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

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.

[1]  P. Dannon,et al.  Cognitive behavioral group therapy in panic disorder patients: the efficacy of CBGT versus drug treatment. , 2004, Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists.

[2]  R. Bentall,et al.  Patients' experiences of homework tasks in cognitive behavioural therapy for psychosis: a qualitative analysis , 2002 .

[3]  M. A. Tompkins.  Guidelines for enhancing homework compliance. , 2002, Journal of clinical psychology.

[4]  P. Rohde,et al.  Does Homework “Matter” in Cognitive Behavioral Therapy for Adolescent Depression? , 2012, Journal of Cognitive Psychotherapy.

[5]  Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D report. , 2007, The American journal of psychiatry.

[6]  Sanjay Arora,et al.  Perceptions of Successful Cues to Action and Opportunities to Augment Behavioral Triggers in Diabetes Self-Management: Qualitative Analysis of a Mobile Intervention for Low-Income Latinos With Diabetes , 2014, Journal of medical Internet research.

[7]  Richard B. Fletcher,et al.  Group Cognitive Behavioural Therapy for Depression Outcomes Predicted by Willingness to Engage in Homework, Compliance with Homework, and Cognitive Restructuring Skill Acquisition , 2008, Cognitive behaviour therapy.

[8]  Jo B. Middlemass,et al.  Integrating online communities and social networks with computerised treatment for insomnia: a qualitative study. , 2012, The British journal of general practice : the journal of the Royal College of General Practitioners.

[9]  Andrea Gaggioli,et al.  Virtual reality and mobile phones in the treatment of generalized anxiety disorders: a phase-2 clinical trial , 2011, Personal and Ubiquitous Computing.

[10]  Z. Segal,et al.  Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. , 2009, Journal of affective disorders.

[11]  Rosalind W. Picard,et al.  Establishing the computer-patient working alliance in automated health behavior change interventions. , 2005, Patient education and counseling.

[12]  D. Dozois,et al.  Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety. , 2007, Journal of consulting and clinical psychology.

[13]  M. Kunik,et al.  Predictors of CBT outcome in older adults with GAD. , 2014, Journal of anxiety disorders.

[14]  Lydia Fehm,et al.  PROBLEMS WITH HOMEWORK IN CBT: RARE EXCEPTION OR RATHER FREQUENT? , 2004, Behavioural and Cognitive Psychotherapy.

[15]  L. Fehm,et al.  Patients' perspective on homework assignments in cognitive-behavioural therapy. , 2008, Clinical psychology & psychotherapy.

[16]  L. Bru,et al.  Participants’ experiences of an early cognitive behavioral intervention for adolescents with symptoms of depression , 2013 .

[17]  Thomas L. Patterson,et al.  The Relationship Between Homework Compliance and Therapy Outcomes: An Updated Meta-Analysis , 2010, Cognitive Therapy and Research.

[18]  S. Shirk,et al.  Promoting Homework Adherence in Cognitive-Behavioral Therapy for Adolescent Depression , 2013, Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53.

[19]  Leanne M. Casey,et al.  The use of mobile telephones as adjuncts to cognitive behavioral psychotherapy. , 2008 .

[20]  Carolyn A. Watters,et al.  Telephone-based mental health interventions for child disruptive behavior or anxiety disorders: randomized trials and overall analysis. , 2011, Journal of the American Academy of Child and Adolescent Psychiatry.

[21]  S. Bauer,et al.  Technology-enhanced maintenance of treatment gains in eating disorders: efficacy of an intervention delivered via text messaging. , 2012, Journal of consulting and clinical psychology.

[22]  Brian D. Kiluk,et al.  Only connect: The working alliance in computer-based cognitive behavioral therapy. , 2014, Behaviour research and therapy.

[23]  John McCarthy,et al.  WHAT IS ARTIFICIAL INTELLIGENCE , 1998 .

[24]  Barbara O Rothbaum,et al.  The "PE coach" smartphone application: an innovative approach to improving implementation, fidelity, and homework adherence during prolonged exposure. , 2013, Psychological services.

[25]  Colin Potts,et al.  Design of Everyday Things , 1988 .

[26]  P. Totterdell,et al.  Time Frames for Mood: Relations between Momentary and Generalized Ratings of Affect , 1995 .

[27]  E. Granholm,et al.  Mobile Assessment and Treatment for Schizophrenia (MATS): a pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations. , 2012, Schizophrenia bulletin.

[28]  P. McGorry,et al.  Online, social media and mobile technologies for psychosis treatment: A systematic review on novel user-led interventions , 2014, Schizophrenia Research.

[29]  J. Treasure,et al.  The use of guided self-help incorporating a mobile component in people with eating disorders: a pilot study. , 2013, European eating disorders review : the journal of the Eating Disorders Association.

[30]  Gareth Furber,et al.  A Comparison Between Phone-Based Psychotherapy With and Without Text Messaging Support In Between Sessions for Crisis Patients , 2014, Journal of medical Internet research.

[31]  Michelle G. Newman,et al.  Efficacy and Utility of Computer-Assisted Cognitive Behavioural Therapy for Anxiety Disorders , 2006 .

[32]  J. Proudfoot.  The future is in our hands: The role of mobile phones in the prevention and management of mental disorders , 2013, The Australian and New Zealand journal of psychiatry.

[33]  G. Parker,et al.  Mobile mental health: Review of the emerging field and proof of concept study , 2011, Journal of mental health.

[34]  John Strang,et al.  Mobile phone ownership, usage and readiness to use by patients in drug treatment. , 2015, Drug and alcohol dependence.

[35]  Jay C Buckey,et al.  A randomized controlled trial of a self-guided, multimedia, stress management and resilience training program. , 2013, Behaviour research and therapy.

[36]  R. Muñoz,et al.  Text Messaging as an Adjunct to CBT in Low-Income Populations: A Usability and Feasibility Pilot Study. , 2011, Professional psychology, research and practice.

[37]  S. Esch,et al.  The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: secondary analysis of a randomized trial. , 2013, Behavior therapy.

[38]  K. O'Connor,et al.  Cognitive-Behaviour Therapy and Medication in the Treatment of Obsessive-Compulsive Disorder: A Controlled Study , 1999, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[39]  N. Kazantzis,et al.  Handbook of homework assignments in psychotherapy : research, practice, and prevention , 2007 .

[40]  R. Heimberg,et al.  Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. , 1996, Behaviour research and therapy.

[41]  K. Freedland,et al.  Predictors of Treatment Response for Depression and Inadequate Social Support – The ENRICHD Randomized Clinical Trial , 2007, Psychotherapy and Psychosomatics.

[42]  S. Gaynor,et al.  Measuring Homework Compliance in Cognitive-Behavioral Therapy for Adolescent Depression , 2006, Behavior modification.

[43]  R. Bentall,et al.  The relationship between patient suitability, therapeutic alliance, homework compliance and outcome in cognitive therapy for psychosis , 2006 .

[44]  Mathijs F. G. Lucassen,et al.  The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial , 2012, BMJ : British Medical Journal.

[45]  S. Bauer,et al.  Mobile therapy: Use of text-messaging in the treatment of bulimia nervosa. , 2010, The International journal of eating disorders.

[46]  M K Shear,et al.  Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. , 2000, JAMA.

[47]  Patients and text messaging: a boundary issue. , 2009, The American journal of psychiatry.

[48]  D. Polcin,et al.  A Cognitive Behavioral Therapy-Based Text Messaging Intervention for Methamphetamine Dependence , 2013, Journal of psychoactive drugs.

[49]  Tilo Kircher,et al.  Specificity of homework compliance effects on treatment outcome in CBT: evidence from a controlled trial on panic disorder and agoraphobia. , 2013, Journal of clinical psychology.

[50]  K. Jones,et al.  Using mobile phones and short message service to deliver self-management interventions for chronic conditions: a meta-review. , 2014, Worldviews on evidence-based nursing.

[51]  C. Sherbourne,et al.  Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement. , 2013, Journal of consulting and clinical psychology.

[52]  Andrea Gaggioli,et al.  Marketing analysis of a positive technology app for the self-management of psychological stress. , 2014, Studies in health technology and informatics.

[53]  Frank P Deane,et al.  A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. , 2005, Journal of consulting and clinical psychology.

[54]  D. King,et al.  Process and treatment adherence factors in group cognitive-behavioral therapy for partner violent men. , 2003, Journal of consulting and clinical psychology.

[55]  S. Whiteside,et al.  Case Examples of Enhancing Pediatric OCD Treatment With a Smartphone Application , 2014 .

[56]  E. Holmes,et al.  Unresolved Issues Regarding Homework Assignments in Cognitive and Behavioural Therapies: An Expert Panel Discussion at AACBT , 2010, Behaviour Change.

[57]  Clinical practice guidelines. Management of anxiety disorders. , 2006, Canadian journal of psychiatry. Revue canadienne de psychiatrie.

[58]  D. Chambless,et al.  Adherence during sessions and homework in cognitive-behavioral group treatment of social phobia. , 1995, Behaviour research and therapy.

[59]  Michael E. Labhard,et al.  Mobile Therapy: Case Study Evaluations of a Cell Phone Application for Emotional Self-Awareness , 2010, Journal of medical Internet research.

[60]  N. Kazantzis,et al.  Handbook of Homework Assignments in Psychotherapy , 2007 .

[61]  B. Brigidi,et al.  Therapeutic Interactive Voice Response for chronic pain reduction and relapse prevention , 2008, PAIN.

[62]  Simone C. Barr,et al.  National Trainers’ Perspectives on Challenges to Implementation of an Empirically-Supported Mental Health Treatment , 2014, Administration and Policy in Mental Health and Mental Health Services Research.

[63]  P. Kendall,et al.  Showing you can do it: homework in therapy for children and adolescents with anxiety disorders. , 2002, Journal of clinical psychology.

[64]  D. Tolin,et al.  An open trial of cognitive-behavioral therapy for compulsive hoarding. , 2007, Behaviour research and therapy.

[65]  R. DeRubeis,et al.  The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. , 2012, Journal of consulting and clinical psychology.

[66]  P. McEvoy,et al.  Relationship Between Homework Completion and Outcome in Cognitive Behaviour Therapy , 2005, Cognitive behaviour therapy.

[67]  Garry Squires,et al.  The Session Bridging Worksheet: impact on outcomes, homework adherence and participants’ experience , 2014, The Cognitive Behaviour Therapist.

[68]  S. Hollon,et al.  6 – Cognitive Therapy of Depression1 , 1979 .

[69]  D. Santor,et al.  Enhancig the Effectivencess and Sustainability of School-Based Mental Health Programs: Maximizing Program Participation, Knowledge Uptake and Ongoing Evaluation using Internet-Based Resources , 2008 .

[70]  M. Craske,et al.  Homework Compliance Counts in Cognitive-Behavioral Therapy , 2013, Cognitive behaviour therapy.

[71]  Harriet J. Rosenberg,et al.  A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. , 2008, Journal of consulting and clinical psychology.

[72]  O. Kristjansdottir,et al.  A Smartphone-Based Intervention With Diaries and Therapist-Feedback to Reduce Catastrophizing and Increase Functioning in Women With Chronic Widespread Pain: Randomized Controlled Trial , 2013, Journal of medical Internet research.

[73]  Sisira Edirippulige,et al.  Journal round up , 2012 .

[74]  O. Kristjansdottir,et al.  Written online situational feedback via mobile phone to support self-management of chronic widespread pain: a usability study of a Web-based intervention , 2011, BMC musculoskeletal disorders.

[75]  M. Boschen,et al.  Technological advances in psychotherapy: implications for the assessment and treatment of obsessive compulsive disorder. , 2013, Journal of anxiety disorders.

[76]  A. Maercker,et al.  Long-Term Effects of an Internet-Based Treatment for Posttraumatic Stress , 2010, Cognitive behaviour therapy.

[77]  K. Gibson,et al.  Young people's experiences of mobile phone text counselling: Balancing connection and control☆ , 2014 .

[78]  G. Myhr,et al.  Increasing Access to Cognitive-Behavioural Therapy (CBT) for the Treatment of Mental Illness in Canada: A Research Framework and Call for Action. , 2010, Healthcare policy = Politiques de sante.

[79]  E. Granholm,et al.  Therapeutic Factors Contributing to Change in Cognitive-Behavioral Group Therapy for Older Persons with Schizophrenia , 2006, Journal of Contemporary Psychotherapy.

[80]  C. Taylor,et al.  A Palmtop Computer Program for the Treatment of Generalized Anxiety Disorder , 1999, Behavior modification.

[81]  M. Zancanaro,et al.  Increasing social engagement in children with high-functioning autism spectrum disorder using collaborative technologies in the school environment , 2013, Autism : the international journal of research and practice.

[82]  Ilkka Korhonen,et al.  Empowering Citizens for Well-being and Chronic Disease Management With Wellness Diary , 2010, IEEE Transactions on Information Technology in Biomedicine.

[83]  F. Deane,et al.  Homework assignments in cognitive and behavioral therapy: a meta-analysis. , 2000 .

[84]  M. Zvolensky,et al.  Homework compliance in a brief cognitive-behavioural and pharmacological intervention for smoking , 2011 .

[85]  Bjarne Hansen,et al.  Videoconference- and cell phone-based cognitive-behavioral therapy of obsessive-compulsive disorder: a case series. , 2012, Journal of anxiety disorders.

[86]  Henry Brodaty,et al.  Internet-delivered cognitive behavioural therapy for depression: A feasibility open trial for older adults , 2013, The Australian and New Zealand journal of psychiatry.

[87]  K. Carroll,et al.  Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. , 2005, Journal of consulting and clinical psychology.

[88]  Jan Scott,et al.  Using homework in therapy for depression. , 2002, Journal of clinical psychology.

[89]  L. Thompson,et al.  The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression. , 2003, The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry.

[90]  Amy Przeworski,et al.  A randomized controlled trial of ecological momentary intervention plus brief group therapy for generalized anxiety disorder. , 2014, Psychotherapy.

[91]  J. Schmitz,et al.  The role of homework in cognitive-behavioral therapy for cocaine dependence. , 2006, Journal of consulting and clinical psychology.

[92]  Judith A. Callan,et al.  The role of homework in cognitive behavior therapy of depression. , 2006 .

[93]  Tiffany Grunwald,et al.  Guidelines for cognitively efficient multimedia learning tools: educational strategies, cognitive load, and interface design. , 2006, Academic medicine : journal of the Association of American Medical Colleges.

[94]  Sagar V Parikh,et al.  E-health: an overview of the uses of the Internet, social media, apps, and websites for mood disorders , 2015, Current opinion in psychiatry.

[95]  R. Leahy.  Improving homework compliance in the treatment of generalized anxiety disorder. , 2002, Journal of clinical psychology.

[96]  Fadel Adib,et al.  Emotion recognition using wireless signals , 2016, MobiCom.