cbt homework importance

How to Design Homework in CBT That Will Engage Your Clients

Take-home assignments provide the opportunity to transfer different skills and lessons learned in the therapeutic context to situations in which problems arise.

These opportunities to translate learned principles into everyday practice are fundamental for ensuring that therapeutic interventions have their intended effects.

In this article, we’ll explore why homework is so essential to CBT interventions and show you how to design CBT homework using modern technologies that will keep your clients engaged and on track to achieving their therapeutic goals.

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

This Article Contains:

Why is homework important in cbt, how to deliver engaging cbt homework, using quenza for cbt: 3 homework examples, 3 assignment ideas & worksheets in quenza, a take-home message.

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

We can find explanations as to why CBT  homework is so crucial in both behaviorist and social learning/cognitive theories of psychology.

Behaviorist theory

Behaviorist models of psychology, such as classical and operant conditioning , would argue that CBT homework delivers therapeutic outcomes by helping clients to unlearn (or relearn) associations between stimuli and particular behavioral responses (Huppert, Roth Ledley, & Foa, 2006).

For instance, imagine a woman who reacts with severe fright upon hearing a car’s wheels skidding on the road because of her experience being in a car accident. This woman’s therapist might work with her to learn a new, more adaptive response to this stimulus, such as training her to apply new relaxation or breathing techniques in response to the sound of a skidding car.

Another example, drawn from the principles of operant conditioning theory (Staddon & Cerutti, 2003), would be a therapist’s invitation to a client to ‘test’ the utility of different behaviors as avenues for attaining reward or pleasure.

For instance, imagine a client who displays resistance to drawing on their support networks due to a false belief that they should handle everything independently. As homework, this client’s therapist might encourage them to ‘test’ what happens when they ask their partner to help them with a small task around the house.

In sum, CBT homework provides opportunities for clients to experiment with stimuli and responses and the utility of different behaviors in their everyday lives.

Social learning and cognitive theories

Scholars have also drawn on social learning and cognitive theories to understand how clients form expectations about the likely difficulty or discomfort involved in completing CBT homework assignments (Kazantzis & L’Abate, 2005).

A client’s expectations can be based on a range of factors, including past experience, modeling by others, present physiological and emotional states, and encouragement expressed by others (Bandura, 1989). This means it’s important for practitioners to design homework activities that clients perceive as having clear advantages by evidencing these benefits of CBT in advance.

For instance, imagine a client whose therapist tells them about another client’s myriad psychological improvements following their completion of a daily thought record . Identifying with this person, who is of similar age and presents similar psychological challenges, the focal client may subsequently exhibit an increased commitment to completing their own daily thought record as a consequence of vicarious modeling.

This is just one example of how social learning and cognitive theories may explain a client’s commitment to completing CBT homework.

Let’s now consider how we might apply these theoretical principles to design homework that is especially motivating for your clients.

In particular, we’ll be highlighting the advantages of using modern digital technologies to deliver engaging CBT homework.

Designing and delivering CBT homework in Quenza

Gone are the days of grainy printouts and crumpled paper tests.

Even before the global pandemic, new technologies have been making designing and assigning homework increasingly simple and intuitive.

In what follows, we will explore the applications of the blended care platform Quenza (pictured here) as a new and emerging way to engage your CBT clients.

Its users have noted the tool is a “game-changer” that allows practitioners to automate and scale their practice while encouraging full-fledged client engagement using the technologies already in their pocket.

To summarize its functions, Quenza serves as an all-in-one platform that allows psychology practitioners to design and administer a range of ‘activities’ relevant to their clients. Besides homework exercises, this can include self-paced psychoeducational work, assessments, and dynamic visual feedback in the form of charts.

Practitioners who sign onto the platform can enjoy the flexibility of either designing their own activities from scratch or drawing from an ever-growing library of preprogrammed activities commonly used by CBT practitioners worldwide.

Any activity drawn from the library is 100% customizable, allowing the practitioner to tailor it to clients’ specific needs and goals. Likewise, practitioners have complete flexibility to decide the sequencing and scheduling of activities by combining them into psychoeducational pathways that span several days, weeks, or even months.

Importantly, reviews of the platform show that users have seen a marked increase in client engagement since digitizing homework delivery using the platform. If we look to our aforementioned drivers of engagement with CBT homework, we might speculate several reasons why.

• Implicit awareness that others are completing the same or similar activities using the platform (and have benefitted from doing so) increases clients’ belief in the efficacy of homework.
• Practitioners and clients can track responses to sequences of activities and visually evidence progress and improvements using charts and reporting features.
• Using their own familiar devices to engage with homework increases clients’ self-belief that they can successfully complete assigned activities.
• Therapists can initiate message conversations with clients in the Quenza app to provide encouragement and positive reinforcement as needed.

The rest of this article will explore examples of engaging homework, assignments, and worksheets designed in Quenza that you might assign to your CBT clients.

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Let’s now look at three examples of predesigned homework activities available through Quenza’s Expansion Library.

Urge Surfing

Many of the problems CBT seeks to address involve changing associations between stimulus and response (Bouton, 1988). In this sense, stimuli in the environment can drive us to experience urges that we have learned to automatically act upon, even when doing so may be undesirable.

For example, a client may have developed the tendency to reach for a glass of wine or engage in risky behaviors, hoping to distract themselves from negative emotions following stressful events.

Using the Urge Surfing homework activity, you can help your clients unlearn this tendency to automatically act upon their urges. Instead, they will discover how to recognize their urges as mere physical sensations in their body that they can ‘ride out’ using a six-minute guided meditation, visual diagram, and reflection exercise.

Moving From Cognitive Fusion to Defusion

Central to CBT is the understanding that how we choose to think stands to improve or worsen our present emotional states. When we get entangled with our negative thoughts about a situation, they can seem like the absolute truth and make coping and problem solving more challenging.

The Moving From Cognitive Fusion to Defusion homework activity invites your client to recognize when they experience a negative thought and explore it in a sequence of steps that help them gain psychological distance from the thought.

Finding Silver Linings

Many clients commencing CBT admit feeling confused or regretful about past events or struggle with self-criticism and blame. In these situations, the focus of CBT may be to work with the client to reappraise an event and have them look at themselves through a kinder lens.

The Finding Silver Linings homework activity is designed to help your clients find the bright side of an otherwise grim situation. It does so by helping the user to step into a positive mindset and reflect on things they feel positively about in their life. Consequently, the activity can help your client build newfound optimism and resilience .

As noted, when you’re preparing homework activities in Quenza, you are not limited to those in the platform’s library.

Instead, you can design your own or adapt existing assignments or worksheets to meet your clients’ needs.

You can also be strategic in how you sequence and schedule activities when combining them into psychoeducational pathways.

Next, we’ll look at three examples of how a practitioner might design or adapt assignments and worksheets in Quenza to help keep them engaged and progressing toward their therapy goals.

In doing so, we’ll look at Quenza’s applications for treating three common foci of treatment: anxiety, depression, and obsessions/compulsions.

When clients present with symptoms of generalized anxiety, panic, or other anxiety-related disorders, a range of useful CBT homework assignments can help.

These activities can include the practice of anxiety management techniques , such as deep breathing, muscle relaxation, and mindfulness training. They can also involve regular monitoring of anxiety levels, challenging automatic thoughts about arousal and panic, and modifying beliefs about the control they have over their symptoms (Leahy, 2005).

Practitioners looking to support these clients using homework might start by sending their clients one or two audio meditations via Quenza, such as the Body Scan Meditation or S.O.B.E.R. Stress Interruption Mediation . That way, the client will have tools on hand to help manage their anxiety in stressful situations.

As a focal assignment, the practitioner might also design and assign the client daily reflection exercises to be completed each evening. These can invite the client to reflect on their anxiety levels during the day by responding to a series of rating scales and open-ended response questions. Patterns in these responses can then be graphed, reviewed, and used to facilitate discussion during the client’s next in-person session.

As with anxiety, there is a range of practical CBT homework activities that aid in treating depression.

It should be noted that it is common for clients experiencing symptoms of depression to report concentration and memory deficits as reasons for not completing homework assignments (Garland & Scott, 2005). It is, therefore, essential to keep this in mind when designing engaging assignments.

CBT assignments targeted at the treatment of depressive symptoms typically center around breaking cycles of negative events, thinking, emotions, and behaviors, such as through the practice of reappraisal (Garland & Scott, 2005).

Examples of assignments that facilitate this may include thought diaries , reflections that prompt cognitive reappraisal, and meditations to create distance between the individual and their negative thoughts and emotions.

To this end, a practitioner looking to support their client might design a sequence of activities that invite clients to explore their negative cognitions once per day. This exploration can center on responses to negative feedback, faced challenges, or general low mood.

A good template to base this on is the Personal Coping Mantra worksheet in Quenza’s Expansion Library, which guides clients through the process of replacing automatic negative thoughts with more adaptive coping thoughts.

The practitioner can also schedule automatic push notification reminders to pop up on the client’s device if an activity in the sequence is not completed by a particular time each day. This function of Quenza may be particularly useful for supporting clients with concentration and memory deficits, helping keep them engaged with CBT homework.

Obsessions/compulsions

Homework assignments pertaining to the treatment of obsessive-compulsive disorder typically differ depending on the stage of the therapy.

In the early stages of therapy, practitioners assigning homework will often invite clients to self-monitor their experience of compulsions, rituals, or responses (Franklin, Huppert, & Roth Ledley, 2005).

This serves two purposes. First, the information gathered through self-monitoring, such as by completing a journal entry each time compulsive thoughts arise, will help the practitioner get clearer about the nature of the client’s problem.

Second, self-monitoring allows clients to become more aware of the thoughts that drive their ritualized responses, which is important if rituals have become mostly automatic for the client (Franklin et al., 2005).

Therefore, as a focal assignment, the practitioner might assign a digital worksheet via Quenza that helps the client explore phenomena throughout their day that prompt ritualized responses. The client might then rate the intensity of their arousal in these different situations on a series of Likert scales and enter the specific thoughts that arise following exposure to their fear.

The therapist can then invite the client to complete this worksheet each day for one week by assigning it as part of a pathway of activities. A good starting point for users of Quenza may be to adapt the platform’s pre-designed Stress Diary for this purpose.

At the end of the week, the therapist and client can then reflect on the client’s responses together and begin constructing an exposure hierarchy.

This leads us to the second type of assignment, which involves exposure and response prevention. In this phase, the client will begin exploring strategies to reduce the frequency with which they practice ritualized responses (Franklin et al., 2005).

To this end, practitioners may collaboratively set a goal with their client to take a ‘first step’ toward unlearning the ritualized response. This can then be built into a customized activity in Quenza that invites the client to complete a reflection.

For instance, a client who compulsively hoards may be invited to clear one box of old belongings from their bedroom and resist the temptation to engage in ritualized responses while doing so.

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Developing and administering engaging CBT homework that caters to your client’s specific needs or concerns is becoming so much easier with online apps.

Further, best practice is becoming more accessible to more practitioners thanks to the emergence of new digital technologies.

We hope this article has inspired you to consider how you might leverage the digital tools at your disposal to create better homework that your clients want to engage with.

Likewise, let us know if you’ve found success using any of the activities we’ve explored with your own clients – we’d love to hear from you.

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

• Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist , 44 (9), 1175–1184.
• Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., & Wong, E. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed.) (pp. 227–306). Wiley.
• Bouton, M. E. (1988). Context and ambiguity in the extinction of emotional learning: Implications for exposure therapy. Behaviour Research and Therapy , 26 (2), 137–149.
• Franklin, M. E., Huppert, J. D., & Roth Ledley, D. (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.
• Garland, A., & Scott, J. (2005). Depression. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 237–261). Routledge.
• Huppert, J. D., Roth Ledley, D., & Foa, E. B. (2006). The use of homework in behavior therapy for anxiety disorders. Journal of Psychotherapy Integration , 16 (2), 128–139.
• Kazantzis, N. (2005). Introduction and overview. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 1–6). Routledge.
• 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., & 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. 9–34). Routledge.
• Leahy, R. L. (2005). Panic, agoraphobia, and generalized anxiety. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 193–218). Routledge.
• Staddon, J. E., & Cerutti, D. T. (2003). Operant conditioning. Annual Review of Psychology , 54 (1), 115–144.

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Assigning Homework in Cognitive Behavioral Therapy

It’s certainly true that therapy outcomes depend in part on the work taking place in each session. But for this progress to reach its full impact, clients need to use what they learn in therapy during their daily lives. 

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

Types of Homework

Some clients may respond well to any type of homework, while others may struggle to complete or find benefit in certain assignments. It’s important for clients to step outside of their comfort zone in some ways. For example, it’s essential to learn to challenge unwanted thoughts and increase understanding of feelings and emotions, especially for people who struggle with emotional expression. 

But there isn’t just one way to achieve these goals. Finding the right type of homework for each client can make success more likely. 

There are many different types of therapy homework. Asking your client to practice breathing exercises when they feel anxious or stressed? That’s homework. Journaling about distressing thoughts and ways to challenge them, or keeping track of cognitive distortions ? Also homework.

Some clients may do well with different assignments each week, while others may have harder times with certain types of homework. For example:

• An artistic client may not get much from written exercises. They might, however, prefer to sketch or otherwise illustrate their mood, feelings, or reactions during the week. 
• Clients who struggle with or dislike reading may feel challenged by even plain-language articles. If you plan to assign educational materials, ask in your first session whether your client prefers audio or written media. 

When you give the assignment, take a few minutes to go over it with your client. Give an example of how to complete it and make sure they understand the process. You’ll also want to explain the purpose of the assignment. Someone who doesn’t see the point of a task may be less likely to put real effort into it. If you give a self-assessment worksheet early in the therapy process, you might say, “It can help to have a clear picture of where you believe you’re at right now. Later in therapy I’ll ask you to complete another assessment and we can compare the two to review what’s changed.” 

Mental Health Apps

Some people may also find apps a useful way to develop and practice emotional wellness coping skills outside of therapy. Therapy apps can help people track their moods, emotions, or other mental health symptoms. They can provide a platform to practice CBT or other therapy skills. They can also offer structured mindfulness meditations or help clients practice other grounding techniques. 

If you’re working with a client who’s interested in therapy apps, you might try using them in treatment. Just keep in mind that not all apps offer the same benefits. Some may have limitations, such as clunky or confusing interfaces and potential privacy concerns. It’s usually a good idea to check whether there’s any research providing support for—or against—a specific app before recommending it to a client. 

Trusted mental health sources, such as the American Psychological Association or Anxiety and Depression Association of America websites, may list some popular mental health apps, though they may not specifically endorse them. These resources can be a good starting place. Other organizations, including Northwestern University’s Center for Behavioral Intervention Technologies and the Defense Department of the United States, have developed their own research-backed mental health apps. 

You can also review apps yourself. Try out scenarios or options within the app to get to know how the app works and whether it might meet your client’s needs. This will put you in a position to answer their questions and help give them tips on getting the most out of the app. 

Benefits of Homework

Some of your clients may wonder why you’re assigning homework. After all, they signed up for therapy, not school. 

When clients ask about the benefits of therapy homework, you can point out how it provides an opportunity to put things learned in session into practice outside the therapy session. This helps people get used to using the new skills in their toolbox to work through issues that come up for them in their daily lives. More importantly, it teaches them they can use these skills on their own, when a therapist or other support person isn’t actively providing coaching or encouragement. This knowledge is an important aspect of therapy success. 

A 2010 review of 23 studies on homework in therapy found evidence to suggest that clients who completed therapy homework generally had better treatment outcomes. This review did have some limitations, such as not considering the therapeutic relationship or how clients felt about homework. But other research supports these findings, leading many mental health experts to support the use of therapy homework, particularly in CBT. Homework can be one of many effective tools in making therapy more successful. 

Improving Homework Compliance

You may eventually work with a client who shows little interest in homework and doesn’t complete the assignments. You know this could impede their progress in therapy, so you’ll probably want to bring this up in session and ask why they’re having difficulty with the homework. You can also try varying the types of homework you assign or asking if your client is interested in trying out a mental health app that can offer similar benefits outside your weekly sessions. 

When you ask a client about homework non-compliance, it’s important to do it in a way that doesn’t anger them, make them feel defensive, or otherwise damage the relationship you’re working to develop. Here are some tips for having this conversation:

• Let them know homework helps them practice their skills outside of therapy. In short, it’s helping them get more out of therapy (more value for their money) and may lead to more improvement, sometimes in a shorter period of time than one weekly session would alone. 
• Bring up the possibility of other types of homework. “If you don’t want to write anything down, would you want to try listening to a guided meditation or tips to help manage upsetting emotions?” 
• Ask about it, in a non-confrontational way. You might say something like, “Is something making it difficult for you to complete the homework assignments? How can I help make the process easier for you?” 

The prospect of homework in therapy may surprise some clients, but for many people, it’s an essential element of success. Those put off by the term “homework” may view “skills practice” or similar phrasing more favorably, so don’t feel afraid to call it something else. The important part is the work itself, not what you call it.    References:

• Ackerman, C. (2017, March 20). 25 CBT techniques and worksheets for cognitive behavioral therapy. Retrieved from https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets
• ADAA reviewed mental health apps. (n.d.). Anxiety and Depression Association of America. Retrieved from https://adaa.org/finding-help/mobile-apps
• Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research, 34 (5), 429-438. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939342
• Mental health apps. (n.d.). The American Institute of Stress. Retrieved from https://www.stress.org/mental-health-apps
• Novotney, A. (2016). Should you use an app to help that client? Monitor on Psychology, 47 (10), 64. Retrieved from https://www.apa.org/monitor/2016/11/client-app
• Tang, W, & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health, 4(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481663

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

1 Discipline of Psychiatry, Department of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada

David Kreindler

2 Division of Youth Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

3 Centre for Mobile Computing in Mental Health, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

4 Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Cognitive behavioral therapy (CBT) is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Homework is an integral component of CBT, but homework compliance in CBT remains problematic in real-life practice. The popularization of the mobile phone with app capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance; however, there are no guidelines for designing mobile phone apps created for this purpose. Existing literature suggests 6 essential features of an optimal mobile app for maximizing CBT homework compliance: (1) therapy congruency, (2) fostering learning, (3) guiding therapy, (4) connection building, (5) emphasis on completion, and (6) population specificity. We expect that a well-designed mobile app incorporating these features should result in improved homework compliance and better outcomes for its users.

Homework Non-Compliance in CBT

Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [ 1 , 2 ]. It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [ 3 - 6 ]. Homework is an important component of CBT; in the context of CBT, homework can be defined as “specific, structured, therapeutic activities that are routinely discussed in session, to be completed between sessions” [ 7 ]. Completion of homework assignments was emphasized in the conception of CBT by its creator, Aaron Beck [ 8 ]. Many types of homework are prescribed by CBT practitioners, including symptom logs, self-reflective journals, and specific structured activities like exposure and response prevention for obsessions and compulsions. These can be divided into the following 3 main categories: (1) psychoeducational homework, (2) self-assessment homework, and (3) modality-specific homework. Psychoeducation is an important component in the early stage of therapy. Reading materials are usually provided to educate the client on the symptomatology of the diagnosed illness, its etiology, as well as other treatment-relevant information. Self-assessment strategies, including monitoring one’s mood using thought records, teach the patients to recognize the interconnection between one’s feelings, thoughts, and behaviors [ 8 ]. For example, depressed patients may be asked to identify thinking errors in daily life and document the negative influences these maladaptive thinking patterns can produce on their behaviors. Various psychiatric disorders may require different types of modality-specific homework. For example, exposure to images of spiders is a treatment method specific to arachnophobia, an example of a “specific phobia” in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [ 9 ]. Homework is strategically created by the therapist to correct and lessen the patient’s psychopathology. The purpose of these exercises is to allow the patients to practice and reinforce the skills learned in therapy sessions in real life.

Homework non-compliance is one of the top cited reasons for therapy failure in CBT [ 10 ] and has remained a persistent problem in the clinical practice. Surveys of practitioners have suggested rates of non-adherence in adult clients of approximately 20% to 50% [ 10 , 11 ] while adherence rates in adolescents have been reported to be approximately 50% [ 12 ]. Many barriers to homework compliance have been identified in the literature; to facilitate discussions, they can be divided into internal and external factors. Internal factors originate from a client’s own psychological environment while external ones are created by external influences. Internal factors that have been identified include lack of motivation to change the situation when experiencing negative feelings, the inability to identify automatic thoughts, disregard for the importance or relevance of the homework, and the need to see immediate results [ 12 - 14 ]. Various external factors have also been identified, including the effort associated with pen-and-paper homework formats, the inconvenience of completing homework because of the amount of time consumed, not understanding of the purpose of the homework, lack of instruction, and failure to anticipate potential difficulties in completing the homework [ 14 - 16 ]. There is strong evidence suggesting that homework compliance is integral to the efficacy of CBT in a variety of psychiatric illnesses. In the treatment of depression with CBT, homework compliance has been correlated with significant clinical improvement and shown to predict decreases in both subjective and objective measures of depressive symptoms [ 17 - 23 ]. Similarly, homework compliance is correlated with short-term and long-term improvement of symptoms in anxiety disorders, including generalized anxiety disorder (GAD), social anxiety disorder (SAD), hoarding, panic disorder, and post-traumatic stress disorder (PTSD) [ 17 , 24 - 32 ]. Fewer studies have been done on homework compliance in other psychiatric conditions, but better homework compliance has been correlated with significant reductions in pathological behaviors in psychotic disorders [ 33 , 34 ], cocaine dependence [ 35 , 36 ], and smoking [ 37 ]. Two meta-analyses further support the notion that greater homework adherence is associated with better treatment outcomes in depression, anxiety-related disorders, and substance use [ 38 , 39 ].

The Utility of Technology in Enhancing CBT Homework

Despite its demonstrated efficacy, access to CBT (as well as other forms of psychotherapy) remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. With the rise of mass-market mobile communication devices such as the iPhone or other kinds of mobile devices with app capabilities (smartphones), new solutions are being sought that will use these devices to provide therapy to patients in a more cost-effective manner. Mobile phones with app capabilities are portable devices that combine features of a cellphone and a hand-held computer with the ability to wirelessly access the Internet. Over time, ownership of mobile phones in North America has grown [ 41 , 42 ] and progressively lower prices have further reduced barriers to their use and ownership [ 43 , 44 ]. As more and more people acquire mobile phones, the acceptance of and the demand for mobile health solutions have been on the rise [ 45 ]. Boschen (2008), in a review predating the popularization of the modern mobile phone, identified the unique features of the mobile telephone that made it a potentially suitable vehicle for adjunctive therapeutic applications: portability, acceptability, low initial cost, low maintenance cost, social penetration and ubiquity, “always on,” “always connected,” programmability, audio and video output, keypad and audio input, user-friendliness, and ease of use [ 46 ]. Over the last decade, modern mobile phones have supplanted the previous generation of mobile telephones; progressive increases in their computing power, ongoing advances in the software that they run and interact with (eg, JAVA, HTML5, etc.), common feature sets across different operating systems such as Google Inc.'s Android or Apple Inc.'s iOS, and adoption of common hardware elements across manufacturers (eg, touch screens, high-resolution cameras, etc) have enabled the development of platform-independent apps for mobile phones, or at least apps on different platforms with comparable functionality (eg, apps written for Apple's HealthKit or the apps written for Microsoft's HealthVault).

The popularization of the smartphone presents a unique opportunity to enhance CBT homework compliance using adjunctive therapeutic applications such that well-designed mobile software may be able to diminish barriers to CBT [ 40 ] by making CBT therapists' work more cost-effective. However, there are no guidelines and no existing research that directly address the design of mobile phone apps for this purpose. Given this gap in the literature, we searched MEDLINE (1946 to April 2015) and PsycINFO (1806 to April 2015) for all articles related to “cognitive behavioral therapy”, “homework”, “mobile applications” and “treatment compliance or adherence”, and reviewed articles related to (1) mobile technologies that address homework completion, (2) essential features of therapy, or (3) barriers to homework completion in CBT. In this article, we propose a collection of essential features for mobile phone-based apps that will optimally support homework compliance in CBT.

A Proposed List of Essential Features for Mobile Apps That Optimally Support CBT Homework Compliance

In order to be effective for patients and acceptable to therapists, an optimal mobile phone app to support CBT homework compliance should conform to the CBT model of homework while addressing barriers to homework compliance. Tompkins (2002) provides a comprehensive guideline on the appropriate ways to provide CBT homework such that homework should be meaningful, relevant to the central goals of therapy, salient to focus of the session, agreeable to both therapist and client, appropriate to sociocultural context, practiced in session to improve skill, doable, begin small, have a clear rationale, include written instructions, and include a backup plan with homework obstacles [ 47 ]. In addition, the therapist providing the homework needs to be curious, collaborative, reinforce all pro-homework behavior and successful homework completion, and emphasize completion over outcome [ 47 ]. By combining Tompkins' guidelines with the need to reduce barriers to homework compliance (as described above), we obtained the following list of 6 essential features that should be incorporated into mobile apps to maximize homework compliance: (1) congruency to therapy, (2) fostering learning, (3) guiding therapy, (4) building connections, (5) emphasizing completion, and (6) population specificity.

Congruency to Therapy

Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered. There are different types of homework in CBT, including (1) psychoeducational homework; (2) self-assessment homework; and (3) modality-specific homework. Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target [ 48 ]. An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy. Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD. Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities.

Psychoeducational Homework

While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy. As psychoeducation is seen as a major component of mobile intervention [ 50 ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ 51 ], anxiety and depression [ 52 ], eating disorders [ 53 ], PTSD [ 54 ], and obsessive compulsive disorder (OCD) [ 55 ]. For example, Mayo Clinic Anxiety Coach is a mobile phone app “designed to deliver CBT for anxiety disorders, including OCD” [ 55 ]. The app contains a psychoeducational module that teaches the user on “the use of the application, the cognitive-behavioral conceptualization of anxiety, descriptions of each anxiety disorder, explanations of CBT, and guidance for assessing other forms of treatment” [ 55 ]. The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches. However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ 50 ].

Self-Assessment Homework

In contrast to conventional, paper-based homework, mobile apps can support in-the-moment self-assessments by prompting the user to record self-report data about the user’s current state [ 56 ]. While information collected retrospectively using paper records can be adversely affected by recall biases [ 57 ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ 58 ]. Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ 59 , 60 ], eating disorders [ 61 ], GAD [ 62 ], and OCD [ 55 ]. Continuing with the previous example, the Mayo Clinic Anxiety Coach offers a self-assessment module that “measures the frequency of anxiety symptoms” with a self-report Likert-type scale [ 55 ]. The app tracks users’ progress over time based on the self-assessment data; users reported liking the record of daily symptom severity scores that the application provides.

Modality-Specific Homework

Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages (short message service, SMS) to therapists in bulimia nervosa [ 61 ]. Mayo Clinic Anxiety Coach, for example, has a treatment module for OCD that “guides patients through the use of exposure therapy” [ 55 ]; patients can use this to build their own fear hierarchies according to their unique diagnoses. Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs. Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ 64 - 66 ]. Apps that provide elements of biofeedback (such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera), have recently begun to be deployed. So-called ”serious games,“ (ie, games developed for treatment purposes), are also showing promise in symptom improvement in certain cases [ 51 , 67 , 68 ].

Fostering Learning

Doing CBT homework properly requires time and effort. As noted above, any sense of inconvenience while doing the homework may hamper a patient’s motivation to complete the homework. While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [ 49 , 52 ]. Therefore, it makes sense that the tasks should be simple, short in duration to begin with, and include detailed instructions [ 47 ], since homework completion rates have been shown to be correlated with patients’ knowing exactly what to do [ 33 , 69 ]. Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ 59 ]. However, the types of homework delivered by these apps are fixed. An app that adapts the contents to the user’s progress in learning homework tasks would be more engaging and effective since therapy should be a flexible process by nature. Ideally, the app would monitor and analyze the user’s progress and adjust the homework's content and difficulty level accordingly. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ 62 ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety. Based on patients’ ratings, the app would respond with encouraging comments and invite patients to practice relaxation techniques or prompt the patient to complete specific built-in cognitive therapy modules if their anxiety exceeded a threshold rating. Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone.

Guiding Therapy

Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan [ 47 ]. Failure to do this has been identified as a barrier to homework compliance. Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ 47 ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ 47 , 70 ]; this can be done during or in between homework assignments, either in-person or remotely (ie, via voice or text messaging) [ 60 , 71 ].

Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD [ 72 ], OCD [ 55 ], chronic pain [ 59 , 60 ], depression and suicide ideation [ 71 ], and situational stress [ 73 ]. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 74 , 75 ]. However, despite incorporating a variety of features including self-monitoring, psychoeducation, scheduled reminders, and graphical feedback [ 52 ], automated apps with minimal therapist guidance have demonstrated elevated homework non-completion rates of up to 40%, which is less than ideal.

Building Connections

The effects of technology should not interfere with but rather encourage a patient’s ability to build meaningful connections with others [ 76 ]. The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].

An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically. Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Furthermore, professional moderation of online communities increases users’ trust of the service [ 84 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.

Emphasizing Completion

A patient’s need to see immediate symptomatic improvement is an impediment to homework compliance since the perception of slow progress can be discouraging to the user [ 35 ]. To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework. In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].

Population Specificity

Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels (including learning or cognitive disabilities). One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ]. In this game, breathing activity is associated with the concept of “Qi” (natural energy) in accordance with Chinese traditions; the name of the game itself references to a famous Chinese novel and the gaming environment features inkwash and watercolor schemes of the East Asian style, making the experience feel more “natural” as reported by the users. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders. In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated.

Other Considerations

There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ]. The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ]. Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ]. Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server.

Finally, while this paper focused on “essential” features of apps, this should not be misunderstood as an attempt to itemize all elements necessary for designing a successful piece of software. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ 100 ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. A variety of barriers exist in traditional, paper-based CBT homework that can significantly hamper clients’ motivation to complete homework as directed. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers. Apps should help the therapist guide the client through therapy and not hinder the therapeutic process or interfere with patient’s building connections with others. It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users.

As an example of how this applies in practice, “Mental Health Telemetry-Anxiety Disorders” (MHT-ANX) is a new mobile app developed by the Centre for Mobile Computing in Mental Health at Sunnybrook Health Sciences Centre in Toronto that helps patients monitor their anxiety symptoms using longitudinal self-report. The symptom log is therapy congruent to the practice of CBT since it promotes patients' awareness of their anxiety symptoms and the symptoms’ intensity. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance. The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use. While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance.

Limitations and Future Challenges

The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence [ 101 ] or emotional sensing [ 102 ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.

This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done. We would anticipate synergistic effects when homework-compliance apps are used in CBT (eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work), but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.

Abbreviations

Conflicts of Interest: None declared.

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Introduction to the Special Issue on Homework in Cognitive Behavioral Therapy: New Clinical Psychological Science

• Published: 18 February 2021
• Volume 45 , pages 205–208, ( 2021 )

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• Nikolaos Kazantzis   ORCID: orcid.org/0000-0001-9559-4160 1  

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This article introduces the Special Issue in Cognitive Therapy and Research that presents advances in clinical psychological science for homework in behavior and cognitive behavioral therapies (CBTs). Studies include sophisticated evaluations of homework adherence, moving beyond simplistic assessments of quantity and quality of completion to more complete assessments of engagement (i.e., perceived difficulty, obstacles, and helpfulness). Studies advance the clinical psychological science by examining therapist behavior as a predictor of homework adherence, by testing homework as a vehicle for specific treatment processes in behavior therapy (e.g., context engagement via exposure), and also by quantifying relational patterns within longitudinal data from mindfulness-based cognitive therapy. The Special Issue also includes two studies on mobile health delivery of CBT interventions and point to advances in gathering objective data on client engagement with homework.

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Homework has been incorporated in behavior and cognitive behavioral therapies (CBT) as a primary means of facilitating generalization and maintenance of skills (Beck et al. 1979 ; Beck 2011 ; Kazantzis et al. 2005 ). Given that homework, in essence, is the extension of the in-session work to the client’s daily life through continuation of the technique from the session or some modification thereof, homework directly supports treatment processes in CBTs (Hofmann and Hayes 2018 ; Klepac et al. 2012 ; Mennin et al. 2013 ). However, more fundamental questions have been posed by researchers seeking to advance the science for this aspect of CBT process.

Acknowledging the limitations of low statistical power (see quantitative review in Kazantzis 2000 ), the typical study on homework has either sought to (a) examine causal effects using experimental methodology, by contrasting CBT with and without homework, or (b) examine correlations involving the quantity of homework completed. When aggregated by multiple research groups, across disorders, across clinical populations and types of homework, these studies provide robust evidence for both causal (Kazantzis et al. 2000 ) and correlational effects (Kazantzis et al. 2016 ; Mausbach et al. 2010 ). The effect of adding homework to therapy is medium and significant ( d  = 0.53; 95% CI 0.35–0.72, p  < 0.0001 in Kazantzis et al. 2010 ) and the linear association between homework compliance and outcome is small and significant ( r  = 0.26; 95% CI 0.19−0.33 in Mausbach et al.). More recently, a focus has been placed on the assessment of quality of homework completed, in relation to outcome (Kazantzis et al. 2016 ). The articles in this Special Issue manage to achieve the impressive task of extending beyond these fundamental questions and draw upon advancements in clinical methods and technological advancements in psychotherapy delivery to examine more complex questions.

The effective facilitation of client engagement in homework is not straightforward; it is a process of CBT nested within a broader therapeutic relationship and demands a variety of therapist behaviors in order to skillfully design, plan, and then review homework. Further complexity can be acknowledged when we consider that the therapist is engaged in a moment-to-moment case conceptualization; drawing links between what the client is currently saying and what they have said in the past, taking into account the client’s current CBT skills (e.g., access to cognitions and personal responsibility for change), their unique beliefs and etiological factors that explain psychopathology (e.g., core beliefs, assumptions, rules, schema, behavioral and relational patterns), while fluidly adjusting generic (e.g., working alliance) and CBT specific elements (i.e., collaboration, empiricism, Socratic dialogue) of the therapeutic relationship based on that evolving conceptualization (Kazantzis et al. 2017 ; Lorenzo-Luaces et al. 2015 ). This process has the potential to activate the client’s negative core beliefs, and lead to a rupture in the working alliance (Okamoto and Kazantzis, in press). Despite the substantial role of the therapist, only a few studies have sought to consider the behavior the therapist as a predictor of engagement.

Studying Therapist Skill as a Predictor

Startup and Edmonds ( 1994 ) conducted an early study examining the behaviors of the therapist (i.e., occurrence of behavior) as a predictor of homework adherence, but were unable to demonstrate a clear link, possibly due to the measures available to identify presence and degree of therapist skill. In a subsequent study by Bryant et al. ( 1999 ), data gathered by trained independent observers using a modification of the Cognitive Therapy Rating Scale (Young and Beck 1980 ) showed an association between therapist skill in reviewing homework and adherence in CBT for depression, findings that were replicated in the context of anxiety (Weck et al. 2013 ). Therapist skill in assigning homework has also been associated with homework adherence in multiple studies (Conklin et al. 2017 ; Jungbluth and Shirk 2013 ; Ryum et al. 2010 ).

The articles in this Special Issue of Cognitive Therapy and Research reflect the latest scientific work on the role of therapist skill as a predictor of homework adherence. The paper by Yew et al. ( 2021 ) considered whether client appraisals of homework, and a broader concept of adherence, engagement (i.e., taking into account client perceptions of the difficulty and obstacles in attempting the homework) served as mediators of relations involving therapist skill/ competence. The paper by Haller and Watzke ( 2021 ) examined associations involving the frequency of therapist behaviors associated with homework adherence and depressive symptoms in telephone delivered CBT.

New Data on Homework-Outcome Relations

The paper by Wheaton and Chen ( 2021 ) focuses on the role of homework as a vehicle for exposure in treating obsessive compulsive disorder. Their paper provides a useful account of how homework facilitates a treatment process of context engagement and offers some useful recommendations for future research on the basis of their findings.

The paper by ter Avest et al. ( 2021 ) examines homework in the context of mindfulness-based cognitive therapy and makes a novel contribution by examining client symptom profile in relation to homework adherence at follow-up assessment points.

Employing Advances in Technology to Advance Clinical Psychological Science for Homework

Early efforts to obtain objective data on client homework adherence were unsuccessful and hampered by the technology available at the time. For example, Hoelscher et al. ( 1984 ) attempted to obtain objective data on clients’ level of relaxation practice by including a timer in an audio cassette player, and because the device was an obviously modified piece of equipment participants were suspicious and this resulted in unreliability of resultant adherence data. Other studies have experienced similar technological challenges, such as in Neimeyer et al. ( 2008 ) where lightly glued pages of a book were used as the measure of adherence (i.e., once opened).

In 2021, technology provides an ethical and far less invasive means of attempting to obtain objective assessments of homework adherence (Aizenstros et al. in press). The paper by Kraepelien et al. ( 2021 ) provides an example of how homework adherence assessment can be enhanced, both in terms of the frequency and focus of assessment. Their study employed weekly adherence assessments and sought to examine client ratings of the helpfulness of the homework.

Two studies examined mobile health delivery of CBT. The paper by Bunnell et al. ( 2021 ) involved interviews with clients and trainers to examine barriers to the successful implementation of homework in youth mental health treatment as well as the potential for mobile solutions to overcome those barriers. The paper by Callan et al. ( 2021 ) outlines an initial development and testing of a mobile mental health smartphone application delivering CBT interventions for depression, a central relationship studied was the extent of app use and symptom reduction.

Finally, an in-depth discussion of the Special Issue’s contributions is provided by Dobson ( 2021 ). Findings from the papers presented from the issue along with opportunities for future research are tied together in this final compelling piece.

Concluding Comments

Homework has been extensively studied in the context of behavior and cognitive-behavior therapies over the past several decades. Theoretical and methodological advances in psychotherapy have occurred during this period and clarity regarding cognitive and behavioral determinants of homework adherence have emerged. As illustrated by papers in this Special Issue, opportunities exist to refine the assessment of homework adherence to include client appraisals in a more complete assessment of the concept of engagement in CBT.

The role of therapist skill, and the broader therapist–client interaction also provides a rich territory for future scientific enquiry. New data have come to light; studies in this Special Issue have examined specific portions of therapist skill in reviewing and assigning homework, and further work is needed to examine the complex interplay between specific skills in using homework, case conceptualization (given that task beliefs serve as determinants of engagement), and more global skills in facilitating a therapeutic relationship in behavior and CBTs. Although a comprehensive model of how therapist behavior, nested within a broader therapeutic relationship, is yet to be published and tested at the time of this writing, the papers in this Special Issue provide encouragement about the current advances in clinical psychological science.

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Kazantzis, N. Introduction to the Special Issue on Homework in Cognitive Behavioral Therapy: New Clinical Psychological Science. Cogn Ther Res 45 , 205–208 (2021). https://doi.org/10.1007/s10608-021-10213-9

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Accepted : 30 January 2021

Published : 18 February 2021

Issue Date : April 2021

DOI : https://doi.org/10.1007/s10608-021-10213-9

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