Published: 14 July 2025

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.

Published: 14 July 2025

When Perfectionism Becomes Dangerous: How One Teen Overcame Anorexia and Obsessive Traits

A detailed case study shows how combining eating disorder treatment with perfectionism therapy can help young people struggling with both conditions

Jenny was the kind of teenager many parents would be proud of: a straight-A student, dedicated soccer player, and someone who always followed the rules. But beneath her high-achieving exterior, a dangerous combination of perfectionism and eating disorder thoughts was taking control of her life.

At 17, Jenny found herself trapped in a web of increasingly rigid rules about food, exercise, and academic performance. What started as a simple "summer diet" had spiraled into full-blown anorexia nervosa, complicated by obsessive-compulsive personality traits that made recovery even more challenging. Her story, detailed in a recent case study, offers hope for other young people facing similar struggles and highlights an important approach to treatment that addresses multiple issues simultaneously.

When Perfect Becomes Problematic

Jenny's journey toward serious mental health problems began innocently enough. During the summer before her senior year, she decided to eat a bit healthier. But for someone with perfectionistic tendencies, "a bit healthier" quickly became an all-consuming obsession.

First, she cut out sweets and snacks. Then sugar entirely. Then oil, white flour, and anything she deemed "unnecessary calories." Meanwhile, she added more and more exercise to her routine, training compulsively beyond her regular soccer practice. Her weight dropped 22 pounds, leaving her significantly underweight with a BMI of just 16.42.

But the eating disorder was only part of the picture. Jenny also displayed what psychologists call Obsessive-Compulsive Personality Disorder (OCPD), which is different from the more well-known OCD. While OCD involves unwanted intrusive thoughts and compulsive behaviors, OCPD is characterized by an overall rigid, perfectionistic approach to life.

Jenny's perfectionism extended far beyond food and weight. She had strict morning and evening routines, obsessed over being "productive" every moment, and developed almost magical thinking around her academic work. She would pack her school backpack in a specific order that couldn't be changed without causing her significant distress. She rarely allowed herself breaks and became extremely upset when confronted with the strict rules governing her life.

The Hidden Connection

What makes Jenny's case particularly important is how it illustrates the complex relationship between eating disorders and perfectionism. Research shows that people with eating disorders, especially anorexia nervosa, are much more likely to have perfectionist personality traits than the general population.

This isn't just coincidence. Both conditions involve rigid thinking, an intense need for control, and setting impossibly high standards. For someone like Jenny, the eating disorder and perfectionism fed off each other, creating a vicious cycle that was difficult to break.

Her therapists recognized that treating only the eating disorder symptoms without addressing the underlying perfectionism would likely lead to limited success. Traditional approaches might help someone gain weight and improve their eating patterns, but if the perfectionistic thinking patterns remain unchanged, relapse becomes much more likely.

A Comprehensive Treatment Approach

Jenny's treatment team used an enhanced version of Cognitive Behavioral Therapy for Eating Disorders (CBT-E), which is considered one of the most effective treatments for anorexia nervosa. But instead of the standard 20 sessions, Jenny received 40 sessions because she was underweight, plus an additional 6 sessions specifically targeting her perfectionism.

The treatment was divided into four distinct phases:

Phase 1: Building Trust and Starting Change The initial focus was on establishing a therapeutic relationship and beginning the process of weight restoration. Jenny was anxious about gaining weight and losing control over her eating, but she was also motivated by her desire to maintain her friendships and academic performance, which were suffering due to her low energy.

One of the first major challenges was addressing her compulsive exercise habits. Both anorexia and perfectionist personality traits are associated with excessive exercise, and Jenny's rigid training schedule was interfering with her ability to gain weight. Working with her parents, the therapist helped establish more reasonable exercise limits.

Phase 2: Planning the Path Forward After some initial progress, the team conducted a comprehensive assessment and developed an updated treatment plan. It became clear that both the eating disorder and the perfectionist personality traits needed to be addressed together for lasting recovery.

Phase 3: Tackling the Core Issues This was the longest and most intensive phase, where Jenny worked on the underlying patterns that drove both her eating disorder and perfectionism. Using techniques from both eating disorder treatment and perfectionism therapy, she learned to question her rigid rules and broaden her definition of self-worth beyond achievements and physical appearance.

One breakthrough came when Jenny realized her perfectionism was actually threatening her relationships with family and friends. Her drive to always be "productive" meant she often declined social invitations in favor of studying or exercising. By connecting her recovery to her values about maintaining close relationships, she found motivation to challenge her rigid thinking.

Phase 4: Maintaining Progress The final phase focused on preventing relapse and maintaining the positive changes. Jenny practiced applying her new, more flexible thinking to various life situations and developed strategies for handling future challenges.

Real World Results

The treatment was remarkably successful. By the end of the year-long therapy process, Jenny had achieved several important milestones:

Physical Recovery: She reached a healthy weight (BMI of 19.2) and was eating a varied diet without the rigid restrictions that had characterized her eating disorder.

Psychological Improvement: Her scores on eating disorder assessments dropped from the severe range to below the clinical threshold. Similarly, her perfectionist traits decreased dramatically, and she no longer met the criteria for obsessive-compulsive personality disorder.

Life Changes: Perhaps most importantly, Jenny was able to enjoy life again. She took a summer trip to one of her favorite countries and rediscovered her love of food and family meals. She learned to set boundaries with academic and volunteer commitments, saying no to some activities to preserve her energy and well-being.

Social Reconnection: She became more spontaneous with friends and family, no longer needing detailed plans for every social interaction.

The Broader Implications

Jenny's case highlights several important points for families, therapists, and young people struggling with similar issues:

Perfectionism Can Be Dangerous: While society often praises perfectionist traits, they can become problematic when they're rigid and interfere with daily functioning. The line between healthy striving and unhealthy perfectionism is important to recognize.

Multiple Issues Need Multiple Solutions: Treating only the eating disorder symptoms without addressing underlying personality traits may not be sufficient for lasting recovery. A comprehensive approach that tackles both issues simultaneously can be more effective.

Integration Works: Using similar cognitive techniques to address both over-evaluation of weight/shape and over-evaluation of achievements helps patients see the connection between different areas of struggle.

Relationships Matter: Jenny's motivation to maintain her friendships and family connections became a powerful tool in recovery, highlighting the importance of social support and meaningful relationships.

Recovery Is Possible: Even when multiple serious mental health conditions are present, comprehensive treatment can lead to full recovery and a return to healthy functioning.

Warning Signs for Parents

Jenny's case also offers important lessons for parents about warning signs to watch for:

• Sudden changes in eating patterns or significant weight loss
• Increasingly rigid routines around food, exercise, or daily activities
• Perfectionist demands that interfere with social activities or rest
• Extreme distress when routines are disrupted
• Declining energy or mood despite apparent "success" in academics or activities
• Social withdrawal or conflicts around meal times

Four weeks after completing her formal treatment, Jenny had a follow-up session to address some remaining perfectionist symptoms that appeared during stressful academic periods. She learned strategies for managing these symptoms and felt confident about maintaining her progress.

The success of Jenny's treatment supports the growing recognition that eating disorders often occur alongside other mental health conditions that need to be addressed in treatment. Rather than treating these as separate problems, an integrated approach that recognizes their interconnections can lead to better outcomes.

For families facing similar challenges, Jenny's story offers hope that recovery is possible, even when multiple serious conditions are present. With comprehensive treatment that addresses the whole person rather than just individual symptoms, young people can overcome these challenges and return to healthy, fulfilling lives.

The key is recognizing that perfectionism, while often seen as a positive trait, can become dangerous when taken to extremes. By addressing both the eating disorder and the underlying perfectionist thinking patterns, Jenny was able to achieve lasting recovery and rediscover the joy in food, relationships, and life itself.

Published: 14 July 2025

Getting Back to Work: How Online Therapy is Helping People with Depression and Anxiety Return to Their Jobs

New Norwegian study shows promising results for internet-based therapy specifically designed to help people get back to work

When Erik, a 45-year-old project manager, found himself on sick leave due to depression and anxiety, he faced a common dilemma: traditional therapy helped with his symptoms, but didn't address his biggest worry—how to return to work. After months away from his job, the thought of walking back into the office felt overwhelming. He wasn't alone in this struggle.

In Norway, mental health conditions like depression and anxiety account for 30% of all annual sick leave, creating enormous personal and economic costs. While traditional therapy can effectively reduce symptoms, it often falls short when it comes to helping people successfully return to their jobs. Now, researchers in Norway have developed and tested an innovative solution: internet-based therapy specifically designed to tackle both mental health symptoms and work-related challenges.

The Problem with Traditional Approaches

Most therapy focuses on reducing symptoms like sadness, worry, or panic attacks. While this is important, it doesn't necessarily prepare someone for the specific challenges of returning to work: dealing with workplace stress, managing energy levels throughout the day, or handling conversations with managers about their absence.

Research shows that while traditional cognitive behavioural therapy (CBT) is effective in reducing symptoms, its impact on helping people return to work is less impressive. This gap has led researchers to develop "work-focused therapy," which directly integrates employment concerns into treatment.

Face-to-face work-focused therapy has shown promise, with studies indicating about a 20% increase in return-to-work rates compared to standard treatment. However, access to this specialized therapy is limited, and many people can't attend regular in-person sessions while they're struggling with mental health issues.

A Digital Solution

The Norwegian research team wondered: could they combine the accessibility of internet-based therapy with the effectiveness of work-focused treatment? They developed what they call W-ICBT (Work-focused Internet Cognitive Behavioral Therapy) — a 12-week online program that addresses both mental health symptoms and work-related challenges.

The program consists of seven chapters that participants work through at their own pace, with support from trained therapists via written messages and occasional phone calls. Unlike traditional therapy that might focus separately on depression or anxiety, this approach takes a "transdiagnostic" view, addressing the common factors that underlie various mental health conditions.

How the Treatment Works

The online program guides participants through several key areas:

Understanding the Connection: Helping people see how their mental health symptoms and work challenges are connected, rather than treating them as separate problems.

Building Self-Efficacy: Developing confidence in one's ability to handle work demands and cope with challenges that arise.

Practical Skills: Learning specific CBT techniques like managing negative thoughts, regulating attention, and planning gradual exposure to challenging situations.

Graded Return Planning: Working through concrete steps for re-entering the workplace, from initial contact with managers to gradually increasing responsibilities.

Setback Management: Preparing for and normalizing the ups and downs that come with returning to work while managing mental health.

The program emphasizes that recovery isn't linear and that feeling tired or anxious when returning to work is normal and expected. This normalization helps reduce the additional stress that comes from thinking "I should be better by now."

Real Results from Real People

The study followed 19 people who were screened for the program, with 15 ultimately participating and 11 completing the full treatment. While the numbers are small, the results were encouraging:

Dramatic Reduction in Sick Leave: Participants' average sick leave dropped from 80% to 33% — meaning most went from being mostly unable to work to working at least two-thirds of their normal schedule.

Improved Confidence: Work-related self-efficacy scores improved significantly, indicating people felt much more capable of handling their job demands.

Better Mental Health: Depression scores improved substantially, and participants reported better quality of life overall.

High Engagement: Nearly 80% of participants completed the full 12-week program, which is comparable to or better than many traditional therapy programs.

What Participants Actually Experienced

Beyond the numbers, researchers conducted detailed interviews with participants to understand their experiences. Four main themes emerged:

The Format Works: People appreciated the flexibility of online therapy. They could work through materials when they felt mentally able, revisit content as needed, and avoid the stress of traveling to appointments when they were struggling.

"It was very positive that I could control it myself," one participant explained. "I could do the treatment from home without the need for travel for sessions."

The Content Made Sense: Participants found the combination of mental health and work content highly relevant. Rather than having to navigate separate treatments, everything was integrated in a way that reflected their real-world experience.

"The combination was very good—not just all about work, not just all about mental health, but a mix where you can actually think about how they are connected," noted another participant.

A Challenging Process: While people found the program helpful, it wasn't easy. Some struggled to find time for the work, others found certain assignments emotionally difficult, and some felt parts of the program didn't perfectly match their situation.

Understanding and Doing Things Differently: All participants reported gaining valuable insights and practical tools. They developed better ways to manage negative thoughts, set boundaries at work, and handle stress.

Why This Approach Works

The success of this program appears to stem from several key factors:

Integrated Approach: Instead of treating mental health and work issues separately, the program recognizes they're deeply connected and addresses them together.

Practical Focus: The therapy doesn't just explore feelings but provides concrete tools and strategies for real-world situations.

Flexibility: The online format allows people to engage when they're mentally able and progress at their own pace.

Normalization: The program acknowledges that returning to work while managing mental health is difficult and that setbacks are normal.

Gradual Progression: Rather than expecting people to jump back into full-time work, the approach supports gradual re-engagement.