homework in therapy

Sending Homework to Clients in Therapy: The Easy Way

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

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

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

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

This Article Contains:

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

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

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

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

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

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

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

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

Internal factors

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

External factors

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wheel of Life

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

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

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

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

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

The Private Garden: A Visualization for Stress Reduction

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

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

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

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

20 Guidelines for Developing a Growth Mindset

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

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

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

Self-Contract

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

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

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

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

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

Realizing Long-Lasting Change by Setting Process Goals

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

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

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

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

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

Couples therapy homework

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

Family therapy homework

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

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

How holistic therapist Jelisa Glanton uses Quenza

Homework ideas for depression and anxiety: 3 Exercises

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

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

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

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

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

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

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

How to build pathways

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond . Guilford Press.
• Dweck, C. S. (2017).  Mindset: The new psychology of success.  Robinson.
• Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research , 34 (5), 429–438.
• Ribbers, A., & Waringa, A. (2015). E-coaching: Theory and practice for a new online approach to coaching . Routledge.
• Shapiro, S. L. (2020).  Rewire your mind: Discover the science and practice of mindfulness. Aster.
• Tang, W., & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health , 4 (2).

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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.

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

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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.

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, 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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A Comprehensive Model of Homework in Cognitive Behavior Therapy

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

Cite this article

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

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

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A Commentary on the Science and Practice of Homework in Cognitive Behavioral Therapy

Keith S. Dobson

Basic Principles and Practice of Cognitive Behavioral Therapy

Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression.

Laren R. Conklin, Daniel R. Strunk & Andrew A. Cooper

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

Article   PubMed   Google Scholar  

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

Article   Google Scholar  

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

Article   PubMed   PubMed Central   Google Scholar  

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

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

Article   CAS   PubMed   Google Scholar  

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

Google Scholar  

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

Article   CAS   Google Scholar  

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

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

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

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

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

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

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

Chapter   Google Scholar  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Book   Google Scholar  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy & Research, 34 , 429–438. https://doi.org/10.1007/s10608-010-9297-z

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Article   CAS   PubMed   PubMed Central   Google Scholar  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Homework in CBT

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

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

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

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

Types of homework

Types of homework assignments.

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

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

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

Applications for the Beck Institute Certified Master Clinician program are open! Learn more .

• Impact of CBT

What is the Status of “Homework” in Cognitive Behavior Therapy, 50 Years On?

By Nikolaos Kazantzis, PhD

The comedian Jerry Seinfeld once asked:

“ What’s the deal with ‘homework?’ It’s not like you’re doing work on your home… ”

The great thing about that quote is that it conveys that the “H” word has some of the most unpleasant associations for clients in CBT. In July 2016, Dr. Judith S. Beck and Dr. Francine Broder wrote an important contribution to the Beck Institute blog giving good reason for a move away from the “H” word in practice.

When developing Cognitive Therapy, Dr. Aaron T. Beck was inspired by existing therapies, including behavior therapy, wherein the educative model to generate clinically meaningful change had been adopted. 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 .

Asking clients to engage with therapeutic tasks between sessions, in a form of action plan has been subject to more empirical study than any other process in CBT 3 .  However, the evidence supporting homework is almost wholly derived from dismantling studies that contrast CBT with CBT without homework, or correlational studies of homework adherence and symptom reduction. Findings from our most recent meta-analysis suggest that homework quantity and quality have little difference in their relations with outcome 4 . As clinicians, we can take from this that we should use homework consistently and be especially encouraged when clients engage with tasks 5 .

However, if we try to seriously answer Jerry’s question above, we have to ask ourselves another important question – what are we actually really interested in with CBT homework?

Current definitions of homework adherence have been derived from the literature on pharmacotherapy, and that might be the source of the problem. Take our two client examples below, Bob and Rob. Both have been prescribed a daily medication script, and if we look at the quantity of what was “done,” Rob looks more “adherent” than Bob.

However, when we take into account the cognitive impairment that Bob has, as well as his capacity to swallow medication following a head injury, then his 6/7 days’ worth of adherence is particularly noteworthy. Of course, in CBT, the content of homework varies on a weekly basis, and is tailored for the client in its design and plan. Therefore, the scope for subjective views of difficulty, and array of unique practical barriers is considerable. Thus, if we are genuinely interested in “engagement,” we need to take into account the inherent difficulties of the homework and practical obstacles to it for each individual client, at each session 6 .

Dr. Judith Beck’s earliest teachings emphasize the importance of the client’s subjective evaluation of homework. Those who are depressed are less likely to recognize their achievements, those with anxiety presentations often have negative predictions about its utility or their ability to carry it out, and many clients abandon the task when encountering obstacles. Those with pervasive interpersonal difficulties often have their core beliefs triggered in carrying out the action plan.  When they do, they may experience intense negative emotion, viewing themselves and/or their therapist negatively. The working alliance may become strained. Dr. Beck has also advocated for use of the cognitive case conceptualization to understand clients’ patterns of engagement and anticipate problems of this nature 7-8 .

Fortunately, the research underpinning CBT homework is moving towards more clinically meaningful studies. Therapist skill in using homework has been shown to predict outcomes 9-10 , and recently a study found that greater consistency of homework with the therapy session resulted in more adherence. 11 Our Cognitive Behavior Therapy Research Lab (currently based at the Turner Institute for Brain and Mental Health at Monash University) is centrally focused on how clients’ adaptive beliefs about homework strengthen their sense of self-efficacy in engaging in homework tasks, despite the difficulties and obstacles they experience. Thus, for several reasons, we can be optimistic that the evidence for homework is an example of how a bridge between science and practice is being built on solid foundations.

A half century after the first practice guide for Cognitive Therapy was published (Beck et al, 1979), we can be curious in the personal meaning our clients attribute to the action plan. How do beliefs about coping and change affect engagement? Are there important maladaptive assumptions and compensatory strategies that might make it difficult for the client to engage? How does the task align with the client’s values? What might be the pros and cons to the client in choosing not to engage? It’s important to focus less on trying to achieve perfect – or even a close approximation of perfect – “adherence” and to focus more on facilitating engagement. An empathic  understanding of challenges clients face completing the homework tasks will better equip us to design and plan future homework. Rather than a focus on “compliance,” let us inspire our clients to tolerate the discomfort and uncertainty in their homework. Let us also celebrate in their discovery of new ideas and perspectives that homework brings.

Nikolaos Kazantzis, PhD is Editor of “Using Homework Assignments in Cognitive Behavior Therapy” (2 nd edition), currently in preparation with Routledge publishers of New York.

• Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression . New York: Guilford Press.
• Kazantzis, N., Dattilio, F. M., & Dobson, K. A. (2017). The therapeutic relationship in cognitive behavioral therapy: A clinician’s guide. New York: Guilford.
• Kazantzis, N., Luong, H. K., Usatoff, A. S., Impala, T., Yew, R. Y., & Hofmann, S. G. (2018). The processes of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 42 (4), 349-357. doi: 10.1007/s10608-018-9920-y 
• Kazantzis, N., Whittington, C. J., Zelencich, L., Norton, P. J., Kyrios, M., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: A meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47 , 755-772. https://doi.org/10.1016/j.beth.2016.05.002
• Callan, J. A., Kazantzis, N., Park, S. Y., Moore, C., Thase, M. E., Emeremni, C. A., Minhajuddin, A., Kornblith, S., & Siegle, G. J. (2019). Effects of cognitive behavior therapy homework adherence on outcomes: Propensity score analysis. Behavior Therapy, 50 (2), 285-299. https://doi.org/10.1016/j.beth.2018.05.010
• Holdsworth, E., Bowen, E., Brown, S., & Howat, D. (2014). Client engagement in psychotherapeutic treatment and associations with client characteristics, therapist characteristics, and treatment factors. Clinical Psychology Review, 34 (5), 428–450. https://doi.org/10.1016/j.cpr.2014.06.004
• Beck, J. S. (2011). Cognitive therapy for challenging problems: What to do when the basics don’t work . New York: Guilford.
• Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York: Guilford.
• Weck, F., Richtberg, S., Esch, S., Hofling, V., & Stangier, U. (2013). The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: Secondary analysis of a randomized trial. Behavior Therapy, 44 (1), 162–172. doi:10.1016/j.beth.2012.09.004
• Conklin, L. R., Strunk, D. R., & Cooper, A. A. (2018). Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression. Cognitive Therapy and Research, 42 (1), 16–23. https://doi.org/10.1007/s10608-017-9873-6
• Jensen, A., Fee, C., Miles, A. L., Beckner, V. L., Owen, D., & Persons, J. B. (in press). Congruence of patient takeaways and homework assignment content predicts homework compliance in psychotherapy. Behavior Therapy. https://doi.org/10.1016/j.beth.2019.07.005

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5 benefits of asking for homework in therapy

The decision to enter into any sort of mental health treatment is never easy. When I went back to therapy over a year ago, I went at the encouragement of friends who noticed I wasn’t acting like myself and that I seemed depressed .

It wasn’t my first foray into therapy. My first experience was right after I was paralyzed in a car accident at 5 years old . After that, I had nominal success when I was treated for post-traumatic stress disorder and depression in high school. However, now in my early 30s, my problems kept creeping back to the surface.

Similar to countless others, these recurring problems had manifested in ways that impacted my daily life and self-esteem at work and in relationships.

I wanted therapy this time to truly give me the tools I needed to handle my illness better. I had to try a new approach: I asked for assignments of things I should work on for the following week. Every therapist I talk to says doing work outside of therapy is crucial to feeling better, but sometimes it’s hard to know what those efforts should look like. Asking for weekly “homework assignments” can provide concrete direction and focus of how to continue the work, and it has been the single best thing I’ve done for my depression recovery.

Most weeks are different, and at the worst of my depression I was having three sessions a week, so the homework assignments were as simple as writing down one thing I like about myself, or leaving the house for 10 minutes every day. While these may sound like easy tasks, anyone who has struggled with severe depression will tell you it can feel impossible to take these baby steps.

Here’s five benefits I experienced:

1. It provides pride and control in the process.

Having more of a stake in my therapy journey has been awesome for my self-esteem. When I was at my sickest, completing my homework gave me a sense of accomplishment, even if I felt like I didn’t get much else done.

2. It’s easier to track progress.

In therapy, there are peaks and valleys of progress, triumphs and frustrations. But in looking at what my assignments were a year ago versus now, it’s a huge indicator of how far I have come. It’s no longer hard to come up with a few things I’m proud of and we can look back and say, “OK, I’ve worked on this and feel good about it. What’s next?”

3. You will learn a lot.

These assignments have helped me learn about how the brain works, about myself and lessened the stigma I had put on myself for having a mental illness. The key is to stay focused, and frequently check your homework assignments and make sure they point back to whatever goals you have.

Health & Wellness The great overlooked story of depression: People can go on to thrive

4. it helps the bond between you and your therapist..

Everyone grows and learns differently. My homework is probably vastly different from what yours would be and that’s completely OK. Finding out what works for you will help your therapist get to know you in a different way. Personally, it gives my therapist and I a great starting point for every session, and has a clear deliverable for the next time we speak.

5. It will help you progress faster.

Look at it this way: When you start working with a personal trainer, do you only work out that one or two days a week when you meet, or are you working out outside of your sessions? Sure you will still make some progress eventually, but it will take you longer if you don’t do the work in between. The same goes for therapy. Neither one can be rushed, but there must be consistent effort, day in and day out.

I know how hard it is to make the choice to seek help. It’s hard to walk into that room for the first time, or recognize there’s something going on. So many people who are confused or suffering, do so alone. This may not work for everyone, but therapy homework has set me up for success and I hope can do the same for many others.

If you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). There is also a crisis text line . Or if you or a loved one needs help with depression, visit SAMHSA.gov or call the hotline at 1-800-662-HELP (4357).

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Barriers Associated with the Implementation of Homework in Youth Mental Health Treatment and Potential Mobile Health Solutions

Brian e. bunnell.

1 Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA

2 Biomedical Informatics Center, College of Medicine, Medical University of South Carolina, Charleston, SC, USA

Lynne S. Nemeth

3 Department of Nursing, College of Nursing, Medical University of South Carolina, Charleston, SC, USA

Leslie A. Lenert

Nikolaos kazantzis.

4 Cognitive Behavior Therapy Research Unit and School of Psychological Sciences, Monash University, Clayton, VIC, Australia

Esther Deblinger

5 Child Abuse Research Education & Service (CARES) Institute, Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA

Kristen A. Higgins

Kenneth j. ruggiero.

6 Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, USA

Author Contributions

Associated Data

Background:.

Homework, or between-session practice of skills learned during therapy, is integral to effective youth mental health TREATMENTS. However, homework is often under-utilized by providers and patients due to many barriers, which might be mitigated via m Health solutions.

Semi-structured qualitative interviews were conducted with nationally certified trainers in Trauma Focused Cognitive Behavioral Therapy (TF-CBT; n =21) and youth TF-CBT patients ages 8–17 ( n =15) and their caregivers ( n =12) to examine barriers to the successful implementation of homework in youth mental health treatment and potential m Health solutions to those barriers.

The results indicated that many providers struggle to consistently develop, assign, and assess homework exercises with their patients. Patients are often difficult to engage and either avoid or have difficulty remembering to practice exercises, especially given their busy/chaotic home lives. Trainers and families had positive views and useful suggestions for m Health solutions to these barriers in terms of functionality (e.g., reminders, tracking, pre-made homework exercises, rewards) and user interface (e.g., easy navigation, clear instructions, engaging activities).

Conclusions:

This study adds to the literature on homework barriers and potential m Health solutions to those barriers, which is largely based on recommendations from experts in the field. The results aligned well with this literature, providing additional support for existing recommendations, particularly as they relate to treatment with youth and caregivers.

Introduction

Homework, or between-session practice of skills learned during therapy, is one of the most integral, yet underutilized components of high-quality, evidence-based mental health care ( Kazantzis & Deane, 1999 ). Homework activities (e.g., self-monitoring, relaxation, exposure, parent behavior management) are assigned by providers in-session and completed by patients between sessions with the goal of “practicing” therapeutic skills in the environment where they will be most needed ( Kazantzis, Deane, Ronan, & L’Abate, 2005 ). There are numerous benefits to the implementation of homework during mental health treatment ( Kazantzis et al., 2016 ; Kazantzis, Deane, & Ronan, 2004 ). Homework enables the generalization of skills and behaviors learned during therapy, facilitates treatment processes, provides continuity between sessions, allows providers to better grasp patients’ learning, and strengthens that learning, leading to improved maintenance of treatment gains ( Hudson & Kendall, 2002 ; Scheel, Hanson, & Razzhavaikina, 2004 ). Meta-analytic and systematic reviews have shown that homework use by providers and adherence by patients predict increased treatment engagement, decreased treatment dropout, and medium-to-large effects on improvements in clinical outcomes for use (Cohen’s d =.48–.77) and adherence ( d =.45–.54) ( Hudson & Kendall, 2002 ; Kazantzis, Deane, & Ronan, 2000 ; Kazantzis & Lampropoulos, 2002 ; Kazantzis, Whittington, & Dattilio, 2010 ; Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010 ; Scheel et al., 2004 ; Sukhodolsky, Kassinove, & Gorman, 2004 ). Simply put, 68% vs . 32% of patients can be expected to improve when therapy involves homework ( Kazantzis et al., 2010 ).

Despite its many benefits, homework is implemented with variable effectiveness in mental health treatment. Only 68% of general mental health providers and ~55% of family providers report using homework “often” to “almost always” ( Dattilio, Kazantzis, Shinkfield, & Carr, 2011 ; Kazantzis, Lampropoulos, & Deane, 2005 ). Further, providers report using homework in an average of 57% of sessions, although this rate is higher for CBT practitioners (66%) vs . non-CBT practitioners (48%). Moreover, only 25% of providers report using expert recommended systematic procedures for recommending homework (i.e., specifying frequency, duration, and location; writing down homework assignments for patients) ( Kazantzis & Deane, 1999 ). A national survey revealed that 93% or general mental health providers estimate rates of patient adherence to homework to be low to moderate ( Kazantzis, Lampropoulos, et al., 2005 ), and research studies report low to moderate rates of youth/caregiver adherence during treatment (i.e., ~39–63%; ( Berkovits, O’Brien, Carter, & Eyberg, 2010 ; Clarke et al., 1992 ; Danko, Brown, Van Schoick, & Budd, 2016 ; Dattilio et al., 2011 ; Gaynor, Lawrence, & Nelson-Gray, 2006 ; Helbig & Fehm, 2004 ; Lyon & Budd, 2010 ; Simons et al., 2012 ).

Numerous barriers to the successful implementation of homework during mental health treatment have largely been suggested by experts in the field, rather than specifically measured ( Dattilio et al., 2011 ), and have generally been classified as occurring on the provider-, patient-, task-, and environmental-level ( Kazantzis & Shinkfield, 2007 ). Provider-level barriers can relate to the therapeutic relationship and the degree to which a collaborative approach is used, provider beliefs about homework and the patient’s adherence, and providers’ ability to effectively design homework tasks ( Callan et al., 2012 ; Coon, Rabinowitz, Thompson, & Gallagher-Thompson, 2005 ; Friedberg & Mcclure, 2005 ; Garland & Scott, 2002 ; Kazantzis & Shinkfield, 2007 ). Patient-level barriers can include patient avoidance and symptomatology, negative beliefs toward the task, not understanding the rationale or how to do the task, forgetting, and beliefs about their ability to complete homework tasks. ( Bru, Solholm, & Idsoe, 2013 ; Callan et al., 2012 ; Dattilio et al., 2011 ; Friedberg & Mcclure, 2005 ; Garland & Scott, 2002 ; Hudson & Kendall, 2005 ; Kazantzis & Shinkfield, 2007 ; Leahy, 2002 ). Relatedly, core beliefs central to the patients’ psychopathology can be activated during homework–thereby triggering withdrawal and avoidance patterns ( Kazantzis & Shinkfield, 2007 ). Task-level barriers include poor match between tasks and therapy goals, tasks that are perceived as vague or unclear, tasks that are perceived as too difficult or demanding in terms of time or effort, tasks being viewed as boring, and general aversiveness of the idea of completing homework ( Bru et al., 2013 ; Callan et al., 2012 ; Dattilio et al., 2011 ; Friedberg & Mcclure, 2005 ; Garland & Scott, 2002 ; Hudson & Kendall, 2005 ). Environmental factors have been noted to include practical obstacles, lack of family/caregiver support, dysfunctional home environments, lack of time due to busy schedules, and lack of reward or reinforcement ( Callan et al., 2012 ; Dattilio et al., 2011 ; Hudson & Kendall, 2005 ).

The advancement and ubiquitousness of technologies such as m Health resources (e.g., mobile- and web-based apps) provide a tremendous opportunity to overcome barriers to homework use and adherence and resultantly, improve the quality of mental health treatment. m Health solutions to improve access and quality of care, have been widely investigated, are effective in facilitating behavior change, practical, desired by patients and providers, and available at low cost ( Amstadter, Broman-Fulks, Zinzow, Ruggiero, & Cercone, 2009 ; Boschen & Casey, 2008 ; Donker et al., 2013 ; Ehrenreich, Righter, Rocke, Dixon, & Himelhoch, 2011 ; Hanson et al., 2014 ; Heron & Smyth, 2010 ; Krebs & Duncan, 2015 ; Luxton, McCann, Bush, Mishkind, & Reger, 2011 ; Ruggiero, Saunders, Davidson, Cook, & Hanson, 2017 ). Existing m Health resources include features that can support homework implementation (e.g., voice and SMS reminders and feedback, self-monitoring and assessment, and modules and activities that can be used to facilitate between-session practice; Bakker, Kazantzis, Rickwood, & Rickard, 2016 ; Tang & Kreindler, 2017 ), but these resources were not designed with the express intention of addressing barriers to homework implementation, particularly for youth and family patient populations.

The extant literature on barriers to homework implementation is limited in that it is largely based on expert recommendations. Therefore, the first aim of this study was to explore provider, youth, and caregiver patient perspectives on barriers to the successful implementation of homework during youth mental health treatment. Further, m Health solutions to those barriers have not been explored, especially for youth and family patients. Thus, the second and third aims of this study were to obtain suggestions for m Health solutions to homework barriers and explore perceptions on the benefits and challenges associated with those m Health solutions.

Institutional Review Board approval was obtained prior to enrolling any participants in the study. The approach for this study was based on the constructivist grounded theory, which acknowledges the researcher’s prior knowledge and influence in the process and supports and guides conceptual framework development to understand interrelations between constructs ( Charmaz, 2006 ). This qualitative study used a thematic analysis of semi-structured interviews in a sample of nationally certified trainers in Trauma-Focused Cognitive Behavioral Therapy (TFCBT; Cohen, Mannarino, & Deblinger, 2017 ), youth who had engaged in TF-CBT, and their caregivers. The initial goal was to conduct interviews with 15–20 interviewees in each group to achieve theoretical saturation (i.e., no new information was derived), consistent with a prior study by members of the research team which used similar semi-structured interviews with national TF-CBT trainers ( Hanson et al., 2014 ), and recommendations by Morse (2000) given the relatively narrow scope and clear nature of the study. Interviews were conducted until interviewers and the study lead determined that no new pertinent information was being obtained.

Participants

National trainers..

Twenty-one national trainers in TF-CBT were interviewed. National trainers are mental health providers who completed a 15-month TF-CBT Train-the-Trainer program led by the TF-CBT developers. Trainers work extensively with numerous community mental health providers to problem-solve common barriers to clinical practice and thus, provide a unique perspective on the barriers to successful homework implementation and possible m Health solutions to those barriers. An e-mail invitation was sent to a list of approved TF-CBT trainers. Twenty-four trainers responded to this e-mail, 22 of whom agreed to participate in an interview, one of whom was unreachable after initial scheduling. Interviews were completed with a total of 21 trainers, who received a $25 gift card in compensation for their time.

Trainers had been treating children for an average of 23.29 years ( SD =8.80) and had been training providers for an average of 14.95 years ( SD =8.98). In the year prior to the interview, they led an average of 17 provider trainings ( SD =21.67) and trained roughly 345 providers ( SD =339.90). All trainers were licensed, and the majority were Clinical Psychologists (47.6%) and Social Workers (33.3%). The average age of trainers was 47.48 years ( SD =13.63) and the majority were female (71.4%), white (95.2%), and non-Hispanic/Latino (85.7%; see Table 1 ).

Trainer Demographics

Twelve families were interviewed for this study. Families were included if they had one or more youth between the ages of 8 and 17 years-of-age and a caregiver who had engaged in at least four sessions for TF-CBT. These criteria were chosen because TF-CBT is typically recommended for youth between the ages of 8 and 17 years-of-age and it was estimated that four sessions would have likely allowed for adequate time for patients to have received homework assignments, consistent with the authors’ experience and prior TF-CBT literature ( Deblinger, Pollio, & Dorsey, 2016 ; Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011 ). Families were recruited via advertisements online and at local community mental health clinics, and from a participant pool from a prior study ( Davidson et al., 2019 ). Twenty-nine families initially expressed interest in participating in the study. Six families were ineligible because they had not received TF-CBT and contact was lost with six families after their initial contact. Seventeen families were scheduled for an interview, five of which were unreachable after initially being scheduled, and interviews were completed with 12 families. Written informed consent from caregivers and assent from youth above the age of 15 were obtained in-person for four families and via a telemedicine-based teleconsent platform (i.e., https://musc.doxy.me ) for eight families. Families received a $30 gift card in compensation for their time.

A total of 15 youth who had engaged in TF-CBT, and their caregivers ( n =12; three families had two youth who had received treatment) were interviewed. Six youth were still in treatment at the time of their interview and nine had finished treatment an average of 49 weeks ( SD =42.32) prior to the interview. The average age of youth was 13.20 years ( SD =3.19), roughly half were female (53.3%), the majority were white (80%), and all were non-Hispanic/Latino. The average age of caregivers was 44.83 years ( SD =7.90), 66.7% were female, and all were White and non-Hispanic/Latino. Youth and caregivers rated their comfort with technology, in general, on a 10-point Likert scale (i.e., 1–10) with higher scores representing higher levels of comfort. Youth reported being very comfortable with technology (M=9.62, SD =1.12), as did their caregivers (M=7.83, SD =2.63; see Table 2 ).

Family Demographics

Trauma-Focused Cognitive Behavioral Therapy

TF-CBT is a well-established and widely disseminated mental health treatment ( Cohen et al., 2017 ; Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011 ; Silverman et al., 2008 ; Wethington et al., 2008 ). It is a conjoint youth-caregiver mental health treatment typically conducted over ~12, 90-minute sessions that address nine major treatment components (i.e., P sychoeducation; P arenting Skills; R elaxation Skills; A ffective Expression and Modulation Skills; C ognitive Coping and Processing Skills; T rauma Narration and Processing; I n Vivo Exposure; C onjoint Child Parent Activities; and E nhancing Future Safety and Development). TF-CBT also addresses a broad range of symptom domains including trauma- and stress-related disorders, disruptive behavior disorders/behaviors, depression/depressive symptoms, and anxiety disorders ( Cohen et al., 2017 ). TF-CBT was chosen as a model treatment for this study because of its broad symptom focus, inclusion of treatment components used in a variety of youth mental health treatments, and involvement of youth and their caregivers, offering potential to improve the applicability of the study’s results to a range of youth mental health treatment approaches.

Procedures for Data Collection

Interviews were conducted via telephone for trainers, and either in-person or via telephone for families based on their preference. A postdoctoral fellow and masters-level research assistant conducted the interviews, which were audio-recorded and transcribed using a professional transcription service. Interviews included three major components. The first component included demographic questions. The second included a brief orientation to the goal of the study, which was to develop a new technology-based resource to help providers and patients during the implementation of homework during mental health treatment. The third component included questions that aimed to assess perspectives on barriers to homework implementation, elicit suggestions for m Health solutions to those barriers, and examine perceptions on the benefits and challenges associated with m Health solutions to homework barriers. The average duration of interviews was 41 minutes for trainers and 37 minutes for families. See Supplementary Materials for complete interviews.

Data Analysis

Transcribed interviews were coded using NVivo qualitative analysis software. NVivo was used to identify common themes (nodes) as they related to (1) patient-, provider-, task-, and environmental-barriers to homework implementation, (2) suggestions for m Health solutions to homework barriers, and (3) benefits and challenges associated with m Health homework solutions. Initial and secondary coding passes were conducted to identify and refine theme classifications as they emerged and impose a data-derived hierarchy to the nodes identified. Focused coding was used to refine the coding and ensure that data were coded completely with minimal redundancy ( Miles & Huberman, 1994 ). Themes were initially proposed by the first author and reviewed by an expert in qualitative and mixed methods research (the second author) and an internationally recognized expert in the implementation of homework and related barriers during CBT (the fourth author). Divergent perspectives on theme descriptions ( n =2) and classifications ( n =1) were compared until agreement was reached.

Results are organized by the main topics explored in this study, including: 1) barriers to the successful implementation of homework, coded on provider, patient, task, and environmental levels; 2) potential m Health solutions to those homework barriers; and 3) perceived benefits and challenges of those potential m Health solutions. Results within each of these topics are presented first from the perspectives of trainers and second from the perspectives of families.

Barriers to the Successful Implementation of Homework

Trainer perspectives..

As displayed in Table 3 , trainers identified several barriers to homework implementation on the provider-, patient-, task-, and environmental-level.

Trainer Perspectives on Homework Barriers

Provider-Level Barriers.

Many trainers felt that providers tend to have difficulty engaging patients in assigned tasks, leading some providers to become discouraged by low levels of engagement. As stated by one trainer,

“I think they recognize that [homework assignments] do have value, but in terms of what I feel, a lot of clinicians are not having success with families completing homework, so it’s diminishing the sense of value…something they’ve tried to put into place and they are not feeling there’s any success in it.”

Trainers also noted that many providers do not see homework as an integral part of therapy. One trainer commented,

“I think there are a lot of concrete barriers, but to me probably the biggest barrier will be the–I think that still to this day [providers] like to think that therapy happens in that one hour.”

Other interrelated difficulties faced by providers related to their capacity to effectively and consistently develop, assess, and assign meaningful and patient-centered homework exercises.

As stated by one trainer,

“I see a lot of that just shooting from the hip, kind of off the cuff, ‘let’s do this,’ but yet, it’s not backed by anything concrete or tangible…I think probably one of the biggest pieces again is the failure on the clinician’s part to follow that up and too often review it at the end of the session.”

Another said,

“I think clinicians don’t always appreciate how hard it is to actually do homework that requires you to make some behavioral change.”

Barriers also related to providers’ time and resources for implementing homework, as conveyed by one trainer’s comment,

“I mean, these people…every minute of every day is filled up with doing, billing, writing, charting, going to meetings, getting supervision, and seeing patients, and then they go home exhausted.”

Patient-Level Barriers.

Many trainers stated that, similar to some providers, patients often do not see homework as an important part of therapy. Put by one trainer,

“I think that some [patients] just feel that coming to the session is enough and that should resolve everything, and that you know, doing homework is just kind of an extra thing…I don’t really need to do it to benefit from the therapy.”

Perhaps relatedly, trainers also noted that patients generally forget to do homework assignments, and often forget why, how, when, and where assignments should be done.

Task-Level Barriers.

Task-level barriers noted by trainers included assignments not always aligning with patient values or treatment goals and that the term ‘homework’ being aversive to patients of all ages. One trainer commented,

“I think it has to be something that [patients] see the value in. And again, we go back to that engagement and them trusting you as well as you explaining to them why this could be helpful…If it didn’t help, we need to change it.”

Another trainer laughed while stating,

“when we use the word homework, we might as well just throw a stink bomb in the room.”

Environmental-Level Barriers.

Finally, on the environmental-level, many trainers suggested that patients’ home lives are busy and chaotic, leaving little-to-no time for homework.

Explained by one trainer,

“I think that for parents…they have many other things in their life; work, parenting, partnerships that they are working on, just day to day chores or things that they have to do in terms of their family or other responsibilities. So, [homework] often feels like, I think for families, to add another thing…it just feels like a lot.”

Associated barriers included limited caregiver involvement and reinforcement for completing homework assignments. One trainer commented,

“So, let’s not forget that the parents need to be encouraged and checked on to make sure the kid is doing it. They have to work at it – It’s not going to just happen. So, helping the parents to see that they’re going to need to work to make sure the kids do it, because again, the kids would rather eat ice-cream than do the work. I mean change is hard.”

Another stated,

“I would say, lack of reinforcement for homework, so maybe for getting what you assign for homework and not reviewing it or the kiddo or the family learning pretty quickly, you know, why do it, because there’s not a lot of support around it. You know, if [patients] don’t get reinforced, whether tangibly or verbally, they may not continue that.”

Family Perspectives.

Families identified several barriers to homework implementation on the patient-, task-, and environmental-level which were similar to many of those noted by national trainers (see Table 4 ).

Family Perspectives on Homework Barriers

Families believed that patients often avoid homework as a result of their symptoms. In other words, the patient’s unhelpful coping strategies are being triggered.

One caregiver commented,

“Sometimes people don’t even want to dig into their feelings even to do the assignment either, you know. It stirs up things. You know, when you’re dealing with feelings, sometimes you don’t want to experience that feeling…you shut down. You don’t want to feel that at that time.”

“When you already have a child that has ADHD or behavior problems, it’s hard to get them motivated and to get them to do these exercises at home.”

Families also felt that patients simply forget to complete homework or bring it to their next session. One child stated,

“That’s my problem, she’ll give me homework, we met once a week, basically, and I would forget it because I’ve got a lot going on, and when I come in and she’s like, ‘Did you do your homework,’ I’m like, ‘Oh man’.”

Similar to trainers, families felt that patients often forget why, how, when and where assignments should be done. As stated by one caregiver,

“I think sometimes it can also be just, like maybe not fully understanding what is being asked of them to do. I know the therapist will ask them in the office, ‘do you understand?’ and of course the kids always go, ‘yes I do, can I go home now’?”

With respect to task-level barriers, most families viewed homework assignments as boring. General consensus from families was that patients–particularly youth– would more often than not just rather be doing something more interesting.

On the environmental level, all families noted that the home-life of patients is busy and chaotic, leaving little perceived time for homework. Everyday responsibilities such as schoolwork, employment, household chores, and familial responsibilities often take precedence. One caregiver stated,

“Well I think it sounds good in the office and then you get home and you just get quite busy and it gets pushed aside.”

Another commented,

“But I know what he’s saying…sometimes seven-and-a-half hours at school and then sometimes his therapy would be an hour-and-a-half. And thank goodness, his teacher was so flexible that on days he has therapy he did not have homework [for school], but he was just so emotionally and physically drained. When he got home, all he wanted to do was just rest or play. Because that’s the therapy, it can be just exhausting.”

Families also believed that that there is often a lack of reinforcement for completing homework assignments.

m Health Solutions to Homework Barriers

Trainer suggestions..

Trainers provided several suggestions for m Health solutions to homework barriers ( Table 5 ). Most trainers felt that reminders and schedules to help patients remember to complete homework assignments would be a crucial feature. One trainer suggested, “Maybe some kind of reminder feature, something that would kind of record into their daily calendars that they use, or an alarm, or something like a daily reminder…set to the times they are most likely to do the homework.”

Trainer Suggestions for m Health Solutions to Homework Barriers

Trainers also suggested including reports or activity summaries of homework completion along with behavior and symptom tracking tools. One trainer thoughtfully commented, “If the homework app can somehow help to provide some data on the actual implementation of certain skills during the week that would be very valuable because I think the constructive feedback and the positive feedback that’s offered by therapists about performance of those skills between sessions can be really valuable.”

Trainers suggested including a variety of interactive, fun, and rewarding activities that engage children and caregivers. For example, one trainer stated,

“I think the more interactive you can make it between parent and child and the more of a game you can make it…kids are more likely to do that and to kind of use those skills.” All trainers ( n =21) felt that a text message-based system for reminding patients to complete homework assignments would be beneficial.

Family Suggestions.

Families suggested that the main function of the resource should serve to provide reminders (e.g., text messages or push notifications) for patients to complete homework assignments as well as instructions for how and when they should be completed. Another common suggestion was to include a reward system within the resource to reinforce engagement with homework assignments. Some suggestions for this reward system included coins, experience points, levels, and customizable avatar characters. One child thoughtfully related,

“there could be a digital reward system like stars or gems or something. Then it could be redeemed or something in the therapist’s office. Like I remember it was a while ago, I remember my therapist said if I was able to do something that I was having trouble with, we would have like brownies or something the next visit.”

Families also recommended that the resource include interactive and fun activities. The most common suggestion was to “gamify” homework assignments to make them more fun and interesting to patients. For example, a caregiver noted,

“I think that if you are able to play a game or level up after you did your activity…I don’t think you would have a problem with them doing the activity. They would be so excited to be able to play the game.”

Families providers also recommended reports and activity summaries so that progress could be tracked and reported to providers to be reviewed during the next treatment session ( Table 6 ). All families ( n =12) felt that a text message-based system for reminding patients to complete homework assignments would be beneficial.

Family Suggestions for m Health Solutions to Homework Barriers

Benefits and Challenges of m Health Solutions to Homework Barriers

The majority of trainers responded that an m Health solution to homework barriers would increase provider use of ( n =20; 95.2%) and family adherence to ( n =21; 100%) homework during mental health treatment. The majority of trainers also responded that such a resource would positively affect the therapeutic relationship ( n =15; 71.4%), increase treatment efficiency ( n =18; 85.7%), and improve treatment effectiveness ( n =18; 85.7%). Neutral responses were provided by all trainers who did not respond affirmatively to these questions (i.e., no negative responses were provided). Trainers also commented on the potential clinical utility of an m Health homework resource in that it would help providers with tracking and assigning homework and patients with skill development while promoting high levels of engagement in youth patients. Access, comfort with technology, and convenience were also noted benefits (See Table 7 ). One trainer commented,

Trainer Perspectives on Benefits and Challenges relating to m Health Solutions to Homework Barriers No. of Trainers

“I feel like so many people now enjoy so much more doing things on electronics and so definitely in sessions with kids I’m often recommending having a clinician use apps…sometimes technology is the way to really hook families in and engage them.”

“You know everybody has a phone and if we can have some apps where…I mean it’s so exciting to me what you are talking about. I can’t think of a better idea, I really can’t. I mean people always have their phones on them even if you are really, really poor, people tend to have a phone.”

Challenges identified by trainers centered around confidentiality, access and comfort with technology, and potential negative impacts on the therapeutic process. For example, one trainer stated,

“I do not know if people worry about if somebody else saw the app and wondered, ‘oh you are in therapy, oh what happened to you?’ So, some things around privacy issues and confidentiality, but those will be pretty easy to fix.”

The majority of families believed that the an m Health homework resource would make practicing therapy skills at home more fun or interesting ( n =11; 91.7%), would help families practice skills more often ( n =12; 100%), would positively affect the therapeutic relationship ( n =12; 100%), and would improve treatment effectiveness ( n =11; 91.7%). Neutral responses were provided by all families who did not respond affirmatively to these questions (i.e., no negative responses were provided). Families also suggested that an m Health homework resource would have excellent clinical utility, helping to improve communication between providers and families, make treatment and homework more rewarding, encourage more engagement from youth One caregiver commented,

“I think it would encourage the kids to get [homework] done even before the parents. The kids would want to do it on the phone, they love messing with phones.”

“I think by having the reminders, as well as having something there that’s interactive for the kids and the caregivers both. I think it would be a huge help.”

Similar to trainers, challenges noted by families related to confidentiality and some families not having access to the technology or the internet. Additional family perspectives on benefits and challenges are provided in Table 8 .

Family Perspectives on Benefits and Challenges relating to m Health Solutions to Homework Barriers

The aims of this study were to assess barriers to the successful implementation of homework during youth mental health treatment, obtain suggestions for m Health solutions to those barriers, and explore perceptions on the benefits and challenges associated with m Health solutions to homework barriers through semi-structured qualitative interviews with relevant stakeholders. National trainers in TF-CBT provided a unique perspective on the common challenges met by mental health providers and their patients as well as potential solutions to those challenges, particularly given their extensive experience problem-solving common clinical challenges with community mental health providers. Interviews with youth TF-CBT patients and their caregivers provided important perspectives from those most affected by homework barriers in mental health treatment.

Perspectives on Barriers to the Successful Implementation of Homework

Trainer and family perspectives on the various barriers to the successful implementation of homework during mental health treatment aligned well with the heuristic proposed by Kazantzis and Shinkfield (2007) , which classifies barriers as occurring on the provider-, patient-, task-, and environmental-levels. Most of the provider-level barriers noted by trainers were consistent with expert recommendations from the research literature, such as providers’ beliefs relating to homework and patient engagement in homework ( Coon et al., 2005 ; Friedberg & Mcclure, 2005 ; Garland & Scott, 2002 ), difficulty designing homework activities and individualizing them to specific patients ( Kazantzis & Shinkfield, 2007 ), forgetting about homework and running out of time during the session ( Friedberg & Mcclure, 2005 ), difficulty with consistency and not wanting to put too many demands on patients ( Coon et al., 2005 ), and difficulty effectively assessing patient barriers ( Kazantzis & Shinkfield, 2007 ). Experts have proposed a model for practice that directly addresses many of these provider-level barriers by proposing an ideal process for facilitating engagement in homework ( Kazantzis, MacEwan, & Dattilio, 2005 ).

Trainer and family perspectives on the most common patient-level homework barriers were similar and were also consistent with the extant literature. These included patients’ avoidance or symptoms ( Coon et al., 2005 ; Dattilio et al., 2011 ; Friedberg & Mcclure, 2005 ; Garland & Scott, 2002 ; Hudson & Kendall, 2005 ; Leahy, 2002 ), forgetting to complete assignments ( Coon et al., 2005 ; Hudson & Kendall, 2005 ), not understanding when, where, or how to do assignments or the rationale ( Dattilio et al., 2011 ; Friedberg & Mcclure, 2005 ; Garland & Scott, 2002 ), and beliefs about homework tasks and their ability to complete them ( Dattilio et al., 2011 ; Kazantzis & Shinkfield, 2007 ). Interestingly, whereas the most commonly endorsed patient-level barrier by trainers was patients not seeing homework as an integral part of therapy or important, the most commonly endorsed barriers by families included avoidance or symptoms, forgetfulness, and lack of understanding about assignments, reflecting differing views on the more significant barriers faced by patients. This discrepancy in the trainers/providers vs . families’ perspectives regarding between session assignments suggests the importance of therapists’ focusing more time on explaining assignments, discussing potential challenges, emphasizing the benefits of completing assignments in overcoming symptoms/difficulties and ultimately inspiring follow through.

Task-level barriers reported by both trainers and families included assignments not aligning with patient values or treatment goals ( Coon et al., 2005 ; Dattilio et al., 2011 ; Hudson & Kendall, 2005 ). Many trainers reported that the word “homework” is an aversive term to patients, particularly to youth patients. Perhaps relatedly, many families reported that children view homework assignments are boring. Negative associations with homework may be addressed by referring to “homework” as practice assignments, experiments, exercises, or action plans, as recommended by a recent Beck Institute blog post by Drs. Judith Beck and Francine Broder ( Beck & Broder, 2016 ).

Finally, environment-level barriers noted by trainers and families included the home lives of patients being busy and chaotic – leaving little time to complete homework assignments; a lack of caregiver involvement in the case of youth; and a lack of reward or reinforcement for completing homework assignments, all of which have been previously noted ( Bru et al., 2013 ; Coon et al., 2005 ; Dattilio et al., 2011 ; Kazantzis & Shinkfield, 2007 ). In sum, trainer and family perspectives on barriers to the successful implementation of homework were largely consistent with those suggested by experts. Further, there was a general agreement between trainers and families with respect to those barriers. It is important to note the interrelatedness of several barriers within various levels. For example, patients not understanding the importance of homework or seeing it as an integral part of therapy could very much reflect a mismatch in alliance, tasks needed to achieve therapy goals, or a poor therapist rationale and opportunity for client feedback and discussion. Further, a patient’s understanding of the rationale for homework might be dependent on the provider’s skill in its explanation.

Trainers and families provided numerous suggestions for m Health solutions to homework barriers. These functionality and content suggestions included: reminders and schedules to overcome barriers to forgetting; behavior and symptom tracking and reports or activity summaries to assist providers in assessing homework completion; a variety of homework activities to choose from to help providers struggling with developing activities; resources for caregivers to improve caregiver support; and an integrated reward system to make completing homework rewarding and reinforcing for patients. Other suggested features related more to user interface and user experience. For example, interviewees felt that the m Health resource should allow easy navigation to relevant resources; include clear instructions via video, text, and audio to help patients understand and remember how to do assignments; include interactive and fun activities to help make the assignments less boring and less like “homework;” and be patient-centered and developmentally appropriate. Trainers and families also felt that a text message-based system for reminding patients to complete homework assignments would be beneficial, indicating that this approach would provide a good alternative to a purely app-based resource.

As outlined in recent reviews, there are several studies on m Health resources that include the functionality and content features suggested in this study and can also be used to facilitate homework implementation ( Bakker et al., 2016 ; Tang & Kreindler, 2017 ). For example, a number of m Health resources can be used for self-monitoring and symptom tracking, and many have engaging activities that can be used to support between-session learning and skill development in the areas of relaxation, cognitive therapy, imaginal exposure, and parent behavioral management ( Bunnell et al., 2019 ; Jungbluth & Shirk, 2013 ; Kristjánsdóttir et al., 2013 ; Newman, Przeworski, Consoli, & Barr Taylor, 2014 ; Reger et al., 2013 ; Shapiro et al., 2010 ; Whiteside, Ale, Vickers Douglas, Tiede, & Dammann, 2014 ). SMS- and app-based reminders and feedback on progress can also be used to encourage continued engagement in skills practice ( Aguilera & Muñoz, 2011 ; Harrison et al., 2011 ; Reger et al., 2013 ; Wiederhold, Boyd, Sulea, Gaggioli, & Riva, 2014 ). However, as stated previously, most of these resources were not designed with the express intention of addressing barriers to homework implementation, particularly for youth and family patient populations, leaving room for future work in this area.

Trainers and families expressed very positive views on m Health solutions to homework barriers. Trainers felt that m Health would increase provider use and family adherence to homework, positively affect the therapeutic relationship, and increase treatment efficiency and effectiveness. Families felt that it would make practicing therapy skills at home more fun or interesting, help families practice skills more often, positively affect the therapeutic relationship, and improve treatment effectiveness. A potential benefit commonly noted by trainers and families was a high likelihood that youth would engage with the resource given their generally strong interest in technology, and that this would help to reinforce the practice of skills learned during therapy. A particular benefit noted was increased access to helpful resources between-sessions. Trainers and families expressed concerns about issues relating to confidentiality. While they did not view this as a fatal flaw of the resource, they suggested implementing appropriate safeguards to protect patient privacy and clearly explaining data protection to encourage use.

Limitations

There are several limitations to this study. Regarding generalizability of results, the selection of trainers and families interviewed was based on experience with TF-CBT, a specific treatment protocol for childhood trauma. Although interview questions were kept general during interviews, referring to mental health treatment rather than solely to TF-CBT, the views expressed by interviewees may relate more to TF-CBT than other child mental health treatments. However, a strength of this research is that TF-CBT has a broad symptom focus (e.g., PTSD, anxiety, depression, anger, disruptive behavior) and includes treatment components used in numerous youth mental health treatments (e.g., psychoeducation, relaxation, cognitive coping, affective modulation, exposure), which suggests that results would be applicable to a range of child mental health treatments. Additionally, national trainers in TF-CBT have consistent exposure to working closely with community mental health providers and regularly help them to problem-solve common barriers in clinical practice. This added insight into difficulties experienced by numerous mental health providers rather than asking individual providers about their experience. This is a strength of this study but also a potential limitation as not directly measured, thus an assumption. The views of trainers may not be completely representative of the every-day challenges to homework implementation experienced by community mental health providers. Given the small samples size and lack of diversity, the results should be interpreted with caution as they may not reflect the experiences or views of therapists and patients who utilize homework across different treatment approaches, therapy settings, and populations.

With respect to interview questions and results, they tended to focus on barriers and challenges and provided less of an opportunity for trainers and family members to share factors that may have led to successes with homework assignments. Such information could also importantly support the development and presentation of m health solutions by therapists. Relatedly, families were asked about barriers faced by youth and caregivers, and not by providers, which would have provided interesting data on family perspectives on providers’ limitations. Although comfort with technology in general was assessed in youth and caregivers, it was not specified as comfort with m Health, and ratings were not collected from trainers. As such, a potential limitation of this study is that participants’ comfort specifically with mHealth was unknown. Furthermore, this study focused specifically on m Health without a comparison to other low-tech solutions, which might have resulted in inflated levels of interest in m health solutions to homework barriers. A final limitation is that interviews were coded by the first author, and there is potential for variability in coding that was not accounted for (i.e., the same themes might have been classified in different ways). Despite this limitation, themes were reviewed and by an internationally recognized expert in the implementation of homework and related barriers during CBT (the fourth author) and compared until agreement was reached, supporting the derived themes.

Conclusions

This study provides important new information on barriers to the successful implementation of homework during youth mental health treatment, based on perspectives of providers, youth, and caregivers with that treatment experience. This study adds to the literature on these barriers, which has been based largely on recommendations from experts in the field. The results of this study aligned well with this literature, providing additional support for these recommendations. Valuable insights on potential m Health solutions to these homework barriers were also provided. These data are being used to inform the development of an m Health resource that aims to address homework barriers in hopes of improving provider use and patient adherence to homework during youth mental health treatment, with the ultimate goal of improving the quality of care received by patients in community mental health settings.

Supplementary Material

10608_2020_10090_moesm1_esm, acknowledgments.

Compliance with Ethical Standards

Funding. Dr. Bunnell was supported by the National Institute of Mental Health (grant numbers F32 MH108250 and K23 MH118482).

Disclosure of Potential Conflicts of Interest

Conflict of Interest. The authors declare that they have no conflict of interest.

Research Involving Human Participants and/or Animals

Statement of Human Rights.

Ethics approval. All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board at the Medical University of South Carolina (Pro00047774) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Statement on the Welfare of Animals

Ethical approval. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

• Aguilera A, & Muñoz RF. (2011). Text messaging as an adjunct to CBT in low-income populations: A usability and feasibility pilot study . Professional Psychology: Research and Practice , 42 ( 6 ), 472–478. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Amstadter AB, Broman-Fulks J, Zinzow H, Ruggiero KJ, & Cercone J. (2009). Internet-based interventions for traumatic stress-related mental health problems: A review and suggestion for future research . Clinical Psychology Review , 29 ( 5 ), 410–420. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Bakker D, Kazantzis N, Rickwood D, & Rickard N. (2016). Mental health smartphone apps: Review and evidence-based recommendations for future developments . JMIR Mental Health , 3 ( 1 ), e7. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Beck JS, & Broder FR. (2016). The new “Homework” in cognitive behavior therapy . Beck Institute for Cognitive Behavior Therapy . Retrieved November 24, 2019, from https://beckinstitute.org/the-new-homework-in-cognitive-behavior-therapy/ [ Google Scholar ]
• Berkovits MD, O’Brien KA, Carter CG, & Eyberg SM. (2010). Early identification and intervention for behavior problems in primary care: A comparison of two abbreviated versions of parent-child interaction therapy . Behavior Therapy , 41 ( 3 ), 375–387. [ PubMed ] [ Google Scholar ]
• Boschen MJ, & Casey LM. (2008). The use of mobile telephones as adjuncts to cognitive behavioral psychotherapy . Professional Psychology: Research and Practice , 39 ( 5 ), 546–552. [ Google Scholar ]
• Bru L, Solholm R, & Idsoe T. (2013). Participants’ experiences of an early cognitive behavioral intervention for adolescents with symptoms of depression . Emotional and Behavioural Difficulties , 18 ( 1 ), 24–43. [ Google Scholar ]
• Bunnell BE, Davidson TM, Winkelmann JR, Maples-Keller JL, Ridings LE, Dahne J, … Ruggiero KJ. (2019). Implementation and utility of an automated text messaging system to facilitate symptom self-monitoring and identify risk for post-traumatic stress disorder and depression in trauma center patients . Telemedicine and E-Health . [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Callan JA, Dunbar-Jacob J, Sereika SM, Stone C, Fasiczka A, Jarrett RB, & Thase ME. (2012). Barriers to cognitive behavioral therapy homework completion scaledepression version: Development and psychometric evaluation . International Journal of Cognitive Therapy , 5 ( 2 ), 219–235. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Charmaz K. (2006). Constructing grounded theory: A practical guide through qualitative analysis . New York, NY: SAGE Publications. [ PubMed ] [ Google Scholar ]
• Clarke G, Hops H, Lewinsohn PM, Andrews J, Seeley JR, & Williams J. (1992). Cognitive-behavioral group treatment of adolescent depression: Prediction of outcome . Behavior Therapy , 23 ( 3 ), 341–354. [ Google Scholar ]
• Cohen JA, Mannarino AP, & Deblinger E. (2017). Treating trauma and traumatic grief in children and adolescents , 2nd ed. New York, NY, US: Guilford Press. [ Google Scholar ]
• Coon DW, Rabinowitz YG, Thompson LW, & Gallagher-Thompson D. (2005). Older adults. In Kazantzis N, Deane F, Ronan K, & L’Abate L. (Eds.), Using Homework Assignments in Cognitive Behavior Therapy (pp. 117–152). New York, NY: Routledge. [ Google Scholar ]
• Danko CM, Brown T, Van Schoick L, & Budd KS. (2016). Predictors and correlates of homework completion and treatment outcomes in parent–child interaction therapy . Child and Youth Care Forum , 45 ( 3 ), 467–485. [ Google Scholar ]
• Dattilio FM, Kazantzis N, Shinkfield G, & Carr AG. (2011). A survey of homework use, experience of barriers to homework, and attitudes about the barriers to homework among couples and family therapists . Journal of Marital and Family Therapy , 37 ( 2 ), 121–136. [ PubMed ] [ Google Scholar ]
• Davidson TM, Bunnell BE, Saunders BE, Hanson RF, Danielson CK, Cook D, … Ruggiero KJ. (2019). Pilot evaluation of a tablet-based application to improve quality of care in child mental health treatment . Behavior Therapy , 50 ( 2 ), 367–379. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Deblinger E, Mannarino AP, Cohen JA, Runyon MK, & Steer RA. (2011). Trauma-Focused Cognitive Behavioral Therapy for children: Impact of the trauma narrative and treatment length . Depression and Anxiety , 28 ( 1 ), 67–75. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Deblinger E, Pollio E, & Dorsey S. (2016). Applying Trauma-Focused Cognitive–Behavioral Therapy in group format . Child Maltreatment , 21 ( 1 ), 59–73. [ PubMed ] [ Google Scholar ]
• Donker T, Petrie K, Proudfoot J, Clarke J, Birch M-R, & Christensen H. (2013). Smartphones for smarter delivery of mental health programs: a systematic review . Journal of Medical Internet Research , 15 ( 11 ), e247. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ehrenreich B, Righter B, Rocke DA, Dixon L, & Himelhoch S. (2011). Are mobile phones and handheld computers being used to enhance delivery of psychiatric treatment ? The Journal of Nervous and Mental Disease , 199 ( 11 ), 886–891. [ PubMed ] [ Google Scholar ]
• Friedberg RD, & Mcclure JM. (2005). Adolescents. In Kazantzis N, Deane F, Ronan K, & L’Abate L. (Eds.), Using Homework Assignments in Cognitive Behavior Therapy (pp. 95–116). New York, NY: Routledge. [ Google Scholar ]
• Garland A, & Scott J. (2002). Using homework in therapy for depression . Journal of Clinical Psychology , 58 ( 5 ), 489–498. [ PubMed ] [ Google Scholar ]
• Gaynor ST, Lawrence PS, & Nelson-Gray RO. (2006). Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: Review, preliminary findings, and implications for theory and practice . Behavior Modification , 30 ( 5 ), 647–672. [ PubMed ] [ Google Scholar ]
• Hanson RF, Gros KS, Davidson TM, Barr S, Cohen J, Deblinger E, … Ruggiero KJ. (2014). National trainers’ perspectives on challenges to implementation of an empirically-supported mental health treatment . Administration and Policy in Mental Health and Mental Health Services Research , 41 ( 4 ), 522–534. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Harrison V, Proudfoot J, Wee PP, Parker G, Pavlovic DH, & Manicavasagar V. (2011, December). Mobile mental health: Review of the emerging field and proof of concept study . Journal of Mental Health . [ PubMed ] [ Google Scholar ]
• Helbig S, & Fehm L. (2004). Problems with homework in CBT: Rare exception or rather frequent? Behavioural and Cognitive Psychotherapy , 32 ( 3 ), 291–301. [ Google Scholar ]
• Heron KE, & Smyth JM. (2010). Ecological momentary interventions: Incorporating mobile technology into psychosocial and health behaviour treatments . British Journal of Health Psychology , 15 ( 1 ), 1–39. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Hudson JL, & Kendall PC. (2002). Showing you can do it: Homework in therapy for children and adolescents with anxiety disorders . Journal of Clinical Psychology , 58 ( 5 ), 525–534. [ PubMed ] [ Google Scholar ]
• Hudson JL, & Kendall PC. (2005). Children. In Kazantzis N, Deane F, Ronan K, & L’Abate L. (Eds.), Using Homework Assignments in Cognitive Behavior Therapy (pp. 75–94). New York, NY: Routledge. [ Google Scholar ]
• Jungbluth NJ, & Shirk SR. (2013). Promoting homework adherence in cognitive-behavioral therapy for adolescent depression . Journal of Clinical Child and Adolescent Psychology , 42 ( 4 ), 545–553. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Kazantzis N, & Deane FP. (1999). Psychologists’ use of homework assignments in clinical practice . Professional Psychology: Research and Practice , 30 ( 6 ), 581–585. [ Google Scholar ]
• Kazantzis N, Deane FP, & Ronan KR. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis . Clinical Psychology: Science and Practice , 7 ( 2 ), 189–202. [ Google Scholar ]
• Kazantzis N, Deane FP, & Ronan KR. (2004). Assessing compliance with homework assingments: Review and recommendations for clinical practice . Journal of Clinical Psychology , 60 ( 6 ), 627–641. [ PubMed ] [ Google Scholar ]
• Kazantzis N, Deane FP, Ronan KR, & L’Abate L. (2005). Using Homework Assignments in Cognitive Behavior Therapy . New York, NY: Routledge. [ Google Scholar ]
• Kazantzis N, & Lampropoulos GK. (2002). Reflecting on homework in psychotherapy: What can we conclude from research and experience? Journal of Clinical Psychology , 58 ( 5 ), 577–585. [ PubMed ] [ Google Scholar ]
• Kazantzis N, Lampropoulos GK, & Deane FP. (2005). A national survey of practicing psychologists’ use and attitudes toward homework in psychotherapy . Journal of Consulting and Clinical Psychology , 73 ( 4 ), 742–748. [ PubMed ] [ Google Scholar ]
• Kazantzis N, MacEwan J, & Dattilio F. (2005). A guiding model for practice. In Kazantzis N, Deane F, Ronan K, & L’Abate L. (Eds.), Using Homework Assignments in Cognitive Behavior Therapy (pp. 359–407). New York: Routledge. [ Google Scholar ]
• Kazantzis Nikolaos, & Shinkfield G. (2007). Conceptualizing patient barriers to nonadherence with homework assignments . Cognitive and Behavioral Practice , 14 ( 3 ), 317–324. [ Google Scholar ]
• Kazantzis Nikolaos, 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. [ Google Scholar ]
• Kazantzis Nikolaos, Whittington C, Zelencich L, Kyrios M, Norton PJ, & Hofmann SG. (2016). Quantity and quality of homework compliance: A meta-analysis of relations with outcome in cognitive behavior therapy . Behavior Therapy , 47 ( 5 ), 755–772. [ PubMed ] [ Google Scholar ]
• Krebs P, & Duncan DT. (2015). Health app use among US mobile phone owners: A national survey . JMIR MHealth and UHealth , 3 ( 4 ), e101. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Kristjánsdóttir ÓB, Fors EA, Eide E, Finset A, Stensrud TL, Van Dulmen S, … Eide H. (2013). A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: Randomized controlled trial . Journal of Medical Internet Research , 15 ( 1 ), e5. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Leahy RL. (2002). Improving homework compliance in the treatment of generalized anxiety disorder . Journal of Clinical Psychology , 58 ( 5 ), 499–511. [ PubMed ] [ Google Scholar ]
• Luxton DD, McCann RA, Bush NE, Mishkind MC, & Reger GM. (2011). MHealth for mental health: Integrating smartphone technology in behavioral healthcare. Professional Psychology : Research and Practice , 42 ( 6 ), 505–512. [ Google Scholar ]
• Lyon AR, & Budd KS. (2010). A community mental health implementation of Parent–Child Interaction Therapy (PCIT) . Journal of Child and Family Studies , 19 ( 5 ), 654–668. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Mausbach BT, Moore R, Roesch S, Cardenas V, & Patterson TL. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis . Cognitive Therapy and Research , 34 ( 5 ), 429–438. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Miles MB, & Huberman AM. (1994). Qualitative data analysis: An expanded sourcebook . Thousand Oaks, CA: Sage Publications. [ Google Scholar ]
• Morse JM. (2000). Determining sample size . Qualitative Health Research , 10 ( 1 ), 3–5. [ PubMed ] [ Google Scholar ]
• Newman MG, Przeworski A, Consoli AJ, & Barr Taylor C. (2014). A randomized controlled trial of ecological momentary intervention plus brief group therapy for generalized anxiety disorder . Psychotherapy , 51 ( 2 ), 198–206. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Reger GM, Hoffman J, Riggs D, Rothbaum BO, Ruzek J, Holloway KM, & Kuhn E. (2013). The “PE coach” smartphone application: An innovative approach to improving implementation, fidelity, and homework adherence during prolonged exposure . Psychological Services , 10 ( 3 ), 342–349. [ PubMed ] [ Google Scholar ]
• Ruggiero KJ, Saunders BE, Davidson TM, Cook DL, & Hanson R. (2017). Leveraging technology to address the quality chasm in children’s evidence-based psychotherapy . Psychiatric Services , 68 , 650–652. [ PubMed ] [ Google Scholar ]
• Scheel MJ, Hanson WE, & Razzhavaikina TI. (2004). The process of recommending homework in psychotherapy: A review of therapist delivery methods, client acceptability, and factors that affect compliance . Psychotherapy , 41 ( 1 ), 38–55. [ Google Scholar ]
• Scheeringa MS, Weems CF, Cohen JA, Amaya-Jackson L, & Guthrie D. (2011). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in threethrough six year-old children: a randomized clinical trial . Journal of Child Psychology and Psychiatry , 52 ( 8 ), 853–860. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Shapiro JR, Bauer S, Andrews E, Pisetsky E, Bulik-Sullivan B, Hamer RM, & Bulik CM. (2010). Mobile therapy: Use of text-messaging in the treatment of bulimia nervosa . International Journal of Eating Disorders , 43 ( 6 ), 513–519. [ PubMed ] [ Google Scholar ]
• Silverman WK, Ortiz CD, Viswesvaran C, Burns BJ, Kolko DJ, Putnam FW, & Amaya-Jackson L. (2008). Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events . Journal of Clinical Child & Adolescent Psychology , 37 ( 1 ), 156–183. [ PubMed ] [ Google Scholar ]
• Simons AD, Marti CN, Rohde P, Lewis CC, Curry J, & March J. (2012). Does homework “matter” in cognitive behavioral therapy for adolescent depression? Journal of Cognitive Psychotherapy , 26 ( 4 ), 390–404. [ Google Scholar ]
• Sukhodolsky DG, Kassinove H, & Gorman BS. (2004). Cognitive-behavioral therapy for anger in children and adolescents: A meta-analysis . Aggression and Violent Behavior , 9 ( 3 ), 247–269. [ Google Scholar ]
• Tang W, & Kreindler D. (2017). Supporting homework compliance in cognitive behavioural therapy: essential features of mobile apps . JMIR Mental Health , 4 ( 2 ), e20. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Wethington HR, Hahn RA, Fuqua-Whitley DS, Sipe TA, Crosby AE, Johnson RL, … Task Force on Community Preventive Services. (2008). The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents . American Journal of Preventive Medicine , 35 ( 3 ), 287–313. 10.1016/j.amepre.2008.06.024 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Whiteside SPH, Ale CM, Vickers Douglas K, Tiede MS, & Dammann JE. (2014). Case examples of enhancing pediatric ocd treatment with a smartphone application . Clinical Case Studies , 13 ( 1 ), 80–94. 10.1177/1534650113504822 [ CrossRef ] [ Google Scholar ]
• Wiederhold BK, Boyd C, Sulea C, Gaggioli A, & Riva G. (2014). Marketing analysis of a positive technology app for the self-management of psychological stress . Studies in Health Technology and Informatics , 199 , 83–87. [ PubMed ] [ Google Scholar ]

Why Jax Taylor & Brittany Cartwright Put Son Cruz in Speech Therapy

Originally appeared on E! Online

Jax Taylor and Brittany Cartwright are getting their son Cruz the help he needs.

In a preview of The Valley 's April 9 episode, the Bravo stars share concerns over their 2-year-old's developing verbal skills.

"Cruz has done everything on time when it comes to crawling, walking, sitting up," Brittany explains in the clip, released Apr. 3. "He was saying 'dada, mama, doggie,' things like that. And then he just seemed to regress one day. Like, he stopped talking almost all together. Now, we're going to put him in speech therapy just to make sure that he has all the help that he needs."

While Jax notes of their son, "I think everything's great except for that. He's a smart kid," Brittany counters, "I just want to make sure that we're giving him all the right tools and everything that he needs."

Jax also shares he's been doing his homework to better understand Cruz's condition.

The Valley : Meet the Cast

"I feel like I've been researching everything," the Vanderpump Rules alum adds, "and I feel like I'm doing everything I'm supposed to be doing."

And when it comes to Cruz's well-being, Jax and Brittany, who recently shared their separation after four years of marriage, made it clear he is their top priority.

"He's No. 1 and we both agree on that," Jax told E! last month. "It's about knowing he's got two loving parents that love him to death and he's gonna have the best life possible, whether we are together or not."

As for what led to their split, Brittany revealed the toxicity and fighting between her and Jax had reached a breaking point.

"I just don't want that for our son," the Kentucky native explained. "I don't want him growing up thinking it's normal to live like that."

See Jax and Brittany's marriage troubles play out when The Valley airs Tuesdays at 9 p.m. on Bravo. And keep reading for a full timeline of their split.

(E! and Bravo are both part of the NBCUniversal family)

Unlocking Progress: Powerful Homework Assignments for Counseling Success

The power of therapeutic homework assignments.

Homework assignments play a significant role in  counseling and therapy , offering clients an opportunity to extend their progress beyond the therapy session. These assignments provide a structured and focused approach to reinforce therapeutic concepts and facilitate personal growth. In this section, we will explore the  importance  of therapeutic homework assignments and the  benefits  they bring to the counseling process.

Introduction to Therapeutic Homework Assignments

Therapeutic homework assignments refer to tasks or exercises that clients undertake between counseling sessions to enhance the effectiveness of therapy. These assignments are carefully designed to target specific therapeutic goals and address individual needs. By engaging in these tasks, clients actively participate in their own healing process, gaining a sense of empowerment and self-efficacy.

Therapeutic homework assignments can take various forms, including written exercises, reflection activities, behavioral experiments, and more. The assignments are tailored to each client’s unique circumstances, ensuring relevance and applicability to their specific challenges and goals. Moreover, they can be facilitated using various digital tools and platforms, providing a seamless experience for both client and therapist.

Benefits of Using Homework Assignments in Counseling

The use of homework assignments in counseling offers several benefits that contribute to the overall success of therapeutic interventions. Here are some key advantages:

• Continuity and Consistency:  Homework assignments create a bridge between counseling sessions, maintaining continuity in the therapeutic process. They allow clients to practice and reinforce therapeutic skills and strategies regularly, integrating them into their daily lives.
• Deepened Insight and Awareness:  Engaging in homework assignments encourages clients to reflect on their thoughts, emotions, and behaviors outside of the therapy session. This heightened self-awareness promotes a deeper understanding of patterns, triggers, and underlying issues.
• Enhanced Skill Development:  Homework assignments provide clients with the opportunity to practice new coping mechanisms, communication skills, and behavioral changes in real-life situations. This active practice helps to consolidate learning and develop new habits.
• Empowerment and Ownership:  By actively participating in their own therapeutic journey, clients develop a sense of ownership and empowerment. Homework assignments allow clients to take charge of their progress, fostering a sense of control and self-efficacy.
• Efficiency and Time Optimization:  Homework assignments optimize the use of therapy time by focusing sessions on processing and discussing the assignments rather than spending valuable session time on skill-building activities.

To effectively implement and maximize the benefits of therapeutic homework assignments, it is essential to tailor the assignments to the individual needs and goals of each client. This includes considering factors such as learning styles, preferences, and age groups. Furthermore, setting clear objectives, providing comprehensive instructions, and encouraging accountability and follow-up are key elements in ensuring the successful implementation of homework assignments.

In the following sections, we will explore different types of therapeutic homework assignments, how to tailor them to clients, and strategies for implementing and evaluating their impact. By utilizing these strategies, therapists can unlock the full potential of therapeutic homework assignments in supporting their clients’ progress and fostering lasting change.

Types of Therapeutic Homework Assignments

Therapeutic homework assignments are a powerful tool utilized in counseling to enhance the therapeutic process and promote client growth and progress. Let’s explore some common types of therapeutic homework assignments that can be effective in supporting the counseling journey.

Cognitive-Behavioral Therapy (CBT) Assignments

Cognitive-Behavioral Therapy (CBT) assignments are widely used in counseling. CBT focuses on identifying and challenging unhelpful thoughts and beliefs, and replacing them with more positive and constructive ones. Homework assignments in CBT often involve activities like thought records, where clients monitor their thoughts and emotions, and work towards reframing negative thinking patterns. These assignments help clients develop new coping strategies and promote self-awareness. For more information on CBT assignments, check out our article on  therapeutic assignments .

Mindfulness and Meditation Exercises

Mindfulness and meditation exercises are valuable tools for promoting relaxation, self-awareness, and emotional regulation. Homework assignments in this category may include guided meditation recordings, breathing exercises, or daily mindfulness practices. These assignments encourage clients to cultivate present-moment awareness, reduce stress, and develop a deeper connection to their thoughts, feelings, and sensations. Mindfulness and meditation exercises can be particularly beneficial for clients experiencing anxiety or stress-related issues.

Journaling and Writing Prompts

Journaling and writing prompts provide clients with a means to express their thoughts, emotions, and reflections in a structured way. These assignments can help clients gain insight, process their experiences, and foster self-reflection. Writing prompts may involve exploring gratitude, identifying strengths, or journaling about specific events or challenges. By engaging in regular journaling, clients can gain a deeper understanding of their emotions and thought patterns. For additional resources on therapeutic writing, visit our article on  therapy homework journal .

Art Therapy and Creative Expression

Art therapy and creative expression assignments utilize artistic mediums to encourage self-expression , exploration, and emotional healing. These assignments can involve activities like drawing, painting, or collage-making. Engaging in creative processes allows clients to tap into their subconscious and express thoughts and feelings that may be difficult to verbalize. Art therapy assignments can be particularly beneficial for clients who struggle with verbal communication or prefer non-traditional forms of expression. For more ideas on incorporating art therapy into counseling, explore our article on  therapeutic homework activities .

By incorporating these types of therapeutic homework assignments, counselors can enhance the effectiveness of their counseling sessions and promote client progress and self-discovery. It’s important to remember that each client is unique, and tailoring homework assignments to their specific needs and goals is crucial. Additionally, providing clear instructions and guidelines, as well as encouraging accountability and follow-up, can further enhance the impact of these assignments.

Tailoring Homework Assignments to Clients

To maximize the effectiveness of therapeutic homework assignments, it’s crucial to tailor them to the unique needs and preferences of each client. This personalized approach ensures that the assignments are meaningful, engaging, and aligned with the client’s therapeutic goals. Here are three key considerations when tailoring homework assignments:

Assessing Client Needs and Goals

Before assigning any homework, it’s essential to conduct a thorough assessment of the client’s needs and goals. This assessment helps to identify areas of focus and determine the most appropriate interventions. By understanding the specific challenges and desired outcomes, you can design homework assignments that directly address the client’s concerns. This personalized approach enhances the relevance and effectiveness of the assigned tasks.

Considering Learning Styles and Preferences

Each client has their own unique learning style and preferences. Some individuals may prefer visual learning, while others may be more inclined towards auditory or kinesthetic learning. By taking into account these learning styles, you can select homework assignments that resonate with the client’s preferred mode of learning. For example, visual learners may benefit from assignments that involve visualizations or drawing, while auditory learners may find audio recordings or guided meditations more effective. Adapting the assignments to match the client’s learning style enhances their engagement and comprehension.

Adapting Assignments for Different Age Groups

Clients of different age groups may require varying approaches to their homework assignments. Children and adolescents, for instance, may benefit from assignments that incorporate play, creativity, or gamification elements. On the other hand, adults may prefer assignments that involve self-reflection, goal-setting, or written exercises. It’s important to consider the developmental stage, cognitive abilities, and interests of the client when designing the assignments. Adapting the assignments to suit different age groups ensures that they are age-appropriate and promote meaningful therapeutic progress.

By considering the client’s needs, goals, learning styles, and age group, you can tailor homework assignments that are relevant, engaging, and effective. This personalized approach fosters a strong therapeutic alliance and empowers clients to actively participate in their own healing journey. Remember to regularly assess the impact of the assignments, gather client feedback, and make necessary adjustments to ensure continued progress.

Implementing Effective Homework Assignments

To maximize the benefits of  homework assignments  in counseling, it is crucial to implement them effectively. This involves setting clear and achievable objectives, providing clear instructions and guidelines, and encouraging accountability and follow-up.

Setting Clear and Achievable Objectives

When assigning homework, it is important to set clear objectives that align with the client’s therapeutic goals. Clearly define what the client is expected to accomplish through the assignment. Objectives should be specific, measurable, achievable, relevant, and time-bound (SMART). This clarity helps clients understand the purpose of the assignment and stay focused on their progress. It also allows both the therapist and client to track the effectiveness of the assignment in addressing the client’s concerns.

Providing Clear Instructions and Guidelines

Clear instructions and guidelines are essential for ensuring that clients understand how to complete their homework assignments effectively. Provide step-by-step instructions that are easy to follow. Use simple language and avoid jargon or technical terms that may confuse or overwhelm clients. Consider providing examples or visual aids to enhance comprehension. Additionally, specify any resources or materials that may be required to complete the assignment. This clarity helps clients feel confident in their ability to complete the assignment and facilitates their engagement in the therapeutic process.

Encouraging Accountability and Follow-Up

Accountability plays a vital role in the success of homework assignments. Encourage clients to take responsibility for their progress by setting expectations for completion and follow-up. Establish a system for clients to report their progress, such as regular check-ins or journal entries. This allows therapists to provide feedback, offer guidance, and address any questions or concerns that may arise. By fostering a sense of accountability, clients are more likely to engage with their homework assignments and actively participate in their therapeutic journey.

Effective implementation of homework assignments involves a collaborative approach between the therapist and the client. By setting clear objectives, providing clear instructions and guidelines, and encouraging accountability, therapists can enhance the therapeutic value of homework assignments and support clients in achieving their counseling goals. For additional resources and ideas, explore our article on  therapeutic homework ideas .

Evaluating the Impact of Homework Assignments

To ensure the effectiveness of  homework assignments  in counseling, it is crucial to evaluate their impact on clients’ progress and well-being. This evaluation process involves gathering client feedback and reflections, adjusting and modifying assignments as needed, and tracking progress and success.

Gathering Client Feedback and Reflections

Regularly seeking feedback from clients is an essential part of evaluating the impact of homework assignments. This feedback can be obtained through verbal discussions during counseling sessions or by providing clients with written evaluation forms. By asking clients about their experiences with the assignments, their level of engagement, and any challenges they may have faced, counselors can gain valuable insights into the effectiveness of the tasks.

Encouraging clients to reflect on the benefits they have derived from completing the assignments is equally important. This reflection can help clients develop self-awareness and cultivate a deeper understanding of their progress and growth throughout the counseling process. By incorporating open-ended questions or journaling prompts into the homework assignments, clients can express their thoughts and insights on their therapeutic journey.

Adjusting and Modifying Assignments as Needed

Based on the feedback received from clients, counselors may need to adjust or modify the homework assignments to better meet their specific needs. This could involve tailoring the assignments to align with clients’ goals, preferences, or learning styles. For instance, if clients express a preference for visual learning, counselors can incorporate more visual elements into the assignments, such as  therapeutic homework worksheets  or  therapeutic homework activities .

Additionally, if clients find certain assignments too challenging or not engaging enough, counselors can adapt the tasks or provide alternative options. This flexibility allows counselors to ensure that the assignments remain relevant and effective in supporting clients’ progress and therapeutic outcomes.

Tracking Progress and Success

Tracking clients’ progress and success is a vital component of evaluating the impact of homework assignments. Counselors can use various methods to monitor clients’ development, such as tracking completion rates, assessing changes in symptoms or behaviors, or comparing pre- and post-assignment outcomes.

A  therapy homework tracker  can be a valuable tool in this regard, providing a visual representation of clients’ progress over time. This can help both clients and counselors recognize patterns, identify areas of improvement, and celebrate achievements. By using a  homework management system  or  therapy homework app , counselors can easily organize and analyze data, ensuring that the evaluation process remains efficient and effective.

By continuously evaluating the impact of homework assignments through client feedback, adjustments, and progress tracking, counselors can optimize the effectiveness of their therapeutic interventions. This evaluation process not only enhances clients’ overall experience but also enables counselors to tailor their approach and ensure that the assignments align with clients’ unique needs and goals.

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