Home » Positive CBT » 25 CBT Techniques and Worksheets for Cognitive Behavioral Therapy
You have definitely heard about CBT.
You may not know it, or you may not immediately assign meaning to those three letters placed side by side, but there’s almost no doubt that you have at least a passing familiarity with CBT.
If you’ve ever interacted with a therapist, a counselor, or a clinician in a professional setting, you have likely participated in CBT. If you’ve ever heard friends or loved ones talk about how a mental health professional helped them recognize their fears or sources of distress and aided them in altering their behavior to more effectively work towards their goals, you’ve heard about the impacts of CBT.
CBT, or cognitive behavioral therapy, is one of the most used tools in the psychologist’s toolbox. It’s based on a fairly simple idea which, when put into practice, can have wildly positive outcomes.
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What is CBT?
This simple idea is that our unique patterns of thinking, feeling, and behaving are significant factors in our experiences, both good and bad. Since these patterns have such a significant impact on our experiences, it follows that altering these patterns can change our experiences (Martin, 2016).
CBT aims to change our thought patterns, the beliefs we may or may not know we hold, our attitudes, and ultimately our behavior in order to help us face our difficulties and more effectively strive towards our goals.
The founder of CBT is a psychiatrist named Aaron Beck, a man who practiced psychoanalysis until he noticed the prevalence of internal dialogues in his clients, and realized how strong the link between thoughts and feelings can be. He altered the therapy he practiced in order to help his clients identify, understand, and deal with the automatic, emotion-filled thoughts that arise throughout the day.
Beck found that a combination of cognitive therapy and behavioral techniques produced the best results for his clients. In describing and honing this new therapy, Beck laid the foundations of the most popular and influential form of therapy of the last 50 years.
This form of therapy is not designed for lifelong participation, but focuses more on helping clients meet their goals in the near future. Most CBT treatment regimens last from five to ten months, with one 50 to 60 minute session per week.
CBT is a hands-on approach that requires both the therapist and the client to be invested in the process and willing to actively participate. The therapist and client work together as a team to identify the problems the client is facing, come up with new strategies for addressing them, and thinking up positive solutions (Martin, 2016).
Many of the most popular and effective CBT techniques are applied to what psychologists call “cognitive distortions” (Grohol, 2016).
Cognitive distortions: inaccurate thoughts that reinforce negative thought patterns or emotions.
Cognitive distortions are faulty ways of thinking that convince us of a reality that is simply not true.
There are 15 main cognitive distortions that can plague even the most balanced thinkers at times:
Filtering refers to the way many of us can somehow ignore all of the positive and good things in our day to focus solely on the negative. It can be far too easy to dwell on a single negative aspect, even when surrounded by an abundance of good things.
Polarized Thinking / “Black and White” Thinking
This cognitive distortion is all about seeing black and white only, with no shades of grey. This is all-or-nothing thinking, with no room for complexity or nuance. If you don’t perform perfectly in some area, then you may see yourself as a total failure instead of simply unskilled in one area.
Overgeneralization is taking a single incident or point in time and using it as the sole piece of evidence for a broad general conclusion. For example, a person may be on the lookout for a job but have a bad interview experience, but instead of brushing it off as one bad interview and trying again, they conclude that they are terrible at interviewing and will never get a job offer.
Jumping to Conclusions
Similar to overgeneralization, this distortion involves faulty reasoning in how we make conclusions. Instead of overgeneralizing one incident, however, jumping to conclusions refers to the tendency to be sure of something without any evidence at all. We may be convinced that someone dislikes us with only the flimsiest of proof, or we may be convinced that our fears will come true before we have a chance to find out.
Catastrophizing / Magnifying or Minimizing
This distortion involves expectations that the worst will happen or has happened, based on a slight incident that is nowhere near the tragedy that it is made out to be. For example, you may make a small mistake at work and be convinced that it will ruin the project you are working on, your boss will be furious, and you will lose your job. Alternatively, we may minimize the importance of positive things, such as an accomplishment at work or a desirable personal characteristic.
This is a distortion where an individual believes that everything they do has an impact on external events or other people, no matter how irrational the link between. The person suffering from this distortion will feel that they have an unreasonably important role in the bad things that happen around them. For instance, a person may believe that the meeting they were a few minutes late in getting to was derailed because of them, and that everything would have been fine if they were on time.
Another distortion involves feeling that everything that happens to you is a result of external forces or due to your own actions. Sometimes what happens to us is due to forces we can’t control, and sometimes what happens is due to our actions, but the false thinking is in assuming that it is always one or the other. We may assume that the quality of our work is due to working with difficult people, or alternatively that every mistake someone else makes is due to something we did.
Fallacy of Fairness
We are often concerned about fairness, but this concern can be taken to extremes. As we know, life is not always fair. The person who goes through life looking for fairness in all their experiences will end up resentful and unhappy. Sometimes things will go our way, and sometimes they will not, regardless of how fair it may seem.
When things don’t go our way, there are many ways we can explain or assign responsibility for the outcome. One method of assigning responsibility is blaming others for what goes wrong. Sometimes we may blame others for making us feel or act a certain way, but this is a cognitive distortion because we are the only ones responsible for the way we feel or act.
“Shoulds” refer to the implicit or explicit rules we have about how we and others should behave. When others break our rules, we are upset. When we break our own rules, we feel guilty. For example, we may have an unofficial rule that customer service representatives should always be accommodating to the customer. When we interact with a customer service representative that is not immediately accommodating, we might get angry. If we have an implicit rule that we are irresponsible if we spend money on unnecessary things, we may feel exceedingly guilty when we spend even a small amount of money on something we don’t need.
This distortion involves thinking that if we feel a certain way, it must be true. For example, if we feel unattractive or uninteresting in the current moment, we must be unattractive or uninteresting. This cognitive distortion boils down to:
“I feel it, therefore it must be true.”
Clearly our emotions are not always indicative of the objective truth, but it can be difficult to look past how we feel.
Fallacy of Change
The fallacy of change lies in expecting other people to change as it suits us. This ties into the feeling that our happinessdepends on other people, and their unwillingness or inability to change, even if we push and press and demand it, keeps us from being happy. This is clearly a damaging way to think, since no one is responsible for our happiness except for us.
Global Labeling / Mislabeling
This cognitive distortion is an extreme form of generalizing, in which we generalize one or two instances or qualities into a global judgment. For example, if we fail at a specific task, we may conclude that we are a total failure in not only this area, but all areas. Alternatively, when a stranger says something a bit rude, we may conclude that he or she is an unfriendly person in general. Mislabeling is specific to using exaggerated and emotionally loaded language, such as saying a woman has abandoned her children when she leaves her children with a babysitter to enjoy a night out.
Always Being Right
While we all enjoy being right, this distortion makes us think we must be right, that being wrong is unacceptable. We may believe that being right is more important than the feelings of others, being able to admit when we’ve made a mistake, or being fair and objective.
Heaven’s Reward Fallacy
This distortion involves expecting that any sacrifice or self-denial on our part will pay off. We may consider this karma, and expect that karma will always immediately reward us for our good deeds. Of course, this results in feelings of bitterness when we do not receive our reward (Grohol, 2016).
Many tools and techniques found in CBT are intended to address or reverse these cognitive distortions.
You can download the printable version of the infographic here.
9 Essential CBT Techniques and Tools
There are many tools and techniques used in CBT, many of which have spread from the therapy context to everyday life. The nine techniques and tools listed below are some of the most common and effective CBT practices.
This technique is a way of “gathering data” about our moods and our thoughts. This journal can include the time of the mood or thought, the source of it, the extent or intensity, and how we responded to it, among other factors. This technique can help us to identify our thought patterns and emotional tendencies, describe them, and find out how to change, adapt, or cope with them.
Unraveling Cognitive Distortions
This is a main goal of CBT, and can be practiced with or without the help of a therapist. In order to unravel the cognitive distortions you hold, you must first become aware of which distortions you are most vulnerable to. Part of this involves identifying and challenging our harmful automatic thoughts, which frequently fall into one of the categories listed earlier.
Once you identify the distortions or inaccurate views on the world you hold, you can begin to learn about how this distortion took root and why you came to believe it. When you discover a belief that is destructive or harmful, you can begin to challenge it. For example, if you believe that you must have a high paying job to be a respectable person, but you lose your high paying job, you will begin to feel bad about yourself.
Instead of accepting this faulty belief that leads you to think unreasonably negative thoughts about yourself, you could take this opportunity to think about what makes a person “respectable,” a belief you may not have explicitly considered before.
Exposure and Response Prevention
This technique is specifically effective for those who suffer from obsessive compulsive disorder (OCD). You can practice this technique by exposing yourself to whatever it is that normally elicits a compulsive behavior, but doing your best to refrain from the behavior and writing about it. You can combine journaling with this technique, or use journaling to understand how this technique makes you feel.
This technique is intended to treat panic and anxiety. It involves exposure to feared bodily sensations in order to elicit the response, activate any unhelpful beliefs associated with the sensations, maintain the sensations without distraction or avoidance, and allow new learning about the sensations to take place. It is intended to help the sufferer see that symptoms of panic are not dangerous, although they may be uncomfortable.
Nightmare Exposure and Rescripting
Nightmare exposure and rescripting is intended specifically for those suffering from nightmares. This technique is similar to interoceptive exposure, in that the nightmare is elicited, which brings up the relevant emotion. Once the emotion has arisen, the client and therapist work together to identify the desired emotion and develop a new image to accompany the desired emotion.
Play the Script Until the End
This technique is especially useful for those suffering from fear and anxiety. In this technique, the individual who is vulnerable to crippling fear or anxiety conducts a sort of thought experiment, where they imagine the outcome of the worst case scenario. Letting this scenario play out can help the individual to recognize that even if everything they fear comes to pass, it will likely turn out okay.
Progressive Muscle Relaxation (PMR)
This is a familiar technique to those who practice mindfulness. Similar to the body scan, this technique instructs you to relax one muscle group at a time until your whole body is in a state of relaxation. You can use audio guidance, a YouTube video, or simply your own mind to practice this technique, and it can be especially helpful for calming nerves and soothing a busy and unfocused mind.
This is another technique that is not specific to CBT, but will be familiar to practitioners of mindfulness. There are many ways to relax and bring regularity to your breath, including guided and unguided imagery, audio recordings, YouTube videos, and scripts. Bringing regularity and calm to your breath will allow you to approach your problems from a place of balance, facilitating more effective and rational decision making (Megan, 2016).
These techniques can help those suffering from a range of mental illnesses and afflictions, including anxiety, depression, OCD, and panic disorder, and they can be practiced with or without the guidance of a therapist. To try some of these techniques without the help of a therapist, see the next section for worksheets and handouts to assist with your practice.
You can download the printable version of the infographichere.
Cognitive Behavioral Therapy Worksheets (PDF) To Print and Use
If you’re a therapist looking for ways to guide your client through treatment or a hands-on person who loves to learn by doing, there are many CBT worksheets that can help.
Alternative Action Formulation
This worksheet instructs the user to first list any problems or difficulties you are having. Next, you list your vulnerabilities (i.e., why you are more likely to experience these problems than someone else) and triggers (i.e., the stimulus or source of these problems).
Once you have defined the problems and understand why you are struggling with them, you go on to list coping strategies. These are not solutions to problems, but ways in which you can deal with the effects of these problems that can have a temporary impact. Next, you list the effects of these coping strategies, such as how they make you feel in the short-term and long-term, and the advantages and disadvantages of each strategy.
Finally, you move on to listing alternative actions. If your coping strategies are not totally effective against the problems and difficulties that are happening, you are instructed to list other strategies that may work better.
This worksheet gets you (or your client) thinking about what you are doing now and whether it is the best way forward. You can find it here.
One popular technique in CBT is functional analysis. This technique helps you (or the client) learn about yourself, specifically what leads to specific behaviors and what consequences result from those behaviors.
In the middle of the worksheet is a box labeled “Behaviors.” In this box, you write down any potentially problematic behaviors or other behaviors you wish to analyze.
On the left side of the worksheet is a box labeled “Antecedents,” in which you or the client write down the factors that preceded a particular behavior. These are factors that led up to the behavior under consideration, either directly or indirectly.
On the right side is the final box, labeled “Consequences.” This is where you write down the consequences of the behavior, or what happened as a result of the behavior under consideration. “Consequences” may sound inherently negative, but they are not necessarily negative; some positive consequences can arise from many types of behaviors, even if more negative consequences result as well.
This worksheet can help you or your client to find out whether particular behaviors are adaptive and helpful in striving towards your goals, or destructive and self-defeating. Follow this linkto print out this worksheet and give it a try.
This worksheet helps you address what some CBT therapists call the “5 P Factors” – presenting, predisposing, precipitating, perpetuating, and positives. This formulation process can help you connect the dots between your core beliefs and thought patterns and your present behavior.
This worksheet presents five boxes at the top of the page, which should be completed before moving on to the rest of the worksheet.
- The first box is labeled “Precipitating Events / Triggers,” and corresponds with the Precipitating factor. In this box, you are instructed to write down the events or stimuli that provoke a certain behavior.
- The next box is labeled “Early Experiences” and corresponds to the Predisposing factor. This is where you list the experiences that you had early on, all the way back to childhood, that may have contributed to the behavior.
- The third box is “Core Beliefs,” which is also related to the Predisposing factor. This is where you write down some of the relevant core beliefs you have regarding this behavior. These are beliefs that may not be explicit, but that you believe deep down, such as “I’m bad” or “I’m not good enough.”
- The fourth box is “Old Rules for Living,” which is where you list the rules that you adhere to, whether consciously or subconsciously. These implicit or explicit rules can perpetuate the behavior, even if it is not helpful or adaptive. Rules are if-then statements that provide a judgment based on a set of circumstances. For instance, you may have the rule “If I do not do something perfectly, I’m a complete failure.”
- The final box is labeled “Presenting Problems / Effects of Old Rules.” This is where you write down how well these rules are working for you. Are they helping you to be the best you can be? Are they helping you to effectively strive towards your goals?
Below this box there are two flow charts that you can fill out based on how these behaviors and feelings are perpetuated. You are instructed to think of a situation that produces a negative automatic thought, and record the emotion and the behavior that this thought provokes, as well as the bodily sensations that can result. Filling out these flow charts can help you see what drives your behavior or thought and what results from it.
Below these two charts is the box “Protective Factors.” This is where you list the factors that can help you deal with the problematic behavior or thought, and perhaps help you break the perpetuating cycle. This can be things that help you cope once the thought or behavior arises or things that can disrupt the pattern once it is in motion.
Finally, the last box is “New Rules for Living.” This box relates to the Positive factor, in that it provides you with an opportunity to create new rules for yourself that will disrupt the destructive cycle and allow you to become more effective in meeting your therapeutic goals. Click here if you’d like to try this worksheet.
Dysfunctional Thought Record
This worksheet is especially helpful for people who are struggling with negative thoughts and need to figure out when and why they are most likely to pop up. By learning more about what provokes certain automatic thoughts, they become easier to address and reverse.
The worksheet is divided into seven columns:
- On the far left, there is space to write down the date and time a dysfunctional thought arose.
- The second column is where the situation is listed. The user is instructed to describe the event that led up to the dysfunctional thought in detail.
- The third column is for the automatic thought. This is where the dysfunctional automatic thought is recorded, along with a rating of belief in the thought on a scale from 0% to 100%.
- The next column is where the emotion or emotions elicited by this thought are listed, also with a rating of intensity on a scale from 0% to 100%.
- The fifth column is labeled “Distortion.” This column is where the user will identify which cognitive distortion(s) they are suffering from with regards to this specific dysfunctional thought, such as all-or-nothing thinking, filtering, jumping to conclusions, etc.
- The second to last column is for the user to write down alternative thoughts, more positive and functional thoughts that can replace the negative one.
- Finally, the last column is for the user to write down the outcome of this exercise. Were you able to confront the dysfunctional thought? Did you write down a convincing alternative thought? Did your belief in the thought and/or the intensity of your emotion(s) decrease? To give this worksheet a try, click here.
Fact or Opinion
One of my favorite CBT worksheets is the “Fact or Opinion” worksheet, because it can be extremely helpful in recognizing that your thoughts are not necessarily true.
At the top of this worksheet is an important lesson:
Thoughts are not facts.
Of course, it can be hard to accept this, especially when we are in the throes of a dysfunctional thought or intense emotion. Filling out this worksheet can help you come to this realization.
The worksheet includes 16 statements that the user must decide are either fact or opinion. These statements include:
- I’m a bad person.
- I failed the test.
- I’m selfish.
- I didn’t lend my friend money when they asked.
This is not a trick – there is a right answer for each of these statements. (In case you’re wondering, the right answers for the statements above are as follows: opinion, fact, opinion, fact.)
This simple exercise can help the user to see that while we have lots of emotionally charged thoughts, they are not all objective truths. Recognizing the difference between fact and opinion can assist us in challenging the dysfunctional or harmful opinions we have about ourselves and others.
If you’d like to print out this worksheet to give it a try, click here.
This worksheet employs the use of Socratic questioning, a technique that can help the user to challenge irrational or illogical thoughts.
The top of the worksheet describes how thoughts are a running dialogue in our minds, and they can come and go so fast that we hardly have time to address them. This worksheet aims to help us capture one or two of these thoughts and analyze them.
- The first box to be filled out is “Thoughts to be questioned.” This is where you write down a specific thought, usually one you suspect is destructive or irrational.
- Next, you write down the evidence for and against this thought. What evidence is there that this thought is accurate? What evidence exists that calls it into question?
- Once you have identified the evidence, you can make a judgment on this thought, specifically whether it is based on facts or your feelings.
- Next, you answer a question on whether this thought is truly a black and white situation, or whether reality leaves room for shades of grey. This is where you think about whether you are using all-or-nothing thinking, or making things unreasonably simple when they are truly complex.
- In the last box on this page, you consider whether you could be misinterpreting the evidence or making any unverified assumptions.
On the next page, you are instructed to think about whether other people might have different interpretations of the same situation, and what those interpretations might be.
Next, ask yourself whether you are looking at all the relevant evidence, or just the evidence that backs up the belief you already hold. Try to be as objective as possible.
The next box asks you whether your thought may an exaggeration of a truth. Some negative thoughts are based in truth, but extended past their logical boundaries.
Next, you are instructed to consider whether you are entertaining this negative thought out of habit or because the facts truly support it.
Once you have decided whether the facts support this thought, you are encouraged to think about how this thought came to you. Was it passed on from someone else? If so, are they a reliable source for truth?
Finally, you complete the worksheet by identifying how likely the scenario your thought brings up actually is, and whether it is the worst case scenario.
These “Socratic questions” encourage a deep dive into the thoughts that may plague you, and offer an opportunity to analyze and evaluate them for truth. If you are having thoughts that do not come from a place of truth, this worksheet can be an excellent tool for identifying and defusing them.
For more CBT worksheets and handouts, visit this website.
Some More CBT Interventions and Exercises
Haven’t had enough CBT toolsand techniques yet? Continue on for more useful and effective exercises!
These are related to thought experiments, in that you engage in a “what if” consideration. Behavioral experiments differ from thought experiments in that you actually test out these “what ifs” outside of your thoughts (Boyes, 2012).
In order to test a thought, you can experiment with the outcomes that different thoughts produce. For example, you can test the thought:
“If I criticize myself, I will be motivated to work harder” vs. “If I am kind to myself, I will be motivated to work harder.”
First, you would try criticizing yourself when you need motivation to work harder and record the results. Then you would try being kind to yourself and recording the results. Next, you would compare the results to see which thought was closer to the truth.
These behavioral experiments can help you learn how to best strive towards your therapeutic goals and how to be your best self.
Thought records are useful in testing the validity of your thoughts (Boyes, 2012). They involve gathering and evaluating the evidence for and against a particular thought, allowing for an evidence-based conclusion on whether the thought is valid or not.
For example, you may have the belief “My friend thinks I’m a bad friend.” You would think of all the evidence for this belief, such as “She didn’t answer the phone the last time I called” or “She cancelled our plans at the last minute”, and evidence against this belief, like “She called me back after not answering the phone” and “She invited me to her barbecue next week. If she thought I was a bad friend, she probably wouldn’t have invited me.”
Once you have evidence for and against, the goal is to come up with more balanced thoughts, such as
“My friend is busy and has other friends, so she can’t always answer the phone when I call. If I am understanding of this, I will truly be a good friend.”
Thought records apply the use of logic to ward off unreasonable negative thoughts and replace them with more balanced, rational thoughts (Boyes, 2012).
Pleasant Activity Scheduling
This technique can be especially helpful for dealing with depression (Boyes, 2012). It involves scheduling activities in the near future that you can look forward to.
For example, you may write down one activity per day that you will engage in over the next week. This can be as simple as watching a movie you are excited to see or calling a friend to chat. It can be anything that is pleasant to you, as long as it is not unhealthy (i.e., eating a whole cake in one sitting or smoking).
You can also try scheduling an activity for each day that provides you with a sense of mastery or accomplishment (Boyes, 2012). It’s great to do something pleasant, but doing something small that can make you feel accomplished may have longer lasting and farther reaching effects.
This simple technique can introduce more positivity into your day and help you make your thinking less negative.
Imagery Based Exposure
This exercise involves thinking about a recent memory that produced strong negative emotions and analyzing the situation.
For example, if you recently had a fight with your significant other and they said something hurtful, you can bring that situation to mind and try to remember it in detail. Next, you would try to label the emotions and thoughts you experienced during the situation and identify the urges you felt (e.g., to run away, to yell at your significant other, to cry).
Visualizing this negative situation, especially for a prolonged period of time, can help you to take away its ability to trigger you and reduce avoidance coping (Boyes, 2012). When you expose yourself to all of the feelings and urges you felt in the situation and survive experiencing the memory, it takes some of its power away.
Situation Exposure Hierarchies
This technique may sound complicated, but it’s relatively simple.
Situation Exposure Hierarchies involves making a list of things that you would normally avoid (Boyes, 2012). For example, someone with severe social anxiety may typically avoid making a phone call instead of emailing or asking someone on a date.
Next, you rate each item on how distressed you think you would be, on a scale from 0 to 10, if you engaged in it. For the person suffering from severe social anxiety, asking someone on a date may be rated a 10 on the scale, while making a phone call instead of emailing might be rated closer to a 3 or 4.
Once you have rated each item, you rank them according to their distress rating. This will help you recognize the biggest difficulties you face, which can help you decide which items to address and in what order. It may be best to start with the less distressing items and work your way up to the most distressing items.
A CBT Manual and Workbook for Your Own Practice + for Your Client
If you’re interested in giving CBT a try with your clients, there are many books and manuals that can help get you started. Some of these books are for the therapist only, and some are to be navigated as a team or with guidance from the therapist.
There are many manuals out there for helping therapists apply CBT in their work, but these are some of the most popular:
For clients or for therapist and client to work through together, these are some of the most popular manuals and workbooks:
There are many other manuals and workbooks out there that can help get you started with CBT, but these are a good start.
5 Last Cognitive Behavioral Activities
Before we go, there are a few more CBT activities and exercises that may be helpful for you or your clients that we’d like to cover.
As readers of this blog will likely know by now, mindfulness can have a wide range of positive impacts, including helping with depression, anxiety, addiction, and many other mental illnesses or difficulties.
Mindfulness can help those suffering from harmful automatic thoughts to disengage from rumination and obsession over these thoughts by helping them stay firmly grounded in the present.
This is a somewhat fancy name for a simple idea that you have likely already hear of: breaking up large tasks into small steps to make it easier to accomplish.
It can be overwhelming to be faced with a huge goal we would like to accomplish, like opening a business or remodeling a house. This is true in mental health treatment as well, since the goal to overcome depression or anxiety and achieve mental wellness can seem like a monumental task to those who are suffering from severe symptoms.
By breaking the large goal into small, easy to accomplish steps, we can map out the path to success and make the journey seem a little less overwhelming.
Writing Self-Statements to Counteract Negative Thoughts
This technique can be difficult for someone just beginning their CBT treatment or suffering from severe symptoms, but it can also be extremely effective (Anderson, 2014).
When you (or your client) are being plagued by negative thoughts, it can be hard to confront them, especially if your belief in these thoughts is strong. To counteract these negative thoughts, it can be helpful to write down a positive, opposite thought.
For example, if the thought that you are worthless keeps popping into your head, try writing down a statement like “I am a person with worth” or “I am person with potential.” In the beginning, it can be difficult to accept these replacement thoughts, but the more you bring out these positive thoughts to counteract the negative ones, the stronger the association will be.
Visualize the Best Parts of Your Day
When you are feeling depressed or negative, it is difficult to recognize that there is good in your life as well. This simple technique of bringing to mind the good parts of your day can be a small step in the direction of recognizing the positive (Anderson, 2014).
All you need to do is write down the things in your life that you are most thankful for or the things that are most positive in your day. The simple act of writing down these good things can forge new associations in your mind which make it easier to see the positive, even when there is plenty of negative as well.
Reframe Your Negative Thoughts
It can be all too easy to succumb to negative thoughts as a default setting. If you find yourself immediately thinking a negative thought when you see something new, such as entering an unfamiliar room and thinking “I hate the color of that wall,” give reframing a try (Anderson, 2014).
Reframing involves countering the negative thought(s) by noticing things you feel positive about as quickly as possible. For instance, in the example where you immediately think of how much you hate the color of that wall, you would push yourself to notice five things in the room that you feel positively about (e.g., the carpet looks comfortable, the lampshade is pretty, the windows let in a lot of sunshine).
You can set your phone to remind you throughout the day to stop what you are doing and think of the positive things around you. This can help you to push your thoughts back into the realm of the positive instead of the negative.
You can download the printable version of the infographic here.
A Take Home Message
As always, I hope this post has been helpful. There are a lot of great tips and techniques in here that can be extremely effective in the battle against depression, anxiety, OCD, and a host of other problems or difficulties.
However, as is the case with many treatments, they depend on you (or your client) putting in a lot of effort. I would encourage you to give these techniques a real try, and allow yourself the luxury of thinking they may actually work. When we approach a potential solution with the assumption that it will not work, then it will probably not work. When we approach a potential solution with an open mind and the thought that it just might work, it has a much better chance of succeeding.
So if you are struggling with negative automatic thoughts, please consider these tips and techniques and give them a real shot. Likewise, if your client is struggling, encourage them to make the effort, because the payoff can be better than they can imagine.
If you are struggling with severe symptoms of depression or suicidal thoughts, please call the following number in your respective country:
- USA: National Suicide Prevention Hotline at 1-800-273-8255
- UK: Samaritans hotline at 116 123
- The Netherlands: Netherlands Suicide Hotline at 09000767
- France: Suicide écoute at 01 45 39 40 00
- Germany: Telefonseelsorge at 0800 111 0 111 for Protestants, 0800 111 0 222 for Catholics, and 0800 111 0 333 for children and youth
For a list of other suicide prevention websites, phone numbers, and resources, see this website.
Please know that there are people out there who care and that there are treatments that can help.
Thank you for reading, and please let us know about your experiences with CBT in the comments section. Have you tried it? How did it work for you? Are there any other helpful exercises or techniques that we did not touch on in this piece?
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- Anderson, J. (2014, June 12). 5 get-positive techniques from Cognitive Behavioral Therapy. Everyday Health. Retrieved from http://www.everydayhealth.com/hs/major-depression-living-well/cognitive-behavioral-therapy-techniques/
- Boyes, A. (2012, December 6). Cognitive behavioral therapy techniques that work: Mix and match Cognitive Behavioral Therapy techniques to fit your preferences. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/in-practice/201212/cognitive-behavioral-therapy-techniques-work
- Grohol, J. (2016). 15 common cognitive distortions. Psych Central. Retrieved from https://psychcentral.com/lib/15-common-cognitive-distortions/
- Martin, B. (2016). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
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About the AuthorCourtney Ackerman is a graduate of the positive organizational psychology and evaluation program at Claremont Graduate University. She is currently working as a researcher for the State of California and her professional interests include survey research, well-being in the workplace, and compassion. When she’s not gleefully crafting survey reminders, she loves spending time with her dogs, visiting wine country, and curling up in front of the fireplace with a good book or video game.
The current study was an updated meta-analysis of manuscripts since the year 2000 examining the effects of homework compliance on treatment outcome. A total of 23 studies encompassing 2,183 subjects were included. Results indicated a significant relationship between homework compliance and treatment outcome suggesting a small to medium effect (r = .26; 95% CI = .19–.33). Moderator analyses were conducted to determine the differential effect size of homework on treatment outcome by target symptoms (e.g., depression; anxiety), source of homework rating (e.g., client; therapist), timing of homework rating (e.g., retroactive vs. contemporaneous), and type of homework rating (e.g., Likert; total homeworks completed). Results indicated that effect sizes were robust across target symptoms, but differed by source of homework rating, timing of homework rating, and type of homework rating. Specifically, studies utilizing combined client and therapist ratings of compliance had significantly higher mean effect size relative to those using therapist only assessments and those using objective assessments. Further, studies that rated the percentage of homeworks completed had a significantly lower mean effect size compared to studies using Likert ratings, and retroactive assessments had higher effect size than contemporaneous assessments.
Keywords: Psychotherapy, Depression, Anxiety, Substance use, Homework
Cognitive and behavior therapies are often considered “first-line” treatments for a number of psychiatric disorders, with various meta-analyses demonstrating the efficacy of these therapies for conditions such as anxiety disorders (Hofmann and Smits 2008; Otto et al. 2004), depression (Dobson 1989; Spek et al. 2007), and substance-use disorders (Duttra et al. 2008). While cognitive and behavior therapies have been established on theoretical foundations, the efficacy of these interventions may lie in their strong history of utilizing homework assignments as a mechanism toward producing beneficial treatment outcomes. That is, practice of skills outside of therapy (i.e., homework) allows clients to master the skills believed necessary to affect symptoms, generalize these skills to their natural settings, and promote prolonged symptom improvement through extending therapeutic aspects of treatment beyond the completion of therapy (Kazantzis and Lampropoulos 2002).
Indeed, the importance of homework for producing positive therapy outcome was demonstrated in a previous meta-analysis (Kazantzis et al. 2000). In their analysis, a Pearson r effect size of .22 was reported for the relationship between homework compliance and therapy outcome in a sample of 1,327 subjects across 27 studies. These results suggest that greater compliance with homework is associated with beneficial treatment outcome, with the strength of the association falling between Cohen’s small and medium effect size cutoffs (Cohen 1988; Kraemer et al. 2003).
Kazantzis et al. (2000) analysis was the first study to examine the type of homework activity and the nature of the client’s presenting problem as moderating variables of homework effectiveness. The presenting problems were categorized as depression, anxiety-related disorders, and other outpatient. The results of this meta-analysis showed the following mean effect sizes for problem type: depression (.22), anxiety (.24), and other outpatient (.17), with homework effects being significantly greater for the treatment of depression than the “other outpatient” sample. Additionally, results indicated that effect sizes were robust across the type of homework completed (no single type, relaxation, or social skills) and time of homework compliance assessment (regular intervals or posttreatment), but differed by the source of homework compliance assessment. Specifically, studies that utilized client and therapist ratings had a significantly lower mean effect size relative to those using objective measures of homework compliance.
In the 8 years since Kazantzis, Deane, and Ronan’s meta-analysis on the effects of homework assignments on treatment outcome, homework has continued to remain “both a traditional and integral component of contemporary manual-based cognitive-behavioral therapy (CBT) approaches” (Coon and Thompson 2003, p. 53). Further, there continues to be support for the effectiveness of cognitive-behavioral interventions to prevent the onset, relapse, and recurrence of a number of psychological disorders (Hollon 2003). The meta-analysis conducted by Kazantzis et al. (2000) included homework-related studies spanning from 1980, 1 year following Beck’s emphasis on regularly using homework in cognitive-behavioral therapy for depression (Beck et al. 1979), through 1998, a time when homework in therapy had been incorporated into a more diverse range of clinical conditions (Kazantzis et al. 2000). Therefore, a significant amount of variance as a function of time may exist within this analysis.
The present study is an updated meta-analysis of the relationship between homework compliance and treatment outcome. We hypothesized that greater homework compliance would be significantly associated with improved treatment outcome. Given that the previous meta-analysis found some evidence that targeted symptoms and source of homework ratings may moderate the effect of homework compliance, we further examined whether treatment target (e.g., symptoms of anxiety, depression, etc.) and source of rating (e.g., therapist, objective) moderated the relationship between homework compliance and therapy outcome. A novel aspect of this meta-analysis is that we examine the moderating effect of rating type (e.g., Likert rating, percentage of homeworks completed).
To identify candidate studies for inclusion in our review, the following inclusion/exclusion criteria were used: (a) studies must have been published between January, 2000 and September, 2008, (b) the study must have been published in English, and (c) the study must have been a treatment study examining pre- and post-treatment outcome and measured some aspect of homework compliance. Guided by these criteria, we searched PsychArticles, PsychInfo, and Medline databases for journal manuscripts published between January 2000 and September 2008 using the key terms homework and compliance and (therapy or psychotherapy or psychosocial intervention or intervention). From this search 87 articles were found. We read the abstracts from these articles to identify potential studies for inclusion as well as manuscript citations to identify further manuscripts that may have initially been missed in our initial search. Articles that were eliminated dealt with methods for improving homework compliance rather than the impact of homework compliance on treatment outcome. Additionally, articles that were book chapters or dissertations were excluded. Twenty-three studies encompassing 2,183 subjects met the inclusion criteria for the meta-analysis and were therefore included in the present study.
Classification and Coding Systems
Only studies looking at the relationship between homework compliance and the therapeutic outcome were included in the present study. In addition to the relations between homework compliance and outcome, the following elements were considered as moderator variables:
Primary treatment target—these included 5 categories: (a) depression, (b) anxiety, (c) substance use, (d) mixed (e.g., both anxiety and depression), and (e) other (e.g., functioning);
Source of homework rating—Four categories were included in this rating: (a) therapist (Likert rating), (b) client (Likert rating), (c) objective (e.g., number of assignments turned in), and (d) client and therapist (e.g., both client and therapist rated homework compliance and average ratings were used).
Type of homework rating—Three categories of homework rating were coded: (a) Likert scale, (b) number of assignments completed, and (c) percentage of homework completed.
Timing of homework rating—Two categories of timing were coded: (a) retroactive ratings of homework compliance (e.g., a single rating at the end of treatment), and (b) contemporaneous ratings of homework compliance (e.g., assessment of homework at each therapy session).
Year of study—In this analysis, we used weighted regression to determine if the linear variable “year of publication” moderated the effect size of homework on outcome.
Calculation of Effect Sizes
Effect size r was used to characterize the relationship between homework compliance and therapy outcome for each of the 20 studies. For studies that did not report correlation coefficients (r), available study statistics were converted to r according to standard formulas (Hunter and Schmidt 1990). As mentioned above, effect sizes were determined by two independent reviewers and for the majority of studies agreement was reached. In three cases, discrepancies were determined by discussion between the two reviewers and a third reviewer. For those studies where available statistics were not readily converted to r, we used the standardized regression coefficient (β; n = 7) or semi-partial correlation coefficient (n = 3) as a proxy for r (Peterson and Brown 2005). Once study-level correlation coefficients were calculated they were weighted, aggregated, and their heterogeneity was assessed with the Q statistic (Hedges and Olkin 1985) using a random effects model.
Characteristics of the Sample
Characteristics of the 23 studies included in this meta-analysis are presented in Table 1. Overall, the number of participants in these studies ranged from 10 to 641, with a mean of approximately 95 participants (median n = 46). Eight studies targeted symptoms of anxiety, 5 targeted symptoms of depression, 3 targeted substance use, and 1 targeted a mix of symptoms. The remaining 6 studies targeted a variety of symptoms including psychosis, body image, and everyday functioning; these were coded as “other”. As for the source of homework ratings, 11 used therapist ratings, 2 used client ratings, 8 used an objective rating, and 2 used both client and therapist ratings. A total of 9 studies used a Likert rating of homework compliance, 7 used the number of homework assignments completed, and 7 used the percentage of homeworks completed.
Effects of Homework Compliance on Therapy Outcome
The overall effect size r between homework compliance and treatment outcome was .26 (95% CI = .19–.33; P < .001), indicating that across treatment targets, sources of homework ratings, and type of homework ratings, greater homework compliance was associated with improved treatment outcome. The overall effect fell within the small-to-medium range (Cohen 1988). This result supported our first hypothesis. Effect sizes ranged from .08 to .93, and the homogeneity analysis indicated significant heterogeneity in results (Q = 39.38, df = 19, P = .004). The fail-safe n (Rosenthal 1979) was computed to be 618.
Results of our 3 moderator analyses are presented in Table 2, and information on study details (e.g., duration, modality, outcome measures) are found in Table 3. Our first moderator analysis examined the effect of homework on treatment outcome by treatment target (e.g., symptoms of anxiety or depression). Overall, treatment target did not significantly moderate the relationship between homework compliance and treatment outcome (Q = .39, df = 4, P = .983). As seen in Table 2, the effect sizes were remarkably robust, ranging from .22 for anxiety to .27 for substance use outcomes.
Our second moderator analysis examined the source of homework ratings (e.g., therapist, client). Results of this analysis indicated a significant moderating effect of homework source (Q = 13.83, df = 3, P = .003). Studies that utilized combined client and therapist ratings had a significantly larger mean effect size than those that utilized objective ratings (P < .001). No significant differences were observed between the other sources of homework ratings.
Our third moderator analysis was for the type of homework compliance rating (e.g., Likert scale). Results of this analysis indicated that type of homework rating significantly moderated the relationship between homework compliance and therapy outcome (Q = 9.51, df = 2, P = .009). Post-hoc analyses indicated that studies utilizing Likert ratings of homework compliance had a significantly higher mean effect size compared to studies using a percentage rating (i.e., percentage of homeworks completed) of homework compliance (P = .002). No significant differences were observed between Likert and total number of homeworks completed or between total number completed and percent completed (P-values > .05).
Our fourth analysis was for timing of homework compliance (e.g., retroactive vs. contemporaneous). Results of this moderator analysis indicated that retroactive ratings of homework compliance (e.g., a single rating of compliance provided at the end of treatment) demonstrated a significantly higher effect size than contemporaneous ratings (e.g., ratings made after each therapy session; Q = 11.90, df = 1, P < .001). Specifically, the mean correlation between homework compliance and outcome was .36 for retroactive ratings and .19 for contemporaneous ratings.
A final analysis examined the moderating effect of publication year. Results of this analysis indicated that year of publication did not moderate the effect of homework on treatment outcome (P = .264).
This meta-analysis examined the relationship between homework compliance and treatment outcome across 23 studies and over 2,000 participants. Similar to results found by Kazantzis et al. (2000), greater homework compliance was associated with improved treatment outcome (r = .27). These results were consistent across a variety of target symptoms including symptoms of anxiety (r = .22), depression (r = .24), and substance use (r = .27), suggesting that compliance with homework is an important component of psychotherapy regardless of the target symptoms. Indeed, this finding is consistent with cognitive and behavioral theories, which suggest that mastery of skills learned in therapy via practice of such skills is important for producing positive treatment outcomes (i.e., improving symptoms).
In the present study, the two most common sources of homework ratings were therapists and objective ratings (e.g., counting the number or percentage of homework turned in), and we found that the source of homework ratings moderated the relationship between homework compliance and treatment outcome. Specifically, when both clients and their therapists provided homework ratings, effect sizes were significantly higher (r = .35) than when objective ratings were used (r = .16). However, because only two studies utilized both client and therapist ratings, these results should be interpreted with caution. Indeed, the two studies that utilized therapist and patient ratings of compliance used quite different methods for assessing homework compliance and had quite different sample sizes. Moreover, our analysis averaged the therapist and patient rating of homework compliance, despite the fact that these ratings may not always be strongly correlated. Indeed, the study by Westra and Dozois (2006) reported only a modest correlation between therapist and client compliance ratings. Again, given the small number of studies utilizing this method and the limitations mentioned here, readers should take caution about interpreting these findings as particularly meaningful.
These findings might be interpreted in a number of different ways. First, they may suggest that future studies of this relationship should utilize both types of ratings, at least on the assumption that this effect size discrepancy is real. Alternatively, this discrepancy in findings might highlight the inherent limitations of using “subjective” ratings as a means of assessing homework compliance. For example, therapists who provide homework ratings may give better scores to those who are doing better in therapy (i.e., “he’s doing better, so he must be doing his homework”).
There were no significant differences between groups when comparing other sources of homework ratings. However, although objective ratings did not differ from client alone or therapist alone ratings, it is interesting to note that our findings differ from those of Kazantzis et al. (2000), who found that objective ratings had a higher overall correlation with treatment outcome. This may be due to the difference in defining “objective” assessment between the two meta-analyses. Specifically, whereas Kazantzis defined “objective” as an electronic marker of homework compliance, our analysis considered “objective” to mean studies that counted the number of homeworks turned into therapists.
Studies that used Likert scales to rate homework compliance had a significantly higher mean effect size (r = .31) than those rating the percentage of homeworks completed (r = .17). Further, studies using Likert scales were higher, but not significantly so, than studies using the number of homeworks completed. While this finding is difficult to explain, it may be due to the fact that Likert ratings might inadvertently reflect quality and quantity ratings, whereas a summary variable such as percent or total homeworks completed reflect quantity only. For example, during the course of therapy, clients may be asked to regularly (e.g., once each day) practice homework. However, they may present at the next therapy session and describe one excellent (and extremely beneficial) example of how he/she practiced homework over the past week. Therapists who rated client homework from 0 (poor) to 6 (outstanding) might rate this compliance relatively high on the scale. In contrast, clients who report doing homework every day but who had difficulty with the assignment or who described it as unhelpful might be rated relatively lower in terms of compliance. Further, Likert scales provide the therapist and the client with a range to rank homework completion. This can be opposed to percentage of homeworks completed and number of homeworks completed, which are often scored on a dichotomous (completed or did not complete) scale. If a client completes part of a homework assignment, the client is given some credit for compliance, even if the effort is minimal.
Further, a “timing effect” was found for contemporaneous versus retrospective ratings of homework completion in that retrospective ratings were a significantly better predictor of outcome than contemporaneous ratings. This may have been due to a bias effect for retroactive ratings. For example, it is possible that patients who have appeared to have done well in therapy could have been rated by their therapist or themselves as more compliant with homework assignments. These results may provide insight into differences in objective versus subjective ratings (i.e., higher effect size for subjective ratings than objective assessments), in that objective ratings are most typically contemporaneous by nature (e.g., paperwork that was turned into and/or discussed with the therapist), and therefore appear more reliable in assessing compliance than retroactive or subjective ratings of compliance.
These issues (objective vs. subjective; Likert vs. non-Likert) highlight the important issue of how we define homework compliance. Specifically, they highlight the important issue of the purpose of conducting a homework analyses, which is to discover the “true nature” of the relationship between homework compliance and treatment outcome, not findings ways of manipulating methods to demonstrate larger effects. Determining the true effect indeed involves finding increasingly “objective”, or bias-free methods of assessing homework compliance. To this end, Kazantzis et al. (2004) has described novel methods of assessing homework in therapy research (e.g., the Homework Rating Scale), which include the assessment of homework quality. However, there has yet to be any consistent use of these methods. We strongly recommend new research incorporate these new methods of assessing homework compliance, as well as develop more objective and accurate means of assessing homework quantity and quality in treatment research and outcome.
There are several limitations to the current review. As previously mentioned, there have been problems with the objective assessment of homework compliance. Additionally, the current review did not examine demographic moderators (i.e., age, gender, ethnicity, education) or the severity of psychopathology (e.g., Major Depressive Disorder vs. Dysthymia; Substance Abuse vs. Substance Dependence) that could contribute to homework compliance. These variables were not included in the current study’s moderator analysis as they were not examined in the results of the studies reviewed. Research has found that clients comply less with homework directives if they have greater and/or more long-lasting symptomology (Worthington 1986). In addition to demographic moderators and severity of psychopathology, other things to keep in mind when considering the relationship between a client’s homework compliance and therapeutic gain are pharmacotherapy (e.g., is the client on antidepressant medications?), if the client is involved in another form of treatment (e.g., social skills training), and use of coping mechanisms for dealing with stress (e.g., does the client take action in response to stress or become less productive? Addis and Jacobson 2000). The results, however, demonstrate a more generalized view of the effects of homework compliance on therapy outcome across a span of different psychological diagnoses and diverse demographic characteristics.
A further limitation of the current review is that it did not take into account the client-therapist relationship. Research has found that a positive and trusting client-therapist relationship may aid recovery in mental illness (Green et al. 2008) regardless of homework. Additionally, the strength of the relationship between the client and the therapist could contribute to homework compliance, with a stronger working relationship leading to increased homework compliance. Without looking at the client-therapist relationship as a moderator between homework compliance and treatment outcome, there is a possibility that the relationship alone contributed to the improvements seen in the clients. However, as mentioned by Kazantzis et al. (2000), there exists an abundance of research that demonstrates the positive effects of the use of homework in therapy on treatment outcome.
Finally, the current review did not examine the client’s attitude towards homework. A negative attitude towards homework, even if the homework is completed, could potentially limit the likelihood that the client will continue to practice the skills learned once therapy is completed. Motivation, lack of effort, and readiness to change are other variables that were not explored in the current study, which are factors that have been found to be correlated with homework compliance (Neimeyer et al. 2008; Yovel and Safren 2007). Addis and Jacobson (2000) examined the relationship between clients acceptance of the treatment rationale and the degree to which clients completed homework, and concluded that the ability to provide a convincing treatment rationale may be one of the crucial skills which determines the success of CBT in real-world clinical settings. Further studies would benefit from exploring these areas in regard to homework compliance.
In sum, the results of this meta-analysis suggest that on the whole, greater compliance with homework is related to improved treatment outcome, and this relationship is robust across a variety of treatment targets (e.g., depression, anxiety, and substance use). However, this study also highlights discrepancies in effect sizes surrounding the method of assessing homework compliance (e.g., objective vs. subjective). Specifically, higher effect sizes were found when therapists and clients both evaluate homework compliance. On one hand, clinicians may desire making homework compliance a collaborative part of treatment (e.g., to structure therapy whereby review of homework is an integral part of sessions). On the other hand, these discrepancies may highlight the inherent limitations in using subjective assessments of homework compliance. To this regard, it may be increasingly important for more standardized and objective methods of assessing homework compliance that are less prone to bias and that capture the true nature of the relationship between homework compliance and treatment outcome. In this vein, suggestions on incorporating homework into therapy and improving compliance are available in the literature (Beck 1995; Tompkins 2004), as are forms for measuring multiple aspects of homework compliance (Kazantzis et al. 2004).
Funding for this manuscript was provided by the National Institute on Aging (NIA) through grant R01 AG031090 and the National Institute of Mental Health (NIMH) through grant R01 MH 084967.
Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
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