1. Parikh S, Segal Z, Grigoriadis S, Ravindran A, Kennedy S, Lam R, Patten S, Canadian Network for MoodAnxiety Treatments (CANMAT) Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord. 2009 Oct;117 Suppl 1:S15–25. doi: 10.1016/j.jad.2009.06.042.[PubMed][Cross Ref]
2. Canadian PA. Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry. 2006 Jul;51(8 Suppl 2):9S–91S.[PubMed]
3. Thase M, Friedman E, Biggs M, Wisniewski S, Trivedi M, Luther J, Fava M, Nierenberg AA, McGrath PJ, Warden D, Niederehe George, Hollon Steven D, Rush A John. Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D report. Am J Psychiatry. 2007 May;164(5):739–52. doi: 10.1176/ajp.2007.164.5.739.[PubMed][Cross Ref]
4. Dannon PN, Gon-Usishkin M, Gelbert A, Lowengrub K, Grunhaus L. Cognitive behavioral group therapy in panic disorder patients: the efficacy of CBGT versus drug treatment. Ann Clin Psychiatry. 2004;16(1):41–6.[PubMed]
5. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA. 2000 May 17;283(19):2529–36.[PubMed]
6. O'Connor K, Todorov C, Robillard S, Borgeat F, Brault M. Cognitive-behaviour therapy and medication in the treatment of obsessive-compulsive disorder: a controlled study. Can J Psychiatry. 1999 Feb;44(1):64–71. doi: 10.1177/070674379904400108.[PubMed][Cross Ref]
7. Kazantzis N, Arntz A, Borkovec T, Holmes E, Wade T. Unresolved issues regarding homework assignments in cognitive and behavioural therapies: an expert panel discussion at AACBT. Behav change. 2012 Feb 22;27(03):119–129. doi: 10.1375/bech.27.3.119.[Cross Ref]
8. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. New York: Guilford Press; 1979.
9. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Washington, DC: American Psychiatric Assoc Pub; 2013.
10. Helbig S, Fehm L. Problems with homework in CBT: rare exception or rather frequent? Behav Cognit Psychother. 1999;32(3):291–301. doi: 10.1017/S1352465804001365.[Cross Ref]
11. Kazantzis N, Lampropoulos GK, Deane FP. A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. J Consult Clin Psychol. 2005 Aug;73(4):742–8. doi: 10.1037/0022-006X.73.4.742.[PubMed][Cross Ref]
12. Gaynor S, Lawrence PS, Nelson-Gray RO. Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: review, preliminary findings, and implications for theory and practice. Behav Modif. 2006 Sep;30(5):647–72. doi: 10.1177/0145445504272979.[PubMed][Cross Ref]
13. Leahy R. Improving homework compliance in the treatment of generalized anxiety disorder. J Clin Psychol. 2002 May;58(5):499–511. doi: 10.1002/jclp.10028.[PubMed][Cross Ref]
14. Garland A, Scott J. Using homework in therapy for depression. J Clin Psychol. 2002 May;58(5):489–98. doi: 10.1002/jclp.10027.[PubMed][Cross Ref]
15. Bru L, Solholm R, Idsoe T. Participants’ experiences of an early cognitive behavioral intervention for adolescents with symptoms of depression. Emot Behav Diff. 2013 Mar;18(1):24–43. doi: 10.1080/13632752.2012.675138.[Cross Ref]
16. Williams C, Squires G. The Session Bridging Worksheet: impact on outcomes, homework adherence and participants’ experience. tCBT. 2014 Apr 23;7 doi: 10.1017/S1754470X1400004X.[Cross Ref]
17. Rees C, McEvoy P, Nathan PR. Relationship between homework completion and outcome in cognitive behaviour therapy. Cogn Behav Ther. 2005;34(4):242–7. doi: 10.1080/16506070510011548.[PubMed][Cross Ref]
18. Simons AD, Marti CN, Rohde P, Lewis CC, Curry J, March J. Does homework “matter” in cognitive behavioral therapy for adolescent depression? J Cogn Psychother. 2012 Nov 01;26(4):390–404. doi: 10.1891/0889-83184.108.40.2060.[Cross Ref]
19. Thase M, Callan JA. The role of homework in cognitive behavior therapy of depression. J Psychother Integr. 2006;16(2):162–177. doi: 10.1037/1053-04220.127.116.11.[Cross Ref]
20. Neimeyer R, Kazantzis N, Kassler D, Baker K, Fletcher R. Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition. Cogn Behav Ther. 2008;37(4):199–215. doi: 10.1080/16506070801981240.[PubMed][Cross Ref]
21. Coon DW, Thompson LW. The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression. Am J Geriatr Psychiatry. 2003;11(1):53–61.[PubMed]
22. Strunk D, Cooper A, Ryan E, DeRubeis R, Hollon S. The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. J Consult Clin Psychol. 2012 Oct;80(5):730–8. doi: 10.1037/a0029281.http://europepmc.org/abstract/MED/22774791. [PMC free article][PubMed][Cross Ref]
23. Cowan M, Freedland K, Burg M, Saab P, Youngblood M, Cornell C, Powell LH, Czajkowski SM. Predictors of treatment response for depression and inadequate social support--the ENRICHD randomized clinical trial. Psychother Psychosom. 2008;77(1):27–37. doi: 10.1159/000110057.[PubMed][Cross Ref]
24. Hundt N, Amspoker A, Kraus-Schuman C, Cully J, Rhoades H, Kunik M, Stanley M. Predictors of CBT outcome in older adults with GAD. J Anxiety Disord. 2014 Dec;28(8):845–50. doi: 10.1016/j.janxdis.2014.09.012.http://europepmc.org/abstract/MED/25445074. [PMC free article][PubMed][Cross Ref]
25. Lebeau RT, Davies C, Culver N, Craske M. Homework compliance counts in cognitive-behavioral therapy. Cogn Behav Ther. 2013;42(3):171–9. doi: 10.1080/16506073.2013.763286.[PubMed][Cross Ref]
26. Edelman RE, Chambless DL. Adherence during sessions and homework in cognitive-behavioral group treatment of social phobia. Behav Res Ther. 1995 Jun;33(5):573–7.[PubMed]
27. Leung AW, Heimberg RG. Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. Behav Res Ther. 1996;34(5-6):423–32.[PubMed]
28. Tolin D, Frost R, Steketee G. An open trial of cognitive-behavioral therapy for compulsive hoarding. Behav Res Ther. 2007 Jul;45(7):1461–70. doi: 10.1016/j.brat.2007.01.001.http://europepmc.org/abstract/MED/17306221. [PMC free article][PubMed][Cross Ref]
29. Westra H, Dozois DJ, Marcus M. Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety. J Consult Clin Psychol. 2007 Jun;75(3):363–73. doi: 10.1037/0022-006X.75.3.363.[PubMed][Cross Ref]
30. Mueser K, Rosenberg S, Xie H, Jankowski M, Bolton E, Lu W, Hamblen L, Rosenberg HJ, McHugo GJ, Wolfe R. A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol. 2008 Apr;76(2):259–71. doi: 10.1037/0022-006X.76.2.259.http://europepmc.org/abstract/MED/18377122. [PMC free article][PubMed][Cross Ref]
31. Cammin-Nowak S, Helbig-Lang S, Lang T, Gloster A, Fehm L, Gerlach A, Ströhle A, Deckert J, Kircher T, Hamm AO, Alpers GW, Arolt V, Wittchen HU. Specificity of homework compliance effects on treatment outcome in CBT: evidence from a controlled trial on panic disorder and agoraphobia. J Clin Psychol. 2013 Jun;69(6):616–29. doi: 10.1002/jclp.21975.[PubMed][Cross Ref]
32. Glenn D, Golinelli D, Rose R, Roy-Byrne P, Stein M, Sullivan G, Bystritksy A, Sherbourne C, Craske MG. Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement. J Consult Clin Psychol. 2013 Aug;81(4):639–49. doi: 10.1037/a0033403.http://europepmc.org/abstract/MED/23750465. [PMC free article][PubMed][Cross Ref]
33. Dunn H, Morrison A, Bentall RP. Patients' experiences of homework tasks in cognitive behavioural therapy for psychosis: a qualitative analysis. Clin Psychol Psychother. 2002 Sep;9(5):361–369. doi: 10.1002/cpp.344.[Cross Ref]
34. Granholm E, Auslander L, Gottlieb J, McQuaid J, McClure FS. Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons with schizophrenia. J Contemp Psychother. 2006 Mar 17;36(1):31–41. doi: 10.1007/s10879-005-9004-7.[Cross Ref]
35. Carroll K, Nich C, Ball S. Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. J Consult Clin Psychol. 2005 Aug;73(4):749–55. doi: 10.1037/0022-006X.73.4.749.http://europepmc.org/abstract/MED/16173864. [PMC free article][PubMed][Cross Ref]
36. Gonzalez V, Schmitz J, DeLaune KA. The role of homework in cognitive-behavioral therapy for cocaine dependence. J Consult Clin Psychol. 2006 Jun;74(3):633–7. doi: 10.1037/0022-006X.74.3.633.[PubMed][Cross Ref]
37. Funk A, Zvolensky M, Schmidt Nb. Homework compliance in a brief cognitive-behavioural and pharmacological intervention for smoking. J Smok Cessat. 2011 Dec;6(2):99–111. doi: 10.1375/jsc.6.2.99.[Cross Ref]
38. Kazantzis N, Deane F, Ronan K. Homework assignments in cognitive and behavioral therapy: a meta-analysis. Clin Psychol Sci Pract. 2000;7(2):189–202. doi: 10.1093/clipsy.7.2.189.[Cross Ref]
39. Mausbach B, Moore R, Roesch S, Cardenas V, Patterson T. The relationship between homework compliance and therapy outcomes: an updated meta-analysis. Cognit Ther Res. 2010 Oct;34(5):429–438. doi: 10.1007/s10608-010-9297-z.http://europepmc.org/abstract/MED/20930925. [PMC free article][PubMed][Cross Ref]
40. Payne KA, Myhr G. Increasing access to cognitive-behavioural therapy (CBT) for the treatment of mental illness in Canada: a research framework and call for action. Healthc Policy. 2010 Feb;5(3):e173–85.http://europepmc.org/abstract/MED/21286263. [PMC free article][PubMed]
41. Smith A. U.S. Smartphone Use in 2015. Washington, DC: Pew Research Center; 2015. Apr 1,
42. Milward J, Day E, Wadsworth E, Strang J, Lynskey M. Mobile phone ownership, usage and readiness to use by patients in drug treatment. Drug Alcohol Depend. 2015 Jan 01;146:111–5. doi: 10.1016/j.drugalcdep.2014.11.001.[PubMed][Cross Ref]
43. Quorus Consulting Group CWTA. 2012. Apr 23, 2012 cell phone consumer attitudes study https://www.cwta.ca/wp-content/uploads/2011/08/CWTA-2012ConsumerAttitudes.pdfwebcite.
44. Boschen M, Casey LM. The use of mobile telephones as adjuncts to cognitive behavioral psychotherapy. Prof Psychol Res Pr. 2008;39(5):546–552. doi: 10.1037/0735-7028.39.5.546.[Cross Ref]
45. Mirani L. Quartz. 2014. Dec 18, [2015-05-24]. $30 smartphones are here—and they’re getting better every day http://qz.com/314285/30-smartphones-are-here-and-theyre-getting-better-every-day/webcite.
46. Dorrier J. SingularityHub. 2014. Mar 7, [2015-05-24]. Cheap devices, like Mozilla’s $25 smartphone, to bring more of developing world online http://singularityhub.com/2014/03/07/cheap-devices-like-mozillas-25-smartphone-to-bring-more-of-developing-world-online/webcite.
47. Tompkins M. Guidelines for enhancing homework compliance. J Clin Psychol. 2002 May;58(5):565–76. doi: 10.1002/jclp.10033.[PubMed][Cross Ref]
48. Kazantzis N, L'Abate L. Handbook of Homework Assignments in Psychotherapy Research, Practice, and Prevention. New York, NY: Springer; 2007.
49. Santor D, Bagnell A. Enhancig the effectivencess and sustainability of school-based mental health programs: maximizing program participation, knowledge uptake and ongoing evaluation using Internet-based resources. Adv Sch Ment Health Promot. 2011 Dec 22;1(2):17–28. doi: 10.1080/1754730X.2008.9715725.[Cross Ref]
50. Proudfoot J. The future is in our hands: the role of mobile phones in the prevention and management of mental disorders. Aust N Z J Psychiatry. 2013 Feb;47(2):111–3. doi: 10.1177/0004867412471441.[PubMed]
By Judith S. Beck, Ph.D., and Francine R. Broder, Psy.D.
Judith S. Beck, Ph.D.
We’ve stopped using the word “homework” in CBT. Too many clients take exception to that term. It reminds them of the drudgery of assignments they had to do at home when they were at school. So in recent times, we’ve switched. “Homework” is now called the “Action Plan.”
We like the label “Action Plan.” It conveys a sense of proactivity, of taking control.
Action plans aren’t optional. They are very carefully created, in a collaborative fashion. Therapists emphasize that most of the work in getting better happens between sessions. A significant part of each session involves helping clients figure out what they need to do outside of the therapy office to feel better and regain a good level of functioning. We tell clients:
Francine R. Broder, Psy.D.
That’s why we make sure that whatever is important for the client to remember about the session, including their Action Plan, is recorded, written down or entered as text or audio into an electronic device.
And that’s why, after we’ve finished collaboratively creating the Action Plan, we ask:
How likely are you to do this assignment(s) this week?
And that’s why we continue talking about potential obstacles that could get in the way when clients say they are 90% or less likely to complete the Action Plan.
Here is an example of a client who did not do his action plan, and this is how we worked on it.
A 28-year-old came to treatment to work on reducing depression, social anxiety, and worry about his irritable bowel syndrome. During our session, he identified “getting into shape” as important to him and set up a specific action plan that included going to the gym he belonged to, two times during the week, for approximately 30 minutes. Upon returning the following week and checking in on how it went, he stated he did not go. When asked what got in his way, he stated he did not know. He was asked to go back to an earlier time in the week, imagine himself about to go to the gym, and to notice the thoughts that were going through his mind. Using imagery, he was able to identify his interfering thoughts. Next, we used Socratic questioning, summarizing his conclusions in a two-column thought record.
The Action Plan isn’t optional. A considerable body of evidence shows that clients who do homework have better outcomes than clients who do not. See, for example Conklin & Strunk (2015); Kazantzis, Deane, Ronan & L’Abate (2005). It’s up to therapists to help clients carefully design meaningful assignments with a good likelihood of success and to motivate clients to follow through. Finally, we used the two-column thought record to anticipate additional interfering thoughts that could get in the way of engaging in his action plan for the coming week.
Conklin, L. R., & Strunk, D. R. (January 01, 2015). A session-to-session examination of homework engagement in cognitive therapy for depression: Do patients experience immediate benefits?. Behaviour Research and Therapy, 72, 56-62.
Kazantzis, N., & L’Abate, L. (2006). Handbook of homework assignments in psychotherapy: Research, practice, and prevention. New York, NY: Springer.