Setting homework with a light touch
When I was training as a GP, an experienced and wise colleague shared one of his high-yield questions with me. It was one he asked patients just after the latter had detailed their problems to him: ‘And what did you hope that I could do about this?’
The question was clearly designed to elicit the patient’s ‘hidden agenda’. But I admit that I was a bit taken aback by its rather bold and bald framing. However I tried it, with an empathic style, and found that only rarely, did patients simply retort ‘I don’t know –you’re the doctor, you tell me’. Mostly, to my surprise, they came up with their own ideas about what would help them to deal with the problem. They might think blood tests, xrays, medicines or a consultant referral would help and we could then discuss the pros and cons of their suggestions and how to best structure the possible solutions. The patients appeared to feel ‘heard’ and worked with rather, than ‘done to’ and it saved valuable time too. The question became a core part of my repertoire fairly quickly.
I have new found myself as a CBT trainee, in a similar position. I’m always short of time and I usually get to minute 47 before pausing to consider ‘this week’s homework’. So I have started to ask the client:
‘And what do you think you could do to put this session’s insights and learning into practice this week?’
And to my surprise (you’d think I’d have learned by now…), the client usually offers up something relevant like:
• ‘I’d like to monitor how often I’m criticising myself’
• ‘I’d like to practice distracting my attention away from worrying’
Sometimes, the client may need some help operationalising the task or extending its scope, for example:
• ‘I’d like to monitor how often I’m criticising myself and then see if I can generate some more realistic perspectives’
• I’d like to distract my attention away from worrying by doing something small and nice for myself like applying cream to my hands’
But for the most part, the question works pretty much as it did in General Practice. It strengthens the therapeutic relationship, emphasises the collaborative nature of CBT and saves time. It also shows clients that they can work out how to test their emerging hypotheses and skills by and for themselves, with a little support.
I don’t reserve this question solely for the end of the session, at the agenda item called ‘homework setting’. I also use it after debriefing Behavioural Experiments or after explaining a new CBT skill:
‘And how could you build on what we’ve just discussed during this coming week? What could you do this week to practice, extend or further test out this new idea/skill?'
Summary points
• it can be done with a light yet deft touch, so that the client can see how to continue setting herself learning tasks once treatment is complete
• my high yield question is: ‘And what do you think you could do to put this session’s insights and learning into practice this week?’