cbft homework tasks are described as

Cognitive-Behavioral Family Therapy

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• Tamara G. Sher 4  

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Name of Model

Cognitive-Behavioral Family Therapy (CBFT)

Behavioral family therapy (BFT)

Introduction

Cognitive-behavioral family therapy (CBFT) was born as the family therapy correlate to cognitive-behavioral therapy. That is, it integrates behaviorism and cognitive approaches and applies them to family systems. Because of its flexibility and continued evolution, CBFT is able to focus on a variety of problems, from promoting changes within individuals in families to altering family interaction styles. Furthermore, CBFT provides the fundamental principles and techniques to various empirically supported interventions and programs.

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Donald Baucom at the University of North Carolina

Norman Epstein at the University of Maryland

Gerald Patterson at the Oregon Social Learning Center at the University of Oregon

Neil Jacobson at the University of Washington

Andrew I. Schwebel at the Ohio State University

Frank Dattilio at Harvard Medical School and the...

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Lan, J., Sher, T.G. (2019). Cognitive-Behavioral Family Therapy. In: Lebow, J.L., Chambers, A.L., Breunlin, D.C. (eds) Encyclopedia of Couple and Family Therapy. Springer, Cham. https://doi.org/10.1007/978-3-319-49425-8_40

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Assigning Homework in Cognitive Behavioral Therapy

It’s certainly true that therapy outcomes depend in part on the work taking place in each session. But for this progress to reach its full impact, clients need to use what they learn in therapy during their daily lives. 

Assigning therapy “homework” can help your clients practice new skills during the week. While many types of therapy may involve some form of weekly assignment, homework is a key component of cognitive behavior therapy. 

Types of Homework

Some clients may respond well to any type of homework, while others may struggle to complete or find benefit in certain assignments. It’s important for clients to step outside of their comfort zone in some ways. For example, it’s essential to learn to challenge unwanted thoughts and increase understanding of feelings and emotions, especially for people who struggle with emotional expression. 

But there isn’t just one way to achieve these goals. Finding the right type of homework for each client can make success more likely. 

There are many different types of therapy homework. Asking your client to practice breathing exercises when they feel anxious or stressed? That’s homework. Journaling about distressing thoughts and ways to challenge them, or keeping track of cognitive distortions ? Also homework.

Some clients may do well with different assignments each week, while others may have harder times with certain types of homework. For example:

• An artistic client may not get much from written exercises. They might, however, prefer to sketch or otherwise illustrate their mood, feelings, or reactions during the week. 
• Clients who struggle with or dislike reading may feel challenged by even plain-language articles. If you plan to assign educational materials, ask in your first session whether your client prefers audio or written media. 

When you give the assignment, take a few minutes to go over it with your client. Give an example of how to complete it and make sure they understand the process. You’ll also want to explain the purpose of the assignment. Someone who doesn’t see the point of a task may be less likely to put real effort into it. If you give a self-assessment worksheet early in the therapy process, you might say, “It can help to have a clear picture of where you believe you’re at right now. Later in therapy I’ll ask you to complete another assessment and we can compare the two to review what’s changed.” 

Mental Health Apps

Some people may also find apps a useful way to develop and practice emotional wellness coping skills outside of therapy. Therapy apps can help people track their moods, emotions, or other mental health symptoms. They can provide a platform to practice CBT or other therapy skills. They can also offer structured mindfulness meditations or help clients practice other grounding techniques. 

If you’re working with a client who’s interested in therapy apps, you might try using them in treatment. Just keep in mind that not all apps offer the same benefits. Some may have limitations, such as clunky or confusing interfaces and potential privacy concerns. It’s usually a good idea to check whether there’s any research providing support for—or against—a specific app before recommending it to a client. 

Trusted mental health sources, such as the American Psychological Association or Anxiety and Depression Association of America websites, may list some popular mental health apps, though they may not specifically endorse them. These resources can be a good starting place. Other organizations, including Northwestern University’s Center for Behavioral Intervention Technologies and the Defense Department of the United States, have developed their own research-backed mental health apps. 

You can also review apps yourself. Try out scenarios or options within the app to get to know how the app works and whether it might meet your client’s needs. This will put you in a position to answer their questions and help give them tips on getting the most out of the app. 

Benefits of Homework

Some of your clients may wonder why you’re assigning homework. After all, they signed up for therapy, not school. 

When clients ask about the benefits of therapy homework, you can point out how it provides an opportunity to put things learned in session into practice outside the therapy session. This helps people get used to using the new skills in their toolbox to work through issues that come up for them in their daily lives. More importantly, it teaches them they can use these skills on their own, when a therapist or other support person isn’t actively providing coaching or encouragement. This knowledge is an important aspect of therapy success. 

A 2010 review of 23 studies on homework in therapy found evidence to suggest that clients who completed therapy homework generally had better treatment outcomes. This review did have some limitations, such as not considering the therapeutic relationship or how clients felt about homework. But other research supports these findings, leading many mental health experts to support the use of therapy homework, particularly in CBT. Homework can be one of many effective tools in making therapy more successful. 

Improving Homework Compliance

You may eventually work with a client who shows little interest in homework and doesn’t complete the assignments. You know this could impede their progress in therapy, so you’ll probably want to bring this up in session and ask why they’re having difficulty with the homework. You can also try varying the types of homework you assign or asking if your client is interested in trying out a mental health app that can offer similar benefits outside your weekly sessions. 

When you ask a client about homework non-compliance, it’s important to do it in a way that doesn’t anger them, make them feel defensive, or otherwise damage the relationship you’re working to develop. Here are some tips for having this conversation:

• Let them know homework helps them practice their skills outside of therapy. In short, it’s helping them get more out of therapy (more value for their money) and may lead to more improvement, sometimes in a shorter period of time than one weekly session would alone. 
• Bring up the possibility of other types of homework. “If you don’t want to write anything down, would you want to try listening to a guided meditation or tips to help manage upsetting emotions?” 
• Ask about it, in a non-confrontational way. You might say something like, “Is something making it difficult for you to complete the homework assignments? How can I help make the process easier for you?” 

The prospect of homework in therapy may surprise some clients, but for many people, it’s an essential element of success. Those put off by the term “homework” may view “skills practice” or similar phrasing more favorably, so don’t feel afraid to call it something else. The important part is the work itself, not what you call it.    References:

• Ackerman, C. (2017, March 20). 25 CBT techniques and worksheets for cognitive behavioral therapy. Retrieved from https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets
• ADAA reviewed mental health apps. (n.d.). Anxiety and Depression Association of America. Retrieved from https://adaa.org/finding-help/mobile-apps
• Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research, 34 (5), 429-438. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939342
• Mental health apps. (n.d.). The American Institute of Stress. Retrieved from https://www.stress.org/mental-health-apps
• Novotney, A. (2016). Should you use an app to help that client? Monitor on Psychology, 47 (10), 64. Retrieved from https://www.apa.org/monitor/2016/11/client-app
• Tang, W, & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health, 4(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481663

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Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps

1 Discipline of Psychiatry, Department of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada

David Kreindler

2 Division of Youth Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

3 Centre for Mobile Computing in Mental Health, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

4 Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Cognitive behavioral therapy (CBT) is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Homework is an integral component of CBT, but homework compliance in CBT remains problematic in real-life practice. The popularization of the mobile phone with app capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance; however, there are no guidelines for designing mobile phone apps created for this purpose. Existing literature suggests 6 essential features of an optimal mobile app for maximizing CBT homework compliance: (1) therapy congruency, (2) fostering learning, (3) guiding therapy, (4) connection building, (5) emphasis on completion, and (6) population specificity. We expect that a well-designed mobile app incorporating these features should result in improved homework compliance and better outcomes for its users.

Homework Non-Compliance in CBT

Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [ 1 , 2 ]. It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [ 3 - 6 ]. Homework is an important component of CBT; in the context of CBT, homework can be defined as “specific, structured, therapeutic activities that are routinely discussed in session, to be completed between sessions” [ 7 ]. Completion of homework assignments was emphasized in the conception of CBT by its creator, Aaron Beck [ 8 ]. Many types of homework are prescribed by CBT practitioners, including symptom logs, self-reflective journals, and specific structured activities like exposure and response prevention for obsessions and compulsions. These can be divided into the following 3 main categories: (1) psychoeducational homework, (2) self-assessment homework, and (3) modality-specific homework. Psychoeducation is an important component in the early stage of therapy. Reading materials are usually provided to educate the client on the symptomatology of the diagnosed illness, its etiology, as well as other treatment-relevant information. Self-assessment strategies, including monitoring one’s mood using thought records, teach the patients to recognize the interconnection between one’s feelings, thoughts, and behaviors [ 8 ]. For example, depressed patients may be asked to identify thinking errors in daily life and document the negative influences these maladaptive thinking patterns can produce on their behaviors. Various psychiatric disorders may require different types of modality-specific homework. For example, exposure to images of spiders is a treatment method specific to arachnophobia, an example of a “specific phobia” in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [ 9 ]. Homework is strategically created by the therapist to correct and lessen the patient’s psychopathology. The purpose of these exercises is to allow the patients to practice and reinforce the skills learned in therapy sessions in real life.

Homework non-compliance is one of the top cited reasons for therapy failure in CBT [ 10 ] and has remained a persistent problem in the clinical practice. Surveys of practitioners have suggested rates of non-adherence in adult clients of approximately 20% to 50% [ 10 , 11 ] while adherence rates in adolescents have been reported to be approximately 50% [ 12 ]. Many barriers to homework compliance have been identified in the literature; to facilitate discussions, they can be divided into internal and external factors. Internal factors originate from a client’s own psychological environment while external ones are created by external influences. Internal factors that have been identified include lack of motivation to change the situation when experiencing negative feelings, the inability to identify automatic thoughts, disregard for the importance or relevance of the homework, and the need to see immediate results [ 12 - 14 ]. Various external factors have also been identified, including the effort associated with pen-and-paper homework formats, the inconvenience of completing homework because of the amount of time consumed, not understanding of the purpose of the homework, lack of instruction, and failure to anticipate potential difficulties in completing the homework [ 14 - 16 ]. There is strong evidence suggesting that homework compliance is integral to the efficacy of CBT in a variety of psychiatric illnesses. In the treatment of depression with CBT, homework compliance has been correlated with significant clinical improvement and shown to predict decreases in both subjective and objective measures of depressive symptoms [ 17 - 23 ]. Similarly, homework compliance is correlated with short-term and long-term improvement of symptoms in anxiety disorders, including generalized anxiety disorder (GAD), social anxiety disorder (SAD), hoarding, panic disorder, and post-traumatic stress disorder (PTSD) [ 17 , 24 - 32 ]. Fewer studies have been done on homework compliance in other psychiatric conditions, but better homework compliance has been correlated with significant reductions in pathological behaviors in psychotic disorders [ 33 , 34 ], cocaine dependence [ 35 , 36 ], and smoking [ 37 ]. Two meta-analyses further support the notion that greater homework adherence is associated with better treatment outcomes in depression, anxiety-related disorders, and substance use [ 38 , 39 ].

The Utility of Technology in Enhancing CBT Homework

Despite its demonstrated efficacy, access to CBT (as well as other forms of psychotherapy) remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. With the rise of mass-market mobile communication devices such as the iPhone or other kinds of mobile devices with app capabilities (smartphones), new solutions are being sought that will use these devices to provide therapy to patients in a more cost-effective manner. Mobile phones with app capabilities are portable devices that combine features of a cellphone and a hand-held computer with the ability to wirelessly access the Internet. Over time, ownership of mobile phones in North America has grown [ 41 , 42 ] and progressively lower prices have further reduced barriers to their use and ownership [ 43 , 44 ]. As more and more people acquire mobile phones, the acceptance of and the demand for mobile health solutions have been on the rise [ 45 ]. Boschen (2008), in a review predating the popularization of the modern mobile phone, identified the unique features of the mobile telephone that made it a potentially suitable vehicle for adjunctive therapeutic applications: portability, acceptability, low initial cost, low maintenance cost, social penetration and ubiquity, “always on,” “always connected,” programmability, audio and video output, keypad and audio input, user-friendliness, and ease of use [ 46 ]. Over the last decade, modern mobile phones have supplanted the previous generation of mobile telephones; progressive increases in their computing power, ongoing advances in the software that they run and interact with (eg, JAVA, HTML5, etc.), common feature sets across different operating systems such as Google Inc.'s Android or Apple Inc.'s iOS, and adoption of common hardware elements across manufacturers (eg, touch screens, high-resolution cameras, etc) have enabled the development of platform-independent apps for mobile phones, or at least apps on different platforms with comparable functionality (eg, apps written for Apple's HealthKit or the apps written for Microsoft's HealthVault).

The popularization of the smartphone presents a unique opportunity to enhance CBT homework compliance using adjunctive therapeutic applications such that well-designed mobile software may be able to diminish barriers to CBT [ 40 ] by making CBT therapists' work more cost-effective. However, there are no guidelines and no existing research that directly address the design of mobile phone apps for this purpose. Given this gap in the literature, we searched MEDLINE (1946 to April 2015) and PsycINFO (1806 to April 2015) for all articles related to “cognitive behavioral therapy”, “homework”, “mobile applications” and “treatment compliance or adherence”, and reviewed articles related to (1) mobile technologies that address homework completion, (2) essential features of therapy, or (3) barriers to homework completion in CBT. In this article, we propose a collection of essential features for mobile phone-based apps that will optimally support homework compliance in CBT.

A Proposed List of Essential Features for Mobile Apps That Optimally Support CBT Homework Compliance

In order to be effective for patients and acceptable to therapists, an optimal mobile phone app to support CBT homework compliance should conform to the CBT model of homework while addressing barriers to homework compliance. Tompkins (2002) provides a comprehensive guideline on the appropriate ways to provide CBT homework such that homework should be meaningful, relevant to the central goals of therapy, salient to focus of the session, agreeable to both therapist and client, appropriate to sociocultural context, practiced in session to improve skill, doable, begin small, have a clear rationale, include written instructions, and include a backup plan with homework obstacles [ 47 ]. In addition, the therapist providing the homework needs to be curious, collaborative, reinforce all pro-homework behavior and successful homework completion, and emphasize completion over outcome [ 47 ]. By combining Tompkins' guidelines with the need to reduce barriers to homework compliance (as described above), we obtained the following list of 6 essential features that should be incorporated into mobile apps to maximize homework compliance: (1) congruency to therapy, (2) fostering learning, (3) guiding therapy, (4) building connections, (5) emphasizing completion, and (6) population specificity.

Congruency to Therapy

Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered. There are different types of homework in CBT, including (1) psychoeducational homework; (2) self-assessment homework; and (3) modality-specific homework. Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target [ 48 ]. An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy. Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD. Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities.

Psychoeducational Homework

While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy. As psychoeducation is seen as a major component of mobile intervention [ 50 ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ 51 ], anxiety and depression [ 52 ], eating disorders [ 53 ], PTSD [ 54 ], and obsessive compulsive disorder (OCD) [ 55 ]. For example, Mayo Clinic Anxiety Coach is a mobile phone app “designed to deliver CBT for anxiety disorders, including OCD” [ 55 ]. The app contains a psychoeducational module that teaches the user on “the use of the application, the cognitive-behavioral conceptualization of anxiety, descriptions of each anxiety disorder, explanations of CBT, and guidance for assessing other forms of treatment” [ 55 ]. The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches. However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ 50 ].

Self-Assessment Homework

In contrast to conventional, paper-based homework, mobile apps can support in-the-moment self-assessments by prompting the user to record self-report data about the user’s current state [ 56 ]. While information collected retrospectively using paper records can be adversely affected by recall biases [ 57 ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ 58 ]. Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ 59 , 60 ], eating disorders [ 61 ], GAD [ 62 ], and OCD [ 55 ]. Continuing with the previous example, the Mayo Clinic Anxiety Coach offers a self-assessment module that “measures the frequency of anxiety symptoms” with a self-report Likert-type scale [ 55 ]. The app tracks users’ progress over time based on the self-assessment data; users reported liking the record of daily symptom severity scores that the application provides.

Modality-Specific Homework

Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages (short message service, SMS) to therapists in bulimia nervosa [ 61 ]. Mayo Clinic Anxiety Coach, for example, has a treatment module for OCD that “guides patients through the use of exposure therapy” [ 55 ]; patients can use this to build their own fear hierarchies according to their unique diagnoses. Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs. Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ 64 - 66 ]. Apps that provide elements of biofeedback (such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera), have recently begun to be deployed. So-called ”serious games,“ (ie, games developed for treatment purposes), are also showing promise in symptom improvement in certain cases [ 51 , 67 , 68 ].

Fostering Learning

Doing CBT homework properly requires time and effort. As noted above, any sense of inconvenience while doing the homework may hamper a patient’s motivation to complete the homework. While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [ 49 , 52 ]. Therefore, it makes sense that the tasks should be simple, short in duration to begin with, and include detailed instructions [ 47 ], since homework completion rates have been shown to be correlated with patients’ knowing exactly what to do [ 33 , 69 ]. Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ 59 ]. However, the types of homework delivered by these apps are fixed. An app that adapts the contents to the user’s progress in learning homework tasks would be more engaging and effective since therapy should be a flexible process by nature. Ideally, the app would monitor and analyze the user’s progress and adjust the homework's content and difficulty level accordingly. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ 62 ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety. Based on patients’ ratings, the app would respond with encouraging comments and invite patients to practice relaxation techniques or prompt the patient to complete specific built-in cognitive therapy modules if their anxiety exceeded a threshold rating. Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone.

Guiding Therapy

Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan [ 47 ]. Failure to do this has been identified as a barrier to homework compliance. Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ 47 ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ 47 , 70 ]; this can be done during or in between homework assignments, either in-person or remotely (ie, via voice or text messaging) [ 60 , 71 ].

Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD [ 72 ], OCD [ 55 ], chronic pain [ 59 , 60 ], depression and suicide ideation [ 71 ], and situational stress [ 73 ]. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 74 , 75 ]. However, despite incorporating a variety of features including self-monitoring, psychoeducation, scheduled reminders, and graphical feedback [ 52 ], automated apps with minimal therapist guidance have demonstrated elevated homework non-completion rates of up to 40%, which is less than ideal.

Building Connections

The effects of technology should not interfere with but rather encourage a patient’s ability to build meaningful connections with others [ 76 ]. The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].

An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically. Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Furthermore, professional moderation of online communities increases users’ trust of the service [ 84 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.

Emphasizing Completion

A patient’s need to see immediate symptomatic improvement is an impediment to homework compliance since the perception of slow progress can be discouraging to the user [ 35 ]. To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework. In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].

Population Specificity

Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels (including learning or cognitive disabilities). One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ]. In this game, breathing activity is associated with the concept of “Qi” (natural energy) in accordance with Chinese traditions; the name of the game itself references to a famous Chinese novel and the gaming environment features inkwash and watercolor schemes of the East Asian style, making the experience feel more “natural” as reported by the users. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders. In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated.

Other Considerations

There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ]. The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ]. Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ]. Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server.

Finally, while this paper focused on “essential” features of apps, this should not be misunderstood as an attempt to itemize all elements necessary for designing a successful piece of software. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ 100 ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. A variety of barriers exist in traditional, paper-based CBT homework that can significantly hamper clients’ motivation to complete homework as directed. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers. Apps should help the therapist guide the client through therapy and not hinder the therapeutic process or interfere with patient’s building connections with others. It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users.

As an example of how this applies in practice, “Mental Health Telemetry-Anxiety Disorders” (MHT-ANX) is a new mobile app developed by the Centre for Mobile Computing in Mental Health at Sunnybrook Health Sciences Centre in Toronto that helps patients monitor their anxiety symptoms using longitudinal self-report. The symptom log is therapy congruent to the practice of CBT since it promotes patients' awareness of their anxiety symptoms and the symptoms’ intensity. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance. The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use. While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance.

Limitations and Future Challenges

The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence [ 101 ] or emotional sensing [ 102 ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.

This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done. We would anticipate synergistic effects when homework-compliance apps are used in CBT (eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work), but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.

Abbreviations

Conflicts of Interest: None declared.

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• December 19, 2023

20 Cognitive Behavioral Therapy (CBT) Techniques with Examples

Muhammad Sohail

Table of contents.

Cognitive Behavioral Therapy (CBT) stands as a powerful, evidence-based therapeutic approach for various mental health challenges. At its core lies a repertoire of techniques designed to reframe thoughts, alter behaviors, and alleviate emotional distress. This article explores 20 most commonly used cbt techniques. These therapy techniques are scientifcally valid, diverse in their application and effectiveness, serve as pivotal tools in helping individuals navigate and conquer their mental health obstacles.

Cognitive Restructuring or Reframing:

This is the most talked about of all cbt techniques. CBT employs cognitive restructuring to challenge and alter negative thought patterns. By examining beliefs and questioning their validity, individuals learn to perceive situations from different angles, fostering more adaptive thinking patterns.

John, feeling worthless after a rejected job application, questions his belief that he’s incompetent. He reflects on past achievements and reframes the situation, realizing the rejection doesn’t define his abilities.

Guided Discovery:

In guided discovery, therapists engage individuals in an exploration of their viewpoints. Through strategic questioning, individuals are prompted to examine evidence supporting their beliefs and consider alternate perspectives, fostering a more nuanced understanding and empowering them to choose healthier cognitive pathways.

During therapy, Sarah explores her fear of failure. Her therapist asks, “What evidence supports your belief that you’ll fail? Can we consider alternate outcomes?” Guided by these questions, Sarah acknowledges her exaggerated fears and explores more balanced perspectives.

Journaling and Thought Records:

Writing exercises like journaling and thought records aid in identifying and challenging negative thoughts. Tracking thoughts between sessions and noting positive alternatives enables individuals to monitor progress and recognize cognitive shifts.

James maintains a thought journal. Between sessions, he records negative thoughts about social situations. He then challenges these thoughts, jotting down positive alternatives and notices a shift in his mindset.

Activity Scheduling and Behavior Activation:

By scheduling avoided activities and implementing learned strategies, individuals establish healthier habits and confront avoidance tendencies, fostering behavioral change.

Emily, struggling with social anxiety, schedules coffee outings with friends. By implementing gradual exposure, she confronts her fear and eventually feels more comfortable in social settings.

Relaxation and Stress Reduction Techniques:

CBT incorporates relaxation techniques like deep breathing, muscle relaxation, and imagery to mitigate stress. These methods equip individuals with practical skills to manage phobias, social anxieties, and stressors effectively.

David practices deep breathing exercises when faced with work stress. By incorporating this technique into his routine, he manages work-related anxiety more effectively.

Successive Approximation:

Breaking overwhelming tasks into manageable steps cultivates confidence through incremental progress, enabling individuals to tackle challenges more effectively.

Maria, overwhelmed by academic tasks, breaks down her study sessions into smaller, manageable sections. As she masters each segment, her confidence grows, making the workload seem more manageable.

Interoceptive Exposure:

This technique targets panic and anxiety by exposing individuals to feared bodily sensations, allowing for a recalibration of beliefs around these sensations and reducing avoidance behaviors.

Tom, experiencing panic attacks, deliberately induces shortness of breath in a controlled setting. As he tolerates this discomfort without avoidance, he realizes that the sensation, though distressing, is not harmful.

Play the Script Until the End:

Encouraging individuals to envision worst-case scenarios helps alleviate fear by demonstrating the manageability of potential outcomes, reducing anxiety.

Facing fear of public speaking, Rachel imagines herself stumbling during a presentation. By playing out this scenario mentally, she realizes that even if it happens, it wouldn’t be catastrophic.

Shaping (Successive Approximation):

Shaping involves mastering simpler tasks akin to the challenging ones, aiding individuals in overcoming difficulties through gradual skill development.

Chris, struggling with public speaking, begins by speaking to small groups before gradually addressing larger audiences. Each step builds his confidence for the next challenge.

Contingency Management:

This method utilizes reinforcement and punishment to promote desirable behaviors, leveraging the consequences of actions to shape behavior positively.

To encourage healthier eating habits, Sarah rewards herself with a favorite activity after a week of sticking to a balanced diet.

Acting Out (Role-Playing):

Role-playing scenarios allow individuals to practice new behaviors in a safe environment, facilitating skill development and desensitization to challenging situations.

Alex, preparing for a job interview, engages in role-playing with a friend. They simulate the interview scenario, allowing Alex to practice responses and manage anxiety.

Sleep Hygiene Training:

Addressing the link between depression and sleep problems, this technique provides strategies for improving sleep quality, a critical aspect of mental well-being.

Lisa, struggling with sleep, follows sleep hygiene recommendations. She creates a calming bedtime routine and eliminates screen time before sleep, noticing improvements in her sleep quality.

Mastery and Pleasure Technique:

Encouraging engagement in enjoyable or accomplishment-driven activities serves as a mood enhancer and distraction from depressive thoughts.

After feeling low, Mark engages in gardening (a mastery activity) and then spends time painting (a pleasure activity). He finds joy in these activities, which uplifts his mood.

Behavioral Experiments:

This technique involves creating real-life experiments to test the validity of certain beliefs or assumptions. By actively exploring alternative thoughts or behaviors, individuals gather concrete evidence to challenge and modify their existing perspectives.

Laura believes people judge her negatively. She experiments by initiating conversations at social gatherings and observes that most interactions are positive, challenging her belief.

Externalizing:

Externalizing helps individuals separate themselves from their problems by giving those issues an identity or persona. This technique encourages individuals to view their problems as separate entities, facilitating a more objective approach to problem-solving.

Adam, dealing with anger issues, visualizes his anger as a separate entity named “Fury.” This helps him view his emotions objectively and manage them more effectively.

Acceptance and Commitment Therapy (ACT):

ACT combines mindfulness strategies with commitment and behavior-change techniques. It focuses on accepting difficult thoughts and emotions while committing to actions aligned with personal values, promoting psychological flexibility.

Sarah practices mindfulness exercises to accept her anxiety while committing to attend social events aligned with her values of connection and growth.

Imagery-Based Exposure:

This technique involves mentally visualizing feared or distressing situations, allowing individuals to confront and manage their anxieties in a controlled, imaginative setting.

Jack, afraid of flying, visualizes being on a plane, progressively picturing the experience in detail until he feels more comfortable with the idea of flying.

Mindfulness-Based Stress Reduction (MBSR):

MBSR incorporates mindfulness meditation and awareness techniques to help individuals manage stress, improve focus, and enhance overall well-being by staying present in the moment.

Rachel practices mindfulness meditation daily. By focusing on the present moment, she reduces work-related stress and enhances her overall well-being.

Systematic Desensitization:

Similar to exposure therapy, systematic desensitization involves pairing relaxation techniques with gradual exposure to anxiety-inducing stimuli. This process helps individuals associate relaxation with the feared stimuli, reducing anxiety responses over time.

Michael, with a fear of heights, gradually exposes himself to elevators first, then low floors in tall buildings, gradually working up to higher levels, reducing his fear response.

Narrative Therapy:

Narrative therapy focuses on separating individuals from their problems by helping them reconstruct and retell their life stories in a more empowering and positive light, emphasizing strengths and resilience.

Emily reevaluates her life story by focusing on instances where she overcame challenges, emphasizing her resilience and strength rather than her setbacks.

Each of these CBT techniques plays a unique role in helping individuals transform their thoughts, behaviors, and emotions. While some focus on cognitive restructuring, others emphasize behavioral modification or stress reduction. Together, they form a comprehensive toolkit empowering individuals to navigate their mental health challenges and foster positive change in their lives.

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Unlocking the Benefits of Cognitive Behavioral Family Therapy

• December 4, 2023

Cognitive Behavioral Family Therapy (CBFT) is an evidence-based approach that aims to improve family relationships and individual mental well-being by identifying and modifying dysfunctional patterns of thinking and behavior within the family system. This therapeutic modality recognizes the interconnectedness of family members and understands that changes in one individual can have profound effects on everyone involved.

Understanding Cognitive Behavioral Family Therapy

CBFT, also known as Cognitive Behavioral Family Therapy, is a therapeutic approach grounded in cognitive-behavioral therapy (CBT) principles . CBT focuses on the link between thoughts, emotions, and behaviors. CBFT expands upon this by considering the family as a whole and the various interactional processes that contribute to individual and family functioning.

CBFT recognizes that families are complex systems with unique dynamics, and it aims to address the specific challenges and issues that arise within the family unit. By working with the family as a whole, CBFT acknowledges that individual problems are often interconnected with family dynamics and that change can be facilitated by addressing these dynamics.

The Core Principles of Cognitive Behavioral Family Therapy

At the core of CBFT are several principles that guide the therapeutic process. One key principle is that behaviors are learned and can be modified through systematic and structured interventions. This means that problematic behaviors within the family can be addressed and changed through targeted interventions that promote healthier ways of interacting.

Additionally, CBFT emphasizes the importance of collaboration between the therapist and the family in setting treatment goals and working towards them together. This collaborative approach ensures that the therapy is tailored to the specific needs and goals of the family, promoting a sense of ownership and empowerment.

Another principle of CBFT is the identification and modification of dysfunctional thought patterns within the family system. By challenging negative or distorted thoughts, individuals and families can adopt more adaptive and constructive ways of thinking. This process of cognitive restructuring helps to improve emotional well-being and promotes healthier communication and problem-solving skills within the family.

Furthermore, CBFT recognizes the influence of the social and environmental context on family dynamics and individual well-being. The therapy aims to improve family functioning by addressing factors such as communication patterns, problem-solving skills, and external stressors. By considering these contextual factors, CBFT helps families develop strategies to cope with challenges and build resilience.

The Role of Family in Cognitive Behavioral Therapy

In CBFT, the family is seen as an essential source of support and resilience. The therapist works collaboratively with the family to identify and address shared thinking and behavior patterns contributing to distress or dysfunction. By involving the entire family in therapy, CBFT acknowledges that each member contributes to the family dynamic and that changes in behavior or perception from one family member can have a ripple effect on the entire system.

This approach promotes a sense of shared responsibility and fosters a supportive environment for everyone involved. By addressing family dynamics and promoting healthy communication and problem-solving skills, CBFT helps families develop stronger bonds and create a positive and nurturing environment for growth and healing.

In conclusion, Cognitive Behavioral Family Therapy is a comprehensive approach that recognizes the interconnectedness of individuals within the family system. CBFT aims to improve family functioning and promote individual well-being by addressing thoughts, emotions, and behaviors. CBFT empowers families to make positive changes and build healthier relationships through collaboration, cognitive restructuring, and addressing contextual factors.

The Benefits of Cognitive Behavioral Family Therapy

CBFT offers numerous benefits for individuals and families seeking help for a wide range of concerns. One significant advantage is the improvement in communication within the family unit.

Improving Communication within the Family

Effective communication is vital for the healthy functioning of the family. CBFT helps family members learn new ways to express themselves, actively listen, and validate each other’s experiences.

By enhancing communication skills, CBFT reduces misunderstandings and conflicts within the family, fostering a more supportive and harmonious environment that promotes emotional well-being for all members.

For example, during CBFT sessions, family members may engage in role-playing exercises to practice effective communication techniques. They may learn how to use “I” statements to express their feelings and needs rather than resorting to blame or criticism. These skills can then be applied in real-life situations, leading to more open and honest conversations among family members.

In addition, CBFT may also incorporate techniques such as active listening, where family members are encouraged to fully engage and understand each other’s perspectives without interrupting or judging. This promotes empathy and deeper connections within the family.

Managing Stress and Anxiety Effectively

CBFT equips individuals and families with the tools to manage stress and anxiety healthily. Through cognitive restructuring and behavior modification, the therapy helps individuals identify and challenge negative thought patterns that contribute to stress and anxiety.

Furthermore, CBFT assists in developing effective coping strategies and problem-solving skills, empowering families to navigate challenges and life stressors more effectively. For instance, CBFT may introduce relaxation techniques such as deep breathing exercises or mindfulness practices to help individuals and families reduce stress levels. By incorporating these techniques into their daily routines, they can better manage their emotions and respond to stressful situations more calmly and composedly.

In addition, CBFT may also focus on identifying and modifying maladaptive behaviors that contribute to stress and anxiety. Family members may learn techniques to challenge negative thoughts or engage in activities that promote relaxation and self-care.

Enhancing Problem-Solving Skills

Cognitive Behavioral Family Therapy emphasizes developing and enhancing problem-solving skills within the family system. Families can learn to approach difficulties with resilience and flexibility by identifying and addressing obstacles to effective problem-solving. CBFT encourages collaboration and mutual understanding, allowing family members to work together to find constructive solutions to challenges. This promotes personal growth and strengthens the family unit as a whole.

For example, CBFT may involve exercises where family members brainstorm and discuss potential solutions to their problems. They may learn to consider multiple perspectives and weigh the pros and cons of different options. Through this process, family members can develop a shared understanding and work towards mutually beneficial outcomes.

Furthermore, CBFT may also focus on teaching conflict resolution skills, helping family members navigate disagreements and find compromises. By learning effective problem-solving techniques, families can build resilience and adaptability, which can be applied to various aspects of their lives.

In conclusion, Cognitive Behavioral Family Therapy offers numerous benefits for individuals and families. By improving communication, managing stress and anxiety effectively, and enhancing problem-solving skills, CBFT promotes healthier family dynamics and emotional well-being for all members.

Implementing Cognitive Behavioral Family Therapy

To implement CBFT successfully, a structured and systematic process is followed. Understanding the different stages of therapy and the role of therapists is crucial for the therapy’s effectiveness.

The Process of Cognitive Behavioral Family Therapy

CBFT typically begins with an initial assessment to gather information about the family’s concerns, strengths, and goals. This assessment helps the therapist develop a comprehensive understanding of the family dynamics and design a tailored treatment plan.

The therapist may use various assessment tools and techniques to gather information during the initial assessment. This may include conducting interviews with individual family members, administering questionnaires, and observing family interactions. The therapist gains insight into the family’s unique challenges and strengths by gathering this information.

Once the assessment is complete, the therapist collaborates with the family to develop a treatment plan. This plan outlines the specific goals and objectives of therapy, as well as the strategies and techniques that will be used to address the identified concerns. The treatment plan is tailored to meet the family’s unique needs, considering their cultural background, values, and preferences.

During therapy sessions, the therapist guides the family through various techniques and strategies targeting specific issues outlined in the treatment plan. These may include cognitive restructuring exercises, communication skill-building activities, and problem-solving tasks.

Cognitive restructuring exercises involve identifying and challenging negative or unhelpful thoughts and beliefs that contribute to distress within the family. By helping family members recognize and reframe their thoughts, the therapist empowers them to develop more adaptive and positive thinking patterns.

Communication skill-building activities focus on improving the quality of communication within the family. The therapist may teach active listening skills, assertiveness techniques, and conflict resolution strategies. These skills help family members express their needs and concerns effectively, leading to healthier and more satisfying relationships.

Problem-solving tasks involve working together as a family to identify and solve specific problems or challenges. The therapist guides the family through a structured problem-solving process, helping them brainstorm solutions, evaluate their effectiveness, and implement the most suitable ones.

The Role of Therapists in Cognitive Behavioral Family Therapy

In CBFT, therapists play a crucial role in facilitating change and growth within the family system. They provide a safe and non-judgmental space for families to explore their concerns and develop new ways of relating.

Therapists establish a strong therapeutic alliance with the family, building trust and rapport. This alliance serves as the foundation for effective therapy, allowing family members to feel supported and understood throughout the therapeutic process.

Therapists also serve as educators, teaching families about the principles and techniques of CBFT and supporting them in implementing these skills outside of therapy sessions. They provide psychoeducation about the underlying principles of CBFT, such as the connection between thoughts, emotions, and behaviors. This knowledge empowers families to understand the rationale behind the therapeutic interventions and apply them in their daily lives.

Furthermore, therapists collaborate with families to set realistic goals and monitor progress throughout the therapeutic journey. They regularly assess the family’s progress, adjusting the treatment plan as needed to ensure that therapy remains effective and relevant to the family’s evolving needs.

Overall, the role of therapists in CBFT is multifaceted. They serve as guides, facilitators, educators, and collaborators, working together with families to create positive and lasting change. Through their expertise and support, therapists empower families to overcome challenges, improve their relationships, and achieve their therapeutic goals.

Overcoming Challenges in Cognitive Behavioral Family Therapy

While CBFT can be highly effective, it is not without its challenges. Therapists must be prepared to address resistance and navigate complex family dynamics to ensure positive outcomes.

Addressing Resistance in Family Therapy

Some family members may initially resist therapy or be hesitant to engage in the therapeutic process. It is essential for therapists to approach resistance with empathy and understanding, working collaboratively with the family to explore the underlying reasons for resistance and finding ways to overcome them.

By fostering a supportive and non-judgmental environment, therapists can gradually help families shift their mindset and become more open to the benefits of therapy.

Dealing with Complex Family Dynamics

Every family has its unique dynamics and challenges. In CBFT, therapists must navigate these complexities, understanding the different roles, power dynamics, and communication patterns within the family. Through a compassionate and individualized approach , therapists help families restructure maladaptive patterns, promoting healthier interactions and strengthened family relationships.

The Future of Cognitive Behavioral Family Therapy

The field of CBFT is continuously evolving, incorporating new developments and innovations to improve outcomes for families seeking therapy. Technological advancements are also playing a significant role in shaping the future of CBFT.

Innovations and Developments in Family Therapy

Researchers and clinicians are constantly exploring innovative ways to enhance the effectiveness of CBFT. This includes integrating other evidence-based therapies, such as mindfulness-based approaches or play therapy, to tailor treatment to specific family needs.

Additionally, advancements in neurobiology and genetics are providing insights into the biological underpinnings of family functioning and mental health, potentially informing more targeted interventions in the future.

The Impact of Technology on Cognitive Behavioral Family Therapy

Technology has opened new possibilities for delivering CBFT, particularly in reaching families who face geographical or logistical barriers to attending in-person sessions. Teletherapy, online resources, and mobile applications are increasingly being utilized to expand access to CBFT and enhance therapeutic outcomes.

The integration of technology also allows for real-time monitoring and feedback, facilitating progress tracking and identifying areas requiring additional support.

Cognitive Behavioral Family Therapy offers a comprehensive approach to improving family relationships and individual well-being. Through its core principles, CBFT promotes effective communication, stress management, problem-solving skills, and resilience within the family system.

While challenges may arise, therapists skilled in CBFT can navigate resistance and complex dynamics to unlock the therapy’s full potential. The future of CBFT holds promise as ongoing innovations and technology-driven advancements continue to shape the field and enhance the accessibility and effectiveness of treatment. To learn how CBFT can help with substance abuse disorders, contact Inspire Malibu today. 

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Homework in CBT

Table of contents, why do homework in cbt, how to deliver homework, strategies to increase confidence.

Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect thoughts, and modify their thinking.

Homework is not something that you just assign randomly. You should make sure you:

• tailor the homework to the patient
• provide a rationale for why the patient needs to do the homework
• uncover any obstacles that might prevent homework from being done (i.e. - busy work schedule, significant neurovegetative symptoms)

Types of homework

Types of homework assignments.

You should also decide the frequency of the homework should be assigned: should it be daily, weekly?

If your patient does not do homework, that’s OK! Explore as a team, in a non-judgmental way, to explore why the homework was not done. Here are some ways to increase adherence to homework:

• Tailor the assignments to the individual
• Provide a rationale for how and why the assignment might help
• Determine the homework collaboratively
• Try to start the homework during the session. This creates some momentum to continue doing the homework
• Set up systems to remember to do the assignments (phone reminders, sticky notes
• It is better to start with easier homework assignments and err on the side of caution
• They should be 90-100% confident they will be able to do this assignment
• Covert rehearsal - running through a thought experiment on a situation
• Change the assignment - It is far better to substitute an easier homework assignment that patients are likely to do than to have them establish a habit of not doing what they had agreed to in session
• Intellectual/emotional role play - “I’ll be the intellectual part of you; you be the emotional part. You argue as hard as you can against me so I can see all the arguments you’re using not to read your coping cards and start studying. You start.”

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Tiara Blain, MA, is a freelance writer for Verywell Mind. She is a health writer and researcher passionate about the mind-body connection, and holds a Master's degree in psychology.

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What Compassion-Focused Therapy Helps With

Effectiveness, things to consider, how to get started.

Compassion-Focused Therapy (CFT), or Compassion Mind Training (CMF), is the concept of incorporating compassion training techniques into psychotherapy to induce kinder thinking habits.

This type of therapy emphasizes the importance of compassion and self-compassion in interactions with the world and the self. CFT stems from Buddhist values that stress the influence compassion has on others’ happiness as well as your own. 

In CFT clients will develop skills that enable them to experience kindness towards themselves and consideration to others through the use of mindfulness -based strategies. CFT is similar to Cognitive-Behavioral Therapy (CBT) but implements techniques that help establish traits like acceptance and self-respect, to enhance self-assurance and positive emotion. CFT is beneficial to those experiencing destructive thoughts, depression, or anxiety to combat feelings of shame and self-criticism.

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Techniques of Compassion-Focused Therapy

CFT techniques include exercises and tasks, such as those discussed below, along with homework, diary entries, and mindfulness/meditation practices. 

Compassion Images

A collection of exercises that include compassion images to help clients gather an understanding of their image of compassion.

Individuals will be asked to express what their ideal depiction of compassion from another would be. They may be asked what compassion may look or sound like via facial expressions and tone of voice. They also have to associate words that connect to this image they created, such as warm or strong. 

The person may also be advised to play the role of a deeply compassionate person and project that image through facial expressions, tone of voice, posture, and words. Clients are asked to picture compassionate images during moments they may usually be self-critical.

Compassion Behavior Tasks

This is a form of exposure therapy. The client is exposed to the new behaviors that are being learned in therapy. They are directed to practice encouraging and sensitive expressions to themselves during fearful or awkward situations. This can help individuals learn to be kind to themselves during difficult situations. 

These types of tasks are also important for clients to accept positive emotions. If an individual has become prone to feelings of guilt or fear during enjoyable moments, they can begin to practice more positive feelings at these times.

CFT helps an individual develop kinder approaches in how to view themselves and interact with others, void of blame and criticism. 

CFT can be beneficial for those seeking support with the following conditions and concerns:

• Self-esteem
• Anxiety  
• Relationships
• Shame  
• Mood Disorders
• Personality Disorders
• Eating Disorders

Benefits of Compassion-Focused Therapy

CFT strategically trains an individual to develop skills that strengthen compassionate thinking, which enhances feelings of self-validation and empathy.

Compassion is considered caring about the suffering of others, but it also means self-compassion , which is being kind to yourself. According to self-compassion expert psychologist, Kristen Neff, self-compassion is actually correlated with compassion for others and overall well-being.

Compassion for others and oneself is associated with greater mental and physical health benefits and enhances the overall quality of life. It enables positive thinking habits, promotes emotional regulation , reduces stress and improves relationship quality. Compassion is also linked to less anxiety, depression, and self-criticism. Additionally, compassion can produce healthier immune responses and helps maintain blood pressure and cortisol levels.

CFT was founded by psychologist Paul Gilbert to help people establish a more compassionate “inner voice,” especially those experiencing a lot of shame. Gilbert’s emphasis is on the importance of learning to engage in “self-soothing” behaviors and “warm” thoughts towards oneself. He conducted a 12-week group session of compassion mind training, in which participants displayed drastic advances in self-compassion that involved being more self-assured and less critical or shameful to oneself. They also exhibited a decrease in depression and anxiety, while displaying more self-soothing and less submissive behaviors.

CFT integrates different fields of psychology such as developmental psychology , evolutionary psychology , Buddhist psychology, and neuropsychology models of compassion. All of these examine the biological , environmental, and motivational contributions that innately drive us to engage in certain emotional and behavioral motives. 

Compassion is associated with neurology; specific areas of the brain are activated in response to the suffering of others and emotional stimuli. Researchers believe that compassion training techniques can possibly enhance feelings of empathy and kindness. Experiencing more feelings of compassion can help initiate self-soothing thoughts as opposed to fearful ones.

CFT has been scientifically supported by empirical literature to be effective within psychotherapy or as a mindfulness training program. A recent systematic review including a collection of various CFT studies validated its benefits towards certain treatment topics, such as depression, trauma, self-esteem, etc. Researchers found CFT to be beneficial in helping with depression, anxiety, feelings of shame, self-criticism, and interacting with others. However, more research within this area is necessary before it can be determined as an official evidence-based practice and to fully understand how effective it is for a variety of conditions.

Here is what might be helpful for you to consider before you begin CFT:

• Prepare to talk about you . With this type of therapy, the focus is on you. This is true for most therapies, but with CFT there is an even greater concentration on the self. The goal of compassion training is to help develop habits that reduce self-criticism and shame to enable a kinder viewpoint of yourself and others. In order to strengthen these abilities, one must first get to the root of self-destructive thinking and behaviors. 
• Be ready to put in work. CFT involves learning about the mind and emotions while implementing what is learned in exercises and homework. It also includes discovering new things about yourself that may feel overwhelming at times. Reducing habits that may be difficult to break may also be a challenging process, but the counselor will work to produce a pace best suited for you.
• Don’t expect instant change. Be patient with yourself and the counselor. You may not notice improvements right away. It will take some time because you are learning and breaking habits all at once. 

If you think the CFT may be beneficial to you, follow the steps below:

• Make the decision. It is up to you to take that first step in deciding to begin therapy. If you feel that you are ready to journey on this path, then you must determine if this specific therapy is the route you want to take. 
• Begin your search. Look for a therapist that specializes in compassion-focused therapy or find a training program that may be offered online. If you already have a therapist, discuss incorporating compassion training into your sessions. 
• Make an effort. Once you begin CFT, try to put your best foot forward and gain all that you can from this experience. Compassionate thinking is something that can generate better well-being and a happier you. If both the counselor and yourself are investing the time, why not make an effort to do the work. 
• Don’t be too tough on yourself. All you can do is try your best in therapy. There will be times that you resort back to old habits, don't get too frustrated with yourself. The main point of compassion therapy is to grow in your thinking and produce kinder approaches to how you communicate with yourself and the world. Accept that this has happened and continue to progress in your training. 

Gilbert P. Introducing compassion-focused therapy. Advances in Psychiatric Treatment . 2009;15(3):199-208. doi:10.1192/apt.bp.107.005264

Lucre KM, Corten N. An exploration of group compassion-focused therapy for personality disorder. 2012; 86(4): 387-400. doi:10.1111/j.2044-8341.2012.02068.x

Gilbert P, Iron C. A pilot exploration of the use of compassionate images in a group of self-critical people. Memory. 2004; 12(4):507-516. doi: 10.1080/09658210444000115

Leaviss J, Uttley L. Psychotherapeutic benefits of compassion-focused therapy: an early systematic review. Psychological Medicine . 2015; 45(5):927-945. doi:10.1017/S0033291714002141

Gross K, Allan S. Compassion focused therapy for eating disorders. HomeInternational Journal of Cognitive Therapy. 2013; 3(2). doi: 10.1521/ijct.2010.3.2.141

Lawrence VA, Lee D. An exploration of people’s experiences of compassion-focused therapy for trauma, using interpretative phenomenological analysis. Clinical Psychology & Psychotherapy. 2014; 21(6):495-507. doi:10.1002/cpp.1854 

Grodin J. Clark JL, Kolts R, Lovejoy TI. Compassion focused therapy for anger: A pilot study of a group intervention for veterans with PTSD. Journal of Contextual Behavioral Science. 2019; 13, 27–33. https://doi.org/10.1016/j.jcbs.2019.06.004

Neff, K. Self-compassion, self-esteem, and well-being. Social and Personality Psychology Compass. 2011; 5(1):1-12. doi: 10.1111/j.1751-9004.2010.00330.x

Cosley BJ, McCoy SK, Saslow LR, Epel ES. Is compassion for others stress buffering? Consequences of compassion and social support for physiological reactivity to stress. Journal of Experimental Social Psychology. 2010; 46:816-823.

Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson RJ. Regulation of the neural circuitry of emotion by compassion meditation: Effects of meditative expertise. 2008; 3(3). doi:10.1371/journal.pone.0001897

Beaumont E, Martin CJH. A narrative review exploring the effectiveness of Compassion-Focused Therapy. The British Counseling Psychology Review. 2015; 30(1). 

By Tiara Blain, MA Tiara Blain, MA, is a freelance writer for Verywell Mind. She is a health writer and researcher passionate about the mind-body connection, and holds a Master's degree in psychology.

All About Cognitive Behavioral Family Therapy

Family therapy is an effective way to address interpersonal conflicts and mental health issues that affect the entire family. Cognitive Behavioral Family Therapy (CBFT) is a specific type of family therapy that focuses on thoughts, emotions, and behaviors. By identifying and changing negative patterns, CBFT can help families communicate better, reduce conflicts, and improve mental health outcomes. In this blog, we’ll explore the benefits of CBFT, the techniques used in therapy sessions, and how to find the right CBFT therapist for your family.

• 1 What Is Cognitive-Behavioral Family Therapy?
• 2.1 Behavioral Couples Therapy
• 2.2 Functional Family Therapy
• 2.3 Parent-Child Interaction Therapy
• 2.4 Multisystem Therapy
• 2.5 Cognitive-Behavioral Conjoint Therapy
• 3 Techniques Used In CBFT
• 4 Benefits Of CBFT
• 5 How To Find The Right Therapist?
• 6 Conclusion

What Is Cognitive-Behavioral Family Therapy?

Types Of Cognitive Behavioral Family Therapy

Given below are some types of cognitive behavioral family therapy:

Behavioral Couples Therapy

BCT is designed to help couples improve their communication and problem-solving skills, increase positive interactions, and decrease negative ones. The therapy is typically structured and involves homework assignments that reinforce new skills learned in sessions. For example, BCT may involve a couple learning to use “I” statements instead of blaming or accusing language during conflicts, which can reduce defensiveness and promote understanding.

Functional Family Therapy

FFT is an evidence-based treatment for families who are struggling with a variety of problems. Such as substance abuse , delinquency, or family conflict. The therapy is typically short-term and focuses on specific problems within the family system. For example, FFT may involve working with a family to develop a plan for reducing conflict and improving communication in the home. Or it may involve developing strategies to prevent a child from engaging in risky behavior.

Parent-Child Interaction Therapy

PCIT is designed to improve the quality of parent-child interactions and increase positive behaviors in children. The therapy involves coaching parents in specific skills. Such as praise, active listening, and effective commands, to improve their interactions with their children. For example, PCIT may involve coaching a parent to use descriptive praise (e.g. “I like how you’re playing so quietly with your toys”) instead of evaluative praise (e.g. “Good job!”), which can be more effective in reinforcing positive behavior.

Multisystem Therapy

Cognitive-Behavioral Conjoint Therapy

CBCT involves both partners in a relationship working together to identify and change problematic patterns of interaction. The therapy typically involves teaching couples specific skills, such as active listening, problem-solving, and negotiation, to improve their communication and strengthen their relationship. For example, CBCT may involve working with a couple to identify their common “ triggers ” for conflict and developing strategies for de-escalating these situations before they become more serious.

Techniques Used In CBFT

Cognitive Behavioral Family Therapy (CBFT) utilizes a range of techniques to help families identify and modify unhelpful thoughts, emotions, and behaviors. Here are some common techniques in CBFT:

• Psychoeducation : CBFT often begins with psychoeducation. The therapist educates the family about the cognitive-behavioral model and how it applies to their specific challenges. This involves explaining the role of thoughts, emotions, and behaviors in shaping their experiences and providing information about specific techniques that will be used in therapy.
• Cognitive Restructuring: This technique involves identifying and challenging unhelpful thoughts and beliefs that contribute to negative emotions and behaviors. The therapist may teach the family to use thought records to track and modify negative thinking patterns.
• Behavioral Activation: This technique involves encouraging the family to engage in positive and rewarding activities, even when they don’t feel like it. This can help to improve mood and reduce negative thinking patterns.
• Communication Skills Training: This technique involves teaching family-specific skills for effective communication , such as active listening, assertiveness , and conflict resolution . The therapist may use role-playing exercises to practice these skills.
• Problem-Solving Skills Training: This technique involves teaching the family how to identify and solve problems constructively. The therapist may use structured problem-solving exercises to help the family work through specific issues.
• Relaxation Techniques : This technique involves teaching the family relaxation techniques, such as deep breathing, progressive muscle relaxation, or mindfulness meditation. These techniques can help to reduce stress and anxiety and promote a sense of calm.
• Exposure and Response Prevention: This technique is often used to treat anxiety disorders and involves gradually exposing the family to feared situations or stimuli while preventing them from engaging in avoidance or safety behaviors.

Benefits Of CBFT

• Improved communication: CBFT can help family members improve their communication skills, which can lead to better understanding and greater empathy . Family members can learn to express their feelings and need more clearly, while also learning to listen and validate the perspectives of others.
• Reduced conflict: By improving communication and teaching conflict resolution skills, CBFT can reduce the amount and intensity of conflict within the family. This can lead to a more peaceful and harmonious home environment.
• Increased problem-solving skills: CBFT can help families develop problem-solving skills that can be applied to a range of situations. Family members can learn to identify problems, generate multiple solutions, and evaluate the pros and cons of each option.
• Improved coping skills: It can help family members develop coping skills to deal with stress, anxiety, and other challenges. This can include relaxation techniques, mindfulness, and other strategies for managing difficult emotions.
• Increased family cohesion: It can help families develop a stronger sense of connection and cohesion. By working together to address challenges and achieve goals, family members can develop a greater sense of teamwork and mutual support.
• Reduced symptoms of mental health disorders: CBFT is effective in reducing symptoms of depression , anxiety, and other mental health disorders. By addressing the underlying thoughts, emotions, and behaviors that contribute to these symptoms, CBFT can help families achieve better mental health outcomes.
• Improved parent-child relationships : It can help parents develop more positive and effective parenting strategies, which can lead to better relationships with their children. This can include developing consistent discipline, setting appropriate boundaries, and providing emotional support.

How To Find The Right Therapist?

• Ask for referrals: Ask your primary care doctor, mental health professional, or trusted friends and family members. They can recommend you a therapist for CBFT.
• Check credentials: Look for licensed therapists with specific training and experience in CBFT. Check their credentials and certifications.
• Research online: Use online resources to search for therapists in your area who specialize in CBFT. Look at their websites, online reviews, and professional affiliations.
• Schedule a consultation: Consider scheduling a consultation with a few potential therapists to get a sense of their communication style and how comfortable you feel working with them.
• Consider insurance coverage: Check if the therapist you’re considering is covered by your insurance plan. If not, ask about payment options or sliding scale fees.
• Trust your instincts: Ultimately, choose a therapist who you feel comfortable with, who listens to your concerns and goals, and who you believe can help your family achieve the outcomes you’re looking for.

In conclusion, Cognitive Behavioral Family Therapy (CBFT) is a highly effective approach to improving family dynamics . By focusing on thoughts, emotions, and behaviors, CBFT can help families develop practical skills and strategies for managing challenges and achieving better outcomes. If you’re struggling with family conflicts or mental health issues, don’t hesitate to seek help from a qualified CBFT therapist. With the right support, you can build stronger relationships, improve your mental health, and create a more harmonious home environment.

For more information, please contact MantraCare.  Parenting  is a challenging yet rewarding experience that is crucial for the development and well-being of a child. If you have any queries regarding  Online Parenting Counseling  experienced  therapists  at MantraCare can help:  Book a trial therapy session .

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