Why are action plans within CBT important? - Chapter 8

This chapter will discuss the important of action plans and how to use them during treatment.

Clients who carry out action plans (homework assignments) progress better in therapy than those who do not. Good action plans provide opportunities for clients to educate themselves further, to collect data, to test their thoughts and beliefs, to modify their thinking, to practice cognitive and behavioral tools, and to experiment with new behaviors. Action plans need to be tailored to the individual.  Not only the type of action plans is important, but also the amount of it. It is therefore important to predict potential difficulties before assigning action plans. The action plans should err on the side of being too easy as opposed to too difficult, clients should not feel like a failure.

In the beginning the therapist will suggest action plans, but as soon as possible the client should try to devise their own action plans. Typical action plans are:

• Behavioral activation, getting active, and scheduling activities.

• Reading the therapy notes. Make the client summarize what they think is most important for them te remember and to do after discussing an issue with you.

• Monitoring automatic thoughts. Clients should ask themselves: ‘What is going through my mind right now?’ when they notice their mood is changing and remind themselves that this thinking may or may not be true.

• Evaluating and responding to automatic thoughts. The therapist will help clients modify their inaccurate and dysfunctional thoughts and write down their new way of thinking. An essential action plans is to have them read these therapy notes on a regular basis. Clients will also learn to evaluate their own thinking and practice doing so between sessions.

• Doing behavioral experiments. It is often important to design eperiments together that clients can do between sessions to test the validity of negative predictions.

• Disengaging from thoughts that are part of an unhelpful thought process. 

• Implementing steps towards the goals of the client.

• Participating in activities that lift affect.

• Clients can write a list of the things they did throughout the day that were a little difficult or more.

• Practicing behavioral skills. Clients might have to learn new skills to effectively solve their problems.

• Bibliotherapy: Important concepts you are discussing in session can be greatly reinforced when clients read about them in books or magazines.

• Preparing for the next session by thinking about what is important to discuss.

How can action plans adherence be increased?

Although some clients easily do the suggested assignments, action plans are more problematic for others. Implementation of the following guidelines increases the likelihood that clients will be successful withaction plans and experience an elevation in mood:

• Tailor the assignment to the individual. (Be 90–100% sure the client can and will do the assignment.)

• Provide a rationale as to how and why the assignment might help. Clients are more likely to comply with action plans if they understand the reason for doing them. This is called providing a rationale. The therapist will provide a brief rationale initially; later in treatment, the therapist will encourage clients to think about the purpose of an assignment.

• Think of action plans together. The therapist seeks the clien’s input and agreement.

• Make action plans a no-lose proposition. Tell the client that it would be good if he/she gets it done, but that it is okay if the client has trouble finishing it. The client should not feel like a failure.

• Give the client explicit instruction on how to do the action plans.

• Begin the assignment in session. This motivates clients to complete the assignment.

• Help set up systems for remembering to do the assignment. What will help the client remember to do the homework?

• Ask clients to imagine completing an item on the action plan. Clients are more likely to complete their action plans if they visualize a positive outcome.

Why should the therapist anticipate and prevent problems with executing the action plans?

Clients who complete action plans between sessions have better treatment outcomes than clients who do no complete the action plans. It is therefore important to predict the types of obstacles that can arise for clients to complete their action plans. To increase the chance clients will actually do their action plans, the therapist can do several things:

• Estimate the likelihood of completion.

• Anticipate possible problems: The therapist should ask the clients how likely he/she is to carry out the assignment (0-100%). If the client is less than 90% confident the therapist can engage in the following strategies: 

  • Covert rehearsal uses induced imagery to uncover and solve potential homework-related problems. Which practical obstacles and dysfunctional cognitions may hinder the completion of homework?

• Be alert for possible negative reactions of the client toward an action plan.

• Talk about the disadvantages and advantages of the action plan toegether.

• Modify the action plan if a client is unsure about completing it.

• Make the plan easy.

Why conceptualizing difficulties?

When clients experience difficulty with completing their action plan, conceptualize why the problems arose.

The first questions that should be asked is: Why did the problem arise, and what was it related to?

Types of problems that may occur:

• A practical problem. A practical problem can often be avoided if the assignment is carefully set. 

• Cogntitions that interfere with doing the items on the action plan.

• A psychological problem masked as a practical problem. Some clients believe that a practical issue is preventing them from doing the action plan, but there may actually be a thought or belief that is inferring. This belief has to be discussed before moving on to solving the practical issue.

• A problem related to the therapist’s cognitions. Therapists can have dysfunctional thoughts about assigning homework or exploring why a client has not done items on the action plan. The therapist should be aware that he is not doing his clients a favor by allowing them to skip items.

Other problems that may occur are:

• Doing the action plan at the last minute.

• Forgetting the rationale for an assignment.

• Difficulty with an item on the action plan.

• Overestimating the demands of an assignment. The client may overestimate the effort, energy and time an assignment will cost.

• Depressed clients often procrastinate and avoid doing things.

There is also a problem related to negative predictions. Clients may have negative predictions about doing the items on the action plan such as: ‘I shouldn’t have to put forth so much effort to feel better’ or ‘I am incompetent. These predictions stand in the way of completing the action plan. It can be helpful to have the client test these predictions. The therapist should prepare the client for their reaction to a possible negative outcome through Socratic questioning. The therapist should make the usefulness of the assignment clear, but has to acknowledge that the outcome of an assignment is never a given to avoid disappointment.