cbt homework assignments

• Last edited on September 9, 2020

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.”

The Counseling Palette

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• Sep 15, 2021
• 10 min read

10 Top CBT Worksheets for Learning Cognitive Behavioral Therapy

Updated: Sep 28, 2023

These worksheets cover the most important skills from cognitive behavioral therapy (CBT)

The magic of CBT worksheets is that they take vague concepts and make them real.

Ironically, you need to do more than think about CBT -- your skills must be put into practice!

CBT worksheets help teach and reinforce skills learned in therapy. They are often used by therapists specialized in cognitive behavioral therapy and related treatments.

Below are the 10 top CBT worksheets focused on dealing with anxiety, restructuring thoughts, and addressing trauma and fears.

They can help treat issues like anxiety, post-traumatic stress disorder (PTSD), phobias, depression, and more.

Need resources right away? Skip ahead to here take a look at the CBT for anxiety and PTSD bundle.

Article Contents:

1. cbt triangle worksheet.

2. Challenging Thoughts Worksheets

3. Anxiety Management Worksheet

4. Strong Emotions Worksheet

5. Trauma-Focused CBT Worksheet

6. Exposure Hierarchy

7. Trauma Narrative

9 . Emotions Wheel Worksheet

10. Mindfulness Worksheet

CBT worksheets and tools are typically very structured, and follow the cognitive behavioral therapy approach. The basic idea of CBT, or cognitive behavioral therapy , is that patterns of thinking impact everything else. How we think about things can make life better or worse, regardless of the circumstances.

Our thoughts influence our feelings, which lead to our behaviors. The printable worksheets below start with the basic approach and expand into specialized areas, such as using CBT to treat PTSD.

Here are 10 top CBT worksheets focused on thoughts, feelings, and behaviors.

The CBT triangle is a commonly used tool to describe the basic principles of this therapy. This worksheet walks you step by step through the most basic process of CBT. It includes examples as well as space to write your own thoughts and begin to challenge them.

The cognitive (CBT) triangle came out of the early work of Aaron Beck, who developed CBT. He noticed that many people in therapy continued to suffer from mental health conditions such as depression, even as therapy progressed.

He termed the phrase “automatic thoughts,” to describe the thinking pattern many people experience. Most significantly, Dr. Beck found that how people thought about a situation resulted in how they experienced it, regardless of the situation itself.

Most significantly, Dr. Beck found that how people thought about a situation resulted in how they experienced it, regardless of the situation itself.

For example, someone may be running late for work. If they begin to think about getting fired and all of the things that would result from that, they might feel panicked or frustrated, and start driving erratically.

Alternatively, the same person may think differently, coaching themselves in a positive way. They may think, “I rarely run late, and my boss is very understanding, so it will be okay.”

With this change in thinking, they are likely to think more clearly and avoid feeling anxious. They may then calmly text their boss and drive carefully but efficiently toward work.

This process demonstrates the event (running late), the thought (catastrophizing versus positive self-talk) and the behavior (erratic driving versus planning).

Shop CBT triangle worksheet.

2. Challenging Thoughts Worksheet

The challenging thoughts worksheet is a cognitive restructuring worksheet. It walks you through challenging everyday negative thoughts, at a bit of a deeper level than the CBT triangle. It can also be an alternative format to learning the triangle.

Negative thoughts are sometimes called core beliefs, Negative core beliefs are thoughts that tend to pervade our everyday lives. They’re the “issues,” or “triggers,” you just can’t seem to get over. While most negative core beliefs are also distorted beliefs, the reverse isn’t necessarily true.

Negative core beliefs tend to involve shame, and how the person feels about themselves as a whole. This often relates to their abilities and worthiness.

For example, a basic distorted belief might be, “I’ll never pass my algebra class,” while a negative core belief might state, “I’m too stupid to succeed at anything.”

Once you understand the basics of CBT, the next step is to begin to challenge specific thoughts that happen regularly. For example, someone may think, “I mess everything up,” or “I can’t keep any friends.” These thoughts become a habit, and are likely to affect self-esteem, and even become a self-fulfilling prophecy. Because someone thinks they can’t keep friends, they stop trying to make them.

This worksheet keeps these thought patterns in mind, and help the user begin to challenge these beliefs. Terms often used include “stuck points,” “cognitive distortions,” or “negative thoughts.”

Shop challenging thoughts worksheet.

While there are multiple types of anxiety conditions, all of them relate to our thoughts. Meanwhile, many CBT therapists start with anxiety management skills. These include steps like mindfulness or self-soothing.

This anxiety management worksheet includes multiple ideas to deal with anxiety, as well as a page to outline your plan for future anxiety spells.

Ongoing anxiety is usually caused by thinking patterns. Ruminating thoughts, catastrophizing, and assuming the worst are common symptoms of multiple conditions. These thought patterns, combined with the hypervigilance that come along with them, can make it difficult to cope day to day.

These anxious thoughts are common, and likely originate from the human need to prepare for the worst and avoid danger. After all, if our ancestors hadn’t been a bit paranoid we may not be here today.

However, frequently thinking negatively can lead to overwhelming anxiety and nearly constant feelings of anxiety. Anxiety worksheets can help with coping while also addressing the root thoughts that perpetuate these fears.

Shop anxiety management worksheet.

4. Dealing With Strong Emotions Worksheet

Strong feelings can be overwhelming. This guide takes a look at how to rate, ride out, or cope with difficult emotions.

For example, if your emotion is simply uncomfortable, it's usually best to wait it out and allow the feeling to move through you. Otherwise it's likely to just keep coming back.

If a feeling is more significant and seems to interfere with your daily life, it may be best to work with a therapist on processing the emotion. Sometimes it's good to face the feeling head on, which will allow your body to learn the difference between the worry about danger and actual danger.

For example, worrying about danger might be thinking about a dog attacking you. It could cause your nervous system to become really alarmed, not realizing that there's no dog in sight.

By staying with that fear, your body will have the experience of getting to the other side and start to figure out that the fear is a feeling and not an event.

In other cases, if you have a history or pattern of self-harm, it's best to work closely with a therapist so you can fine-tune your plan. In some cases you may want to face your emotions while in other cases you may need some soothing to get through the moment.

This CBT worksheet on dealing with strong emotions is a great resource for therapists and their clients to work on feelings together.

Shop strong emotions worksheet.

This worksheet is created for trauma focused CBT Therapies. It includes the most common steps used in therapies like TF-CBT (trauma-focused CBT) and CPT (cognitive processing therapy).

Many people think of PTSD as simply a result of trauma. While trauma is at the core of it, it goes beyond that. The majority of people experience trauma at some point. At first, it causes feelings of worry, confusion, and sometimes self-blame for what happened.

However, within a few weeks to a month, most people come to terms with what happened. They understand that the trauma was an isolated event, and that there wasn’t anything they could do to change it.

A percentage of people, however, aren’t able to get through this process. This could be due to still being in danger, to past trauma complicating their ability to process, or simply having too much going on to deal with it initially.

This lack of processing leads to “stuck points,” or cognitive distortions relating to the trauma. They typically run along the lines of people blaming themselves, or feeling they can’t deal with difficulties in the world.

The most effective trauma therapies all deal with processing of the traumatic event, and this worksheet walks through the typical steps.

Shop the trauma thoughts worksheet.

6. Exposure Hierarchy Worksheet

Many people develop avoidance as a way to deal with anxiety, phobias, and PTSD. An exposure hierarchy helps people measure which fears are the worst, and how they progress over time.

This worksheet includes a simple but effective way to create an exposure hierarchy, as well as homework sheets to record your exposure activities.

Exposure, or fear, hierarchies are commonly used in CBT, CPT, and TF-CBT therapies.

Fears are sometimes measured by numbers, called SUDS (subjective units of distress). Over time the fear is tracked, to see if it becomes better or worse.

Most often, exposure hierarchies are used along with homework assignments to help people face their fears. This exposure helps them overcome avoidance that may be interfering with their daily life.

The avoidance hierarchy worksheet includes the basic steps to get started.

Shop the exposure hierarchy worksheet.

The trauma narrative is a technique commonly used in therapies like cognitive processing therapy (CPT), or trauma-focused cognitive behavioral therapy (TF-CBT). This worksheet is written with the client in mind, and should generally be used under the direction of a trained therapist.

A trauma narrative is sometimes used as a part of cognitive behavioral PTSD therapies. It involves writing about memories of a difficult situation.

When someone is experiencing PTSD, it's because their brain is confusing the memory of a bad event with the actual event. Your brain continues to think about what happened, and it keeps your brain on high alert, creating a cycle.

One of the ways to interrupt that process is to write about the difficult memories so that you can integrate them into your life, rather than continue to re-experience them. As mentioned, it's recommended that you work through a trauma narrative as part of trauma-focused CBT therapy.

Shop the trauma narrative worksheet.

8. Kids Anger Worksheet

One of the most common struggle kids deal with are angry outbursts . This is because they haven't had the time to understand and learn how to cope with strong emotions.

Although it doesn't say it outright, this set of kids anger worksheets address the CBT triangle. It uses the anger iceberg as a way to illustrate feelings underlying anger.

It actually is a set of three worksheets covering identifying emotions, recognizing harmful behaviors, and creating more positive behaviors. The worksheets are kid-friendly and work well with TF-CBT therapy for kids.

Shop the kids anger worksheets.

9. Emotions Wheel Worksheet

Emotions are a sometimes overlooked part of CBT treatment. Sometimes people think they should or shouldn't be having certain feelings . They might also be unsure of what they're feeling and when.

However, feelings worksheets help with recognizing, regulating, and coping with emotions. This makes it easier to move into the next step of recognizing how thoughts can relate to ongoing emotional struggles.

Common difficult emotions relating to anxiety, depression, or trauma include:

Frustration

Disappointment

The emotions wheel set includes multiple handouts and worksheets based on feelings wheels. It covers both comfortable and uncomfortable emotions like those above. It also has sections that recognize the physical sensations of emotions, and sections to create your own emotional coping wheel.

Shop the emotions wheel worksheets.

10. Mindfulness for CBT Worksheet

New waves of cognitive therapies, including CBT, incorporate mindfulness. It's an important part of the regulating step, and helps you soothe the flight-or fight response.

It can also make it easier to move onto the next steps of recognizing thoughts and emotions. When your brain is in survival mode it can be difficult to work through challenging thoughts or exposure techniques.

Mindfulness takes it down a notch, much like medication would. It also is a great skill in and of itself, and can prevent mental health, and even some physical conditions, down the road.

Shop the mindfulness worksheet.

CBT Therapy Worksheet Bundle

Over the years, I've found that many of the same strategies overlap for conditions like anxiety and PTSD. At the same time, there are some additional steps necessary when processing trauma. I've bundled all of my related pages into this set .

More CBT Resources

In addition to worksheets, CBT-based games can be a great way to teach important concepts. Here's a list of some of our other activities. You can find them all together in our Giant Store Bundle .

CBT Coping Jeopardy-Like Game

If you're looking for a fun, interactive game for classrooms or telehealth, check this out! It covers many of the CBT concepts in the worksheets. It's a great way to reinforce all of the concepts you're learning. Learn more.

CBT Lingo (Bingo-Like Game)

CBT Lingo is a fun, interactive, educational game that helps you teach concepts of CBT. It goes beyond the typical "novelty" cards often created for therapy and other classroom games. The game is compatible with real bingo, so you can actually "call" the game with numbers, either in-person or via telehealth.

CBT Lingo, which works similar to bingo, includes 75 prompts focused on topics like thoughts, feelings, and behaviors, and skills used in cognitive behavioral therapy. It has various options, so it works with teens, college students, and adults.

It can even help with teaching CBT concepts to therapy students.

Here are some sample prompts included in the game:

What does all or nothing thinking mean?

What's one physical symptom of anxiety?

What are the three points of the CBT triangle?

What is ruminating?

Want to give it a go? You can download and use it in-person or via telehealth. Get more details here.

CBT Quest Board Game

CBT board games are another less intimidating way to teach skills. This downloadable board game , called CBT quest, can be printed and used in person, or adapted for online use. It includes 32 prompts with reusable questions, such as:

Give an example of a challenging thought

Describe or show a grounding technique

Describe or name a cognitive distortion

Interested in trying this fun activity? Download it here.

Finding Peace from PTSD Book

If you're working specifically with PTSD, this book is helpful. It lays out the most common strategies used in trauma-focused CBT therapies. Such therapies include:

Prolonged Exposure

Cognitive Processing Therapy

Trauma-Focused CBT

The book was also created to go along with the worksheets in the CBT for PTSD and Anxiety bundle, so the two make great companions! Learn more about the book.

Obviously games and worksheets can’t replace other types of therapy. However, these tools can help you learn to identify thinking patterns, challenge everyday negative thoughts, question your anxiety thoughts, and understand your thoughts relating to PTSD.

For more helpful tools, download it all with our giant store bundle. It includes all of the activities above plus many more great resources .

Sources: Beck Institute for Cognitive Behavioral Therapy. 2021, https://beckinstitute.org/

Chand SP, Kuckel DP, Huecker MR. Cognitive Behavior Therapy. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan.

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Cognitive Behavioural Therapy Worksheets and Exercises

The following Cognitive Behavioural Therapy – CBT worksheets and exercises can be downloaded free of charge for use by individuals undertaking NHS therapy or by NHS practitioners providing CBT in primary or secondary care settings. These worksheets form part of the Think CBT Workbook, which can also be downloaded as a static PDF at the bottom of this page. Please share or link back to our page to help promote access to our free CBT resources. 

The Think CBT workbook and worksheets are also available as an interactive/dynamic document that can be completed using mobile devices, tablets and computers. The interactive version of the workbook can be purchased for single use only for £25. All Think CBT clients receive a free interactive/dynamic copy of the workbook and worksheets free of charge.

Whilst these worksheets can be used to support self-help or work with other therapists, Cognitive Behavioural Therapy is best delivered with the support of a BABCP accredited CBT specialist. If you want to book an appointment with a professionally accredited CBT expert, call (01732) 808626, complete the simple contact form on the right side of this page or email [email protected]  

Please note: if you are a private business or practitioner and wish to use our resources, please email [email protected]  to purchase a registered copy. This material is protected by UK copyright law. Please respect copyright ownership.

Exercise 1 - Problem Statements

Download Here

Exercise 2 - Goals for Therapy

Exercise 3 - personal strengths / resources, exercise 4 - costs / benefits of change, exercise 5 - personal values, exercise 6 - the cbt junction model, exercise 7 - the cross-sectional cbt model, exercise 8 - the longitudinal assessment, exercise 9 - layers of cognition, exercise 10 - cognitive distortions, exercise 11 - theory a-b exercise, exercise 12 - the cbt thought record, exercise 13 - cognitive disputation "putting your thoughts on trial", exercise 14 - the cbt continuum, exercise 15 - the self-perception continuum, exercise 16 - the cbt responsibility pie chart, exercise 17 - noticing the thought, exercise 18 - four layers of abstraction, exercise 19 - semantic satiation, exercise 20 - the characterisation game, exercise 21 - speed up / slow down, exercise 22 - word translation, exercise 23 - the time-traveller's log, exercise 23a -the time-traveller's log continued, exercise 24 - leaves on a stream, exercise 25 - the traffic, exercise 26 - clouds in the sky, exercise 27 - taming the ape - an anchoring exercise, exercise 28 - the abc form in functional analysis, exercise 29 - pace activity exercise, exercise 30 - graded hierachy of anxiety provoking situations, exercise 31 - the behavioural experiment, exercise 32 - act exposures exercise, exercise 33 - worry - thinking time, exercise 34 - submissive, assertive & aggressive communication, exercise 35 - sleep hygiene factors, exercises 36 - 38.

(Abdominal Breathing, Aware Breathing & The Five-Minute Daily Recharge Practice)

Exercise 39 - Wheel of Emotions

Exercise 40 - linking feelings and appraisals, exercise 41 - personal resilience plan, exercise 42 - cbt learning log, act with choice exercise, angels and devils worksheet, transdiagnostic model of ocd worksheet, tuning in exercise, penguin-based therapy (pbt), big picture exercise, post-therapy journal, catch it-check it-change it exercise.

A brief cognitive change exercise for identifying and altering negative thinking

Download here

Download The Think CBT Workbook Here

To get a free copy of the 90 page Think CBT Workbook and Skills Primer, click on the download button and save the PDF document to your personal drive or device. The free version of the Think CBT Workbook is presented as a static PDF, so that you can read the document on your device and print worksheets to complete by hand.

In return for a free copy of the workbook, please help us to promote best practice in CBT by sharing this page or linking back to your website or social media profile.

Download a copy

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CBT Worksheets, Handouts, And Skills-Development Audio: Therapy Resources for Mental Health Professionals

Resource type

Therapy tool.

"Should" Statements

Information handouts.

A Guide To Emotions (Psychology Tools For Living Well)

Books & Chapters

A Memory Of Caring For Others

A Memory Of Feeling Cared For

Abandonment

Activity Diary (Hourly Time Intervals)

Activity Diary (No Time Intervals)

Activity Menu

Activity Planning

Activity Selection

All-Or-Nothing Thinking

Alternative Action Formulation

Am I Experiencing Anorexia?

Am I Experiencing Body Dysmorphic Disorder (BDD)?

Am I Experiencing Bulimia?

Am I Experiencing Burnout?

Am I Experiencing Death Anxiety?

Am I Experiencing Depersonalization And Derealization?

Am I Experiencing Depression?

Am I Experiencing Generalized Anxiety Disorder (GAD)?

Am I Experiencing Health Anxiety?

Am I Experiencing Low Self-Esteem?

Am I Experiencing Obsessive Compulsive Disorder (OCD)?

Am I Experiencing Panic Attacks?

Am I Experiencing Panic Disorder?

Am I Experiencing Perfectionism?

Am I Experiencing Post-Traumatic Stress Disorder (PTSD)?

Am I Experiencing Psychosis?

Am I Experiencing Social Anxiety?

An Introduction To CBT (Psychology Tools For Living Well)

Anger - Self-Monitoring Record

Anger Decision Sheet

Anger Diary (Archived)

Anger Self-Monitoring Record (Archived)

Anger Thought Challenging Record

Anxiety - Self-Monitoring Record

Anxiety Self-Monitoring Record (Archived)

Approach Instead Of Avoiding (Psychology Tools For Overcoming Panic)

Approval-/Admiration-Seeking

Arbitrary Inference

Assertive Communication

Assertive Responses

Attention - Self-Monitoring Record

Attention Training Experiment

Attention Training Practice Record

Audio Collection: Psychology Tools For Developing Self-Compassion

Audio Collection: Psychology Tools For Mindfulness

Audio Collection: Psychology Tools For Overcoming PTSD

Audio Collection: Psychology Tools For Relaxation

Autonomic Nervous System

Avoidance Hierarchy (Archived)

Barriers Abusers Overcome In Order To Abuse

Before I Blame Myself And Feel Guilty

Behavioral Activation Activity Diary

Behavioral Activation Activity Planning Diary

Behavioral Experiment

Behavioral Experiment (Portrait Format)

Behaviors In Panic (Psychology Tools For Overcoming Panic)

Being A Compassionate Person

Being With Difficulty (Audio)

Belief Driven Formulation

Belief-O-Meter (CYP)

Body Posture

Body Scan (Audio)

Body Sensations In Panic (Psychology Tools For Overcoming Panic)

Boundaries - Self-Monitoring Record

Breathing To Activate Your Soothing System

Breathing To Calm The Body Sensations Of Panic (Psychology Tools For Overcoming Panic)

Broadening Your Perspective

Catastrophizing

Catching Your Thoughts (CYP)

CBT Appraisal Model

CBT Daily Activity Diary With Enjoyment And Mastery Ratings

CBT Thought Record Portrait

CFT Calm Place

Challenging Your Negative Thinking (Archived)

Changing Avoidance (Behavioral Activation)

Checking Certainty And Doubt

Checklist For Better Sleep

Classical Conditioning

Coercive Methods For Enforcing Compliance

Cognitive Behavioral Model Of Anorexia Nervosa (Fairburn, Cooper, Shafran, 2003)

Cognitive Behavioral Model Of Body Dysmorphic Disorder (BDD: Veale, 2004)

Cognitive Behavioral Model Of Bulimia Nervosa (Fairburn, Cooper, Shafran, 2003)

Cognitive Behavioral Model Of Clinical Perfectionism (Shafran, Cooper, Fairburn, 2002)

Cognitive Behavioral Model Of Depersonalization (Hunter, Phillips, Chalder, Sierra, David, 2003)

Cognitive Behavioral Model Of Fear Of Body Sensations

Cognitive Behavioral Model Of Generalized Anxiety Disorder (GAD: Dugas, Gagnon, Ladouceur, Freeston, 1998)

Cognitive Behavioral Model Of Health Anxiety (Salkovskis, Warwick, Deale, 2003)

Cognitive Behavioral Model Of Insomnia (Harvey, 2002)

Cognitive Behavioral Model Of Intolerance Of Uncertainty And Generalized Anxiety Disorder Symptoms (Hebert, Dugas, 2019)

Cognitive Behavioral Model Of Panic (Clark, 1986)

Cognitive Behavioral Model Of Persistent Postural-Perceptual Dizziness (PPPD: Whalley, Cane, 2017)

Cognitive Behavioral Model Of Post Traumatic Stress Disorder (PTSD: Ehlers & Clark, 2000)

Cognitive Behavioral Model Of Social Phobia (Clark, Wells, 1995)

Cognitive Behavioral Model Of The Relapse Process (Marlatt & Gordon, 1985)

Cognitive Behavioral Model Of Tinnitus (McKenna, Handscombe, Hoare, Hall, 2014)

Cognitive Behavioral Treatment Of Childhood OCD: It's Only A False Alarm: Therapist Guide

Treatments That Work™

What is Psychology Tools?

Psychology Tools develops and publishes evidence-based psychotherapy resources and tools for mental health professionals. Our online library gives you access to everything you need to deliver more effective therapy and support your practice. With a wide range of topics and resource types covered, you can feel confident knowing you’ll always have a range of accessible and effective materials to support your clients, whatever challenges they are facing, whatever stage you are at, and however you work.

Choose from assessment and case formulations to psychoeducation, interventions and skills development, CBT worksheets, exercises, and much more. Our resources include detailed therapist guidance, references and instructions, so they are equally suitable for those with less experience but who want to expand their practice. Each resource explains how to work with the material most effectively, and how to use it with clients.

Are these resources suitable for you?

Psychology Tools is used by thousands of professionals all over the world as a key part of their practice and preparation, and our resources are designed to be used with clients who experience psychological difficulties or distress. Professionals who use our resources include:

• Clinical, Counseling, and Practitioner Psychologists
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Psychology Tools resources are perfect for individuals, teams and students, whatever their preferred modality, or career stage.

What kinds of resources are available at Psychology Tools?

Psychology Tools offers a range of relatable, engaging, and evidence-based resources to ensure that your clients get the most out of therapy or counseling. Each resource has been carefully designed with accessibility in mind and is informed by best practice guidelines and the latest scientific research.

Therapeutic exercises are used in many evidence-based psychotherapies including cognitive behavioral therapy, rational emotive behavior therapy, compassion-focused therapy, schema therapy, emotion-focused therapy, systemic family-based therapies, and several others.

Therapists and counselors benefit from incorporating exercises into their work. They can be used to:

• Introduce and explain key concepts.
• Collect information about clients’ difficulties.
• Bring therapeutic ideas to life.
• Keep therapy active and engaging.
• Alleviate distress and/or reduce problematic symptoms.
• Practice new skills and coping strategies.
• Develop new insights and self-awareness.
• Give clients a sense of accomplishment and progress.

Psychology Tools offers a variety of exercises that you can use with your clients as a part of therapy or counseling. These interventions can be incorporated into your sessions, assigned as homework tasks, or used stand-alone interventions. Many of our exercises are either evidence-based (meaning they have been shown to effectively treat certain difficulties) or evidence-derived (meaning they form part of a treatment program that has been shown to effectively treat certain difficulties).

The exercises available at Psychology Tools have a variety of applications. You can use them to:

• Develop case conceptualizations , formulations, and treatment plans.
• Address specific difficulties, such as worry, insomnia, and self-focused attention.
• Introduce clients to new skills, such as grounding , problem-solving, relaxation, and assertiveness .
• Support key interventions, such as exposure and response prevention, safety planning with high-risk clients, and perspective-taking.
• Plan treatments and prepare for supervision.

Psychology Tools exercises have been developed with practicality and convenience in mind. Most exercises include simple step-by-step instructions so that clients can use them independently or with the support of their therapist or counselor. In addition, therapist guidance is available for each exercise, which includes a detailed description of the task, relevant background information, an overview of its aims and potential uses in therapy, and simple instructions for its delivery. A comprehensive list of references is also provided so that you can access key studies and further your understanding of each exercise’s applications in psychotherapy.

Did you know that 40 – 80% of medical information is immediately forgotten by patients (Kessels, 2003)? The same is probably true of therapy and counseling, so clients will almost always benefit from having access to additional written information.

Psychology Tools information handouts provide clear, concise, and reliable information, which will empower your clients to take an active role in their treatment. Learning about their mental health, helpful strategies and techniques, and other psychoeducation topics helps clients better understand and overcome their difficulties. Moreover, clients who understand the process and content of therapy are more likely to invest in the process and commit to making positive changes.

Psychology Tools information handouts can help your clients:

• Understand their difficulties and what keeps them going.
• Learn what therapy is and how it works.
• Understand what they are doing in therapy and why.
• Remember and build upon what has been discussed during sessions.
• Create a personalized collection of resources that can used between appointments.

Our illustrated information handouts cover a wide variety topics. Each has been informed by scientific evidence, best practice guidelines, and expert opinion, ensuring they are both credible and consistent with evidence-based therapies. Topics featured among these resources include:

• ‘ What is… ’ handouts. These one-page resources provide a concise summary of common mental health problems (e.g., anxiety , depression , low self-esteem ), key therapeutic approaches (such as cognitive behavioral therapy, eye movement desensitisation and reprocessing , and compassion-focused therapy), and psychological mechanisms which maintain the problem (such as worry and rumination ).
• ‘ What keeps it going… ’ handouts. These handouts explain the key mechanisms that maintain difficulties such as burnout, panic disorder, PTSD, and perfectionism. You can use them to inform your case conceptualization or as a roadmap in therapy.
• ‘ Recognizing… ’ handouts. These guides can help you identify and assess specific disorders, comparing key diagnostic criteria taken from leading diagnostic manuals.
• Simple explanations of key psychological concepts, such as safety behaviors , psychological flexibility, thought suppression, and unhelpful thinking styles .
• Overviews of important psychological theories, such as operant conditioning and exposure.

Each information handout comes with guidance written specifically for therapists and counselors. It provides suggestions for introducing psychoeducation topics, facilitating helpful discussions related to the handout, and ensuring the content is relevant to your clients.

Worksheets are a core ingredient of many evidence-based therapies such as CBT. Our worksheets take many forms (e.g., diaries, diagrams, activity planners, records, and questionnaires) and can be used throughout the course of therapy.

How you incorporate worksheets into therapy or counselling depends on each client’s difficulties, goals, and stage of recovery. You can use them to:

• Assess and monitor clients’ difficulties.
• Inform treatment plans and guide decision-making.
• Teach clients new skills such as ‘self-monitoring’ or ‘thought challenging’.
• Ensure that clients apply their learning in the real world.
• Track their progress over time.
• Help clients to take an active role in their recovery.

Clients also benefit from using worksheets. These tools can help them:

• Become more aware of their difficulties.
• Identify when, how, and why these problems occur.
• Practice using new skills and techniques.
• Express and explore difficult feelings.
• Process difficult events.
• Consolidate and integrate insights from therapy.
• Support their self-reflection.
• Feel empowered and build self-efficacy.

Psychology Tools offers a wide variety of worksheets. They include general forms that are widely applicable, disorder-specific worksheets, and logs that are used in specific therapies such as CBT , schema therapy, and compassion-focused therapy . These resources are typically available in editable or fillable formats, so that they can be tailored to your client’s needs and used in a flexible manner.

Guides & self-help

People want clear guidance on mental health, whether for themselves or a loved one.

Our ‘ Understanding… ’ series is designed to introduce common mental health difficulties such as depression, PTSD, or social anxiety. Each of these guide uses a clear and accessible structure so that readers can understand them without any prior therapy knowledge. Topics addressed in each guide include:

• What the problem is.
• How it arises.
• Where it might come from.
• What keeps it going.
• How the problem can be treated.

Other guides address important topics such as trauma and dissociation, or the effects of perfectionism. They usually contain a mixture of psychoeducation, practical exercises and skills development. They promote knowledge, optimism, and positive action related to these difficulties, and have been informed by current research and evidence-based treatments, ensuring they are consistent with best practices.

Therapists can use Psychology Tools guides in several ways:

• As a screening tool. Clients can read the guide to see if the difficulty or topic is relevant to them.
• As psychoeducation. Each guide provides essential information related to the difficulty or topic so that client can develop a better understanding of it.
• As self-help. Each guide describes key skills and techniques that can be used to overcome the difficulty.

Each guide contains informative illustrations, practical examples, and simple instructions so that clients can easily relate to the content and apply it to their difficulties.

Therapy audio

Audio exercises are a particularly convenient and engaging way help your clients and can add variety to your therapeutic toolkit. Psychology Tools audio resources can help your clients:

• Augment and consolidate their learning in therapy.
• Practice new techniques.
• Integrate skills and practices into their daily lives.
• Access additional support when they need it.
• Create a sense a continuity between your meetings.

A variety of audio resources are available at Psychology Tools. Each one has been developed and recorded by highly experienced clinical psychologists and can be easily integrated into your therapeutic practice. Audio collections include:

• Psychology Tools for Developing Self-Compassion
• Psychology Tools for Relaxation
• Psychology Tools for Mindfulness
• Psychology Tools for Overcoming PTSD

Many of these audio resources are widely applicable (e.g., mindfulness-based tools), although problem-specific resources are also available (e.g., tools for overcoming PTSD). You can use these tools:

• During your therapy sessions.
• As a homework task for clients to complete.
• As a stand-alone intervention or ongoing part of therapy.

Treatments That Work®

Authored by leading psychologists including David Barlow, Michelle Craske, and Edna Foa,  Treatments That Work ® is a series of workbooks based on the principles of cognitive behavioral therapy (CBT). Each pair of books in the series – therapist guide and workbook – contains step by step procedures for delivering evidence-based psychological interventions. Clinical illustrations and worksheets are provided throughout.

You can use these workbooks:

• To plan treatment for a range of specific difficulties including depression, obsessive compulsive disorder (OCD), social anxiety, and substance use.
• As a self-help intervention that you guide the client through during sessions.
• As a supplement to therapy, which clients work through independently.
• To consolidate the content of your sessions.
• As an ongoing intervention at the end of treatment (e.g., for difficulties that haven’t been fully addressed).

Each book is available to download chapter-by-chapter, and Psychology Tools members with a currently active subscription to our ‘Complete’ plan are licensed to share copies with their clients.

Archived resources

We work hard to keep all resources up to date, so we regularly review and update our library. However, we understand that you might get used to a certain version of a resource as part of your workflow. Instead of removing older versions, we keep them in our archive so that you can still access them if you want to. We also clearly explain if an improved version is available, so you can choose which you prefer.

Series and ranges

As well as many topic-specific resources, we also publish a variety of ranges and series.    

• The ‘What is…’ series. These one-page resources cover a range of common mental health problems. In client friendly language they provide a concise summary of the problem, what it can feel like, what maintains it and an overview of key evidence-based therapeutic approaches (e.g., CBT, EMDR, and compassion-focused therapy) to treatment.
• The ‘What keeps it going…’ series . These are one-page diagrams that explain what tends to maintain common mental health conditions such as burnout, panic disorder, PTSD, and perfectionism. You can use them to inform your case conceptualization or as a roadmap in therapy. They provide a quick and easy way for clients to understand why their disorder persists and how it might be interrupted.
• The ‘Recognizing…’ series can help you identify and assess specific disorders, comparing key diagnostic criteria from leading diagnostic manuals.
• The ‘Understanding…’ series is a collection of psychoeducation guides for common mental health conditions. Friendly and explanatory, they are comprehensive sources of information for your clients. Concepts are explained in an easily digestible way with plenty of case examples and diagrams. Each guide covers symptoms, treatments and some key maintenance factors .
• The ‘Guide to…’ resources give clients a deep dive into a condition or treatment approach. They cover a mixture of information, psychoeducation, practical exercises and skills development to help clients learn to manage their condition. Each of these guides offers psychoeducation about the topic alongside a range of practical exercises with clear instructions to help clients identify, monitor, and address their symptoms.
• The ‘ Self-monitoring’ collection provides problem-specific records designed to help you and your clients get the most from this essential but often overlooked technique. Covering a broad range of conditions, these worksheets allow you to give clients a tool that is targeted to their experience, with relevant language and prompts.
• The ‘Formulation’ series provides a client-friendly adaptation of cognitive behavioral models for disorders including panic, PTSD, and social anxiety. These useful tools can help you and your clients come to a shared understanding of their difficulties, and can help you to develop a roadmap for therapy.  

Multilingual library of translations

Did you know that Psychology Tools has the largest online, searchable library of multilingual therapy resources? We aim to make our resources accessible to everyone. With over 3500 resources across 70 languages, you can give clients resources in their native language, enabling a deeper understanding and engagement with the treatment process. Translations are carried out by specially selected professional translators with experience of psychology, and our pool of volunteer mental health professionals. We also make sure that the resource design is the same for each translated resource so that you can be confident you know what section you are looking at, even if you don’t speak the language.

Simply find the resource you want to use, then explore which languages that resource is available in, or you can see all the resources available in a particular language by using our search filters.  

What formats are the resources available in, and how can I use them?

People work in different ways. Our formats are designed to reflect that, so you can choose the style that suits how you and your client want to work. Psychology Tools resources are perfectly formatted to work whether you practice face to face, remotely, or use a blended approach.

• Professional version. Designed for clinicians, this comprehensive option includes everything you need to use the resource confidently. As well as the resource, each PDF contains useful information, including therapist guidance explaining how to use the resource most effectively, descriptions that provide theoretical context, instructions, therapist prompts, and references. Some resources also include case examples and annotations where appropriate.
• Client version.  This is a blank PDF of the resource, with client-friendly instructions where appropriate, but without the theoretical description. These are ideal for printing and using in-session, or giving to a client.
• Fillable PDFs are great for clients who want to work with resources online instead of on paper. Your client can fill in and save the resource on a computer, before sending it back to you without the need for a printer. This format is also useful if you have remote sessions with clients and want to work through a resource on screen together.
• Editable PowerPoint documents are useful if you want to make any changes to the resource structure, or personalize it for your client.
• Editable Word documents are also useful if you want to make changes to the resource, and are more suited to printing.

How do we design our resources to support your practice?

Our resources are informed by evidence-based treatments, best practice guidelines, and the latest published research. They are written by highly experienced therapists and experts in mental health, ensuring they are effective and as up to date as possible. In addition, every resource goes through a rigorous peer review process to confirm they are accurate and easy to use.

Each resource is designed with both clients’ and therapists’ needs in mind. For clients, that means using clear, user-friendly language, as well as plenty of visual and case examples, illustrations, diagrams and vignettes that readers can relate to. They include information on how the resource can help them, how they should use it, and other useful tips.

We also include useful information and descriptions for clinicians to help them use the resource most effectively. The therapist versions of each resource contain therapist guidance, prompts, instructions, and full references. They outline how the resource can be used and what types of problems it could be helpful for.

• Designed to make strong theory-practice links . We pay close attention to the theory underpinning our resources, which provides therapists with useful context and helps them make theory-practice links. Having a greater understanding of each tool ensures best practice.
• One concept per page. Wherever possible, we create resources using the principle of one therapeutic concept per page, as this ensures that we have distilled the idea down to its essence. This makes each tool simple for therapists to communicate and easy for clients to grasp. We also pay close attention to visual layout and design, to make our resources as accessible as possible. Every resource aims to maximize clinical benefit and engagement, without overwhelming readers.
• Action focused. Resources are designed to be interactive, collaborative and goal-focused, with prompts to facilitate self-monitoring of progress and goals.

How can I use this page?

This page is where you can explore all the resources in the Psychology Tools library. The different search filters on the left-hand side enable you to customize your search, depending on what you need. Materials are organized by resource type, problem, and therapy tool, though you can also filter by language or use the search box. You can find more detailed instructions for how to find resources here .  

Can I share resources directly with my clients?

If you have a paid Psychology Tools membership, you are licensed to share resources with clients in the course of your professional work. You can even email resources (even large audio collections) directly to your clients from our website. All emails are secure and encrypted, so it is a quick and easy way to save you time and facilitate clients’ self-practice.

What if I need more help?

We have a wide range of ‘ How-to’ guides and an FAQ in our help centre , which answers questions on how to use the library and tools, such as ‘ How do I download resources? ’ or ‘ How do I email resources to my clients directly from the website? ’.

Kessels, R. P. C. (2003). Patients’ memory for medical information . Journal of the Royal Society of Medicine, 96 , 219-222.

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Top 10 CBT Worksheets Websites

The best cognitive behavioural therapy resources, activities and assignments all in one place.

Hi, it’s Rosie here, Uncommon Knowledge’s content manager.  I’ve been hearing a lot from practitioners who use Cognitive Behavioural Therapy (CBT) and are on the lookout for new resources, especially CBT worksheets.

So to flesh out our resources, I’ve had this list put together, which features ten of the best websites featuring CBT worksheets.

Where to find CBT worksheets

CBT  is one of the most widely used therapeutic treatment approaches in mental health today. Because it is an action-oriented approach, homework is a key aspect of the change process. And CBT tools such as worksheets, activity assignments, bibliotherapy and guided imagery can all be useful homework assignments.

But finding those clinically-sound, cost-effective and easy-to-access resources can be the therapist’s challenge. There’s not always time to sift through books or surf the ‘net looking for those CBT worksheets or teaching tools that are “just right”. Aside from staying on schedule, you want to spend time with your clients, helping them achieve their goals.

So here’s a list of ten of the best CBT resource sites for you to use as a reference point for your practice:

1. Therapist Aid

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The site contains a huge selection of CBT worksheets as well as videos, guides and other resources. ‘The ABC model of CBT’ is a particularly good video to help clients understand the relationship between their thoughts, feelings and behaviours.

2. Psychology Tools

Psychology Tools is another one of those really great sites that has been created by practitioners for practitioners. It was designed as a way to share materials among therapists. The site offers a number of CBT-specific articles, assessments and tools for clinical use. There is also a self-help section.

One of the strengths of this site is that it offers resources for several other therapies including ACT, DBT and EMDR. Therapists can also submit their own worksheets or other resources for consideration of inclusion on the website.

3. Excel At Life

Guided imagery and mindfulness meditation are often used as part of a CBT approach to treatment. This site offers a range of free audio downloads for a variety of needs. These downloads can be used in the office or as part of a homework assignment.

This site offers several CBT resources for the practitioner as well as the client seeking self-directed support including informative articles and forms such as a mood diary and various questionnaires. This site is exceptionally user-friendly.

4. Living CBT

This site offers a number of worksheets and tools including diary forms, action plans and a number of helpful self-statements that are great for sharing with clients. The tools are mostly in PDF and are easy to download. The site also offers several self-help books for purchase.

Aside from the self-help section, this site also has a Free CBT Therapist Resources section. The tools available here are similar to those found in the general section but some are more appropriate for use in the clinical setting.

5. Veronica Walsh’s CBT Blog

This site is a great little gem chock full of CBT resources and downloads. Worksheets cover everything from a CBT journaling guide to incorporating mindfulness to using CBT with cyberbullying. Spend a little time on this site and you’ll find all kinds of useful tools that you and your client can work with. The owner of this site has put a lot of work into making a plethora of resources available to the user.

6. Specialty Behavioral Health

This site offers a variety of worksheets for the practitioner as well as worksheets specifically for CBT. They are well-designed and easily adapted to a variety of clients. Two worksheets to check out are the ‘Ways to Challenge Your Thoughts’ and the ‘Procrastination Profiles’, as well as accompanying ‘Task Master Worksheet (for Procrastination)’. These are nicely done and would be particularly useful with the client struggling to understand thought patterns and challenging negative thinking.

7. GetSelfHelp

This website provides a number of CBT self-help and therapy resources, including downloadable worksheets, information sheets and CBT formulations.

One of the standouts of this site is the 40-page CBT-based self-help course. It’s free and chock full of information and tools to help your clients understand and implement changes. You can find the course here.

8. Hertfordshire Partnership University NHS Foundation Trust

This is a 52-page fully downloadable CBT workbook from the Hertfordshire Partnership University NHS Foundation Trust. It is full of client-friendly descriptions, activities and tools for setting and achieving goals. This workbook is the kind of tool that can be used by the therapist with a client or as a self-help tool for self-motivated clients.

9. Martin CBT

This site is often mentioned when the question of CBT resources comes up. While not as extensive an offering as some sites, the forms and tools found here are well-produced, immediately usable and user-friendly.

One of the highlights is the ‘Cycle of Maladaptive Behavior’ sheet. Clients don’t always understand the cycle and how their behaviours manifest. This worksheet does a good job of describing the cycle and how it unfolds. The site also offers an excellent handout with examples and descriptions of cognitive distortions. Definitely worth a visit!

10. EPISCenter

A list of CBT worksheets would not be complete without including a few child specific resources. CBT has been shown to be effective with children, especially in trauma work.

This workbook is an excellent resource for CBT and trauma work with children. There are relatively few tools specifically designed for children. This workbook is particularly well-constructed and child-friendly.

So there you have it. Ten of the best sites out there for CBT resources and tools. Are there more out there? You bet! There are lots of great resources out there for every level of need and every type of problem. But these sites represent some of the best of what’s out there and will get you started in working with your clients using CBT worksheets. You’ll have more time with your clients and your clients will benefit from having some of the best tools out there.

Update: This post was so popular with readers we added another! Read 10 More Top CBT Worksheets Websites here .

Cognitive Behavioural Therapy is an important part of the treatment jigsaw and our co-founder Mark Tyrrell would want me to mention the following articles we already have available, in the spirit of setting it in a wider context:

• 3 Instantly Calming CBT Techniques for Anxiety
• The Sensible Psychology Dictionary defines CBT

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About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses .

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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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Created by Experts. 100% Science-based.

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

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

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

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

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

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

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

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

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Assigning CBT Homework: Tips for Therapists

This article is an excerpt from the Shortform book guide to "Cognitive Behavior Therapy: Basics and Beyond" by Judith S. Beck. Shortform has the world's best summaries and analyses of books you should be reading.

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What tips can help you assign CBT homework to your patients? What are some examples of cbt homework tasks? How can you improve the completion rate?

Assigning homework during a CBT session can improve patient progress dramatically. It gives the patient a chance to practice what they have learned during the therapy session. Learning how to assign CBT homework successfully and improve completion rate will help your patient achieve their goals.  

Keep reading for tips about assigning CBT homework. 

CBT Homework Assignments

CBT homework gives the patient opportunities to practice new behaviors and thinking. Patients who regularly complete homework show better progress.

Principles of Homework

Explain the rationale of CBT homework, often in terms of improving patient affect or in proven efficacy.

Sessions should typically begin with review of homework completion, outcomes from doing homework, and appropriateness of tasks for future homework in CBT sessions.

• If the patient didn’t complete the homework, you should take blame for assigning too difficult an assignment or not explaining it well enough.

Set CBT homework collaboratively. Get patient buy-in for homework assignment.

Lean toward making homework assignments easy and able to be completed than too hard. Aim for 90-100% likelihood of completion.

• Ask the patient for their own estimation of how likely they are to complete, from 0-100%.
• It’s better to remove an assignment than to set the habit of not completing an assignment.

Make CBT homework no-lose—even if the patient doesn’t complete homework, she’ll discover thoughts that prevent her from making progress.

Homework Assignment Tasks

CBT homework assignments can take a variety of forms. Here are common tasks for patients:

• Behavior activation—the patient just does activities, such as doing light exercise or making a phone call to a friend. For newer patients, this is often more useful to improve affect than more intellectual tasks.
• Notice automatic thoughts.
• Evaluate automatic thoughts.
• Example of a coping card: “If I start to think that I can’t apply for a job, remind myself that I’m only going to do it for 10 minutes, that it may be difficult but probably won’t be impossible, and that the first minute will be hardest and then it’ll get easier.”
• Problem solving—implement the solutions devised during sessions.
• Conduct behavior experiments. Record data as evidence for or against negative thoughts.
• Read other source material.
• Prepare for the next therapy session.
• Set reminders to read over homework multiple times per day.

As therapy progresses, the nature of homework may change:

• The patient may start proposing homework in CBT sessions and giving the rationale for the tasks.
• The tasks can become more complex, diving deeper into the cognitive model.
• Some regular tasks will still remain, like reviewing therapy notes daily.

Improving Homework Completion Rate

Here are techniques to increase CBT homework completion rate:

• Daily checklists of tasks
• Scheduling tasks in the patient’s calendar
• Ask the patient to leave a voicemail with you whenever finishing a task
• Rehearse the situation leading up to doing homework to find issues.
• These may be practical barriers, such as lacking time in schedule or forgetting.
• Ask the patient what the worst that can happen is, and the best.
• Remind the patient that they’re not aiming for perfection.
• Anticipate negative results of homework and address subsequent automatic thoughts
• Start homework in session, so that offline homework is merely continuation of the task rather than completion.

From this article, you’ll see that homework in CBT can be made more efficient and successful. Follow the above advice to improve the progress of your patient.

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Elizabeth graduated from Newcastle University with a degree in English Literature. Growing up, she enjoyed reading fairy tales, Beatrix Potter stories, and The Wind in the Willows. As of today, her all-time favorite book is Wuthering Heights, with Jane Eyre as a close second. Elizabeth has branched out to non-fiction since graduating and particularly enjoys books relating to mindfulness, self-improvement, history, and philosophy.

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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.

Empower Your Clients: Effective Therapy Homework Ideas Unveiled

The power of therapy homework, what is therapy homework.

Therapy homework refers to assignments or tasks that are given to clients by therapists, psychologists, coaches, or practitioners as part of the therapeutic process. These assignments are designed to be completed outside of therapy sessions and are tailored to address specific therapeutic goals and objectives.

Therapy homework can take various forms, depending on the therapeutic approach and the client’s needs. It may involve activities such as journaling, practicing mindfulness exercises, completing worksheets or thought records, engaging in self-reflection, or working on specific skills. The purpose of therapy homework is to actively involve clients in their own healing process and empower them to take ownership of their growth and development.

Benefits of Assigning Therapy Homework

Assigning therapy homework offers numerous benefits for both clients and therapists. Some of the key advantages include:

• Continuity and Reinforcement : Therapy homework provides an opportunity for clients to reinforce and apply what they have learned in therapy sessions to their daily lives. It helps to bridge the gap between sessions, ensuring that progress continues beyond the therapy room.
• Active Engagement : Engaging in therapy homework encourages clients to actively participate in their treatment. It promotes a sense of agency and responsibility, empowering clients to take an active role in their own healing journey.
• Skill Development : Therapy homework allows clients to practice and develop new skills, strategies, and coping mechanisms in real-life situations. It helps to reinforce positive changes and build resilience.
• Generalization of Learning : Through therapy homework, clients have the opportunity to generalize the insights gained in therapy to different contexts and relationships. It supports the transfer of therapeutic gains into their day-to-day lives.
• Increased Self-Awareness : Therapy homework often involves self-reflection and introspection, which can deepen clients’ self-awareness and understanding of their thoughts, emotions, and behaviors. This increased self-awareness can be a catalyst for personal growth and transformation.
• Collaborative Process : Assigning therapy homework fosters a collaborative therapeutic relationship between clients and therapists. It encourages open communication, feedback, and discussion, leading to a more effective and tailored treatment approach.

By incorporating therapy homework into the therapeutic process, therapists can enhance the effectiveness of their interventions and facilitate meaningful change in their clients’ lives.

To explore therapy homework ideas for different therapeutic needs, refer to our articles on  therapy homework assignments ,  therapy homework for anxiety ,  therapy homework for depression , and many more.

Finding the Right Therapy Homework Ideas

When it comes to assigning therapy homework,  tailoring  the activities to each individual client is essential for maximizing their engagement and progress. By customizing the homework, therapists can address specific needs and help clients work towards their therapeutic goals. Additionally, incorporating the client’s  goals and interests  into the assignments can enhance motivation and make the process more enjoyable.

Tailoring Homework to the Client

To ensure the therapy homework is effective, it’s crucial to consider the unique characteristics and preferences of each client. Tailoring the assignments involves taking into account factors such as the client’s age, cultural background, learning style, and personal circumstances.

For example, if a client is struggling with anxiety, it may be beneficial to assign homework that focuses on relaxation techniques, such as deep breathing or progressive muscle relaxation. On the other hand, a client who is working on building assertiveness skills may benefit from practicing role-plays or assertiveness exercises outside of therapy sessions.

By tailoring the therapy homework to the client’s specific needs and challenges, therapists can provide targeted support and facilitate progress towards their therapeutic goals. For more ideas on therapy homework assignments, check out our article on  therapy homework assignments .

Incorporating Client Goals and Interests

Incorporating the client’s goals and interests into therapy homework is an effective way to increase motivation and engagement. By aligning the assignments with the client’s aspirations, they are more likely to be actively involved in the therapeutic process.

For example, if a client is working towards improving their self-esteem, therapy homework could involve engaging in self-affirmation exercises or creating a self-compassion journal. If a client is interested in mindfulness, incorporating mindfulness exercises and  meditation  into the homework can be highly beneficial.

By connecting the therapy homework to the client’s personal goals and interests, therapists can foster a sense of ownership and investment in the therapeutic journey. This approach helps to create a more meaningful and impactful therapeutic experience.

Remember, therapy homework is most effective when it is tailored to the client’s individual needs and incorporates their goals and interests. By taking these factors into account, therapists can empower their clients to actively engage in their own healing process.

Therapy Homework Ideas for Different Needs

When it comes to therapy homework, tailoring the assignments to the unique needs of each client is essential. This ensures that the homework aligns with their therapeutic goals and interests. In this section, we will explore therapy homework ideas for different needs, including  Cognitive Behavioral Therapy (CBT) techniques ,  mindfulness and meditation exercises ,  journaling and writing prompts , and  creative expressive arts activities .

Cognitive Behavioral Therapy (CBT) Techniques

CBT techniques are widely used in therapy to help individuals identify and modify negative thought patterns and behaviors. Assigning CBT-based homework can provide clients with practical tools to challenge unhelpful thoughts and develop healthier coping mechanisms. Some therapy homework ideas for CBT may include:

• Thought Records : Encourage clients to keep a thought record where they write down and examine their negative thoughts, identify cognitive distortions, and reframe them with more realistic and positive alternatives.
• Behavioral Experiments : Suggest clients engage in real-life experiments to test the validity of their negative beliefs and assumptions, helping them gather evidence to challenge and modify those beliefs.
• Activity Scheduling : Encourage clients to create a schedule of activities that promote positive emotions, engagement, and a sense of accomplishment. This can help them break the cycle of negative thoughts and behaviors.

To discover more therapy homework ideas for specific topics or concerns, such as anxiety, depression, self-esteem, or assertiveness, check out our article on  therapy homework assignments .

Mindfulness and Meditation Exercises

Mindfulness and meditation exercises can be valuable homework assignments to help clients develop present-moment awareness, reduce stress, and cultivate emotional well-being. Some therapy homework ideas for mindfulness and meditation include:

• Breathing Exercises : Encourage clients to practice deep breathing exercises, focusing on their breath as it enters and leaves their body. This can help promote relaxation and reduce anxiety.
• Body Scan Meditation : Suggest clients engage in a body scan meditation, guiding their attention from head to toe, paying attention to physical sensations and releasing tension.
• Mindful Eating : Encourage clients to practice mindful eating by fully engaging their senses, savoring each bite, and paying attention to the tastes, textures, and smells of their food.

For more mindfulness and meditation exercises, along with guided scripts, consider referring to our article on  therapy homework for mindfulness .

Journaling and Writing Prompts

Journaling and writing prompts can be effective tools for self-reflection, emotional expression, and personal growth. Assigning writing exercises as therapy homework allows clients to explore their thoughts, feelings, and experiences in a safe and structured way. Some therapy homework ideas for journaling and writing prompts include:

• Gratitude Journal : Encourage clients to keep a gratitude journal, writing down three things they are grateful for each day. This practice can help shift their focus towards positive aspects of their lives.
• Letter Writing: Suggest clients write a letter to themselves, expressing self-compassion , forgiveness, or encouragement. This can be a powerful exercise for promoting self-acceptance and self-care.
• Emotional Release Writing : Encourage clients to engage in free-writing, allowing their thoughts and emotions to flow onto the paper without judgment or self-censorship. This can be a cathartic exercise for emotional processing.

To explore more journaling and writing prompts for therapy homework, consider referring to our article on  therapy homework for journaling .

Creative Expressive Arts Activities

Engaging in creative expressive arts activities can provide clients with a unique and alternative way to explore their emotions, enhance self-expression, and gain insights into their inner world. Some therapy homework ideas for creative expressive arts activities include:

• Art Therapy : Encourage clients to engage in art therapy exercises, such as drawing, painting, or collaging, to express their emotions and access their subconscious mind.
• Music Therapy : Suggest clients create a playlist of songs that resonate with their emotions and help them process their feelings, or encourage them to engage in music improvisation as a form of expression.
• Drama Therapy : Encourage clients to engage in role-playing exercises or create and act out scenes to explore different perspectives and gain insights into their own experiences.

For additional therapy homework ideas for creative expressive arts activities, refer to our article on  therapy homework for self-expression .

By incorporating therapy homework ideas that align with the specific needs and interests of each client, therapists can empower their clients to actively participate in their own healing journey and make progress towards their therapeutic goals.

Implementing Effective Therapy Homework

To ensure the effectiveness of therapy homework assignments, it is crucial to follow certain guidelines. This section will discuss three key aspects of implementing effective therapy homework:  providing clear instructions ,  setting realistic expectations , and  encouraging accountability and follow-up .

Providing Clear Instructions

When assigning therapy homework, it is essential to provide your clients with clear and concise instructions. Clearly outline the purpose of the assignment, the specific tasks or exercises involved, and any guidelines or resources they may need. Using simple and straightforward language will help ensure that your clients understand what is expected of them.

Additionally, consider providing written instructions or  therapy homework worksheets  that your clients can refer to as they complete their assignments. This will serve as a helpful reminder and guide, increasing the likelihood of successful completion.

Setting Realistic Expectations

Setting realistic expectations is crucial when assigning therapy homework. Take into account your clients’ individual circumstances, such as their available time, resources, and personal commitments. Tailor the assignments to their specific needs and abilities to ensure they can be realistically accomplished within the given timeframe.

By setting achievable goals, you will motivate your clients and increase their confidence in their ability to complete the assignments. This, in turn, will enhance their engagement and overall progress during therapy.

Encouraging Accountability and Follow-up

Encouraging accountability and follow-up is essential for effective therapy homework. Regularly check in with your clients to inquire about their progress and address any challenges or questions they may have. This demonstrates your support and commitment to their growth.

Encourage your clients to keep a record of their experiences, insights, or reflections related to their therapy homework. This can be in the form of a journal, a digital document, or even a dedicated  therapy homework app  that allows them to track their progress and thoughts.

By reviewing their completed assignments and discussing their experiences during therapy sessions, you can provide valuable feedback and insights. This feedback will reinforce their efforts and help them integrate their learnings into their daily lives.

Remember to offer encouragement and praise for your clients’ hard work and dedication. Celebrate their achievements, no matter how small, as it will motivate them to continue their therapeutic journey.

As you implement these strategies for effective therapy homework, you will empower your clients to actively engage in their healing process. Providing clear instructions, setting realistic expectations, and encouraging accountability and follow-up will ensure that therapy homework becomes a valuable tool for their growth and progress.

Enhancing Client Engagement

When it comes to therapy homework,  client engagement  is vital for effective progress and positive outcomes. Building a supportive relationship, offering feedback and encouragement, and addressing challenges and concerns are key elements in fostering client engagement .

Building a Supportive Relationship

Establishing a supportive and trusting relationship with clients is essential for effective therapy. Creating a safe and non-judgmental environment allows clients to feel comfortable sharing their thoughts, emotions, and experiences. Actively listening, demonstrating empathy, and validating their feelings are effective ways to build rapport and foster a strong therapeutic alliance.

By developing a supportive relationship, clients are more likely to engage in therapy homework willingly and openly. They will feel understood, respected, and motivated to actively participate in their therapeutic journey.

Offering Feedback and Encouragement

Providing feedback and encouragement throughout the therapy process can significantly enhance client engagement. Regularly acknowledging their progress, recognizing their efforts, and celebrating their achievements can boost their motivation and self-confidence.

Offering constructive feedback that highlights their strengths and areas of improvement can help clients gain valuable insights. It’s essential to provide feedback in a compassionate and non-judgmental manner, ensuring that clients feel supported and encouraged to continue their growth.

Addressing Challenges and Concerns

Therapy is not always a smooth journey, and clients may encounter challenges or have concerns along the way. As a therapist, it is crucial to address these issues promptly and effectively. Actively listen to their concerns, validate their emotions, and work collaboratively to find solutions.

By addressing challenges and concerns, clients will feel heard and supported, which promotes their engagement in therapy. Whether it’s modifying therapy homework assignments, exploring different strategies, or adjusting treatment goals, adapting the therapy process to meet their specific needs can enhance client engagement and overall therapeutic outcomes.

Remember, client engagement is a dynamic process that requires ongoing attention and effort. By building a supportive relationship, offering feedback and encouragement, and addressing challenges and concerns, therapists can empower their clients and create a collaborative therapeutic environment. This environment promotes active engagement in therapy homework and facilitates positive change.

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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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Homework Completion, Patient Characteristics, and Symptom Change in Cognitive Processing Therapy for PTSD

Shannon wiltsey stirman.

a National Center for PTSD and Stanford University, 795 Willow Rd., NCPTSD, Menlo Park, CA 94025, USA

Cassidy A. Gutner

b National Center for PTSD at VA Boston Healthcare System, and Boston University School of Medicine, 150 South Huntington Street. Boston, MA 02130, USA

Michael Suvak

c Psychology Department, Suffolk University, 73 Tremont Street, 8 th Floor, Boston, MA 02108, USA

d National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Street, Boston, MA 02130, USA

Amber Calloway

e National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Street, Boston, MA 02130, USA

Patricia A. Resick

f Duke University Medical School, Durham, North Carolina 27701, USA

Associated Data

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n=140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pre-treatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.

Cognitive behavioral therapies (CBT) have received extensive empirical support for a variety of mental health disorders ( Beck 2005 ). Because CBT emphasizes the development of strategies to modify problematic cognitions and behaviors, most CBT protocols emphasize the use of between-session homework as a means of practicing and solidifying new skills. Despite the central role of homework in these treatments, the nature of the relationship between homework completion and symptom change is still not well understood. Theoretically, CBT homework assignments provide clients the opportunity to practice the skills they learn in session so that they can begin to apply CBT skills in their daily lives and experience more rapid and sustained symptom relief ( Beck, 1979 ). Research on the clinical impact of homework completion has demonstrated some support for this theory, though there have been some methodological limitations to consider.

In previous research, studies comparing protocols that included homework with those that did not include homework have demonstrated larger effect sizes for protocols that included homework ( Kazantzis, Whittington, & Dattilio, 2010 ; Neimeyer & Feixas, 1990 ). Other studies on CBT for depression and anxiety have identified a relationship between homework completion and symptom reduction ( Bryant, Simons, & Thase, 1999 ; Burns & Nolen-Hoeksema, 1991 ; Busch, Uebelacker, Kalibatseva, & Miller, 2010 ; Conklin & Strunk, 2015 ; Kazantzis, Deane, & Ronan, 2000 ). However, some of the research on homework has been conducted with small samples that may be insufficient to detect moderation (e.g., Bryant, Simons, & Thase, 1999 , n =26;. Busch et al., n =12; Olatunji et al., n =27). Additionally, while some larger studies (e.g., Burns & Spangler, 2000 ; Burns & Nolen-Hoeksema, 1991 ) have identified a positive association between homework completion and symptom improvement, most previous studies have lacked the precision required to understand the temporal relationship between homework completion and symptom change. Burns and Spangler (2000) employed structural equation modeling to examine whether CBT homework completion increased as a result of symptom change among 399 depressed clients. While this methodology represented an advance in identifying the structure of the correlation that has been observed between homework completion and symptom change, the measure used for homework completion was a single retrospective rating of overall compliance, which was assigned by clinicians towards the end of treatment. Other studies on CBT for cocaine dependence improved upon this methodology by using repeated therapist-rated assessments of the degree of homework completion for 60 patients, which was validated in some studies by observer ratings of their review of the homework in session ( Carroll, Nich, & Ball, 2005 ). However, as with previous studies, homework completion scores were aggregated across sessions, and the potential impact of prior symptom change on homework completion was not assessed. Thus, while the findings of these previous studies suggest that homework completion may precede symptom change, relatively little is known about the temporal relationship between homework completion and symptom change.

Establishing temporal precedence of a process variable is critical to understanding the nature of the relationship between that variable and a clinical outcome ( Judd & Kenny, 1981 ). Few studies to date have examined this relationship using session-to-session measures of homework completion and symptom change. Yovel and Safren (2007) did not detect a statistically significant relationship between session-to-session homework completion and attention deficit hyperactivity disorder symptom change, although their sample size was very small (n=16). However, Olatunji and colleagues (2015) demonstrated that CBT homework completion among 27 youth with obsessive-compulsive disorder predicted symptom change at the next session. Studies with larger samples have reported significant relationships between homework and symptom change. Strunk and colleagues (2010) demonstrated that adherence to behavioral methods and homework predicted session-to-session symptom change among 60 depressed outpatients receiving a combination of medication and cognitive therapy. Subsequently, Conklin and Strunk (2015) found that observer ratings of adherence to behavioral strategies and homework predicted session-to-session depression change ( n =53), and Schmidt and Woolaway-Bickel (2000) demonstrated that greater homework completion was associated with panic disorder symptom change in some sessions ( n =48). Thus, some evidence indicates that homework completion is associated with subsequent decreases in depression and anxiety.

Even if homework predicts symptom change, understanding the relationship between client factors, homework, and symptom change is necessary to inform treatment planning. If clients with particular characteristics are less likely to complete homework, strategies to address barriers to increase compliance may need to be integrated into treatment to optimize its effectiveness. A systematic review revealed that relatively few studies have examined whether client-level characteristics such as age, education level, or diagnostic factors predict homework completion (Scheel, Hanson, & Razzhavaikina, 2004). Those that have examined potential relationships between demographic variables and homework have studied small samples and found very few associations. For example, Bryant, Simons, and Thase (1999 ; n =25) did not find a relationship between homework completion during cognitive therapy and demographic variables or symptoms, but they did find that a higher number of prior depressive episodes predicted lower homework completion in CBT for depression. Another study found a positive association between homework completion and both age and unemployment status among individuals with panic disorder ( Schmidt & Woolaway-Bickel, 2000 ). The few other studies that have examined the relationship between symptom profiles and homework completion have generally not found an association (Scheel, Hanson, & Razzhavaikina, 2004).

There has been little research on homework in trauma-focused psychotherapy. Because avoidance is a hallmark symptom of posttraumatic stress disorder (PTSD), engaging clients in CBT homework can represent a considerable challenge ( Reger et al., 2013 ). Whether symptom severity or client factors have an impact on homework completion that requires attention to memories, thoughts and feelings related to the trauma requires exploration. These factors inform clinical decision making about patients' appropriateness for trauma-focused treatments, with clinicians citing severity, chronicity, and perceived client ability to engage in homework as factors in deciding whether to provide trauma-focused treatments ( Cook, Dinnen, Simiola, Thompson, & Schnurr, 2014 ; Osei-Bonsu, 2016). Potential predictors of symptom change or homework engagement that have been examined in previous research ( Rizvi et al., 2009 ; Bryant, Simons, & Thase, 1999 ; Schmidt & Woolaway-Bickrel) such as education level, employment status, severity, or chronicity may predict homework engagement or moderate relationships between homework completion and symptom change. It is also important to understand whether homework completion is predictive of symptom change, rather than increasing or decreasing as symptoms decrease. If patients are not improving, they may begin to do less homework, or they may begin to work harder. Similarly, symptom improvement may motivate patients to do homework because they perceive treatment to be helping, or they might reduce the amount they do if they believe they have already experienced sufficient benefit. If higher levels of homework engagement precede symptom change, rather than resulting from it, homework completion should be prioritized in treatment, whereas the second scenario would indicate that as clients improve, their compliance with treatment may also increase.

Because homework assignments differ over the course of cognitive behavioral trauma treatments (c.f., Cooper et al., 2017 ; Resick, Monson, & Chard., 2016), examining associations of homework engagement at different time points can provide more specific information about whether and how certain types of between-session activities are associated with symptom change ( Cooper et al., 2017 ). Previous studies have found an association between assigned or completed homework and symptom change in single ( Mueser et al., 2008 , n =81) and larger, combined datasets ( Ho & Lee, 2012 , n =227), but only one PTSD study examined the temporal relationship between homework and symptom change through session-to-session analyses. In a study of Prolonged Exposure for PTSD ( n =134), higher self-reported imaginal homework adherence predicted greater symptom improvement between sessions and across treatment ( Cooper et al., 2017 ). Relationships between cognitively-oriented homework and PTSD symptom change have not yet been explored.

The current study therefore aimed to examine the temporal relationship between homework completion and session-to-session PTSD symptom change in a CBT for PTSD. Cognitive Processing Therapy (CPT; Resick et al. 2008 ) is a 12-session protocol that involves the assignment of homework to promote practice of the skills taught in session. In CPT, clients are taught to challenge their beliefs and assumptions about why the trauma occurred, as well as its implications for the way they view themselves and the world. Standardized homework is assigned at each session. CPT has been shown effective for treating PTSD, with or without the assignment of written trauma accounts, across a variety of populations and demonstrated long-term benefits ( Bass et al., 2013 ; Resick et al., 2015 ; Resick, Williams, Suvak, Monson, & Gradus, 2012 ). Combined data from two randomized controlled trials of CPT ( Resick et al., 2008 ; Resick, Nishith, Weaver, Astin, & Feuer, 2002 ) provides a larger sample than most previous studies, which is necessary to examine moderators of treatment outcome (LeGrange et al., 2012).

The primary goal of this study was to examine whether homework completion predicted subsequent symptom change. We hypothesized that homework completion would predict subsequent symptom change after controlling for PTSD symptoms. We also sought to explore associations between homework engagement and dropout and whether treatment condition (CPT with written trauma narrative or CPT without it) was associated with homework completion and symptom change. The second, exploratory aim was to examine demographic and diagnostic predictors of homework completion. Although important to examine for PTSD treatments, based on null findings in the research literature for other disorders (Scheel, Hanson, & Razzhavaikina, 2004), we did not expect that any specific demographic and diagnostic factors would be associated with overall homework completion. Finally, to inform future research, we examined potential patient-level moderators of the relationship between homework and symptom change, identifying potential moderators from previous studies examining associations between patient factors and homework completion or symptom change ( Bryant, Simons & Thase, 1999 ; Rizvi, Vogt, & Resick, 2009 ; Scheel, Hanson, & Razzhavaikina, 2004; Schmidt & Woolaway Bickrel, 2000 ).

Structure of CPT and Homework

Table 1 lists the homework assigned at each session, which varies in content and purpose across the course of treatment. In CPT, progressive worksheets are introduced in each session to help clients evaluate their thinking with regard to the index trauma, and each worksheet builds on previous skills and material. If homework was not completed, at least one worksheet was completed in session with therapist guidance and patients were asked to complete more for homework in addition to the newly assigned homework. While the original CPT protocol incorporated both a cognitive component and written accounts of the trauma, in a dismantling study, the cognitive-only condition demonstrated comparable improvements to the original protocol at posttreatment and 6-month follow-up, although those who were not assigned written trauma accounts improved more quickly ( Resick et al., 2008 ). Thus, it is important to examine whether differences in the homework assignments between the two treatment versions that may have accounted for differences in the trajectory of symptom change. As Table 1 indicates, in the first third of the treatments, homework centers around the use of ABC sheets to differentiate thoughts and feelings, writing an impact statement, and writing trauma narratives in the version of CPT with a written account (after sessions 3 & 4). If written narratives (e.g., impact statement or trauma accounts) were not completed for homework as assigned, they were completed verbally in session and assigned again for homework along with the appropriate worksheets. In the middle phase of treatment, new worksheets are introduced that are intended to support practice of cognitive restructuring skills; each new worksheet is assigned one session earlier in the version of CPT that does not include the written account. In the final third of treatment, the skills are combined into a single worksheet. Patients used the set of skills covered in previous sessions plus the newly introduced skill to complete each subsequent written homework assignment whether or not they had completed previously assigned homework. During the last phase of treatment (sessions 10-12), clients are also instructed to give and receive compliments and do something nice for oneself. In both studies included in this investigation, twice weekly sessions were scheduled.

Note: HW = homework completion; PSS/PDS = PTSD Symptom Scale/Posttraumatic Diagnostic Scale.

Participants

Participants were all women who consented to participate in one of two different trials of CPT ( Resick et al., 2008 ; Resick et al., 2002 ) and were assigned to CPT with or without the written trauma account. Sixty-five (78.3%) out of the 85 participants from Study 1 who were randomized to CPT, and in Study 2, 75 out of the 100 participants assigned to either CPT with ( n = 39) or without the written account ( n = 36) attended at least one session. Data from these 140 participants were used for the current study. Participants across both studies were female victims of sexual or physical violence who met DSM-IV criteria for PTSD at intake based on the Clinician-Administered PTSD Scale (CAPS, Blake et al., 1995), with initial CAPS scores representing severe levels of PTSD symptoms ( M = 73.49, SD = 18.86). At intake, the average time since the index trauma was 12.38 years ( SD = 13.38, n = 138). The mean age of participants at intake was 34.63 years old ( SD = 11.71, n = 139). The majority of the sample was White ( n = 99; 70.7%), while 22.1% identified as African American ( n = 31). The majority of the sample was single, separated, divorce, or widowed ( n = 108, 70.1%), while a minority ( n = 32, 22.9%) were married or cohabitating. The mean years of education endorsed by participants was 14.4 ( SD = 2.69, n = 139). Treatment in this study, which was reviewed by the university's Institutional Review board, occurred in a university trauma clinic that served traumatized individuals in the St. Louis community and was delivered by masters or doctoral level clinicians who were trained to deliver CPT for the purpose of the studies (see Resick et al., 2002 ; 2008 for further details regarding recruitment, inclusion criteria, random assignment, and retention rates).

Demographic factors

Demographic variables, collected by self-report at intake, included age, years of education, race and ethnicity.

PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993 )/Postraumatic Diagnostic Scale (PDS; Foa, 1995 )

PTSD symptoms were assessed using the PSS ( Foa, Riggs, Dancu, & Rothbaum, 1993 ) from Study 1, and its modified version, the PDS ( Foa, 1995 ) from Study 2. Despite slightly different wording, each measure contains 17 items that correspond to the DSM-IV PTSD symptoms, yielding nearly identical scales. Participants indicate the frequency/severity of 17 symptoms in the past week on a scale from 0 = “ not at all/only one time” to 3 = “ 5 or more times per week/almost always” . A total score is obtained by summing the items. For Study 1, the average total score at pre-treatment was 29.30 ( SD = 8.75). For Study 2, the average total score at pre-treatment was 29.01 ( SD = 9.53). The PSS and PDS have demonstrated high reliability and validity and high diagnostic agreement with other clinical diagnostic measures of trauma related psychopathology ( Foa, Cashman, Jaycox, & Perry, 1997 ). In the current study, alpha coefficients were .83 and .86, respectively. These measures have been combined in previous secondary analyses (e.g. Lester, Resick, Young-Xu, & Artz, 2010 ; Stein, Dickstein, Schuster, Litz, & Resick, in press). We followed the same procedure to generate a dataset that combined the symptom scores from the two studies.

Beck Depression Inventory (BDI; (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961)/Beck Depression Inventory—II (BDI–II; Beck, Steer, & Brown, 1996 )

The BDI (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) was used to assess depression symptoms for Study 1 and the BDI-II ( Beck, Steer, & Brown, 1996 ) for Study 2. Both measures contain 21-items assessing depressive symptoms and have been widely used with good reliability and validity ( Beck, Steer, & Brown, 1996 ). Coefficient alpha for the studies were .92 for the treatment study and .91 for the dismantling study. Scores on these measures were standardized prior to combining.

Assessment of Homework Completion

The homework review form assessed how often clients worked on or reviewed homework materials between sessions. For each homework assignment, clients indicated the frequency of homework completion using a 5-point Likert scale (1 = “not at all”, 2 = “less than 2 times”, 3 = “2-5 times”, 4 = “6-10 times”, 5 = “more than 10 times”). Clients and therapists completed the homework review sheet together before each session, using the number of worksheets and other materials that the client completed to corroborate their assessment of the frequency of their homework completion. Use of homework assignments between each assessment point (every other session) were averaged to generate a homework variable for each time period (“HW”) in the current analyses.

Clients completed the PSS/PDS and BDI/BDI-II at baseline, prior to sessions 2, 4, 6, 8, 10, and 12, and post-treatment. The homework completion form was completed by the therapist and client together at the beginning of each session. Observer ratings of fidelity were conducted on a randomly selected subset of sessions and indicated that the homework review procedures and forms were completed in 100% of the sessions that were rated.

Data Analyses

Our primary goal was to examine the association between homework completion during a particular week on subsequent changes in PTSD symptoms from that point in treatment through the post-treatment assessment, and to determine whether this differed based on whether patients received the version of CPT that included the trauma account. To accomplish this goal, we evaluated a series of piecewise growth models conducted using multilevel regression (Singer & Willett, 2003) with the Mplus software package (Version 7; Muthén & Muthén, 1998-2012). A piecewise growth model breaks an overall trajectory into multiple distinct phases. The focus of the current manuscript investigated change over time during treatment following the week during which homework was assessed. We conducted piecewise growth modeling (as opposed to only including data points following homework assessment) because the piecewise regression approach uses all of the information available for each participant (before and after the session of interest) to produce the most accurate and powerful estimates of subsequent change.

The right side of Table 2 depicts the time variables that were used in the piecewise models. With the exception of the first phase, between baseline and session 2, two sessions and homework assignments were completed between PTSD symptom assessment points. Thus, Table 2 shows that time was modeled as session number increasing by two from one assessment to the next, with the exception of an increase in one from session 12 to post-treatment. Two time variables were entered as Level-1 (within participants) predictors of PTSD symptoms in each piecewise model. The first time variable was described above and centered (or zeroed) at the second session of each assessment phase. As shown in Table 2 , the remaining time variables were modeled as recommended by Singer & Willet (2003).

Note. Time Variables = the time variables used for the regression analysis at each assessment; S = session number, _PST = the second time coefficient; Est. = estimate; 95% CI = 95% confidence interval; ΔPTSD = change in PTSD. Intercept corresponds to the level of PTSD at that assessment.

Three time coefficients were produced from these piecewise models. The intercept term estimated PTSD symptoms assessed prior to the second session of the phase in which homework was assessed (the assessment for which both time variables were equal to zero in Table 2 ), the coefficient for the first time variable produced an estimate in change in PTSD from that session to post-treatment, and the coefficient for the second time variable represented the difference in rate of change prior to and after the session. The intercept and coefficient for the first time variable were of most interest to the current analyses. To evaluate the impact of homework on subsequent change in PTSD symptoms, homework completion was entered as a Level-2 predictor of each change coefficient, and the primary coefficient of interest was the Homework × time variable interaction, which assessed the impact of homework during that phase (the two sessions between assessment points) on subsequent changes in PTSD symptoms through post-treatment. To evaluate the impact of treatment condition (CPT with or without the trauma account) on the homework effect on subsequent change in PTSD, we added a treatment condition variable and a treatment condition × homework interaction (product) term as Level-2 predictors of each time coefficient. We then conducted a logistic regression analyses with treatment dropout status (0,1) regressed on homework scores to evaluate the relationship between homework and dropout.

For our exploratory analyses, we examined zero-order correlations between patient characteristics and homework completion to determine whether certain characteristics predicted the amount of homework that patients complete. We next conducted exploratory analyses that included patient characteristics that might moderate the relationship between homework completion and symptom change as Level-2 predictors in the piecewise models described above.

Homework and Treatment Outcome

The left side of Table 2 reports the model-derived estimates for PTSD levels and subsequent change in PTSD for each time point. Table 3 reports the coefficients for estimates of the impact of homework completion on the level of PTSD at each assessment point (i.e., impact on the intercept of the piecewise models) and impact of HW on subsequent change on PTSD. Significant effects of homework emerged at two sessions, as described below. The extent to which patients completed the homework assigned in Sessions 2 and 3 (HW2; when ABC worksheets are assigned to help the patient identify and differentiate between thoughts and feelings and at session 3 when first written account or focusing all of the ABC worksheets on the worst traumatic event is assigned) was related to both PTSD levels at Session 4 and subsequent changes from Session 4 to post-treatment. Participants who scored a zero (lowest score) on homework completion during these sessions on average exhibited a 7.24 ( d = -.82) decrease in PTSD symptoms from Session 4 to post treatment, while people who scored a five (highest score) exhibited a 22.49 ( d = -2.55) decrease in PTSD symptoms during this time period.

Note. Results on the left side indicate findings for the entire sample, homework by time interaction. Analyses represented on the right side included an interaction between time and a variable indicating whether or not the trauma account was assigned. HW = homework completion, S = session, n = sample size for that analysis, CR = critical ratio ( b /standard error of b, which follows a z -distribution), p = p -value, d = effect size estimate calculated using d = 2 CR n , with .20, .50, and .80 indicating the cutoffs for small, medium, and large effect sizes. The Level-1 regression equation for the analysis was Y ij = b o + b 1 Time1 + b 2 Time2 + r ij , where Y ij = PTSD symptoms for participant at assessment i for participant j, b o = the regression intercept (PTSD levels at that session); b 1 Time1 = Change in PTSD from that session to the posttreatment assessment; PTSD Time2 = the difference in rate of change in PTSD before and after the session, and r ij = the level-1 residual. All of these terms as well as homework use × time parameters interactions were included in the model. However, to facilitate interpretation of the results, only the parameters representing the impact of HW on PTSD levels and subsequent change are presented on the left, and the main effects of Time, HW, and the moderator, as well as all two way and three way interactions were included in the model reported on the right. Coefficients for the entire model can be obtained from the authors.

Figure 1 shows that participants who completed more homework during the HW2 phase, comprising Sessions 2 and 3 of treatment, initially exhibited higher PTSD levels at Session 4 and experienced larger subsequent decreases in PTSD relative to participants who completed less homework that was assigned in Sessions 2 and 3. Mplus allows intercepts and slopes to be modeled as predictors or outcomes at Level-2. Because homework completion during the phase comprising Sessions 2 and 3 was associated with higher Session 4 PTSD symptom levels, but larger decreases in PTSD symptoms, we evaluated a model with the two time coefficients regressed on the Level-1 intercept (which represented PTSD levels at Session 4) to evaluate change over time when controlling for Session 4 PTSD levels. In this model, the impact of homework after Sessions 2 and 3 on subsequent PTSD approached statistical significance ( b = -0.21, CR = -1.86, p = 0.063, d = -0.32). Thus, the larger decrease in PTSD symptoms exhibited from Session 4 to post-treatment by participants who completed more homework at Sessions 2 and 3 relative to those who completed less homework was largely accounted for by differences in PTSD symptoms prior to Session 4. Participants who completed more homework during this phase had exhibited more PTSD symptoms prior to Session 4 than participants who completed less homework assigned in Sessions 2 and 3. Participants who completed more homework during this phase also exhibited larger decreases from Session 4 to post-treatment. While completion of homework assigned in Sessions 2 and 3 was not associated with post-treatment PTSD scores, patients who were scoring higher in symptoms prior to Session 4 and did more homework at Sessions 2 and 3 were able to catch up to their counterparts who were experiencing lower symptoms during this earlier phase of treatment.

The impact of sessions 2 and 3 homework: a) overall, b) at high levels of years of education, and c) at low levels of years of education. HW2 = Homework completion for sessions 2 and 3

The amount of homework completed during the phase comprising Sessions 8 and 9 (when Challenging Beliefs worksheets, which guide the patient in challenging their beliefs and identifying more adaptive beliefs, and modules on Trust and Power and Control are assigned) also predicted subsequent changes in PTSD symptoms. Participants who scored a zero (lowest score) on homework use during this time period on average exhibited a .01 ( d < -.01) decrease in PTSD symptoms from Session 10 to post treatment, while people who scored a 3.75 (highest score) exhibited a 5.93 ( d = -.49) decrease in PTSD symptoms during this time period. However, as indicated in Table 4 , the amount of homework completed after Sessions 8 and 9 was not associated with Session 12 PTSD symptoms, and when controlling for Session 10 PTSD symptoms, the impact of homework completion on symptom change over the remainder of the protocol remained significant ( b = -0.56, CR = -2.134, p = 0.033, d = -0.39). While on average, participants who completed more homework assigned in Sessions 8 and 9 reported fewer PTSD symptoms at post-treatment, the effect was small, and this difference did not approach statistical significance ( b = -0.74, CR = -1.027, p = 0.471, d = -0.13).

PSS/PDS = PTSD Symptom Scale/Posttraumatic Diagnostic Scale; HW = homework completion; n = sample size; M = mean; SD = standard deviation. Because some data were missing in the original data set, sample sizes are noted with descriptive statistics.

The righthand side of Table 3 presents results of a moderator analysis to determine whether treatment version (CPT with or without the account) was associated with symptom change. Treatment version did not moderate the relationship between homework and symptom change. This held true even during the time periods when the trauma account would have been assigned, completed, and reviewed (HW2 and HW3) or at the subsequent assessment period, when worksheet assignments between the two versions of the treatment (as described in Table 1 ).

We next conducted a series of logistic regression analyses examining HW as a predictor of whether or not participants dropped out of treatment. Twenty-five (18.0%) of the 139 participants with data for Session 1 (HW1) dropped out of treatment. HW1 did not significantly predict dropout status ( b = .35, CR = 1.39, p = .165, OR 1 = 1.41, OR/SD = 1.65). HW2 (Session 2 and 3, b = -.20, CR = -.78, p = .438, OR = .82, OR/SD = .88) and HW3 (Session 4 and 5, b = .23, CR = .67, p = .501, OR = 1.25, OR/SD = 1.46) scores also did not significantly predict treatment dropout. Five (4.2%) of the 119 participants who had HW4 scores available dropped out of treatment. HW4 (Session 6 and 7) homework scores predicted dropout ( b = -2.96, CR = -2.43, p = .015, OR = .05, OR/SD = .10) such that a one SD increase in homework completion was associated with a 9.55 times decrease in the likelihood of dropping out. Similarly, six (5%) of the 119 participants who had HW5 scores available dropped out of treatment with HW5 (sessions 8 and 9) scores inversely related to dropout ( b = -1.43, CR = -2.69, p = .007, OR = .24, OR/SD = .26) such that a one SD increase in homework completion was associated with a 3.82 times decrease in the likelihood of dropping out. Only four (4.5%) of 89 participants with HW6 (session 10-11) scores available dropped out of treatment. The association between HW6 and dropout approached statistical significance ( b = -4.47, CR = -1.69, p = .090, OR = .01, OR/SD = .01). However the odds ratios were quite small and indicated a one SD increase in homework completion was associated with at 72.89 times decrease in the likelihood of dropping out, suggesting the failure to reach statistical significance may have been due having such a small number of dropouts during this phase.

Relationship between baseline characteristics, homework completion, and symptom change

Table 4 displays zero-order correlations among demographic variables, initial PTSD symptom levels, and the HW variables between each PTSD assessment point, as well as descriptive statistics for these variables. The scores indicate that on average, clients endorsed doing homework either less than two times or two to five times between sessions, which were scheduled twice per week. As indicated in Table 4 , the initial PTSD scores were positively correlated with HW1 (Session 1; r = .20, p = .016), such that those endorsing higher initial PTSD symptoms reported completing the first homework assignment more frequently. Initial depression scores were positively correlated with HW1 (Session 1) in the same manner; r = .20, p = .011. Number of years of education was significantly, positively associated with completion of homework assigned in Sessions 3 and 4 (HW2; r = .21, p = .015) and Sessions 10 and 11 (HW6; r = .28, p = .008). Number of years since the index trauma was negatively associated with HW6 ( r = -.22, p = .044). Average homework completion did not correlate with any other demographic or baseline variable. The supplemental table summarizes the findings of the exploratory analyses examining moderators of the impact of homework on changes in PTSD. Only one significant moderator by homework interaction emerged, that of years of education and completion of homework assigned after Sessions 2 and 3 (HW2). Figure 1b and 1c shows that completion of the homework assigned in Sessions 2 and 3 was associated with better outcomes for patients with fewer years of formal education compared to those who endorsed more years of education.

With data from two clinical trials of CPT, this study examined the association between homework completion and symptom change in a cognitive behavioral therapy. We employed a session-to-session measure of homework completion to investigate the relationship between specific homework activities and subsequent symptom change. We found some support for the hypothesis that homework completion is associated with greater overall symptom change, with homework engagement at certain timepoints associated with subsequent symptom change. Whether patients received the version of CPT that included a written trauma account or the version that did not include the account, did not appear to moderate the association between homework completion and symptom change at any timepoint in the treatment. Our results regarding the relationship between homework completion and subsequent dropout also suggested that homework completion in the latter half of treatment may be a good indicator of treatment engagement as patients who completed more homework were less likely to drop out. Finally, we found evidence that while certain client characteristics were associated with early homework completion, they do not predict overall engagement in homework. For the most part, they did not moderate the relationship between homework completion and treatment outcomes, with one exception (years of education).

More frequent completion of homework assigned in Sessions 2 and 3 was associated with smaller short-term decreases in PTSD symptoms at Session 4 regardless of whether the trauma account was assigned in Session 3. However, homework completion during this time period predicted greater symptom change over the course of treatment. While this may have been because in part there was more room for improvement among those who completed more homework, it suggests that those with higher symptoms in Sessions 2 and 3 may be able to “catch up” to those with lower symptoms by completing more homework. In both forms of the treatment (with and without the trauma account), homework assignments in these early sessions require attention to the index trauma and identification of associated thoughts and feelings. While the decreases in avoidance required to do this work may initially reduce the amount of symptom change that patients experience, or even occasionally result in a transient increase in symptoms (Larsen, Stirman, Smith, & Resick, 2016), working on the traumatic event between sessions ultimately appears to be beneficial. These findings suggest that clients, especially those who are experiencing less improvement in early sessions, should be encouraged to complete more homework during these sessions, and reassured that doing so, even if challenging in the short-term, is associated with better longer-term results.

Because patients with higher levels of education completed more homework assigned in Sessions 2 and 3, but those with lower levels of education appeared to benefit more from these assignments, it may be important for clinicians to encourage those with lower levels of education to complete assignments early in treatment. Education has not consistently been identified as a prognostic variable in previous CBT research, but it was found to predict dropout in a previous study that examined treatment outcome in CPT and Prolonged Exposure ( Rizvi, Vogt, & Resick, 2009 ). Findings related to education should be replicated, particularly because they were not significant at every timepoint, but is possible that individuals with lower levels of education may struggle more with some concepts of CPT and that additional practice is required early on in order to maximize treatment effectiveness and engagement. Additional practice at identifying thoughts and differentiating them from feelings may benefit individuals with lower levels of education by promoting a sense of mastery and providing a solid foundation on which new skills are introduced.

The frequency of homework completion decreased somewhat during the middle weeks of therapy before increasing over the last two assignments. Particularly in Sessions 6 and 7, the restricted range may have made it difficult to discern whether increased engagement was related to symptom change, and completion of the assignments in these two sessions was not correlated with completion of earlier assignments. It is possible that during the middle period of treatment, cognitive work completed during sessions impacted symptom change in addition to (or instead of) homework completed outside of session, which is designed to reinforce the work done within sessions. The nature of the homework may also play a role in this pattern of change. A worksheet (Challenging Beliefs Worksheet) that combines all other cognitive restructuring elements and takes longer to complete, especially in the beginning, was introduced during this time period. Participants may have had some difficulty completing this assignment without additional practice and guidance, which may have limited the assignment's impact on symptom change when it was first introduced. In contrast, homework completion for Sessions 8 and 9, which occur after that worksheet was introduced and practiced in earlier sessions, predicted a decrease in PTSD symptoms. Thus, even towards the end of treatment, completion of homework is associated with additional improvement, with those who completed more assignments during this phase experiencing an additional benefit of nearly a 6-point difference, which can be considered clinically meaningful (Larsen et al., 2016).

The participants in this study represented a diverse population of multiply traumatized, low income women who, for the most part, had not completed college and endorsed significant symptoms of depression. Our findings indicated that they were able to practice and benefit from a standardized set of homework activities, and that the relationship between homework completion and symptom change was not due to an association with number of years of education. These findings have implications for the implementation of CPT outside the context of research settings. Considered in conjunction with other studies of CPT conducted with diverse populations ( Schulz, Huber, & Resick, 2006 ), our results support a growing body of literature suggesting that CPT homework can be assigned to clients of diverse cultural and educational backgrounds. Homework completion was associated with PTSD symptom change, at least for participants with lower levels of education and those with higher symptoms in early sessions. However, because this sample comprised only women who experienced interpersonal violence index traumas, future research should examine the impact of homework completion in other populations of clients who experience PTSD. Of course, it is also possible that individuals with certain characteristics such as motivation that were not measured in this study are more likely to complete homework, and that homework is a proxy for a particular trait or psychological process that impacts treatment, such as willingness to learn new skills ( Burns & Nolen-Hoeksema, 1991 ) or motivation ( Huppert et al., 2006 ). While previous research on client characteristics, including factors such as resourcefulness were not related to homework completion ( Bryant, Simons, & Thase, 1999 ), factors such as motivation, self-efficacy, or expectancies have not been examined in relation to homework. Other factors such as the therapeutic alliance, fidelity to the treatment, and patient receptivity/resistance were not measured in session, but may impact treatment outcome ( DeRubeis, Brotman, & Strunk, 2005 ).

There is a relative dearth of studies examining the impact of homework completion on treatment outcome in CBTs for PTSD, and the current analyses used data from two RCTs that were not specifically designed to assess the impact of homework completion on symptom change. Therefore, rather than a conservative or strict test of a well-developed theoretical model about the relative importance of different homework assignments, the current study was conducted in the spirit of providing research findings that can facilitate the generation of hypotheses for future studies designed specifically to assess the impact of homework completion on symptom change. Although our investigation of homework was one of the largest to date, we did not have a sufficient sample size to examine homework and their interactions with time simultaneously and instead evaluated the impact of homework between each PTSD assessment in separate models. Because we conducted multiple analyses, particularly for our exploratory moderator analyses, these findings should therefore be interpreted with caution and replicated in future research. However, the effect sizes for our findings regarding Sessions 2 and 3, including that of education as a potential moderator, suggest that they should be investigated further. Replication of our findings with a very large sample and a more conservative, confirmatory analytic approach is necessary.

The current study did not assess the quality of the homework completed or the amount of time spent on the assignments, which are limitations. While our results suggest that irrespective of quality, the frequency of engagement with homework assignments is associated with clinical improvement, it is possible that an assessment of quality or quantity would allow for a greater understanding of the relationship between homework completion and symptom change, as prior research suggests that quality may be more predictive of outcomes than quantity ( Schmidt & Woolaway-Bickel, 2000 ). The current study also did not examine whether specific assignments or elements of homework led to symptom change. Although the homework assignments built on one another, it is possible that clients who did not complete an assignment and had it re-assigned in addition to current homework may have experienced different levels of session-to-session symptom change than those who completed homework on time. Furthermore, if clients were engaged in the form of CPT that does not include a trauma account, they began using some cognitive worksheets sooner and more Socratic questioning than their counterparts who completed the written account. Relationships between specific homework activities and symptom change warrants exploration in a dataset in which symptoms were assessed at every session. Because samples for later analyses were smaller due to treatment dropout, results for these sessions in particular require replication.

While observer ratings of homework completion may also enhance our understanding of the role of homework in CBT, previous research has suggested that self-reports of homework completion, when collected in each session, can be reliable sources of data ( Burns & Spangler, 2000 ; Kassler & Neimeyer, 1997 ). A recent meta-analysis suggested that in studies of homework and clinical outcomes, combined therapist and client ratings are associated with greater effect sizes than observer ratings (Mausbach et al., 2010). The fact that the questionnaire used in this study was completed by therapists and clients together, using the completed homework worksheets to corroborate clients' reports of homework activities, strengthened our confidence in these assessments as reliable estimates of homework completion. In future research, session-to-session (rather than every other session) assessments will allow greater precision in identifying relationships between specific assignments and subsequent symptom change.

Despite these limitations, this study provides additional support for the theory that practicing skills between sessions through completion of homework may be associated with greater symptom improvement ( Beck, 1979 ). It adds to a small literature suggesting that patients in trauma-focused treatment who complete more homework (which focuses on extending key aspects of treatment between sessions) experience decreases in PTSD that are greater than those who are less engaged in homework ( Cooper et al., 2017 ; Mueser et al., 2008 ). Similar to other recent findings ( Cooper et al., 2017 ), our results suggest that either certain assignments, or homework at specific timepoints, may be particularly important. Furthermore, this study suggests that later in treatment, homework completion may indicate greater engagement in treatment and a lower likelihood of dropout. Collectively, these studies point to compelling directions for future experimental and naturalistic investigations of associations between homework and symptom change.

Homework is sometimes perceived as a burden on clients, and both clinicians who are learning CBT and clients who are beginning treatment may struggle to integrate it into treatment (Waltman, Hall, McFarr, Beck, & Creed, 2016). Further research on homework will be useful when conducted in routine care settings, because there have been very few empirical studies on compliance with and impact of homework during routine clinical practice. However, our findings suggest that completion of homework is associated with clinical improvements, and that encouraging early and frequent homework activities may enhance treatment outcome.

• Examined associations between patient factors, CPT homework, and symptom change.
• Homework completion after certain sessions predicted subsequent symptom change.
• Few patient characteristics predicted CPT homework completion.
• Education moderated associations between Session 2 and 3 homework and symptom change.

Supplementary Material

Acknowledgments.

The datasets used for this research was collected through studies funded by the National Institute of Mental Health (NIH-1 R01-MH51509 and NIH-2 R01-MH51509), awarded to Dr. Resick while she was at University of Missouri, St. Louis. Dr. Gutner's work was supported by a career development award from the National Institute of Mental Health (1K23MH103396)

1 OR = Odds Ratio. With continuous predictors it is difficult to interpret the strength (i.e., effect size) of odds ratios because the unit of continuous measures is usually arbitrary. Therefore, we also calculated the odds ratio per standard deviations of the predictor variable (OR/SD). The OR/SD values can be interpreted as the increase in the likelihood of dropping out of treatment associated with a one standard deviation increase in HW scores.

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