Sending Homework to Clients in Therapy: The Easy Way

Homework in therapy

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).

How to send homework

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.

Quenza Homework

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

Quenza Sending message

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?

Quenza Wheel of life

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.

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.

Quenza Self contract

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.

Quenza realizing long-lasting 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).

Quenza Activity Builder

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.

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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What Is Therapy Homework?

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

homework assigned as a part of cognitive therapy

Dr. Sabrina Romanoff, PsyD, is a licensed clinical psychologist and a professor at Yeshiva University’s clinical psychology doctoral program.

homework assigned as a part of cognitive therapy

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.

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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.

A Comprehensive Model of Homework in Cognitive Behavior Therapy

  • Original Article
  • Published: 03 July 2021
  • Volume 46 , pages 247–257, ( 2022 )

Cite this article

  • Nikolaos Kazantzis   ORCID: orcid.org/0000-0001-9559-4160 1 , 2 &
  • Allen R. Miller 2  

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This article contributes a comprehensive model of homework in cognitive behavior therapy (CBT). To this end, several issues in the definition of homework and homework compliance are outlined, research on homework-outcome relations is critiqued, before an overview of classical and operant conditioning along with various cognitive theories are tied together in a c omprehensive model. We suggest engagement represents a more clinically meaningful construct than compliance (or adherence). We describe how established behavior and cognitive theories are relevant for understanding patient engagement and what between-session and in-session processes are useful in a comprehensive model. Our primary conclusion from the review of this literature is that current research has focused on limited aspects of homework and missed theoretically meaningful determinants of engagement. Further, little research has sought to examine the role of the therapist in facilitating these theoretically meaningful determinants. The literature on homework is the most advanced of the process research in CBT; the comprehensive model presented here offers clarity for the practicing clinician and represents a testable model for researchers interested in quantifying determinants of homework engagement and the process of integrating homework into CBT.

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Aizenstros, A., Bakker, D., Hofmann, S., Curtiss, J., & Kazantzis, N. (2020). Engagement with smartphone-delivered behavioural activation interventions: A study of the MoodMission smartphone application. Behavioural and Cognitive Psychotherapy . https://doi.org/10.1017/S1352465820000922

Article   PubMed   Google Scholar  

Ajzen, I., & Fishbein, M. (1977). Attitude-behavior relations: A theoretical analysis and review of empirical research. Psychological Bulletin, 84 , 888–914.

Article   Google Scholar  

Asnaani, A., & Hofmann, S. G. (2012). Collaboration in multicultural therapy: Establishing a strong therapeutic alliance across cultural lines. Journal of Clinical Psychology, 68 (2), 187–197. https://doi.org/10.1002/jclp.21829

Article   PubMed   PubMed Central   Google Scholar  

Bakker, D., Kazantzis, N., Rickwood, D., & Rickard, N. (2018). A randomized controlled trial of three smartphone apps for enhancing public mental health. Behaviour Research & Therapy, 109 , 75–83.

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84 , 191–215.

Article   CAS   PubMed   Google Scholar  

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory . Prentice Hall.

Google Scholar  

Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist, 44 , 1175–1184.

Article   CAS   Google Scholar  

Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., Bentley, K. H., Thompson- Hollands, J., Conklin, L. R., Boswell, J. F., Ametaj, A., Carl, J. R., Boettcher, H. T., & Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional dis-orders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry, 74 (9), 875–884. https://doi.org/10.1001/jamapsychiatry.2017.2164

Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., & Bois-SeauAllenEhrenreich-May, C. L. L. B. J. (2011). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide . Oxford University Press.

Beck, A. T., Rush, A. J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression . Guilford Press.

Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work . Guilford.

Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press.

Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford.

Beck, J. S., & Tompkins, M. A. (2007). Cognitive therapy. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, prevention (pp. 51–63). Springer. https://doi.org/10.1007/978-0-387-29681-4_4

Chapter   Google Scholar  

Bouton, M. E. (1988). Context and ambiguity in the extinction of emotional learning: Implications for exposure therapy. Behaviour Research & Therapy, 26 , 137–149.

Brodley, B. T. (2006). Client-initiated homework in client-centered therapy. Journal of Psychotherapy Integration, 16 (2), 140–161. https://doi.org/10.1037/1053-0479.16.2.140

Bryant, M. J., Simons, A. D., & Thase, M. E. (1999). Therapist skill and patient variables in homework compliance: Controlling an uncontrolled variable in cognitive therapy outcome research. Cognitive Therapy and Research, 23 (4), 381–399. https://doi.org/10.1023/A:1018703901116

Bunnell, B. E., Nemeth, L. S., Lenert, L. A., Kazantzis, N., Deblinger, E., Higgins, K. A., & Ruggiero, K. J. (2021). Barriers associated with the implementation of homework in youth mental health treatment and potential mobile health solutions. Cognitive Therapy and Research, 45 (2), 272–286.

Burns, D. D., & Spangler, D. (2000). Does psychotherapy homework lead to changes in depression in cognitive behavioral therapy? Or does clinical improvement lead to homework compliance? Journal of Consulting and Clinical Psychology, 68 , 46–56.

Callan, J. A., Kazantzis, N., Park, S. Y., Moore, C., Thase, M. E., Emeremni, C. A., Minhajuddin, A., Kornblith, S., & Siegle, G. J. (2019). Effects of cognitive behavior therapy homework adherence on outcomes: Propensity score analysis. Behavior Therapy, 50 (2), 285–299. https://doi.org/10.1016/j.beth.2018.05.010

Callan, J. A., Sigle, G. J., Day, A., Thase, M. E., Kazantzis, N., Devito Dabbs, A. D., Rotondi, A., Sereika, S., & Dunbar Jacob, J. (2021). CBT MobileWork: Development and testing of a mobile mental health application using patient-centered design. Cognitive Therapy and Research, 45 , 287.

Conklin, L. R., Strunk, D. R., & Cooper, A. A. (2017). Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression. Cognitive Therapy & Research . https://doi.org/10.1007/s10608-017-9873-6

Cronin, T. J., Lawrence, K. A., Taylor, K., Norton, P. J., & Kazantzis, N. (2015). Integrating between-session interventions (homework) in therapy: A focus on the therapeutic relationship and cognitive case conceptualization. Journal of Clinical Psychology, 71 , 439–450. https://doi.org/10.1002/jclp.22180

Dattilio, F. M., & Hanna, M. A. (2012). Collaboration in cognitive-behavioral therapy. Journal of Clinical Psychology, 68 , 146–158.

Dattilio, F. M., & Padesky, C. A. (1990). Cognitive therapy with couples . Professional Resource Exchange.

Deci, E. L., Eghrari, H., Patrick, B. C., & Leone, D. R. (1994). Facilitating internalization: The self-determination theory perspective. Journal of Personality, 62 , 119–142.

Deci, E. L., & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry: An International Journal for the Advancement of Psychological Theory, 11 , 227–268.

DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez, M. M., & Rossi, J. S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59 , 295–304.

Dobson, D. J. G., & Dobson, K. S. (2013). In-session structure and collaborative empiricism. Cognitive and Behavioral Practice, 20 , 410–418.

Dobson, K. S., & Kazantzis, N. (in press). Cognitive theory in psychotherapy. APA Handbook of Psychotherapy.

Dobson, K., & Kazantzis, N. (2003). The therapist in cognitive-behavioral therapy: Introduction to a special section. Psychotherapy Research, 13 , 131–134. https://doi.org/10.1080/713869635

Dozois, D. J. A. (2010). Understanding and enhancing the effects of homework in cognitive-behavioral therapy. Clinical Psychology: Science and Practice, 17 , 157–161. https://doi.org/10.1111/j.1468-2850.2010.01205.x

Ellis, A. E. (1995). Changing rational-emotive therapy (RET) to rational emotive behavior therapy (REBT). Journal of Rational-Emotive and Cognitive-Behavior Therapy, 13 , 85–89.

Evans, I. M. (2015). How and why thoughts change: Foundations of cognitive psychotherapy . Oxford University Press.

Book   Google Scholar  

Fehm, L., & Kazantzis, N. (2004). Attitudes and use of homework assignments in therapy: A survey of German psychotherapists. Clinical Psychology & Psychotherapy, 11 , 332–343. https://doi.org/10.1002/cpp.419

Flückiger, C., Del Re, A. C., Wlodasch, D., Horvath, A. O., Solomonov, N., & Wampold, B. E. (2020). Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. Journal of Counseling Psychology, 67 (6), 706–711. https://doi.org/10.1037/cou0000424

Franklin, M. E., Huppert, J. D., & Ledley, D. R. (2005). Obsessions and compulsions. In N. Kazantzis, F. P. Deane, K. R. Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 219–236). Routledge.

Haarhoff, B. A., & Kazantzis, N. (2007). How to supervise the use of homework in cognitive behavior therapy: The role of trainee therapist beliefs. Cognitive and Behavioral Practice, 14 , 325–332. https://doi.org/10.1016/j.cbpra.2006.08.004

Haller, E., & Watzke, B. (2021). The role of homework engagement, homework-related therapist behaviors, and their association with depressive symptoms in telephone-based CBT for depression. Cognitive Therapy & Research, 45 , 224.

Hoelscher, T. J., Lichstein, K. L., & Rosenthal, T. L. (1984). Objective vs subjective assessment of relaxation compliance among anxious individuals. Behaviour Research and Therapy, 22 (2), 187–193. https://doi.org/10.1016/0005-7967(84)90107-4

Hoelscher, T. J., Lichstein, K. L., & Rosenthal, T. L. (1986). Home relaxation practice in hypertension treatment: Objective assessment and compliance induction. Journal of Consulting and Clinical Psychology, 54 (2), 217–221. https://doi.org/10.1037/0022-006X.54.2.217

Hofmann, S. G., & Hayes, S. C. (2018). The future of intervention science: Process-based therapy. Clinical Psychological Science, 7 (1), 37–50. https://doi.org/10.1177/2167702618772296

Holdsworth, E., Bowen, E., Brown, S., & Howat, D. (2014). Client engagement in psychotherapeutic treatment and associations with client characteristics, therapist characteristics, and treatment factors. Clinical Psychology Review, 34 (5), 428–450. https://doi.org/10.1016/j.cpr.2014.06.004

Huibers, M. J. H., Lorenzo-Luaces, L., Cuijpers, P., & Kazantzis, N. (2021). On the road to personalized psychotherapy: A research agenda based on cognitive behavior therapy for depression. Frontiers in Psychiatry, 1 , 607508. https://doi.org/10.3389/fpsyt.2020.607508

Jungbluth, N. J., & Shirk, S. R. (2013). Promoting homework adherence in cognitive-behavioral therapy for adolescent depression. Journal of Clinical Child & Adolescent Psychology, 42 (4), 545–553. https://doi.org/10.1080/15374416.2012.743105

Kanfer, F. H. (1970). Self-monitoring, methodological limitations, and clinical applications. Journal of Consulting and Clinical Psychology, 35 , 148–152.

Kazantzis, N. (2000). Power to detect homework effects in psychotherapy outcome research. Journal of Consulting and Clinical Psychology, 68 , 166–170. https://doi.org/10.1037/0022-006X.68.1.166

Kazantzis, N., Arntz, A., Borkovec, T., Holmes, E. A., & Wade, T. (2010a). Unresolved issues regarding homework assignments in cognitive and behavioral therapies: An expert discussion at AACBT. Behaviour Change, 27 , 119–129. https://doi.org/10.1375/bech.27.3.119

Kazantzis, N., Beck, J. S., Clark, D. A., Dobson, K. S., Hofmann, S. G., Leahy, R. L., & Wong, W. C. (2018). Socratic dialogue and guided discovery in cognitive behavioral therapy: A modified Delphi panel. International Journal of Cognitive Therapy, 11 (2), 140–157. https://doi.org/10.1007/s41811-018-0012-2

Kazantzis, N. (2018). Introduction to the special issue on processes of cognitive behavioral therapy: Does necessary, but not sufficient” still capture it? Cognitive Therapy & Research, 42 (2), 115–120. https://doi.org/10.1007/s10608-018-9891-z

Kazantzis, N., Beck, J. S., Dattilio, F. M., Dobson, K. S., & Rapee, R. M. (2013). Collaborative empiricism as the central therapeutic relationship element in CBT: An expert panel discussion at the 7th International Congress of Cognitive Psychotherapy. International Journal of Cognitive Therapy, 6 (4), 386–4000.

Kazantzis, N., Brownfield, N., Mosely, L., Usatoff, A., & Flighty, A. (2017a). Homework in CBT: A systematic review of adherence assessment in anxiety and depression treatment (2011–2016). Psychiatric Clinics of North America, 40 (4), 625–639. https://doi.org/10.1016/j.psc.2017.08.001

Kazantzis, N., & Dattilio, F. M. (2010). Definitions of homework, types of homework, and ratings of the importance of homework among psychologists with cognitive behavior therapy and psychoanalytic theoretical orientations. Journal of Clinical Psychology, 66 (7), 1–16. https://doi.org/10.1002/jclp.20699

Kazantzis, N., Dattilio, F. M., & Dobson, K. S. (2017b). The therapeutic relationship in cognitive behavior therapy: A clinician’s guide . Guilford.

Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7 , 189–202. https://doi.org/10.1093/clipsy.7.2.189

Kazantzis, N., Deane, F. P., Ronan, K. R., & L’Abate, L. (Eds.). (2005). Using homework assignments in cognitive behavioral therapy. New York: Routledge.

Kazantzis, N., Freeman, A., Fruzzetti, A. E., Persons, J. B., & Smucker, M. (2010b). Unresolved issues regarding the therapeutic relationship element of collaborative empiricism in cognitive and behavioural therapies: An expert panel discussion at AACBT. Behaviour Change, 27 , 119–129. https://doi.org/10.1375/bech.27.3.119

Kazantzis, N., & Hofmann, S. G. (2019). Additional approaches to treatment of depression. JAMA, 321 (16), 1635. https://doi.org/10.1001/jama.2019.2068

Kazantzis, N., & L’Abate, L. (2005). Theoretical foundations. In N. Kazantzis, F. P. Deane., K. R. Ronan., & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 9–33). Routledge.

Kazantzis, N., & L’Abate, L. (2007). Handbook of homework assignments in psychotherapy: Research, practice, & prevention . Springer. https://doi.org/10.1007/978-0-387-29681-4

Kazantzis, N., Lampropoulos, G. L., & Deane, F. P. (2005). A national survey of practicing psychologists’ use and attitudes towards homework in psychotherapy. Journal of Consulting and Clinical Psychology, 73 , 742–748. https://doi.org/10.1037/0022-006X.73.4.742

Kazantzis, N., MacEwan, J., & Dattilio, F. M. (2005). A guiding model for practice. In N. Kazantzis, F. P. Deane., K. R. Ronan., & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 359–407). New York: Routledge.

Kazantzis, N., Ronan, K. R., & Deane, F. P. (2001). Concluding causation from correlation: Comment on Burns and Spangler (2000). Journal of Consulting and Clinical Psychology, 69 , 1079–1083. https://doi.org/10.1037/0022-006X.69.6.1079

Kazantzis, N., & Stuckey, M. E. (2018). Inception of a discovery: Re-defining the use of Socratic dialogue in cognitive behavioral therapy. International Journal of Cognitive Therapy, 11 , 177–123. https://doi.org/10.1007/s41811-018-0015-z

Kazantzis, N., Whittington, C. J., & Dattilio, F. M. (2010c). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17 , 144–156.

Kazantzis, N., Whittington, C. J., Zelencich, L., Norton, P. J., Kyrios, M., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: A meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47 , 755–772. https://doi.org/10.1016/j.beth.2016.05.002

Kelly, G. A. (1955). The psychology of personal constructs . Norton.

Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., et al. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: Report of the Inter-Organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education. Behavior Therapy, 43 (4), 687–697. https://doi.org/10.1016/j.beth.2012.05.002

Kraepelien, M., Blom, K., Jernelöv, S., & Kaldo, V. (2021). Weekly self-ratings of treatment involvement and their relation to symptom reduction in internet cognitive behavioral therapy for insomnia. Cognitive Therapy & Research, 45 (2), 262–271. https://doi.org/10.1007/s10608-020-10151-y

Lambert, M. J., Harmon, S. C., & Slade, K. (2007). Directions for research on homework in psychotherapy and behavior change. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 407–424). Springer.

Leventhal, H. (1970). Findings and theory in the study of fear communications. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 3, pp. 119–186). Academic Press.

Levis, D. J., & Malloy, P. F. (1982). Research in infrahuman and human conditioning. In G. T. Wilson & C. M. Franks (Eds.), Contemporary behavior therapy: Conceptual and empirical foundations (pp. 65–118). Guilford Press.

Lieberman, P. A. (1993). Learning: Behavior and cognition . Brooks/Cole.

Maddock, J. W. (1975). Initiation problems and time structuring in brief sex therapy. Journal of Sex & Marital Therapy, 1 , 190–197.

Mahoney, M. J., Kazdin, A. E., & Lesswing, N. J. (1974). Behavior modification: Delusion or deliverance. In C. M. Franks & G. T. Wilson (Eds.), Annual review of behavior therapy and practice (Vol. 2, pp. 169–193). Brunner/Mazel.

Mahrer, A. R., Nordin, S., & Miller, L. S. (1995). If a client has this kind of problem, prescribe that kind of post-session behavior. Psychotherapy, 32 , 194–203.

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 & Research, 34 , 429–438. https://doi.org/10.1007/s10608-010-9297-z

Mennin, D. S., Ellard, K. K., Fresco, D. M., & Gross, J. J. (2013). United we stand: Emphasizing commonalities across cognitive-behavioral therapy. Behavior Therapy, 44 , 234–248. https://doi.org/10.1016/j.beth.2013.02.004

Mischel, W. (1968). Personality and assessment . Wiley.

Mischel, W. (1973). Facing the issues. Journal of Abnormal Psychology, 82 , 541–542.

Neimeyer, R. A. (1985). The development of personal construct psychology . University of Nebraska Press.

Neimeyer, R. A., Kazantzis, N., Kassler, D. M., Baker, K. D., & Fletcher, R. (2008). Group cognitive behavior therapy for depression: Outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition. Cognitive Behavior Therapy, 37 , 199–215. https://doi.org/10.1080/16506070801981240

Nelson, D. L., Castonguay, L. G., & Barwick, F. (2007). Directions for the integration of homework in practice. In N. Kazantzis & L. L’Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, and prevention (pp. 425–444). Springer.

Petrik, A. M., Kazantzis, N., & Hofmann, S. G. (2013). Distinguishing integrative from eclectic practice in cognitive behavioral therapies. Psychotherapy: Theory, Research, Practice, Training, 50 (3), 392–397. https://doi.org/10.1037/a0032412

Petty, R. E., & Cacioppo, J. T. (1981). Attitudes and persuasion: Classic and contemporary approaches . Brown.

Primakoff, L., Epstein, N., & Covi, L. (1986). Homework compliance: An uncontrolled variable in cognitive therapy outcome research. Behavior Therapy, 17 , 433–446.

Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19 , 276–288.

Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rakowski, W., et al. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13 , 39–46.

Rescorla, R. A. (1988). Pavlovian conditioning: It’s not what you think it is. American Psychologist, 43 , 151–160.

Rogers, R. W., & Prentice-Dunn, S. (1997). Protection motivation theory. In David S. Gochman (Ed.), Handbook of Health Behavior Research (Vol.1. pp 113–132). New York: Plenum Press.

Rosenstock, I. M. (1960). What research in motivation suggests for public health. American Journal of Public Health, 50 , 295–301.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Ryum, T., Stiles, T. C., Svartberg, M., & McCullough, L. (2010). The effects of therapist competence in assigning homework in cognitive therapy with cluster C personality disorders: Results from a randomized controlled trial. Cognitive and Behavioral Practice, 17 (3), 283–289. https://doi.org/10.1016/j.cbpra.2009.10.005

Scheel, M. J., Seaman, S., Roach, K., Mullin, T., & Mahoney, K. B. (1999). Client implementation of therapist recommendations predicted by client perception of fit, difficulty of implementation, and therapist influence. Journal of Counseling Psychology, 46 (3), 308–316.

Shelton, J. L., & Ackerman, J. M. (1974). Homework in counseling and psychotherapy: Examples of systematic assignments for therapeutic use by mental health professionals . Thomas.

Shelton, J. L., & Levy, R. L. (1981a). Behavioral assignments and treatment compliance: A handbook of clinical strategies . Research Press.

Shelton, J. L., & Levy, R. L. (1981b). A survey of the reported use of assigned homework activities in contemporary behavior therapy literature. The Behavior Therapist, 4 , 13–14.

Skinner, B. F. (1971). Beyond freedom and dignity . Knopf.

Skinner, B. F. (1974). About behaviorism . Alfred A. Knopf.

Staats, A. W. (1996). Behavior and personality: Psychological behaviorism . Springer.

Startup, M., & Edmonds, J. (1994). Compliance with homework assignments in cognitive-behavioral psychotherapy for depression: Relation to outcome and methods of enhancement. Cognitive Therapy & Research, 18 , 567–579.

Strecher, V. J., Champion, V. L., & Rosenstock, I. W. (1997). In D. S. Gochman (Ed.), Handbook of Health Behavior Research I: Personal and Social Determinants (pp. 71–91). New York: Plenum Press.

Taylor, C. B., Agras, W. S., Schneider, J. A., & Allen, R. A. (1983). Adherence to instructions to practice relaxation exercises. Journal of Consulting and Clinical Psychology, 51 (6), 952–953.

Tee, J., & Kazantzis, N. (2011). Collaborative empiricism in cognitive therapy: A definition and theory for the relationship construct. Clinical Psychology: Science & Practice, 18 , 48–62. https://doi.org/10.1111/j.1468-2850.2010.01234.x

Tharp, R. G., & Wetzel, R. J. (1969). Behavior modification in the natural environment . Academic Press.

Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78 (2), 200–211. https://doi.org/10.1037/a0018912

Weck, F., Richtberg, S., Esch, S., Höfling, V., & Stangier, U. (2013). The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: Secondary analysis of a randomized trial. Behavior Therapy, 44 (1), 162–172. https://doi.org/10.1016/j.beth.2012.09.004

Weinstein, N. D. (1993). Testing four competing theories of health-protective behavior. Health Psychology, 12 , 324–333.

Wheaton, M. G., & Chen, S. C. (2021). Homework completion in treating obsessive-compulsive disorder with exposure and ritual prevention: A review of the empirical literature. Cognitive Therapy and Research, 45 (2), 236–249. https://doi.org/10.1007/s10608-020-10125-0

Yew, R. Y., Dobson, K. S., Zypher, M., & Kazantzis, N. (2021). Mediators and moderators of homework-outcome relations in CBT for depression: A study of engagement, therapist skill, and client factors. Cognitive Therapy and Research, 45 (2), 209–223. https://doi.org/10.1007/s10608-019-10059-2

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The authors thank Aaron T. Beck and Judith S. Beck for helpful discussions and guidance on the topic of integrating homework into CBT.

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Kazantzis, N., Miller, A.R. A Comprehensive Model of Homework in Cognitive Behavior Therapy. Cogn Ther Res 46 , 247–257 (2022). https://doi.org/10.1007/s10608-021-10247-z

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Homework in CBT

Table of contents, why do homework in cbt, how to deliver homework, strategies to increase confidence.

Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect thoughts, and modify their thinking.

Homework is not something that you just assign randomly. You should make sure you:

  • tailor the homework to the patient
  • provide a rationale for why the patient needs to do the homework
  • uncover any obstacles that might prevent homework from being done (i.e. - busy work schedule, significant neurovegetative symptoms)

Types of homework

Types of homework assignments.

You should also decide the frequency of the homework should be assigned: should it be daily, weekly?

If your patient does not do homework, that’s OK! Explore as a team, in a non-judgmental way, to explore why the homework was not done. Here are some ways to increase adherence to homework:

  • Tailor the assignments to the individual
  • Provide a rationale for how and why the assignment might help
  • Determine the homework collaboratively
  • Try to start the homework during the session. This creates some momentum to continue doing the homework
  • Set up systems to remember to do the assignments (phone reminders, sticky notes
  • It is better to start with easier homework assignments and err on the side of caution
  • They should be 90-100% confident they will be able to do this assignment
  • Covert rehearsal - running through a thought experiment on a situation
  • Change the assignment - It is far better to substitute an easier homework assignment that patients are likely to do than to have them establish a habit of not doing what they had agreed to in session
  • Intellectual/emotional role play - “I’ll be the intellectual part of you; you be the emotional part. You argue as hard as you can against me so I can see all the arguments you’re using not to read your coping cards and start studying. You start.”

homework assigned as a part of cognitive therapy

Homework Compliance and Quality in Cognitive Behavioral Therapies for Anxiety Disorders and Obsessive-Compulsive Disorder

Affiliations.

  • 1 VA Central Ohio Healthcare System. Electronic address: [email protected].
  • 2 Center for Anxiety and Related Disorders at Boston University.
  • PMID: 34134818
  • DOI: 10.1016/j.beth.2021.01.001

Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention.

Keywords: anxiety disorders; cognitive behavioral therapy; homework compliance; homework quality; obsessive-compulsive disorder.

Copyright © 2021. Published by Elsevier Ltd.

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  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Anxiety Disorders / therapy
  • Cognitive Behavioral Therapy*
  • Obsessive-Compulsive Disorder* / therapy
  • Panic Disorder*
  • Phobia, Social*
  • Treatment Outcome

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The New “Homework” in Cognitive Behavior Therapy

The New “Homework” in Cognitive Behavior Therapy

By Judith S. Beck, Ph.D., and Francine R. Broder, Psy.D.

Judith S. Beck, Ph.D.

We’ve stopped using the word “homework” in CBT. Too many clients take exception to that term. It reminds them of the drudgery of assignments they had to do at home when they were at school. So in recent times, we’ve switched. “Homework” is now called the “Action Plan.”

We like the label “Action Plan.” It conveys a sense of proactivity, of taking control.

The New Homework Quote

Action plans aren’t optional. They are very carefully created, in a collaborative fashion. Therapists emphasize that most of the work in getting better happens between sessions. A significant part of each session involves helping clients figure out what they need to do outside of the therapy office to feel better and regain a good level of functioning. We tell clients:

Fran Web

That’s why we make sure that whatever is important for the client to remember about the session, including their Action Plan, is recorded, written down or entered as text or audio into an electronic device.

And that’s why, after we’ve finished collaboratively creating the Action Plan, we ask:

How likely are you to do this assignment(s) this week?

And that’s why we continue talking about potential obstacles that could get in the way when clients say they are 90% or less likely to complete the Action Plan.

Here is an example of a client who did not do his action plan, and this is how we worked on it.

A 28-year-old came to treatment to work on reducing depression, social anxiety, and worry about his irritable bowel syndrome.  During our session, he identified “getting into shape” as important to him and set up a specific action plan that included going to the gym he belonged to, two times during the week, for approximately 30 minutes.  Upon returning the following week and checking in on how it went, he stated he did not go.  When asked what got in his way, he stated he did not know.  He was asked to go back to an earlier time in the week, imagine himself about to go to the gym, and to notice the thoughts that were going through his mind.  Using imagery, he was able to identify his interfering thoughts.  Next, we used Socratic questioning, summarizing his conclusions in a two-column thought record.

The New Homework Chart

The Action Plan isn’t optional. A considerable body of evidence shows that clients who do homework have better outcomes than clients who do not. See, for example Conklin & Strunk (2015); Kazantzis, Deane, Ronan & L’Abate (2005). It’s up to therapists to help clients carefully design meaningful assignments with a good likelihood of success and to motivate clients to follow through. Finally, we used the two-column thought record to anticipate additional interfering thoughts that could get in the way of engaging in his action plan for the coming week.

Conklin, L. R., & Strunk, D. R. (January 01, 2015). A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits? .  Behaviour Research and Therapy, 72,  56-62.

Kazantzis, N., & L’Abate, L. (2006).  Handbook of homework assignments in psychotherapy: Research, practice, and prevention . New York, NY: Springer.

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Promoting Homework Adherence in Cognitive-Behavioral Therapy for Adolescent Depression

Nathaniel j. jungbluth.

Department of Psychiatry and Behavioral Medicine, Seattle Children’s Hospital, Seattle, WA

Stephen R. Shirk

Department of Psychology, University of Denver, Denver, CO

This study used prospective, observational methods to evaluate six features of therapist behavior as predictors of homework adherence in cognitive-behavioral therapy (CBT) for adolescent depression, with the goal of identifying therapist strategies with the potential to improve adolescent adherence. Therapist behaviors were expected to interact with initial levels of client resistance or adherence to predict subsequent homework completion.

Participants were 50 referred adolescents (33 females, 54% ethnic minority) ages 14–18 ( M =15.9) meeting diagnostic criteria for a depressive disorder, and without co-morbid psychotic disorder, bipolar disorder, autism spectrum disorder, intellectual disability, or concurrent treatments. Therapist homework-related behaviors were coded from audiotapes of Sessions 1 and 2 and used to predict adolescents’ homework adherence, coded from audiotapes of Sessions 2 and 3.

Several therapist behaviors were predictive of subsequent homework adherence, particularly for initially resistant or non-adherent adolescents. Stronger homework rationale and greater time allocated to explaining homework in Session 1 predicted greater adherence at Session 2, particularly for initially resistant adolescents. Stronger rationale and eliciting reactions/troubleshooting obstacles in Session 2 predicted greater adherence at Session 3, particularly for adolescents who were less adherent to prior homework.

Conclusions

Strategies such as providing a strong rationale, allocating more time to assigning homework, and eliciting reactions/troubleshooting obstacles may be effective ways to bolster homework adherence among initially less engaged, depressed teens.

The assignment of homework is considered important in Cognitive-Behavioral Therapy (CBT) as a means to build and generalize new client skills. A growing body of evidence supports homework as an active ingredient in CBT for adults (see Kazantzis et al., 2010 , for a meta-analysis). Although only a handful of empirical studies have examined the role of homework in youth treatments ( Clarke et al., 1992 ; Gaynor, Lawrence & Nelson-Gray, 2006 ; Hughes and Kendall, 2007 ; Kazdin, Bass, Siegel, & Thomas, 1989 ), there is some evidence supporting its positive association with outcome. Two studies of homework in CBT for adolescent depression yielded small to moderate correlations between homework adherence and outcome ( Clark et al., 1992 ; Gaynor et al., 2006 ). In both studies, adolescents completed about half of assigned homework tasks. Initial results, then, suggest homework completion contributes to better depression outcomes, but adolescent adherence is far from optimal. Thus, one way to improve CBT for adolescent depression could be through increased homework adherence.

A small number of studies in the adult treatment literature have examined therapist behaviors thought to be associated with increased homework adherence. These empirical studies have largely focused on four cognitive therapy strategies originally prescribed by Beck, Rush, Shaw, and Emery (1979) , which include: 1) providing clear and specific task instructions and custom-tailoring homework tasks to client problems when possible; 2) providing a rationale for the assignment, stressing the importance and the goals of the task; 3) eliciting patient reactions and possible obstacles to completion of the homework, troubleshooting when necessary; and 4) reviewing assignments from the previous session, summarizing progress made or conclusions drawn from the exercise. Each of these strategies has received some empirical support with adults ( Bryant, Simons & Thase, 1999 ; Detweiler-Bedell & Whisman, 2005 ; Ryum, Stiles, Svartberg, & McCullough, 2010 ; Shaw et al., 1999 ).

Despite suboptimal homework adherence among teens, little is known about processes that improve adherence in youth. Beck and colleagues’ (1979) prescribed strategies provide a framework for examining therapist homework-related behavior with adolescents. From a developmental perspective, the strategy of eliciting adolescent reactions and perceived obstacles to homework completion seems particularly important given that a collaborative approach has been shown to facilitate alliance development with adolescents ( Diamond, Liddle, Hogue, & Dakof, 1999 ), who can be reactive to adult prescriptions or requests.

Of course, “adherence-enhancing behaviors” do not occur in a vacuum. Adolescents vary significantly in their readiness to engage in treatment, and prior research has found that adolescents with higher levels of initial resistance showed poorer subsequent involvement in treatment tasks ( Jungbluth & Shirk, 2009 ). Similarly, early homework adherence has been found to predict subsequent adherence ( Addis & Jacobson, 2000 ). Thus, adolescents who have shown high initial resistance or poor adherence to a previous homework task are likely at greater risk for future non-adherence. It is hypothesized that initially resistant or non-adherent adolescents might benefit most from additional therapist use of adherence-enhancing strategies. Specifically, greater therapist attention to specifying homework tasks, providing a strong rationale, and troubleshooting obstacles, as well as the sheer amount of time devoted to assigning tasks, may be especially relevant for adolescents who are initially resistant or non-adherent to previous assignments. These same therapist behaviors may not be as critical for adolescents with good early engagement or strong prior homework adherence. Teens who have been adherent to prior homework tasks may benefit more from different therapist behaviors, such as more extensive homework review and therapist use of praise.

In summary, this study evaluated six features of therapist behavior as predictors of homework adherence in CBT for adolescent depression. Session recordings from a study of individually delivered, manual-guided CBT for adolescent depression were utilized. Therapist behaviors were expected to interact with initial levels of client resistance and adherence to predict subsequent homework completion. Coding and analysis of therapist adherence-enhancing behaviors were limited to the first two sessions of treatment for two reasons: 1) Previous research with adults has linked early homework to treatment gains ( Addis & Jacobson, 2000 ; Fennell & Teasdale, 1987 ) and later homework adherence ( Addis & Jacobson, 2000 ); 2) Sample size constrained our ability to evaluate complex interactions in later sessions (when therapist behavior may interact with or depend upon factors from all prior sessions, such as the cumulative effects of resistance, prior therapist behavior, and the trajectory of homework adherence).

Participants

The data were obtained from an open clinical trial of CBT for depressed adolescents in an urban setting in the Rocky Mountain West (see Shirk, Kaplinski & Gudmundsen, 2009 , for a detailed description of study procedures, which were IRB approved prior to initiating the study). Current study participants were 50 referred adolescents (33 females), between ages 14 and 18 ( M = 15.9), who met diagnostic criteria for Major Depressive Disorder ( n =37), Dysthymic Disorder ( n =10), or Depressive Disorder, Not Otherwise Specified ( n =3), as assessed with the Computerized Diagnostic Interview Scale for Children (C-DISC; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000 ). Exclusionary criteria were: diagnoses of co-morbid Psychotic Disorder, Bipolar Disorder, Autism Spectrum Disorder, or Intellectual Disability; concurrent therapy; or medication for depressive symptoms.

Sixty-six percent of the sample met criteria for a comorbid disorder including generalized anxiety disorder (42%), conduct disorder (34%), social phobia (22%), and attention deficit/hyperactivity disorder (12%). Twenty-eight percent of the treatment sample met criteria for three or more disorders. Forty percent reported a lifetime history of attempted suicide.

By self-report, 54 percent of the sample identified as ethnic minority, including 11 African American/Black, 11 Hispanic/Latino, two Native American, two Biracial, and two Other, with some adolescents endorsing multiple categories. Socioeconomic status was indexed by parent occupation on the Hollingshead Index ( Hollingshead, 1976 ), with an average score of 4.1 ( SD= 2.1), corresponding to skilled manual workers, craftsmen, and small business owners. Fifty adolescents started treatment, with two dropping out before the second session and five more before Session 3. Available sample size varied across primary analyses from 41 to 33 due to client dropout, mechanical audiotape failure, therapist failure to record a session, and, in a small number of cases, insufficient detail on the audiotape for coding of homework adherence, as discussed in greater detail below. Demographic or study variables did not differ across groups with or without missing data.

High school site coordinators identified and referred potential participants for inclusion in the study. Participants completed a computer-administered diagnostic interview (C-DISC) and demographic questionnaires at the pre-treatment interview. Participating adolescents received free treatment and monetary compensation for completion of research interviews.

A twelve-session, manual-guided, outpatient cognitive-behavioral treatment, adapted for adolescents and evaluated by Rossello and Bernal (1999) , was delivered by eight therapists. Goals of the first session were to build rapport, gather information, provide rationale and expectations for treatment, provide education about depression, and introduce mood monitoring homework. The second session included education about negative thinking and its link to mood, followed by introduction of a thought monitoring homework task. In session three, therapists continued discussing negative thinking in relation to depressed mood and introduced skills for challenging negative thoughts, which were then assigned as homework. A review of 25 percent of audiotapes selected randomly indicated high therapist fidelity to the treatment manual, with 83 percent of components delivered ( Shirk, Gudmundsen, Crisp Kaplinski, & McMakin, 2008 ).

All eight therapists had doctoral degrees in clinical psychology, attended a daylong workshop, conducted a supervised practice case, and then received 1.5 hours of weekly group supervision by a licensed psychologist with extensive CBT experience.

Weekly homework assignments were described in the manual, and time was allocated in every session for assigning new homework and reviewing the previous session’s homework. Teens also received workbooks and handouts on which to record assignments. Session 1 homework required adolescents to record daily mood ratings and triggers for negative arousal. Session 2 was the same, but included recording automatic thoughts associated with negative mood or events. Specific guidelines for how to assign homework were not included in the manual.

Computerized Diagnostic Interview Scale for Children 4.0 (C-DISC)

The C-DISC ( Shaffer et al., 2000 ) is a highly structured diagnostic interview with good reliability and criterion validity for identifying psychiatric disorders among youth ( Shaffer et al., 2000 ). The mood, anxiety, and disruptive behavior modules were computer administered to screen for inclusion and exclusion disorders and to measure depression severity based on total symptoms endorsed.

Homework Adherence

Homework adherence was coded from audiotapes of Sessions 2 and 3, in random order, on a seven-point scale (0=“no effort” to 6=“did more than was asked or exceptional effort”). Reliability of homework adherence coding, based on double coding of 30 percent of sessions ( n = 25), was good, with a two-way random effects intraclass correlation ( ICC ) of .72. Of the 91 existing sessions we set out to code, 84 were given homework adherence ratings. The remaining seven sessions (7.7 percent) could not be coded for one of several reasons: 1) mechanical audiotape error, 2) therapist forgot to record the session, or 3) there was insufficient information on the audiotape to determine a rating. Observed adherence ratings ranged from 0 to 6 (Session 2 M =4.51, SD =1.01 and Session 3 M= 4.21, SD =1.12 after outlier adjustment).

Adherence-Enhancing Behaviors

Behaviors thought to promote homework adherence were measured using the Therapist Homework Adherence Behavior Scale (THABS), an adaptation of Bryant and colleagues’ (1999) measure from CT for depressed adults. The scale includes six items: 1) specification of the task, 2) provision of rationale, 3) elicitation of client reactions and troubleshooting of difficulties, 4) review of previous homework assignment, 5) praise for homework adherence, and 6) total time spent assigning the task. The first five items were rated on a scale from zero (not done) to four (very well done) and anchored to enhance reliability. The sixth item was scored as simply the number of seconds devoted to assigning homework. Two-way random effects intraclass correlations ( ICC s), based on double coding of 21 percent of available sessions ( n = 19), ranged from .27 to .84 (mean ICC = .67; See Table 1 for item descriptions, ICC s, and descriptive data). Item 4 (review of previous homework assignment) was dropped due to low reliability. Four Session 1 tapes could not be coded because of mechanical tape failure ( n = 2) and therapists forgetting to tape the session ( n = 2). One Session 2 tape could not be coded because a therapist forgot to tape the session.

Adherence-Enhancing Behaviors: Item Descriptions, ICCs and Descriptive Data

Initial Resistance

Initial resistance was assessed during Session 1 using six items adapted from the observational Vanderbilt Negative Indicators Scale ( Suh, Strupp, & O’Malley, 1986 ). Observers used audiotapes to code a 15-minute segment for each client, beginning five minutes into Session 1. This early segment was chosen to begin after introductions and initial scheduling concerns were addressed but before the therapist had time to build much rapport, to better capture the client’s contribution to process. Client demeanor was rated using five items covering five dimensions: hostile, frustrated, impatient, intellectualizing, and defensive. A sixth item was used to rate client negative reactions to the therapist. All items were rated on a 5-point scale ranging from 1 ( not at all ) to 5 ( a great deal ) and totaled. Internal consistency for the scale was good (Cronbach’s alpha = .89) and a one-way mixed random ICC (using 25% of scores) demonstrated strong inter-rater reliability ( ICC = .88). Four Session 1 tapes could not be coded for initial resistance, for reasons listed above. Initial resistance, adherence-enhancing behaviors, and homework adherence were coded by separate sets of coders to avoid bias. Scores ranged from 6 to 25 ( M =7.54, SD =1.91, after outlier adjustment).

Outliers were identified for three of the Session 1 THABS items (specifying task: 3 outliers; providing rationale: 5 outliers; time spent assigning: 2 outliers), and both homework adherence variables (Session 2 adherence: 5 outliers; Session 3 adherence: 6 outliers). Outliers were adjusted by bringing them in to 1.5 times the interquartile range beyond the first or third quartile to prevent undue influence. Skew and kurtosis were within acceptable ranges for all variables. Examination of Mahalanobis distance for all interaction model variables revealed no multivariate outliers.

Client characteristics

We tested client demographic (age, gender, race/ethnicity) and clinical (initial depression severity) variables as predictors of homework adherence at Sessions 2 and 3. The only predictor was Hispanic/Latino ethnicity ( Spearman r = −.31, p = .03), such that adolescents who self-identified as Hispanic/Latino were less adherent for the first homework task. Thus, Hispanic/Latino was included as a control variable in all analyses predicting homework adherence.

Initial resistance

As expected, initial resistance showed a small, though non-significant, association with homework adherence at Session 2 ( r = −.26, p = .09) and Session 3 ( r = −.23, p = .18). Initial resistance was included as a predictor or moderator in all analyses of therapist behaviors in relation to homework adherence.

Therapist effects

Analyses were conducted to evaluate the possible influence of therapist effects on homework adherence. Two separate univariate Analysis of Variance (ANOVA) models were run with therapists as the independent grouping factor and Session 2 and Session 3 homework adherence ratings as dependent variables. Results showed no significant therapist effects on these variables ( p ’s > .4).

Correlations among HWA predictors

Pearson correlation coefficients were calculated to examine the association among the six therapist behaviors, as well as the three other predictor variables (initial resistance, Session 2 homework adherence, and Hispanic/Latino ethnicity) to be evaluated as predictors of HWA. These associations are presented in Table 2 . Although several of the therapist behaviors were significantly correlated with one another, no correlation exceeded .52 and most associations were very small and non-significant; thus, the coding system appears to have captured relatively discrete, non-overlapping constructs. Also, therapist behaviors were generally not associated with initial resistance or homework adherence at Session 2, and initial resistance and homework adherence at Session 2 were only associated with one another at a trend level. Hispanic/Latino ethnicity was associated greater therapist provision of rationale at Session 2 (r = .29, p < .05).

Correlations Among Session 1 and 2 Predictors of Homework Adherence

Session 1 therapist behaviors predicting homework adherence in Session 2

Each of the four Session 1 therapist behaviors were entered into separate multiple regressions. In each regression, therapist behavior was entered along with initial resistance, Hispanic/Latino ethnicity, and the interaction term (therapist behavior centered x initial resistance centered) as predictors of homework adherence at Session 2. Results of these regressions are described below and in Table 3 .

Multiple Regression Analyses Predicting Homework Adherence at Session 2 from Therapist Adherence-Enhancing Behaviors in Session 1

Initial resistance demonstrated a small to medium effect across regressions ( β ’s from −.23 to −.40), as did Hispanic/Latino ethnicity ( β ’s from −.33 to −.44). In addition, interaction effects were observed for two therapist behaviors: As illustrated in Figure 1 , and consistent with our hypothesis, provision of rationale in Session 1 predicted Session 2 adherence more strongly for adolescents who were initially more resistant (interaction term β = .31, p = .03). As illustrated in Figure 2 , and also consistent with our hypothesis, the positive predictive association between time spent assigning in Session 1 and adherence in Session 2 appeared stronger for adolescents who were initially more resistant (interaction term β = .30, p = .03). (In Figures 1 and ​ and2, 2 , initial resistance was dichotomized at the median into high and low groups for the purposes of illustration.) There was also a trend-level main effect for time spent assigning the homework ( β = .26, p = .07) predicting Session 2 adherence.

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The interaction between initial resistance (IR) and provision of rationale in Session 1 to predict homework adherence at Session 2, controlling for Hispanic/Latino ethnicity.

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The interaction between initial resistance (IR) and the amount of time therapist spent assigning homework in Session 1 to predict homework adherence at Session 2, controlling for Hispanic/Latino ethnicity.

Session 2 therapist behaviors predicting clients’ homework adherence at Session 3, considering prior adherence

Next, we examined whether the same four adherence-enhancing behaviors, this time measured in Session 2, would interact with clients’ level of prior homework adherence to predict adherence at Session 3. Each of the four therapist behaviors were entered into separate multiple regressions along with Session 2 homework adherence, initial resistance, Hispanic/Latino ethnicity, and the interaction term (therapist behavior centered x Session 2 homework adherence centered). The dependent variable was homework adherence at Session 3. Results of these multiple regressions are described below and displayed in Table 4 .

Multiple Regression Analyses Predicting Homework Adherence at Session 3 from Therapist Adherence-Enhancing Behaviors in Session 2

Initial resistance demonstrated a small to medium effect across regressions ( β ’s from −.20 to −.47), and Session 2 homework adherence demonstrated a medium effect across regressions ( β ’s from .34 to .43) predicting Session 3 adherence. In addition, interaction effects were observed for two of the therapist behaviors: Consistent with our prediction, and as illustrated in Figure 3 , provision of rationale in Session 2 predicted homework adherence at Session 3 most strongly for those adolescents who had shown poorer adherence to the previous homework task (interaction term β = −.45, p = .01). Also consistent with our prediction, and as illustrated in Figure 4 , eliciting client reactions and troubleshooting obstacles to adherence in Session 2 was positively associated with homework adherence in Session 3 for adolescents who had shown poorer prior adherence (interaction term β = −.40, p = .026). (In Figures 3 and ​ and4, 4 , Session 2 homework adherence was dichotomized into high and low groups for the purposes of illustration. High adherence reflected scores of “5” or higher, and low adherence reflected scores lower than “5” on the homework adherence scale.)

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The interaction between Session 2 homework adherence (HW2) and Session 2 providing rationale to predict homework adherence at Session 3, controlling for level of initial resistance and Hispanic/Latino ethnicity.

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The interaction between Session 2 homework adherence (HW2) and Session 2 eliciting reactions/troubleshooting obstacles to predict homework adherence at Session 3, controlling for level of initial resistance and Hispanic/Latino ethnicity.

Contingent praise in Session 2 was also examined as a predictor of Session 3 homework adherence using multiple regression. Of 33 participants with complete data for this analysis, 28 had completed at least some of the first homework assignment and were included. Praise, Session 2 homework adherence, initial resistance and Hispanic/Latino ethnicity were entered as predictors of Session 3 homework adherence. Results showed significant main effects for Session 2 homework adherence ( β = .62, p = .002) and initial resistance ( β = −.48, p = .008). The praise term was not significant ( p = .18).

The current study used prospective, observational methods to examine six therapist behaviors thought to bolster adolescents’ adherence to homework tasks. Consistent with the adult literature, homework adherence was not merely a function of client characteristics, but instead was associated with variations in the way therapists assigned and reviewed homework tasks. Importantly, the positive impact of several therapist behaviors on early homework adherence was conditioned by client behaviors, including early resistance and prior adherence, underscoring the interactive nature of therapy processes.

It was hypothesized that four therapist behaviors—specifying the task, providing rationale, eliciting reactions/troubleshooting obstacles, and amount of time spent assigning—would predict subsequent adherence, with the greatest effects for adolescents who were at risk for poor homework adherence. Adolescents were determined to be at risk for poor adherence if they demonstrated higher levels of initial resistance in Session 1 and if they demonstrated poor adherence on the first homework task, due in Session 2. Consistent with predictions, three therapist behaviors interacted with the risk variables to predict subsequent adherence.

First, adolescents with higher levels of initial resistance and lower levels of initial adherence were more likely to adhere to subsequent homework assignments when therapists provided a strong rationale. This association was not observed with less resistant and initially more adherent adolescents. Greater provision of rationale did not predict adherence with adults ( Bryant et al. 1999 ), but only main effects were examined. Alternatively, provision of a clear rationale may be particularly important for adolescents compared to adults.

Second, the amount of time therapists devoted to assigning homework in Session 1 predicted adherence in Session 2 at a trend level, and this effect was stronger for adolescents who were initially more resistant. This finding suggests therapists may be able to promote greater adherence by setting aside more time in sessions for assigning tasks, especially for relatively disengaged teens. Associations among therapist behavior variables suggest therapists who spent more time assigning homework were also doing a better job specifying the task and providing rationale for it. Time spent in Session 2 did not predict subsequent adherence, perhaps owing to similarity of homework assignments across early sessions.

Third, when adolescents did not show strong adherence to the first homework assignment, therapist efforts to elicit reactions and troubleshoot obstacles in the second session predicted better adherence to the next assignment. This finding converges with three studies with adults indicating positive effects for eliciting reactions and troubleshooting ( Bryant et al., 1999 , Detweiler-Bedell & Whisman, 2005 , & Worthington, 1986 ). The same therapist behavior, when measured in the first session, did not predict adherence in Session 2, even when initial resistance was considered as a moderator. It may have been easier to identify and address obstacles after they occurred than before.

Another behavior, specifying the homework task, did not predict subsequent adherence in either session, which may reflect that worksheets with clear written instructions were provided. Providing written reminders has been linked to improved medical adherence ( Cox, Tisdelle & Culbert, 1988 , Stone et al., 2002 ) and better therapy outcomes for depressed adults ( Detweiler-Bedell & Whisman, 2005 ).

In examining these four therapist behaviors, consideration of context variables (initial resistance and prior adherence) was essential. Contrary to expectations, only one of the four therapist behaviors trended toward a main effect on subsequent adherence. The remaining predictive effects were only significant when considering these moderators, and results begin to address the clinically important question of how to improve low adherence.

There was also an association between Hispanic/Latino ethnicity and adherence to the first homework task; however, this finding is viewed with caution, as Hispanic/Latino ethnicity was not associated with adherence to the second homework task or initial resistance, nor did it predict alliance or outcome in a previous study with the current sample ( Shirk, Gudmundsen, Crisp Kaplinski, & McMakin, 2008 ).

This study had a number of limitations. First, though larger than most prior studies in this literature, sample size was limited. Given power limitations (power for medium effects ranged between .5 and .7) and the exploratory nature of the study, we made no alpha adjustment for the number of analyses conducted; with Bonferroni correction for the main analyses, adjusted alpha would have been .004. Consequently, replication is essential. Second, identified associations were correlational. Future studies should experimentally manipulate therapist behaviors to clarify causality. Third, therapist behaviors were not examined beyond the second session of treatment; thus, current findings may not generalize to middle and later phases of therapy when assignments often become more demanding. Fourth, although standardized homework assignments in the current protocol offered methodological advantages (e.g., variability in adherence across adolescents could not be attributed to variation in homework tasks), this prevented examination of some therapist strategies (e.g., collaborative task generation, individual tailoring) and may have constrained effect sizes for others (e.g., task specification). Similarly, the manual’s specification of homework review likely constrained variation in this behavior. Finally, interrater reliability for therapist praise was suboptimal.

Clinically, therapists faced with depressed adolescents who initially show poor engagement or marginal homework adherence may consider spending more time assigning homework and providing a strong rationale linking homework tasks to recovery. In addition, therapists may be able to improve poor initial adherence by taking time to troubleshoot obstacles that arise. In sum, how therapists address homework relates to how much homework depressed adolescents will do.

Contributor Information

Nathaniel J. Jungbluth, Department of Psychiatry and Behavioral Medicine, Seattle Children’s Hospital, Seattle, WA.

Stephen R. Shirk, Department of Psychology, University of Denver, Denver, CO.

  • Addis M, Jacobson N. A closer look at the treatment rationale and homework compliance in cognitive-behavioral therapy for depression. Cognitive Therapy and Research. 2000; 24 :313–326. doi: 10.1023/A:1005563304265. [ CrossRef ] [ Google Scholar ]
  • Beck A, Rush A, Shaw B, Emery G. Cognitive therapy of depression. New York, NY: Guilford; 1979. [ Google Scholar ]
  • Bryant M, Simons A, Thase M. Therapist skill and patient variables in homework compliance: Controlling an uncontrolled variable in cognitive therapy outcome research. Cognitive Therapy and Research. 1999; 23 :381–399. doi: 10.1023/A:1018703901116. [ CrossRef ] [ Google Scholar ]
  • Clarke G, Hops H, Lewinsohn P, Andrews J, Seeley J, Williams J. Cognitive-behavioral group treatment of adolescent depression: Prediction of outcome. Behavior Therapy. 1992; 23 :341–354. doi: 10.1016/S0005-7894(05)80162-5. [ CrossRef ] [ Google Scholar ]
  • Cox D, Tisdelle D, Culbert J. Increasing adherence to behavioral homework assignments. Journal of Behavioral Medicine. 1988; 11 :519–522. doi: 10.1007/BF00844844. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Detweiler-Bedell J, Whisman M. A lesson in assigning homework: Therapist, client, and task characteristics in cognitive therapy for depression. Professional Psychology: Research and Practice. 2005; 36 :219–223. doi: 10.1037/0735-7028.36.2.219. [ CrossRef ] [ Google Scholar ]
  • Diamond G, Liddle H, Hogue A, Dakof G. Alliance-building interventions with adolescents in family therapy: A process study. Psychotherapy: Theory, Research, Practice, Training. 1999; 36 :355–368. doi: 10.1037/h0087729. [ CrossRef ] [ Google Scholar ]
  • Fennell M, Teasdale J. Cognitive therapy for depression: Individual differences and the process of change. Cognitive Therapy and Research. 1987; 11 :253–271. doi: 10.1007/BF01183269. [ CrossRef ] [ Google Scholar ]
  • Gaynor S, Lawrence P, Nelson-Gray R. Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: Review, preliminary findings, and implications for theory and practice. Behavior Modification. 2006; 30 :647–672. doi: 10.1177/0145445504272979. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Hollingshead AB. Four factor index of social status. New Haven, CT: Yale University Press; 1976. [ Google Scholar ]
  • Hughes A, Kendall P. Prediction of cognitive behavior treatment outcome for children with anxiety disorders: Therapeutic relationship and homework compliance. Behavioural and Cognitive Psychotherapy. 2007; 35 :487–494. doi: 10.1017/S1352465807003761. [ CrossRef ] [ Google Scholar ]
  • Jungbluth N, Shirk S. Therapist strategies for building involvement in cognitive–behavioral therapy for adolescent depression. Journal of Consulting and Clinical Psychology. 2009; 77 :1179–1184. doi: 10.1037/a0017325. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Kazantzis N, Whittington C, Dattilio F. Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice. 2010; 17 :144–156. doi: 10.1111/j.1468-2850.2010.01204.x. [ CrossRef ] [ Google Scholar ]
  • Kazdin A, Bass D, Siegel T, Thomas C. Cognitive-behavioral therapy and relationship therapy in the treatment of children referred for antisocial behavior. Journal of Consulting and Clinical Psychology. 1989; 57 :522–535. doi: 10.1037/0022-006X.57.4.522. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Rossello J, Bernal G. The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology. 1999; 67 :734–745. doi: 10.1037/0022-006X.67.5.734. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Ryum T, Stiles T, Svartberg M, McCullough L. The effects of therapist competence in assigning homework in cognitive therapy with cluster C personality disorders: Results from a randomized controlled trial. Cognitive and Behavioral Practice. 2010; 17 :283–289. doi: 10.1016/j.cbpra.2009.10.005. [ CrossRef ] [ Google Scholar ]
  • Shaffer D, Fisher P, Lucas C, Dulcan M, Schwab-Stone M. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): Description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry. 2000; 39 :28–38. doi: 10.1097/00004583-200001000-00014. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Shaw BF, Elkin I, Yamaguchi J, Olmsted M, Vallis TM, Dobson KS, Imber SD. Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression. Journal of Consulting and Clinical Psychology. 1999; 67 :837–846. doi: 10.1037/0022-006X.67.6.837. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Shirk S, Gudmundsen G, Crisp Kaplinski H, McMakin D. Alliance and outcome in cognitive-behavioral therapy for adolescent depression. Journal of Clinical Child and Adolescent Psychology. 2008; 37 :631–639. doi: 10.1080/15374410802148061. [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Shirk S, Kaplinski H, Gudmundsen G. School-based cognitive-behavioral therapy for adolescent depression: A benchmarking study. Journal of Emotional and Behavioral Disorders. 2009; 17 :106–117. doi: 10.1177/1063426608326202. [ CrossRef ] [ Google Scholar ]
  • Stone E, Morton S, Hulscher M, Maglone M, Roth E, Grimsjaw J, Shekelle P. Interventions That Increase Use of Adult Immunization and Cancer Screening Services: A Meta-Analysis. Annals of Internal Medicine. 2002; 136 :641–651. Retrieved from http://www.annals.org/ [ PubMed ] [ Google Scholar ]
  • Suh C, Strupp H, O’Malley S. The Vanderbilt process measures: The Psychotherapy Process Scale (VPPS) and the Negative Indicators Scale (VNIS) In: Greenberg LS, Pinsof WM, editors. The psychotherapeutic process: A research handbook. New York, NY US: Guilford Press; 1986. pp. 285–323. [ Google Scholar ]
  • Worthington E. Client compliance with homework directives during counseling. Journal of Counseling Psychology. 1986; 33 :124–130. doi: 10.1037/0022-0167.33.2.124. [ CrossRef ] [ Google Scholar ]

IMAGES

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    Over the last nine chapters, homework administration is described within cognitive and behavioral therapy for anxiety and depression, chronic pain, delusions and hallucinations, obsessions and compulsions, marital and sexual problems, personality disorders, children and adolescents, group and family therapy, and older adults.

  10. A Commentary on the Science and Practice of Homework in Cognitive

    Homework assignments represent the translation of the in- session efforts to understand the problems faced by the client into meaningful and relevant behavioral change, and to discern strategies to try to shift these problems into solutions (Kazantzis, Deane, et al., 2005; Kazantzis, Wedge, et al., 2005 ).

  11. A Comprehensive Model of Homework in Cognitive Behavior Therapy

    Aaron T. Beck et al. had conducted various studies of cognitive therapy outcomes during this period, and the first clinician guide " Cognitive Therapy of Depression" ( 1979) emerged placing homework as a core and crucial vehicle of change.

  12. The Role of Homework Assignments in Cognitive Therapy for Depression

    Homework assignments are an integral part of most cognitive therapy treatments for depression. Although investigations of the association between homework adherence and outcome are relatively few in number, recent studies suggest that clients who adhere to homework assignments show greater improvement than those who do not.

  13. Homework in CBT

    Here are some ways to increase adherence to homework: Tailor the assignments to the individual. Provide a rationale for how and why the assignment might help. Determine the homework collaboratively. Try to start the homework during the session. This creates some momentum to continue doing the homework.

  14. Homework Compliance and Quality in Cognitive Behavioral ...

    Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. ... which varied in degree of assigned homework. Despite this, there were no differences in average homework ...

  15. The New "Homework" in Cognitive Behavior Therapy

    Judith S. Beck, Ph.D. We've stopped using the word "homework" in CBT. Too many clients take exception to that term. It reminds them of the drudgery of assignments they had to do at home when they were at school. So in recent times, we've switched. "Homework" is now called the "Action Plan.". We like the label "Action Plan.".

  16. Therapist Behaviors as Predictors of Immediate Homework Engagement in

    Homework assignments are an essential part of cognitive therapy (CT) for depression (Beck, Rush, Shaw, & Emery, 1979).In CT, therapists utilize homework to help patients practice using and integrating CT skills into their lives (Kazantzis & Lampropoulos, 2002).Common homework assignments in CT depression include self-monitoring activities to understand the connection between daily activities ...

  17. The role of homework assignments in cognitive therapy for depression

    Homework assignments are an integral part of most cognitive therapy treatments for depression. Although investigations of the association between homework adherence and outcome are relatively few in number, recent studies suggest that clients who adhere to homework assignments show greater improvement than those who do not. Following their assessment of the potential impact of homework ...

  18. PSYCH FINAL EXAM Flashcards

    Homework assigned as a part of cognitive therapy A. often involves attending peer-led workshops B. may be written or behavioral C. is rarely discussed during subsequent sessions D. is best conceptualized as a behavioral activation technique

  19. Using Homework Assignments in Cognitive Behavior Therapy

    Over the last nine chapters, homework administration is described within cognitive and behavioral therapy for anxiety and depression, chronic pain, delusions and hallucinations, obsessions and compulsions, marital and sexual problems, personality disorders, children and adolescents, group and family therapy, and older adults.

  20. Clinical Psych Psych 352 W1 Chapter 15 Flashcards

    Marsha Linehan Judith Beck Steven Hayes Aaron Beck, Homework assigned as a part of cognitive therapy _____. often involves attending peer-led workshops may be written or behavioral is rarely discussed during subsequent sessions is best conceptualized as a behavioral activation technique and more.

  21. chapter 15 clinical psychology, chapter 14 clinical psy

    Since the 1980s, the popularity of cognitive psychotherapy among clinical psychologists has ____. A. increased. Cognitive therapy. C. represents a reaction against behavioral and psychodynamic approaches. _____ are considered leaders in the cognitive therapy movement. A. Aaron Beck and Albert Ellis. The primary goal of cognitive psychotherapy is.

  22. Promoting Homework Adherence in Cognitive-Behavioral Therapy for

    The assignment of homework is considered important in Cognitive-Behavioral Therapy (CBT) as a means to build and generalize new client skills. A growing body of evidence supports homework as an active ingredient in CBT for adults (see Kazantzis et al., 2010, for a meta-analysis). Although only a handful of empirical studies have examined the ...

  23. Psych Quizzes Chapter 12-15 Flashcards

    Latency, oral, anal, genital, phallic. a. Relative to its prominence in the early and mid-1900s, psychodynamic psychotherapy is currently. a. equally prominent. b. less prominent. c. more prominent. d. more prominent for adult therapists and less prominent for child therapists. b. The main goal of behavior therapy is.