report no conflicts of interest in this work.
IMAGES
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COMMENTS
Chelsea was in 10th grade the first time I told her directly to stop doing her homework and get some sleep. I had been working with her since she was in middle school, treating her anxiety ...
Acknowledge every increment of effort, however small. Be positive and give frequent encouragement. Make note of every improvement, not every mistake. Be generous with your praise. Praise their ...
Primary School Homework Struggles: Getting the Basic Right. Consistency is key when dealing with primary school homework battles. Young children especially benefit from a structured routine. Making homework a regular, yet brief, part of their day can work wonders. Aim for a consistent time slot, turning it into a habit as natural as brushing teeth.
Third to fifth grades. Many children will be able to do homework independently in grades 3-5. Even then, their ability to focus and follow through may vary from day to day. "Most children are ...
Stay focused on your job, which is to help your child do their job. Don't do it for them. If you feel frustrated, take a break from helping your child with homework. Your blood pressure on the rise is a no-win for everyone. Take five or ten minutes to calm down, and let your child do the same if you feel a storm brewing.
2. The perfectionist. Beyond the pull of Pokémon, there may a deeper reason your kid is putting off homework. If he can't bear the thought of not doing it perfectly, he just won't do it. Kids who are sensitive or who are identified as giftedare especially prone to perfectionism, Lapointe says.
creating a homework schedule, writing all assignments in an agenda, properly filing and dating all papers, reviewing all class work, proofreading all assignments before turning them in, or creating flash cards as work is assigned. To keep from overwhelming your child, have them select no more than three goals.
Don't get sucked into arguments with your child about homework. Make it very clear that if they don't do their homework, then the next part of their night does not begin. Keep discussions simple. Say to your child: "Right now is homework time. The sooner you get it done, the sooner you can have free time.".
How to Help Students Develop the Skills They Need ...
The challenge: Learning independently. It's important for kids to learn how to do homework without help. Using a homework contract can help your child set realistic goals. Encourage "thinking out loud.". Get tips for helping grade-schoolers do schoolwork on their own.
Teens with ADHD who push back against homework often do so because they don't think it has a purpose; adding external incentives is a good way to make the benefits of homework concrete for teens with ADHD. Thomas E. Brown, Ph.D., is a member of ADDitude's ADHD Medical Review Panel. This advice came from "The Teen Years with ADHD: A ...
17. Praise those students who finish their tasks at school during the time given. 18. Send home only one homework task at a time. As the learner shows success finishing tasks at home, slowly increase the number of homework tasks sent home. 19. Show the tasks in the most attractive and exciting manner possible. 20.
Consider, for example, how one seventh grade teacher described his approach to homework: "I post the answers to the homework for every course online. The kids do the homework, and they're ...
Dear ADDitude: My Teen Won't Do His Homework!
Homework & Study Distraction Tips From The Experts
Q&A: My teen is skipping homework and failing classes
He paces, stands, shifts, and becomes more agitated by the second. As dinnertime approaches, he becomes more upset about the work not having been completed. By the time he goes to bed, he is angry, hurt, and overwhelmed. Typically, his homework is still not done.". "Even when we set a goal like 'Social studies done in 45 minutes ...
2. Give them a warning. Giving out a simple warning would be an ideal approach when handling students who have not completed their work. This means letting them know of any consequences or possible punishments that can be given if they do not complete their homework.
He does an average of five or six hours of homework every weeknight, and that's on top of spending most of the weekend writing essays or studying for tests. His school says that each of his five ...
Fortunately, the research underpinning CBT homework is moving towards more clinically meaningful studies. Therapist skill in using homework has been shown to predict outcomes 9-10, and recently a study found that greater consistency of homework with the therapy session resulted in more adherence. 11 Our Cognitive Behavior Therapy Research Lab (currently based at the Turner Institute for Brain ...
Here are two main strategies: 1. By task: Pick one small task that your child can do to get started. If he's been assigned an essay, have him start by writing the title page. If she's been assigned a math worksheet with 20 problems, get her to complete the first two — then follow up with a short break. 2.
He Does His Homework Without Difficulty - Free download as PDF File (.pdf), Text File (.txt) or read online for free.
Most practicing CBT therapists report that they use homework and consider homework important for many problems 14 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 ...