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Homework in therapy: a case of it ain't what you do, it's the way that you do it.

Published online by Cambridge University Press:  26 August 2015

It is argued, illustrated by a case example, that homework quality and end of therapy outcomes can be positively affected when ideas of compassion and attention to individual frames of reference are considered. It is suggested that by exploring the affect experienced when completing tasks and being mindful of client learning (i.e. the zone of proximal development), engagement and emotional connection with homework increase.

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  • Duncan L. Harris (a1) (a2) and Syd Hiskey (a2)
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How to Design Homework in CBT That Will Engage Your Clients

Homework in CBT

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

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

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

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

This Article Contains:

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

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

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

Behaviorist theory

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

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

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

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

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

Social learning and cognitive theories

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

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

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

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

Warr Affect

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

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

Designing and delivering CBT homework in Quenza

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

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

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

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

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

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

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

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

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

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

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

Urge Surfing

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

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

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

Moving From Cognitive Fusion to Defusion

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

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

Finding Silver Linings

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

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

Quenza Stress Diary

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  • Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist , 44 (9), 1175–1184.
  • Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., & Wong, E. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed.) (pp. 227–306). Wiley.
  • Bouton, M. E. (1988). Context and ambiguity in the extinction of emotional learning: Implications for exposure therapy. Behaviour Research and Therapy , 26 (2), 137–149.
  • Franklin, M. E., Huppert, J. D., & Roth Ledley, D. (2005). Obsessions and compulsions. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 219–236). Routledge.
  • Garland, A., & Scott, J. (2005). Depression. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 237–261). Routledge.
  • Huppert, J. D., Roth Ledley, D., & Foa, E. B. (2006). The use of homework in behavior therapy for anxiety disorders. Journal of Psychotherapy Integration , 16 (2), 128–139.
  • Kazantzis, N. (2005). Introduction and overview. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 1–6). Routledge.
  • Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta‐analysis. Clinical Psychology: Science and Practice , 7 (2), 189–202.
  • Kazantzis, N., & L’Abate, L. (2005). Theoretical foundations. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 9–34). Routledge.
  • Leahy, R. L. (2005). Panic, agoraphobia, and generalized anxiety. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 193–218). Routledge.
  • Staddon, J. E., & Cerutti, D. T. (2003). Operant conditioning. Annual Review of Psychology , 54 (1), 115–144.

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

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

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

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

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


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

Trial Registration NCT02667366. Registered on 3 December 2015.

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

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

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

Homework-Related Therapist Behaviors

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

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

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

Homework Engagement in Telephone-Based CBT

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

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

Aim of the Current Study

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

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

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

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

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

Measures and Assessment

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

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

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

Ratings of Tel-CBT Sessions

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

Raters and Rater Training

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

Rating Procedure

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

Statistical Analysis

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

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

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

Descriptive Statistics of Sample

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

Psychometric Properties of GHES and StHAR

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

Descriptive Statistics of Homework, HE, and TBH

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

Course of HE and TBH and Their Association

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

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

Association Between HE, TBH, and Depressive Symptoms

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

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

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

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

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

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

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

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

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

Data Availability

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

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Haller, E., Watzke, B. The Role of Homework Engagement, Homework-Related Therapist Behaviors, and Their Association with Depressive Symptoms in Telephone-Based CBT for Depression. Cogn Ther Res 45 , 224–235 (2021).

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Child and Adolescent Adherence with Cognitive Behavioral Therapy for Anxiety: Predictors and Associations with Outcomes

Phyllis lee.

1 University of Connecticut Health, Farmington, CT, ( moc.liamg@dhpeelsillyhp ), ( ude.chcu@reeghez ), ( ude.chcu@grubsnigg )

Asima Zehgeer

Golda s. ginsburg, james mccracken.

2 UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, CA, ( ude.alcu.tendem@nekcarccmj ), ( ude.alcu.tendem@sirept )

Courtney Keeton

3 Johns Hopkins University, Baltimore, MD, ( ude.imhj@ecreipc )

Philip C. Kendall

4 Temple University, Philadelphia, PA, ( ude.elpmet@lladnekp )

Boris Birmaher

5 University of Pittsburgh, Pittsburgh, PA, ( ude.cmpu@BrehamriB ), ( ude.cmpu@jdykslokas )

Dara Sakolsky

John walkup.

6 Cornell University, New York, NY, ( ude.llenroc.dem@1009wtj )

Anne Marie Albano

7 Columbia University, New York, NY, ( ude.aibmuloc.ipsyn@Aonabla )

Scott Compton

8 Duke University, Durham, NC, ( [email protected] )

Cognitive Behavioral Therapy (CBT) for anxiety disorders is effective, but non-adherence with treatment may reduce the benefits of CBT. This study examined (a) four baseline domains (i.e., demographic, youth clinical characteristics, therapy-related, family/parent factors) as predictors of youth adherence with treatment and (b) the associations between youth adherence and treatment outcomes.

Data were from 279 youth (ages 7 to 17 years, 51.6% female; 79.6% White, 9% African American) with DSM-IV-TR diagnoses of separation anxiety disorder, generalized anxiety disorder and/or social phobia, who participated in CBT in the Child/Adolescent Anxiety Multimodal Study (CAMS). Adherence was defined in three ways (session attendance, therapist-rated compliance, and homework completion).

Multiple regressions revealed several significant predictors of youth adherence with CBT, but predictors varied according to the definition of adherence.The most robust predictors of greater adherence were living with both parents and fewer youth comorbid externalizing disorders. With respect to outcomes, therapist ratings of higher youth compliance with CBT predicted several indices of favorable outcome: lower anxiety severity, higher global functioning, and treatment responder status after 12 weeks of CBT. Number of sessions attended and homework completion did not predict treatment outcomes.


Findings provide information about risks for youth non-adherence which can inform treatment, and highlight the importance of youth compliance with participating in therapy activities, rather than just attending sessions or completing homework assignments.

Youth Adherence with Cognitive Behavioral Therapy for Anxiety Disorders: Predictors and Associations with Outcomes

Anxiety disorders are among the most common youth mental health disorders and are associated with broad impairments in functioning ( Beesdo, Knappe, & Pine, 2009 ; Davis, Ollendick,&Nebel-Schwalm, 2008 ; Hughes, Lourea-Waddell, & Kendall, 2008 ). There is substantial evidence that cognitive behavioral therapy (CBT) is effective (e.g., Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016 ; Walkup et al., 2008 ); however, about 40–50% of youth do not show clinically meaningful improvement ( James, Soler, & Weatherall, 2005 ).Although a number of factors have been examined in relation to CBT outcomes for anxiety (e.g., baseline anxiety levels, parental psychopathology; see Compton et al., 2014 ; Southam-Gerow, Kendall, & Weersing, 2001 ), one factor that has received relatively little attention, yet may be critical for understanding child psychotherapy outcomes, is patient adherence ( McNicholas, 2012 ; Nock & Ferriter, 2005 ).

In general, patient adherence is conceptualized as participation in prescribed therapy activities. However, there is no “gold standard” definition of adherence with CBT and prior studies have used varying definitions. The three most common indicators of patient adherence with therapy are attendance, observer ratings of adherence/compliance, and homework completion. Attendance encompasses the number of therapy sessions attended and is sometimes examined as treatment completion, early termination, or dropout, which are closely related constructs. In addition to attending sessions, researchers have emphasized the importance of complying with therapeutic activities, including participation and involvement in the therapy session and actively engaging in activities such as role-playing ( Becker et al., 2015 ; Nock & Ferriter, 2005 ). The degree of compliance in the therapy session is typically measured by the therapist (e.g., Nock, Ferriter, & Holmberg, 2007 ) or independent observer (e.g., Chu & Kendall, 2004 ). Also, homework is an essential component of CBT for anxiety and completing homework assignments outside of the therapy session may impact treatment outcomes ( Hudson & Kendall, 2002 ). Studies of treatment adherence for youth mental health disorders have focused on treatment for externalizing disorders, which are primarily behavioral interventions with parents, and have examined parent attendance and therapist-rated quality of participation in parent management training sessions (e.g. Dumas, Nissley-Tsiopinis, & Moreland, 2007 ; Nix, Bierman, McMahon, & CPPRG, 2009 ). Studies that have examined internalizing and externalizing disorder treatment, have mostly looked at retention or completion of treatment (e.g. Miller, Southam-Gerow, &Allin, 2008 ; Pellerin, Costa, Weems, & Dalton, 2010 ). Moreover, findings from this literature have been inconsistent in terms of predictors of attendance and therapist ratings of compliance, which may be partly due to the different definitions of adherence ( Nix et al., 2009 ; Nock & Ferriter, 2005 ).Because there is no unitary “gold standard” definition of adherence this study examined three related, but distinct constructs of adherence: attendance, observer ratings of compliance, and homework completed.

Given the importance of youth adherence in predicting therapy outcomes ( Becker et al., 2015 ; Nock & Ferriter, 2005 ) and the limited data on youth adherence with treatments for anxiety, this study focused on youth adherence with CBT for anxiety in a large sample of children and adolescents and explored: a) predictors of different aspects of youth adherence and b) the associations between youth adherence and CBT treatment outcomes for anxiety.

Predictors of Youth Adherence

Based on prior reviews of patient adherence with treatment across the lifespan ( Kardas, Lewek, & Matyjaszcyk, 2013 ; Nock & Ferriter, 2005 ; Sabate, 2003 ), four domains of predictors of youth adherence with anxiety treatment were examined: demographics, youth clinical characteristics, therapy-related factors, and parent/family factors.


With respect to demographic factors, low socioeconomic status (SES), ethnic minority status, and living with a single parent have been associated with fewer sessions attended and lower quality participation in parent management training for young children with disruptive behavior problems ( Nix et al., 2009 ; Dumas et al., 2007 ). However, studies that have looked at treatment completion in community mental health clinics have yielded inconsistent findings. In a sample of children from early childhood through adolescence, Miller and colleagues (2008) found that SES, race/ethnicity, and single parent status were the most common differences between youth who remained in outpatient therapy and those who terminated early at a clinic serving youth with a variety of diagnoses and therapy treatments. However, Pellerin and colleagues (2010) reported no significant associations between demographics(such as child age, ethnicity, gender and family income) and child and adolescent treatment completion or attendance with therapy treatment at an urban community mental health clinic. There are two studies that have examined demographic predictors of youth adherence with anxiety treatment. In one study, ethnic minorities and children from single parent households were more likely to terminate CBT treatment prematurely ( Kendall & Sugarman, 1997 ). However, in another study with a similar but smaller sample, there were no significant associations between demographics and child involvement in therapy ( Chu & Kendall, 2004 ). Additional studies are needed to clarify differences in findings.

Youth clinical characteristics.

With respect to youth clinical characteristics, greater internalizing or externalizing symptom severity and impairment in functioning were associated with premature termination ( Pellerin et al., 2010 ).Data on child clinical predictors of adherence with treatment for anxiety disorders is limited, with one study finding no associations between internalizing and externalizing symptom ratings and completion of CBT for anxiety ( Pina, Silverman, Weems, Kurtines, & Goldman, 2003 ).

Therapy-related factors.

Research on therapy-related factors has examined a number of variables in relation to treatment adherence, such as expectations and attitudes about treatment ( Becker et al., 2015 ). Specifically, positive parent and child beliefs about the effectiveness of treatment significantly predict greater therapist-rated adherence and attendance, respectively ( Edlund et al., 2002 ; Nock et al., 2007 ).These expectancies have yet to be examined in predicting youth adherence with anxiety treatment.

An additional therapy-related factor is the therapeutic relationship, and children with positive relationships with their therapists are more likely to attend therapy sessions for a range of mental health disorders ( Garcia & Weisz, 2002 ). For youth anxiety treatment specifically, there is little data supporting this hypothesis. Hughes and Kendall (2007) found a moderate correlation ( r = .38) between the average rating of the therapeutic relationship and homework compliance concurrently. Additional research is needed to examine whether initial therapeutic relationship predicts adherence.

Parent/family factors.

Parents play an important role in whether a child or adolescent is adherent with therapy. Parents are typically responsible for transportation and payment for services, directly influencing session attendance ( Nock & Ferriter, 2005 ). Factors associated with parents and families, such as parental psychopathology and family stress, are believed to have an impact on homework completion and managing the child’s involvement in out of session therapy activities for treatment of anxiety disorders ( Hudson & Kendall, 2002 ). Some, but not all, studies on adherence with treatments for a range of mental health disorders have revealed that greater parental depressive symptoms is associated with lower quality participation in parent management training ( Nix et al., 2009 ) and youth completion of mental health treatment ( Pellerin et al., 2010 ). Also, parents who reported more parenting and life stress were more likely to have children who attended fewer therapy sessions and dropped out of treatment prematurely ( Miller et al., 2008 ; Pellerin et al., 2010 ).Overall, there is limited research examining predictors of youth adherence with CBT for anxiety treatment.

Youth Adherence and Therapy Outcomes

In theory, patient adherence with treatment is critical to the effectiveness of the treatment, however, few empirical studies have explored these effects for child anxiety treatment outcomes and extant findings are inconsistent. For instance, when defined as observer ratings of practicing and using prescribed treatment skills, there is preliminary evidence that greater child involvement in individual therapy sessions, especially at mid-treatment, is associated with larger reductions in anxiety symptom severity and impairment ratings post-treatment ( Chu & Kendall, 2004 ). However, when defining adherence as completion of therapy assignments out of session (i.e. homework assignments), data are mixed—with some studies showing a positive relation with outcomes ( Kazantzis, Deane, & Ronan, 2000 ; White et al., 2013 ) and others ( Hughes & Kendall, 2007 ) suggesting that other variables such as therapeutic relationship are more important predictors of CBT treatment outcome for youth anxiety. Replication of these findings with well-powered samples is needed, given the modest sample sizes of prior reports.

The Current Study

The first study aim was to identify baseline and initial therapy predictors of treatment adherence. Four domains of predictors were examined: baseline demographics, clinical characteristics, therapy-related factors, and family and parent factors. Given the limited and mixed research on predictors of youth adherence with CBT, the first aim was exploratory using a large number of baseline and initial therapy predictors. In terms of demographic predictors, it was hypothesized that higher SES, non-racial/ethnic minority status, and living with both parents would be associated with greater adherence. Other hypothesized predictors of higher levels of youth adherence include: less severe internalizing and externalizing symptoms, expectancy that therapy will be effective, a positive therapeutic relationship, lower parental psychopathology and lower family stress. The second study aim was to examine the association between adherence and treatment outcomes. Based on prior studies, it was hypothesized that greater adherence would predict better treatment response, reduced anxiety symptoms, and greater overall functioning at post treatment.


Participants were 279 children and adolescents (51.6% female; 79.6% White, 9% African American, 2.5% Asian, 1.4% Native American; 13.3% Hispanic) from six sites enrolled in the Child/Adolescent Anxiety Multimodal Study (CAMS; see Compton et al., 2010 ; Walkup et al., 2008 for detailed study methods) who were randomly assigned to the two conditions including CBT (CBT only n = 139 and combination CBT and Sertraline (COMB)n = 140).Participants were recruited through advertisements and other outreach in effort to represent the populations typically seeking services at the various clinics located in urban settings in the United States. Comparison of participants in CBT only and COMB showed no significant differences on any measures of youth adherence with CBT. Eligible participants were ages 7–17 years old, who met criteria for at least one of the following DSM-IV TR ( American Psychiatric Association, 2000 ) anxiety disorders: separation anxiety disorder (SAD), social phobia (SoP), or generalized anxiety disorder (GAD). Although participants with a wide range of comorbidities were included, youth with the following primary disorders were excluded: major depressive disorder, bipolar disorder, pervasive developmental disorder, and schizophrenia or schizoaffective disorder. Youth with low IQ were generally excluded, since low IQ may limit the youth’s ability to participate in CBT. Participants were from predominantly middleclass and upper middle class families, with 75.6% scoring at or above 4 on the Hollingshead Two-Factor Scale (range 0 – 5; Hollingshead, 1971 ).

CAMS CBT Intervention

CAMS used the Coping Cat , which is a manual-based CBT for children and adolescents. There are two age-appropriate versions of the Coping Cat protocol: Coping Cat for children ( Kendall & Hedtke, 2006 ) and C.A.T. Project for adolescents ( Kendall, Choudhury, Hudson, & Webb, 2002 ). Both protocols include 12 individual child sessions (60 minutes each) and 2 parent only sessions scheduled over 12 weeks. Each session includes a homework assignment, referred to as a STIC (Show That I Can) task to practice coping skills, and/or exposure task performed outside of sessions. CBT was provided by trained therapists (see Podell et al., 2013 for full description).

After families signed informed consent, data collection started at baseline with a semi-structured diagnostic interview conducted by Independent Evaluators (IEs). IEs were certified to evaluate participants and supervised throughout the study. Also at baseline, the child/adolescent and parent/guardian filled out questionnaires. In the CAMS project, eligible youth were randomized into one of four treatment conditions: CBT only, SRT (Sertraline medication) only, COMB (combination CBT and SRT), or PBO (placebo) (see Walkup et al., 2008 for the CONSORT diagram for CAMS). In the present study which examined youth adherence with CBT only, youth in the SRT only and PBO were therefore excluded.For youth in the CBT and COMB conditions, their CBT therapist completed a session summary form at every session during the treatment period. At 12 weeks (post treatment), IEs conducted the diagnostic interview and rated symptom severity and functioning. IEs were masked to participants’ treatment conditions. Families were compensated for their participation. All study procedures were approved and monitored by the Institutional Review Boards at each site.

Demographic predictors (collected from the parent) included youth age, sex, race, ethnicity, socioeconomic status (SES), and whom the youth was living with.Because most youth in this study were White (79.6%), race was dichotomized into White and non-White. SES was derived from parent reports of parental occupation and parental education level using Hollingshead’s (1971) two-factor index. Total scores ranged from 1 to 5, and were dichotomized into low SES (scores 1–3) and high SES (scores 4–5).Baseline clinical characteristics (principal diagnosis, number of comorbid internalizing and externalizing disorders) were assessed using the Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent Versions (ADIS-IV-C/P; Silverman & Albano, 1996 ). The ADIS-IV-C/P has demonstrated excellent psychometrics ( Lyneham, Abbott, & Rapee, 2007 ; Silverman, Saavedra, & Pina, 2001 ). In CAMS, 10% of IE evaluations were assessed for inter-rater reliability, calculated as intraclass correlation coefficients, which ranged from .82 to .88 ( Compton et al., 2014 ). The IEs identified the principal diagnosis and determined the number of other internalizing (depressive or anxiety disorders other than SAD, SoP, or GAD) and externalizing (ADHD, ODD, or CD) diagnoses. Using information gleaned during the ADIS-IV-C/P interview, IEs also rated the global anxiety symptom severity using the Clinical Global Impressions Scale – Severity (CGI-S; Guy 1976 ). The CGI-S ranges from 1 (not at all ill) to 7 (extremely ill), with higher scores indicating greater severity.The CGI-S has demonstrated strong associations with self-report and therapist administered measures of symptom severity and impairment ( Zaider, Heimberg, Fresco, Schneier, & Liebowitx, 2003 ).To assess overall functional impairment, the Children’s Global Assessment Scale (CGAS; Shaffer et al., 1983 ) was rated by the IE on a scale from 0 to 100. Lower scores reflect greater functional impairment and lower overall functioning. The CGAS has acceptable psychometric properties ( Green, Shirk, Hanze, & Wanstrath, 1994 ).

Therapy-related factors included pretreatment expectancy and initial therapeutic relationship. Pretreatment expectancy was assessed at baseline prior to randomization, by asking each child/adolescent and parent to indicate how much improvement they expected under each of the treatments (COMB, SRT, CBT, PBO). Possible ratings were 1 (very much worse) to 7 (very much improvement). Treatment expectancy ratings for the treatment to which the youth was randomly assigned (CBTor COMB) were used in the current analyses.The quality of the initial Therapeutic Relationship was rated by the therapist after the first CBT session using a 7-point Likert scale, with responses ranging from “very poor” to “very good.”

Family/parental psychopathology was assessed at baseline using multiple measures of parent psychopathology, burden, and family functioning. The Brief Symptom Inventory (BSI; Derogatis, 1993 ) was rated by the parent and assessed distress associated with parental psychopathology. The BSI is a 53-item self-report measure, rated on a 5-point Likert scale from 0 (not at all) to 4 (extremely). The BSI Global Severity Index (BSI-GSI) provides a single score of current psychological distress and symptoms (higher values indicate greater severity). Prior studies have demonstrated good psychometrics ( Derogatis & Melisaratos, 1983 ), and in this sample, the alpha for the BSI-GSI was .95 at baseline. The family Burden Assessment Scale (BAS; Reinhard, Gubman, Horwitz, & Minsky, 1994 ) is a 21-item measure of caregiver strain around having a child with a mental health disorder. Parents completed the BAS and items included questions about how much their child’s anxiety disrupts family life, routines, and emotions over the previous two weeks using a scale ranging from 1 (not at all) to 5 (very much). Higher scores indicate greater burden. Reliability and validity for the BAS have been demonstrated ( Reinhard et al., 1994 ); the alpha was .92 at baseline for this sample. The Brief Family Assessment Measure-III (BFAM-III; Skinner, Steinhauer, & Santa-Barbara, 1995 ) provides an assessment of family functioning from the perspective of children/adolescents and their parents.Parents and children/adolescents responded to 14 items using a 5-point scale.The BFAM-III General Scale, tapping overall perceived family health, was used. Higher scores suggest greater levels of perceived family dysfunction. There is discriminant and content validity for the BFAM-III ( Bloomquist & Harris, 1984 ), and the alpha was .85 for parent report and .75 for youth report at baseline for this sample.

Adherence measures.

Sessions attended: attendance was scored as the number of youth therapy sessions attended within the 12 week treatment period (possible range 1–12 sessions). Therapist-rated compliance: after each CBT session, therapists rated the youth’s overall compliance on the session summary form, defined as one question asking how well the child completed the requirements of the therapy as given by the therapist (e.g. works on the assignments of the session, works on homework) and how engaged the child is in the treatment process (e.g. engaged in the sessions, resists or dismisses the therapists’ suggestions). Therapists were instructed to consider compliance independently of improvement or adverse events and provided a rating using a 7-point Likert scale, with responses ranging from “poor” to “good”.Therapist-rated compliance was averaged over all completed sessions to form a mean compliance score per person. Homework completed: therapists reported whether a child completed a STIC or exposure task prior to the session (yes/no) at each CBT session. The measure of homework completed was calculated as a ratio of the total number of sessions that the youth completed homework divided by the total number of sessions the youth attended. This data was extracted from the session summary form.

Treatment outcomes.

Three different measures of youth treatment outcomes were used, which were assessed by IEs at baseline and 12 weeks post randomization.The Pediatric Anxiety Rating Scale (PARS; RUPP, 2002) is a measure of the severity/impairment associated with a broad range of anxiety symptoms. The IE-rated PARS total score in this study was calculated by summing six items assessing anxiety severity, frequency, distress, avoidance, and interference in the previous week.Scores ranged from 0 to 30, with higher scores reflecting greater anxiety symptom severity.The PARS has demonstrated good reliability and validity ( RUPP, 2002 ). Global functioning at 12 weeks was assessed by the IE with the CGAS (previously described with the clinical predictors at baseline).The Clinical Global Impressions-Improvement (CGI-I; Zaider et al., 2003 ) scale assessed “responder status”.IEs rated the CGI-I on a scale from 1 (very much improved) to 7 (very much worse). Responder status was used as a dichotomous measure; youth with CGI-I scores of 1 (very much improved) or 2 (much improved) were categorized as treatment responders. The CGI-I has demonstrated strong associations with self-report and therapist administered measures of symptom severity and impairment ( Zaider et al., 2003 ).

Data Analysis

Missing data..

All but 18 children participated in the post-treatment assessment at 12 weeks (6.5% missing). There was also a small percentage of missing data for baseline and adherence measures (0.4 – 2.9% missing), and missing data was imputed using Multiple Imputation in SPSS 23. After examining the missing data, 20 datasets were imputed ( Graham, Olchowski, & Gilreath, 2007 ).

Plan of analysis.

Although youth were nested within therapists, intraclass correlations were low (ICCs < .10), so ratings were determined to be independent and multilevel models were not used. The first aim explored predictors of adherence, so four multiple regressions were conducted (one for each predictor domain: demographic, clinical, therapy-rated, family/parental psychopathology) to identify significant predictors of attendance. Four additional multiple regressions were conducted each for predictors of therapist-rated compliance and homework completion. The second aim examined associations between adherence and youth anxiety outcomes after 12 weeks of treatment. Three regressions with all three indicators of adherence (number of sessions attended, therapist-rated compliance, homework completion) were conducted, controlling for youth age, sex, race, family SES, treatment condition, site and baseline anxiety severity and functioning. Linear regressions were used for continuous outcomes (PARS, CGAS) and logistic regression was used for CGI-I response status (dichotomous).

Descriptive Statistics

Means and standard deviations for all measures are presented in Table 1 . Descriptive statistics were calculated prior to multiple imputation. On average, children attended 10 out of 12 possible child therapy sessions, reflecting the low early termination rates from both conditions (4.3% CBT and 9.3% COMB). Over 90% attended at least 8 sessions, and 35.1% completed all 12 sessions; only 2.2% attended 1 session. CBT therapists reported mean compliance rating of 5.58 (SD =1.15). In terms of homework completion (STIC tasks and/or exposures), 31.5% of children completed at least 1 therapy activity at home prior to all of their sessions, whereas 8.8% did not complete any therapy activities outside of sessions. The three adherence indicators (number of sessions attended, therapist-rated compliance, and homework completion) were significantly correlated with each other ( r = .20 to .34, p < .01). The magnitude was modest, suggesting some independence among these variables.

Means, Standard Deviations, and Ranges for all Variables

Mean (SD)Range
No. sessions attended10.2 (2.34)1.00 – 12.00
Therapist-rated compliance5.58 (1.15)1.40 – 7.00
Homework completed.75 (.30).00 – 1.00
Age (years)11.25 (2.83)7 – 17.8
Sex51.6% female, 48.4% male
Race79.6% White, 9% Black, 2.5% Asian, 1.4% American Indian,
.4% Native Hawaiian/Pacific Islander, 7.2% other
Ethnicity13.3% Hispanic, 86.7% non-Hispanic
Socioeconomic status24.4% SES 1–3, 75.6% SES 4–5
Whom youth living with73.1% both natural parents, 26.9% not both natural parents
CGI-S5.06 (.72)4 – 7
Total internalizing disorders45.6% with internalizing disorders other than separation anxiety,
social phobia, or generalized anxiety disorder
Total externalizing disorders18.7% with externalizing disorders
Principal diagnosis21.5% separation anxiety disorder, 43.7% social phobia, 34.8%
generalized anxiety disorder
Child pretreatment expectancy 5.75 (1.23)1 – 7
Parent pretreatment expectancy 6.08 (.79)3 – 7
Initial therapeutic relationship5.28 (1.3)1 – 7
BSI total27.0 (22.3)0 – 124
BAS total47.9 (14.1)21 – 92
BFAM child total14.4 (5.51)1 – 29
BFAM parent total11.6 (5.34)0 – 30
PARS total baseline19.3 (4.07)7 – 29
PARS total 12 week8.69 (6.13)0 – 26
CGAS baseline50.6 (7.33)30 – 71
CGAS 12 week67.3 (10.8)30 – 91
CGI-I responder74.7% responder, 25.3% non-responder

Note . CGI-S = Clinical Global Impressions Scale – Severity, BSI = Brief Symptom Inventory, BAS = Burden Assessment Scale, BFAM = Brief Family Assessment Measure, PARS = Pediatric Anxiety Rating Scale, CGAS = Children’s Global Assessment Scale, CGI-I = Clinical Global Impressions – Improvement.

Predictors of Adherence

Demographic predictors..

There were few significant demographic predictors (see Table 2 ). Children living with both natural parents were more adherent (across all three indicators of adherence; β = .13 to .17, p < .05). In addition, children from higher SES families attended more CBT sessions (β = .16, p < .01). No other demographic variables (age, sex, race, ethnicity) predicted adherence.

Multiple Regressions Predicting Adherence to CBT

No. sessions attendedTherapist-rated
FR βFR βFR β
5.0 .10 2.6 .05 2.4 .05
Age (years)−.07−.04−.02
.16 .09.10
Whom child living
.15 .13 .17
. .05
Total internalizing
.07.13 .04
Total externalizing
−.10−.13 −.19
Principal diagnosis−.01.00.04

3.9 .04 40 .30 1.7.02
Child pretreatment
Parent pretreatment
.18 .03.07
Initial therapeutic
.02.52 .08

3.3 .05 2.6 .04 .82.01
BSI total−.23 −.07−.11
BAS total.01.03.06
BFAM child.02−.18 .02
BFAM parent.03.01−.01

Note . CGI-S = Clinical Global Impressions Scale – Severity, CGAS = Children’s Global Assessment Scale, BSI = Brief Symptom Inventory, BAS = Burden Assessment Scale, BFAM = Brief Family Assessment Measure.

Youth with fewer externalizing disorders were rated as more compliant(β = −.13, p < .05) and completed more homework assignments (β = −.19, p < .01). In contrast, youth with more internalizing disorders were rated as more compliant(β = .13, p < .05). None of the other youth clinical characteristics (anxiety symptom severity, global functioning, or principal diagnosis) at baseline predicted adherence.

Parent pre-treatment expectancy that their children would improve with treatment was significantly associated with youth attending more sessions (β = .18, p < .01). Better therapeutic relationship assessed at the first session significantly predicted higher mean therapist ratings of compliance(β = .52, p < .01). None of the therapy-related factors significantly predicted homework completion.

Family and parent factors.

Less parental psychopathology predicted more sessions attended (β = −.21, p < .01). Youth-reports of less family dysfunction (BFAM) was associated with higher therapist ratings of compliance in sessions (β = −.18, p < .01). None of the family or parent factors predicted homework completion.

Effects of Adherence on Treatment Outcomes

In multiple linear regressions with all three adherence variables predicting treatment outcomes ( Table 3 ), only therapist ratings of compliance predicted decreased anxiety symptoms (PARS; β = −.23, p < .01),increased global functioning (CGAS; β = .35, p < .01) and responder status [ OR = .45 (95% CI = .31, .68), p < .01], at the post treatment assessment.

MultipleRegressions Predicting Child Outcomes with Adherence

Linear RegressionsPARS totalCGAS
F∆R βF∆R β
Step 1 Control variables9.6 .20 8.1 .17
Step 212 .12 12 .13
Step 2 No. of sessions
Step 2 Therapist-rated
−.23 .35
Step 2 Homework completed−.10.04
Logistic RegressionsCGI-I Response
BPOdds Ratio95% CI
No. sessions attended−.44.17.64[.34, 1.21]
Therapist-rated compliance−.79 .00.45[.31, .68]
Homework completed−.31.10.74[.51, 1.05]

Note. Analyses control for baseline score on the treatment outcome, child age, sex, race, family socioeconomic status, treatment condition, and site.

Note . PARS = Pediatric Anxiety Rating Scale, CGAS = Children’s Global Assessment Scale, CGI-I = Clinical Global Impressions – Improvement: 0 = responder (CGI-I = 1 or 2), 1 = non-responder.

Although CBT is an effective treatment for pediatric anxiety disorders (e.g. Higa-McMillan et al., 2016 ), youth adherence with treatment is considered to be required for optimizing benefits. This study explored predictors of youth adherence with CBT and the relation between youth adherence and treatment outcomes. The most robust predictors of greater youth adherence were living with both parents and fewer child externalizing disorders. In addition, higher therapist-rated compliance (but not sessions attended or amount of homework completed), was associated with better post treatment outcomes.

Predictors of Youth Adherence with CBT

This study is one of the largest and the first to examine a broad range of predictors of youth adherence with CBT for anxiety, using three definitions of adherence.With respect to demographic variables, children living with both parents were more adherent based on all three adherence measures. Similarly, children in homes with higher family income attended more therapy sessions. A two parent living situation and higher family income likely translate into higher family supports in the household, as families with both parents have more adults available to bring children to therapy sessions and support homework compliance. In addition, higher SES families have more resources to support child attendance and fewer financial and transportation obstacles that are often barriers for single parent and lower income families ( Owens et al., 2002 ). Overall, however, the demographic predictors accounted for 5–10% of the variance in adherence suggesting additional variables should be examined.

With respect to baseline youth clinical characteristics, results indicated that youth with a higher number of comorbid internalizing disorders, such as depression or obsessive compulsive disorder,and those with fewer externalizing disorders, were rated as more adherent by their therapists. It may be that children with more internalizing symptoms (and fewer externalizing symptoms), experience more internal distress and thus higher motivation to engage in therapy to achieve symptom relief. Children with externalizing symptoms such as inattention, impulsivity, and oppositionality may be more likely to be noncompliant with homework assignments, disorganized, have difficulty following through with therapist directions, or they may outright refuse to complete homework. Of note, and consistent with previous studies ( Chu & Kendall, 2004 ; Pina et al., 2003 ), other child clinical factors such as principal anxiety disorder, severity of anxiety symptoms (CGI-S), and global functioning (CGAS) did not predict adherence. Despite these findings baseline clinical characteristics accounted for small amounts of variance in all three indicators of adherence (2–5%) and many clinical characteristics (such as baseline anxiety severity and functioning) were not predictive of treatment adherence.

In contrast to demographics and baseline child clinical characteristics, therapy-related predictors, in particular therapeutic relationship, accounted for a substantial amount of variance (30%) in therapist-rated compliance (but was not related to number of sessions attended or homework completed). Since the therapist rated both the initial therapeutic relationship and compliance at each session, this association is not surprising and may be inflated. Although there may be biases with this association, the importance of the therapeutic relationship for youth adherence with treatment (and outcomes) is also theoretically supported and the bedrock of most approaches to psychotherapy ( Shirk & Karver, 2003 ). These findings support this theory indicating that the more therapists perceived a positive therapeutic relationship early in treatment, the more the youth was rated by the therapist as treatment compliant throughout treatment. Another therapy-related predictor was parental beliefs that their children would improve with treatment, which significantly predicted greater number of sessions attended. Parents are often responsible for bringing children to therapy, and parents who perceive that treatment will be beneficial are more likely to bring their children to therapy sessions.

With respect to parent and family factors, these variables accounted for very little of the variance in adherence (1–5%). When examining individual parent and family predictors, less parental psychopathology was associated with more therapy sessions attended. Since parents are typically responsible for bringing children to therapy sessions, this finding that parental psychopathology predicts session attendance is consistent with prior research ( Nock et al., 2007 ; Pellerin et al., 2010 ). Also, youth-reports of less family dysfunction were associated with higher therapist ratings of compliance. Perhaps when children perceive less stress at home, they are more likely to be able to participate in therapy activities ( Kazdin, Holland, & Crowley, 1997 ).

Overall, the current findings provide support for Kazdin’s barriers to treatment model ( Kazdin et al., 1997 ),which proposes that barriers to treatment, such as stressors and obstacles that impede participation (e.g. parental stress and psychopathology, accessibility of treatment setting, parent expectations about treatment effectiveness) and issues with treatment demands better explain adherence in youth therapy rather than demographic or clinical characteristics of the child/adolescent.Therefore, therapists should take into consideration the living situation of families and stressors that families without both parents in the household may encounter that impede treatment adherence. In addition, parent factors such as parental psychopathology and parent expectations about treatment were significantly associated with session attendance, and highlight the importance of supporting parents when promoting youth adherence with CBT.Although type of primary anxiety diagnosis and anxiety symptom severity did not predict youth adherence with CBT, number of internalizing and externalizing disorders did, suggesting that addressing symptoms of inattention, impulsivity, and/or defiance may increase youth adherence with treatment for anxiety, even when anxiety is considered the primary, or most impairing, disorder. Finally, while the initial therapeutic relationship predicted therapist ratings of youth adherence, additional research is needed to clarify and understand the processes through with therapists may promote youth adherence through the therapeutic relationship.

Youth Adherence and Treatment Outcomes

A critical question related to youth adherence is whether more is better, with respect to treatment outcomes. Data on this relation in the literature is mixed–with variations in findings due in part to how youth adherence has been defined.To address this limitation, the current study examined three indicators of youth adherence, yet, only one of the three adherence variables was related to treatment outcomes. Specifically, only therapist-rated compliance was a predictor of outcomes, accounting for up to 13% of the variance in outcomes above and beyond the variance explained by demographic control variables such that children rated as more compliant with therapy tasks (both within and outside of treatment sessions) were more likely to be treatment responders, had lower anxiety severity, and increased global functioning at post treatment. These findings are consistent with previous studies that have examined attendance and therapist-rated compliance together, and found that therapist ratings of compliance, but not attendance predicts treatment outcomes (e.g. Garvey, Julion, Fogg, Kratovil, & Gross, 2006 ; Nix et al., 2009 ). One “take home” message is that since CBT involves skill development and practice, it is especially important for children to actively participate and follow through with therapy activities throughout treatment ( Chu & Kendall, 2004 ).

Limitations and Future Directions

Results should be interpreted in the context of limitations. Overall, this study was notable for high treatment completion and attendance rates, which may have reduced the ability to detect some associations due to the restricted range and limited variability of adherence scores. This study used therapist ratings for one measure of adherence and one of the predictors (initial therapeutic relationship), which may have influenced these relations. It is possible that therapists’ perception of a more positive therapeutic relationship may bias them to rate the child/adolescent as more compliant. Youth ratings of therapeutic relationship at the initial session were not assessed, but should be included in future studies. Also, future studies should include observer ratings of compliance, which would reduce the issue of shared method variance. Furthermore, the therapist rating of compliance includes ratings of engagement, which are overlapping constructs that may also have differences. For example, treatment engagement may also include readiness for treatment ( Becker et al., 2015 ), but the distinction between compliance and engagement could not be disentangled is this study and warrant exploration in future research. Although this study focused on youth adherence, it was acknowledged that parents can play a role in youth adherence with treatment. Future studies could explore the adherence of parents in supporting youth adherence. In addition, therapists may have assigned differing amounts and levels of difficulty of homework, which may have influenced youth adherence.

There may be predictors of adherence that were not measured, such as therapist demographics, therapist experience, or parent and youth perceptions of the accessibility of services. This study focused on baseline and initial therapy predictors of youth adherence, however, there may be factors during treatment (e.g. changes in therapeutic relationship, changes in symptom severity) that contribute to adherence, and these time-varying factors should be examined in future studies.

The primarily Caucasian, non-Hispanic, high SES sample living with both parents may limit variability in some measures and restricts the generalizability of findings.Cultural differences in the perception of mental health and treatment may impact adherence and treatment outcomes. In addition, youth from lower SES families or not living with both parents may face additional challenges that reduce adherence, which should be explored further with a more diverse sample. This study found that adherence was associated with treatment outcomes, so it is necessary to examine adherence in samples with greater risks as those findings may inform interventions to increase adherence and thus treatment outcomes.Given the small percentage of racial minority youth in this study, the measure of race was dichotomized and racial minorities were grouped together; however, there may be different associations with adherence for different racial groups that this study was unable to explore.

Clinical Implications

Many interventions for treatment adherence have focused on increasing attendance (e.g. appointment reminders, promoting accessibility to services; Lindsey et al., 2014 ).The current findings suggest that attending sessions is not sufficient for positive treatment outcomes, particularly for youth anxiety treatment. Rather, overall youth adherence with therapy, including engagement and participation in skill development in session as well as practicing these skills, is associated with positive treatment outcomes. Therefore, future research should examine interventions that target promoting youth behaviors of engaging and participating in therapy activities. There are important implications of these findings for therapists to employ strategies that promote youth engagement and involvement in therapy activities. Also, this study identified predictors that may be targeted in interventions to increase youth adherence with therapy. For example, interventions can incorporate strategies for addressing barriers to treatment adherence, such as those associated with living with a single parent, low expectations about treatment, support for parental psychopathology and family stress, and management of externalizing behaviors (e.g. Chronis, Gamble, Roberts, & Pelham, 2006 ; Miller & Rollnick, 2002 ). Further exploration of supports for these predictors of adherence and whether they have a positive impact on treatment outcomes is needed.


National Institute of Mental Health: U01MH064092,U01MH63747,U01MH64003,U01MH64088,U01MH64089,U01MH64107

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  1. Supporting Homework Compliance in Cognitive Behavioural Therapy

    Homework Non-Compliance in CBT. Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [1,2].It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [3-6].

  2. A Comprehensive Model of Homework in Cognitive Behavior Therapy

    This article contributes a comprehensive model of homework in cognitive behavior therapy (CBT). To this end, several issues in the definition of homework and homework compliance are outlined, research on homework-outcome relations is critiqued, before an overview of classical and operant conditioning along with various cognitive theories are tied together in a comprehensive model. We suggest ...

  3. The Relationship Between Homework Compliance and Therapy Outcomes: An

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  4. Promoting Homework Adherence in Cognitive-Behavioral Therapy for

    The assignment of homework is considered important in Cognitive-Behavioral Therapy (CBT) as a means to build and generalize new client skills. A growing body of evidence supports homework as an active ingredient in CBT for adults (see Kazantzis et al., 2010, for a meta-analysis). Although only a handful of empirical studies have examined the ...

  5. Homework Compliance and Quality in Cognitive Behavioral ...

    H omework is considered an integral part of cognitive behavioral therapy (CBT) and has been incorporated into CBT for a variety of emotional disorders, including the range of anxiety and obsessive-compulsive disorders (Beck et al., 1979, Kazantzis et al., 2000).Homework in CBT encourages practice of cognitive and behavioral skills to help patients integrate the use of adaptive strategies into ...

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    The available evidence suggests homework is a contributor to positive therapeutic outcomes in cognitive behavioral therapy. Although therapists play an important role in facilitating clients' engagement with homework as they develop greater facility with CBT skills, little is known about the contributions of specific approaches to promoting ...

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

    Early CBT research attempted to document how much of the outcome in treatment could be ascribed to homework assignments. Much of this work was correlational, in that researchers typically measured the degree and/ or quality of homework conducted between sessions of CBT, and then correlated these measurements with clinical outcome (Kazantzis et al., 2016; Mausbach et al., 2010).

  10. The Use of Homework in Cognitive Behavior Therapy ...

    Therapy must become part of the patient's life. The CBT tasks of monitoring automatic thoughts, identifying and examining schema, and behavioral change are essential ingredients that must be ongoing. Homework cannot be an addendum to therapy but an integrated and focused part of the therapy that is introduced in the very first session.

  11. Measuring Homework Compliance in Cognitive-Behavioral Therapy for

    This is especially true among youth receiving CBT. The present study begins to address how best to measure homework compliance and offers a fine-grained, single-case analysis of homework compliance during acute treatment with depressed adolescents. The results demonstrate that 56% of homework assignments were completed.

  12. Problems With Homework in Cbt: Rare Exception or Rather Frequent?

    Despite this, little is known about problems with homework completion or possible influences on homework compliance. The aim of the present practitioner survey was to provide data on problems related to homework use and compliance. Furthermore, the relationships between different variables and homework compliance were examined.

  13. The role of homework engagement, homework-related therapist behaviors

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  15. PDF A Comprehensive Model of Homework in Cognitive Behavior Therapy

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    Embedding the silver thread in all-age psychological services: training and supervising younger therapists to deliver CBT for anxiety or depression to older people with multi-morbidity. The Cognitive Behaviour Therapist, Vol. 15, Issue. ,

  17. British Journal of Clinical Psychology

    Cognitive behavioural therapy (CBT) is an effective treatment for depression, but many clients do not complete therapy. What clients find difficult about CBT is poorly understood. This study explored clients' views and experiences of face-to-face CBT. Design. A mixed methods design was used to collect data as part of the CoBalT trial. Method

  18. Predictors of Homework Engagement in CBT Adapted for ...

    Between-session interventions (i.e., homework) are integral to CBT, and represent the main vehicle for the generalization of in-session learning (Beck 2011).Meta-analyses have demonstrated clinically significant relationships between higher levels of homework quantity and quality (i.e., skill acquisition), and better CBT outcomes (Kazantzis et al. 2000, 2010, 2016, 2018b; Mausbach et al. 2010).

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

    We explore why homework in CBT is so essential and how you can design engaging, effective CBT interventions using modern technology. ... Homework assignments have been a central feature of the Cognitive-Behavioral Therapy (CBT) process since the 1970s (Kazantzis, 2005). ... Scholars have also drawn on social learning and cognitive theories to ...

  20. Cognitive-behavioral therapy for management of mental health and stress

    Research on CBT. Using "CBT "and "biopsychosocial" as PubMed search terms, 345 studies published between January 1987 and May 2021 were identified (Fig. 1); 14 of 154 review articles were systemic reviews, and 45 of 53 clinical trials were randomized controlled trials.Most clinical trials recruited the samples from patient populations in order to assess specific diseases, but some ...

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

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

  22. Cognitive-Behavioral Treatments for Anxiety and Stress-Related

    Cognitive-behavioral therapy (CBT) is a first-line, empirically supported intervention for anxiety disorders. CBT refers to a family of techniques that are designed to target maladaptive thoughts and behaviors that maintain anxiety over time. Several individual CBT protocols have been developed for individual presentations of anxiety.

  23. Child and Adolescent Adherence with Cognitive Behavioral Therapy for

    Cognitive Behavioral Therapy (CBT) for anxiety disorders is effective, but non-adherence with treatment may reduce the benefits of CBT. This study examined (a) four baseline domains (i.e., demographic, youth clinical characteristics, therapy-related, family/parent factors) as predictors of youth adherence with treatment and (b) the associations ...