Joel Minden, PhD

How Much Does Homework Matter in Therapy?

What research reveals about the work you do outside of therapy sessions..

Posted April 16, 2017 | Reviewed by Ekua Hagan

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Homework is an important component of cognitive behavior therapy (CBT) and other evidence-based treatments for psychological symptoms. Developed collaboratively during therapy sessions, homework assignments may be used by clients to rehearse new skills, practice coping strategies, and restructure destructive beliefs.

Although some clients believe that the effectiveness of psychotherapy depends on the quality of in-session work, consistent homework during the rest of the week may be even more important. Without homework, the insights, plans, and good intentions that emerge during a therapy session are at risk of being buried by patterns of negative thinking and behavior that have been strengthened through years of inadvertent rehearsal. Is an hour (or less) of therapeutic work enough to create change during the other 167 hours in a week?

Research on homework in therapy

Research on homework in therapy has revealed some meaningful results that can be understood collectively through a procedure called meta-analysis. A meta-analysis is a statistical summary of a body of research. It can be used to identify the average impact of psychotherapy homework on treatment outcomes across numerous studies. The results of four meta-analyses listed below highlight the value of homework in therapy:

  • Kazantzis and colleagues (2010) examined 14 controlled studies that directly compared treatment outcomes for clients assigned to psychotherapy with or without homework. The data favored the homework conditions, with the average client in the homework group reporting better outcomes than about 70% of those in the no-homework conditions.
  • Results from 16 studies (Kazantzis et al., 2000) and an updated analysis of 23 studies (Mausbach et al., 2010) found that, among those who received homework assignments during therapy, greater compliance led to better treatment outcomes. The effect sizes were small to medium, depending on the method used to measure compliance.
  • Kazantzis et al. (2016) examined the relations of both quantity (15 studies) and quality (3 studies) of homework to treatment outcome. The effect sizes were medium to large, and these effects remained relatively stable when follow-up data were collected 1-12 months later.

Taken together, the research suggests that the addition of homework to psychotherapy enhances its effectiveness and that clients who consistently complete homework assignments tend to have better mental health outcomes. Finally, although there is less research on this issue, the quality of homework may matter as much as the amount of homework completed.

To enhance the quality of homework, homework assignments should relate directly to a specific goal, the process should be explained with clarity by the therapist, its method should be rehearsed in session, and opportunities for thoughtful out-of-session practice should be scheduled with ideas about how to eliminate obstacles to completion.

To find a therapist, please visit the Psychology Today Therapy Directory .

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(2), 189-202.

Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta‐analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17(2), 144-156.

Kazantzis, N., Whittington, C., Zelencich, L., Kyrios, M., Norton, P. J., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: a meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47(5), 755-772.

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.

Joel Minden, PhD

Joel Minden, Ph.D., is a clinical psychologist, author of Show Your Anxiety Who’s Boss , director of the Chico Center for Cognitive Behavior Therapy, and lecturer in the Department of Psychology at California State University, Chico.

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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.”

why is homework important in cbt

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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.)

An external file that holds a picture, illustration, etc.
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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.

An external file that holds a picture, illustration, etc.
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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.

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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.

why is homework important in cbt

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

why is homework important in cbt

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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.

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Quick Tips for Therapists

The Five Rs of Effective Homework

May 25, 2021 | analis | Quick Tips For Therapists

By David A. Clark, PhD

In recent years, homework has been getting bad press in cognitive behavioral therapy (CBT) circles. For many clients, the word has an unpleasant association, conjuring up dark memories of late-night school assignments imposed by unforgiving teachers and enforced by unrelenting parents. Resistance to therapeutic homework is common , with clients either refusing outright or offering up a half-hearted attempt at best. 

For the conscientious CBT therapist, this is a most troubling situation. Homework is the cornerstone of CBT— and it improves treatment outcomes . Some therapists have responded with a name change. Instead of “homework,” they call it “skills practice,” “action plans,” “practice assignments,” etc. But for the “hardcore homework-resistant,” is a more positive label enough? A more in-depth response may be necessary. Consider these five Rs of therapeutic homework intended to boost client engagement:

  • Relevance – A homework assignment must be consistent with treatment goals, and a natural product of the session theme. If not, the assignment will seem irrelevant.
  • Reasonableness – The assignment must be practical, considering time constraints and all the demands of daily living. It should be written down, concise, and focused.
  • Relatable – The assignment should be done collaboratively so the client has a personal  

investment in the task. Individuals who perceive the assignment as an obligation imposed by the therapist will be less committed.

  • Rationale – Therapy time should be devoted to explaining the reason for doing the

homework assignment. Clients need to understand why the assignment is important, and its benefits.

  • Reviewed – Homework assignments must be reviewed at the subsequent session.

The most destructive scenario is when a client completes an assignment, but the therapist fails to spend time interpreting and consolidating the results. Homework is an opportunity for clients to demonstrate real learning from the therapy sessions. But homework engagement is an uphill struggle for many clients, which requires therapists to demonstrate creativity, patience, and understanding.

why is homework important in cbt

David A. Clark, PhD , is a clinical psychologist and professor emeritus at the University of New Brunswick. He is author or coauthor of several books on depression, anxiety, and obsessive-compulsive disorder (OCD), including The Anxiety and Worry Workbook with Aaron T. Beck (founder of cognitive therapy), The Anxious Thoughts Workbook , and Cognitive-Behavioral Therapy for OCD and Its Subtypes . Clark is a founding fellow and trainer consultant with the Academy of Cognitive and Behavioral Therapies, and fellow of the Canadian Psychological Association. He is author of the blog, The Runaway Mind , on www.psychologytoday.com.

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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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The Role of Homework Engagement, Homework-Related Therapist Behaviors, and Their Association with Depressive Symptoms in Telephone-Based CBT for Depression

  • Original Article
  • Open access
  • Published: 22 July 2020
  • Volume 45 , pages 224–235, ( 2021 )

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  • Elisa Haller 1 &
  • Birgit Watzke 1  

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Telephone-based cognitive behavioral therapy (tel-CBT) ascribes importance to between-session learning with the support of the therapist. The study describes patient homework engagement (HE) and homework-related therapist behaviors (TBH) over the course of treatment and explores their relation to depressive symptoms during tel-CBT for patients with depression.

Audiotaped sessions (N = 197) from complete therapies of 22 patients (77% female, age: M  = 54.1, SD  = 18.8) were rated by five trained raters using two self-constructed rating scales measuring the extent of HE and TBH (scored: 0–4).

Average scores across sessions were moderate to high in both HE ( M  = 2.71, SD  = 0.74) and TBH ( M  = 2.1, SD  = 0.73). Multilevel mixed models showed a slight decrease in HE and no significant decrease in TBH over the course of treatment. Higher TBH was related to higher HE and higher HE was related to lower symptom severity.

Conclusions

Results suggest that HE is a relevant therapeutic process element related to reduced depressive symptoms in tel-CBT and that TBH is positively associated with HE. Future research is needed to determine the causal direction of the association between HE and depressive symptoms and to investigate whether TBH moderates the relationship between HE and depressive symptoms.

Trial Registration

ClinicalTrials.gov NCT02667366. Registered on 3 December 2015.

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Avoid common mistakes on your manuscript.

Introduction

Therapeutic homework in terms of inter-session activity presents a central component of psychotherapy and is particularly inherent to cognitive behavioral therapy (CBT; Beck et al. 1979 ). The core principle of this treatment is to equip patients with tools to change thoughts, behaviors, emotions, and their interplay. Homework may be defined as activities carried out between sessions in order to practice skills outside of therapy and to generalize to the natural environment (Kazantzis and L’Abate 2007 ; Lambert et al. 2007 ). Rather than exclusively discussing problems in an isolated setting, patients are encouraged to address the problem in their everyday life with the intention to produce and maintain a therapeutic effect (Lambert et al. 2007 ). The theorized mechanisms of the effect of homework build upon the skills-building approach of CBT (Beck et al. 1979 ; Detweiler and Whisman, 1999 ), as therapeutic exercises provide an opportunity for the patient to gather information and practice newly gained skills. Ultimately, practicing skills outside therapy helps becoming aware of the problem and consolidating new beliefs and behaviors (Beck et al. 1979 ). Homework thus serves as a means of transferring strategies outside the therapy context and enables the patient to practice new skills in real-life situations in order to maintain therapeutic gain (Kazantzis and Ronan 2006 ).

Homework is a commonly studied process variable in CBT and has empirically been investigated primarily in association with treatment outcome. Previous research has demonstrated that a high level of homework compliance is related to improvements in depressive symptoms (e.g., Kazantzis et al. 2010 ). Meta-analyses have established correlational evidence for the homework compliance and outcome relationship (e.g., Mausbach et al. 2010 ) as well as experimental evidence for the superiority of treatments that incorporate homework over treatments without homework (Kazantzis et al. 2010 , 2016 ).

It has previously been noted that an “evidence-based” assessment of homework compliance (Dozois 2010 , p. 158) requires the consideration of qualitative aspects of homework completion throughout the course of the treatment (Dozois 2010 ; Kazantzis et al. 2010 , 2017 ). This has been neglected in previous studies on the homework-outcome relationship, which rely solely on adherence or compliance measures that focus on the proportion of completed homework or global single-item measures of whether the patient attempted the homework or not (e.g., Bryant et al. 1999 ; Aguilera et al. 2018 ). In a recent systematic review of homework adherence assessments in major depressive disorder (MDD), Kazantzis et al. ( 2017 ) found that only 2 out of 25 studies reported the measures that addressed the quality of homework completion. Furthermore, the single-item Assignment Compliance Rating Scale (ACRS; Primakoff et al. 1986 ) does not capture the depth of HE and the Homework Rating Scale (HRS; Kazantzis et al. 2004 ) is a client self-report measure, which might over- or underestimate homework compliance compared to objective measures. Studies increasingly put effort on focusing on qualitative aspects of homework completion. For this reason, the term and concept of homework engagement (HE) has been deemed relevant: it refers to the extent to which a patient has completed homework in an elaborate and clinically meaningful manner (Dozois 2010 ; Conklin and Strunk 2015 ). Furthermore, less empirical attention has been paid to underlying mechanisms going beyond patient factors, including therapist behaviors influencing HE and their relation to depressive symptoms.

Homework-Related Therapist Behaviors

Theoretical considerations and clinical recommendations of therapist behaviors related to homework (TBH) mainly build on four strategies suggested by Beck et al. ( 1979 ): (1) Homework should be described clearly and should be specific; (2) homework should be assigned with a cogent rationale; (3) patients’ reactions and should be elicited and in order to troubleshoot difficulties; (4) progress should be summarized when reviewing homework. Expert clinicians have also pointed out the value of formulating simple and feasible homework tasks and emphasized the patient involvement when developing homework assignments that are agreeable to the patient (Kazantzis et al. 2003 ; Tompkins 2002 ). Moreover, factors such as the match between the assignment and the client, as well as the wording of the homework task should be considered (Detweiler and Whisman 1999 ).

The suggested domains have also received some empirical attention. To our knowledge, four studies have focused on TBH in face-to-face treatment of MDD, which provide inconsistent findings. First, Startup and Edmonds ( 1994 ) investigated whether patient ratings of therapist behaviors promoting homework compliance were associated with therapist-rated homework compliance in a sample of 25 patients. The results did not demonstrate a significant relation between any facet of TBH (providing rationale, clear description, anticipation of problems, involving the patient) and homework compliance, which was largely attributed to ceiling effects of the patients’ ratings of TBH. Second, Bryant et al. ( 1999 ) assessed observer-rated homework compliance and TBH (reviewing previous assignment, providing rationale, clearly assigning and tailoring, seeking reactions and troubleshooting problems) in 26 depressed patients receiving cognitive therapy (CT). The study confirmed that patients that are more compliant experienced greater symptom improvement, and demonstrated a non-significant trend that suggests a relation between the overall score of the therapist homework behavior scale and homework compliance. Item-based analyses, however, demonstrated that therapist reviewing (TBH-R), but not therapist assigning behavior (TBH-A), was related to homework compliance. Third, in a sample of adolescents with depression, Jungbluth and Shirk ( 2013 ) demonstrated that providing a strong rationale and allocating more time in the beginning of treatment predicted greater homework compliance in the subsequent session, especially for initially resistant individuals. Fourth, the most recent study, conducted by Conklin et al. ( 2018 ), evaluated three classes of TBH in a sample of 66 patients with MDD undergoing CT. The authors reported that TBH-A, but not TBH-R were predictive of HE in the early sessions of CT, which stands in contrast to the findings of Bryant et al. ( 1999 ).

In consideration of the therapist’s prominent role in making use of therapeutic homework and the available inconclusive findings, the contribution of TBH to HE and their relation to depressive symptoms needs further exploration.

Homework Engagement in Telephone-Based CBT

The introduction of low-intensity CBT led to a way of delivering evidence-based treatments that is characterized by limited therapist input, technology-support, and increased use of self-help. These features are conflated in telephone-based CBT (tel-CBT). Tel-CBT puts emphasis on patients’ independent engagement with the therapeutic contents outside of therapy sessions by making systematic use of homework activities. The therapist plays an active role in structuring the treatment, providing input, and facilitating the comprehension and the use of homework. To the best of the authors’ knowledge, a limited number of studies with regard to homework in guided self-help and technology-supported treatment exists. One study investigating overall and component-specific homework compliance in an internet-based treatment with minimal therapist guidance found that overall homework compliance predicted 15% of the reductions in depressive symptoms (Kraepelien et al. 2019 ). Another study investigated TBH-R and homework completion in a telephone-delivered CBT (Aguilera et al. 2018 ). The authors found that the number of sessions in which a patient completed homework was related to a decrease in depressive symptoms at the end of treatment. This relationship disappeared when taking into account TBH-R, which, however, was positively associated with symptom reduction. These findings suggest that aspects of TBH are important factors for improved symptom outcome, but that TBH does not moderate the effect of homework compliance on improved symptom outcome (Aguilera et al. 2018 ).

Given the emphasis on patients’ contribution and self-reliance in the present treatment format, the assessment of HE might be a relevant process variable related to treatment outcome and an important therapy process that therapists can build upon. We would like to extend the current literature by using HE—a construct that is conceptually different from homework compliance and adherence—and by evaluating all sessions of the treatment (on average 9 sessions). This allows gaining a deeper understanding of the course of HE and TBH as well as the potential association between these variables and depressive symptoms.

Aim of the Current Study

The overall aim of the study is to provide insight into the occurrence and the course of HE and TBH in tel-CBT for depression. Additionally, first evidence on the relationship between HE, TBH, and depressive symptoms should be provided. Three objectives are pursued: (1) The assessment of the amount of homework, the proportion of different homework types, and the types of difficulties faced by patients when engaging with homework; (2) the description of initial status and course of HE and TBH in tel-CBT; (3) first examination of the relation between HE, TBH, and depressive symptoms over the course of the treatment.

The current study draws on data from a randomized controlled trial (RCT; Haller et al. 2019 ) investigating the effectiveness of tel-CBT compared to treatment as usual. Information on detailed study procedures and methods of the overarching RCT can be found in the study protocol (Watzke et al. 2017 ). The trial was approved by the local Ethics Committee. Inclusion criteria for the study were a PHQ-9 score of > 5 and ≤ 15, a diagnosis of mild or moderate depression according to ICD-10 (F32.0, F32.1, F33.0, F33.1), and the provision of a written informed consent. Patients were excluded, if they showed suicidality (item 9 > 0 on PHQ-9) or severe or chronic depression (F32.2, F34.1), if their physical or mental condition did not allow completion of questionnaires, if they were not proficient in the German language, or if they were in psychotherapeutic or psychological treatment at the time of intake or 3 months prior. For the main trial, 152 patients were screened for eligibility, of which 54 were included and randomized to either intervention or control group.

Data of each therapy session from patients randomized in the intervention group, i.e., those who received and completed the tel-CBT ( N  = 24), were used. We included data from all patients of which more than 80% of the therapy sessions were available and audio-recorded. The sample for the current study was necessarily reduced to N  = 22 because from two patients the majority of therapy sessions was missing due to technical failure to record. The two excluded patients did not differ from the intervention group in clinical status and sociodemographic variables with the exception that their age is in the lower range.

For the included 22 patients, three therapists who were employed at the University’s outpatient clinic were involved in providing tel-CBT. All therapists were female and 34 years old on average ( SD  = 5.9). The therapists were clinical psychologists with previous experience in treating patients with depression, and were in advanced training of CBT (current duration of training: M  = 4.3 years, SD  = 1.5). They received specific training in tel-CBT prior to the study and regular supervision by a senior clinician and researcher (BW) during the treatment provision.

Tel-CBT starts with a personal face-to-face session with the therapist and comprises 8–12 subsequent telephone sessions, which last between 30 and 40 min. The treatment program is called “Creating a balance” and is conceptualized as a guided self-help CBT delivered over the telephone. The content is based on core CBT elements—psychoeducation, behavioral activation, cognitive restructuring, and relapse prevention—within a total of eight chapters. The intervention entails a treatment manual for therapists and a workbook for patients to read and practice skills in between sessions. Each chapter is structured in a psychoeducational part with reading materials and case vignettes and a practical part with step-by-step instructions for exercises (i.e., homework). Copies of additional worksheets to complete homework are provided at the end of each chapter. Therapists were instructed to adhere closely to the treatment manual. This included agreeing upon a homework assignment in each therapy session, and reviewing the previously assigned homework at the beginning of the subsequent therapy session. The types of homework in the treatment manual were classified as: (1) Psychoeducational homework, including reading materials and case vignettes; (2) behavioral homework, including scheduling and undertaking pleasant activities; (3) cognitive homework, including replacing dysfunctional thoughts; (4) self-monitoring homework, referring to observing and monitoring thoughts and emotions; and (5) relapse prevention homework, including recognizing warning signs and establishing an emergency plan.

Measures and Assessment

Global Homework Engagement Scale (GHES). We developed an instrument measuring global HE independent of the type of homework assigned. The previously established homework engagement scale (HES) for CT by Conklin and Strunk ( 2015 ) served as a basis for the instrument. GHES consists of seven items regarding quantitative and qualitative aspects of homework completion. Each item is described in detail and is assessed on a 5-point Likert scale, varying from 0 ( not at all ) to 4 ( considerably ). Each of the five item manifestations contains a verbal anchoring tailored to the respective item in order to determine specific criteria connected to the rater’s decision, helping to ensure a uniform understanding of each item’s characteristics. The seven items cover the following aspects of HE: (1) Extent to which patients engaged with homework tasks; (2) whether and to which extent patients carried out homework as agreed upon; (3) whether and to which extent patients applied learnt strategies in difficult times; (4) the intensity of HE; (5) whether and to which extent patients faced difficulties when carrying out homework; (6) whether and to which extent patients could benefit from completed homework tasks; (7) estimated time that patients spent on HE. Additionally, and similarly to HES by Conklin and Strunk ( 2015 ), the scale contains two items which serve as a homework log. In the first log-item, homework that was reportedly completed from the previous session were written down by the raters. For the second log-item, research assistants recorded homework assignments for the next session before the rating procedure started. This procedure ensured that raters were informed about which previously assigned homework the discussion in a session is referring to. For the global GHES score, an average score of items 1 to 7 is calculated with higher scores indicating more HE.

Scale for Therapeutic Homework Assignment and Review (StHAR). An instrument to assess TBH was constructed for the purpose of this study. The instrument consists of eight items covering the process of assigning the upcoming homework (TBH-A) and the process of reviewing previously assigned homework (TBH-R). All items are assessed on a 5-point Likert scale, varying from 0 ( not at all ) to 4 ( considerably ). Each item is described in detail and contains a verbal anchoring for each item manifestation. The five items covering TBH-A build the subscale StH-A and comprise: (1) providing a rationale for the homework; (2) tailoring the homework to the individual situation; (3) addressing potential challenges of completing the homework; (4) specifying the homework; (5) ensuring comprehension of the homework. The subscale StH-R includes three items relating to TBH-R: (1) extent of discussing previous homework; (2) drawing conclusions of the homework; and (3) using homework to strengthen self-efficacy expectation of patient. The global StHAR score is calculated with an average score of all items, with StH-A items used from the previous session and StH-R items used from the subsequent session. Higher scores indicate a larger extent of TBH. Items from both scales are displayed in Table  1 . The German versions of the scales can be retrieved upon request from the corresponding author.

Patient Health Questionnaire (PHQ - 9) . Depressive symptoms were assessed at the beginning of each session using the German version of the PHQ-9 (Löwe et al. 2002 ). Nine items regarding primary and secondary depression symptoms are assessed on a 4-point Likert scale and build a sum score between 0 and 27. Therapists went through each item of the PHQ-9 right at the beginning of each session as part of the symptom monitoring. Patients had a copy of the PHQ-9 in front of them, answering whether the symptom was available 0 ( none of the days ) to 3 ( almost every day ). Although originally developed as a self-report measure, telephone administration of the PHQ-9 seems to be a reliable and valid procedure to assess depression (Pinto-Meza et al. 2005 ).

Ratings of Tel-CBT Sessions

Audio recordings were available for all therapy sessions of the included 22 treatments. All available recordings of per protocol therapy sessions were included in the dataset. We did not include the initial face-to-face appointment, as this was not relevant for the assessed process variables. From 210 tel-CBT sessions that had taken place within this sample, we were able to rate 194 sessions (92.4%). We had to exclude sessions that deviated from the treatment manual ( n  = 4) or where audio recordings were not available or unusable due to technical failure to record the session, or due to poor quality of the recording ( n  = 12), respectively. Deviation of the treatment manual is defined as a session that did not target the planned content. This was the case, when therapists had to react to a crisis situation of the patient. The mean duration of one telephone session was 43 min ( SD  = 9.6).

Raters and Rater Training

HE and TBH were rated by five independent raters (one Doctoral candidate and four Master-level students in clinical psychology). All raters were blind to treatment outcome of the patients. During a period of 4 weeks, raters received 54 hours of training in the employed treatment manual and the use of the rating instruments. Training consisted of discussing the content of the treatment manual, particularly homework types in the tel-CBT. Furthermore, defining adequate and competent therapist behaviors regarding assignment and review of homework were discussed. Following the training phase, three successive trial ratings were completed by the raters. Each trial rating was discussed and in case of disagreement, the wording of the items were refined until consensus was reached. Prior to the rating phase, three therapy sessions from two excluded cases were randomly selected and rated by all five raters in order to examine initial inter-rater reliability (IRR). Calculation of intra-class correlation coefficients (ICC) in a two-way random model ICC (2,2) (Shrout and Fleiss, 1979 ) revealed an average ICC (2,2) of .91 and a median ICC (2,2) of .93 across all raters and all items of GHES, and an average ICC (2,2) of .81 and a median ICC (2,2) of .88 across all raters and all items of StHAR. This result indicated that IRR was high, and that formal ratings could start subsequently.

Rating Procedure

All items were rated on a 5-point Likert scale in order to determine the estimated extent of patient`s HE as well as the extent of TBH. Raters were encouraged to take notes while listening to the audio file and rate all items at the end of the session. Of the 197 eligible audio recordings, each rater was randomly assigned between 32 and 38 sessions for the main rating. Session allocation was stratified by therapist, patient, and treatment phase (phase I: sessions 1–4; phase II: sessions 5–9). A subsample of therapy sessions was double-coded in order to establish IRR. 40% of the total amount of sessions were drawn to carry out double-ratings resulting in a total of 57 to 62 sessions rated per rater. Each rater was paired with every other rater an approximately equal number of times. For the double-rated sessions, the average score of the rater pair for each item was used in the final analyses.

Statistical Analysis

As GHES and StHAR are newly developed rating instruments, analyses of the psychometric properties were conducted before turning to the research questions under investigation. We calculated Pearson`s r for corrected item-total-correlations and coefficient omega (ω) to measure internal consistency of both scales. IRR was assessed by calculating ICC in a two-way random model (ICC 2,2 ) (Shrout and Fleiss 1979 ) testing for absolute agreement between two raters and within one rater, respectively.

In order to meet research objective one, the types of homework assigned as well as types of difficulties faced when completing homework are reported. Moreover, descriptive statistics (means and standard deviations) of the individual items and the total scores of the scales GHES and StHAR (including subscales StH-A and StH-R) are presented. For research objective two, multilevel mixed models (MLM) were applied to examine between- and within-patient variability of HE and TBH over the course of treatment in a nested data set. In two-level models HE and TBH assessed at each of the nine telephone sessions (level 1) are modelled within each of the 22 individuals (level 2). The inter-individual variability in terms of initial status and growth of HE and TBH are modelled at level 2. For research objective three, MLM was analysed with depressive symptoms measured with PHQ-9 defined as criterion on level 1. Depressive symptoms were assessed in each session. HE of the same session, and TBH (consisting of TBH-A of the previous session and TBH-R of the current session), were gradually introduced as time-varying predictors of the session-specific symptom severity. In total, five stepwise built multilevel models were calculated. First, the null or unconditional model was created, including the intercept and the random term (null-model). Second, the null-model was expanded by adding a random slope for time (model 1). Third, one time-varying predictor (HE) was introduced into the random intercept random slope model (model 2). Lastly, random intercept and random slope models with two time-varying predictors (HE and TBH; model 3) and an interaction term between HE and TB (model 4) were created. A separate model that included HE as criterion and TBH as predictor was analysed.

All models were estimated using restricted maximum likelihood (RML). In order to compare the appropriateness of the specified models, AIC, BIC and log-likelihood values were used. Analyses were performed using R software (version 6.3.0; R Core Team 2014 ), the lme4 package (Bates et al. 2015 ) and the psych package (Revelle, 2019 ).

Descriptive Statistics of Sample

Baseline sociodemographic and clinical characteristics of the N  = 22 included patients are displayed in Table  2 . The majority of the sample was female and on average 56 years old ( SD  = 18.1). Symptom severity ranged from mild to moderately severe levels of depression (6 ≤ PHQ-9 ≤ 20) at the beginning of treatment resulting in a moderately depressed status on average.

Psychometric Properties of GHES and StHAR

With regard to psychometric properties of the scales, corrected item-total correlations ranged from .46 to .78 for GHES and from .39 to .61 for StHAR. Internal consistency of GHES was excellent across treatment (ω = .87), with values ranging from .79 to .91 across sessions. Internal consistency for StHAR was good across treatment (ω = .80) with values ranging from .63 to .87 across sessions. Internal consistency for StH-A was .73 and .68 for StH-R. We calculated ICC using a two-way random effects model (ICC 2,2 ) (Shrout and Fleiss, 1979 ) to estimate IRR. For GHES, ICCs (2,2) across all rater dyads ranged from .41 to .81, resulting in a moderate average ICC (2,2) of .68 as well as a moderate median ICC (2,2) of .70. For StHAR, ICCs (2,2) across rater dyads ranged between .45 and .83 resulting in a moderate average ICC of .64 and a moderate median IRR of .64. Due to the good psychometric properties of StHAR, the global StHAR score was used instead of the subscales StH-A and StH-R in further analyses.

Descriptive Statistics of Homework, HE, and TBH

Across all telephone sessions and patients, 411 homework activities were assigned in total, resulting in approximately two defined homework tasks per session and per patient on average. The majority of the homework was classified as psychoeducational ( n  = 142; 35%) and behavioral ( n  = 138; 31%), followed by cognitive ( n  = 76; 18%), self-monitoring ( n  = 36; 9%), and relapse prevention ( n  = 29; 7%) homework. In total, 380 (92.5%) of the homework activities were completed. Across all patients and therapy sessions HE was on average M  = 2.71 ( SD  = 0.74), which translates into moderate to high HE when using the item anchors. Difficulties in completing homework assignments were reported in 75% of the sessions, with the extent of difficulties showing an average of M  = 1.53 ( SD  = 1.10). Using the item anchors, this value translates to small to moderate difficulties. Most commonly assessed types of difficulties encountered by patients were negative events that impeded homework completion (34.1%), depressive symptoms (29.7%), and lack of strategies and options to complete homework (13.7%). Lack of time (8.2%), homework being too difficult (8.2%), and other homework-related aspects (6.0%) were further reported difficulties in completing the task. HE and TBH showed a small significant association across sessions, with a mean correlation of r  = .28 ( p  < .05). Descriptive information on HE and TBH per session are presented in Table  3 .

Course of HE and TBH and Their Association

With regard to variation in HE among patients and across treatment, we first ran an unconditional or null model with HE as criterion. The average HE across patients and treatment is 2.70 ( SE  = 0.09). Calculations of ICC using the within- and between-patient variance shows that 25% of the variance in initial status of HE are attributed to differences among patients. Entering time as predictor (model 1), the unconditional growth model demonstrates that patients start on average with high HE ( M  = 3.00, SE  = 0.13) and show a small reduction in HE during the course of treatment (− 0.05, p  = .011). With regard to TBH, 14.8% of variance can be attributed to differences between patients. The initial status of TBH is 2.32 ( SE  = 0.13) and shows a similarly small, but statistically non-significant reduction during the course of the treatment (− 0.04, p  = .307). The models regarding course of HE and TBH are displayed in Table  4 .

In order to explore the association between HE and TBH, stepwise multilevel models were built with HE as criterion in a separate model. TBH consisting of TBH-A from the previous session and TBH-R from the following session was entered as a time-varying predictor of HE in the subsequent session. TBH was significantly and positively related to HE over the course of treatment (0.24, SE  = 0.07, p  = .032). Results are displayed in Table  5 .

Association Between HE, TBH, and Depressive Symptoms

For the association between HE, TBH, and depressive symptoms, we first ran an unconditional or null model, which demonstrated a within-patient variability in depressive symptoms of 38% (data not shown), indicating a nested structure of the data. After modelling the time slope (model 1), time-varying predictor 1 was entered at level 1 (model 2). Time-varying predictor 1 was HE of the current session, since ratings refer to the interval between two sessions. Higher scores on HE were associated with lower depressive symptoms over the course of treatment (− 0.83, SD  = 0.35, p  = .015). Comparison of model 1 and model 2 returned better fit indices for model 2 (log-likelihood for model 1 = - 451.37 and for model 2 = − 448.05, p  = .009; AIC for model 1 = 910.74 and for model 2 = 906.10; BIC for model 1 = 923.3 and for model 2 = 921.8;) for the random intercept random slope model with HE as predictor (smaller values indicate better fit). Next, the second time-varying predictor—TBH from the previous session—was introduced into the model at level 1. TBH was not significantly related to depressive symptoms (0.23, SD  = 0.30, p  = .437). Compared to model 2, model 3 did not show improved model fit (log-likelihood for model 2 = − 444.69 and for model 3 = − 444.24, p  = .346; AIC for model 2 = 903.4, and for model 3 = 904.5; BIC for model 2 = 925.4 and for model 3 = 929.6), indicating the model with HE as predictor fits the data better. The last model (model 4) included an interaction between the two time-varying predictors, however the model did not converge. Results of the random intercept model (model 1), the random intercept and random slope model with one predictor (model 2), and the random intercept random slope model with two predictors (model 3) are presented in Table  6 .

The present study describes types and amount of homework assigned and depicts rather high levels of HE in tel-CBT. Results of our study further show that HE decreases slightly throughout the course of therapy and that TBH is related to HE over the course of therapy. Ultimately, results reveal that higher scores on HE are associated with lower levels of depressive symptoms, but that TBH and depressive symptoms are not associated.

The study demonstrates that homework assignments and engagement with homework play a central role in tel-CBT – as could be expected from the guided self-help approach. This is indicated by the overall amount of assigned homework across therapy and patients, the proportion of homework completed by patients, and the patients’ rather high HE throughout the course of the treatment. As expected, we found that homework was overall assigned in most of the therapy sessions. The fact that on average two homework assignments were prepared in each session confirms that contents were employed and implemented as scheduled by tel-CBT. This treatment format lays special emphasis on this kind of intersession activity.

When modelling the status and course of HE and TBH, both variables showed more within-patient variability compared to between-patient variability over the course of the treatment, as indicated by the ICC calculations of variance components and the slopes of the variables in the models. Inter-individual differences explained rather small proportions of the variance (25% in HE, 15% in TBH), which might indicate that both variables are dynamic rather than stable patient characteristics. The overall high HE across patients might be explained by sociodemographic and clinical patient characteristics. The average age of our sample was rather high and the vast majority of patients reported having had previous depressive episodes and psychotherapy experience. It is likely that patients with a history of depression and of undergoing treatment are trying particularly hard to make the most out of therapy. Moreover, older patients might show a sense of self-responsibility when it comes to carrying out therapeutic homework. Contrary to the belief that adult patients may have reservations regarding homework due to their age, there is evidence that adult patients have positive attitudes towards homework, with the vast majority of patients not perceiving themselves too old for homework (Fehm and Mrose 2008 ). HE declined slightly over the course of treatment and visual inspection of the individual courses of HE showed that drops in HE happened in some patients in single sessions. These variations are expected to be due to specific external factors that have an influence on the patient's HE at a given session. For example, further explorative analyses might scrutinize which external factors regarding homework (such as difficulties completing the homework task; lack of resources or time in a given week) and session content might be responsible for situations with a drop in HE. In view of previous suggestions that homework compliance might not be linear across treatment of social anxiety disorder (Leung and Heimberg 1996 ), future studies might employ statistical models that are suitable to detect various patterns of HE. For example, latent growth analysis, which requires much larger samples than the one used in our study, would allow to detect differences in latent factors between groups of patients, and to relate different HE patterns to treatment outcome (Collins and Sayer 2001 ).

Our study provides empirical support for the association between HE and depressive symptoms throughout the course of tel-CBT in mildly to moderately depressed patients. Using MLM with repeated measures of predictors and outcome, we found a medium-sized association between HE shown between sessions and depressive symptoms in the subsequent session. In other words, when HE increases by one unit in an interval of two sessions, patient's symptomatology decreases an average of 0.8 units on the PHQ-9 in the subsequent session. Overall, this result goes in line with meta-analytic evidence of the relation between homework compliance and treatment outcome showing a weighted mean effect size on therapy outcome of r  = .22 for homework compliance and r  = .36 for the employment of homework in therapy (Kazantzis et al. 2000 ). Moreover, the result corresponds to one previous study focusing on a similar conceptualization of HE, which found an immediate effect of HE on symptom outcome in the subsequent session (Conklin and Strunk 2015 ). In our study, TBH was not associated with depressive symptoms in the subsequent session. However, our results indicate that TBH was significantly related to HE over the course of treatment, which corresponds to results of a previous study that found TBH to significantly predict subsequent HE (Conklin et al. 2018 ). Explanations for these findings could be that some clinically beneficial TBH might have been less present in the overall therapists’ behaviors and therefore exerted an effect on HE but not on depressive symptoms. Even though the homework procedure in our study tended to be therapist-initiated, the patients took an active part in tel-CBT, as the majority of the session time was spent on reviewing patients’ experiences with the previous homework and discussing future homework It needs to be stressed that therapists were not trained in specific assignment and review procedures. This means that some aspects of assigning homework that received clinical and empirical support in previous work, were not implemented in our study. For example, it is recommended to write down homework tasks and instructions (Cox et al. 1988 ) in order to assure higher homework compliance. Moreover, a recent study provides preliminary support for the importance of designing homework tasks that are congruent with what the patient perceived helpful in the session (Jensen et al. 2020 ). Since therapists were instructed to adhere to the homework assignments as scheduled, they were not entirely free to consider whether the homework type scheduled for a specific session was appropriate for the patients’ current problem or situation. It is likely that therapists—despite strictly assigning the activity types as scheduled in the treatment manual—adequately adapted the different homework types to the patient's individual situation and promoted patient's willingness and ability to engage with homework outside the therapy session. Our results further suggest that the specific type of homework might not be the only relevant factor for higher HE, as long as therapists assign and review homework in an elaborate, comprehensible, and convincing manner. Lastly, it is important to consider that the association between TBH and HE might run in the opposite direction in that patients’ higher HE and reporting thereof might have influenced the therapists’ reactions to the patients’ reports.

The present results need to be interpreted in due consideration of several limitations: First, the predictor variables were assessed using two self-constructed rating scales, which have not been validated prior to the study. We did not use standardized or validated instruments to assess HE and TBH, because no process rating instrument targeting the particular conceptualization of these variables exists. We aimed at expanding on the previously reported Homework Engagement Scale (HES) by Conklin and Strunk ( 2015 ) by adding indicators such as intensity of HE or difficulties faced when engaging with homework. Despite good psychometric properties for both scales with regard to internal consistency and moderate to good properties regarding IRR, the validity of GHES might be constrained: Even though GHES is an objective observer-based rating instrument with a precise rating manual, the items do not always allow a direct observation of facets relevant to HE. The appraisal of each item relies on the patient expressing his or her thoughts and experiences with the homework process. However, these narratives might not cover all areas of interest in the rating instrument. For example, the rating on the difficulty-item is indirectly inferred from the narratives of the patient about how engaging with homework went. If the patient did in fact face difficulties affecting HE, but not explicitly mention these when talking about how homework activity went, the measurement of difficulties faced in this situation might not be representative of HE. The rating therefore relates to the raters’ appraisal of whether a patient had faced challenges that might have affected HE, rather than the patients’ subjective feelings or the true influence of experienced difficulties on HE. Objective and observer-based assessments of HE might be supplemented by patients’ reports of difficulties faced as well as by patient ratings on the profoundness with which patients engaged in homework activities as well as the perceived benefits of homework in future research. Second, the StHAR did not specifically target competence or quality of assigning and reviewing homework. Future studies might develop and employ rating instruments that clearly differentiate the extent of TBH shown by the therapist from the competency of these therapeutic actions. Moreover, patient ratings of whether therapists assigned and reviewed the homework in a skilful manner in the patients’ views might add to a better understanding of clinically meaningful TBH.

Third, our methodology and our analytic strategy do not allow for any causal inferences regarding HE and depressive symptoms, despite multiple assessments of HE in session intervals and the depressive symptoms assessed at the beginning of each session. Reverse causation cannot be excluded, since patients might have reported about homework more elaborately and positively in the sessions due to an improved mood. Moreover, depressive symptoms were assessed retrospectively for the time period since the last therapy session. Fourth, the study sample was rather small. Therefore, additional exploratory statistical models for our third research question (e.g., including interaction terms) could not be converged in our models. Lastly, selection bias might have occurred as the majority of the patients self-referred to the overarching clinical trial, potentially leading to the inclusion of generally motivated patients who showed rather small variability in HE and therefore also did not require the therapist to intervene in a way that promotes HE or improves depressive symptoms.

Even though our results should be regarded as preliminary evidence, the findings add to the body of literature due to several strengths. A more comprehensive concept of the extent of homework compliance was used in the present study, going beyond commonly used quantitative measures of homework completion or single-item compliance measures. Several differences between HE and previous operationalizations of homework compliance exist. HE incorporates facets of the quality and the intensity of patient's engagement with the homework tasks, the estimated benefit for the patient of undertaking homework, the estimated transference of acquired skills to the patients’ daily lives, as well as the difficulties experienced by the patient when completing homework. Another strength of the study is the conceptualization of TBH, which incorporates multiple facets regarding preparing and reviewing homework, informed by clinical recommendations. These aspects were derived from listening to and rating complete therapy sessions with high reliability, as indicated by the IRR analyses. Moreover, observer-based ratings of both HE and TBH might provide more objective estimations of HE and discussion of tasks in the therapy session compared to client or therapist reports (Mausbach et al. 2010 ). Lastly, our study provides insight into the course of HE and TBH throughout the entire treatment, which helps generating hypotheses regarding the nature of HE and its relation to TBH and depressive symptoms.

The study provides evidence that homework is implemented by therapists and patients in tel-CBT. Engagement with homework and therapists’ actions to assign and discuss homework varies across treatment in this sample. However, on average a slight decrease of HE throughout the treatment was observed and patients, who show high HE, experience lower depressive symptoms on average. Future studies with designs allowing to determine the direction of causality and with  reliable and more economic ways of retrieving information regarding HE in the patients’ natural environments (e.g., using ecological momentary assessment) are warranted. This approach would allow for recording patients’ HE close to occurrence and provide information regarding reasons for low HE as well as facilitators for completing homework without recall bias. TBH was not related to depressive symptoms but showed an association with HE. Future studies might examine whether TBH moderates the HE-symptom improvement relationship and whether specific homework types require specific therapist skills to assign and review in a meaningful way.

Data Availability

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

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Haller, E., Watzke, B. The Role of Homework Engagement, Homework-Related Therapist Behaviors, and Their Association with Depressive Symptoms in Telephone-Based CBT for Depression. Cogn Ther Res 45 , 224–235 (2021). https://doi.org/10.1007/s10608-020-10136-x

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Homework in CBT

why is homework important in cbt

Cognitive Behavioural Therapy (CBT) is a very practical therapy that involves homework as a huge part of the therapy process.

You may think of school when they hear the term “homework”, and that's understandable. However, homework in CBT is actually a really good thing. The reason that there is a heavy focus on homework or “between session tasks,” during the therapy process is because it is at this point where you can practice the skills you have learnt in therapy.  It also tends to be where the magic happens, new learning takes place and people start to notice a shift in how they are feeling.

Imagine you and a friend want to learn a new language and sign up for Spanish lessons once a week. If you attend the one-hour weekly session but do not practise between sessions, but your friend practises daily in addition to attending the weekly session, who do you think will pick up more of the language? If your answer is your friend, then you are right! CBT is very similar in that those who make the time to practise using CBT skills daily are more likely to recover quicker and benefit more from CBT than those who just attend weekly sessions but do not complete the homework in between therapy sessions.

The goal of CBT is to teach you skills to become your own therapist so you can go on and self-manage your day-to-day symptoms and ultimately oversee your recovery. So, the more you practice mastering the skills outside of your therapy sessions, the better you will become in using those skills on your own and well into the future.

Quite often, us Brits like a quick fix, and many come to therapy expecting to be fixed without really doing anything. Unfortunately, this expectation is unrealistic. Most therapies nowadays involve work on both sides, and CBT is no different.

A typical homework task may be something such as completing an activity during the week that you used to enjoy or tackling something that you have been putting off such as paying a bill or booking a doctor’s appointment. It may also be something like having a conversation with a stranger, making a call to someone, or going somewhere that you have been avoiding, such as the supermarket. All homework tasks are decided together with your therapist and are designed to push you slightly out of your comfort zone. The tasks are always in line with your therapy goals and should be designed with those in mind.

Homework can be hard, especially if we are unmotivated or anxious about completing it. If you are having trouble completing the homework, have a chat with your therapist. Together, you should be able to problem solve it and come up with some solutions to try and make things seem more manageable. For example, it might be setting an alarm for a specific time each day to remind you to complete the task you have set yourself. Or it may be breaking the task down to something smaller that feels less overwhelming and more achievable.

It may also be worth thinking about how the homework task will help you work towards achieving your goals. Doing nothing, although easier, is not going to get you where you want to be and will likely keep you stuck where you are. However, doing the homework task will require effort and time, but it is likely to help you work step by step towards where you truly want to be.

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https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/

The New “Homework” in Cognitive Behavior Therapy | Beck Institute for Cognitive Behavior Therapy

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Benefits of CBT: 8+ Results of Cognitive Behavioral Therapy

Benefits of CBT

CBT is both brief and time-limited in comparison to other types of therapy. Cognitive-Behavioral Therapy is based upon the idea that our thoughts, not external events like people or situations, are actually the cause of our feelings and behaviors.

What this tells us is that we have a lot more control than we think and we can change things by changing our thoughts. In light of this, we have to ask ourselves what the research says about this groundbreaking therapy.

In this article, we will examine the scientific benefits as well as the research of Cognitive-Behavioral Therapy.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into Positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What are the benefits of cognitive-behavioral therapy, a look at the research, different types of cbt, the benefits of cbt for anxiety, can cbt help with depression, 9 ways to implement these beneficial cbt practices, a take-home message.

According to the National Association of Cognitive-Behavioral Therapists (2021), CBT is based on the cognitive model of emotional response. This model tells us that our feelings and behaviors stem from our thoughts, as opposed to external stimuli. CBT is a goal-oriented and problem-focused therapy, unlike its psychoanalytical predecessors.

As a result of this, CBT focuses on the present and on the here and now, rather than on a lengthy analysis of the subject’s developmental history.

Cognitive-Behavioral Therapy is known for its quick results. Both therapists and psychologists use CBT in the treatment of certain mental disorders.

While the ideal number of CBT sessions a client should undertake will vary depending on their situation, treatments tend to range from between five to 20 sessions (Mayo Clinic, 2019). In comparison, other kinds of therapy may take months or even years of regular sessions in order to see results.

Other advantages of CBT include the fact that it:

  • Is highly engaging.
  • Holds the patient accountable for the therapeutic outcome.
  • Is centered on the idea that one’s emotions and thoughts are responsible for how they behave and feel.

While CBT may not work for those with severe mental disorders or those with learning difficulties, it is a great form of therapy for helping people accept and understand that they can change things by simply changing their thoughts.

This is a major advantage because it helps people understand that altering their thought processes can lead to a positive outcome. This is a much different type of therapy in comparison to more traditional therapy, which typically focuses on trying to change or re-evaluate past actions or fears.

CBT Research

As such, it is used to ease the symptoms of a wide range of conditions, including (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012):

  • Substance use disorders
  • Schizophrenia and other psychotic disorders
  • Depression and Bipolar disorder
  • Anxiety Disorders
  • Somatoform disorders
  • Eating disorders
  • Personality Disorders
  • Aggression, anger and criminal behaviors
  • Stress in general
  • Distress due to medical conditions
  • Chronic pain and fatigue
  • Female hormonal conditions as well as pregnancy-related distress

In 2012, Hofmann and colleagues conducted a review of 106 meta-analyzes assessing CBT’s efficacy in treating these listed conditions.

Their findings revealed overwhelming support for CBT as an effective psychotherapeutic treatment option for all these conditions. In particular, the strongest support for the use of CBT was shown for anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress (Hofmann et al., 2012).

Additionally, of the eleven studies reviewed which compared the effects between CBT and other treatments or control conditions, patients undergoing CBT exhibited greater improvements than the comparison conditions in seven of the studies reviewed. Indeed, only one review identified CBT as being less effective than comparison treatments.

While not explored in Hofmann’s study, CBT is also widely used to help people with Obsessive-Compulsive Disorder (OCD) . Commonly used components of CBT used in the treatment of OCD include exposure and response prevention as well as a range of cognitive interventions.

Evidencing CBT’s effectiveness for treating OCD, one study of fifty young people aged 12-17 years found that undergoing up to 14 sessions of CBT significantly reduced the sample’s symptoms of OCD and anxiety. Even more promising is that these improvements in OCD symptoms were shown to have been maintained in a six-month follow-up (Reynolds et al., 2013).

why is homework important in cbt

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Given CBT’s efficacy, many offshoots of this popular therapy have evolved, including:

  • Positive CBT
  • Behavioral Activation
  • Trauma-focused CBT
  • Acceptance and Commitment Therapy (ACT)
  • Mindfulness-based CBT (MBCT)

According to research by Turner and Swearer Napolitano (2010), there is also a range of different therapeutic approaches that share the same theoretical underpinnings as CBT. These approaches include:

  • Rational Emotive Behavior Therapy (REBT)
  • Cognitive Therapy
  • Rational Behavior Therapy
  • Rational Living Therapy
  • Schema-Focused Therapy
  • Dialectical Behavior Therapy (DBT)

Benefits of CBT

Therefore, we will now consider the evidence for the approach’s efficacy in the treatment of these conditions in turn.

To begin, CBT for the treatment of anxiety has been shown to be highly effective in both rigorous randomized placebo-controlled trials and natural field studies (Otte, 2011).

In randomized controlled trials, a treatment is compared against a placebo condition, where study participants have regular contact with a therapist and talk generally about their psychological issues, but the therapist does not apply a CBT approach to treatment. Therefore, all conditions surrounding the therapies remain the same, with the exception of the CBT paradigm, making it a strong test of CBT’s efficacy.

Promisingly, one review of 27 such trials found that CBT was significantly more effective than the control condition in treating a range of anxiety-related conditions, including social anxiety disorder, panic disorder, and generalized anxiety disorder (Hofmann & Smits, 2008).

In naturalistic settings, CBT has been shown to be similarly effective in the treatment of anxiety. In a review of 56 studies exploring real-world applications of CBT for anxiety, Stewart and Chambless (2009) again found strong evidence for the effectiveness of these treatments for anxiety comparable to that shown in well-controlled experimental conditions.

Overall, these findings point to CBT as a reliable and efficacious treatment option for a range of psychological conditions characterized by anxiety.

3 Instantly calming CBT techniques for anxiety – Mark Tyrrell

Next, let’s review CBT for the treatment of depression.

Findings again indicate the effectiveness of CBT for the easing of depressive symptoms. However, the evidence suggesting that CBT is superior to other methods of treatment is not as strong.

Indeed, in a point of view colloquially known as the ‘Dodo bird verdict,’ some scholars and clinicians argue that all forms of psychotherapy are equally effective and that CBT is by no means superior.

In an effort to refute this claim, Honyashiki and colleagues (2014) conducted a review of 18 randomized placebo-controlled trials. The results found that CBT in the treatment of depression was significantly more likely to yield improvements than no-treatment conditions but that CBT was not necessarily more effective than psychological placebos (e.g., general talk therapy).

This result regarding the lack of difference between CBT and placebos appeared at least partially attributable to the length of the treatment. As participants underwent more CBT sessions, the improvements to their psychological states became more substantial.

In another review of 82 studies that examined CBT interventions in the treatment of depression, Lepping and colleagues (2017) found that CBT produced greater improvements among participants than other psychological or pharmacological treatments.

However, findings revealed that CBT applied in combination with a second active therapy, such as behavioral activation , produced even greater improvements for participants.

Therefore, results suggest that when using CBT to treat depression, clinicians can feel confident about the treatment’s efficacy. Nonetheless, careful consideration should be given to the number of sessions a client should undergo as well as whether any additional forms of treatment may help.

Cognitive Attribution Circle

CBT is a firmly established method of treatment for many mental health conditions. The research also shows that the skills people learn through CBT last long after the treatment ends (Hawton, Salkovskis, Kirk, & Clark, 1989).

A key reason for CBT’s effectiveness lies in its applicability to real-life situations. To this end, CBT therapists are increasingly adopting a blended care approach to conducting CBT that encourages clients to practice interventions in their daily lives with the aid of portable technologies.

For example, using the e-therapy platform Quenza (pictured here), a CBT therapist can assign their client meditations, reflection exercises, and a range of other activities which clients can complete on the go via their smartphone or tablet.

The advantage of this convenience is that patients undergoing CBT can test their learned skills and techniques in response to real stressors in the environment.

For instance, while the practice of cognitive defusion—a technique that helps clients to reframe negative thoughts—is excellent in theory, being able to apply the technique independently upon receiving difficult feedback or finding oneself in conflict with a friend is likely to have myriad benefits for easing negative emotions and preventing negative thought-cycles in the moment.

6 Common CBT Interventions

Six common CBT interventions include things like:

  • Learning how to set goals that are realistic and problem-solving.
  • Learning how to better manage things like stress and anxiety.
  • Learning how to identify situations that you might avoid and gradually approaching feared situations.
  • Doing more enjoyable activities like hobbies, social activities, and exercise.
  • Learning to identify and challenge automatic negative thoughts (ANTS).
  • Journaling and keeping track of your feelings, thoughts, and behaviors (Patterson, 2009).

Setting realistic goals and learning how to solve problems might involve engaging in more social activities or learning how to be more assertive.

In order to better manage stress and anxiety, you can learn relaxation techniques and deep breathing techniques. You can also use positive self-talk or use a distraction technique like taking a deep breath to calm your energy in stressful situations.

Learning to be more comfortable in situations you might normally avoid is another good technique. This might involve networking more often or simply getting comfortable walking up to and greeting strangers at a party.

There is nothing more enjoyable than doing something you love, so engaging in hobbies and social activities can go a long way to helping you heal.

Because CBT involves changing how you think, it can also be helpful to identify and challenge those automatic negative thoughts. Instead of telling yourself things never work for you, try telling yourself that life supports you in every moment.

Keeping track of those negative thoughts, feelings and behaviors might also be helpful so it’s a good reason to journal or simply record your thoughts on a regular basis.

Other CBT Common Practices include:

  • Mindfulness-based cognitive therapy
  • Cognitive restructuring or reframing
  • Cognitive journaling

The UK National Institute of Clinical Excellence has recently endorsed Mindfulness-Based Cognitive Therapy as an effective treatment for prevention and relapse for those who are clinically depressed (Crane & Kuyken, 2013). However, these same techniques can also help those who aren’t clinically depressed.

Mindfulness-Based Cognitive Therapy (MBCT) combines Cognitive-Behavioral techniques with mindfulness activities and strategies to help you better understand and manage your thoughts and emotions.

MBCT was originally developed to help give patients the necessary tools to combat depressive symptoms as they arise, but it can also be helpful for those who are merely looking for ways to combat stress.

Practicing mindfulness can also help you improve your mental and physical health. Mindfulness is all about turning off the endless chatter in your mind.

You can practice mindfulness by simply living in the present moment or by breathing in and out and observing the breath.

Mindfulness involves being aware of your thoughts, but not judging them. By observing your thoughts in a detached manner, you can let go of all cares and concerns.

Mindfulness practices are also a great way to combat those automatic negative thoughts.

Cognitive restructuring or reframing is another great technique. This technique allows you to identify the filter through which you see the world and change how you view things.

When you discover a belief that is destructive or harmful, you can then begin to challenge it and reframe it. When you reframe something, you learn to look at it differently.

When properly and consistently utilized, cognitive reframing can help you eliminate unproductive thoughts and challenging limiting beliefs.

Cognitive Reframing

Cognitive reframing involves:

  • Learning about basic cognitive errors.
  • Developing mental awareness.
  • Challenging your conclusions.
  • Replacing faulty beliefs.

The truth is, we all see the world a little differently. Because we see things differently, we form different conclusions about things. Learning about common mental errors, like blaming or emotional reasoning, can help us develop more mental awareness.

Challenging your conclusions allows you to reframe them and see things in a new light. Once you do all of this, you can then replace those faulty beliefs.

For example, just because you believe something to be true, doesn’t necessarily mean it is so.

Let’s say you believe life is hard and friends are hard to come by. You can begin by asking yourself a series of questions like:

  • Why do I believe this is true?
  • Where did these “beliefs” come from?
  • What is it that is holding me back or keeping me from achieving success?
  • What can I do to change it?

Try listing all of those negative beliefs or unproductive thoughts and then challenging yourself to think about them in a more productive way.

Instead of saying “ I am not a people person ,” you can turn the statement around and say “ I have some great people in my life ” instead.

Rewriting your thoughts is also a great way to start thinking differently.

Cognitive Journaling

Cognitive journaling is another great technique. Cognitive journaling uses something known as the “ABC Model” where you also include the letter D for Disputing.

ABC stands for:

  • Activating Event – The actual event and your immediate interpretations of the event.
  • Beliefs about the event – Which can be rational or irrational.
  • Consequences – How you feel, what you do or other thoughts.
  • Disputing – Identifying alternative beliefs that would lead to healthier consequences.

Let’s look at an activating event involving someone who constantly interrupts you or talks over you.

As a result of this, you may believe this person doesn’t like you. You may deem them rude. You may even think your thoughts aren’t important to them. These are your beliefs.

The consequences are that you feel bad. You may get anxious or nervous or even annoyed.

To dispute this, you have to look at things differently. Maybe this person is just excited to tell you something. Maybe they didn’t do it on purpose. Maybe you could simply mention the fact that this bothers you, and let it go. It’s not about YOU.

Cognitive-Behavioral Therapy is a technique that is highly engaging and a technique that offers quick results when compared to standard psychotherapy.

CBT helps us understand that we have the power to change things. CBT tells us that external situations, interactions with others’ and negative events are not actually responsible for our poor moods and problems.

The truth is that our own reactions to events and the things we tell ourselves about those events are most likely the cause.

With Cognitive-Behavioral Therapy, you can learn to change the way you think, which in turn changes the way you feel. All of that then changes the way you view the world and how you handle difficult situations when they do arise.

The better you become at disrupting those unproductive thoughts, the happier you will be.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

  • Crane, R. S., & Kuyken, W. (2013). The implementation of mindfulness-based cognitive therapy: Learning from the UK health service experience.  Mindfulness , 4(3), 246-254.
  • David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy.  Frontiers in Psychiatry , 9.
  • Hawton, K. E., Salkovskis, P. M., Kirk, J. E., & Clark, D. M. (1989).  Cognitive behaviour therapy for psychiatric problems: A practical guide . New York, NY: Oxford University Press.
  • Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses.  Cognitive Therapy and Research ,  36 (5), 427-440.
  • Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. The Journal of Clinical Psychiatry , 69(4), 621-632.
  • Honyashiki, M., Furukawa, T. A., Noma, H., Tanaka, S., Chen, P., Ichikawa, K., … & Caldwell, D. M. (2014). Specificity of CBT for depression: A contribution from multiple treatments meta-analyses. Cognitive Therapy and Research , 38(3), 249-260.
  • Lepping, P., Whittington, R., Sambhi, R. S., Lane, S., Poole, R., Leucht, S., … & Waheed, W. (2017). Clinical relevance of findings in trials of CBT for depression. European Psychiatry , 45, 207-211.
  • Mayo Clinic. (2019). Cognitive behavioral therapy. Retrieved from https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610#
  • National Association of Cognitive-Behavioral Therapists. (2021). What is cognitive-behavioral therapy? Retrieved from https://www.nacbt.org/whatiscbt-htm/
  • Otte C. (2011). Cognitive-behavioral therapy in anxiety disorders: Current state of the evidence. Dialogues in Clinical Neuroscience, 13 (4), 413–421.
  • Patterson, M. (2009). CBT in practice: Part science, part art. Visions Journal, 6 (1).
  • Reynolds, S. A., Clark, S., Smith, H., Langdon, P. E., Payne, R., Bowers, G., … & McIlwham, H. (2013). Randomized controlled trial of parent-enhanced CBT compared with individual CBT for obsessive-compulsive disorder in young people. Journal of Consulting and Clinical Psychology , 81(6), 1021-1026.
  • Stewart, R. E., & Chambless, D. L. (2009). Cognitive–behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology , 77(4), 595–606.
  • Turner, R., & Swearer Napolitano, S. (2010). Cognitive Behavioral Therapy (CBT). In C. Clauss-Ehlers (Ed.), Encyclopedia of cross-cultural school psychology (pp. 226-229). New York, NY: Springer.

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Stacy jablonoski

I read your whole paid and I’m starting cbt soon and a lot you talk about scares me very much i just hope it can really help me as i find myself unfixed at times so I’m going to give it all i got and hope for the best thank you for all your knowledge now g just have to get my feet wet take care

z jones

I am currently writing a paper for school about cognitive behavioral therapy. How might I use the information from the article to site as a reference?

Nicole Celestine

Hi Z Jones,

You can cite the article using APA 7th formatting as follows:

Riopel, L. (2020). 8 Benefits of Cognitive Behavioral Therapy (CBT) according to science. PositivePsychology.com . Retrieved from https://positivepsychology.com/benefits-of-cbt/

Good luck with your paper!

– Nicole | Community Manager

Guna

Pls help on CBT therapy for depression

Hi Guna, You can find more information about CBT for depression at this link. – Nicole | Community Manager

Hi Guna, You can read more about CBT for depression here. If you search your local area, you should be able to find a CBT therapist who can work with you on depression within a CBT framework. Hope this helps. – Nicole | Community Manager

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it’s benefit for our daily life

Lauren E North

Dear Leslie, this article is extremely informative and helpful. With your permission and agreement I would like to use this info and quotes for a book I am working on. Please email me at [email protected] Thank you! Lauren

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Hi Lauren Glad to hear you found it informative. You are welcome to share it by clicking on the big green YES option at the bottom of the post, which will give you sharing options. All the best, Annelé

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why is homework important in cbt

3 Positive CBT Exercises (PDF)

IMAGES

  1. Lecture 9 homework in cbt

    why is homework important in cbt

  2. CBT and 6 Stages of Homework

    why is homework important in cbt

  3. Types of Homework in CBT

    why is homework important in cbt

  4. CBT (Cognitive Behavioral Therapy), Homework and Kids

    why is homework important in cbt

  5. Which Factors CBT Homework Compliance Is Effected By?

    why is homework important in cbt

  6. 15 Reasons Why Homework Is Important?

    why is homework important in cbt

VIDEO

  1. The Homework of CBT Cognitive Behavioral Therapy

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  3. CBT Adaptive Strategies: Homework For Positive Outcomes

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  5. CBT Homework done, Junk Journaling is more fun

  6. Effective Discipline Techniques Positive Parenting StrategiesPart088

COMMENTS

  1. Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps

    Homework is an important component of CBT; in the context of CBT, homework can be defined as "specific, structured, therapeutic activities that are routinely discussed in session, to be completed between sessions" [ 7 ]. Completion of homework assignments was emphasized in the conception of CBT by its creator, Aaron Beck [ 8 ].

  2. How to Design Homework in CBT That Will Engage Your Clients

    Why Is Homework Important in CBT? Many psychotherapists and researchers agree that homework is the chief process by which clients experience behavioral and cognitive improvements from CBT (Beutler et al., 2004; Kazantzis, Deane, & Ronan, 2000).

  3. Assigning Homework in Cognitive Behavioral Therapy

    Assigning therapy "homework" can help your clients practice new skills during the week. While many types of therapy may involve some form of weekly assignment, homework is a key component of...

  4. How Much Does Homework Matter in Therapy?

    Homework is an important component of cognitive behavior therapy (CBT) and other evidence-based treatments for psychological symptoms. Developed collaboratively during therapy sessions,...

  5. Homework in CBT

    Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect thoughts, and modify their thinking. How to deliver homework Homework is not something that you just assign randomly. You should make sure you: tailor the homework to the patient

  6. Sending Homework to Clients in Therapy: The Easy Way

    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).

  7. CBT Session Structure and Use of Homework

    Homework tasks are an important part of CBT practice, based on the view that client change does not come about purely as a result of in-session work - i.e. that significant effort is required by the client between sessions. In other words, there are 168 hours in the client's week and only one of them is spent with the therapist.

  8. Homework in Cognitive Behavioral Supervision: Theoretical Background

    The homework aims to generalize the patient's knowledge and encourage practicing skills learned during therapy sessions. Encouraging and facilitating homework is an important part of supervisees in their supervision, and problems with using homework in therapy are a common supervision agenda.

  9. 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).

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

    Background This article discusses the concept of homework in cognitive-behavioral therapy (CBT), and reviews the articles in this special issue of Cognitive Therapy and Research. The article underscores the pivotal role of between- session activities and demonstrates that this role has been recognized for many years. Methods This article reviews the articles from this special issue and uses ...

  11. A Comprehensive Model of Homework in Cognitive Behavior Therapy

    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 comprehensive model. We suggest ...

  12. Therapy Homework: Purpose, Benefits, and Tips

    Table of Contents Types of Therapy That Involve Homework Benefits Tips 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.

  13. What is the Status of "Homework" in Cognitive Behavior Therapy, 50

    The inclusion of homework as a crucial feature of Cognitive Therapy made perfect sense 1. Homework is a collaborative endeavor. It is also ideally empirical and can help to promote the reappraisal of key cognitions 2.

  14. The Five Rs of Effective Homework

    homework assignment. Clients need to understand why the assignment is important, and its benefits. Reviewed - Homework assignments must be reviewed at the subsequent session. The most destructive scenario is when a client completes an assignment, but the therapist fails to spend time interpreting and consolidating the results.

  15. The New "Homework" in Cognitive Behavior Therapy

    "Homework" is now called the "Action Plan." We like the label "Action Plan." It conveys a sense of proactivity, of taking control. 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.

  16. The Role of Homework Engagement, Homework-Related Therapist ...

    1 Altmetric Explore all metrics Abstract Background Telephone-based cognitive behavioral therapy (tel-CBT) ascribes importance to between-session learning with the support of the therapist.

  17. Homework In Cognitive Behavioral Supervision

    Most practicing CBT therapists report that they use homework and consider homework important for many problems 14 and believe in the role of homework in improving therapeutic outcomes. 24,27 Encouraging and facilitating homework is a basic skill of a CBT therapist; therefore, it is an important part of supervision. 19,20,26 Homework needs to be ...

  18. The key principles of cognitive behavioural therapy

    Cognitive behavioural therapy (CBT) explores the links between thoughts, emotions and behaviour. It is a directive, time-limited, structured approach used to treat a variety of mental health disorders. It aims to alleviate distress by helping patients to develop more adaptive cognitions and behaviours. It is the most widely researched and ...

  19. Homework in CBT

    Homework in CBT. Cognitive Behavioural Therapy (CBT) is a very practical therapy that involves homework as a huge part of the therapy process. You may think of school when they hear the term "homework", and that's understandable. However, homework in CBT is actually a really good thing. The reason that there is a heavy focus on homework or ...

  20. Therapeutic relationships in cognitive behavioral therapy: Theory and

    In the context of Cognitive Behavior Therapy (CBT) the work of Aaron T. Beck and colleagues placed an emphasis on the therapeutic relationship as "necessary" for change (Beck et al., 1979 ). The therapeutic relationship in CBT requires adaptation and variation for each client, where empathic understanding and effective interpersonal style ...

  21. Benefits of CBT: 8+ Results of Cognitive Behavioral Therapy

    According to the National Association of Cognitive-Behavioral Therapists (2021), CBT is based on the cognitive model of emotional response. This model tells us that our feelings and behaviors stem from our thoughts, as opposed to external stimuli. CBT is a goal-oriented and problem-focused therapy, unlike its psychoanalytical predecessors.

  22. Why is Homework Important?

    Homework is an opportunity to learn and retain information in an environment where they feel most comfortable, which can help accelerate their development. 5. Using Learning Materials. Throughout a child's education, understanding how to use resources such as libraries and the internet is important. Homework teaches children to actively ...