cbt homework for trauma

23 Post Traumatic Growth Worksheets for Therapy (+PDF)

Post Traumatic Growth, or PTG, explains how trauma survivors can not only heal from their trauma, but can actually learn from the experience to become more resilient individuals.

In the mid-1990s, psychologists Richard Tedeschi and Lawrence Calhoun (Tedeschi & Calhoun, 1996) discovered that the severe psychological struggle that follows major life crises can result in positive growth and deepening resilience afterward.

While our other PTG article defines Post-Traumatic Growth with detail on the concept itself and the science behind it, this article provides you with practical tools to apply PTG with your clients or students.

Before you continue, we thought you might like to download our three Resilience Exercises for free . These engaging, science-based exercises will help you cope with difficult circumstances and give you the tools to improve the resilience of your clients, students, or employees.

This Article Contains:

A look at trauma therapy techniques, post traumatic growth worksheet, 6 ptsd worksheets (pdf), 3 common therapy techniques for trauma, 16 pdf trauma worksheets, activities for trauma therapy, positivepsychology.com resources, a take-home message.

There are many trauma therapy techniques mentioned in this article. In this section, we will explore how some of these techniques can be applied to promote post-traumatic growth (PTG) using the model developed by Stephanie D. Nelson, a Behavioral Science Officer from the United States Army.

In 2011, Nelson developed a posttraumatic growth path (PTGP) for veterans suffering from post-traumatic stress disorder ( PTSD ; Nelson, 2011). This pathway can also work with other types of trauma survivors.

The program comprises four stages for those struggling with PTSD symptoms (Nelson, 2011):

Evidence shows the techniques applied during each stage are beneficial for relieving specific PTSD symptoms in all types of trauma survivors and promoting post-traumatic growth (Ogilvie & Carson, 2021).

1. Deal – Writing a Trauma Narrative

This stage consists of writing a trauma narrative by focusing on the facts surrounding the incident(s), including the who, what, where, and when. Next, the client describes the thoughts and feelings that arose during the experience to create a comprehensive narrative.

Finally, the client is asked to write a paragraph reflecting on how they feel now, what they have learned, and if they have grown from the experience. Trauma survivors should complete this exercise with a therapist or counselor for support with any distressing feelings and sensations that may arise such as flashbacks, anxiety, or panic.

Once the trauma narrative is completed, the client proceeds to step 2.

2. Feel – Imaginal Exposure

The next step involves experiencing the feelings aroused by reading the trauma narrative aloud using imaginal exposure.

Exposure therapies work by exposing then desensitizing clients to any uncomfortable, distressing, and frightening feelings associated with the original trauma (Van Der Kolk, 2014).

Imaginal exposure entails revisiting the experience in the mind’s eye using the vivid sensory capacity of the imagination. Imaginary exposure to traumatic experiences using a trauma narrative, helps clients fully process their feelings with the support of a counselor or therapist.

This technique reconnects the client to their original emotional responses to the trauma which otherwise can become displaced onto other associated stimuli called ‘triggers’. Often, trauma survivors avoid emotional triggers which can lead to a narrowing of life experience and a lower quality of life.

For example, physical contact with their partner or spouse may trigger a rape survivor who withdraw or even freeze upon physical contact. This can destroy a survivor’s capacity for intimate relationships. Imaginal exposure allows a client to process any repressed feelings safely, and overcome avoidance.

3. Heal – Channeling PTG

Stage three helps the client reintegrate their feelings and thoughts about the original trauma to facilitate opportunities for learning and growth. The healing stage involves three phases.

• Freedom of choice During this phase, the therapist explains that while the client did not choose their traumatic experience, they can choose how to go forward. The narrative therapy technique of “rewriting the ending” can help the client create their own path.
• Finding meaning The client is encouraged to find meaning in their experience in whatever way is appropriate and workable for them.
• The hero archetype Finally, the therapist guides the client through the transformative journey of the Hero archetype by re-telling their story in the context of the client’s spiritual and cultural values to make the experience more meaningful. The client may also benefit from hearing stories where the hero experiences a significant trauma and becomes a much stronger person as a result.

Once these three techniques have been explored, the therapist can teach the client PTG channeling which involves redirecting their emotional energy away from avoiding triggers into productive, goal-oriented behavior. The therapist may assign the client homework exercises to help shift them from survival toward post-traumatic growth.

4. Seal – The mind as a filing cabinet

The last step of the post-traumatic growth path involves reorganizing the traumatic memory using the “mind as a filing cabinet” metaphor. This likens the memory of the traumatic experience to disorganized information scattered throughout the filing system of the mind.

Rather than the files being neatly ordered, numerous folders contain fragments of information that are confusing and disorientating.

The ‘sealing’ step reorganizes memories as files and stores them away safely. Files can be consulted in the future, but are no longer anything more than one of the many files that are stored in the cabinet of the mind.

The client may need to repeat this process of reorganizing further memories over the course of therapy.

For a moving true-life account of how traumatic childhood experiences can lead to post-traumatic growth and a rounded, fulfilling life, check out this TEDx talk by Martha Londagin below.

Here at PositivePsychology.com, we have several free worksheets that help clients deal with trauma.

However, we selected one as the ultimate post traumatic growth worksheet.

The worksheet start by identifying what is distressful, and causes avoidance.

Avoidance is a strategy trauma survivors often use to eliminate triggers and other associations with the original traumatic event. The problem with avoidance is that it constrains life by restricting options and prevents learning and growth.

The consequences of avoidance are an intensification of fear and restrictions that undermine quality of life .

It is possible to overcome avoidance through gradual exposure until desensitized to the triggering stimuli. Although this process is uncomfortable, it results in an increased sense of safety, widens options, and leads to a more fulfilling life (Collier, 2016).

The post-traumatic growth worksheet then assists with selecting and implementing healthier coping mechanisms than avoidance.

You can access the Conquering Avoidant Tendencies worksheet via the link.

The worksheets include identifying triggers, self-regulating emotions, grounding, decatastrophizing, and taking steps towards gratitude for the things they still enjoy and that support them as they heal.

1. What are your unique triggers?

Identifying triggers is an essential coping skill that can help a client manage their symptoms during their recovery. If a client is aware of their triggers this also helps in overcoming avoidance (Van Der Kolk, 2014).

Look at our What Are Your Unique Triggers? worksheet for guidance.

2. Letter of self-compassion

Cultivating self-compassion is crucial when recovering from a traumatic experience (Collier, 2016). All too often we expect way too much of ourselves and don’t give ourselves enough time and space to heal. Try our Letter of Self-compassion worksheet and read it aloud whenever the inner critic looms.

3. Skills for self-regulating emotions

An ability to self-regulate our emotions is an essential life skill in any context but this can be especially challenging after a traumatic experience when our emotions can become unpredictable or even numb (Van Der Kolk, 2014).

Try our Skills for Self-Regulating Emotions worksheet to help clients self-soothe.

4. Catastrophizing and decatastrophizing

Catastrophizing entails imagining the worst-case scenario every time we face a problem. It is rooted in a limbic brain response designed to protect us from danger, but following trauma, it can be a symptom of hypervigilance (Van Der Kolk, 2014).

Try our Decatastrophizing worksheet for practical support.

5. Countdown to calmness

Grounding ourselves is essential when feeling disconnected from our body or environment, or after catastrophizing (Van Der Kolk, 2014).

Try our Countdown to Calmness worksheet which uses radical acceptance to ground you by focusing on your five senses.

6. It could be worse

Despair and anger are natural responses to a traumatic experience that can rob our lives of meaning (Collier, 2016).

Download 3 Free Resilience Exercises (PDF)

These detailed, science-based exercises will equip you or your clients to recover from personal challenges and turn setbacks into opportunities for growth.

Download 3 Free Resilience Tools Pack (PDF)

By filling out your name and email address below.

Although there are various therapies that can be used for trauma therapy, including EMDR , the following are commonly known therapy types used.

Narrative Therapy

Narrative therapy was developed in the 1980s by Michael White and David Epston (White & Epston, 1990). We explained above how writing a trauma narrative can be used to process and integrate traumatic experiences.

White and Epston believed that separating a person from their problematic behavior was crucial for therapeutic success (White, 2011). Narrative therapy achieves this by helping clients externalize their experience in writing.

White and Epston (1990) formulated their model using three key principles:

• Narrative therapy is respectful.
• Narrative therapy is non-judgmental.
• Narrative therapy views the client as the expert on their problems.

Narrative therapy equips clients with story-telling skills to help separate their sense of personal identity from their trauma. When the client stops seeing their trauma as an integral part of their identity, resolving to learn and grow from the experience becomes easier (Van Der Kolk, 2014).

Art Therapy

Art therapy is a therapeutic practice that uses visual arts techniques to facilitate the therapeutic process and can be especially helpful given that many aspects of traumatic experiences are difficult to express in words (Malchiodi, 2020).

A client doesn’t need any artistic skills to take part in this type of therapy. Rather, the art therapist encourages the client to tap into their creative process to explore and express emotions and develop greater self-awareness. This can help with processing buried conflicts and unresolved trauma.

For a more detailed account of this approach to trauma therapy, we recommend these art therapy , and expressive arts therapies articles.

Play Therapy

Play therapy is typically used to facilitate psychotherapy with children but can also be used with adults. Play therapy requires movement which can help address unresolved trauma that is difficult to express in words, especially for children (Allen & Hoskowitz, 2017).

Play therapy incorporates many techniques such as sand and water play, role play, and the use of representational toys like dolls, trucks, and guns to create play that expresses the client’s traumatic experience. This helps the client externalize their trauma similar to narrative therapy and art therapy, making the experience easier to process (Allen & Hoskowitz, 2017).

We have grouped them into 5 themes for your convenience.

1. Strengths

Identifying a client’s strengths and previous experiences of overcoming difficulties helps with recovery from a traumatic experience. These two worksheets help clients identify their character strengths and recognize their capacity for post-traumatic growth.

• Exploring Character Strengths
• Exploring Past Resilience

2. Exposure

Exposure is an evidence-based approach to overcoming triggers and avoidance. These three worksheets can help guide clients through different types of exposure.

• For physiological symptoms of trauma try our Interoceptive Exposure worksheet,
• For traumatic memories try our Imagery Based Exposure worksheet
• For feared objects and situations try our Graded Exposure worksheet.

Fear and anxiety are common responses to trauma which can lead to dysfunctional thinking. These four worksheets are designed to help clients cope with the anxiety that often arises during and after trauma, and support them in moving on to post-traumatic growth.

• Challenging Catastrophic Thinking Worksheet
• Replacing ‘What if’ Statements
• Dysfunctional Thought Record
• FLARE for Anxiety and Fear

4. Grounding

Feeling far away or unreal is common following a traumatic experience. This is because of the dissociation and depersonalization that can occur as the body struggles to process sensory overload.

These three worksheets are designed to ground clients in the present moment using breathwork and radical acceptance.

• Yogic Breathing
• Anchor Breathing
• Focus on the Present for Radical Acceptance

Finally, these four worksheets have been designed using evidence-based interventions that promote post-traumatic growth.

Eye Movement Desensitization and Reprocessing (EMDR) involves coupling negative cognition with a chosen target image, selecting a positive replacement cognition, then reprocessing traumatic memories into more adaptive thoughts.

Download our EMDR Worksheet to find out more.

Meanwhile, our Imaginal Exposure worksheet uses the Subjective Units of Distress Scale (SUDS) to quantify the disturbance a client feels when revisiting their traumatic experience during therapy. It is especially useful for those who misuse substances to self-soothe.

Your clients can also try this Goal Planning and Achievement Tracker worksheet to monitor their progress during their post-traumatic growth journey.

Finally, our Growing Stronger From Trauma worksheet helps clients identify what they’ve learned from a traumatic experience, and appreciate the strengths they have developed as a result. This exercise helps clients cultivate a more balanced perspective on previous trauma and identify ways to manage future challenges.

The following activities aim at improving the reintegration of the mind, heart, and body connection that is often fragmented by a traumatic experience.

1. Psychoeducation

Psychoeducation is an important intervention to help trauma survivors understand they are experiencing a normal response to an abnormal experience. (Whitworth, 2016).

Our article on psychoeducation interventions explains more.

2. Self-soothing

Equipping a client with self-soothing skills will help support their recovery between sessions (Dreisoerner et al., 2021).

Look at our article 24 Best Self-Soothing Techniques and Strategies for Adults for more resources.

3. Expressive arts

Expressive arts activities can help to process blocked emotional responses to trauma through painting, drawing, clay modeling, photography, music, and movement (Malchiodi, 2020).

Check out our article Expressive Arts Therapy: 15 Creative Activities and Techniques for more resources.

4. Mindfulness

Mindful movement can support grounding when clients feel scattered or fragmented (Teut et al., 2013). Take a look at our articles on Mindful Yoga and Mindful Walking for further guidance.

5. Nature therapy

Ecotherapy interventions are deeply grounding for trauma survivors (Atkins & Snyder, 2017). Activities include forest bathing (Mao et al., 2012), walking in nature, or just gazing at the ocean (Cracknell, 2019).

17 Tools To Build Resilience and Coping Skills

Empower others with the skills to manage and learn from inevitable life challenges using these 17 Resilience & Coping Exercises [PDF] , so you can increase their ability to thrive.

Created by Experts. 100% Science-based.

Besides all the resources we’ve included above, consider our 6-module, science-based Realizing Resilience Masterclass© . It includes all the resources you’ll need to deliver high-quality resilience training and more.

We have other useful related articles with linked resources including:

• 7+ Trauma-Focused Cognitive-Behavioral Therapy Worksheets . Trauma-focused CBT comes highly recommended by the APA as a trauma treatment with a firm evidence base.
• What is Post-Traumatic Growth? (+ Inventory & Scale) examines the science behind PGT in detail.
• PTSD Treatment: How to Support Clients Dealing With Trauma includes psychoeducation tips and resources for working with children and groups.
• Military Counseling & Helping Veterans Deal With Trauma offers more specialized guidance on working with this client group after they have served in an active combat zone.

If you’re looking for more science-based ways to help others overcome adversity, this collection contains 17 Resilience & Coping Exercises . Use them to help others recover from personal challenges and turn setbacks into opportunities for growth.

We hope you find the resources in this article useful. Nobody wants to suffer, but we will inevitably face adverse experiences, whether it’s through loss and grief, sudden illness or injury, a natural calamity, or witnessing violence and extreme suffering in others.

If you struggle with trauma and its aftermath, remember that you have overcome obstacles in the past, and that you can draw on those experiences to cultivate the skills you need to process your experience, and become a wiser, more compassionate, and more resilient person as a result.

Finally, if you would like further inspiration about the potential for growth after trauma check out this short and powerful TED Talk by trauma survivor Charles Hunt. You won’t regret it!

We hope you enjoyed reading this article. Don’t forget to download our three Resilience Exercises for free .

• Allen, B. & Hoskowitz, N. A. (2017). Structured trauma-focused CBT and unstructured play/experiential techniques in the treatment of sexually abused children: A field study with practicing clinicians. Child Maltreatment 22(2) , 112-120.
• Atkins, S., & Snyder, M. (2017). Nature-based expressive arts therapy: Integrating the expressive arts and ecotherapy . Jessica Kingsley Publishers.
• Collier, L. (2016). Growth after trauma. Monitor on Psychology, 47(10).
• Cracknell, D. (2019). By the sea: The therapeutic benefits of being in, on, and by the water . Aster.
• Dreisoerner, A., Junker, N. M., Schlotz, W., Heimrich, J., Bloemeke, S., Ditzen, B., & van Dick, R. (2021). Self-soothing touch and being hugged reduce cortisol responses to stress: A randomized controlled trial on stress, physical touch, and social identity. Comprehensive Psychoneuroendocrinology, 8.
• Malchiodi, C. A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process. Guilford Press.
• Mao, G. X., Lan, X. G., Cao, Y. B., Chen, Z. M., He, Z. H., Lv, Y. D., Wang, Y. Z., Hu, X. L., Wang, G. F., & Yan, J. (2012). Effects of short-term forest bathing on human health in a broad-leaved evergreen forest in Zhejiang Province, China. Biomedical Environmental Science. 25(3) , 317-24.
• Nelson, S. D. (2011). The posttraumatic growth path: An emerging model for prevention and treatment of trauma-related behavioral health conditions. Journal of Psychotherapy Integration 21 , 1-42.
• Ogilvie, L. & Carson, J. (2021) Trauma, stages of change and post-traumatic growth in addiction: A new synthesis. Journal of Substance Use , 27 (2), 122-127.
• Tedeschi, R. G. & Calhoun L. G. (1996). The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. Journal of Traumatic Stress . 9(3), 455-71.
• Teut, M., Roesner, E. J., Ortiz, M., Reese, F., Binting, S., Roll, S., … Brinkhaus, B. (2013). Mindful walking in psychologically distressed individuals: A randomized controlled trial. Evidence-Based Complementary and Alternative Medicine , 1–7.
• Van Der Kolk, B. (2014). The body keeps the score . Penguin.
• Whitworth, J. D. (2016). The role of psychoeducation in trauma recovery: Recommendations for content and delivery. Journal of Evidence-Informed Social Work , 13(5), 442-51.
• White, M. & Epston, D. (1990). Narrative means to therapeutic ends . W. W. Norton & Company.
• White, M. (2011). Narrative practice: Continuing the conversations (D. Denborough, Ed.), W.W. Norton.

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A parent of a Marine that just had a tragic experience, and as a father would like to help in his recovery from PTSD from war ….

I’m a solution-focused narrative therapy and your PTG approach so resonates with me. Appreciate your work and resources and worksheets.

Thank you for the information!

Great information!

Great article. Interesting worksheets. Is there any link to these worksheets to download in pdf. Also looking for the ACTUAL PTG-24 tool link.

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Glad you liked the article! If you click the hyperlinks in-text where the worksheet name is mentioned, they’ll take you to the PDF download. Also, I’m not finding a tool with this name in our Toolkit. Could you elaborate on what specifically the tool is about and perhaps I can help find what you’re looking for.

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10 Top CBT Worksheets for Learning Cognitive Behavioral Therapy

Updated: Sep 28, 2023

These worksheets cover the most important skills from cognitive behavioral therapy (CBT)

The magic of CBT worksheets is that they take vague concepts and make them real.

Ironically, you need to do more than think about CBT -- your skills must be put into practice!

CBT worksheets help teach and reinforce skills learned in therapy. They are often used by therapists specialized in cognitive behavioral therapy and related treatments.

Below are the 10 top CBT worksheets focused on dealing with anxiety, restructuring thoughts, and addressing trauma and fears.

They can help treat issues like anxiety, post-traumatic stress disorder (PTSD), phobias, depression, and more.

Need resources right away? Skip ahead to here take a look at the CBT for anxiety and PTSD bundle.

Article Contents:

1. cbt triangle worksheet.

2. Challenging Thoughts Worksheets

3. Anxiety Management Worksheet

4. Strong Emotions Worksheet

5. Trauma-Focused CBT Worksheet

6. Exposure Hierarchy

7. Trauma Narrative

9 . Emotions Wheel Worksheet

10. Mindfulness Worksheet

CBT worksheets and tools are typically very structured, and follow the cognitive behavioral therapy approach. The basic idea of CBT, or cognitive behavioral therapy , is that patterns of thinking impact everything else. How we think about things can make life better or worse, regardless of the circumstances.

Our thoughts influence our feelings, which lead to our behaviors. The printable worksheets below start with the basic approach and expand into specialized areas, such as using CBT to treat PTSD.

Here are 10 top CBT worksheets focused on thoughts, feelings, and behaviors.

The CBT triangle is a commonly used tool to describe the basic principles of this therapy. This worksheet walks you step by step through the most basic process of CBT. It includes examples as well as space to write your own thoughts and begin to challenge them.

The cognitive (CBT) triangle came out of the early work of Aaron Beck, who developed CBT. He noticed that many people in therapy continued to suffer from mental health conditions such as depression, even as therapy progressed.

He termed the phrase “automatic thoughts,” to describe the thinking pattern many people experience. Most significantly, Dr. Beck found that how people thought about a situation resulted in how they experienced it, regardless of the situation itself.

Most significantly, Dr. Beck found that how people thought about a situation resulted in how they experienced it, regardless of the situation itself.

For example, someone may be running late for work. If they begin to think about getting fired and all of the things that would result from that, they might feel panicked or frustrated, and start driving erratically.

Alternatively, the same person may think differently, coaching themselves in a positive way. They may think, “I rarely run late, and my boss is very understanding, so it will be okay.”

With this change in thinking, they are likely to think more clearly and avoid feeling anxious. They may then calmly text their boss and drive carefully but efficiently toward work.

This process demonstrates the event (running late), the thought (catastrophizing versus positive self-talk) and the behavior (erratic driving versus planning).

Shop CBT triangle worksheet.

2. Challenging Thoughts Worksheet

The challenging thoughts worksheet is a cognitive restructuring worksheet. It walks you through challenging everyday negative thoughts, at a bit of a deeper level than the CBT triangle. It can also be an alternative format to learning the triangle.

Negative thoughts are sometimes called core beliefs, Negative core beliefs are thoughts that tend to pervade our everyday lives. They’re the “issues,” or “triggers,” you just can’t seem to get over. While most negative core beliefs are also distorted beliefs, the reverse isn’t necessarily true.

Negative core beliefs tend to involve shame, and how the person feels about themselves as a whole. This often relates to their abilities and worthiness.

For example, a basic distorted belief might be, “I’ll never pass my algebra class,” while a negative core belief might state, “I’m too stupid to succeed at anything.”

Once you understand the basics of CBT, the next step is to begin to challenge specific thoughts that happen regularly. For example, someone may think, “I mess everything up,” or “I can’t keep any friends.” These thoughts become a habit, and are likely to affect self-esteem, and even become a self-fulfilling prophecy. Because someone thinks they can’t keep friends, they stop trying to make them.

This worksheet keeps these thought patterns in mind, and help the user begin to challenge these beliefs. Terms often used include “stuck points,” “cognitive distortions,” or “negative thoughts.”

Shop challenging thoughts worksheet.

While there are multiple types of anxiety conditions, all of them relate to our thoughts. Meanwhile, many CBT therapists start with anxiety management skills. These include steps like mindfulness or self-soothing.

This anxiety management worksheet includes multiple ideas to deal with anxiety, as well as a page to outline your plan for future anxiety spells.

Ongoing anxiety is usually caused by thinking patterns. Ruminating thoughts, catastrophizing, and assuming the worst are common symptoms of multiple conditions. These thought patterns, combined with the hypervigilance that come along with them, can make it difficult to cope day to day.

These anxious thoughts are common, and likely originate from the human need to prepare for the worst and avoid danger. After all, if our ancestors hadn’t been a bit paranoid we may not be here today.

However, frequently thinking negatively can lead to overwhelming anxiety and nearly constant feelings of anxiety. Anxiety worksheets can help with coping while also addressing the root thoughts that perpetuate these fears.

Shop anxiety management worksheet.

4. Dealing With Strong Emotions Worksheet

Strong feelings can be overwhelming. This guide takes a look at how to rate, ride out, or cope with difficult emotions.

For example, if your emotion is simply uncomfortable, it's usually best to wait it out and allow the feeling to move through you. Otherwise it's likely to just keep coming back.

If a feeling is more significant and seems to interfere with your daily life, it may be best to work with a therapist on processing the emotion. Sometimes it's good to face the feeling head on, which will allow your body to learn the difference between the worry about danger and actual danger.

For example, worrying about danger might be thinking about a dog attacking you. It could cause your nervous system to become really alarmed, not realizing that there's no dog in sight.

By staying with that fear, your body will have the experience of getting to the other side and start to figure out that the fear is a feeling and not an event.

In other cases, if you have a history or pattern of self-harm, it's best to work closely with a therapist so you can fine-tune your plan. In some cases you may want to face your emotions while in other cases you may need some soothing to get through the moment.

This CBT worksheet on dealing with strong emotions is a great resource for therapists and their clients to work on feelings together.

Shop strong emotions worksheet.

This worksheet is created for trauma focused CBT Therapies. It includes the most common steps used in therapies like TF-CBT (trauma-focused CBT) and CPT (cognitive processing therapy).

Many people think of PTSD as simply a result of trauma. While trauma is at the core of it, it goes beyond that. The majority of people experience trauma at some point. At first, it causes feelings of worry, confusion, and sometimes self-blame for what happened.

However, within a few weeks to a month, most people come to terms with what happened. They understand that the trauma was an isolated event, and that there wasn’t anything they could do to change it.

A percentage of people, however, aren’t able to get through this process. This could be due to still being in danger, to past trauma complicating their ability to process, or simply having too much going on to deal with it initially.

This lack of processing leads to “stuck points,” or cognitive distortions relating to the trauma. They typically run along the lines of people blaming themselves, or feeling they can’t deal with difficulties in the world.

The most effective trauma therapies all deal with processing of the traumatic event, and this worksheet walks through the typical steps.

Shop the trauma thoughts worksheet.

6. Exposure Hierarchy Worksheet

Many people develop avoidance as a way to deal with anxiety, phobias, and PTSD. An exposure hierarchy helps people measure which fears are the worst, and how they progress over time.

This worksheet includes a simple but effective way to create an exposure hierarchy, as well as homework sheets to record your exposure activities.

Exposure, or fear, hierarchies are commonly used in CBT, CPT, and TF-CBT therapies.

Fears are sometimes measured by numbers, called SUDS (subjective units of distress). Over time the fear is tracked, to see if it becomes better or worse.

Most often, exposure hierarchies are used along with homework assignments to help people face their fears. This exposure helps them overcome avoidance that may be interfering with their daily life.

The avoidance hierarchy worksheet includes the basic steps to get started.

Shop the exposure hierarchy worksheet.

The trauma narrative is a technique commonly used in therapies like cognitive processing therapy (CPT), or trauma-focused cognitive behavioral therapy (TF-CBT). This worksheet is written with the client in mind, and should generally be used under the direction of a trained therapist.

A trauma narrative is sometimes used as a part of cognitive behavioral PTSD therapies. It involves writing about memories of a difficult situation.

When someone is experiencing PTSD, it's because their brain is confusing the memory of a bad event with the actual event. Your brain continues to think about what happened, and it keeps your brain on high alert, creating a cycle.

One of the ways to interrupt that process is to write about the difficult memories so that you can integrate them into your life, rather than continue to re-experience them. As mentioned, it's recommended that you work through a trauma narrative as part of trauma-focused CBT therapy.

Shop the trauma narrative worksheet.

8. Kids Anger Worksheet

One of the most common struggle kids deal with are angry outbursts . This is because they haven't had the time to understand and learn how to cope with strong emotions.

Although it doesn't say it outright, this set of kids anger worksheets address the CBT triangle. It uses the anger iceberg as a way to illustrate feelings underlying anger.

It actually is a set of three worksheets covering identifying emotions, recognizing harmful behaviors, and creating more positive behaviors. The worksheets are kid-friendly and work well with TF-CBT therapy for kids.

Shop the kids anger worksheets.

9. Emotions Wheel Worksheet

Emotions are a sometimes overlooked part of CBT treatment. Sometimes people think they should or shouldn't be having certain feelings . They might also be unsure of what they're feeling and when.

However, feelings worksheets help with recognizing, regulating, and coping with emotions. This makes it easier to move into the next step of recognizing how thoughts can relate to ongoing emotional struggles.

Common difficult emotions relating to anxiety, depression, or trauma include:

Frustration

Disappointment

The emotions wheel set includes multiple handouts and worksheets based on feelings wheels. It covers both comfortable and uncomfortable emotions like those above. It also has sections that recognize the physical sensations of emotions, and sections to create your own emotional coping wheel.

Shop the emotions wheel worksheets.

10. Mindfulness for CBT Worksheet

New waves of cognitive therapies, including CBT, incorporate mindfulness. It's an important part of the regulating step, and helps you soothe the flight-or fight response.

It can also make it easier to move onto the next steps of recognizing thoughts and emotions. When your brain is in survival mode it can be difficult to work through challenging thoughts or exposure techniques.

Mindfulness takes it down a notch, much like medication would. It also is a great skill in and of itself, and can prevent mental health, and even some physical conditions, down the road.

Shop the mindfulness worksheet.

CBT Therapy Worksheet Bundle

Over the years, I've found that many of the same strategies overlap for conditions like anxiety and PTSD. At the same time, there are some additional steps necessary when processing trauma. I've bundled all of my related pages into this set .

More CBT Resources

In addition to worksheets, CBT-based games can be a great way to teach important concepts. Here's a list of some of our other activities. You can find them all together in our Giant Store Bundle .

CBT Coping Jeopardy-Like Game

If you're looking for a fun, interactive game for classrooms or telehealth, check this out! It covers many of the CBT concepts in the worksheets. It's a great way to reinforce all of the concepts you're learning. Learn more.

CBT Lingo (Bingo-Like Game)

CBT Lingo is a fun, interactive, educational game that helps you teach concepts of CBT. It goes beyond the typical "novelty" cards often created for therapy and other classroom games. The game is compatible with real bingo, so you can actually "call" the game with numbers, either in-person or via telehealth.

CBT Lingo, which works similar to bingo, includes 75 prompts focused on topics like thoughts, feelings, and behaviors, and skills used in cognitive behavioral therapy. It has various options, so it works with teens, college students, and adults.

It can even help with teaching CBT concepts to therapy students.

Here are some sample prompts included in the game:

What does all or nothing thinking mean?

What's one physical symptom of anxiety?

What are the three points of the CBT triangle?

What is ruminating?

Want to give it a go? You can download and use it in-person or via telehealth. Get more details here.

CBT Quest Board Game

CBT board games are another less intimidating way to teach skills. This downloadable board game , called CBT quest, can be printed and used in person, or adapted for online use. It includes 32 prompts with reusable questions, such as:

Give an example of a challenging thought

Describe or show a grounding technique

Describe or name a cognitive distortion

Interested in trying this fun activity? Download it here.

Finding Peace from PTSD Book

If you're working specifically with PTSD, this book is helpful. It lays out the most common strategies used in trauma-focused CBT therapies. Such therapies include:

Prolonged Exposure

Cognitive Processing Therapy

Trauma-Focused CBT

The book was also created to go along with the worksheets in the CBT for PTSD and Anxiety bundle, so the two make great companions! Learn more about the book.

Obviously games and worksheets can’t replace other types of therapy. However, these tools can help you learn to identify thinking patterns, challenge everyday negative thoughts, question your anxiety thoughts, and understand your thoughts relating to PTSD.

For more helpful tools, download it all with our giant store bundle. It includes all of the activities above plus many more great resources .

Sources: Beck Institute for Cognitive Behavioral Therapy. 2021, https://beckinstitute.org/

Chand SP, Kuckel DP, Huecker MR. Cognitive Behavior Therapy. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan.

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CBT Worksheets, Handouts, And Skills-Development Audio: Therapy Resources for Mental Health Professionals

Resource type

Therapy tool.

"Should" Statements

Information handouts.

A Guide To Emotions (Psychology Tools For Living Well)

Books & Chapters

A Memory Of Caring For Others

A Memory Of Feeling Cared For

Abandonment

Activity Diary (Hourly Time Intervals)

Activity Diary (No Time Intervals)

Activity Menu

Activity Planning

Activity Selection

All-Or-Nothing Thinking

Alternative Action Formulation

Am I Experiencing Anorexia?

Am I Experiencing Body Dysmorphic Disorder (BDD)?

Am I Experiencing Bulimia?

Am I Experiencing Burnout?

Am I Experiencing Death Anxiety?

Am I Experiencing Depersonalization And Derealization?

Am I Experiencing Depression?

Am I Experiencing Generalized Anxiety Disorder (GAD)?

Am I Experiencing Health Anxiety?

Am I Experiencing Low Self-Esteem?

Am I Experiencing Obsessive Compulsive Disorder (OCD)?

Am I Experiencing Panic Attacks?

Am I Experiencing Panic Disorder?

Am I Experiencing Perfectionism?

Am I Experiencing Post-Traumatic Stress Disorder (PTSD)?

Am I Experiencing Psychosis?

Am I Experiencing Social Anxiety?

An Introduction To CBT (Psychology Tools For Living Well)

Anger - Self-Monitoring Record

Anger Decision Sheet

Anger Diary (Archived)

Anger Self-Monitoring Record (Archived)

Anger Thought Challenging Record

Anxiety - Self-Monitoring Record

Anxiety Self-Monitoring Record (Archived)

Approach Instead Of Avoiding (Psychology Tools For Overcoming Panic)

Approval-/Admiration-Seeking

Arbitrary Inference

Assertive Communication

Assertive Responses

Attention - Self-Monitoring Record

Attention Training Experiment

Attention Training Practice Record

Audio Collection: Psychology Tools For Developing Self-Compassion

Audio Collection: Psychology Tools For Mindfulness

Audio Collection: Psychology Tools For Overcoming PTSD

Audio Collection: Psychology Tools For Relaxation

Autonomic Nervous System

Avoidance Hierarchy (Archived)

Barriers Abusers Overcome In Order To Abuse

Before I Blame Myself And Feel Guilty

Behavioral Activation Activity Diary

Behavioral Activation Activity Planning Diary

Behavioral Experiment

Behavioral Experiment (Portrait Format)

Behaviors In Panic (Psychology Tools For Overcoming Panic)

Being A Compassionate Person

Being With Difficulty (Audio)

Belief Driven Formulation

Belief-O-Meter (CYP)

Body Posture

Body Scan (Audio)

Body Sensations In Panic (Psychology Tools For Overcoming Panic)

Boundaries - Self-Monitoring Record

Breathing To Activate Your Soothing System

Breathing To Calm The Body Sensations Of Panic (Psychology Tools For Overcoming Panic)

Broadening Your Perspective

Catastrophizing

Catching Your Thoughts (CYP)

CBT Appraisal Model

CBT Daily Activity Diary With Enjoyment And Mastery Ratings

CBT Thought Record Portrait

CFT Calm Place

Challenging Your Negative Thinking (Archived)

Changing Avoidance (Behavioral Activation)

Checking Certainty And Doubt

Checklist For Better Sleep

Classical Conditioning

Coercive Methods For Enforcing Compliance

Cognitive Behavioral Model Of Anorexia Nervosa (Fairburn, Cooper, Shafran, 2003)

Cognitive Behavioral Model Of Body Dysmorphic Disorder (BDD: Veale, 2004)

Cognitive Behavioral Model Of Bulimia Nervosa (Fairburn, Cooper, Shafran, 2003)

Cognitive Behavioral Model Of Clinical Perfectionism (Shafran, Cooper, Fairburn, 2002)

Cognitive Behavioral Model Of Depersonalization (Hunter, Phillips, Chalder, Sierra, David, 2003)

Cognitive Behavioral Model Of Fear Of Body Sensations

Cognitive Behavioral Model Of Generalized Anxiety Disorder (GAD: Dugas, Gagnon, Ladouceur, Freeston, 1998)

Cognitive Behavioral Model Of Health Anxiety (Salkovskis, Warwick, Deale, 2003)

Cognitive Behavioral Model Of Insomnia (Harvey, 2002)

Cognitive Behavioral Model Of Intolerance Of Uncertainty And Generalized Anxiety Disorder Symptoms (Hebert, Dugas, 2019)

Cognitive Behavioral Model Of Panic (Clark, 1986)

Cognitive Behavioral Model Of Persistent Postural-Perceptual Dizziness (PPPD: Whalley, Cane, 2017)

Cognitive Behavioral Model Of Post Traumatic Stress Disorder (PTSD: Ehlers & Clark, 2000)

Cognitive Behavioral Model Of Social Phobia (Clark, Wells, 1995)

Cognitive Behavioral Model Of The Relapse Process (Marlatt & Gordon, 1985)

Cognitive Behavioral Model Of Tinnitus (McKenna, Handscombe, Hoare, Hall, 2014)

Cognitive Behavioral Treatment Of Childhood OCD: It's Only A False Alarm: Therapist Guide

Treatments That Work™

What is Psychology Tools?

Psychology Tools develops and publishes evidence-based psychotherapy resources and tools for mental health professionals. Our online library gives you access to everything you need to deliver more effective therapy and support your practice. With a wide range of topics and resource types covered, you can feel confident knowing you’ll always have a range of accessible and effective materials to support your clients, whatever challenges they are facing, whatever stage you are at, and however you work.

Choose from assessment and case formulations to psychoeducation, interventions and skills development, CBT worksheets, exercises, and much more. Our resources include detailed therapist guidance, references and instructions, so they are equally suitable for those with less experience but who want to expand their practice. Each resource explains how to work with the material most effectively, and how to use it with clients.

Are these resources suitable for you?

Psychology Tools is used by thousands of professionals all over the world as a key part of their practice and preparation, and our resources are designed to be used with clients who experience psychological difficulties or distress. Professionals who use our resources include:

• Clinical, Counseling, and Practitioner Psychologists
• Family Doctors / General Practitioners
• Licensed Clinical Social Workers
• Mental Health Nurses
• Psychiatrists
• Psychological Wellbeing Practitioners
• Psychotherapists
• Therapists (CBT Therapists, ACT Therapists, DBT Therapists)

Psychology Tools resources are perfect for individuals, teams and students, whatever their preferred modality, or career stage.

What kinds of resources are available at Psychology Tools?

Psychology Tools offers a range of relatable, engaging, and evidence-based resources to ensure that your clients get the most out of therapy or counseling. Each resource has been carefully designed with accessibility in mind and is informed by best practice guidelines and the latest scientific research.

Therapeutic exercises are used in many evidence-based psychotherapies including cognitive behavioral therapy, rational emotive behavior therapy, compassion-focused therapy, schema therapy, emotion-focused therapy, systemic family-based therapies, and several others.

Therapists and counselors benefit from incorporating exercises into their work. They can be used to:

• Introduce and explain key concepts.
• Collect information about clients’ difficulties.
• Bring therapeutic ideas to life.
• Keep therapy active and engaging.
• Alleviate distress and/or reduce problematic symptoms.
• Practice new skills and coping strategies.
• Develop new insights and self-awareness.
• Give clients a sense of accomplishment and progress.

Psychology Tools offers a variety of exercises that you can use with your clients as a part of therapy or counseling. These interventions can be incorporated into your sessions, assigned as homework tasks, or used stand-alone interventions. Many of our exercises are either evidence-based (meaning they have been shown to effectively treat certain difficulties) or evidence-derived (meaning they form part of a treatment program that has been shown to effectively treat certain difficulties).

The exercises available at Psychology Tools have a variety of applications. You can use them to:

• Develop case conceptualizations , formulations, and treatment plans.
• Address specific difficulties, such as worry, insomnia, and self-focused attention.
• Introduce clients to new skills, such as grounding , problem-solving, relaxation, and assertiveness .
• Support key interventions, such as exposure and response prevention, safety planning with high-risk clients, and perspective-taking.
• Plan treatments and prepare for supervision.

Psychology Tools exercises have been developed with practicality and convenience in mind. Most exercises include simple step-by-step instructions so that clients can use them independently or with the support of their therapist or counselor. In addition, therapist guidance is available for each exercise, which includes a detailed description of the task, relevant background information, an overview of its aims and potential uses in therapy, and simple instructions for its delivery. A comprehensive list of references is also provided so that you can access key studies and further your understanding of each exercise’s applications in psychotherapy.

Did you know that 40 – 80% of medical information is immediately forgotten by patients (Kessels, 2003)? The same is probably true of therapy and counseling, so clients will almost always benefit from having access to additional written information.

Psychology Tools information handouts provide clear, concise, and reliable information, which will empower your clients to take an active role in their treatment. Learning about their mental health, helpful strategies and techniques, and other psychoeducation topics helps clients better understand and overcome their difficulties. Moreover, clients who understand the process and content of therapy are more likely to invest in the process and commit to making positive changes.

Psychology Tools information handouts can help your clients:

• Understand their difficulties and what keeps them going.
• Learn what therapy is and how it works.
• Understand what they are doing in therapy and why.
• Remember and build upon what has been discussed during sessions.
• Create a personalized collection of resources that can used between appointments.

Our illustrated information handouts cover a wide variety topics. Each has been informed by scientific evidence, best practice guidelines, and expert opinion, ensuring they are both credible and consistent with evidence-based therapies. Topics featured among these resources include:

• ‘ What is… ’ handouts. These one-page resources provide a concise summary of common mental health problems (e.g., anxiety , depression , low self-esteem ), key therapeutic approaches (such as cognitive behavioral therapy, eye movement desensitisation and reprocessing , and compassion-focused therapy), and psychological mechanisms which maintain the problem (such as worry and rumination ).
• ‘ What keeps it going… ’ handouts. These handouts explain the key mechanisms that maintain difficulties such as burnout, panic disorder, PTSD, and perfectionism. You can use them to inform your case conceptualization or as a roadmap in therapy.
• ‘ Recognizing… ’ handouts. These guides can help you identify and assess specific disorders, comparing key diagnostic criteria taken from leading diagnostic manuals.
• Simple explanations of key psychological concepts, such as safety behaviors , psychological flexibility, thought suppression, and unhelpful thinking styles .
• Overviews of important psychological theories, such as operant conditioning and exposure.

Each information handout comes with guidance written specifically for therapists and counselors. It provides suggestions for introducing psychoeducation topics, facilitating helpful discussions related to the handout, and ensuring the content is relevant to your clients.

Worksheets are a core ingredient of many evidence-based therapies such as CBT. Our worksheets take many forms (e.g., diaries, diagrams, activity planners, records, and questionnaires) and can be used throughout the course of therapy.

How you incorporate worksheets into therapy or counselling depends on each client’s difficulties, goals, and stage of recovery. You can use them to:

• Assess and monitor clients’ difficulties.
• Inform treatment plans and guide decision-making.
• Teach clients new skills such as ‘self-monitoring’ or ‘thought challenging’.
• Ensure that clients apply their learning in the real world.
• Track their progress over time.
• Help clients to take an active role in their recovery.

Clients also benefit from using worksheets. These tools can help them:

• Become more aware of their difficulties.
• Identify when, how, and why these problems occur.
• Practice using new skills and techniques.
• Express and explore difficult feelings.
• Process difficult events.
• Consolidate and integrate insights from therapy.
• Support their self-reflection.
• Feel empowered and build self-efficacy.

Psychology Tools offers a wide variety of worksheets. They include general forms that are widely applicable, disorder-specific worksheets, and logs that are used in specific therapies such as CBT , schema therapy, and compassion-focused therapy . These resources are typically available in editable or fillable formats, so that they can be tailored to your client’s needs and used in a flexible manner.

Guides & self-help

People want clear guidance on mental health, whether for themselves or a loved one.

Our ‘ Understanding… ’ series is designed to introduce common mental health difficulties such as depression, PTSD, or social anxiety. Each of these guide uses a clear and accessible structure so that readers can understand them without any prior therapy knowledge. Topics addressed in each guide include:

• What the problem is.
• How it arises.
• Where it might come from.
• What keeps it going.
• How the problem can be treated.

Other guides address important topics such as trauma and dissociation, or the effects of perfectionism. They usually contain a mixture of psychoeducation, practical exercises and skills development. They promote knowledge, optimism, and positive action related to these difficulties, and have been informed by current research and evidence-based treatments, ensuring they are consistent with best practices.

Therapists can use Psychology Tools guides in several ways:

• As a screening tool. Clients can read the guide to see if the difficulty or topic is relevant to them.
• As psychoeducation. Each guide provides essential information related to the difficulty or topic so that client can develop a better understanding of it.
• As self-help. Each guide describes key skills and techniques that can be used to overcome the difficulty.

Each guide contains informative illustrations, practical examples, and simple instructions so that clients can easily relate to the content and apply it to their difficulties.

Therapy audio

Audio exercises are a particularly convenient and engaging way help your clients and can add variety to your therapeutic toolkit. Psychology Tools audio resources can help your clients:

• Augment and consolidate their learning in therapy.
• Practice new techniques.
• Integrate skills and practices into their daily lives.
• Access additional support when they need it.
• Create a sense a continuity between your meetings.

A variety of audio resources are available at Psychology Tools. Each one has been developed and recorded by highly experienced clinical psychologists and can be easily integrated into your therapeutic practice. Audio collections include:

• Psychology Tools for Developing Self-Compassion
• Psychology Tools for Relaxation
• Psychology Tools for Mindfulness
• Psychology Tools for Overcoming PTSD

Many of these audio resources are widely applicable (e.g., mindfulness-based tools), although problem-specific resources are also available (e.g., tools for overcoming PTSD). You can use these tools:

• During your therapy sessions.
• As a homework task for clients to complete.
• As a stand-alone intervention or ongoing part of therapy.

Treatments That Work®

Authored by leading psychologists including David Barlow, Michelle Craske, and Edna Foa,  Treatments That Work ® is a series of workbooks based on the principles of cognitive behavioral therapy (CBT). Each pair of books in the series – therapist guide and workbook – contains step by step procedures for delivering evidence-based psychological interventions. Clinical illustrations and worksheets are provided throughout.

You can use these workbooks:

• To plan treatment for a range of specific difficulties including depression, obsessive compulsive disorder (OCD), social anxiety, and substance use.
• As a self-help intervention that you guide the client through during sessions.
• As a supplement to therapy, which clients work through independently.
• To consolidate the content of your sessions.
• As an ongoing intervention at the end of treatment (e.g., for difficulties that haven’t been fully addressed).

Each book is available to download chapter-by-chapter, and Psychology Tools members with a currently active subscription to our ‘Complete’ plan are licensed to share copies with their clients.

Archived resources

We work hard to keep all resources up to date, so we regularly review and update our library. However, we understand that you might get used to a certain version of a resource as part of your workflow. Instead of removing older versions, we keep them in our archive so that you can still access them if you want to. We also clearly explain if an improved version is available, so you can choose which you prefer.

Series and ranges

As well as many topic-specific resources, we also publish a variety of ranges and series.    

• The ‘What is…’ series. These one-page resources cover a range of common mental health problems. In client friendly language they provide a concise summary of the problem, what it can feel like, what maintains it and an overview of key evidence-based therapeutic approaches (e.g., CBT, EMDR, and compassion-focused therapy) to treatment.
• The ‘What keeps it going…’ series . These are one-page diagrams that explain what tends to maintain common mental health conditions such as burnout, panic disorder, PTSD, and perfectionism. You can use them to inform your case conceptualization or as a roadmap in therapy. They provide a quick and easy way for clients to understand why their disorder persists and how it might be interrupted.
• The ‘Recognizing…’ series can help you identify and assess specific disorders, comparing key diagnostic criteria from leading diagnostic manuals.
• The ‘Understanding…’ series is a collection of psychoeducation guides for common mental health conditions. Friendly and explanatory, they are comprehensive sources of information for your clients. Concepts are explained in an easily digestible way with plenty of case examples and diagrams. Each guide covers symptoms, treatments and some key maintenance factors .
• The ‘Guide to…’ resources give clients a deep dive into a condition or treatment approach. They cover a mixture of information, psychoeducation, practical exercises and skills development to help clients learn to manage their condition. Each of these guides offers psychoeducation about the topic alongside a range of practical exercises with clear instructions to help clients identify, monitor, and address their symptoms.
• The ‘ Self-monitoring’ collection provides problem-specific records designed to help you and your clients get the most from this essential but often overlooked technique. Covering a broad range of conditions, these worksheets allow you to give clients a tool that is targeted to their experience, with relevant language and prompts.
• The ‘Formulation’ series provides a client-friendly adaptation of cognitive behavioral models for disorders including panic, PTSD, and social anxiety. These useful tools can help you and your clients come to a shared understanding of their difficulties, and can help you to develop a roadmap for therapy.  

Multilingual library of translations

Did you know that Psychology Tools has the largest online, searchable library of multilingual therapy resources? We aim to make our resources accessible to everyone. With over 3500 resources across 70 languages, you can give clients resources in their native language, enabling a deeper understanding and engagement with the treatment process. Translations are carried out by specially selected professional translators with experience of psychology, and our pool of volunteer mental health professionals. We also make sure that the resource design is the same for each translated resource so that you can be confident you know what section you are looking at, even if you don’t speak the language.

Simply find the resource you want to use, then explore which languages that resource is available in, or you can see all the resources available in a particular language by using our search filters.  

What formats are the resources available in, and how can I use them?

People work in different ways. Our formats are designed to reflect that, so you can choose the style that suits how you and your client want to work. Psychology Tools resources are perfectly formatted to work whether you practice face to face, remotely, or use a blended approach.

• Professional version. Designed for clinicians, this comprehensive option includes everything you need to use the resource confidently. As well as the resource, each PDF contains useful information, including therapist guidance explaining how to use the resource most effectively, descriptions that provide theoretical context, instructions, therapist prompts, and references. Some resources also include case examples and annotations where appropriate.
• Client version.  This is a blank PDF of the resource, with client-friendly instructions where appropriate, but without the theoretical description. These are ideal for printing and using in-session, or giving to a client.
• Fillable PDFs are great for clients who want to work with resources online instead of on paper. Your client can fill in and save the resource on a computer, before sending it back to you without the need for a printer. This format is also useful if you have remote sessions with clients and want to work through a resource on screen together.
• Editable PowerPoint documents are useful if you want to make any changes to the resource structure, or personalize it for your client.
• Editable Word documents are also useful if you want to make changes to the resource, and are more suited to printing.

How do we design our resources to support your practice?

Our resources are informed by evidence-based treatments, best practice guidelines, and the latest published research. They are written by highly experienced therapists and experts in mental health, ensuring they are effective and as up to date as possible. In addition, every resource goes through a rigorous peer review process to confirm they are accurate and easy to use.

Each resource is designed with both clients’ and therapists’ needs in mind. For clients, that means using clear, user-friendly language, as well as plenty of visual and case examples, illustrations, diagrams and vignettes that readers can relate to. They include information on how the resource can help them, how they should use it, and other useful tips.

We also include useful information and descriptions for clinicians to help them use the resource most effectively. The therapist versions of each resource contain therapist guidance, prompts, instructions, and full references. They outline how the resource can be used and what types of problems it could be helpful for.

• Designed to make strong theory-practice links . We pay close attention to the theory underpinning our resources, which provides therapists with useful context and helps them make theory-practice links. Having a greater understanding of each tool ensures best practice.
• One concept per page. Wherever possible, we create resources using the principle of one therapeutic concept per page, as this ensures that we have distilled the idea down to its essence. This makes each tool simple for therapists to communicate and easy for clients to grasp. We also pay close attention to visual layout and design, to make our resources as accessible as possible. Every resource aims to maximize clinical benefit and engagement, without overwhelming readers.
• Action focused. Resources are designed to be interactive, collaborative and goal-focused, with prompts to facilitate self-monitoring of progress and goals.

How can I use this page?

This page is where you can explore all the resources in the Psychology Tools library. The different search filters on the left-hand side enable you to customize your search, depending on what you need. Materials are organized by resource type, problem, and therapy tool, though you can also filter by language or use the search box. You can find more detailed instructions for how to find resources here .  

Can I share resources directly with my clients?

If you have a paid Psychology Tools membership, you are licensed to share resources with clients in the course of your professional work. You can even email resources (even large audio collections) directly to your clients from our website. All emails are secure and encrypted, so it is a quick and easy way to save you time and facilitate clients’ self-practice.

What if I need more help?

We have a wide range of ‘ How-to’ guides and an FAQ in our help centre , which answers questions on how to use the library and tools, such as ‘ How do I download resources? ’ or ‘ How do I email resources to my clients directly from the website? ’.

Kessels, R. P. C. (2003). Patients’ memory for medical information . Journal of the Royal Society of Medicine, 96 , 219-222.

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Trauma-Focused Cognitive Behavior Therapy

Reviewed by Psychology Today Staff

Trauma-focused cognitive behavioral therapy (TF-CBT) addresses the mental health needs of children, adolescents, and families suffering from the destructive effects of early trauma. The treatment is particularly sensitive to the unique problems of youth with post- traumatic stress and mood disorders resulting from sexual abuse , as well as from physical abuse, violence, or grief . Because the client is usually a child, TF-CBT often brings non-offending parents or other caregivers into treatment and incorporates principles of family therapy.

The trauma-focused approach to therapy was first developed in the 1990s by psychiatrist Judith Cohen and psychologists Esther Deblinger and Anthony Mannarino, whose original intent was to better serve children and adolescents who had experienced sexual abuse. TF-CBT has expanded over the years to include services for youths who have experienced many forms of severe trauma or abuse.

• When It's Used
• What to Expect
• How It Works
• What to Look for in a Trauma-Focused Cognitive Behavioral Therapist

TF-CBT was originally geared toward helping children who were the victims of sexual abuse , but its scope has widened to include children and adolescents who have experienced a single or repeated experience of sexual , physical, or mental abuse or who have developed post- traumatic symptoms, depression , or anxiety .

If a child or adolescent also exhibits serious behavioral, substance abuse , or suicidal ideation, other forms of treatment, such as dialectical behavior therapy , may be more appropriate as an initial intervention and can be followed up with a trauma-sensitive approach.

TF-CBT is a short-term intervention that generally lasts anywhere from eight to 25 sessions and can take place in an outpatient mental health clinic, group home, community center, hospital, school, or in-home setting. Treatment takes place with a non-offending parent or caregiver . Often, the treatment will begin where the child and non-offending caregiver have separate therapy sessions and advance to engaging in joint sessions.

Cognitive behavioral techniques are used to help modify distorted or unhelpful thinking and negative reactions and behaviors. Learning to challenge invasive thoughts of guilt and fear can help a patient to reorganize their thinking in a healthier and happier way.

The family therapy aspect of trauma-focused CBT attends to the problems family members may have in dealing with the trauma suffered by the child, including the use of various stress management , communication, and parenting skills.

Research comparing TF-CBT to other treatment models shows significantly greater gains in well-being for children and parents.

Early trauma can lead to guilt, anger , feelings of powerlessness, self-harm , acting out, depression, and anxiety. Post-traumatic stress disorder, which affects children and adults, can manifest in a number of ways, such as negative recurring thoughts about the traumatic experience, emotional numbness, sleep problems, difficulty concentrating, and extreme physical and emotional responses to anything that triggers a memory of the trauma.

By integrating the theories and techniques of several therapeutic interventions, TF-CBT can address and improve the symptoms of post-traumatic stress in youth. Core features of TF-CBT treatment include:

• Psychoeducation , which teaches the victim about the normal reactions to traumatic experiences. This can help them reduce feelings of guilt or culpability for what happened.
• Coping skills , including relaxation exercises like deep breathing, mindfulness , acceptance, identifying and redirecting thoughts, and other methods.
• Gradual exposure , which involves gradually introducing the patient to memories of their traumatic experience, with the goal of reconditioning their response to triggers and easing emotional distress.
• Cognitive processing , which can include developing skills to recontextualize unhelpful feelings and thoughts, and regulate emotions.
• Caregiver involvement , which may include rebuilding trusting adult relationships for the child and training the caregiver in how to best be a resource for the child.

The goal of the treatment is to help the patient develop a sense of safety and security, to repair or develop healthy social skills, and for the caregiver to feel more confident in their ability to help the child in a productive manner.

There is no official accreditation for trauma-focused cognitive behavioral therapy, though supplemental trainings and courses exist. It’s most important to look for someone with experience in the practice and someone with whom you feel comfortable discussing personal problems.

Some helpful questions to ask a TF-CBT therapist include:

• The extent of their experience with trauma-focused CBT treatment.
• Whether there is an assessment process to track the functioning of the patient and family, in order to monitor the progress of the treatment.
• Whether there will be joint therapy sessions with the child and parent, and to what degree.
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CBT + Notebook

Search cbt + notebook resources, therapist resources, cbt+ component flows.

• CBT+ Flow Trauma + Depression
• CBT+ Flow Trauma
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Cheat Sheets

• Motivational Enhancement
• Trauma-Focused CBT A-Practice Checklist

"Need to Know" Sheets

• At-Home Practice (Homework)
• Behavioral Activation
• Changing Unhelpful Cognitions

Coping Skills

• Engagement Motivation
• Fear Ladder
• One on One Time
• Psychoeducation
• Trauma Narrative
• Weekly Practice Tracking Examples

Therapist Materials

• Adherence Checklist – Cohen & Mannarino (Final)
• ATSA Task Force on Child Sexual Behavior Problems
• Bernier Lab UW Autism Spectrum Disorder Reference Guide
• Bernier Lab UW Trauma and ASD Reference Guide
• CBT+ Culturally Responsive Questions
• CBT+ Steps for Initial Engagement
• CBT+ Phases for Treatment
• CBT+ Triangle
• Child Caregiver Conjoint Work Fitzgerald
• Guidelines for Managing the Trauma Narrative
• How Can Trauma Affect the Brain?
• Practice on Getting “Buy In” for Engaging in Trauma Narrative
• Technique for Preparing for and Conducting Parent-Child Sessions
• Report of the APSAC Task Force on Therapy…
• Smartphone Apps for Clinical Use
• Smartphone Apps for Depression and Anxiety – Evaluation
• Socratic Techniques for Changing Unhelpful Thoughts
• Tips for Managing the Crisis Of the Week
• Trauma References
• What is Attachment and Attachment Problems in Children?

Useful Links

Supervisor/organization resources, organizational practice guides.

• Practical Guide for EBP Implementation
• Everyday Competence and Fidelity Guide
• Practical Guide for Orienting New Providers to CBT+
• EBP Reporting Guide

Engagement/Motivational Enhancement

Client handouts.

• Decisional Balance Scale
• Stages of Change “Not Ready, Unsure, Ready”
• Learning About Your (BRIEF Patient Guide)
• Learning About You (BRIEF Therapist Guide)
• Cheat Sheet – Motivational Enhancement
• N2K (Need to Know) Engagement/Motivational Enhancement Sheet
• Stages of Change – Therapist’s Motivational Tasks
• Steps for Initial Engagement
• Therapeutic Alliance
• Engagement Question Decks (Play in PowerPoint mode)
• Learning About You (THERAPIST GUIDE)
• Learning About You (Patient Guide)

Standardized Measures

• Cheat Sheet Measures
• CATS Scoring Tip Sheet
• Clinical Guide for Administering CATS

Caregiver Report

• CATS-ICD Caregiver
• Child and Adolescent Trauma Screen (CATS) – Caregiver Report (Ages 3-6)
• Child and Adolescent Trauma Screen (CATS) – Caregiver Report (Ages 3-6) – Spanish
• Child and Adolescent Trauma Screen (CATS) – Caregiver Report (Ages 7-17)
• Child and Adolescent Trauma Screen (CATS) – Caregiver Report (Ages 7-17) – Spanish
• Moods and Feelings Questionnaire – Caregiver Report
• SCARED Anxiety – Caregiver version
• SCARED – Parent version in Spanish
• Pediatric Symptom Checklist (PSC-17)
• Pediatric Symptom Checklist (PSC-17) – Externalizing Subscale
• Pediatric Symptom Checklist (PSC-17) – Spanish version
• Pediatric Symptom Checklist (PSC-17) – Externalizing Subscale – Spanish Version

Child Self-Report

• Child and Adolescent Trauma Screen (CATS) – Youth Report (Ages 7-17)
• Child and Adolescent Trauma Screen (CATS) – Youth Report (Ages 7-17) – Spanish
• SCARED Anxiety – Child version
• Moods and Feelings Questionnaire

Teen/Adult Self Report

• Patient Health Questionnaire (PHQ-9)
• Patient Health Questionnaire (PHQ-9) – Spanish Version
• PTSD-Checklist-DSM5-(PCL-5)-Adult-(18+).pdf
• PTSD Checklist DSM5 (PCL-5) SPANISH Adult (18+)
• GAD-7 (Spanish Version)
• Assessment “Need to Know” Sheet
• Idiographic Goal Progress Monitoring Chart
• Personalized Goals Examples for Therapists

Challenging Thoughts (Client Handouts)

• CBT+ Triangle Worksheet
• Challenging Thoughts Worksheet
• Cognitive Restructuring Worksheet
• CPT – Challenging Beliefs Worksheet
• CPT Handout – Hard Questions
• CPT Homework Assignments
• Negative Thinking Traps
• My Strengths ABC
• Proof Positive Exercise
• Stop, Think, and Act
• What Am I Thinking (for kids)
• What are the Thoughts You Have? (for kids)

Managing Anger (Client Handouts)

• Getting Good at Turning Down the Mad! – Tracking Breaks and Hot and Cool Thoughts – Large Blocks
• Good Thoughts – Bad Thoughts
• Learning to Argue with Yourself
• Pleasant Feelings Diary
• Problem Solving Skills Worksheet (forAdults)
• Problem Solving Skills Worksheet (for Kids)
• Reducing Anger
• Turtle Technique
• Anger Marbles
• Anger Pattern Exercise
• Anger Arousing and Anger Reducing Self Talk
• Anger Self Talk Examples and Practice
• Anger Steps
• Constructive Emotion Regulation
• Emotion Regulation
• Getting Good at Turning Down the Mad! – Tracking Breaks and Hot and Cool Thoughts Each Day

Managing Distress (Client Handouts)

• What Will People Think of Me?
• Who Holds Up My Safety Net? (Boys)
• Who Holds Up My Safety Net? (Girls)
• Challenging Thoughts Exercise
• Coping Skills (for Adults)
• Coping Skills (for Caregivers and Children)
• Coping Skills Diary Card
• Crisis Prevention Plan (CPP) Guide Tips Sheet
• Crisis Prevention Plan (CPP) Template for CBT
• Emotions Thermomenter
• Feelings Ball Game
• Helping Me Handle My Emotions
• If I Need Help Form
• In the Moment Coping Skill Toolbox Personal Time Out
• Mood Monitoring Sheet
• My Strengths
• The Critic Inside You
• Things I Do Well
• Viewing My Problems in a New Light

Identifying and Rating Feelings (Client Handouts)

• Distress Thermometer
• Feeling Detective – 1
• Feeling Detective – 2
• How Does My Body React
• Masking Your Feelings
• Working with Our Feelings (Young Child)
• Working with Our Feelings 2
• Writing About Your Feelings (Anxious & Coping)

Relaxation (Client Handouts)

• Active Relaxation
• Breathing Retraining Exercises
• CBT+Relaxation Homework sheet
• Controlled Breathing Log
• Learn How to Relax
• Muscle Relaxing
• Observing Your Breath Exercises for Parents
• Relaxation Exercises
• Relaxation Journal
• Relaxation Log
• Relaxation Scripts for Kids
• Relaxation Scripts for Younger Children
• Tense or Relaxed
• Ways to Relax by Using Breathing

Sleep Hygiene (Client Handouts)

• Sleep Tips for Teens
• Tips For a Great Night’s Sleep (Teens)
• Tips For a Great Night’s Sleep (Kids)
• Conquering Nightmares
• My Plan for a Great Night’s Sleep
• Sleep Hygiene: Basic Guidelines
• Sleep Hygiene Tips (Adults)

Tips for Parents

• Help With Getting Your Child to Sleep – Basic Suggestions From the American Academy of Pediatrics
• How Do I Teach My Child Good Sleep Habits
• Ways to Help My Child Sleep
• Muscle Relaxation Exercise Transcript
• Sample Teaching Activities for Feelings Identification

CBT for Anxiety

Anxiety (client handouts).

• Anxiety Common Unhelpful Helpful Thoughts Tool
• Anxiety Common Unhelpful Helpful Thoughts Tool – Spanish
• CBT+ Relaxation Homework sheet
• Anxiety Information
• Anxiety Information – Spanish version
• Anxiety Treatment Description
• Feeling Pattern Exercise
• Negative Self-Talk
• Parental/Caregiver Involvement: Helping Your Child Manage Anxiety
• Replacing Negative Thoughts
• Replacing Negative Thoughts Exercise
• Worry Time Log
• Stress worry anxiety Handout for parents

For Coping Skills Please Refer to Coping Skills Page Cognitive Restructuring

• Cognitive Restructuring Worksheet – Spanish

Exposure (Client Handouts)

• Sample In Vivo Exposures CBT+
• Doing Exposure Worksheet
• Exposure Homework Worksheet
• Hercules and the Hydra: Explaining Avoidance and Gradual Exposure
• How to Handle Anxious Thinking
• How to Handle Anxious Thinking – Spanish
• CBT+ Strategies for Worry: A Therapist’s Guide
• Cheat Sheet – Anxiety
• N2K (Need to Know) Changing Unhelpful Cognitions Sheet
• N2K (Need to Know) Exposure/Facing Up Skills Sheet
• N2K (Need to Know) Fear Ladder Sheet

Training Videos

Cbt for depression, depression (client handouts).

• Small Talk and Friend Making Tips
• Take Action to Feel Better
• Taking Charge of Negative Emotions
• What Gets in Your Way
• Actions I Took to Feel Better
• Activity Scheduling – At Home Practice Sheet
• Activity Scheduling – At Home Practice Sheet – Spanish Version
• CBT+ Getting Active Homework Sheet
• CBT+ Getting Active Homework Sheet – Spanish
• CBT+ Goal Setting Worksheet
• Depression Relapse Prevention Worksheet
• Depression Common Unhelpful Helpful Thoughts Tool
• Depression Information
• Depression Information – Spanish version
• Depression Information and Treatment Roadmap
• Depression Information and Treatment Roadmap – Spanish
• Depression Pattern Exercise
• Depression Steps
• FAST D Activity Scheduling
• Getting Active
• Goal Setting Bricks Handout
• Goal Setting Bricks Handout – Spanish
• List of Things I Can Do to Feel Good
• Mood Monitoring Homework Sheet
• Mood Monitoring Homework Sheet – Spanish version
• Problem Solving Worksheet Advanced
• Problem Solving Worksheet Advanced – Spanish
• Problem Solving Skills Worksheet – Basic
• Problem Solving Skills Worksheet – Basic – Spanish
• So You Have a Problem
• Thinking Mistakes for Kids
• Cheat Sheet – Depression
• N2K (Need to Know) Behavioral Activation Sheet
• Socratic Techniques for Changing Unhelpful Thought

CBT for Trauma

Trauma information.

• Trauma and Posttraumatic Stress Youth
• Trauma Information Pamphlet For Parents (from UCLA)
• Trauma Psycho Ed Cards For Children
• CBT for Trauma Information Youth
• Date Rape/Acquaintance Rape
• Dissociation Information
• Finding a Therapist for Evidence-Based Treatment
• Gangs: Tips for Parents (NCTSN link)
• Parenting Tips When Your Child Has Experienced Trauma
• Parenting Tips When Your Child Has Experienced Trauma – Spanish version
• Psychoeducation: General Questions
• SA Psychoed Children
• Talking With Your Child About Trauma: Guidelines For Foster Parents
• TF-CBT Information
• Things Families Can Do to Cope with Trauma
• Things Families Can Do to Cope with Trauma – Spanish version
• Trauma and Posttraumatic Stress – Spanish
• Trauma and Posttraumatic Stress
• Trauma and Posttraumatic Stress Caregiver – Spanish
• Trauma and Posttraumatic Stress Caregiver

Trauma Related (Client Handouts)

• I Think This Happened Because…
• Letter to Mom (Sexual Assault)
• Name the Blame: Who’s at Fault
• PTSD Coping Tool
• Questions About Your Understanding of Family Violence
• Self Talk Examples
• Thoughts and Feelings Children Have
• Trauma Common Unhelpful Helpful Thoughts Tool
• WHY Checklist (for Physical Abuse)
• WHY Checklist (for Sexual Assault)

Child Sexual Abuse

• Facts About Child Sexual Assualt
• If Your Child Has Been Sexually Abused
• What is Sexual Assault? (Teen Handout)

Client's Rights

• A Child’s Bill of Personal Safety Rights
• My Dating Bill of Rights
• Rights of Child Victims and Witnesses (RCW)

For Coping Skills Please Refer to Coping Skills Page Creating the Trauma Narrative (Client Handouts)

• Clarification Questions To Sexual Assault Offenders
• Dealing with Trauma: A TF-CBT Workbook for Teens
• Dealing with Trauma: A TF-CBT Workbook for Teens – Spanish version
• Feelings Children Have (About Abuse)
• Feelings About Being Abused
• How the Abuse Has Affected How I See Myself
• Letter to the Perpetrator
• Remembering What Happened
• Telling the Sexual Assault Secret
• Tu Libro de Actividades de TF-CBT (Your Very Own TF-CBT Workbook – Spanish version)
• Your Very Own Grief TF-CBT Workbook
• What Will People Think of Me
• Your Own TF-CBT Workbook
• Imaginal Exposure Homework
• Sexual Abuse Alert List for Children
• Telling About What Happened
• Thinking about my Experience
• Hercules and Hydra Example: Explaining Avoidance and Gradual Exposure in Trauma
• In Vivo Exposure Homework
• Integrating Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Racial Socialization for Black Youth and Families: An Implementation Manual
• BT+ Framework
• Cheat Sheet – TF-CBT A-Practice Checklist
• Child Caregiver Conjoint Work – Fitzgerald
• Dyad Practice-Facilitating Detailed Narratives
• Engaging Highly Anxious/Resistant Kids in Starting the TN
• Exposure Treatment Exercise – Sample
• N2K (Need to Know) Trauma Narrative Sheet
• Prolonged Exposure Protocol with Details
• Sample Gradual Exposure Hierarchy
• Sample Thought Stopping Scripts From TF CBT Website Training
• Technique for Preparing for and Conducting Parent Child Sessions
• Socratic Strategies for Self-Blame Thoughts
• TF-CBT A – Take 5
• Trauma and Autism Spectrum Disorder – A Reference Guide
• The Trauma Narrative
• CBT for Trauma Checklist
• Trauma Narrative Gradual Exposure Handout
• Trauma Narrative Steps
• Implementing Trauma-Focused Cognitive Behavioral Therapy for LGBTQ Youth and their Caregivers

Parent Management Training (PMT)

Cdc parenting videos (links), child sexual behaviors.

• ATSA Report of the Task Force on Children with Sexual Behavior Problems
• Child Sexual Behavior Rules Examples
• Cover your BASES for Parents
• Sexual Behavior and Children: When Is It a Problem and What to Do About It
• Touching Rules for Young Children

Links to Handouts in Spanish

Parenting handouts.

• CBT+ Home Token Economy Guide
• Child – Directed Interaction Skills
• Difficult Teens
• Discipline Skills to Master
• Giving Effective Instructions
• Giving Good Directions
• Guidelines for Effective Discipline
• My Child’s Problem Behavior: Info for Caregivers
• How to Motivate your Younger Child to Behave
• How to Motivate Your Teen to Behave
• Praisable Behaviors
• Parental-Caregiver Involvement: Helping Your Child Manage Anxiety
• Thoughts and Actions: An Exercise for Parents
• Time-Out Tips for Caregivers
• Tips for Managing Extreme Behavior in the Moment
• Tips for Managing Extreme Behavior in the Moment – Spanish
• Types of Discipline
• Types of Rewards
• Using Planned Ignoring and Attending
• Using Time-Out
• 101 Phrases of Praise
• 101 Phrases of Praise – Spanish
• Behavior Plan Caregiver Worksheet Our Plan to Change Behavior
• Behavior Problems Information
• Behavior Problems Information – Spanish

Parenting Worksheets

• Helping Your Child Learn Appropriate Ways to Express Feelings
• Identifying Your Problematic Thoughts Worksheet
• If… Then (Privileges Worksheet)
• Low Cost Rewards
• Low Cost Rewards – Spanish
• Natural and Logical Consequences
• Parents: Common Feelings and Thoughts about Sexual Abuse
• Physical Punishment Information Sheet
• Praise and Recognition – a parents Worksheet
• Praise/Recognition Worksheet – Spanish
• Problem Solving Skills Worksheet
• Removing Privileges
• Rewarding Good Behavior Star Chart
• Tantrum Tips
• Tracking Behavior
• Tracking Behavior – Detailed
• Tracking Behavior – Detailed – Spanish
• Tracking Behavior – Positive
• Using Time Out Worksheet
• ABC Worksheet for behavior problems – Spanish
• Are We Having Fun Yet?
• Behavior Chart (Sun and Sail)
• Behavior Management Basics
• Behavior Plan Caregiver Worksheet Our Plan to Change Behavior – Spanish
• Communication Checks: A Self Quiz
• Functional Behavioral Caregiver Handout
• Functional Behavioral Caregiver Handout – Spanish

Teacher Handouts

• Behavior Chart (Great Start – Car)
• Behavior Chart (Right Track – Train)
• Behavior Chart (Sun and Sail – Blank)
• Behavior Chart (Ladybug)
• Daily School Behavior Report Card
• Cheat Sheet – Behavior
• Functional Behavior Analysis Article from Child Study Center
• Functional Behavior Analysis Handout
• N2K (Need to Know) One on One Time Sheet
• N2K (Need to Know) Praise Sheet
• N2K (Need to Know) Rewards Sheet

General Skills

• CBT+ Screen and Device Struggles
• Let’s Be Friends
• Me and My Friends
• My Prevention Plan (Sexual Assault)
• Problem Checklist
• Problem Clues
• Problem Solving Steps
• Psych-Ups (Learned Optimism)
• Rappin’ the Problem
• Role-Play Situations Related to Making Requests: Example Situations for Children
• Small Talk and Friend Making
• Being Assertive

Family Communication

• Common Unreasonable Beliefs – Parent Worksheet
• Constructive Family Communication Patterns
• Family Communication Agreement for Action
• Family Communication Patterns Handout
• How to Communicate with Support
• Negative Family Communication Patterns
• Problem Solving Communication Training Article

Family Problem Solving

• Example Behavior Contracts For Kids
• Parent Assessment
• Problem Solving Worksheet (Family Communication)
• Problem Solving Outline
• Problem Solving (Overview)
• Steps to Family Problem Solving

Substance Use

Substance use (client handouts).

• CRAAFT Screening Test – Self Administered
• Effects of High Risk Drinking
• WHO – ASSIST
• ASSIST Feedback Sheet
• CBT+ Screening and Brief Intervention for Substance Use
• CETA Brief Intervention for Substance Abuse
• CRAAFT Screening Interview – Clinician Administered
• CRAFFT Screen Scoring Tool and Intervention Steps

Suicide and Self Injury

Assessment tools.

• WICHE SPRC Pocket Guide for Primary Care
• Sample In-Depth Safety Assessment and Decision Tree (Seattle Children’s Hospital)

Clinical Tools

• CBT+ Managing and Treating Suicide Risk and Non-Suicidal Self-Injury – Clinical Tips
• CBT+ Safety Plan Worksheet
• CBT+ Safety Plan How-To Guide for Clinicians
• Crisis Support Plan for Family (from SPRC & WICHE Behavioral Health Program)
• Chain Analysis Worksheet

Apps/Technology

Organizational tools.

• National Suicide Prevention Toolkit for Primary Care Practices

Training Resources

• National Suicide Prevention Toolkit for Primary Care (WICHE Behavioral Health Program)
• Cover your BASES (for Parents)
• “Not Okay” Behaviors that Break the Sexual Behavior Rules
• Sexual Behavior Rules Example
• Touching Rules (for Young Children)
• Sexual Behavior and Children: When is it a Problem and What to do About it
• SBP Recommendations for Supervision and parenting

Other Mental Health Problems

Info sheets on other mental health problems.

• Attachment Disorders and Attachment Problems
• Attachment Explanation for Caregivers
• Attention Deficit Hyperactivity Disorder(ADHD)
• Autism and Autism Spectrum Disorder
• Psychosis in Children and Adolescents

Helpful Videos

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Homework Completion, Patient Characteristics, and Symptom Change in Cognitive Processing Therapy for PTSD

Shannon wiltsey stirman.

a National Center for PTSD and Stanford University, 795 Willow Rd., NCPTSD, Menlo Park, CA 94025, USA

Cassidy A. Gutner

b National Center for PTSD at VA Boston Healthcare System, and Boston University School of Medicine, 150 South Huntington Street. Boston, MA 02130, USA

Michael Suvak

c Psychology Department, Suffolk University, 73 Tremont Street, 8 th Floor, Boston, MA 02108, USA

d National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Street, Boston, MA 02130, USA

Amber Calloway

e National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Street, Boston, MA 02130, USA

Patricia A. Resick

f Duke University Medical School, Durham, North Carolina 27701, USA

Associated Data

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n=140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pre-treatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.

Cognitive behavioral therapies (CBT) have received extensive empirical support for a variety of mental health disorders ( Beck 2005 ). Because CBT emphasizes the development of strategies to modify problematic cognitions and behaviors, most CBT protocols emphasize the use of between-session homework as a means of practicing and solidifying new skills. Despite the central role of homework in these treatments, the nature of the relationship between homework completion and symptom change is still not well understood. Theoretically, CBT homework assignments provide clients the opportunity to practice the skills they learn in session so that they can begin to apply CBT skills in their daily lives and experience more rapid and sustained symptom relief ( Beck, 1979 ). Research on the clinical impact of homework completion has demonstrated some support for this theory, though there have been some methodological limitations to consider.

In previous research, studies comparing protocols that included homework with those that did not include homework have demonstrated larger effect sizes for protocols that included homework ( Kazantzis, Whittington, & Dattilio, 2010 ; Neimeyer & Feixas, 1990 ). Other studies on CBT for depression and anxiety have identified a relationship between homework completion and symptom reduction ( Bryant, Simons, & Thase, 1999 ; Burns & Nolen-Hoeksema, 1991 ; Busch, Uebelacker, Kalibatseva, & Miller, 2010 ; Conklin & Strunk, 2015 ; Kazantzis, Deane, & Ronan, 2000 ). However, some of the research on homework has been conducted with small samples that may be insufficient to detect moderation (e.g., Bryant, Simons, & Thase, 1999 , n =26;. Busch et al., n =12; Olatunji et al., n =27). Additionally, while some larger studies (e.g., Burns & Spangler, 2000 ; Burns & Nolen-Hoeksema, 1991 ) have identified a positive association between homework completion and symptom improvement, most previous studies have lacked the precision required to understand the temporal relationship between homework completion and symptom change. Burns and Spangler (2000) employed structural equation modeling to examine whether CBT homework completion increased as a result of symptom change among 399 depressed clients. While this methodology represented an advance in identifying the structure of the correlation that has been observed between homework completion and symptom change, the measure used for homework completion was a single retrospective rating of overall compliance, which was assigned by clinicians towards the end of treatment. Other studies on CBT for cocaine dependence improved upon this methodology by using repeated therapist-rated assessments of the degree of homework completion for 60 patients, which was validated in some studies by observer ratings of their review of the homework in session ( Carroll, Nich, & Ball, 2005 ). However, as with previous studies, homework completion scores were aggregated across sessions, and the potential impact of prior symptom change on homework completion was not assessed. Thus, while the findings of these previous studies suggest that homework completion may precede symptom change, relatively little is known about the temporal relationship between homework completion and symptom change.

Establishing temporal precedence of a process variable is critical to understanding the nature of the relationship between that variable and a clinical outcome ( Judd & Kenny, 1981 ). Few studies to date have examined this relationship using session-to-session measures of homework completion and symptom change. Yovel and Safren (2007) did not detect a statistically significant relationship between session-to-session homework completion and attention deficit hyperactivity disorder symptom change, although their sample size was very small (n=16). However, Olatunji and colleagues (2015) demonstrated that CBT homework completion among 27 youth with obsessive-compulsive disorder predicted symptom change at the next session. Studies with larger samples have reported significant relationships between homework and symptom change. Strunk and colleagues (2010) demonstrated that adherence to behavioral methods and homework predicted session-to-session symptom change among 60 depressed outpatients receiving a combination of medication and cognitive therapy. Subsequently, Conklin and Strunk (2015) found that observer ratings of adherence to behavioral strategies and homework predicted session-to-session depression change ( n =53), and Schmidt and Woolaway-Bickel (2000) demonstrated that greater homework completion was associated with panic disorder symptom change in some sessions ( n =48). Thus, some evidence indicates that homework completion is associated with subsequent decreases in depression and anxiety.

Even if homework predicts symptom change, understanding the relationship between client factors, homework, and symptom change is necessary to inform treatment planning. If clients with particular characteristics are less likely to complete homework, strategies to address barriers to increase compliance may need to be integrated into treatment to optimize its effectiveness. A systematic review revealed that relatively few studies have examined whether client-level characteristics such as age, education level, or diagnostic factors predict homework completion (Scheel, Hanson, & Razzhavaikina, 2004). Those that have examined potential relationships between demographic variables and homework have studied small samples and found very few associations. For example, Bryant, Simons, and Thase (1999 ; n =25) did not find a relationship between homework completion during cognitive therapy and demographic variables or symptoms, but they did find that a higher number of prior depressive episodes predicted lower homework completion in CBT for depression. Another study found a positive association between homework completion and both age and unemployment status among individuals with panic disorder ( Schmidt & Woolaway-Bickel, 2000 ). The few other studies that have examined the relationship between symptom profiles and homework completion have generally not found an association (Scheel, Hanson, & Razzhavaikina, 2004).

There has been little research on homework in trauma-focused psychotherapy. Because avoidance is a hallmark symptom of posttraumatic stress disorder (PTSD), engaging clients in CBT homework can represent a considerable challenge ( Reger et al., 2013 ). Whether symptom severity or client factors have an impact on homework completion that requires attention to memories, thoughts and feelings related to the trauma requires exploration. These factors inform clinical decision making about patients' appropriateness for trauma-focused treatments, with clinicians citing severity, chronicity, and perceived client ability to engage in homework as factors in deciding whether to provide trauma-focused treatments ( Cook, Dinnen, Simiola, Thompson, & Schnurr, 2014 ; Osei-Bonsu, 2016). Potential predictors of symptom change or homework engagement that have been examined in previous research ( Rizvi et al., 2009 ; Bryant, Simons, & Thase, 1999 ; Schmidt & Woolaway-Bickrel) such as education level, employment status, severity, or chronicity may predict homework engagement or moderate relationships between homework completion and symptom change. It is also important to understand whether homework completion is predictive of symptom change, rather than increasing or decreasing as symptoms decrease. If patients are not improving, they may begin to do less homework, or they may begin to work harder. Similarly, symptom improvement may motivate patients to do homework because they perceive treatment to be helping, or they might reduce the amount they do if they believe they have already experienced sufficient benefit. If higher levels of homework engagement precede symptom change, rather than resulting from it, homework completion should be prioritized in treatment, whereas the second scenario would indicate that as clients improve, their compliance with treatment may also increase.

Because homework assignments differ over the course of cognitive behavioral trauma treatments (c.f., Cooper et al., 2017 ; Resick, Monson, & Chard., 2016), examining associations of homework engagement at different time points can provide more specific information about whether and how certain types of between-session activities are associated with symptom change ( Cooper et al., 2017 ). Previous studies have found an association between assigned or completed homework and symptom change in single ( Mueser et al., 2008 , n =81) and larger, combined datasets ( Ho & Lee, 2012 , n =227), but only one PTSD study examined the temporal relationship between homework and symptom change through session-to-session analyses. In a study of Prolonged Exposure for PTSD ( n =134), higher self-reported imaginal homework adherence predicted greater symptom improvement between sessions and across treatment ( Cooper et al., 2017 ). Relationships between cognitively-oriented homework and PTSD symptom change have not yet been explored.

The current study therefore aimed to examine the temporal relationship between homework completion and session-to-session PTSD symptom change in a CBT for PTSD. Cognitive Processing Therapy (CPT; Resick et al. 2008 ) is a 12-session protocol that involves the assignment of homework to promote practice of the skills taught in session. In CPT, clients are taught to challenge their beliefs and assumptions about why the trauma occurred, as well as its implications for the way they view themselves and the world. Standardized homework is assigned at each session. CPT has been shown effective for treating PTSD, with or without the assignment of written trauma accounts, across a variety of populations and demonstrated long-term benefits ( Bass et al., 2013 ; Resick et al., 2015 ; Resick, Williams, Suvak, Monson, & Gradus, 2012 ). Combined data from two randomized controlled trials of CPT ( Resick et al., 2008 ; Resick, Nishith, Weaver, Astin, & Feuer, 2002 ) provides a larger sample than most previous studies, which is necessary to examine moderators of treatment outcome (LeGrange et al., 2012).

The primary goal of this study was to examine whether homework completion predicted subsequent symptom change. We hypothesized that homework completion would predict subsequent symptom change after controlling for PTSD symptoms. We also sought to explore associations between homework engagement and dropout and whether treatment condition (CPT with written trauma narrative or CPT without it) was associated with homework completion and symptom change. The second, exploratory aim was to examine demographic and diagnostic predictors of homework completion. Although important to examine for PTSD treatments, based on null findings in the research literature for other disorders (Scheel, Hanson, & Razzhavaikina, 2004), we did not expect that any specific demographic and diagnostic factors would be associated with overall homework completion. Finally, to inform future research, we examined potential patient-level moderators of the relationship between homework and symptom change, identifying potential moderators from previous studies examining associations between patient factors and homework completion or symptom change ( Bryant, Simons & Thase, 1999 ; Rizvi, Vogt, & Resick, 2009 ; Scheel, Hanson, & Razzhavaikina, 2004; Schmidt & Woolaway Bickrel, 2000 ).

Structure of CPT and Homework

Table 1 lists the homework assigned at each session, which varies in content and purpose across the course of treatment. In CPT, progressive worksheets are introduced in each session to help clients evaluate their thinking with regard to the index trauma, and each worksheet builds on previous skills and material. If homework was not completed, at least one worksheet was completed in session with therapist guidance and patients were asked to complete more for homework in addition to the newly assigned homework. While the original CPT protocol incorporated both a cognitive component and written accounts of the trauma, in a dismantling study, the cognitive-only condition demonstrated comparable improvements to the original protocol at posttreatment and 6-month follow-up, although those who were not assigned written trauma accounts improved more quickly ( Resick et al., 2008 ). Thus, it is important to examine whether differences in the homework assignments between the two treatment versions that may have accounted for differences in the trajectory of symptom change. As Table 1 indicates, in the first third of the treatments, homework centers around the use of ABC sheets to differentiate thoughts and feelings, writing an impact statement, and writing trauma narratives in the version of CPT with a written account (after sessions 3 & 4). If written narratives (e.g., impact statement or trauma accounts) were not completed for homework as assigned, they were completed verbally in session and assigned again for homework along with the appropriate worksheets. In the middle phase of treatment, new worksheets are introduced that are intended to support practice of cognitive restructuring skills; each new worksheet is assigned one session earlier in the version of CPT that does not include the written account. In the final third of treatment, the skills are combined into a single worksheet. Patients used the set of skills covered in previous sessions plus the newly introduced skill to complete each subsequent written homework assignment whether or not they had completed previously assigned homework. During the last phase of treatment (sessions 10-12), clients are also instructed to give and receive compliments and do something nice for oneself. In both studies included in this investigation, twice weekly sessions were scheduled.

Note: HW = homework completion; PSS/PDS = PTSD Symptom Scale/Posttraumatic Diagnostic Scale.

Participants

Participants were all women who consented to participate in one of two different trials of CPT ( Resick et al., 2008 ; Resick et al., 2002 ) and were assigned to CPT with or without the written trauma account. Sixty-five (78.3%) out of the 85 participants from Study 1 who were randomized to CPT, and in Study 2, 75 out of the 100 participants assigned to either CPT with ( n = 39) or without the written account ( n = 36) attended at least one session. Data from these 140 participants were used for the current study. Participants across both studies were female victims of sexual or physical violence who met DSM-IV criteria for PTSD at intake based on the Clinician-Administered PTSD Scale (CAPS, Blake et al., 1995), with initial CAPS scores representing severe levels of PTSD symptoms ( M = 73.49, SD = 18.86). At intake, the average time since the index trauma was 12.38 years ( SD = 13.38, n = 138). The mean age of participants at intake was 34.63 years old ( SD = 11.71, n = 139). The majority of the sample was White ( n = 99; 70.7%), while 22.1% identified as African American ( n = 31). The majority of the sample was single, separated, divorce, or widowed ( n = 108, 70.1%), while a minority ( n = 32, 22.9%) were married or cohabitating. The mean years of education endorsed by participants was 14.4 ( SD = 2.69, n = 139). Treatment in this study, which was reviewed by the university's Institutional Review board, occurred in a university trauma clinic that served traumatized individuals in the St. Louis community and was delivered by masters or doctoral level clinicians who were trained to deliver CPT for the purpose of the studies (see Resick et al., 2002 ; 2008 for further details regarding recruitment, inclusion criteria, random assignment, and retention rates).

Demographic factors

Demographic variables, collected by self-report at intake, included age, years of education, race and ethnicity.

PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993 )/Postraumatic Diagnostic Scale (PDS; Foa, 1995 )

PTSD symptoms were assessed using the PSS ( Foa, Riggs, Dancu, & Rothbaum, 1993 ) from Study 1, and its modified version, the PDS ( Foa, 1995 ) from Study 2. Despite slightly different wording, each measure contains 17 items that correspond to the DSM-IV PTSD symptoms, yielding nearly identical scales. Participants indicate the frequency/severity of 17 symptoms in the past week on a scale from 0 = “ not at all/only one time” to 3 = “ 5 or more times per week/almost always” . A total score is obtained by summing the items. For Study 1, the average total score at pre-treatment was 29.30 ( SD = 8.75). For Study 2, the average total score at pre-treatment was 29.01 ( SD = 9.53). The PSS and PDS have demonstrated high reliability and validity and high diagnostic agreement with other clinical diagnostic measures of trauma related psychopathology ( Foa, Cashman, Jaycox, & Perry, 1997 ). In the current study, alpha coefficients were .83 and .86, respectively. These measures have been combined in previous secondary analyses (e.g. Lester, Resick, Young-Xu, & Artz, 2010 ; Stein, Dickstein, Schuster, Litz, & Resick, in press). We followed the same procedure to generate a dataset that combined the symptom scores from the two studies.

Beck Depression Inventory (BDI; (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961)/Beck Depression Inventory—II (BDI–II; Beck, Steer, & Brown, 1996 )

The BDI (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) was used to assess depression symptoms for Study 1 and the BDI-II ( Beck, Steer, & Brown, 1996 ) for Study 2. Both measures contain 21-items assessing depressive symptoms and have been widely used with good reliability and validity ( Beck, Steer, & Brown, 1996 ). Coefficient alpha for the studies were .92 for the treatment study and .91 for the dismantling study. Scores on these measures were standardized prior to combining.

Assessment of Homework Completion

The homework review form assessed how often clients worked on or reviewed homework materials between sessions. For each homework assignment, clients indicated the frequency of homework completion using a 5-point Likert scale (1 = “not at all”, 2 = “less than 2 times”, 3 = “2-5 times”, 4 = “6-10 times”, 5 = “more than 10 times”). Clients and therapists completed the homework review sheet together before each session, using the number of worksheets and other materials that the client completed to corroborate their assessment of the frequency of their homework completion. Use of homework assignments between each assessment point (every other session) were averaged to generate a homework variable for each time period (“HW”) in the current analyses.

Clients completed the PSS/PDS and BDI/BDI-II at baseline, prior to sessions 2, 4, 6, 8, 10, and 12, and post-treatment. The homework completion form was completed by the therapist and client together at the beginning of each session. Observer ratings of fidelity were conducted on a randomly selected subset of sessions and indicated that the homework review procedures and forms were completed in 100% of the sessions that were rated.

Data Analyses

Our primary goal was to examine the association between homework completion during a particular week on subsequent changes in PTSD symptoms from that point in treatment through the post-treatment assessment, and to determine whether this differed based on whether patients received the version of CPT that included the trauma account. To accomplish this goal, we evaluated a series of piecewise growth models conducted using multilevel regression (Singer & Willett, 2003) with the Mplus software package (Version 7; Muthén & Muthén, 1998-2012). A piecewise growth model breaks an overall trajectory into multiple distinct phases. The focus of the current manuscript investigated change over time during treatment following the week during which homework was assessed. We conducted piecewise growth modeling (as opposed to only including data points following homework assessment) because the piecewise regression approach uses all of the information available for each participant (before and after the session of interest) to produce the most accurate and powerful estimates of subsequent change.

The right side of Table 2 depicts the time variables that were used in the piecewise models. With the exception of the first phase, between baseline and session 2, two sessions and homework assignments were completed between PTSD symptom assessment points. Thus, Table 2 shows that time was modeled as session number increasing by two from one assessment to the next, with the exception of an increase in one from session 12 to post-treatment. Two time variables were entered as Level-1 (within participants) predictors of PTSD symptoms in each piecewise model. The first time variable was described above and centered (or zeroed) at the second session of each assessment phase. As shown in Table 2 , the remaining time variables were modeled as recommended by Singer & Willet (2003).

Note. Time Variables = the time variables used for the regression analysis at each assessment; S = session number, _PST = the second time coefficient; Est. = estimate; 95% CI = 95% confidence interval; ΔPTSD = change in PTSD. Intercept corresponds to the level of PTSD at that assessment.

Three time coefficients were produced from these piecewise models. The intercept term estimated PTSD symptoms assessed prior to the second session of the phase in which homework was assessed (the assessment for which both time variables were equal to zero in Table 2 ), the coefficient for the first time variable produced an estimate in change in PTSD from that session to post-treatment, and the coefficient for the second time variable represented the difference in rate of change prior to and after the session. The intercept and coefficient for the first time variable were of most interest to the current analyses. To evaluate the impact of homework on subsequent change in PTSD symptoms, homework completion was entered as a Level-2 predictor of each change coefficient, and the primary coefficient of interest was the Homework × time variable interaction, which assessed the impact of homework during that phase (the two sessions between assessment points) on subsequent changes in PTSD symptoms through post-treatment. To evaluate the impact of treatment condition (CPT with or without the trauma account) on the homework effect on subsequent change in PTSD, we added a treatment condition variable and a treatment condition × homework interaction (product) term as Level-2 predictors of each time coefficient. We then conducted a logistic regression analyses with treatment dropout status (0,1) regressed on homework scores to evaluate the relationship between homework and dropout.

For our exploratory analyses, we examined zero-order correlations between patient characteristics and homework completion to determine whether certain characteristics predicted the amount of homework that patients complete. We next conducted exploratory analyses that included patient characteristics that might moderate the relationship between homework completion and symptom change as Level-2 predictors in the piecewise models described above.

Homework and Treatment Outcome

The left side of Table 2 reports the model-derived estimates for PTSD levels and subsequent change in PTSD for each time point. Table 3 reports the coefficients for estimates of the impact of homework completion on the level of PTSD at each assessment point (i.e., impact on the intercept of the piecewise models) and impact of HW on subsequent change on PTSD. Significant effects of homework emerged at two sessions, as described below. The extent to which patients completed the homework assigned in Sessions 2 and 3 (HW2; when ABC worksheets are assigned to help the patient identify and differentiate between thoughts and feelings and at session 3 when first written account or focusing all of the ABC worksheets on the worst traumatic event is assigned) was related to both PTSD levels at Session 4 and subsequent changes from Session 4 to post-treatment. Participants who scored a zero (lowest score) on homework completion during these sessions on average exhibited a 7.24 ( d = -.82) decrease in PTSD symptoms from Session 4 to post treatment, while people who scored a five (highest score) exhibited a 22.49 ( d = -2.55) decrease in PTSD symptoms during this time period.

Note. Results on the left side indicate findings for the entire sample, homework by time interaction. Analyses represented on the right side included an interaction between time and a variable indicating whether or not the trauma account was assigned. HW = homework completion, S = session, n = sample size for that analysis, CR = critical ratio ( b /standard error of b, which follows a z -distribution), p = p -value, d = effect size estimate calculated using d = 2 CR n , with .20, .50, and .80 indicating the cutoffs for small, medium, and large effect sizes. The Level-1 regression equation for the analysis was Y ij = b o + b 1 Time1 + b 2 Time2 + r ij , where Y ij = PTSD symptoms for participant at assessment i for participant j, b o = the regression intercept (PTSD levels at that session); b 1 Time1 = Change in PTSD from that session to the posttreatment assessment; PTSD Time2 = the difference in rate of change in PTSD before and after the session, and r ij = the level-1 residual. All of these terms as well as homework use × time parameters interactions were included in the model. However, to facilitate interpretation of the results, only the parameters representing the impact of HW on PTSD levels and subsequent change are presented on the left, and the main effects of Time, HW, and the moderator, as well as all two way and three way interactions were included in the model reported on the right. Coefficients for the entire model can be obtained from the authors.

Figure 1 shows that participants who completed more homework during the HW2 phase, comprising Sessions 2 and 3 of treatment, initially exhibited higher PTSD levels at Session 4 and experienced larger subsequent decreases in PTSD relative to participants who completed less homework that was assigned in Sessions 2 and 3. Mplus allows intercepts and slopes to be modeled as predictors or outcomes at Level-2. Because homework completion during the phase comprising Sessions 2 and 3 was associated with higher Session 4 PTSD symptom levels, but larger decreases in PTSD symptoms, we evaluated a model with the two time coefficients regressed on the Level-1 intercept (which represented PTSD levels at Session 4) to evaluate change over time when controlling for Session 4 PTSD levels. In this model, the impact of homework after Sessions 2 and 3 on subsequent PTSD approached statistical significance ( b = -0.21, CR = -1.86, p = 0.063, d = -0.32). Thus, the larger decrease in PTSD symptoms exhibited from Session 4 to post-treatment by participants who completed more homework at Sessions 2 and 3 relative to those who completed less homework was largely accounted for by differences in PTSD symptoms prior to Session 4. Participants who completed more homework during this phase had exhibited more PTSD symptoms prior to Session 4 than participants who completed less homework assigned in Sessions 2 and 3. Participants who completed more homework during this phase also exhibited larger decreases from Session 4 to post-treatment. While completion of homework assigned in Sessions 2 and 3 was not associated with post-treatment PTSD scores, patients who were scoring higher in symptoms prior to Session 4 and did more homework at Sessions 2 and 3 were able to catch up to their counterparts who were experiencing lower symptoms during this earlier phase of treatment.

The impact of sessions 2 and 3 homework: a) overall, b) at high levels of years of education, and c) at low levels of years of education. HW2 = Homework completion for sessions 2 and 3

The amount of homework completed during the phase comprising Sessions 8 and 9 (when Challenging Beliefs worksheets, which guide the patient in challenging their beliefs and identifying more adaptive beliefs, and modules on Trust and Power and Control are assigned) also predicted subsequent changes in PTSD symptoms. Participants who scored a zero (lowest score) on homework use during this time period on average exhibited a .01 ( d < -.01) decrease in PTSD symptoms from Session 10 to post treatment, while people who scored a 3.75 (highest score) exhibited a 5.93 ( d = -.49) decrease in PTSD symptoms during this time period. However, as indicated in Table 4 , the amount of homework completed after Sessions 8 and 9 was not associated with Session 12 PTSD symptoms, and when controlling for Session 10 PTSD symptoms, the impact of homework completion on symptom change over the remainder of the protocol remained significant ( b = -0.56, CR = -2.134, p = 0.033, d = -0.39). While on average, participants who completed more homework assigned in Sessions 8 and 9 reported fewer PTSD symptoms at post-treatment, the effect was small, and this difference did not approach statistical significance ( b = -0.74, CR = -1.027, p = 0.471, d = -0.13).

PSS/PDS = PTSD Symptom Scale/Posttraumatic Diagnostic Scale; HW = homework completion; n = sample size; M = mean; SD = standard deviation. Because some data were missing in the original data set, sample sizes are noted with descriptive statistics.

The righthand side of Table 3 presents results of a moderator analysis to determine whether treatment version (CPT with or without the account) was associated with symptom change. Treatment version did not moderate the relationship between homework and symptom change. This held true even during the time periods when the trauma account would have been assigned, completed, and reviewed (HW2 and HW3) or at the subsequent assessment period, when worksheet assignments between the two versions of the treatment (as described in Table 1 ).

We next conducted a series of logistic regression analyses examining HW as a predictor of whether or not participants dropped out of treatment. Twenty-five (18.0%) of the 139 participants with data for Session 1 (HW1) dropped out of treatment. HW1 did not significantly predict dropout status ( b = .35, CR = 1.39, p = .165, OR 1 = 1.41, OR/SD = 1.65). HW2 (Session 2 and 3, b = -.20, CR = -.78, p = .438, OR = .82, OR/SD = .88) and HW3 (Session 4 and 5, b = .23, CR = .67, p = .501, OR = 1.25, OR/SD = 1.46) scores also did not significantly predict treatment dropout. Five (4.2%) of the 119 participants who had HW4 scores available dropped out of treatment. HW4 (Session 6 and 7) homework scores predicted dropout ( b = -2.96, CR = -2.43, p = .015, OR = .05, OR/SD = .10) such that a one SD increase in homework completion was associated with a 9.55 times decrease in the likelihood of dropping out. Similarly, six (5%) of the 119 participants who had HW5 scores available dropped out of treatment with HW5 (sessions 8 and 9) scores inversely related to dropout ( b = -1.43, CR = -2.69, p = .007, OR = .24, OR/SD = .26) such that a one SD increase in homework completion was associated with a 3.82 times decrease in the likelihood of dropping out. Only four (4.5%) of 89 participants with HW6 (session 10-11) scores available dropped out of treatment. The association between HW6 and dropout approached statistical significance ( b = -4.47, CR = -1.69, p = .090, OR = .01, OR/SD = .01). However the odds ratios were quite small and indicated a one SD increase in homework completion was associated with at 72.89 times decrease in the likelihood of dropping out, suggesting the failure to reach statistical significance may have been due having such a small number of dropouts during this phase.

Relationship between baseline characteristics, homework completion, and symptom change

Table 4 displays zero-order correlations among demographic variables, initial PTSD symptom levels, and the HW variables between each PTSD assessment point, as well as descriptive statistics for these variables. The scores indicate that on average, clients endorsed doing homework either less than two times or two to five times between sessions, which were scheduled twice per week. As indicated in Table 4 , the initial PTSD scores were positively correlated with HW1 (Session 1; r = .20, p = .016), such that those endorsing higher initial PTSD symptoms reported completing the first homework assignment more frequently. Initial depression scores were positively correlated with HW1 (Session 1) in the same manner; r = .20, p = .011. Number of years of education was significantly, positively associated with completion of homework assigned in Sessions 3 and 4 (HW2; r = .21, p = .015) and Sessions 10 and 11 (HW6; r = .28, p = .008). Number of years since the index trauma was negatively associated with HW6 ( r = -.22, p = .044). Average homework completion did not correlate with any other demographic or baseline variable. The supplemental table summarizes the findings of the exploratory analyses examining moderators of the impact of homework on changes in PTSD. Only one significant moderator by homework interaction emerged, that of years of education and completion of homework assigned after Sessions 2 and 3 (HW2). Figure 1b and 1c shows that completion of the homework assigned in Sessions 2 and 3 was associated with better outcomes for patients with fewer years of formal education compared to those who endorsed more years of education.

With data from two clinical trials of CPT, this study examined the association between homework completion and symptom change in a cognitive behavioral therapy. We employed a session-to-session measure of homework completion to investigate the relationship between specific homework activities and subsequent symptom change. We found some support for the hypothesis that homework completion is associated with greater overall symptom change, with homework engagement at certain timepoints associated with subsequent symptom change. Whether patients received the version of CPT that included a written trauma account or the version that did not include the account, did not appear to moderate the association between homework completion and symptom change at any timepoint in the treatment. Our results regarding the relationship between homework completion and subsequent dropout also suggested that homework completion in the latter half of treatment may be a good indicator of treatment engagement as patients who completed more homework were less likely to drop out. Finally, we found evidence that while certain client characteristics were associated with early homework completion, they do not predict overall engagement in homework. For the most part, they did not moderate the relationship between homework completion and treatment outcomes, with one exception (years of education).

More frequent completion of homework assigned in Sessions 2 and 3 was associated with smaller short-term decreases in PTSD symptoms at Session 4 regardless of whether the trauma account was assigned in Session 3. However, homework completion during this time period predicted greater symptom change over the course of treatment. While this may have been because in part there was more room for improvement among those who completed more homework, it suggests that those with higher symptoms in Sessions 2 and 3 may be able to “catch up” to those with lower symptoms by completing more homework. In both forms of the treatment (with and without the trauma account), homework assignments in these early sessions require attention to the index trauma and identification of associated thoughts and feelings. While the decreases in avoidance required to do this work may initially reduce the amount of symptom change that patients experience, or even occasionally result in a transient increase in symptoms (Larsen, Stirman, Smith, & Resick, 2016), working on the traumatic event between sessions ultimately appears to be beneficial. These findings suggest that clients, especially those who are experiencing less improvement in early sessions, should be encouraged to complete more homework during these sessions, and reassured that doing so, even if challenging in the short-term, is associated with better longer-term results.

Because patients with higher levels of education completed more homework assigned in Sessions 2 and 3, but those with lower levels of education appeared to benefit more from these assignments, it may be important for clinicians to encourage those with lower levels of education to complete assignments early in treatment. Education has not consistently been identified as a prognostic variable in previous CBT research, but it was found to predict dropout in a previous study that examined treatment outcome in CPT and Prolonged Exposure ( Rizvi, Vogt, & Resick, 2009 ). Findings related to education should be replicated, particularly because they were not significant at every timepoint, but is possible that individuals with lower levels of education may struggle more with some concepts of CPT and that additional practice is required early on in order to maximize treatment effectiveness and engagement. Additional practice at identifying thoughts and differentiating them from feelings may benefit individuals with lower levels of education by promoting a sense of mastery and providing a solid foundation on which new skills are introduced.

The frequency of homework completion decreased somewhat during the middle weeks of therapy before increasing over the last two assignments. Particularly in Sessions 6 and 7, the restricted range may have made it difficult to discern whether increased engagement was related to symptom change, and completion of the assignments in these two sessions was not correlated with completion of earlier assignments. It is possible that during the middle period of treatment, cognitive work completed during sessions impacted symptom change in addition to (or instead of) homework completed outside of session, which is designed to reinforce the work done within sessions. The nature of the homework may also play a role in this pattern of change. A worksheet (Challenging Beliefs Worksheet) that combines all other cognitive restructuring elements and takes longer to complete, especially in the beginning, was introduced during this time period. Participants may have had some difficulty completing this assignment without additional practice and guidance, which may have limited the assignment's impact on symptom change when it was first introduced. In contrast, homework completion for Sessions 8 and 9, which occur after that worksheet was introduced and practiced in earlier sessions, predicted a decrease in PTSD symptoms. Thus, even towards the end of treatment, completion of homework is associated with additional improvement, with those who completed more assignments during this phase experiencing an additional benefit of nearly a 6-point difference, which can be considered clinically meaningful (Larsen et al., 2016).

The participants in this study represented a diverse population of multiply traumatized, low income women who, for the most part, had not completed college and endorsed significant symptoms of depression. Our findings indicated that they were able to practice and benefit from a standardized set of homework activities, and that the relationship between homework completion and symptom change was not due to an association with number of years of education. These findings have implications for the implementation of CPT outside the context of research settings. Considered in conjunction with other studies of CPT conducted with diverse populations ( Schulz, Huber, & Resick, 2006 ), our results support a growing body of literature suggesting that CPT homework can be assigned to clients of diverse cultural and educational backgrounds. Homework completion was associated with PTSD symptom change, at least for participants with lower levels of education and those with higher symptoms in early sessions. However, because this sample comprised only women who experienced interpersonal violence index traumas, future research should examine the impact of homework completion in other populations of clients who experience PTSD. Of course, it is also possible that individuals with certain characteristics such as motivation that were not measured in this study are more likely to complete homework, and that homework is a proxy for a particular trait or psychological process that impacts treatment, such as willingness to learn new skills ( Burns & Nolen-Hoeksema, 1991 ) or motivation ( Huppert et al., 2006 ). While previous research on client characteristics, including factors such as resourcefulness were not related to homework completion ( Bryant, Simons, & Thase, 1999 ), factors such as motivation, self-efficacy, or expectancies have not been examined in relation to homework. Other factors such as the therapeutic alliance, fidelity to the treatment, and patient receptivity/resistance were not measured in session, but may impact treatment outcome ( DeRubeis, Brotman, & Strunk, 2005 ).

There is a relative dearth of studies examining the impact of homework completion on treatment outcome in CBTs for PTSD, and the current analyses used data from two RCTs that were not specifically designed to assess the impact of homework completion on symptom change. Therefore, rather than a conservative or strict test of a well-developed theoretical model about the relative importance of different homework assignments, the current study was conducted in the spirit of providing research findings that can facilitate the generation of hypotheses for future studies designed specifically to assess the impact of homework completion on symptom change. Although our investigation of homework was one of the largest to date, we did not have a sufficient sample size to examine homework and their interactions with time simultaneously and instead evaluated the impact of homework between each PTSD assessment in separate models. Because we conducted multiple analyses, particularly for our exploratory moderator analyses, these findings should therefore be interpreted with caution and replicated in future research. However, the effect sizes for our findings regarding Sessions 2 and 3, including that of education as a potential moderator, suggest that they should be investigated further. Replication of our findings with a very large sample and a more conservative, confirmatory analytic approach is necessary.

The current study did not assess the quality of the homework completed or the amount of time spent on the assignments, which are limitations. While our results suggest that irrespective of quality, the frequency of engagement with homework assignments is associated with clinical improvement, it is possible that an assessment of quality or quantity would allow for a greater understanding of the relationship between homework completion and symptom change, as prior research suggests that quality may be more predictive of outcomes than quantity ( Schmidt & Woolaway-Bickel, 2000 ). The current study also did not examine whether specific assignments or elements of homework led to symptom change. Although the homework assignments built on one another, it is possible that clients who did not complete an assignment and had it re-assigned in addition to current homework may have experienced different levels of session-to-session symptom change than those who completed homework on time. Furthermore, if clients were engaged in the form of CPT that does not include a trauma account, they began using some cognitive worksheets sooner and more Socratic questioning than their counterparts who completed the written account. Relationships between specific homework activities and symptom change warrants exploration in a dataset in which symptoms were assessed at every session. Because samples for later analyses were smaller due to treatment dropout, results for these sessions in particular require replication.

While observer ratings of homework completion may also enhance our understanding of the role of homework in CBT, previous research has suggested that self-reports of homework completion, when collected in each session, can be reliable sources of data ( Burns & Spangler, 2000 ; Kassler & Neimeyer, 1997 ). A recent meta-analysis suggested that in studies of homework and clinical outcomes, combined therapist and client ratings are associated with greater effect sizes than observer ratings (Mausbach et al., 2010). The fact that the questionnaire used in this study was completed by therapists and clients together, using the completed homework worksheets to corroborate clients' reports of homework activities, strengthened our confidence in these assessments as reliable estimates of homework completion. In future research, session-to-session (rather than every other session) assessments will allow greater precision in identifying relationships between specific assignments and subsequent symptom change.

Despite these limitations, this study provides additional support for the theory that practicing skills between sessions through completion of homework may be associated with greater symptom improvement ( Beck, 1979 ). It adds to a small literature suggesting that patients in trauma-focused treatment who complete more homework (which focuses on extending key aspects of treatment between sessions) experience decreases in PTSD that are greater than those who are less engaged in homework ( Cooper et al., 2017 ; Mueser et al., 2008 ). Similar to other recent findings ( Cooper et al., 2017 ), our results suggest that either certain assignments, or homework at specific timepoints, may be particularly important. Furthermore, this study suggests that later in treatment, homework completion may indicate greater engagement in treatment and a lower likelihood of dropout. Collectively, these studies point to compelling directions for future experimental and naturalistic investigations of associations between homework and symptom change.

Homework is sometimes perceived as a burden on clients, and both clinicians who are learning CBT and clients who are beginning treatment may struggle to integrate it into treatment (Waltman, Hall, McFarr, Beck, & Creed, 2016). Further research on homework will be useful when conducted in routine care settings, because there have been very few empirical studies on compliance with and impact of homework during routine clinical practice. However, our findings suggest that completion of homework is associated with clinical improvements, and that encouraging early and frequent homework activities may enhance treatment outcome.

• Examined associations between patient factors, CPT homework, and symptom change.
• Homework completion after certain sessions predicted subsequent symptom change.
• Few patient characteristics predicted CPT homework completion.
• Education moderated associations between Session 2 and 3 homework and symptom change.

Supplementary Material

Acknowledgments.

The datasets used for this research was collected through studies funded by the National Institute of Mental Health (NIH-1 R01-MH51509 and NIH-2 R01-MH51509), awarded to Dr. Resick while she was at University of Missouri, St. Louis. Dr. Gutner's work was supported by a career development award from the National Institute of Mental Health (1K23MH103396)

1 OR = Odds Ratio. With continuous predictors it is difficult to interpret the strength (i.e., effect size) of odds ratios because the unit of continuous measures is usually arbitrary. Therefore, we also calculated the odds ratio per standard deviations of the predictor variable (OR/SD). The OR/SD values can be interpreted as the increase in the likelihood of dropping out of treatment associated with a one standard deviation increase in HW scores.

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Program: Health Report

Exploring whether cognitive behavioural therapy works on trauma

• X (formerly Twitter)

Trauma can be a complex thing to tackle. It can present in many different ways depending on the cause (or causes) and the person themselves.

Cognitive behavioural therapy (CBT) is a common tool used in many circumstances, but is it effective for everyone?

A new review has looked into how CBT impacts a range of young people who’ve experienced trauma.

More Information

The Lancet: Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials

Phoenix Australia

• Norman Swan, Presenter

Autism's gender influence, lives saved by COVID vaccines, and trauma therapy

In this episode

What gender means to autism and lives saved by COVID vaccines

Cognitive behavioural therapy for trauma

Cow's milk or formula and when changes to who guidelines for babies.

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