homework in mental health

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More than two hours of homework may be counterproductive, research suggests.

A Stanford education researcher found that too much homework can negatively affect kids, especially their lives away from school, where family, friends and activities matter.   "Our findings on the effects of homework challenge the traditional assumption that homework is inherently good," wrote Denise Pope , a senior lecturer at the Stanford Graduate School of Education and a co-author of a study published in the Journal of Experimental Education .   The researchers used survey data to examine perceptions about homework, student well-being and behavioral engagement in a sample of 4,317 students from 10 high-performing high schools in upper-middle-class California communities. Along with the survey data, Pope and her colleagues used open-ended answers to explore the students' views on homework.   Median household income exceeded $90,000 in these communities, and 93 percent of the students went on to college, either two-year or four-year.   Students in these schools average about 3.1 hours of homework each night.   "The findings address how current homework practices in privileged, high-performing schools sustain students' advantage in competitive climates yet hinder learning, full engagement and well-being," Pope wrote.   Pope and her colleagues found that too much homework can diminish its effectiveness and even be counterproductive. They cite prior research indicating that homework benefits plateau at about two hours per night, and that 90 minutes to two and a half hours is optimal for high school.   Their study found that too much homework is associated with:   • Greater stress : 56 percent of the students considered homework a primary source of stress, according to the survey data. Forty-three percent viewed tests as a primary stressor, while 33 percent put the pressure to get good grades in that category. Less than 1 percent of the students said homework was not a stressor.   • Reductions in health : In their open-ended answers, many students said their homework load led to sleep deprivation and other health problems. The researchers asked students whether they experienced health issues such as headaches, exhaustion, sleep deprivation, weight loss and stomach problems.   • Less time for friends, family and extracurricular pursuits : Both the survey data and student responses indicate that spending too much time on homework meant that students were "not meeting their developmental needs or cultivating other critical life skills," according to the researchers. Students were more likely to drop activities, not see friends or family, and not pursue hobbies they enjoy.   A balancing act   The results offer empirical evidence that many students struggle to find balance between homework, extracurricular activities and social time, the researchers said. Many students felt forced or obligated to choose homework over developing other talents or skills.   Also, there was no relationship between the time spent on homework and how much the student enjoyed it. The research quoted students as saying they often do homework they see as "pointless" or "mindless" in order to keep their grades up.   "This kind of busy work, by its very nature, discourages learning and instead promotes doing homework simply to get points," said Pope, who is also a co-founder of Challenge Success , a nonprofit organization affiliated with the GSE that conducts research and works with schools and parents to improve students' educational experiences..   Pope said the research calls into question the value of assigning large amounts of homework in high-performing schools. Homework should not be simply assigned as a routine practice, she said.   "Rather, any homework assigned should have a purpose and benefit, and it should be designed to cultivate learning and development," wrote Pope.   High-performing paradox   In places where students attend high-performing schools, too much homework can reduce their time to foster skills in the area of personal responsibility, the researchers concluded. "Young people are spending more time alone," they wrote, "which means less time for family and fewer opportunities to engage in their communities."   Student perspectives   The researchers say that while their open-ended or "self-reporting" methodology to gauge student concerns about homework may have limitations – some might regard it as an opportunity for "typical adolescent complaining" – it was important to learn firsthand what the students believe.   The paper was co-authored by Mollie Galloway from Lewis and Clark College and Jerusha Conner from Villanova University.

Clifton B. Parker is a writer at the Stanford News Service .

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Is homework a necessary evil?

After decades of debate, researchers are still sorting out the truth about homework’s pros and cons. One point they can agree on: Quality assignments matter.

By Kirsten Weir

March 2016, Vol 47, No. 3

Print version: page 36

• Schools and Classrooms

Homework battles have raged for decades. For as long as kids have been whining about doing their homework, parents and education reformers have complained that homework's benefits are dubious. Meanwhile many teachers argue that take-home lessons are key to helping students learn. Now, as schools are shifting to the new (and hotly debated) Common Core curriculum standards, educators, administrators and researchers are turning a fresh eye toward the question of homework's value.

But when it comes to deciphering the research literature on the subject, homework is anything but an open book.

The 10-minute rule

In many ways, homework seems like common sense. Spend more time practicing multiplication or studying Spanish vocabulary and you should get better at math or Spanish. But it may not be that simple.

Homework can indeed produce academic benefits, such as increased understanding and retention of the material, says Duke University social psychologist Harris Cooper, PhD, one of the nation's leading homework researchers. But not all students benefit. In a review of studies published from 1987 to 2003, Cooper and his colleagues found that homework was linked to better test scores in high school and, to a lesser degree, in middle school. Yet they found only faint evidence that homework provided academic benefit in elementary school ( Review of Educational Research , 2006).

Then again, test scores aren't everything. Homework proponents also cite the nonacademic advantages it might confer, such as the development of personal responsibility, good study habits and time-management skills. But as to hard evidence of those benefits, "the jury is still out," says Mollie Galloway, PhD, associate professor of educational leadership at Lewis & Clark College in Portland, Oregon. "I think there's a focus on assigning homework because [teachers] think it has these positive outcomes for study skills and habits. But we don't know for sure that's the case."

Even when homework is helpful, there can be too much of a good thing. "There is a limit to how much kids can benefit from home study," Cooper says. He agrees with an oft-cited rule of thumb that students should do no more than 10 minutes a night per grade level — from about 10 minutes in first grade up to a maximum of about two hours in high school. Both the National Education Association and National Parent Teacher Association support that limit.

Beyond that point, kids don't absorb much useful information, Cooper says. In fact, too much homework can do more harm than good. Researchers have cited drawbacks, including boredom and burnout toward academic material, less time for family and extracurricular activities, lack of sleep and increased stress.

In a recent study of Spanish students, Rubén Fernández-Alonso, PhD, and colleagues found that students who were regularly assigned math and science homework scored higher on standardized tests. But when kids reported having more than 90 to 100 minutes of homework per day, scores declined ( Journal of Educational Psychology , 2015).

"At all grade levels, doing other things after school can have positive effects," Cooper says. "To the extent that homework denies access to other leisure and community activities, it's not serving the child's best interest."

Children of all ages need down time in order to thrive, says Denise Pope, PhD, a professor of education at Stanford University and a co-founder of Challenge Success, a program that partners with secondary schools to implement policies that improve students' academic engagement and well-being.

"Little kids and big kids need unstructured time for play each day," she says. Certainly, time for physical activity is important for kids' health and well-being. But even time spent on social media can help give busy kids' brains a break, she says.

All over the map

But are teachers sticking to the 10-minute rule? Studies attempting to quantify time spent on homework are all over the map, in part because of wide variations in methodology, Pope says.

A 2014 report by the Brookings Institution examined the question of homework, comparing data from a variety of sources. That report cited findings from a 2012 survey of first-year college students in which 38.4 percent reported spending six hours or more per week on homework during their last year of high school. That was down from 49.5 percent in 1986 ( The Brown Center Report on American Education , 2014).

The Brookings report also explored survey data from the National Assessment of Educational Progress, which asked 9-, 13- and 17-year-old students how much homework they'd done the previous night. They found that between 1984 and 2012, there was a slight increase in homework for 9-year-olds, but homework amounts for 13- and 17-year-olds stayed roughly the same, or even decreased slightly.

Yet other evidence suggests that some kids might be taking home much more work than they can handle. Robert Pressman, PhD, and colleagues recently investigated the 10-minute rule among more than 1,100 students, and found that elementary-school kids were receiving up to three times as much homework as recommended. As homework load increased, so did family stress, the researchers found ( American Journal of Family Therapy , 2015).

Many high school students also seem to be exceeding the recommended amounts of homework. Pope and Galloway recently surveyed more than 4,300 students from 10 high-achieving high schools. Students reported bringing home an average of just over three hours of homework nightly ( Journal of Experiential Education , 2013).

On the positive side, students who spent more time on homework in that study did report being more behaviorally engaged in school — for instance, giving more effort and paying more attention in class, Galloway says. But they were not more invested in the homework itself. They also reported greater academic stress and less time to balance family, friends and extracurricular activities. They experienced more physical health problems as well, such as headaches, stomach troubles and sleep deprivation. "Three hours per night is too much," Galloway says.

In the high-achieving schools Pope and Galloway studied, more than 90 percent of the students go on to college. There's often intense pressure to succeed academically, from both parents and peers. On top of that, kids in these communities are often overloaded with extracurricular activities, including sports and clubs. "They're very busy," Pope says. "Some kids have up to 40 hours a week — a full-time job's worth — of extracurricular activities." And homework is yet one more commitment on top of all the others.

"Homework has perennially acted as a source of stress for students, so that piece of it is not new," Galloway says. "But especially in upper-middle-class communities, where the focus is on getting ahead, I think the pressure on students has been ratcheted up."

Yet homework can be a problem at the other end of the socioeconomic spectrum as well. Kids from wealthier homes are more likely to have resources such as computers, Internet connections, dedicated areas to do schoolwork and parents who tend to be more educated and more available to help them with tricky assignments. Kids from disadvantaged homes are more likely to work at afterschool jobs, or to be home without supervision in the evenings while their parents work multiple jobs, says Lea Theodore, PhD, a professor of school psychology at the College of William and Mary in Williamsburg, Virginia. They are less likely to have computers or a quiet place to do homework in peace.

"Homework can highlight those inequities," she says.

Quantity vs. quality

One point researchers agree on is that for all students, homework quality matters. But too many kids are feeling a lack of engagement with their take-home assignments, many experts say. In Pope and Galloway's research, only 20 percent to 30 percent of students said they felt their homework was useful or meaningful.

"Students are assigned a lot of busywork. They're naming it as a primary stressor, but they don't feel it's supporting their learning," Galloway says.

"Homework that's busywork is not good for anyone," Cooper agrees. Still, he says, different subjects call for different kinds of assignments. "Things like vocabulary and spelling are learned through practice. Other kinds of courses require more integration of material and drawing on different skills."

But critics say those skills can be developed with many fewer hours of homework each week. Why assign 50 math problems, Pope asks, when 10 would be just as constructive? One Advanced Placement biology teacher she worked with through Challenge Success experimented with cutting his homework assignments by a third, and then by half. "Test scores didn't go down," she says. "You can have a rigorous course and not have a crazy homework load."

Still, changing the culture of homework won't be easy. Teachers-to-be get little instruction in homework during their training, Pope says. And despite some vocal parents arguing that kids bring home too much homework, many others get nervous if they think their child doesn't have enough. "Teachers feel pressured to give homework because parents expect it to come home," says Galloway. "When it doesn't, there's this idea that the school might not be doing its job."

Galloway argues teachers and school administrators need to set clear goals when it comes to homework — and parents and students should be in on the discussion, too. "It should be a broader conversation within the community, asking what's the purpose of homework? Why are we giving it? Who is it serving? Who is it not serving?"

Until schools and communities agree to take a hard look at those questions, those backpacks full of take-home assignments will probably keep stirring up more feelings than facts.

Further reading

• Cooper, H., Robinson, J. C., & Patall, E. A. (2006). Does homework improve academic achievement? A synthesis of research, 1987-2003. Review of Educational Research, 76 (1), 1–62. doi: 10.3102/00346543076001001
• Galloway, M., Connor, J., & Pope, D. (2013). Nonacademic effects of homework in privileged, high-performing high schools. The Journal of Experimental Education, 81 (4), 490–510. doi: 10.1080/00220973.2012.745469
• Pope, D., Brown, M., & Miles, S. (2015). Overloaded and underprepared: Strategies for stronger schools and healthy, successful kids . San Francisco, CA: Jossey-Bass.

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Homework Struggles May Not Be a Behavior Problem

Exploring some options to understand and help..

Posted August 2, 2022 | Reviewed by Abigail Fagan

• What Is Anxiety?
• Take our Generalized Anxiety Disorder Test
• Find a therapist to overcome anxiety
• Mental health challenges and neurodevelopmental differences directly affect children's ability to do homework.
• Understanding what difficulties are getting in the way—beyond the usual explanation of a behavior problem—is key.
• Sleep and mental health needs can take priority over homework completion.

Chelsea was in 10th grade the first time I told her directly to stop doing her homework and get some sleep. I had been working with her since she was in middle school, treating her anxiety disorder. She deeply feared disappointing anyone—especially her teachers—and spent hours trying to finish homework perfectly. The more tired and anxious she got, the harder it got for her to finish the assignments.

One night Chelsea called me in despair, feeling hopeless. She was exhausted and couldn’t think straight. She felt like a failure and that she was a burden to everyone because she couldn’t finish her homework.

She was shocked when I told her that my prescription for her was to go to sleep now—not to figure out how to finish her work. I told her to leave her homework incomplete and go to sleep. We briefly discussed how we would figure it out the next day, with her mom and her teachers. At that moment, it clicked for her that it was futile to keep working—because nothing was getting done.

This was an inflection point for her awareness of when she was emotionally over-cooked and when she needed to stop and take a break or get some sleep. We repeated versions of this phone call several times over the course of her high school and college years, but she got much better at being able to do this for herself most of the time.

When Mental Health Symptoms Interfere with Homework

Kids with mental health or neurodevelopmental challenges often struggle mightily with homework. Challenges can come up in every step of the homework process, including, but not limited to:

• Remembering and tracking assignments and materials
• Getting the mental energy/organization to start homework
• Filtering distractions enough to persist with assignments
• Understanding unspoken or implied parts of the homework
• Remembering to bring finished homework to class
• Being in class long enough to know the material
• Tolerating the fear of not knowing or failing
• Not giving up the assignment because of a panic attack
• Tolerating frustration—such as not understanding—without emotional dysregulation
• Being able to ask for help—from a peer or a teacher and not being afraid to reach out

This list is hardly comprehensive. ADHD , autism spectrum disorder, social anxiety , generalized anxiety, panic disorder, depression , dysregulation, and a range of other neurodevelopmental and mental health challenges cause numerous learning differences and symptoms that can specifically and frequently interfere with getting homework done.

The Usual Diagnosis for Homework Problems is "Not Trying Hard Enough"

Unfortunately, when kids frequently struggle to meet homework demands, teachers and parents typically default to one explanation of the problem: The child is making a choice not to do their homework. That is the default “diagnosis” in classrooms and living rooms. And once this framework is drawn, the student is often seen as not trying hard enough, disrespectful, manipulative, or just plain lazy.

The fundamental disconnect here is that the diagnosis of homework struggles as a behavioral choice is, in fact, only one explanation, while there are so many other diagnoses and differences that impair children's ability to consistently do their homework. If we are trying to create solutions based on only one understanding of the problem, the solutions will not work. More devastatingly, the wrong solutions can worsen the child’s mental health and their long-term engagement with school and learning.

To be clear, we aren’t talking about children who sometimes struggle with or skip homework—kids who can change and adapt their behaviors and patterns in response to the outcomes of that struggle. For this discussion, we are talking about children with mental health and/or neurodevelopmental symptoms and challenges that create chronic difficulties with meeting homework demands.

How Can You Help a Child Who Struggles with Homework?

How can you help your child who is struggling to meet homework demands because of their ADHD, depression, anxiety, OCD , school avoidance, or any other neurodevelopmental or mental health differences? Let’s break this down into two broad areas—things you can do at home, and things you can do in communication with the school.

Helping at Home

The following suggestions for managing school demands at home can feel counterintuitive to parents—because we usually focus on helping our kids to complete their tasks. But mental health needs jump the line ahead of task completion. And starting at home will be key to developing an idea of what needs to change at school.

• Set an end time in the evening after which no more homework will be attempted. Kids need time to decompress and they need sleep—and pushing homework too close to or past bedtime doesn’t serve their educational needs. Even if your child hasn’t been able to approach the homework at all, even if they have avoided and argued the whole evening, it is still important for everyone to have a predictable time to shut down the whole process.
• If there are arguments almost every night about homework, if your child isn’t starting homework or finishing it, reframe it from failure into information. It’s data to put into problem-solving. We need to consider other possible explanations besides “behavioral choice” when trying to understand the problem and create effective solutions. What problems are getting in the way of our child’s meeting homework demands that their peers are meeting most of the time?
• Try not to argue about homework. If you can check your own anxiety and frustration, it can be more productive to ally with your child and be curious with them. Kids usually can’t tell you a clear “why” but maybe they can tell you how they are feeling and what they are thinking. And if your child can’t talk about it or just keeps saying “I don't know,” try not to push. Come back another time. Rushing, forcing, yelling, and threatening will predictably not help kids do homework.

Helping at School

The second area to explore when your neurodiverse child struggles frequently with homework is building communication and connections with school and teachers. Some places to focus on include the following.

• Label your child’s diagnoses and break down specific symptoms for the teachers and school team. Nonjudgmental, but specific language is essential for teachers to understand your child’s struggles. Breaking their challenges down into the problems specific to homework can help with building solutions. As your child gets older, help them identify their difficulties and communicate them to teachers.
• Let teachers and the school team know that your child’s mental health needs—including sleep—take priority over finishing homework. If your child is always struggling to complete homework and get enough sleep, or if completing homework is leading to emotional meltdowns every night, adjusting their homework demands will be more successful than continuing to push them into sleep deprivation or meltdowns.
• Request a child study team evaluation to determine if your child qualifies for services under special education law such as an IEP, or accommodations through section 504—and be sure that homework adjustments are included in any plan. Or if such a plan is already in place, be clear that modification of homework expectations needs to be part of it.

The Long-Term Story

I still work with Chelsea and she recently mentioned how those conversations so many years ago are still part of how she approaches work tasks or other demands that are spiking her anxiety when she finds herself in a vortex of distress. She stops what she is doing and prioritizes reducing her anxiety—whether it’s a break during her day or an ending to the task for the evening. She sees that this is crucial to managing her anxiety in her life and still succeeding at what she is doing.

Task completion at all costs is not a solution for kids with emotional needs. Her story (and the story of many of my patients) make this crystal clear.

Candida Fink, M.D. , is board certified in child/adolescent and general psychiatry. She practices in New York and has co-authored two books— The Ups and Downs of Raising a Bipolar Child and Bipolar Disorder for Dummies.

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Health Hazards of Homework

March 18, 2014 | Julie Greicius Pediatrics .

A new study by the Stanford Graduate School of Education and colleagues found that students in high-performing schools who did excessive hours of homework “experienced greater behavioral engagement in school but also more academic stress, physical health problems, and lack of balance in their lives.”

Those health problems ranged from stress, headaches, exhaustion, sleep deprivation, weight loss and stomach problems, to psycho-social effects like dropping activities, not seeing friends or family, and not pursuing hobbies they enjoy.

In the Stanford Report story about the research, Denise Pope , a senior lecturer at the Stanford Graduate School of Education and a co-author of the  study published in the  Journal of Experimental Education , says, “Our findings on the effects of homework challenge the traditional assumption that homework is inherently good.”

The study was based on survey data from a sample of 4,317 students from 10 high-performing high schools in California communities in which median household income exceeded $90,000. Of the students surveyed, homework volume averaged about 3.1 hours each night.

“It is time to re-evaluate how the school environment is preparing our high school student for today’s workplace,” says Neville Golden, MD , chief of adolescent medicine at Stanford Medicine Children’s Health and a professor at the School of Medicine. “This landmark study shows that excessive homework is counterproductive, leading to sleep deprivation, school stress and other health problems. Parents can best support their children in these demanding academic environments by advocating for them through direct communication with teachers and school administrators about homework load.”

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Homework as a Mental Health Concern It's time for an in depth discussion about homework as a major concern for those pursuing mental health in schools. So many problems between kids and their families, the home and school, and students and teachers arise from conflicts over homework. The topic is a long standing concern for mental health practitioners, especially those who work in schools. Over the years, we have tried to emphasize the idea that schools need to ensure that homework is designed as "motivated practice," and parents need to avoid turning homework into a battleground. These views are embedded in many of the Center documents. At this time, we hope you will join in a discussion of what problems you see arising related to homework and what you recommend as ways to deal with such problems, what positive homework practices you know about, and so forth. Read the material that follows, and then, let us hear from you on this topic. Contact: [email protected] ######################### As one stimulus, here's a piece by Sharon Cromwell from Education World prepared for teachers " The Homework Dilemma: How Much Should Parents Get Involved? " http://www.education-world.com/a_curr/curr053.shtml . What can teachers do to help parents help their children with homework? Just what kind of parental involvement -- and how much involvement -- truly helps children with their homework? The most useful stance parents can take, many experts agree, is to be somewhat but not overly involved in homework. The emphasis needs to be on parents' helping children do their homework themselves -- not on doing it for them. In an Instructor magazine article, How to Make Parents Your Homework Partner s, study-skills consultant Judy Dodge maintains that involving students in homework is largely the teacher's job, yet parents can help by "creating a home environment that's conducive to kids getting their homework done." Children who spend more time on homework, on average, do better academically than children who don't, and the academic benefits of homework increase in the upper grades, according to Helping Your Child With Homework , a handbook by the Office of Education Research and Improvement in the U.S. Department of Education. The handbook offers ideas for helping children finish homework assignments successfully and answers questions that parents and people who care for elementary and junior high school students often ask about homework. One of the Goals 2000 goals involves the parent/school relationship. The goal reads, "Every school will promote partnerships that will increase parental involvement and participation in promoting the social, emotional, and academic growth of children." Teachers can pursue the goal, in part, by communicating to parents their reasons for assigning homework. For example, the handbook states, homework can help children to review and practice what they have learned; prepare for the next day's class; use resources, such as libraries and reference materials; investigate topics more fully than time allows in the classroom. Parents can help children excel at homework by setting a regular time; choosing a place; removing distractions; having supplies and resources on hand; monitoring assignments; and providing guidance. The handbook cautions against actually doing the homework for a child, but talking about the assignment so the child can figure out what needs to be done is OK. And reviewing a completed assignment with a child can also be helpful. The kind of help that works best depends, of course, partly on the child's age. Elementary school students who are doing homework for the first time may need more direct involvement than older students. HOMEWORK "TIPS" Specific methods have been developed for encouraging the optimal parental involvement in homework. TIPS (Teachers Involve Parents in Schoolwork) Interactive Homework process was designed by researchers at Johns Hopkins University and teachers in Maryland, Virginia, and the District of Columbia to meet parents' and teachers' needs, says the Phi Delta Kappa Research Bulletin . The September 1997 bulletin reported the effects of TIPS-Language Arts on middle-grade students' writing skills, language arts report card grades, and attitudes toward TIPS as well as parents' reactions to interactive homework. TIPS interactive homework assignments involve students in demonstrating or discussing homework with a family member. Parents are asked to monitor, interact, and support their children. They are not required to read or direct the students' assignments because that is the students' responsibility. All TIPS homework has a section for home-to-school communication where parents indicate their interaction with the student about the homework. The goals of the TIPS process are for parents to gain knowledge about their children's school work, students to gain mastery in academic subjects by enhancing school lessons at home, and teachers to have an understanding of the parental contribution to student learning. "TIPS" RESULTS Nearly all parents involved in the TIPS program said TIPS provided them with information about what their children were studying in school. About 90 percent of the parents wanted the school to continue TIPS the following year. More than 80 percent of the families liked the TIPS process (44 percent a lot; 36% a little). TIPS activities were better than regular homework, according to 60 percent of the students who participated. About 70 percent wanted the school to use TIPS the next year. According to Phi Delta Kappa Research Bulletin , more family involvement helped students' writing skills increase, even when prior writing skills were taken into account. And completing more TIPS assignments improved students' language arts grades on report cards, even after prior report card grades and attendance were taken into account. Of the eight teachers involved, six liked the TIPS process and intended to go on using it without help or supplies from the researchers. Furthermore, seven of the eight teachers said TIPS "helps families see what their children are learning in class." OTHER TIPS In "How to Make Parents Your Homework Partners," Judy Dodge suggests that teachers begin giving parent workshops to provide practical tips for "winning the homework battle." At the workshop, teachers should focus on three key study skills: Organizational skills -- Help put students in control of work and to feel sure that they can master what they need to learn and do. Parents can, for example, help students find a "steady study spot" with the materials they need at hand. Time-management skills -- Enable students to complete work without feeling too much pressure and to have free time. By working with students to set a definite study time, for example, parents can help with time management. Active study strategies -- Help students to achieve better outcomes from studying. Parents suggest, for instance, that students write questions they think will be on a test and then recite their answers out loud. Related Resources Homework Without Tears by Lee Canter and Lee Hauser (Perennial Library, 1987). A down-to-earth book by well-known experts suggests how to deal with specific homework problems. Megaskills: How Families Can Help Children Succeed in School and Beyond by Dorothy Rich (Houghton Mifflin Company, 1992). Families can help children develop skills that nurture success in and out of school. "Helping Your Student Get the Most Out of Homework" by the National PTA and the National Education Association (1995). This booklet for teachers to use with students is sold in packages of 25 through the National PTA. The Catalog item is #B307. Call 312-549-3253 or write National PTA Orders, 135 South LaSalle Street, Dept. 1860, Chicago, IL 60674-1860. Related Sites A cornucopia of homework help is available for children who use a computer or whose parents are willing to help them get started online. The following LINKS include Internet sites that can be used for reference, research, and overall resources for both homework and schoolwork. Dr. Internet. The Dr. Internet Web site, part of the Internet Public Library, helps students with science and math homework or projects. It includes a science project resource guide Help With Homework. His extensive listing of Internet links is divided into Language Art Links, Science Links, Social Studies Links, Homework Help, Kids Education, and Universities. If students know what they are looking for, the site could be invaluable. Kidz-Net... Links to places where you can get help with homework. An array of homework help links is offered here, from Ask Dr. Math (which provides answers to math questions) to Roget's Thesaurus and the White House. Surfing the Net With Kids: Got Questions? Links to people -- such as teachers, librarians, experts, authors, and other students -- who will help students with questions about homework. Barbara J. Feldman put together the links. Kidsurfer: For Kids and Teens The site, from the National Children's Coalition, includes a Homework/Reference section for many subjects, including science, geography, music, history, and language arts. Homework: Parents' Work, Kid's Work, or School Work? A quick search of this title in the Education Week Archives and you'll find an article presenting a parent's viewpoint on helping children with homework. @#@#@#@@# As another stimulus for the discussion, here is an excerpt from our online continuing education module Enhancing Classroom Approaches for Addressing Barriers to Learning ( https://smhp.psych.ucla.edu ) Turning Homework into Motivated Practice Most of us have had the experience of wanting to be good at something such as playing a musical instrument or participating in a sport. What we found out was that becoming good at it meant a great deal of practice, and the practicing often was not very much fun. In the face of this fact, many of us turned to other pursuits. In some cases, individuals were compelled by their parents to labor on, and many of these sufferers grew to dislike the activity. (A few, of course, commend their parents for pushing them, but be assured these are a small minority. Ask your friends who were compelled to practice the piano.) Becoming good at reading, mathematics, writing, and other academic pursuits requires practice outside the classroom. This, of course, is called homework. Properly designed, homework can benefit students. Inappropriately designed homework, however, can lead to avoidance, parent-child conflicts, teacher reproval, and student dislike of various arenas of learning. Well-designed homework involves assignments that emphasize motivated practice. As with all learning processes that engage students, motivated practice requires designing activities that the student perceives as worthwhile and doable with an appropriate amount of effort. In effect, the intent is to personalize in-class practice and homework. This does not mean every student has a different practice activity. Teachers quickly learn what their students find engaging and can provide three or four practice options that will be effective for most students in a class. The idea of motivated practice is not without its critics. I don't doubt that students would prefer an approach to homework that emphasized motivated practice. But �� that's not preparing them properly for the real world. People need to work even when it isn't fun, and most of the time work isn't fun. Also, if a person wants to be good at something, they need to practice it day in and day out, and that's not fun! In the end, won't all this emphasis on motivation spoil people so that they won't want to work unless it's personally relevant and interesting? We believe that a great deal of learning and practice activities can be enjoyable. But even if they are not, they can be motivating if they are viewed as worthwhile and experienced as satisfying. At the same time, we do recognize that there are many things people have to do in their lives that will not be viewed and experienced in a positive way. How we all learn to put up with such circumstances is an interesting question, but one for which psychologists have yet to find a satisfactory answer. It is doubtful, however, that people have to experience the learning and practice of basic knowledge and skills as drudgery in order to learn to tolerate boring situations. Also in response to critics of motivated practice, there is the reality that many students do not master what they have been learning because they do not pursue the necessary practice activities. Thus, at least for such individuals, it seems essential to facilitate motivated practice. Minimally, facilitating motivated practice requires establishing a variety of task options that are potentially challenging -- neither too easy nor too hard. However, as we have stressed, the processes by which tasks are chosen must lead to perceptions on the part of the learner that practice activities, task outcomes, or both are worthwhile -- especially as potential sources of personal satisfaction. The examples in the following exhibit illustrate ways in which activities can be varied to provide for motivated learning and practice. Because most people have experienced a variety of reading and writing activities, the focus here is on other types of activity. Students can be encouraged to pursue such activity with classsmates and/or family members. Friends with common interests can provide positive models and support that can enhance productivity and even creativity. Research on motivation indicates that one of the most powerful factors keeping a person on a task is the expectation of feeling some sense of satisfaction when the task is completed. For example, task persistence results from the expectation that one will feel smart or competent while performing the task or at least will feel that way after the skill is mastered. Within some limits, the stronger the sense of potential outcome satisfaction, the more likely practice will be pursued even when the practice activities are rather dull. The weaker the sense of potential outcome satisfaction, the more the practice activities themselves need to be positively motivating. Exhibit � Homework and Motivated Practice Learning and practicing by (1) doing using movement and manipulation of objects to explore a topic (e.g., using coins to learn to add and subtract) dramatization of events (e.g., historical, current) role playing and simulations (e.g., learning about democratic vs. autocratic government by trying different models in class; learning about contemporary life and finances by living on a budget) actual interactions (e.g., learning about human psychology through analysis of daily behavior) applied activities (e.g., school newspapers, film and video productions, band, sports) actual work experience (e.g., on-the-job learning) (2) listening reading to students (e.g., to enhance their valuing of literature) audio media (e.g., tapes, records, and radio presentations of music, stories, events) listening games and activities (e.g., Simon Says; imitating rhymes, rhythms, and animal sounds) analyzing actual oral material (e.g., learning to detect details and ideas in advertisements or propaganda presented on radio or television, learning to identify feelings and motives underlying statements of others) (3) looking directly observing experts, role models, and demonstrations visual media visual games and activities (e.g., puzzles, reproducing designs, map activities) analyzing actual visual material (e.g., learning to find and identify ideas observed in daily events) (4) asking information gathering (e.g., investigative reporting, interviewing, and opinion sampling at school and in the community) brainstorming answers to current problems and puzzling questions inquiry learning (e.g., learning social studies and science by identifying puzzling questions, formulating hypotheses, gathering and interpreting information, generalizing answers, and raising new questions) question-and-answer games and activities (e.g., twenty questions, provocative and confrontational questions) questioning everyday events (e.g., learning about a topic by asking people about how it effects their lives) O.K. That's should be enough to get you going. What's your take on all this? What do you think we all should be telling teachers and parents about homework? Let us hear from you ( [email protected] ). Back to Hot Topic Home Page Hot Topic Home Page --> Table of Contents Home Page Search Send Us Email School Mental Health Project-UCLA Center for Mental Health in Schools WebMaster: Perry Nelson ([email protected])

Opinion | Social-Emotional Learning

If we’re serious about student well-being, we must change the systems students learn in, here are five steps high schools can take to support students' mental health., by tim klein and belle liang     oct 14, 2022.

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This article is part of the collection: Making Sense of K-12 Student Mental Health.

Educators and parents started this school year with bated breath. Last year’s stress led to record levels of teacher burnout and mental health challenges for students.

Even before the pandemic, a mental health crisis among high schoolers loomed. According to a survey administered by the Centers for Disease Control and Prevention in 2019, 37 percent of high school students said they experienced persistent sadness or hopelessness and 19 percent reported suicidality. In response, more than half of all U.S. states mandated that schools have a mental health curriculum or include mental health in their standards .

As mental health professionals and co-authors of a book about the pressure and stress facing high school students, we’ve spent our entire careers supporting students’ mental health. Traditionally, mental health interventions are individualized and they focus on helping students manage and change their behaviors to cope with challenges they’re facing. But while working with schools and colleges across the globe as we conducted research for our book , we realized that most interventions don’t address systemic issues causing mental health problems in the first place.

It’s time we acknowledge that our education systems are directly contributing to the youth mental health crisis. And if we are serious about student well-being, we must change the systems they learn in.

Here are five bold steps that high schools can take to boost mental health.

Limit Homework or Make it Optional

Imagine applying for a job, and the hiring manager informs you that in addition to a full workday in the office, you’ll be assigned three more hours of work every night. Does this sound like a healthy work-life balance? Most adults would consider this expectation ridiculous and unsustainable. Yet, this is the workload most schools place on high school students.

Research shows that excessive homework leads to increased stress, physical health problems and a lack of balance in students' lives. And studies have shown that more than two hours of daily homework can be counterproductive , yet many teachers assign more.

Homework proponents argue that homework improves academic performance. Indeed, a meta-analysis of research on this issue found a correlation between homework and achievement. But correlation isn’t causation. Does homework cause achievement or do high achievers do more homework? While it’s likely that homework completion signals student engagement, which in turn leads to academic achievement, there’s little evidence to suggest that homework itself improves engagement in learning.

Another common argument is that homework helps students develop skills related to problem-solving, time-management and self-direction. But these skills can be explicitly taught during the school day rather than after school.

Limiting homework or moving to an optional homework policy not only supports student well-being, but it can also create a more equitable learning environment. According to the American Psychological Association, students from more affluent families are more likely to have access to resources such as devices, internet, dedicated work space and the support necessary to complete their work successfully—and homework can highlight those inequities .

Whether a school limits homework or makes it optional, it’s critical to remember that more important than the amount of homework assigned, is designing the type of activities that engage students in learning. When students are intrinsically motivated to do their homework, they are more engaged in the work, which in turn is associated with academic achievement.

Cap the Number of APs Students Can Take

Advanced Placement courses give students a taste of college-level work and, in theory, allow them to earn college credits early. Getting good grades on AP exams is associated with higher GPAs in high school and success in college, but the research tends to be correlational rather than causational.

In 2008, a little over 180,000 students took three or more AP exams. By 2018, that number had ballooned to almost 350,000 students .

However, this expansion has come at the expense of student well-being.

Over the years, we’ve heard many students express that they feel pressure to take as many AP classes as possible, which overloads them with work. That’s troubling because studies show that students who take AP classes and exams are twice as likely to report adverse physical and emotional health .

AP courses and exams also raise complex issues of equity. In 2019, two out of three Harvard freshmen reported taking AP Calculus in high school, according to Jeff Selingo, author of “ Who Gets In and Why: A Year Inside College Admissions ,” yet only half of all high schools in the country offer the course. And opportunity gaps exist for advanced coursework such as AP courses and dual enrollment, with inequitable distribution of funding and support impacting which students are enrolling and experiencing success. According to the Center for American Progress, “National data from the Civil Rights Data Collection show that students who are Black, Indigenous, and other non-Black people of color (BIPOC) are not enrolled in AP courses at rates comparable to their white and Asian peers and experience less success when they are—and the analysis for this report finds this to be true even when they attend schools with similar levels of AP course availability.”

Limiting the number of AP courses students take can protect mental health and create a more equitable experience for students.

Eliminate Class Rankings

In a study we conducted about mental health problems among high school girls, we found that a primary driver of stress was their perception of school as a hypercompetitive, zero-sum game where pervasive peer pressure to perform reigns supreme.

Class rankings fuel these cutthroat environments. They send a toxic message to young people: success requires doing better than your peers.

Ranking systems help highly selective colleges decide which students to admit or reject for admission. The purpose of high school is to develop students to their own full potential, rather than causing them to fixate on measuring up to others. Research shows that ranking systems undercut students’ learning and damage social relationships by turning peers into opponents.

Eliminating class rankings sends a powerful message to students that they are more than a number.

Become an Admission Test Objector

COVID-19 ushered in the era of test-optional admissions. De-centering standardized tests in the college application process is unequivocally a good thing. Standardized tests don’t predict student success in college , they only widen the achievement gap between privileged and underprivileged students and damage students' mental health .

Going “test optional” is an excellent first step, but it's not enough.

Even as more colleges have made tests optional, affluent students submit test scores at a higher rate than their lower-income peers and are admitted at higher rates , suggesting that testing still gives them an edge.

High schools must adhere to standardized test mandates, but they don’t have to endorse them. They can become test objectors by publicly proclaiming that these tests hold no inherent value. They can stop teaching to the test and educate parents on why they are doing so. Counseling departments can inform colleges that their school is a test objector so admission teams won’t penalize students.

Of course, students and families will still find ways to wield these tests as a competitive advantage. Over time, the more schools and educators unite to denounce these tests, the less power they will hold over students and families.

Big change starts with small steps.

Stand For What You Value

Critics may argue that such policies might hurt student outcomes. How will colleges evaluate school rigor if we limit AP courses and homework? How will students demonstrate their merits without class rankings and standardized test scores?

The truth is, the best school systems in the world succeed without homework, standardized test scores or an obsession with rigorous courses. And many U.S. schools have found creative and empowering ways to showcase student merit beyond rankings and test scores.

If we aren’t willing to change policies and practices that have been shown to harm students’ well-being, we have to ask ourselves: Do we really value mental health?

Thankfully, it doesn’t have to be an either/or scenario: We can design school systems that help students thrive academically and psychologically.

Belle Liang and Tim Klein are mental health professionals and co-authors of “How To Navigate Life: The New Science of Finding Your Way in School, Career and Life.”

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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.

Sending Homework to Clients in Therapy: The Easy Way

Successful therapy relies on using assignments outside of sessions to reinforce learning and practice newly acquired skills in real-world settings (Mausbach et al., 2010).

Up to 50% of clients don’t adhere to homework compliance, often leading to failure in CBT and other therapies (Tang & Kreindler, 2017).

In this article, we explore how to use technology to create homework, send it out, and track its completion to ensure compliance.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

Is homework in therapy important, how to send homework to clients easily, homework in quenza: 5 examples of assignments, 5 counseling homework ideas and worksheets, using care pathways & quenza’s pathway builder, a take-home message.

Cognitive-Behavioral Therapy has “been shown to be as effective as medications in the treatment of a number of psychiatric illnesses” (Tang & Kreindler, 2017, p. 1).

Homework is a vital component of CBT, typically involving completing a structured and focused activity between sessions.

Practicing what was learned in therapy helps clients deal with specific symptoms and learn how to generalize them in real-life settings (Mausbach et al., 2010).

CBT practitioners use homework to help their clients, and it might include symptom logs, self-reflective journals , and specific tools for working on obsessions and compulsions. Such tasks, performed outside therapy sessions, can be divided into three types (Tang & Kreindler, 2017):

• Psychoeducation Reading materials are incredibly important early on in therapy to educate clients regarding their symptoms, possible causes, and potential treatments.
• Self-assessment Monitoring their moods and completing thought records can help clients recognize associations between their feelings, thoughts, and behaviors.
• Modality specific Therapists may assign homework that is specific and appropriate to the problem the client is presenting. For example, a practitioner may use images of spiders for someone with arachnophobia.

Therapists strategically create homework to lessen patients’ psychopathology and encourage clients to practice skills learned during therapy sessions, but non-adherence (between 20% and 50%) remains one of the most cited reasons for CBT failure (Tang & Kreindler, 2017).

Reasons why clients might fail to complete homework include (Tang & Kreindler, 2017):

Internal factors

• Lack of motivation to change what is happening when experiencing negative feelings
• Being unable to identify automatic thoughts
• Failing to see the importance or relevance of homework
• Impatience and the wish to see immediate results

External factors

• Effort required to complete pen-and-paper exercises
• Inconvenience and amount of time to complete
• Failing to understand the purpose of the homework, possibly due to lack of or weak instruction
• Difficulties encountered during completion

Homework compliance is associated with short-term and long-term improvement of many disorders and unhealthy behaviors, including anxiety, depression, pathological behaviors, smoking, and drug dependence (Tang & Kreindler, 2017).

Greater homework adherence increases the likelihood of beneficial therapy outcomes (Mausbach et al., 2010).

With that in mind, therapy must find ways to encourage the completion of tasks set for the client. Technology may provide the answer.

The increased availability of internet-connected devices, improved software, and widespread internet access enable portable, practical tools to enhance homework compliance (Tang & Kreindler, 2017).

Clients who complete their homework assignments progress better than those who don’t (Beck, 2011).

Having an ideal platform for therapy makes it easy to send and track clients’ progress through assignments. It must be “user-friendly, accessible, reliable and secure from the perspective of both coach and client” (Ribbers & Waringa, 2015, p. 103).

In dedicated online therapy and coaching software, homework management is straightforward. The therapist creates the homework then forwards it to the client. They receive a notification and complete the work when it suits them. All this is achieved in one system, asynchronously; neither party needs to be online at the same time.

For example, in Quenza , the therapist can create a worksheet or tailor an existing one from the library as an activity that asks the client to reflect on the progress they have made or work they have completed.

The activity can either be given directly to the client or group, or included in a pathway containing other activities.

Here is an example of the activity parameters that Quenza makes possible.

A message can be attached to the activity, using either a template or a personally tailored message for the client. Here’s an example.

Once the activity is published and sent, the client receives a notification about a received assignment via their coaching app (mobile or desktop) or email.

The client can then open the Quenza software and find the new homework under their ‘To Do’ list.

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Quenza provides the ability to create your own assignments as well as a wide selection of existing ones that can be assigned to clients for completion as homework.

The following activities can be tailored to meet specific needs or used as-is. Therapists can share them with the client individually or packaged into dedicated pathways.

Such flexibility allows therapists to meet the specific needs of the client using a series of dedicated and trackable homework.

Examples of Quenza’s ready-to-use science-based activities include the following:

Wheel of Life

The Wheel of Life is a valuable tool for identifying and reflecting on a client’s satisfaction with life.

You can find the worksheet in the Positive Psychology Toolkit© , and it is also included in the Quenza library. The client scores themselves between 1 and 10 on specific life domains (the therapist can tailor the domains), including relationships, career development, and leisure time.

This is an active exercise to engage the client early on in therapy to reflect on their current and potential life. What is it like now? How could it look?

The wheel identifies where there are differences between perceived balance and reality .

The deep insights it provides can provide valuable input and prioritization for goal setting.

The Private Garden: A Visualization for Stress Reduction

While stress is a normal part of life, it can become debilitating and interfere with our everyday lives, stopping us from reaching our life goals.

We may notice stress as worry, anxiety, and tension and resort to avoidant or harmful behaviors (e.g., abusing alcohol, smoking, comfort eating) to manage these feelings.

Visualization is simple but a powerful method for reducing physical and mental stress, especially when accompanied by breathing exercises.

The audio included within this assignment helps the listener visualize a place of safety and peace and provides a temporary respite from stressful situations.

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20 Guidelines for Developing a Growth Mindset

Research into neuroplasticity has confirmed the ability of the adult brain to continue to change in adulthood and the corresponding capacity for people to develop and transform their mindsets (Dweck, 2017).

The 20 guidelines (included in our Toolkit and part of the Quenza library) and accompanying video explain our ability to change mentally and develop a growth mindset that includes accepting imperfection, leaning into challenges, continuing to learn, and seeing ‘failure’ as an opportunity for growth.

Adopting a growth mindset can help clients understand that our abilities and understanding are not fixed; we can develop them in ways we want with time and effort.

Self-Contract

Committing to change is accepted as an effective way to promote behavioral change – in health and beyond. When a client makes a contract with themselves, they explicitly state their intention to deliver on plans and short- and long-term goals.

Completing and signing such a self-contract (included in our Toolkit and part of the Quenza library) online can help people act on their commitment through recognizing and living by their values.

Not only that, the contract between the client and themselves can be motivational, building momentum and self-efficacy.

The contract can be automatically personalized to include the client’s name but also manually reworded as appropriate.

The client completes the form by restating their name and committing to a defined goal by a particular date, along with their reasons for doing so.

Realizing Long-Lasting Change by Setting Process Goals

We can help clients realize their goals by building supportive habits. Process goals – for example, eating healthily and exercising – require ongoing actions to be performed regularly.

Process goals (unlike end-state goals, such as saving up for a vacation) require long-lasting and continuous change that involves monitoring standards.

This tool (included in our Toolkit and part of the Quenza library) can help clients identify positive actions (rather than things to avoid) that they must carry out repeatedly to realize change.

We have many activities that can be used to help clients attending therapy for a wide variety of issues.

In this section, we consider homework ideas that can be used in couples therapy, family therapy, and supporting clients with depression and anxiety.

Couples therapy homework

Conflict is inevitable in most long-term relationships. Everyone has their idiosyncrasies and individual set of needs. The Marital Conflicts worksheet captures a list of situations in which conflicts arise, when they happen, and how clients feel when they are (un)resolved.

Family therapy homework

Families, like individuals, are susceptible to times of stress and disruptions because of life changes such as illness, caring for others, and job and financial insecurity.

Mind the Gap is a family therapy worksheet where a family makes decisions together to align with goals they aspire to. Mind the gap is a short exercise to align with values and improve engagement.

How holistic therapist Jelisa Glanton uses Quenza

Homework ideas for depression and anxiety: 3 Exercises

The following exercises are all valuable for helping clients with the effects of anxiety and depression.

Activity Schedule is a template assisting a client with scheduling and managing normal daily activities, especially important for those battling with depression.

Activity Menu is a related worksheet, allowing someone with depression to select from a range of normal activities and ideas, and add these to a schedule as goals for improvement.

The Pleasurable Activity Journal focus on activities the client used to find enjoyable. Feelings regarding these activities are journaled, to track recovery progress.

Practicing mindfulness is helpful for those experiencing depression (Shapiro, 2020). A regular gratitude practice can develop new neural pathways and create a more grateful, mindful disposition (Shapiro, 2020).

Each activity can be tailored to the client’s needs; shared as standalone exercises, worksheets, or questionnaires; or included within a care pathway.

A pathway is an automated and scheduled series of activities that can take the client through several stages of growth, including psychoeducation , assessment, and action to produce a behavioral change in a single journey.

How to build pathways

The creator can add two pathway titles. The second title is not necessary, but if entered, it is seen by the client in place of the first.

Once named, a series of steps can be created and reordered at any time, each containing an activity. Activities can be built from scratch, modified from existing ones in the library, or inserted as-is.

New activities can be created and used solely in this pathway or made available for others. They can contain various features, including long- and short-answer boxes, text boxes, multiple choice boxes, pictures, diagrams, and audio and video files.

Quenza can automatically deliver each step or activity in the pathway to the client following the previous one or after a certain number of days. Such timing is beneficial when the client needs to reflect on something before completing the next step.

Practitioners can also designate steps as required or optional before the client continues to the next one.

Practitioners can also add helpful notes not visible to the client. These comments can contain practical reminders of future changes or references to associated literature that the client does not need to see.

It is also possible to choose who can see client responses: the client and you, the client only, or the client decides.

Tags help categorize the pathway (e.g., by function, intended audience, or suggested timing within therapy) and can be used to filter what is displayed on the therapist’s pathway screen.

Once designed, the pathway can be saved as a draft or published and sent to the client. The client receives the notification of the new assignment either via email or the coaching app on their phone, tablet, or desktop.

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Success in therapy is heavily reliant on homework completion. The greater the compliance, the more likely the client is to have a better treatment outcome (Mausbach et al., 2010).

To improve the likelihood that clients engage with and complete the assignments provided, homework must be appropriate to their needs, have a sound rationale, and do the job intended (Beck, 2011).

Technology such as Quenza can make homework readily available on any device, anytime, from any location, and ensure it contains clear and concise psychoeducation and instructions for completion.

The therapist can easily create, copy, and tailor homework and, if necessary, combine multiple activities into single pathways. These are then shared with the click of a button. The client is immediately notified but can complete it at a time appropriate to them.

Quenza can also send automatic reminders about incomplete assignments to the client and highlight their status to the therapist. Not only that, but any resulting questions can be delivered securely to the therapist with no risk of getting lost in a busy email inbox.

Why not try the Quenza application? Try using some of the existing science-based activities or create your own. It offers an impressive array of functionality that will not only help you scale your business, but also ensure proactive, regular communication with your existing clients.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond . Guilford Press.
• Dweck, C. S. (2017).  Mindset: The new psychology of success.  Robinson.
• 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.
• Ribbers, A., & Waringa, A. (2015). E-coaching: Theory and practice for a new online approach to coaching . Routledge.
• Shapiro, S. L. (2020).  Rewire your mind: Discover the science and practice of mindfulness. Aster.
• Tang, W., & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health , 4 (2).

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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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Education scholar Denise Pope has found that too much homework has negative effects on student well-being and behavioral engagement. (Image credit: L.A. Cicero)

A Stanford researcher found that too much homework can negatively affect kids, especially their lives away from school, where family, friends and activities matter.

“Our findings on the effects of homework challenge the traditional assumption that homework is inherently good,” wrote Denise Pope , a senior lecturer at the Stanford Graduate School of Education and a co-author of a study published in the Journal of Experimental Education .

The researchers used survey data to examine perceptions about homework, student well-being and behavioral engagement in a sample of 4,317 students from 10 high-performing high schools in upper-middle-class California communities. Along with the survey data, Pope and her colleagues used open-ended answers to explore the students’ views on homework.

Median household income exceeded $90,000 in these communities, and 93 percent of the students went on to college, either two-year or four-year.

Students in these schools average about 3.1 hours of homework each night.

“The findings address how current homework practices in privileged, high-performing schools sustain students’ advantage in competitive climates yet hinder learning, full engagement and well-being,” Pope wrote.

Pope and her colleagues found that too much homework can diminish its effectiveness and even be counterproductive. They cite prior research indicating that homework benefits plateau at about two hours per night, and that 90 minutes to two and a half hours is optimal for high school.

Their study found that too much homework is associated with:

* Greater stress: 56 percent of the students considered homework a primary source of stress, according to the survey data. Forty-three percent viewed tests as a primary stressor, while 33 percent put the pressure to get good grades in that category. Less than 1 percent of the students said homework was not a stressor.

* Reductions in health: In their open-ended answers, many students said their homework load led to sleep deprivation and other health problems. The researchers asked students whether they experienced health issues such as headaches, exhaustion, sleep deprivation, weight loss and stomach problems.

* Less time for friends, family and extracurricular pursuits: Both the survey data and student responses indicate that spending too much time on homework meant that students were “not meeting their developmental needs or cultivating other critical life skills,” according to the researchers. Students were more likely to drop activities, not see friends or family, and not pursue hobbies they enjoy.

A balancing act

The results offer empirical evidence that many students struggle to find balance between homework, extracurricular activities and social time, the researchers said. Many students felt forced or obligated to choose homework over developing other talents or skills.

Also, there was no relationship between the time spent on homework and how much the student enjoyed it. The research quoted students as saying they often do homework they see as “pointless” or “mindless” in order to keep their grades up.

“This kind of busy work, by its very nature, discourages learning and instead promotes doing homework simply to get points,” Pope said.

She said the research calls into question the value of assigning large amounts of homework in high-performing schools. Homework should not be simply assigned as a routine practice, she said.

“Rather, any homework assigned should have a purpose and benefit, and it should be designed to cultivate learning and development,” wrote Pope.

High-performing paradox

In places where students attend high-performing schools, too much homework can reduce their time to foster skills in the area of personal responsibility, the researchers concluded. “Young people are spending more time alone,” they wrote, “which means less time for family and fewer opportunities to engage in their communities.”

Student perspectives

The researchers say that while their open-ended or “self-reporting” methodology to gauge student concerns about homework may have limitations – some might regard it as an opportunity for “typical adolescent complaining” – it was important to learn firsthand what the students believe.

The paper was co-authored by Mollie Galloway from Lewis and Clark College and Jerusha Conner from Villanova University.

Media Contacts

Denise Pope, Stanford Graduate School of Education: (650) 725-7412, [email protected] Clifton B. Parker, Stanford News Service: (650) 725-0224, [email protected]

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By submitting my email address. i certify that i am 13 years of age or older, agree to recieve marketing email messages from the princeton review, and agree to terms of use., homework wars: high school workloads, student stress, and how parents can help.

Studies of typical homework loads vary : In one, a Stanford researcher found that more than two hours of homework a night may be counterproductive. The research , conducted among students from 10 high-performing high schools in upper-middle-class California communities, found that too much homework resulted in stress, physical health problems and a general lack of balance.

Additionally, the  2014 Brown Center Report on American Education , found that with the exception of nine-year-olds, the amount of homework schools assign has remained relatively unchanged since 1984, meaning even those in charge of the curricula don't see a need for adding more to that workload.

But student experiences don’t always match these results. On our own Student Life in America survey, over 50% of students reported feeling stressed, 25% reported that homework was their biggest source of stress, and on average teens are spending one-third of their study time feeling stressed, anxious, or stuck.

The disparity can be explained in one of the conclusions regarding the Brown Report:

Of the three age groups, 17-year-olds have the most bifurcated distribution of the homework burden. They have the largest percentage of kids with no homework (especially when the homework shirkers are added in) and the largest percentage with more than two hours.

So what does that mean for parents who still endure the homework wars at home?

Read More: Teaching Your Kids How To Deal with School Stress

It means that sometimes kids who are on a rigorous college-prep track, probably are receiving more homework, but the statistics are melding it with the kids who are receiving no homework. And on our survey, 64% of students reported that their parents couldn’t help them with their work. This is where the real homework wars lie—not just the amount, but the ability to successfully complete assignments and feel success.

Parents want to figure out how to help their children manage their homework stress and learn the material.

Our Top 4 Tips for Ending Homework Wars

1. have a routine..

Every parenting advice article you will ever read emphasizes the importance of a routine. There’s a reason for that: it works. A routine helps put order into an often disorderly world. It removes the thinking and arguing and “when should I start?” because that decision has already been made. While routines must be flexible to accommodate soccer practice on Tuesday and volunteer work on Thursday, knowing in general when and where you, or your child, will do homework literally removes half the battle.

2. Have a battle plan.

Overwhelmed students look at a mountain of homework and think “insurmountable.” But parents can look at it with an outsider’s perspective and help them plan. Put in an extra hour Monday when you don’t have soccer. Prepare for the AP Chem test on Friday a little at a time each evening so Thursday doesn’t loom as a scary study night (consistency and repetition will also help lock the information in your brain). Start reading the book for your English report so that it’s underway. Go ahead and write a few sentences, so you don’t have a blank page staring at you. Knowing what the week will look like helps you keep calm and carry on.

3. Don’t be afraid to call in reserves.

You can’t outsource the “battle” but you can outsource the help ! We find that kids just do better having someone other than their parents help them —and sometimes even parents with the best of intentions aren’t equipped to wrestle with complicated physics problem. At The Princeton Review, we specialize in making homework time less stressful. Our tutors are available 24/7 to work one-to-one in an online classroom with a chat feature, interactive whiteboard, and the file sharing tool, where students can share their most challenging assignments.

4. Celebrate victories—and know when to surrender.

Students and parents can review completed assignments together at the end of the night -- acknowledging even small wins helps build a sense of accomplishment. If you’ve been through a particularly tough battle, you’ll also want to reach reach a cease-fire before hitting your bunk. A war ends when one person disengages. At some point, after parents have provided a listening ear, planning, and support, they have to let natural consequences take their course. And taking a step back--and removing any pressure a parent may be inadvertently creating--can be just what’s needed.

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When Is Homework Stressful? Its Effects on Students’ Mental Health

Are you wondering when is homework stressful? Well, homework is a vital constituent in keeping students attentive to the course covered in a class. By applying the lessons, students learned in class, they can gain a mastery of the material by reflecting on it in greater detail and applying what they learned through homework. 

However, students get advantages from homework, as it improves soft skills like organisation and time management which are important after high school. However, the additional work usually causes anxiety for both the parents and the child. As their load of homework accumulates, some students may find themselves growing more and more bored.

Students may take assistance online and ask someone to do my online homework . As there are many platforms available for the students such as Chegg, Scholarly Help, and Quizlet offering academic services that can assist students in completing their homework on time. 

Negative impact of homework

There are the following reasons why is homework stressful and leads to depression for students and affect their mental health. As they work hard on their assignments for alarmingly long periods, students’ mental health is repeatedly put at risk. Here are some serious arguments against too much homework.

No uniqueness

Homework should be intended to encourage children to express themselves more creatively. Teachers must assign kids intriguing assignments that highlight their uniqueness. similar to writing an essay on a topic they enjoy.

Moreover, the key is encouraging the child instead of criticizing him for writing a poor essay so that he can express himself more creatively.

Lack of sleep

One of the most prevalent adverse effects of schoolwork is lack of sleep. The average student only gets about 5 hours of sleep per night since they stay up late to complete their homework, even though the body needs at least 7 hours of sleep every day. Lack of sleep has an impact on both mental and physical health.

No pleasure

Students learn more effectively while they are having fun. They typically learn things more quickly when their minds are not clouded by fear. However, the fear factor that most teachers introduce into homework causes kids to turn to unethical means of completing their assignments.

Excessive homework

The lack of coordination between teachers in the existing educational system is a concern. As a result, teachers frequently end up assigning children far more work than they can handle. In such circumstances, children turn to cheat on their schoolwork by either copying their friends’ work or using online resources that assist with homework.

Anxiety level

Homework stress can increase anxiety levels and that could hurt the blood pressure norms in young people . Do you know? Around 3.5% of young people in the USA have high blood pressure. So why is homework stressful for children when homework is meant to be enjoyable and something they look forward to doing? It is simple to reject this claim by asserting that schoolwork is never enjoyable, yet with some careful consideration and preparation, homework may become pleasurable.

No time for personal matters

Students that have an excessive amount of homework miss out on personal time. They can’t get enough enjoyment. There is little time left over for hobbies, interpersonal interaction with colleagues, and other activities. 

However, many students dislike doing their assignments since they don’t have enough time. As they grow to detest it, they can stop learning. In any case, it has a significant negative impact on their mental health.

Children are no different than everyone else in need of a break. Weekends with no homework should be considered by schools so that kids have time to unwind and prepare for the coming week. Without a break, doing homework all week long might be stressful.

How do parents help kids with homework?

Encouraging children’s well-being and health begins with parents being involved in their children’s lives. By taking part in their homework routine, you can see any issues your child may be having and offer them the necessary support.

Set up a routine

Your student will develop and maintain good study habits if you have a clear and organized homework regimen. If there is still a lot of schoolwork to finish, try putting a time limit. Students must obtain regular, good sleep every single night.

Observe carefully

The student is ultimately responsible for their homework. Because of this, parents should only focus on ensuring that their children are on track with their assignments and leave it to the teacher to determine what skills the students have and have not learned in class.

Listen to your child

One of the nicest things a parent can do for their kids is to ask open-ended questions and listen to their responses. Many kids are reluctant to acknowledge they are struggling with their homework because they fear being labelled as failures or lazy if they do.

However, every parent wants their child to succeed to the best of their ability, but it’s crucial to be prepared to ease the pressure if your child starts to show signs of being overburdened with homework.

Talk to your teachers

Also, make sure to contact the teacher with any problems regarding your homework by phone or email. Additionally, it demonstrates to your student that you and their teacher are working together to further their education.

Homework with friends

If you are still thinking is homework stressful then It’s better to do homework with buddies because it gives them these advantages. Their stress is reduced by collaborating, interacting, and sharing with peers.

Additionally, students are more relaxed when they work on homework with pals. It makes even having too much homework manageable by ensuring they receive the support they require when working on the assignment. Additionally, it improves their communication abilities.

However, doing homework with friends guarantees that one learns how to communicate well and express themselves. 

Review homework plan

Create a schedule for finishing schoolwork on time with your child. Every few weeks, review the strategy and make any necessary adjustments. Gratefully, more schools are making an effort to control the quantity of homework assigned to children to lessen the stress this produces.

Bottom line

Finally, be aware that homework-related stress is fairly prevalent and is likely to occasionally affect you or your student. Sometimes all you or your kid needs to calm down and get back on track is a brief moment of comfort. So if you are a student and wondering if is homework stressful then you must go through this blog.

While homework is a crucial component of a student’s education, when kids are overwhelmed by the amount of work they have to perform, the advantages of homework can be lost and grades can suffer. Finding a balance that ensures students understand the material covered in class without becoming overburdened is therefore essential.

Zuella Montemayor did her degree in psychology at the University of Toronto. She is interested in mental health, wellness, and lifestyle.

Psychreg is a digital media company and not a clinical company. Our content does not constitute a medical or psychological consultation. See a certified medical or mental health professional for diagnosis.

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What Is Therapy Homework?

Astrakan Images / Getty Images

Types of Therapy That Involve Homework

If you’ve recently started going to therapy , you may find yourself being assigned therapy homework. You may wonder what exactly it entails and what purpose it serves. Therapy homework comprises tasks or assignments that your therapist asks you to complete between sessions, says Nicole Erkfitz , DSW, LCSW, a licensed clinical social worker and executive director at AMFM Healthcare, Virginia.

Homework can be given in any form of therapy, and it may come as a worksheet, a task to complete, or a thought/piece of knowledge you are requested to keep with you throughout the week, Dr. Erkfitz explains.

This article explores the role of homework in certain forms of therapy, the benefits therapy homework can offer, and some tips to help you comply with your homework assignments.

Therapy homework can be assigned as part of any type of therapy. However, some therapists and forms of therapy may utilize it more than others.

For instance, a 2019-study notes that therapy homework is an integral part of cognitive-behavioral therapy (CBT) . According to Dr. Erkfitz, therapy homework is built into the protocol and framework of CBT, as well as dialectical behavior therapy (DBT) , which is a sub-type of CBT.

Therefore, if you’re seeing a therapist who practices CBT or DBT, chances are you’ll regularly have homework to do.

On the other hand, an example of a type of therapy that doesn’t generally involve homework is eye movement desensitization and reprocessing (EMDR) therapy. EMDR is a type of therapy that generally relies on the relationship between the therapist and client during sessions and is a modality that specifically doesn’t rely on homework, says Dr. Erkfitz.

However, she explains that if the client is feeling rejuvenated and well after their processing session, for instance, their therapist may ask them to write down a list of times that their positive cognition came up for them over the next week.

"Regardless of the type of therapy, the best kind of homework is when you don’t even realize you were assigned homework," says Erkfitz.

Benefits of Therapy Homework

Below, Dr. Erkfitz explains the benefits of therapy homework.

It Helps Your Therapist Review Your Progress

The most important part of therapy homework is the follow-up discussion at the next session. The time you spend reviewing with your therapist how the past week went, if you completed your homework, or if you didn’t and why, gives your therapist valuable feedback on your progress and insight on how they can better support you.

It Gives Your Therapist More Insight

Therapy can be tricky because by the time you are committed to showing up and putting in the work, you are already bringing a better and stronger version of yourself than what you have been experiencing in your day-to-day life that led you to seek therapy.

Homework gives your therapist an inside look into your day-to-day life, which can sometimes be hard to recap in a session. Certain homework assignments keep you thinking throughout the week about what you want to share during your sessions, giving your therapist historical data to review and address.

It Helps Empower You

The sense of empowerment you can gain from utilizing your new skills, setting new boundaries , and redirecting your own cognitive distortions is something a therapist can’t give you in the therapy session. This is something you give yourself. Therapy homework is how you come to the realization that you got this and that you can do it.

"The main benefit of therapy homework is that it builds your skills as well as the understanding that you can do this on your own," says Erkfitz.

Tips for Your Therapy Homework

Below, Dr. Erkfitz shares some tips that can help with therapy homework:

• Set aside time for your homework: Create a designated time to complete your therapy homework. The aim of therapy homework is to keep you thinking and working on your goals between sessions. Use your designated time as a sacred space to invest in yourself and pour your thoughts and emotions into your homework, just as you would in a therapy session .
• Be honest: As therapists, we are not looking for you to write down what you think we want to read or what you think you should write down. It’s important to be honest with us, and yourself, about what you are truly feeling and thinking.
• Practice your skills: Completing the worksheet or log are important, but you also have to be willing to put your skills and learnings into practice. Allow yourself to be vulnerable and open to trying new things so that you can report back to your therapist about whether what you’re trying is working for you or not.
• Remember that it’s intended to help you: Therapy homework helps you maximize the benefits of therapy and get the most value out of the process. A 2013-study notes that better homework compliance is linked to better treatment outcomes.
• Talk to your therapist if you’re struggling: Therapy homework shouldn’t feel like work. If you find that you’re doing homework as a monotonous task, talk to your therapist and let them know that your heart isn’t in it and that you’re not finding it beneficial. They can explain the importance of the tasks to you, tailor your assignments to your preferences, or change their course of treatment if need be.

"When the therapy homework starts 'hitting home' for you, that’s when you know you’re on the right track and doing the work you need to be doing," says Erkfitz.

A Word From Verywell

Similar to how school involves classwork and homework, therapy can also involve in-person sessions and homework assignments.

If your therapist has assigned you homework, try to make time to do it. Completing it honestly can help you and your therapist gain insights into your emotional processes and overall progress. Most importantly, it can help you develop coping skills and practice them, which can boost your confidence, empower you, and make your therapeutic process more effective.

Get Help Now

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Conklin LR, Strunk DR, Cooper AA. Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression . Cognit Ther Res . 2018;42(1):16-23. doi:10.1007/s10608-017-9873-6

Lebeau RT, Davies CD, Culver NC, Craske MG. Homework compliance counts in cognitive-behavioral therapy . Cogn Behav Ther . 2013;42(3):171-179. doi:10.1080/16506073.2013.763286

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Homework can be bad for your mental health. Should we get rid of it?

• Teachers are taking to social media apps like TikTok to take a stand against the idea
• Heavy workloads can be extra stressful for students, especially during the Covid-19 pandemic

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It’s no secret that homework can be a pain. And as students grapple with an ongoing pandemic that has had a wide-range of mental health impacts, is it time schools start listening to their pleas about their workloads?

Some teachers are turning to social media to take a stand against homework.

Tiktok user @misguided.teacher says he doesn’t assign it because the “whole premise of homework is flawed.”

Do students need homework to learn?

For starters, he says he can’t grade work on “even playing fields” when students’ home environments can be vastly different.

“Even students who go home to a peaceful house, do they really want to spend their time on busy work? Because typically that’s what a lot of homework is, it’s busy work,” he says in the video that has garnered 1.6 million likes. “You only get one year to be 7, you only got one year to be 10, you only get one year to be 16, 18.”

Mental health experts agree heavy work loads have the potential do more harm than good for students, especially when taking into account the impacts of the pandemic. But they also say the answer may not be to eliminate homework altogether.

Chinese schoolgirl uses robot to do her homework

Emmy Kang, mental health counselor at Humantold, says studies have shown heavy workloads can be “detrimental” for students and cause a “big impact on their mental, physical and emotional health.”

“More than half of students say that homework is their primary source of stress, and we know what stress can do on our bodies,” she says, adding that staying up late to finish assignments also leads to disrupted sleep and exhaustion.

Cynthia Catchings, a licensed clinical social worker and therapist at Talkspace, says heavy workloads can also cause serious mental health problems in the long run, like anxiety and depression.

And for all the distress homework causes, it’s not as useful as many may think, says Dr. Nicholas Kardaras, a psychologist and CEO of Omega Recovery treatment center.

“The research shows that there’s really limited benefit of homework for elementary age students, that really the school work should be contained in the classroom,” he says.

For older students, Kang says homework benefits plateau at about two hours per night.

Should Hong Kong introduce a zero-homework policy?

“Most students, especially at these high-achieving schools, they’re doing a minimum of three hours, and it’s taking away time from their friends from their families, their extracurricular activities. And these are all very important things for a person’s mental and emotional health.”

Catchings, who taught Primary Three to Secondary 6 for 12 years, says she’s seen the positive effects of a no homework policy while working with students abroad.

“Not having homework was something that I always admired from French students (and) French schools, because that helped students really have time off and disconnect from school,” she says.

The answer may not be to eliminate homework completely, but to be more mindful of the type of work students go home with, suggests Kang, who was a secondary school teacher for 10 years.

“I don’t think (we) should scrap homework, I think we should scrap meaningless, purposeless, busy work-type homework. That’s something that needs to be scrapped entirely,” she says, encouraging teachers to be thoughtful and consider the amount of time it would take for students to complete assignments.

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Struggling to Find an In-Network Mental Health Provider? Here’s What You Can Do.

Insurers’ failures to update their provider directories have led to dire consequences for people seeking mental health care. Experts, clinicians and advocates explain how you can navigate these challenges to find treatment.

Series: America’s Mental Barrier: How Insurers Interfere With Mental Health Care

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

It’s hard to know if your health insurance plan is as good as advertised. You pay a monthly premium to access a network of health providers. But call the numbers in your provider directory, and you’re bound to find ones who can’t — or won’t — see you.

These errors are at the heart of a ghost network. Some providers have moved, retired or even died; others left insurance networks because of low pay and intense scrutiny . Even though these providers no longer accept your insurance, their names may remain in the directory. When that happens, policyholders are left to believe that the plan has more options than actually exist.

“Any inaccuracy constitutes a ghost network,” said Abigail Burman, a consumer protection attorney who studies provider directory errors. “This is basic information. It needs to be right.”

Insurers’ failures to correct these errors have led to dire consequences for people seeking mental health care, as demonstrated by a recent ProPublica investigation of one man’s months of struggle to access treatment . Because of the widespread nature of ghost networks, some policyholders are more likely to pay out-of-network costs and face a greater chance of treatment delays — if they get treatment at all.

ProPublica spoke with experts, clinicians and advocates to understand the challenges posed by provider directory errors. They all suggested specific ways for policyholders to navigate a ghost network.

How much do insurers know about the errors in their directories? And what are they required to do about it?

Insurers have acknowledged the problem and in some cases have vowed to address it. AHIP, a national association of health insurers, said in a 2023 statement to the U.S. Senate Committee on Finance that insurers update provider directories through “regular phone calls, emails, online reminders, and in-person visits.” However, AHIP wrote that insurers can’t always quickly fix errors because providers sometimes fail to keep their own professional information up to date. (AHIP declined ProPublica’s request for an interview.)

But Dr. Robert Trestman, a Virginia psychiatrist who testified about ghost networks to the same committee, told ProPublica that insurers are able to track “every detail of finance” around things such as billing and coding. Because of that, he said, insurers’ failures “to set up a system for keeping track of who is in network or not is on them.”

But insurers haven’t had to make it a priority. Simon Haeder, a Texas A&M University professor who studies ghost networks, said that insurers have “very little incentive” to closely monitor directories. Unless tougher regulations are passed, he said, policyholders will continue to struggle with directories full of “inconsistent, outdated or incomplete data.”

For years, it has fallen to academic researchers and secret shopper surveys to reveal the pervasiveness of these errors. Lawmakers have passed bills and called for further reforms. In spite of that, the errors still plague policyholders.

I’m shopping for a plan. How do I know if it is as good as advertised?

Do your homework. In the absence of the insurer making it a priority to update its directory, the task of checking its accuracy falls to you. You can head to the website of the insurer whose health plan you’re interested in buying. Find the provider portal. Since an insurer may offer different networks for each plan, experts suggest double-checking that you’re only searching for providers available in the network that you want.

If you already have a provider, type in their name to see if that person is listed in-network. If you don’t have one, find a provider that’s listed as being in network and taking new patients, and who seems to meet your needs. From there, experts encourage reaching out directly to the provider to verify that both of those things are true.

“Verify, verify, verify,” said Dr. Jane Zhu, an associate professor at Oregon Health & Science University’s medical school who studies ghost networks. “Accuracy in behavioral health provider directories is akin to a coin flip.”

I already have a health plan. What should I do?

Don’t worry if you’ve paid for a plan or have one through your employer. There are other ways to minimize the perils of provider directory errors.

But experts say that you’ll need to arm yourself with some facts.

Track down your “Evidence of Coverage.” The document, which is typically about 100 pages long, outlines what your insurer must do to fulfill its contractual obligations. For instance, if you can’t access an in-network mental health provider within a certain period of time, the insurer may be on the hook for tracking down an out-of-network provider.

From there, you can call the insurer to find out if it handles your mental health benefits or if it has outsourced management of them. If those benefits are “carved out” from your plan, you may have to seek answers about provider directory errors from that subcontractor. (Should you encounter any errors in your directory, this information could come in handy.)

Experts say that by getting these answers, you’ll be able to better fight for your rights.

What should I do if I encounter provider directory errors?

Health care experts warn that you’re likely to encounter errors in your provider directory. They advise not to become discouraged when you do.

David Lloyd, chief policy officer with the mental health advocacy group Inseparable, suggests taking notes of the calls to providers. Did they answer the phone? Did they say they accept your plan? Do they see new patients? You can write all your notes down in this handy worksheet created by Cover My Mental Health, an Illinois-based consumer advocacy group. Take photos of the directory errors, too.

How many calls should I be expected to make?

Some policyholders have called at least 50 supposedly in-network providers in pursuit of an appointment. But experts say you shouldn’t have to contact that many. Burman suggests making a “reasonable effort.” To her, that means making five to 10 calls to providers listed in-network.

She and others note that if you’re in distress because of your mental health, you don’t have to call on your own.

“Ask a friend or family member for assistance and to help advocate for you,” said Wendell Potter, a former Cigna vice president who is now a consumer advocate.

None of my calls secured an appointment. What should I do now?

If you’ve made that reasonable effort and haven’t managed to lock down a provider, experts recommend making another call to your insurer. Inform the customer service rep that you couldn’t make an appointment with a listed provider despite multiple attempts. Request that the rep schedule an appointment for you. Then ask for the rep’s email address and put the request in writing — and ask the rep to reply the same way.

Meiram Bendat, a lawyer and psychotherapist in California, suggests reminding insurers that they “must share in the responsibility of identifying timely and geographically accessible providers.” The exact regulations depend on where you live and the kind of plan you have, so some research may be required before the call. In some instances, you can ask for a care manager and the insurer will assign an employee who can help secure a mental health appointment.

“Set the expectation that the customer service rep needs to solve this problem,” said Joe Feldman, founder of Cover My Mental Health.

If the rep doesn’t connect you with a provider, health insurance experts recommend asking the rep to file an administrative grievance. Persistence is key, Burman said. Be assertive. Demand the grievance be addressed — or escalated to a manager who will resolve your concern.

“Don’t feel like you’re the problem,” Burman said. “They are the problem for engaging in deceptive practices.”

My ghost network grievance hasn’t been resolved. Now what?

While waiting for your insurer to act, health insurance experts also encourage reaching out to your insurance regulator.

Finding that regulator can be a tricky task given America’s complex patchwork of insurance regulations. You’ll need to determine which government agency oversees your insurer. While more research is required to see who will be able help, experts point to the following agencies as a starting point:

• If you purchased a plan from your state’s Health Insurance Marketplace, or have a fully insured plan through your private employer, you can get in touch with your state’s insurance department .
• If you have a Medicaid plan, you can contact your state’s Medicaid agency .
• If you are enrolled in Medicare, you can reach out to the Centers for Medicare & Medicaid Services .
• If you have a self-funded plan from your private employer or a health and welfare benefit plan from your union, you can try the U.S. Department of Labor’s Employee Benefits Security Administration .

Once you find the right agency, experts suggest that you prepare your complaint. You don’t have to write a new one from scratch. Gather information from your grievance, along with any other new developments, and submit that to the regulator.

Is there anything else I can do?

Yes, there are a few other ways. Whatever approach you take, Potter urges you to make noise, as if you are “a relentless squeaky wheel.”

If you are covered through an employer’s health plan, see if your human resources department can help talk to the insurer.

Or contact the constituency service offices of your federal and state elected lawmakers. They might be able to directly reach out, too.

Depending on where you live, there may even be legal services or consumer advocacy agencies that can help out as well.

“As a consumer, your superpower is not going away,” Burman said. “Your strongest weapon, in the face of a company that wants you to go away, is to not go away.”

We’re Investigating Mental Health Care Access. Share Your Insights.

ProPublica’s reporters want to talk to mental health providers, health insurance insiders and patients as we examine the U.S. mental health care system. If that’s you, reach out.

“I Don’t Want to Die”: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network

Ravi Coutinho bought a health insurance plan thinking it would deliver on its promise of access to mental health providers. But even after 21 phone calls and multiple hospitalizations, no one could find him a therapist.

by Max Blau , illustrations by Vanessa Saba , special to ProPublica , Sept. 8, 6:05 a.m. EDT

What Mental Health Care Protections Exist in Your State?

Insurers have wide latitude on when and how they can deny mental health care. We looked at the laws in all 50 states and found that some are charting new paths to secure mental health care access.

by Annie Waldman and Maya Miller , Aug. 27, 7 a.m. EDT

Why It’s So Hard to Find a Therapist Who Takes Insurance

Those who need therapy often have to pay out of pocket or go without care, even if they have health insurance. Hundreds of mental health providers told us they fled networks because insurers made their jobs impossible and their lives miserable.

by Annie Waldman , Maya Miller , Duaa Eldeib and Max Blau , photography by Tony Luong, special to ProPublica , design by Zisiga Mukulu , Aug. 25, 7 a.m. EDT

Missouri Outlawed Abortion, and Now It’s Funding an Anti-Abortion Group That Works in Other States

With millions in expanded tax credits and direct state funding going to anti-abortion groups, the nonprofit Coalition Life has expanded its operations beyond Missouri and into states where the procedure is still legal.

by Jeremy Kohler , Aug. 19, 5 a.m. EDT

Utah Supreme Court Rules That Alleged Sexual Assault by a Doctor Is Not “Health Care”

The decision revives a lawsuit filed by 94 women who said their OB-GYN sexually abused them. Previously, a lower court determined that the actions they alleged had to be treated as medical malpractice.

by Jessica Schreifels , The Salt Lake Tribune , Aug. 9, 2 p.m. EDT

Local Reporting Network

Texas Sends Millions to Crisis Pregnancy Centers. It’s Meant to Help Needy Families, But No One Knows if It Works.

Two years after Roe v. Wade was overturned, Texas leads the nation in funding for crisis pregnancy centers. The system is meant to help growing families, but it’s riddled with waste and lacks oversight, a ProPublica and CBS News investigation found.

by Cassandra Jaramillo , Jeremy Kohler and Sophie Chou , ProPublica, and Jessica Kegu , CBS News , July 9, 7 a.m. EDT

Inside Ziklag, the Secret Organization of Wealthy Christians Trying to Sway the Election and Change the Country

The little-known charity is backed by famous conservative donors, including the families behind Hobby Lobby and Uline. It’s spending millions to make a big political push for this election — but it may be violating the law.

by Andy Kroll , ProPublica, and Nick Surgey , Documented , July 13, 5 a.m. EDT

Trump Built a National Debt So Big That It’ll Weigh Down the Economy for Years

The “King of Debt” promised to reduce the national debt — then his tax cuts made it surge. Add in the pandemic, and he oversaw the third-biggest deficit increase of any president.

by Allan Sloan , ProPublica, and Cezary Podkul for ProPublica , Jan. 14, 2021, 5 a.m. EST

School District With Highest Student Arrest Rate in the Nation Agrees to Reform How It Disciplines Disabled Students

Following a ProPublica-Chicago Tribune investigation, the Garrison School in Illinois will change its disciplinary practices and provide services to those who missed class due to being arrested or sent to a seclusion room.

by Jennifer Smith Richards and Jodi S. Cohen , Sept. 6, 10:15 a.m. EDT

by Max Blau , Sept. 8, 6 a.m. EDT

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It’s a nice idea, but more therapy won’t fix our growing mental health crisis

Bianca denny, save articles for later.

Add articles to your saved list and come back to them any time.

By this time of year, most people who regularly see a psychologist will have exhausted their allocation of 10 Medicare-funded sessions. This, combined with statistics showing that one in five Australians experience mental illness, has prompted calls from some within the sector for additional funding and an increase in the number of government-subsided sessions available to Australians.

But as a psychologist working in private practice, let me tell you that more psychology sessions is not the answer to our national mental health crisis.

Australians are currently entitled to 10 Medicare-rebated private psychology sessions each year. Some experts say this is not enough. Credit: Istock

I’ve dedicated my professional life to psychology and therapy, and continue to spend a fair bit of my personal life engaged in it, too. Beyond the superficial position of potential financial gain, I know that carte blanche funding for private services is not the best way to allocate mental health funds. This is namely because the people who need services the most are those most likely to find themselves effectively shut out of the current system through unaffordability (most private psychologists charge a gap fee) or ineligibility (Better Access does not include family therapy or couples’ counselling). This is especially true for adolescents and young adults, who are disproportionately represented in mental illness statistics, but are the least likely to engage in private therapy. Low-income and unemployed adults are similarly impacted.

Adding additional sessions for people already in treatment would also impact a psychologist’s capacity to accept new referrals. It would do nothing but potentially drive up the already too-long wait times.

Decades of empirical evidence demonstrate conditions such as anxiety, mild-to-moderate depression, and simple phobias (such as arachnophobia, fear of flying, fear of heights) can be treated in around 10 sessions. For these people, who are generally relatively psychologically healthy but experiencing a specific life crisis, this brief intervention may be sufficient to help them gain insight and develop coping skills.

Longer-term therapy can also be beneficial. This comprises of more than simply providing the same treatment over a longer period, and many psychologists are simply not trained to deliver this kind of care. And so, in a system with limited resources and an ongoing shortage of psychologists, an unenviable choice must be made – provide fewer people with more treatment, or more people with some.

For many, a set number of sessions can be containing and sends a message that their concerns are valid but treatable. Endless sessions without clear goals or outcomes, on the other hand, can erroneously signal their problems to be insurmountable.

Of course, mental illness and its treatment is not one-size-fits-all – any system treating it as such is problematic. But instead of a continued focus on more individual therapy, we need to look towards providing services to those most in need, not just those who can afford it. This “missing middle” of people who are too unwell for private psychology services, but not unwell enough for public mental health services.

Despite the government acknowledging more needs to be done for this population, there has been no uptake of recommendations for a stepped care model, in which sessions are allocated based on patient need and clinician skill, despite this model has demonstrated efficacy.

Perhaps more interesting than the political fray around funding, though, is the impetus for additional psychology sessions.

Psychologists often bemoan the inadequacy of the short intervention model, despite evidence pointing to its efficacy. It is sad to see a seeming increase in self-interest among some psychologists who perpetuate the idea that more sessions is the only antidote to a person’s problems. Perhaps this is motivated by the financial incentive of retaining a full caseload, or is indicative of a “saviour complex” that reflects the need of some psychologists have to be wanted or revered. But in calling for more private sessions, psychologists risk no longer fulfilling their fundamental role of expressing empathy and providing treatment that supports improved wellbeing and instead joining a patient in their despair. Here, empathy and collusion blur. And while the former is essential in promoting a patient’s wellbeing, the latter is decidedly unhelpful.

Of course, current times are difficult. But no time in history has been without its challenges. The role of a private psychologist working under the Better Access scheme is not to remedy all perceived ills, but to help patients regain and maintain sufficient psychological health to enjoy a life of function and purpose.

Sometimes I am asked how I cope in a vocation in which, as one acquaintance framed it, I am exposed daily to “a carousel of human misery”. My answer is always the same: I can cope because I see that most people get better.

Yes, a panacea for our current mental health crisis is a big ask. But at the very least, we should be ensuring the equitable opportunity for treatment for everybody.

Dr Bianca Denny is a practising clinical psychologist based in Melbourne.

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NYC Teenspace

NYC Teenspace is a free mental health support program available to any teenager age 13 to 17 living in New York City. Whether you struggle with mental health challenges or just want somebody to talk to about your everyday ups and downs, you can sign up for Teenspace to be connected to a licensed therapist for ongoing support. You will also get access to online mental health exercises to complete at your own pace.

Teenspace is offered by the NYC Health Department and powered by Talkspace.

Sign Up Instructions for Teens

Follow these steps to register:

• Visit Talkspace and enter your address and birthday.
• Enter your parent or guardian’s information and email address so they can provide consent.
• Complete a simple online assessment to share your mental health needs and preferences.

You will then get matched with a licensed therapist for ongoing virtual support, access to online mental health exercises or both.

Types of Care Provided

Once signed up, a teen will be matched with a therapist within days. All Talkspace therapists participating in this program are licensed in New York and have experience working with teens. They can address a vast range of mental health conditions and concerns, including anxiety, depression, stress, relationships, grief and trauma.

Teens do not need to be experiencing mental health symptoms to participate. You can sign on with a Talkspace therapist to discuss thoughts and feelings about your day-to-day life.

Therapy will take place primarily through messaging on the secure Talkspace platform. You can message your therapist as much as you like and the therapist will reply five days per week. As part of the Teenspace program you can also schedule one 30-minute live virtual session, by via video or audio, each month.

Teens will also have access to interactive exercises and short lessons designed specifically to support teen mental health.

Eligibility

The NYC Teenspace program is free to anyone ages 13 to 17 living in New York City, regardless of school, income level or insurance status. If a teen turns 18 while enrolled in the program, they can continue with their therapist until June 30 of the following year. Then, if they choose to continue, they can pay with insurance or out-of-pocket.

Additional Resources

• To learn more or sign up visit Talkspace
• Teenspace FAQ for Parents/Guardians (PDF) Other Languages: Español | Русский | 繁體中文 | 简体中文 | Kreyòl ayisyen | 한국어 | বাংলা | Italiano | Polski | العربية | Français | ײִדיש | اردو | O'zbek
• Teenspace FAQ for Schools (PDF) Other Languages: Español | Русский | 繁體中文 | 简体中文 | Kreyòl ayisyen | 한국어 | বাংলা | Italiano | Polski | العربية | Français | ײִדיש | اردو
• Teenspace Poster (PDF) Other Languages: Español | Русский | 繁體中文 | 简体中文 | Kreyòl ayisyen | 한국어 | বাংলা | Italiano | Polski | العربية | Français | ײִדיש | اردو
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Lampard Inquiry: Deaths of thousands of mental health patients in Essex to be investigated as families hope for answers

Melanie Leahy, whose son Matthew is among those who died, has said she believes the fatalities were part of a "cull of our most vulnerable, our most gentle, our most needy".

Communities correspondent @BeckyJohnsonSky

Sunday 8 September 2024 07:56, UK

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The deaths of around 2,000 mental health patients will be investigated as a long-awaited new public inquiry begins on Monday.

Warning: The following article contains details some readers may find distressing

Families of the patients who died in Essex have been campaigning for years, claiming they have not been told the truth about what happened to their loved ones.

Melanie Leahy, whose son Matthew is among those who died, believes the large number of deaths being investigated will continue to grow.

"I think we're going to find there's a lot, lot more. And I think it's absolutely horrendous," she told Sky News.

"I believe it's a cull. It's a cull of our most vulnerable, our most gentle, our most needy."

Matthew Leahy, 20, died in November 2012.

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He was found unresponsive in his room at the Linden Centre, a secure mental health unit in Chelmsford, eight days after he was sectioned.

His mother received a call to tell her what had happened. She raced to the hospital but it was too late.

She recalls going in and "there lay Matthew, on the trolley, he had a blue hospital gown on… And in that instant I just wanted to go and grab him and hold him and bring him back to life".

Mrs Leahy says she was told by staff: "Don't touch, he's a crime scene."

"I was taken into a side room and asked what undertaker I had planned," she remembers. "I was planning his 21st birthday."

It was soon after Mr Leahy's death that she grew concerned that things she was being told about what happened didn't add up.

Mrs Leahy also has unanswered questions about a serious allegation her son had made days before his death.

Mr Leahy had called his father and told him he had been raped.

He then called police and can be heard on the 999 call telling the operator: "I've been raped and the doctors refuse to acknowledge it."

Police went to the unit but no arrests were made.

Read more: Children's health facing a deadly crisis, report warns Iran 'sends hundreds of missiles to Russia' Body found in search for missing wife of former rugby star

An inquest into Mr Leahy's death found it occurred after a "series of multiple failings and missed opportunities". Staff even falsified his care plan after he died.

During years of fighting for answers, Mrs Leahy has met many other families who have also lost loved ones who were mental health patients in Essex.

In 2021 the Essex Partnership University NHS Foundation Trust was fined £1.5m over failures in care that led to the deaths of 11 patients after pleading guilty to safety breaches that meant it failed to "prevent suicides".

Since then the number of deaths under investigation has continued to grow.

The 2,000 deaths the new inquiry will examine all took place between the start of 2000 and the end of 2023.

Priya Singh is a lawyer representing dozens of families involved in the inquiry and says the details of cases she's involved with are harrowing.

"Allegations of physical abuse and sexual abuse have come up many, many, many times," she told Sky News.

"I don't feel that we're just only looking at negligence here. We're looking at abuse."

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She believes it's essential that national recommendations are made while the new inquiry is ongoing, to protect mental health patients across the NHS.

"This is definitely happening all over the country. Psychiatric care in this country is almost not fit for purpose right now," she says.

The inquiry will be known as the Lampard Inquiry, chaired by Baroness Lampard who previously led the investigation into abuse by Jimmy Savile in the NHS.

Paul Scott, chief executive of Essex Partnership University NHS Foundation Trust (EPUT), said: "We know how painful this time will be for those who have lost loved ones and our thoughts are with them.

"We will continue to do all we can to support Baroness Lampard and her team to provide the answers that patients, families and carers are seeking."

Anyone feeling emotionally distressed or suicidal can call Samaritans for help on 116 123 or email [email protected] in the UK. In the US, call the Samaritans branch in your area or 1 (800) 273-TALK.

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Trump’s Mental Health Faces More Serious Scrutiny After Bizarre “Incoherent” Response

by Lisandra Gomez-Tate in Daily Edition | September 7, 2024

Donald Trump, photo: Gage Skidmore , CC BY-SA 2.0 , via Wikimedia Commons

The progressive New Republic , spring-boarding off an explosive take on Donald Trump ‘s mental health by veteran journalist Mike Barnicle, is criticizing the lack of mainstream media coverage concerning the mental fitness of the Republican presidential nominee.

Trump’s increasingly erratic rhetoric and chronic fabulations demand far more scrutiny, critics say, and Trump’s bizarre “incoherent” ramble at the New York Economic Club this week sounded ever louder alarm bells.

[Trump dementia bells were rung earlier this year when a senior lecturer in the Psychology Department at Cornell University and in the Psychiatry Department at Weill Cornell Medicine claimed Trump’s intermittent phonemic paraphasia signaled “signs of early dementia.” As for TNR’s springboard, Barnicle said on Morning Joe : “We have a damaged, delusional, old man who again might get reelected to the presidency of the United States.”]

TNR contends that “merely covering each of Trump’s hallucinatory claims as news items, even if that includes aggressively fact-checking them, doesn’t do justice to the much bigger story that’s unfolding right at the end of all of our noses.”

In an article titled Finally: Top Journo Erupts at Media for Ignoring Trump’s Mental State , the magazine claims that the “bigger story” is that Trump’s mental faculties have dangerously diminished — a problem that supersedes political differences. (But, of course, it can’t supersede them — since everything is political — and Trump effectively turns any question into an attack.)

Getting larger is the pile of Trump critics asking members of the mainstream media to give as much consideration to the bizarre things Trump says as they gave the subject of Joe Biden’s age and mental acuity before he withdrew from the race.

[ New Statesman headline on Trump: Donald Trump Is Losing It: His alarming cognitive decline deserves the scrutiny that Joe Biden received .]

Donald Trump was asked today what he’d do about child care if elected president. This is what he said, in its entirety: pic.twitter.com/k32oHFm04B — Sahil Kapur (@sahilkapur) September 5, 2024

Then this week Trump’s particularly nonlinear, off-subject response to a question about child care asked at Economic Club of New York poured gasoline on the Trump mental health fire. (See Trump’s answer below.)

Reshma Saujani, who asked Trump the question, later told CNN’s Jake Tapper that his answer showed Trump was “not fit to be President.”

Saujani asked: “Can you commit to prioritizing legislation to make child care affordable and if so, what specific piece of legislation will you advance?”

“Well, I would do that, and we’re sitting down — you know, I was, uh, somebody, we had Sen. Marco Rubio [(R-Fla.)] and my daughter, Ivanka, was so, uh, impactful on that issue. It’s a very important issue. But I think when you talk about the kind of numbers that I’m talking about, that — because child care is child care. It’s, couldn’t — you know, it’s something, you have to have it. In this country, you have to have it. But when you talk about those numbers compared to the kind of numbers that I’m talking about by taxing foreign nations at levels that they’re not used to but they’ll get used to it very quickly. And it’s not going to stop them from doing business with us, but they’ll have a very substantial tax when they send product into our country. Those numbers are so much bigger than any numbers that we’re talking about, including child care, that it’s gonna take care. We’re gonna have — I, I look forward to having no deficits within a fairly short period of time. Coupled with, uh, the reductions that I told you about on waste and fraud and all of the other things that are going on in our country — because I have to say with child care, I want to stay with child care, but those numbers are small relative to the kind of economic numbers that I’m talking about, including growth. But growth also headed up by what the plan is that I just, uh, that I just told you about. We’re gonna be taking in trillions of dollars, and as much as child care is talked about as being expensive, it’s, relatively speaking, not very expensive compared to the kind of numbers we’ll be taking in. We’re going to make this into an incredible country that can afford to take care of its people and then we’ll worry about the rest of the world. Let’s help other people. But we’re gonna take care of our country first. This is about America first. It’s about: Make America great again. We have to do it, because right now we’re a failing nation. So we’ll take care of it. Thank you. Very good question.” Donald Trump

All this has contributed to the recent surge in concern that the media has no tools — and maybe less willingness — to properly cover Trump’s “weave” and unrelenting barrage of falsehoods, not to mention his refusal or inability to remain on topic.

Earlier this summer Trump’s unwieldy ramble about sharks and electrocution got a lot of attention, but the former President defends this kind of speaking style as his “weave” and dismisses his critics.

The Guardian responded to Trump’s “weave” claim with this headline: Trump rebrands his ramblings as ‘I do the weave’ – but is he just losing it?

That’s the question now being raised more forcefully: Is Trump losing it?

The former president has also begun denying things he previously acknowledged. Always comfortable with asserting untrue things and sticking to them, recent episodes of equivocation by Trump are relatively new and previously rare.

Even the far-right took Trump to task recently for his apparent waffling on his abortion stance, and then having acknowledged last week there was an altercation at Arlington National Cemetery, he later said that nothing happened there , and that the conflict was a “made-up” story.

The Atlantic , highlighting the same concern as other media outlets, wrote after Trump’s child care answer that “the biggest problem, the problem that all journalistic analysis of Trump’s response ought to lead with, is that his answer makes absolutely no sense.”

The title of The Atlantic email in the aftermath was “A new level of incoherence from Trump.”