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Why does my patients not do their assignments in CBT?

Updated the 19th of March 2023

The purpose of homework in Cognitive Behavioral Therapy (CBT) is for patients to have the opportunity to practice skills presented in the therapy room, and is an important part of the therapeutic process. Research shows that doing homework is associated with better outcomes. Despite this, many patients experience difficulties in carrying out their tasks. Here are some common reasons why patients do not complete their assignments.


What is homework in CBT?

A homework assignment in CBT can be described as a specific therapeutic activity that is discussed in a session, and  is assigned to be performed and documented by the patient before the next session. Within the framework of this definition, psychologists can work in different ways in designing tasks. The task can be relatively standardized as part of a treatment protocol. Tasks can also only be created as a verbal agreement.

Are patients adherent to assignments in CBT?

Measuring compliance within CBT is complicated. This is because a homework assignment has both a qualitative and quantitative component. Homework can be carried out without contributing to the patient's improvement. Thus, the quantity of compliance may be good but the quality of the task is low. On the other hand, a patient can quantitatively perform few tasks, but the tasks that are performed contribute to better outcomes. This may be due to the patient doing the tasks that are relevant to the patient's problem. Therefore, you need to measure both the quality of the tasks, alongside the quantity of the execution. This means that in research it is difficult to say definitively how well patients comply to treatment in general. An estimate of compliance is that approximately 50% of patients complete or partially perform relevant tasks. The reasons for not doing homework can be divided into external or internal reasons.


Reasons why patients don't perform their assignments 

External reasons for not performing assignments

External reasons for not performing tasks  have to do with the ​patient's environment. Here are some reasons cited in research.

  • Lack of obstacle planning. When a task is given to a patient, it is reasonable to assume that a wide range of situations can make it difficult for the patient to perform the task. Failure to plan for obstacles in advance can increase the likelihood that the patient will not perform tasks at all.

  • The tasks are perceived to take a lot of time to perform. This is often closely related to the fact that the tasks are perceived as complicated.

  • Inadequate instructions. A common reason why tasks are not performed is because the patient simply does not understand the purpose of the task. This may be because either no rationale is given for the task, or the ration is not perceived as valid by the patient.

  • Analog formats for the task. Some patients may find it difficult to manage paper forms. Paper needs to be stored, and is difficult to carry around to record something important, when it happens.


Internal reasons to not perform assignments in CBT

Internal reasons for not completing  tasks have to do with the patient's thoughts or behaviors related to tasks. Here are some reasons cited in research:


  • Assigments often contain long-term rewards. Performing a task is often theoretically closely related to experiencing short-term discomfort. The discomfort arises fundamentally from the patient confronting negative emotions when they challenge various forms of ingrained patterns. The reward for this behavior is  mostly something that happens cumulatively and in small increments over several sessions, and thus the initial response can be unpleasant for the patient.

  • Symptom reduction can reduce the incentive to continue doing the tasks. Given that patients are initially motivated to reduce their symptoms, the successful performance of assignments can have an initially positive feedback loop as symptoms may initially decrease. Although this is positive, this might also reduce the natural reinforcement in performing the task. It is therefore important to plan for consistency over the long-term.


Want to see how to create consistently good homework? Read our related article on How to keep your patient motivated for treatment.


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