The Homework Problem: Why Some People Struggle with Therapy "Assignments" and How to Fix It
Major research review reveals what makes the difference between success and failure in cognitive behavioral therapy homework
When Sarah first started cognitive behavioral therapy for her anxiety, she was enthusiastic about getting better. But as the weeks went on, she found herself consistently avoiding the "homework" her therapist assigned between sessions. Recording her anxious thoughts felt overwhelming, and the breathing exercises seemed pointless when she was stressed at work. She wasn't alone in this struggle, and new research helps explain why.
A comprehensive review of 59 studies has revealed the factors that determine whether people will actually complete the between-session work that's crucial to successful therapy outcomes. The findings offer hope for both therapists and patients by identifying specific, changeable factors that can dramatically improve engagement with therapy homework.
Why Homework Matters in Therapy
Unlike traditional talk therapy where the main work happens in the therapist's office, cognitive behavioral therapy (CBT) relies heavily on what happens between sessions. Patients are typically asked to practice new skills, monitor their thoughts and behaviors, complete reading assignments, or gradually face their fears through exposure exercises.
This "between-session work" isn't just busy work. Multiple research studies have consistently shown that people who engage with their therapy homework see significantly better outcomes. They recover faster, maintain their progress longer, and are less likely to drop out of treatment early.
"Between-session work acts as the vehicle to translate skills learnt in therapy sessions into adaptive changes in everyday life," the researchers explain. It's the bridge between learning something in a safe therapy room and applying it in real-world situations where anxiety, depression, or other problems actually occur.
Yet despite its proven importance, homework completion remains a persistent challenge. Some studies have found that up to 75% of therapy sessions include discussions about difficulties completing assigned tasks. Understanding why some people struggle while others succeed has become a critical question for improving mental health treatment.
The Big Picture: What the Research Revealed
The research team analyzed studies involving thousands of people receiving CBT for conditions like depression, anxiety, obsessive-compulsive disorder, and post-traumatic stress. They identified ten major categories of factors that influence whether someone will complete their therapy homework, ranging from personal beliefs to therapist behaviors to practical obstacles.
While the findings showed that homework engagement is complex and influenced by many factors, several clear patterns emerged that offer practical solutions for both therapists and patients.
The Strongest Predictors: What Really Makes the Difference
Patient Beliefs About Homework
The most consistent finding was that what people believe about their homework assignments strongly predicts whether they'll complete them. When patients see assignments as helpful and relevant to their problems, they're much more likely to follow through. Conversely, when tasks seem pointless, too difficult, or disconnected from their goals, engagement plummets.
One study participant captured this perfectly: "I found the assignments difficult to carry out. Just reading them made me anxious, thinking: 'what do I do now?'" This highlights how homework that feels overwhelming or unclear can actually increase distress rather than reduce it.
On the flip side, patients who experienced positive consequences from homework, such as improved mood or a sense of progress, became more motivated to continue. This creates a positive cycle where early success breeds continued engagement.
Therapist Competence in Planning and Reviewing Homework
The research revealed that how therapists handle homework makes a huge difference. Effective therapists consistently do several key things:
Provide Clear Rationales: They explain why a specific assignment will help with the patient's particular problems, not just what to do.
Plan Collaboratively: Instead of simply assigning tasks, they involve patients in designing homework that fits their specific situation and preferences.
Address Obstacles Proactively: They anticipate potential barriers and problem-solve solutions before the patient encounters difficulties.
Review Thoroughly: They dedicate time in each session to discussing what happened with the previous week's assignments, celebrating successes and troubleshooting problems.
Stay Flexible: They're willing to modify assignments based on patient feedback and changing circumstances.
As one therapist noted, "Patient involvement in task design, clear task specification, pre-emptive problem solving to address potential barriers to completion, and ongoing task review" were crucial for success.
Patient Resistance During Sessions
Perhaps surprisingly, what happens during therapy sessions strongly predicts between-session engagement. Patients who express resistance, argue against treatment approaches, or engage in what therapists call "counter change talk" are much less likely to complete homework.
This finding highlights the importance of addressing ambivalence and building motivation before assigning tasks. When patients feel pushed or pressured, they often rebel by avoiding homework, even if they don't express this directly to their therapist.
The Murky Middle: Factors with Mixed Results
Depression and Anxiety Severity
One might expect that people with more severe symptoms would struggle more with homework, but the research showed mixed results. Some studies found that higher depression levels made homework completion harder, while others found the opposite. Similarly, anxiety severity showed inconsistent relationships with homework engagement.
This suggests that symptom severity alone doesn't determine homework success. Other factors, like how well the homework is designed and how motivated the person feels, may be more important than the raw level of distress.
The Therapeutic Relationship
Surprisingly, the quality of the therapeutic relationship showed mixed effects on homework completion. While some studies found that stronger therapeutic alliances led to better homework engagement, others found no effect or even negative effects.
This challenges the common assumption that a good relationship automatically leads to better treatment compliance. It may be that other factors, like the specific homework assignments and how they're presented, matter more than general rapport.
Demographics and Background
Age, gender, education level, and marital status showed little consistent relationship with homework completion. However, there were some concerning patterns around race and socioeconomic status. People from racial minority backgrounds and those with lower socioeconomic status were less likely to complete homework in several studies.
This may reflect the fact that CBT was developed primarily with White, middle-class populations in mind, and homework assignments may not always be culturally relevant or accessible to diverse populations.
Practical Barriers: The Obstacles
Beyond psychological factors, the research highlighted numerous practical barriers that prevent homework completion:
Time Constraints: Many people struggle to find time for homework while juggling work, childcare, and other responsibilities.
Privacy Concerns: Some worry about family members or roommates discovering their therapy materials.
Timing Issues: Assignments often get left until the end of the day when people are tired and less motivated.
Disorganization: Simple logistical issues like forgetting materials or losing worksheets can derail engagement.
These findings underscore the importance of designing homework that fits into people's actual lives rather than ideal circumstances.
What This Means for People in Therapy
If you're currently in CBT or considering it, these findings offer several practical insights:
Speak Up About Your Homework Experience: If assignments feel irrelevant, too difficult, or unclear, tell your therapist. Good therapists want this feedback and can modify approaches based on your input.
Ask for Rationales: Don't hesitate to ask why a specific assignment will help you. Understanding the purpose increases motivation and engagement.
Identify Your Barriers: Be honest about practical obstacles like time constraints or family situations. Your therapist can help design workarounds.
Start Small: If homework feels overwhelming, ask for simpler tasks initially to build confidence and momentum.
Celebrate Small Wins: Notice and acknowledge when you complete assignments, even imperfectly. This positive reinforcement helps maintain motivation.
What This Means for Therapists
The research offers clear guidance for improving homework engagement:
Focus on Beliefs First: Before assigning tasks, explore what patients think about homework in general and specific assignments in particular. Address negative beliefs directly.
Enhance Your Homework Skills: Invest time in learning how to plan, assign, and review homework effectively. This isn't just an add-on to therapy; it's a core skill.
Use Motivational Techniques: When patients show resistance, shift to motivational interviewing techniques rather than pushing harder with assignments.
Consider Cultural Factors: Be aware that standard CBT homework may not resonate with all cultural backgrounds. Adapt assignments to be more culturally relevant when needed.
Address Practical Barriers: Help patients problem-solve real-world obstacles rather than assuming everyone has ideal conditions for completing homework.
The Future of Therapy Homework
This research highlights both the promise and the challenges of between-session work in therapy. On the positive side, the factors that most strongly predict homework success, patient beliefs and therapist competence, are modifiable. With proper training and attention, these can be improved.
The research also points to several areas needing further development:
Better Measurement: Currently, most studies measure only whether homework was completed, not how well it was done or what was learned. Future research needs better ways to assess the quality of engagement.
Cultural Adaptation: More work is needed to ensure homework assignments are relevant and accessible across diverse populations.
Technology Integration: As therapy increasingly moves online and incorporates apps and digital tools, new research is needed on how technology affects homework engagement.
Personalization: The one-size-fits-all approach to homework clearly doesn't work for everyone. Future developments may focus on matching homework types to individual preferences and circumstances.
Therapy homework isn't just an optional extra; it's a crucial component of successful treatment. When people engage with between-session work, they get better faster and maintain their progress longer. When they don't, therapy becomes less effective.
The good news is that homework engagement isn't mysterious or unchangeable. The research shows that specific, learnable skills on the part of therapists, combined with attention to patient beliefs and practical barriers, can dramatically improve completion rates.
For people struggling with mental health issues, this research offers hope that therapy can be more effective when homework is designed and implemented thoughtfully. For therapists, it provides a roadmap for improving one of the most impactful but underutilized aspects of treatment.
As one study participant noted, when homework is done well, it becomes "the biggest factor during therapy" for positive change. When it's done poorly, it becomes "the biggest challenge." The difference lies not in the patient or their motivation, but in how thoughtfully the homework is crafted, explained, and supported.
The path to better therapy outcomes may be as simple as paying more attention to what happens between sessions. For millions of people seeking help for depression, anxiety, and other conditions, that attention could make all the difference.
