Mediators and Moderators of Homework–Outcome Relations in CBT for Depression: A Study of Engagement, Therapist Skill, and Client Factors

A new short version of the Cognitive Therapy Scale Revised (CTSR-4): preliminary psychometric evaluation

“…However, no study has yet shown that CTSR can identify such variances in CBT competence, and the results of previous studies arguably point in the direction that a competent therapist shows similar levels of competence across therapeutic domains [ 30 , 37 ]. Also, while most agree that some CBT components, such as setting the agenda and eliciting key cognitions, are hallmarks of quality CBT, there is very little research confirming that specific CBT components are essential for patient outcomes (however, see [ 38 , 39 ]. Recent research has also shown that sometimes skills specific to a treatment manual or model may be more important than general CBT skills for treatment outcomes [ 15 , 40 ].…”

Clinician experiences of homework in couples and family therapy: A survey of perceived impact on the working alliance

“…These results support claims made in clinical practice recommendations for the use of homework with couples and families (Dattilio & Collins, 2018; Epstein & Baucom, 2007; Newcomb & Lebow, 2007; Robbins, Szapocznik & Perez, 2007) and recent reviews underscoring the importance of homework for these client groups (Mutschler, Malivoire, Schumm & Monson, 2022; Sibley, Link, Torres Antunez & Greenwood, 2022). These findings also underscore the importance of psychotherapy process research on pinpointing the impact of persistent non‐engagement with homework (Callan et al ., 2018) and therapist strategies to facilitate adherence with homework (Ryum, Stiles, Svartberg & McCullough, 2010; Ryum, Svartberg & Stiles, 2021; Yew, Dobson, Zyphur & Kazantzis, 2021) and call for their extension in the context of couples and family therapy.…”

“…Previous surveys have shown that therapists can have very negative attitudes toward homework as a process of psychotherapy (Kazantzis, Lampropoulos & Deane, 2005), and the present data extend those in showing that when clinicians have been working with couple and family clients and experience low homework adherence, there is a tendency to view a negative impact on bond and agreement . Therapists experiencing low adherence may therefore benefit from reflecting on their understanding of their couple and family clients' perceptions of the homework and its benefits, given that client beliefs about homework are important in understanding engagement (Kazantzis & Miller, 2022; Yew, Dobson, Zyphur & Kazantzis, 2021). A potential source of an alliance rupture is the client's appraisal of the specific task, rather than their feelings toward the therapist or their agreement to engage with homework.…”

“…Content for the 20 IHN on alliance items was based on previous theoretical and empirical work on the working alliance (Farber & Doolin, 2011; Friedlander et al ., 2006; Friedlander, Escudero, Heatherington & Diamond, 2011; Goldfried & Hayes, 1989; Goldfried & Newman, 1992; Horvath, Del Re, Flückiger & Symonds, 2011; Horvath & Greenberg, 1989; Mendelsohn, 1987; Muran & Barber, 2010) and covered the three elements of the working alliance: (1) agreement (i.e., agreement on goals, agreement on tasks); (2) bond (i.e., concern, empathy, genuineness/congruence, neutrality, positive regard, sincerity, warmth, caring, manage feelings about the client, interpretation of relationship, commitment to therapy, mutual liking, perceived similarity, respect, trust), and (3) in‐session relational processes (i.e., collaboration, appropriate feedback, repair of alliance ruptures). Given the feedback clients provide periodically through the session when discussing homework, as well as the emerging research drawing together therapist competence in homework, the alliance, and other in‐session processes (see Kazantzis, 2021; Ryum, Stiles, Svartberg & McCullough, 2010; Ryum, Svartberg & Stiles, 2021; Strunk, 2002; Yew, Dobson, Zyphur & Kazantzis, 2021), appropriate feedback was included among the IHN on alliance items as distinct from structured feedback obtained with rating forms (see Norcross & Lambert, 2018). IHN was assessed on a five‐point scale, with these options: 1 ( negative impact ), 2 ( somewhat negative impact ), 3 ( no impact ), 4 ( somewhat positive impact ), and 5 ( positive impact ).…”

Editorial: Contemporary Issues in Defining the Mechanisms of Cognitive Behavior Therapy

“…Various CBTs have well-documented efficacy (3,4) that have led to considerable dissemination efforts (5), but the literature on mechanisms of action is less evolved (6)(7)(8)(9). This literature can be classified into three groups: (1) research designed to identify patient features that may serve as prognostic predictors, as well as moderators or mediators of treatment effects (10-12); (2) research focused on generic relational processes in psychotherapy, such as foundational counseling skills, typically assessed as empathy, warmth, positive regard, and agreement on goals and tasks of therapy, comprising the combined construct of working alliance (13,14); as well as (3) research aiming to examine specific aspects of the delivery of CBT, such as collaborative-empiricism, Socratic dialogue (15) and facilitation of homework assignments (16,17). These various research efforts each involve methodological challenges including the indexing of patient characteristics and evaluation of therapist competence (18,19).…”